Bleeding (obstetric)

Bleeding (obstetric) is usually divided into bleeding in the consecutive period and bleeding in the early postpartum period.

Bleeding in the consecutive period occurs with hypotension of the uterus, abnormalities of location and attachment of the placenta (presentation, tight attachment, increment of the placenta), injuries of soft tissues of the birth canal (cervix, perineum, etc.), incomplete separation of the placenta from the walls of the uterus in the 3rd period Childbirth.

Symptoms, course. Bleeding at the rupture of soft tissues of the birth canal is characterized by the following symptoms: with a well-contracted uterus from the genital tract, the flow of blood continues, the introduction of uterine contracting drugs does not reduce bleeding. If bleeding occurs as a result of hypotension of the uterus or delayed separation of the placenta (infringement, with or without signs of complete separation of the placenta), the uterus continues to be insufficiently contracted, and bleeding continues.

Treatment. When there is bleeding in the third stage of labor, first of all it is necessary to exclude ruptures of the cervix and soft tissues of the birth canal, having examined them with the help of wide vaginal mirrors. After this, it should be established whether the latter has separated or not separated from the uterine walls. When separating the afterbirth (positive signs of Alfeld, Chukalov-Kyustner, Schroeder, etc.), the therapeutic measures are carried out in the following order: 1) empty the bladder with a catheter; 2) apply techniques Abuladze, Krod-Lazarevich, Genter, etc., aimed at removing from the uterus of the already separated afterbirth. Usually, after the birth of the bleeding, the bleeding stops, If the latter only partially separated from the uterine wall (signs of Alfeld, Chukalov-Kyustner, Schroeder are negative), then the sequence of therapeutic measures is as follows: 1) empty the bladder with a catheter; 2) injecting uterine contracting agents (1 ml of a 1% solution of methylergometrin, or 1 ml of oxytocin); 3) perform manual separation and separation of the afterburn. With severe bleeding immediately begin to manually separate and isolate the afterbirth, without wasting time on less effective measures.

In case of delay in the uterus of parts of the placenta under mask etheric-oxygen or under intravenous anesthesia (propanidide, sombrevin) carry out manual examination of the uterus. With a true increment of the placenta (in these cases, bleeding may be absent), do not try to separate the placenta by hand (the danger of fatal bleeding!), But proceed to the operation of supravaginal amputation of the uterus. Simultaneously with the measures for separation and isolation of the after-effects, a set of measures aimed at the full recovery of blood loss (infusion of plasma, erythrocyte mass, blood substitutes, etc.) is carried out.

Bleeding in the early postpartum period may be due to hypo- or atony of the uterus (most often); Delayed parts of the placenta in the uterus (see above); Rupture of the uterus; Hypofibrinogenemia.

Symptoms, course. When hypotension the uterus is flabby, poorly contracted under the influence of external massage, poorly contoured through the anterior abdominal wall, located relatively high (the bottom above the navel). Blood from the genital tract is excreted either by a stream (with or without clots), or flows in separate portions. The maternal condition progressively worsens as the amount of blood lost increases. Collapse and acute posthemorrhagic anemia are on the rise. If the measures are not taken in a timely manner, then the woman can die.

Hypofibrinogenemia (coagulopathic) bleeding can be combined with uterine hypotonia or arise independently. From the genital tract, liquid blood without clots is secreted. For the diagnosis of hypophybrinogenemia in bed, the patient should immediately apply a sample with dissolution of a blood clot. To do this, in a healthy parturient woman take 2 ml of blood from the vein into a test tube; The blood coagulates in 2-3 minutes. In another tube take the same amount of blood from the vein of the patient (the blood does not coagulate). This blood is then gradually transferred to the first tube, where the clot dissolves.

Treatment. First of all, make sure the integrity of the afterburn. With its defect, it is necessary to perform a manual examination of the uterus. Then they carry out a complex of measures aimed at combating the hypotonia of the uterus: emptying the bladder with a catheter; Intravenous administration of uterine contracting agents; External massage of the uterus; Ice on the bottom of the abdomen. If the bleeding does not stop, then resort to measures aimed at reducing the flow of blood to the uterus (finger compression of the aorta, the imposition of terminals on the parameters, etc.). If the bleeding continues, then as an interim measure you can make a ligation of the main vessels of the uterus. If all of the above measures were ineffective, then they begin the operation of supravaginal amputation of the uterus or its extirpation, which is absolutely indicated in the case of a disorder in the blood coagulation system (see the treatment of bleeding due to a disorder in the blood coagulation system, see Premature detachment of the normally located placenta).

Prevention of bleeding in the consecutive and early postpartum periods requires the allocation of "high-risk" groups in women's clinics and maternity hospitals (frequent or complicated abortions, infantilism, polyhydramnios, multiple pregnancies, delayed pregnancies). In the women's consultation, these pregnant women are prescribed ascorbic acid, vitamin B12, its derivatives, co-amide, vikasol, and conduct physiopsychoprophylaxis classes. Such women should be hospitalized in the maternity hospital 2 weeks before the birth. In the maternity hospital for the prevention of bleeding it is recommended at the end of the second period to start / in the drip injection of 1 ml (5 units) of oxytocin in 500 ml of 5% glucose solution. In the 3rd stage of IV delivery, 1 ml of metipergometrine is administered together with 20 ml of a 40% solution of glucose.