Lecture 8

BLEEDING IN POST AND EARLY

POSTPARTUM PERIOD

1. Bleeding in the afterbirth period.

2. Bleeding in the early postpartum period.

3. Pathogenesis of bleeding.

4. Therapy.

5. Literature.

In modern obstetrics, bleeding remains one of the main causes of maternal mortality. They not only complicate the course of pregnancy, childbirth and the postpartum period, but also lead to the development of neuroendocrine pathology in the long term of a woman’s life.

Every year, 127,000 women around the world die from bleeding. This accounts for 25% of all maternal deaths. In Russia, bleeding is the leading cause of death in patients and accounts for 42% of deaths associated with pregnancy, childbirth and the postpartum period. Moreover, in 25% of cases, bleeding is the only cause of an unfavorable pregnancy outcome.

Causes of mortality:

· delayed inadequate hemostasis;

· incorrect infusion-transfusion tactics;

· violation of the phasing and sequence of obstetric care.

Physiologically, pregnancy is never accompanied by bleeding. At the same time, the hemochorial type of human placentation predetermines a certain amount of blood loss in the third stage of labor. Let's consider the mechanism of normal placentation.

The fertilized egg enters the uterine cavity at the morula stage, surrounded on all sides by trophoblast. Trophoblast cells have the ability to secrete a proteolytic enzyme, due to which the fertilized egg, in contact with the uterine mucosa, attaches to it, dissolves the underlying areas of decidual tissue, and nidation occurs within 2 days. As nidation proceeds, the proteolytic properties of the cytotrophoblast increase. Destruction of the decidua on the 9th day of ontogenesis leads to the formation of lacunae containing maternal blood poured out from the destroyed vessels. From the 12-13th day, connective tissue begins to grow into the primary villi, and then vessels. Secondary and then tertiary villi are formed. Gas exchange and provision of nutrients to the fetus will depend on the correct formation of villi. The main organ of pregnancy, the placenta, is formed. Its main anatomical and physiological unit is placenton. Its components are cotylidon and curuncle. Cotylidon- this is the fruiting part of the placenton, it consists of stem villi with numerous branches containing fruiting vessels. Their bulk is localized in the superficial – compact layer of the endometrium, where they float freely in the intervillous spaces filled with maternal blood. To ensure fixation of the placenta to the wall of the uterus, there are “anchor” villi that penetrate into the deeper, spongy layer of the endometrium. There are significantly fewer of them than the main villi and they are torn during the separation of the placenta from the uterine wall in the afterbirth period. The loose spongy layer easily moves with a sharp decrease in the uterine cavity, while the number of exposed anchor villi is not large, which reduces blood loss. During normal placentation, chorionic villi never penetrate the basal layer of the endometrium. From this layer the endometrium will be reborn in the future.

Thus, normal placentation guarantees a woman in the future the normal functioning of the most important organ - the uterus.

From the maternal surface, each cotyledon corresponds to a certain section of the decidua - curuncle. At its bottom, a spiral artery opens, supplying the lacuna with blood. They are separated from each other by incomplete partitions - septa. Thus, the cavities of the intervillous spaces - curuncles - communicate. The total number of spiral arteries reaches 150-200. From the moment the placenta is formed, the spiral arteries approaching the intervillous space, under the influence of the trophoblast, lose their muscle elements and lose the ability to vasoconstrict, not responding to all vasopressors. Their lumen increases from 50 to 200 microns, and by the end of pregnancy to 1000 microns. This phenomenon is called “physiological denervation of the uterus.” This mechanism is necessary to maintain the blood supply to the placenta at a constant optimal level. When systemic pressure increases, the blood supply to the placenta does not decrease.

The process of trophoblast invasion is completed by the 20th week of pregnancy. By this time, the uteroplacental circuit contains 500-700 ml of blood, the fetal-placental circuit - 200-250 ml.

During the physiological course of pregnancy, the uterus-placenta-fetus system is closed. Maternal and fetal blood do not mix and do not flow out. Bleeding occurs only if the connection between the placenta and the wall of the uterus is disrupted; normally it occurs in the third stage of labor, when the volume of the uterus decreases sharply. The placental area does not shrink throughout pregnancy and childbirth. After the expulsion of the fetus and the rupture of the posterior waters, the intrauterine pressure sharply decreases. In a small area of ​​the placental area within the spongy layer, the anchor villi rupture and bleeding begins from the exposed spiral arteries. The area of ​​the placental area is exposed, which is a vascularized wound surface. 150-200 spiral arteries open into this zone, the end sections of which do not have a muscular wall, and create the danger of large blood loss. At this moment, the myotamponade mechanism begins to operate. Powerful contractions of the muscle layers of the uterus lead to mechanical closure of the mouths of bleeding vessels. In this case, the spiral arteries twist and are drawn into the thickness of the uterine muscle.

At the second stage, the mechanism of thrombotamponade is implemented. It consists of intensive formation of clots in compressed spiral arteries. Blood coagulation processes in the area of ​​the placental site are ensured by a large amount of tissue thromboplastin formed during placental abruption. The rate of clot formation in this case exceeds the rate of thrombus formation in the systemic circulation by 10-12 times.

Thus, in the postpartum period, hemostasis is carried out at the first stage by effective myotamponade, which depends on the contraction and retraction of myometrial fibers, and full thrombotamponade, which is possible in the normal state of the hemostatic system of the puerperal woman.

It takes 2 hours for the final formation of a dense thrombus and its relatively reliable fixation on the vessel wall. In this regard, the duration of the early postpartum period, during which there is a risk of bleeding, is determined by this time period.

During the normal course of the succession period, the volume of blood lost is equal to the volume of the intervillous space and does not exceed 300-400 ml. Taking into account thrombosis of the placental bed, the volume of external blood loss is 250-300 ml and does not exceed 0.5% of the woman’s body weight. This volume does not affect the condition of the postpartum woman, which is why in obstetrics there is the concept of “physiological blood loss.”

This is a normal mechanism of placentation and the course of the afterbirth and early postpartum period. With placentation mechanisms, the leading symptom is bleeding.

Disorders of the placentation mechanism

The causes of disruption of the placentation mechanism are pathological changes in the endometrium that occurred before pregnancy:

1. Chronic inflammatory processes in the endometrium (acute or chronic endomyometritis).

2. Dystrophic changes in the myometrium, resulting from frequent abortions, miscarriages with curettage of the walls of the uterine cavity, especially complicated by subsequent inflammatory complications.

3. Dystrophic changes in the myometrium in multiparous women.

4. Inferiority of the endometrium during infantilism.

5. Changes in the endometrium in pregnant women with uterine fibroids, especially with submucosal localization of nodes

6. Inferiority of the endometrium due to abnormal development of the uterus.

Bleeding in the afterbirth period

Disruption of placenta separation processes

Tight attachment of the placenta

True placenta accreta

Hypotonic state of the uterus

Location of the placenta in one of the uterine angles

Rupture of the uterus, soft birth canal

Ø Infringement of the separated placenta

Ø DIC syndrome

Ø Irrational management of the afterbirth period (pulling the umbilical cord - uterine inversion, untimely use of uterotonics).

With changes in the endometrium, the essence of which is the thinning or complete absence of the spongy layer, four options for pathological attachment of the placenta are possible.

1. Placentaadhaerens– false rotation of the placenta. Occurs when there is a sharp thinning of the spongy layer of the endometrium. Separation of the placenta is possible only with mechanical destruction of the villi within the compact layer. Anchor villi penetrate the basal layer and are localized close to the muscle layer. The placenta seems to “stick” to the wall of the uterus, and the absence of the spongy layer leads to the fact that after the uterus is emptied, there is no disruption of the connection between the placenta and the uterine wall.

2. Placentaaccraeta - true rotation of the placenta. In the complete absence of the spongy layer of the endometrium, chorionic villi, growing through the basal layer, penetrate into the muscle tissue. In this case, destruction of the myometrium does not occur, but separation of the placenta from the uterine wall by hand is impossible.

3. Placentaincraeta – deeper invasion of chorionic villi, accompanied by their penetration into the thickness of the myometrium with destruction of muscle fibers. Occurs with complete atrophy of the endometrium, as a result of severe septic postpartum, post-abortion complications, as well as endometrial defects that arise during surgical interventions on the uterus. In this case, the basal layer of the endometrium loses its ability to produce antienzymes, which normally prevent the chorionic villi from penetrating deeper than the spongy layer. An attempt to separate such a placenta leads to massive endometrial trauma and fatal bleeding. The only way to stop it is to remove the organ along with the accreta placenta.

4. Placentapercraeta– is rare, chorionic villi grow into the uterine wall to the serous covering and destroy it. The villi are exposed, and profuse intra-abdominal bleeding begins. This pathology is possible when the placenta is attached to the scar area, where the endometrium is completely absent and the myometrium is almost not expressed, or when the fertilized egg is nidated in the rudimentary uterine horn.

If a violation of the placental attachment occurs in some part of the placental site, this is a partial abnormal attachment of the placenta. After the birth of the fetus, normal processes of separation of the placenta begin in unchanged areas, which is accompanied by blood loss. The greater it is larger area exposed placental area. The placenta sags in an area that has not separated, is abnormally attached, does not allow the uterus to contract, and there are no signs of placental separation. The absence of myotamponade leads to bleeding in the absence of signs of placental separation. This is afterbirth bleeding, the method of stopping it is the operation of manual separation and release of the placenta. The operation is performed under general anesthesia. The operation lasts no more than 1-2 minutes, but requires a quick introduction of the patient into a state of anesthesia, because everything happens against the background of unstoppable bleeding. During the operation, it is possible to determine the type of placentation pathology and the depth of villi invasion into the uterine wall. With Pl adharens, the placenta is easily separated from the uterine wall, because you are working within the functional layer of the endometrium. With Pl accraeta, it is not possible to separate the placenta in this area - sections of tissue hang from the wall of the uterus, and the bleeding intensifies and begins to become profuse. With Pl incraeta, attempts to remove placental tissue lead to the formation of defects, niches in the uterine muscle, and bleeding becomes threatening. If the placenta is partially firmly attached, one should not persist in attempts to separate the non-detachable areas of the placenta and proceed to surgical treatment methods. Attempts should never be made to isolate the placenta in the absence of signs of placental separation in conditions of afterbirth bleeding.

The clinical picture in cases of total tight attachment of the placenta is extremely rare. In the afterbirth period, there is no violation of the integrity of the intervillous spaces, there are no signs of placental separation and no bleeding. In this situation, the waiting time is 30 minutes. If during this time there are no signs of placental separation and no bleeding, the diagnosis of total placental implantation becomes obvious. Tactics - active separation of the placenta and release of the placenta. The type of placentation abnormality is determined during the operation. In this case, blood loss exceeds physiological, because separation occurs within the compact layer.

BLEEDING IN THE FOLLOW-UP PERIOD.

DETENTION OF THE BABY SEAT AND ITS PARTS IN THE UTERINE CAVITY

Bleeding that occurs after the birth of the fetus is called bleeding in the afterbirth period. It occurs when a child’s seat or parts of it are delayed. During the physiological course of the succession period, the uterus after the birth of the fetus decreases in volume and sharply contracts, the placental area decreases in size and becomes smaller than the size of the placenta. During the afterbirth contractions, the muscular layers of the uterus are retracted in the area of ​​the placental area, due to which the spongy layer of the decidua ruptures. The process of separation of the placenta is directly related to the strength and duration of the retraction process. The maximum duration of the afterbirth period is normally no more than 30 minutes.

Postpartum hemorrhage.

According to the time of occurrence, they are divided into early - occurring in the first 2 hours after birth and late - after this time and up to the 42nd day after birth.

Early postpartum bleeding.

The causes of early postpartum bleeding can be:

A. hypo- and atony of the uterus

b. birth canal injuries

V. coagulopathy.

Hypotony of the uterus- this is a condition in which the tone and contractility of the uterus are sharply reduced. Under the influence of measures and means that stimulate the contractile activity of the uterus, the uterine muscle contracts, although often the strength of the contractile reaction does not correspond to the force of the impact.

Uterine atony- this is a condition in which drugs that stimulate the uterus do not have any effect on it. The neuromuscular apparatus of the uterus is in a state of paralysis. Uterine atony is rare, but causes massive bleeding.

Reasons for the development of uterine hypotension in the early postpartum period. Muscle fiber loses the ability to contract normally in three cases:

1. Excessive overdistension: this is facilitated by polyhydramnios, multiple pregnancies and the presence of a large fetus.

2. Excessive muscle fiber fatigue. This situation is observed during a long period of labor, when irrational use large doses of tonomotor drugs, with fast and rapid labor, resulting in exhaustion. Let me remind you that labor should be considered rapid if it lasts less than 6 hours for a primiparous woman, and less than 4 hours for a multiparous woman. Labor is considered rapid if it lasts less than 4 hours for a first-time mother and less than 2 hours for a multiparous woman.

3. The muscle loses the ability to contract normally in the event of structural changes of a scarring, inflammatory or degenerative nature. Acute and chronic inflammatory processes involving the myometrium, uterine scars of various origins, uterine fibroids, numerous and frequent curettages of the walls of the uterine cavity, in multiparous women and with short intervals between births, in women in labor with manifestations of infantilism, abnormal development of the genital organs.

The leading syndrome is bleeding, in the absence of any complaints. An objective examination reveals what can be determined by palpation through the anterior abdominal wall decrease in the tone of the uterus, its slight increase due to the accumulation of clots in its cavity and liquid blood. External bleeding, as a rule, does not correspond to the amount of blood loss. When the uterus is massaged, liquid dark blood with clots pours out through the anterior abdominal wall. General symptoms depend on the deficiency of circulating blood volume. When it decreases by more than 15%, manifestations of hemorrhagic shock begin.

There are two clinical variants of early postpartum hypotonic bleeding:

1. Bleeding is profuse from the very beginning, sometimes in a stream. The uterus is flabby, atonic, the effect of therapeutic measures short-term

2. Initial blood loss is small. The uterus periodically relaxes, blood loss increases gradually. Blood is lost in small portions – 150-200 ml, which allows the postpartum woman’s body to adapt over a certain period of time. This option is dangerous because the patient’s relatively satisfactory state of health disorients the doctor, which can lead to inadequate therapy. At a certain stage, bleeding begins to rapidly increase, the condition worsens sharply and DIC syndrome begins to develop intensively.

Differential diagnosis hypotonic bleeding is carried out with traumatic injuries of the birth canal. In contrast to hypotonic bleeding with trauma to the birth canal, the uterus is dense and well contracted. Examination of the cervix and vagina using mirrors and manual examination of the walls of the uterine cavity confirm the diagnosis of ruptures of the soft tissues of the birth canal and bleeding from them.

There are 4 main groups of methods to combat bleeding in the early postpartum period.

1. Methods aimed at restoring and maintaining contractile activity of the uterus include:

The use of oxytotic drugs (oxytocin), ergot drugs (ergotal, ergotamine, methylergometrine, etc.). This group of drugs gives a fast, powerful, but rather short-term contraction of the uterine muscles.

Massage of the uterus through the anterior abdominal wall. This manipulation should be carried out in doses, carefully, without excessively rough and prolonged exposure, which can lead to the release of thromboplastic substances into the mother’s bloodstream and lead to the development of disseminated intravascular coagulation syndrome.

Coldness in the lower abdomen. Prolonged cold irritation reflexively maintains the tone of the uterine muscles.

2. Mechanical irritation of the reflex zones of the vaginal vault and cervix:

Tamponade of the posterior vaginal vault with ether.

Electrotonization of the uterus is performed if equipment is available.

The listed reflex effects on the uterus are performed as additional, auxiliary methods that complement the main ones, and are carried out only after the operation of manual examination of the walls of the uterine cavity.

The operation of manual examination of the walls of the uterine cavity refers to methods of reflex action on the uterine muscle. This is the main method that should be performed immediately after a set of conservative measures.

Tasks that are solved during the operation of manual examination of the uterine cavity:

n exclusion of uterine trauma (complete and incomplete rupture). In this case, they urgently switch to surgical methods to stop bleeding.

n removal of remnants of the fertilized egg retained in the uterine cavity (placental lobules, membranes).

n removal of blood clots accumulated in the uterine cavity.

n the final stage of the operation is a massage of the uterus on a fist, combining mechanical and reflex methods of influencing the uterus.

3. Mechanical methods.

Include manual compression of the aorta.

Clamping of parametriums according to Baksheev.

Currently used as a temporary measure to gain time in preparation for surgical methods to stop bleeding.

4. Surgical operative methods. These include:

n clamping and bandaging great vessels. They are resorted to in cases of technical difficulties when performing a caesarean section.

n hysterectomy – amputation and extirpation of the uterus. Serious, mutilating operations, but, unfortunately, the only correct measures with massive bleeding, allowing for reliable hemostasis. In this case, the choice of the extent of the operation is individual and depends on the obstetric pathology that caused the bleeding and the condition of the patient.

Supravaginal amputation of the uterus is possible with hypotonic bleeding, as well as with true rotation of the placenta with a highly located placental platform. In these cases, this volume allows you to remove the source of bleeding and ensure reliable hemostasis. However, when the clinical picture of disseminated intravascular coagulation syndrome has developed as a result of massive blood loss, the scope of the operation should be expanded to simple extirpation of the uterus without appendages with additional double drainage abdominal cavity.

Extirpation of the uterus without appendages is indicated in cases of cervical-isthmus location of the placenta with massive bleeding, with PONRP, Couveler's uterus with signs of DIC, as well as with any massive blood loss accompanied by DIC.

Dressing Art Iliaca interna. This method is recommended as an independent method, preceding or even replacing hysterectomy. This method is recommended as the final stage in the fight against bleeding in cases of advanced disseminated intravascular coagulation after hysterectomy and the absence of sufficient hemostasis.

In case of any bleeding, the success of the measures taken to stop the bleeding depends on timely and rational infusion-transfusion therapy.

TREATMENT

Treatment for hypotonic bleeding is complex. It is started without delay, and at the same time measures are taken to stop bleeding and replenish blood loss. Therapeutic manipulations should begin with conservative ones; if they are ineffective, then immediately move on to surgical methods, including transsection and removal of the uterus. All manipulations and measures to stop bleeding should be carried out in a strictly defined order without interruption and be aimed at increasing the tone and contractility of the uterus.

The system for combating hypotonic bleeding includes three stages.

First stage: Blood loss exceeds 0.5% of body weight, averaging 401-600 ml.

The main task of the first stage is to stop the bleeding, prevent large blood loss, prevent a shortage of blood loss compensation, maintain the volume ratio of administered blood and blood substitutes equal to 0.5-1.0, compensation is 100%.

First stage events The fight against bleeding comes down to the following:

1) emptying the bladder with a catheter, therapeutic dosed massage of the uterus through the abdominal wall for 20-30 seconds. after 1 min., local hypothermia (ice on the stomach), intravenous administration of crystalloids ( saline solutions, concentrated glucose solutions);

2) simultaneous intravenous administration of 0.5 ml of methylergometrine and oxytocin. in one syringe followed by drip administration of these drugs in the same dose at a rate of 35-40′ drops. per minute within 30-40 minutes;

3) manual examination of the uterus to determine the integrity of its walls, removal of parietal blood clots, and two-handed massage of the uterus;

4) examination of the birth canal, suturing ruptures;

5) intravenous administration of a vitamin-energy complex to increase the contractile activity of the uterus: 100-150 ml. 40% glucose solution, 12-15 units of insulin (subcutaneous), 10 ml. 5% ascorbic acid solution, 10 ml. calcium gluconate solution, 50-100 mg. cocarboxylase hydrochloride.

If there is no effect, confidence in the cessation of bleeding, and also with blood loss equal to 500 ml, blood transfusion should be started.

If the bleeding does not stop or resumes during pregnancy, immediately proceed to the second stage of the fight against hypotonic bleeding.

If bleeding continues, proceed to the third stage.

Third stage: blood loss exceeding masses bodies i.e. 1001-1500 ml.

The main tasks of the third stage of the fight against hypotonic bleeding: removal of the uterus before development hypocoagulation, prevention of reimbursement deficiency blood loss more than 500 ml., maintaining the volume ratio of administered blood and blood substitutes: 1, timely compensation of respiratory function (ventilator) and kidneys, which allows stabilization hemodynamics. Reimbursement of blood loss by 200.

Third stage events .

In case of uncontrolled bleeding, intubation anesthesia with mechanical ventilation, transection, temporary stop of bleeding for the purpose of normalization hemodynamic And coagulation indicators (application of clamps to the angles of the uterus, bases of the broad ligaments, isthmic part of the tubes, own ligaments of the ovaries and round ligaments of the uterus).

The choice of the scope of the operation (amputation or hysterectomy) is determined by the pace, duration, volume blood loss, state of systems hemostasis. During development DIC syndrome Only hysterectomy should be performed.

I do not recommend using the position Trendelenburg, which sharply worsens lung ventilation and function cordially- vascular system, repeated manual examination and scrape pouring uterine cavity, repositioning of terminals, simultaneous administration of large quantities of drugs tonomotor actions.

Uterine tamponade and Lositskaya suture as methods of combating postpartum hemorrhage have been removed from the range of means as dangerous and misleading the doctor about the true size blood loss and uterine tone, in communications, with which surgical intervention turns out to be late.

Pathogenesis of hemorrhagic shock

The leading place in the development of severe shock belongs to the disproportion between the blood volume and the capacity of the vascular bed.

BCC deficiency leads to a decrease in venous return and cardiac output. The signal from the valumoreceptors of the right atrium enters the vasomotor center and leads to the release of catecholamines. Peripheral vasospasm occurs mainly in the venous part of the vessels, because It is this system that contains 60-70% of the blood.

Redistribution of blood. In a postpartum woman, this is accomplished by the release of blood into the bloodstream from the uterine circuit, containing up to 500 ml of blood.

Redistribution of fluid and transition of extravascular fluid into the bloodstream is autohemodilution. This mechanism compensates for blood loss of up to 20% of the blood volume.

In cases where blood loss exceeds 20% of the bcc, the body is not able to restore the correspondence between the bcc and the vascular bed using its reserves. Blood loss enters the decompensated phase and centralization of blood circulation occurs. To increase venous return, arteriovenous shunts are opened, and the blood, bypassing the capillaries, enters the venous system. This type of blood supply is possible for organs and systems: skin, subcutaneous tissue, muscles, intestines, and kidneys. This entails a decrease in capillary perfusion and hypoxia of the tissues of these organs. The volume of venous return increases slightly, but to ensure adequate cardiac output, the body is forced to increase the heart rate - in the clinic, along with a slight decrease in systolic blood pressure with an increased diastolic blood pressure, tachycardia appears. Stroke volume increases, and residual blood in the ventricles of the heart decreases to a minimum.

The body cannot work at this rhythm for a long time and tissue hypoxia occurs in organs and tissues. A network of additional capillaries opens. The volume of the vascular bed increases sharply with a deficiency of bcc. The resulting discrepancy leads to a fall blood pressure to critical values, at which tissue perfusion in organs and systems practically stops. Under these conditions, perfusion is maintained for life. important organs. When blood pressure in large vessels decreases to 0, blood flow in the brain and coronary arteries is maintained.

In conditions of a secondary decrease in blood volume and low blood pressure due to a sharp decrease in stroke volume in the capillary network, “sludge syndrome” (“sludge”) occurs. Gluing of formed elements occurs with the formation of microclots and thrombosis of the microvasculature. The appearance of fibrin in the bloodstream activates the fibrinolysis system - plasminogen is converted into plasmin, which breaks down the fibrin filaments. The patency of blood vessels is restored, but clots that form again and again, absorbing blood factors, lead to depletion of the blood coagulation system. Aggressive plasmin, not finding a sufficient amount of fibrin, begins to break down fibrinogen - in the peripheral blood, along with fibrin degradation products, fibrinogen degradation products appear. DIC enters the hypocoagulation stage. Almost deprived of coagulation factors, the blood loses its ability to coagulate. In the clinic, bleeding occurs with non-coagulating blood, which, against the background of multiple organ failure, leads to the death of the body.

Diagnosis of obstetric hemorrhagic shock should be based on clear and accessible criteria that would make it possible to catch the moment when a relatively easily reversible situation decompensates and approaches irreversible. To do this, two conditions must be met:

n blood loss should be determined as accurately and reliably as possible

n there must be an objective individual assessment of the patient's response to this blood loss.

The combination of these two components will make it possible to choose the correct algorithm of actions to stop bleeding and create an optimal program of infusion-transfusion therapy.

In obstetric practice, the accurate determination of blood loss is of great importance. This is due to the fact that any childbirth is accompanied by blood loss, and bleeding is sudden, profuse and requires quick and correct action.

As a result of numerous studies, average volumes of blood loss have been developed in various obstetric situations. (slide)

During vaginal delivery, a visual method for assessing blood loss using measuring containers. This method, even for experienced specialists, produces 30% errors.

Determination of blood loss by hematocrit presented by Moore formulas: In this formula, instead of the hematocrit indicator, it is possible to use another indicator - hemoglobin content; the true values ​​of these parameters become real only 2-3 days after achieving complete blood dilution.

Nelson's formula is based on hematocrit. It is reliable in 96% of cases, but is informative only after 24 hours. It is necessary to know the initial hematocrit.

There is an interdependence between indicators of blood density, hematocrit and volume of blood loss (slide)

When determining intraoperative blood loss, a gravimetric method is used, which involves weighing the surgical material. Its accuracy depends on the intensity of blood soaking of the operating linen. The error is within 15%.

In obstetric practice, the visual method and Liebov's formula are most acceptable. There is a certain relationship between body weight and bcc. For women, BCC is 1/6 of body weight. Physiological blood loss is considered to be 0.5% of body weight. This formula is applicable to almost all pregnant women, except for patients who are obese and have severe forms of gestosis. Blood loss of 0.6-0.8 refers to pathological compensated, 0.9-1.0 – pathological decompensated and more than 1% – massive. However, such an assessment is only applicable in combination with clinical data, which is based on an assessment of the signs and symptoms of developing hemorrhagic shock using blood pressure, pulse rate, hematocrit, and the calculation of the Altgover index.

The Altgover index is the ratio of heart rate to systolic blood pressure. Normally it does not exceed 0.5.

The success of measures to combat bleeding is determined by the timeliness and completeness of measures to restore myotamponade and ensure hemostasis, but also by the timeliness and well-constructed program of infusion-transfusion therapy. Three main components:

1. volume of infusion

2. composition of infusion media

3. infusion rate.

The volume of infusion is determined by the volume of recorded blood loss. With blood loss of 0.6-0.8% of body weight (up to 20% of the bcc), it should be 160% of the volume of blood loss. At 0.9-1.0% (24-40% bcc) – 180%. With massive blood loss - more than 1% of body weight (more than 40% of the bcc) - 250-250%.

The composition of infusion media becomes more complex as blood loss increases. With a 20% deficiency of bcc, colloids and crystalloids in a 1:1 ratio, blood is not transfused. At 25-40% of the bcc - 30-50% of blood loss is blood and its preparations, the rest is colloids: crystalloids - 1:1. If blood loss is more than 40% of the bcc, 60% is blood, the ratio of blood: FFP is 1:3, the rest is crystalloids.

The rate of infusion depends on the value of systolic blood pressure. When blood pressure is less than 70 mm Hg. Art. – 300 ml/min, at readings of 70-100 mm Hg – 150 ml/min, then the usual infusion rate under the control of the central venous pressure.

Prevention of bleeding in the postpartum period

1. Timely treatment inflammatory diseases, the fight against abortion and recurrent miscarriage.

2. Proper management of pregnancy, prevention of gestosis and complications of pregnancy.

3. Correct management of childbirth: competent assessment of the obstetric situation, optimal regulation of labor. Pain relief during labor and timely resolution of the issue of surgical delivery.

4. Prophylactic administration of uterotonic drugs starting from the moment of cutting in the head, careful monitoring in the postpartum period. Especially in the first 2 hours after birth.

Mandatory emptying of the bladder after the birth of the child, ice on the lower abdomen after the birth of the placenta, periodic external massage of the uterus. Careful accounting of lost blood and assessment of the general condition of the postpartum woman.

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Bleeding in the afterbirth and early postpartum periods

What is Bleeding in the afterbirth and early postpartum periods -

Bleeding in the afterbirth (in the third stage of labor) and in the early postpartum periods may occur as a result of disruption of the processes of separation of the placenta and discharge of the placenta, decreased contractile activity of the myometrium (hypo- and atony of the uterus), traumatic damage to the birth canal, and disturbances in the hemocoagulation system.

Blood loss of up to 0.5% of body weight is considered physiologically acceptable during childbirth. A volume of blood loss greater than this indicator should be considered pathological, and blood loss of 1% or more is classified as massive. Critical blood loss is 30 ml per 1 kg of body weight.

Hypotonic bleeding is caused by a condition of the uterus in which there is a significant decrease in its tone and a significant decrease in contractility and excitability. With uterine hypotension, the myometrium reacts inadequately to the strength of the stimulus to mechanical, physical and medicinal influences. In this case, periods of alternating decrease and restoration of uterine tone may be observed.

Atonic bleeding is the result of a complete loss of tone, contractile function and excitability of the neuromuscular structures of the myometrium, which are in a state of paralysis. In this case, the myometrium is unable to provide sufficient postpartum hemostasis.

However, from a clinical point of view, the division of postpartum hemorrhage into hypotonic and atonic should be considered conditional, since medical tactics primarily depends not on what kind of bleeding it is, but on the massiveness of blood loss, the rate of bleeding, the effectiveness of conservative treatment, and the development of disseminated intravascular coagulation syndrome.

What provokes / Causes of Bleeding in the afterbirth and early postpartum periods:

Although hypotonic bleeding always develops suddenly, it cannot be considered unexpected, since each specific clinical observation reveals certain risk factors for the development of this complication.

• Physiology of postpartum hemostasis

The hemochorionic type of placentation determines the physiological volume of blood loss after separation of the placenta in the third stage of labor. This volume of blood corresponds to the volume of the intervillous space, does not exceed 0.5% of the woman’s body weight (300-400 ml of blood) and does not negatively affect the condition of the postpartum woman.

After separation of the placenta, an extensive, richly vascularized (150-200 spiral arteries) subplacental area opens, which creates a real risk of rapid loss of a large volume of blood. Postpartum hemostasis in the uterus is ensured both by contraction of the smooth muscle elements of the myometrium and thrombus formation in the vessels of the placental site.

Intense retraction of the muscle fibers of the uterus after separation of the placenta in the postpartum period contributes to compression, twisting and retraction of the spiral arteries into the thickness of the muscle. At the same time, the process of thrombus formation begins, the development of which is facilitated by the activation of platelet and plasma coagulation factors, and the influence of the elements of the fetal egg on the hemocoagulation process.

At the beginning of thrombus formation, loose clots are loosely bound to the vessel. They easily come off and are washed out by the blood flow when uterine hypotension develops. Reliable hemostasis is achieved 2-3 hours after the formation of dense, elastic fibrin blood clots, firmly connected to the vessel wall and covering their defects, which significantly reduces the risk of bleeding in the event of decreased uterine tone. After the formation of such blood clots, the risk of bleeding decreases with a decrease in myometrial tone.

Consequently, an isolated or combined violation of the presented components of hemostasis can lead to the development of bleeding in the afterbirth and early postpartum periods.

• Disorders of postpartum hemostasis

Disturbances in the hemocoagulation system can be caused by:

• changes in hemostasis that existed before pregnancy;
• disorders of hemostasis due to complications of pregnancy and childbirth (antenatal death of the fetus and its prolonged retention in the uterus, gestosis, premature placental abruption).

Disorders of myometrial contractility, leading to hypo- and atonic bleeding, are associated with various causes and can occur both before the onset of labor and occur during childbirth.

In addition, all risk factors for the development of uterine hypotension can be divided into four groups.

• Factors determined by the characteristics of the patient’s socio-biological status (age, socio-economic status, profession, addictions and habits).
• Factors determined by the premorbid background of the pregnant woman.
• Factors determined by the peculiarities of the course and complications of this pregnancy.
• Factors associated with the characteristics of the course and complications of these births.

Consequently, the following can be considered prerequisites for a decrease in uterine tone even before the onset of labor:

• Ages 30 years and older are the most at risk for uterine hypotension, especially for primiparous women.
• The development of postpartum hemorrhage in female students is facilitated by high mental stress, emotional stress and overexertion.
• Parity of birth does not have a decisive influence on the frequency of hypotonic bleeding, since pathological blood loss in primigravidas is observed as often as in multiparous women.
• Dysfunction of the nervous system, vascular tone, endocrine balance, water-salt homeostasis (myometrial edema) due to various extragenital diseases (presence or exacerbation of inflammatory diseases; pathology of the cardiovascular, bronchopulmonary systems; kidney diseases, liver diseases, thyroid diseases, diabetes diabetes), gynecological diseases, endocrinopathies, disorders fat metabolism and etc.
• Dystrophic, cicatricial, inflammatory changes in the myometrium, which caused the replacement of a significant part of the muscle tissue of the uterus with connective tissue, due to complications after previous births and abortions, operations on the uterus (the presence of a scar on the uterus), chronic and acute inflammatory processes, tumors of the uterus (uterine fibroids).
• Insufficiency of the neuromuscular apparatus of the uterus against the background of infantilism, abnormal development of the uterus, and ovarian hypofunction.
• Complications of this pregnancy: breech presentation of the fetus, FPN, threatened miscarriage, previa or low location of the placenta. Severe forms late gestosis are always accompanied by hypoproteinemia, increased permeability vascular wall, extensive hemorrhages in tissues and internal organs. Thus, severe hypotonic bleeding in combination with gestosis is the cause of death in 36% of women in labor.
• Overdistension of the uterus due to a large fetus, multiple pregnancy, polyhydramnios.

The most common causes of dysfunction of the myometrium that arise or worsen during childbirth are the following.

Depletion of the neuromuscular apparatus of the myometrium due to:

• excessively intense labor (quick and rapid labor);
• discoordination of labor;
• protracted labor (weakness of labor);
• irrational administration of uterotonic drugs (oxytocin).

It is known that in therapeutic doses, oxytocin causes short-term, rhythmic contractions of the body and fundus of the uterus, does not have a significant effect on the tone of the lower segment of the uterus and is quickly destroyed by oxytocinase. In this regard, to maintain the contractile activity of the uterus, long-term intravenous administration is required. drip administration.

Long-term use of oxytocin for labor induction and labor stimulation can lead to blockade of the neuromuscular apparatus of the uterus, resulting in its atony and subsequent immunity to drugs that stimulate myometrial contractions. The risk of amniotic fluid embolism increases. The stimulating effect of oxytocin is less pronounced in multiparous women and women over 30 years of age. At the same time, hypersensitivity to oxytocin was noted in patients with diabetes mellitus and with pathology of the diencephalic region.

Surgical delivery. The frequency of hypotensive bleeding after surgical delivery is 3-5 times higher than after vaginal delivery. In this case, hypotensive bleeding after surgical delivery can be due to various reasons:

• complications and diseases that caused surgical delivery (weakness of labor, placenta previa, gestosis, somatic diseases, clinically narrow pelvis, anomalies of labor);
• stress factors in connection with the operation;
• the influence of painkillers that reduce myometrial tone.

It should be noted that operative delivery not only increases the risk of developing hypotonic bleeding, but also creates the preconditions for the occurrence of hemorrhagic shock.

Damage to the neuromuscular apparatus of the myometrium due to the entry into the vascular system of the uterus of thromboplastic substances with elements of the fertilized egg (placenta, membranes, amniotic fluid) or products of the infectious process (chorioamnionitis). In some cases, the clinical picture caused by amniotic fluid embolism, chorioamnionitis, hypoxia and other pathology may be blurred, abortive in nature and manifested primarily by hypotonic bleeding.

The use of medications during childbirth that reduce myometrial tone (painkillers, sedatives and antihypertensive drugs, tocolytics, tranquilizers). It should be noted that when prescribing these and other medications during childbirth, as a rule, their relaxing effect on myometrial tone is not always taken into account.

In the afterbirth and early postpartum period, a decrease in myometrial function under other of the above circumstances can be caused by:

• rough, forced management of the afterbirth and early postpartum period;
• dense attachment or placenta accreta;
• retention of parts of the placenta in the uterine cavity.

Hypotonic and atonic bleeding can be caused by a combination of several of these reasons. Then the bleeding takes on its most dangerous character.

In addition to the listed risk factors for the development of hypotonic bleeding, their occurrence is also preceded by a number of shortcomings in the management of pregnant women at risk both in the antenatal clinic and in the maternity hospital.

Complicating prerequisites for the development of hypotonic bleeding during childbirth should be considered:

• discoordination of labor (more than 1/4 of observations);
• weakness of labor (up to 1/5 of observations);
• factors leading to hyperextension of the uterus (large fetus, polyhydramnios, multiple pregnancy) - up to 1/3 of observations;
• high traumatism of the birth canal (up to 90% of observations).

The opinion that death due to obstetric hemorrhage is unpreventable is deeply erroneous. In each specific case, a number of preventable tactical errors associated with insufficient observation and untimely and inadequate therapy are noted. The main errors leading to the death of patients from hypotonic bleeding are the following:

• incomplete examination;
• underestimation of the patient's condition;
• inadequate intensive care;
• delayed and inadequate replacement of blood loss;
• loss of time when using ineffective conservative methods of stopping bleeding (often repeatedly), and as a result - a late operation - removal of the uterus;
• violation of surgical technique (long operation, injury to neighboring organs).

Pathogenesis (what happens?) during Bleeding in the afterbirth and early postpartum periods:

Hypotonic or atonic bleeding, as a rule, develops in the presence of certain morphological changes in the uterus that precede this complication.

In histological examination of preparations of uteruses removed due to hypotonic bleeding, almost all observations show signs of acute anemia after massive blood loss, which are characterized by pallor and dullness of the myometrium, the presence of sharply dilated gaping blood vessels, the absence of blood cells in them or the presence of leukocyte accumulations due to blood redistribution.

A significant number of specimens (47.7%) revealed pathological ingrowth of chorionic villi. At the same time, chorionic villi covered with syncytial epithelium and single cells of chorionic epithelium were found among the muscle fibers. In response to the introduction of elements of the chorion, foreign to muscle tissue, lymphocytic infiltration occurs in the connective tissue layer.

The results of morphological studies indicate that in a large number of cases, uterine hypotension is functional in nature, and bleeding was preventable. However, as a result of traumatic labor management, prolonged labor stimulation, repeated

manual entry into the postpartum uterus, intensive massage of the “uterus on a fist”, a large number of red blood cells with elements of hemorrhagic impregnation, multiple microtears of the uterine wall are observed among the muscle fibers, which reduces the contractility of the myometrium.

Chorioamnionitis or endomyometritis during childbirth, found in 1/3 of cases, have an extremely adverse effect on the contractility of the uterus. Among the irregularly located layers of muscle fibers in the edematous connective tissue, abundant lympholeukocyte infiltration is noted.

Characteristic changes are also edematous swelling of muscle fibers and edematous loosening of the interstitial tissue. The persistence of these changes indicates their role in the deterioration of uterine contractility. These changes are most often a consequence of obstetric and gynecological diseases in the anamnesis, somatic diseases, gestosis, leading to the development of hypotonic bleeding.

Consequently, often defective contractile function of the uterus is caused by morphological disorders of the myometrium, which arose as a result of inflammatory processes and the pathological course of this pregnancy.

And only in isolated cases does hypotonic bleeding develop as a result of organic diseases of the uterus - multiple fibroids, extensive endometriosis.

Symptoms of Bleeding in the afterbirth and early postpartum periods:

Bleeding in the afterbirth period

Hypotony of the uterus often begins already in the afterbirth period, which at the same time has a longer course. Most often, in the first 10-15 minutes after the birth of the fetus, no intense contractions of the uterus are observed. On external examination, the uterus is flabby. Its upper border is at the level of the navel or significantly higher. It should be emphasized that sluggish and weak contractions of the uterus with its hypotension do not create the proper conditions for retraction of muscle fibers and rapid separation of the placenta.

Bleeding during this period occurs if partial or complete separation of the placenta has occurred. However, it is usually not permanent. Blood is released in small portions, often with clots. When the placenta separates, the first portions of blood accumulate in the uterine cavity and vagina, forming clots that are not released due to the weak contractile activity of the uterus. Such accumulation of blood in the uterus and vagina can often create a false impression that there is no bleeding, as a result of which appropriate therapeutic measures may be started late.

In some cases, bleeding in the afterbirth period may be due to retention of the separated placenta due to incarceration of part of it in the uterine horn or cervical spasm.

Cervical spasm occurs due to a pathological reaction of the sympathetic part of the pelvic nerve plexus in response to injury to the birth canal. The presence of the placenta in the uterine cavity with normal excitability of its neuromuscular system leads to increased contractions, and if there is an obstacle to the release of the placenta due to spasm of the cervix, bleeding occurs. Removing cervical spasm is possible by using antispasmodic drugs followed by release of the placenta. Otherwise, under anesthesia, manual removal of the placenta with inspection of the postpartum uterus should be performed.

Disturbances in the discharge of the placenta are most often caused by unreasonable and rough manipulations of the uterus during a premature attempt to discharge the placenta or after the administration of large doses of uterotonic drugs.

Bleeding due to pathological attachment of the placenta

The decidua is a functional layer of the endometrium that changes during pregnancy and in turn consists of the basal (located under the implanted fertilized egg), capsular (covers the fertilized egg) and parietal (the rest of the decidua lining the uterine cavity) sections.

In the basal decidua there are compact and spongy layers. The basal lamina of the placenta is formed from the compact layer located closer to the chorion and the cytotrophoblast of the villi. Individual chorionic villi (anchor villi) penetrate into the spongy layer, where they are fixed. During the physiological separation of the placenta, it is separated from the wall of the uterus at the level of the spongy layer.

Violation of the separation of the placenta is most often caused by its tight attachment or accretion, and in more rare cases, ingrowth and germination. These pathological conditions are based on a pronounced change in the structure of the spongy layer of the basal decidua or its partial or complete absence.

Pathological changes in the spongy layer can be caused by:

• previously transferred inflammatory processes in the uterus after childbirth and abortion, with specific endometrial lesions (tuberculosis, gonorrhea, etc.);
• hypotrophy or atrophy of the endometrium after surgical interventions (caesarean section, conservative myomectomy, uterine curettage, manual separation of the placenta in previous births).

It is also possible to implant the fertilized egg in areas with physiological endometrial hypotrophy (in the area of ​​the isthmus and cervix). The likelihood of pathological attachment of the placenta increases with malformations of the uterus (septum in the uterus), as well as in the presence of submucosal myomatous nodes.

Most often, there is a tight attachment of the placenta (placenta adhaerens), when the chorionic villi firmly grow together with the pathologically altered underdeveloped spongy layer of the basal decidua, which entails a violation of the separation of the placenta.

There is a partial dense attachment of the placenta (placenta adhaerens partialis), when only individual lobes have a pathological nature of attachment. Less common is complete dense attachment of the placenta (placenta adhaerens totalis) - over the entire area of ​​the placental area.

Placenta accreta is caused by the partial or complete absence of the spongy layer of the decidua due to atrophic processes in the endometrium. In this case, the chorionic villi are adjacent directly to the muscular layer or sometimes penetrate into its thickness. There are partial placenta accreta (placenta accreta partialis) and complete placenta accreta totalis.

Much less common are such serious complications as ingrowth of villi (placenta increta), when chorionic villi penetrate into the myometrium and disrupt its structure, and ingrowth (placenta percreta) of villi into the myometrium to a considerable depth, right up to the visceral peritoneum.

With these complications, the clinical picture of the process of separation of the placenta in the third stage of labor depends on the degree and nature (complete or partial) of disruption of the placenta.

With partial tight attachment of the placenta and with partial placenta accreta due to its fragmented and uneven separation, bleeding always occurs, which begins from the moment the normally attached areas of the placenta are separated. The degree of bleeding depends on the disruption of the contractile function of the uterus at the placenta attachment site, since part of the myometrium in the projection of the unseparated parts of the placenta and in nearby areas of the uterus does not contract to the proper extent, as required to stop bleeding. The degree of contraction weakening varies widely, which determines the clinical picture of bleeding.

The contractile activity of the uterus outside the placenta insertion usually remains at a sufficient level, as a result of which bleeding for a relatively long time may be insignificant. In some women in labor, a violation of myometrial contraction can spread to the entire uterus, causing hypo- or atony.

With complete tight attachment of the placenta and complete accretion of the placenta and the absence of its forced separation from the uterine wall, bleeding does not occur, since the integrity of the intervillous space is not violated.

Differential diagnosis of various pathological forms of placenta attachment is possible only during its manual separation. In addition, these pathological conditions should be differentiated from the normal attachment of the placenta in the tubal angle of the bicornuate and double uterus.

If the placenta is tightly attached, as a rule, it is always possible to completely separate and remove all parts of the placenta by hand and stop the bleeding.

In the case of placenta accreta, heavy bleeding occurs when attempting to manually separate it. The placenta comes off in pieces and is not completely separated from the wall of the uterus; some of the placenta lobes remain on the wall of the uterus. Atonic bleeding, hemorrhagic shock, and disseminated intravascular coagulation syndrome develop rapidly. In this case, to stop the bleeding, only removal of the uterus is possible. A similar way out of this situation is also possible with the ingrowth and growth of villi into the thickness of the myometrium.

Bleeding due to retention of parts of the placenta in the uterine cavity

In one option, postpartum bleeding, which usually begins immediately after the discharge of the placenta, may be due to the retention of its parts in the uterine cavity. These may be lobules of the placenta, parts of the membrane that prevent normal contractions of the uterus. The reason for the retention of parts of the placenta is most often partial placenta accreta, as well as improper management of the third stage of labor. Upon careful examination of the placenta after birth, most often, without much difficulty, a defect in the tissues of the placenta, membranes, and the presence of ruptured vessels located along the edge of the placenta are revealed. Identification of such defects or even doubt about the integrity of the placenta serves as an indication for an urgent manual examination of the postpartum uterus with removal of its contents. This operation is performed even if there is no bleeding when a defect in the placenta is detected, since it will certainly appear later.

It is unacceptable to perform curettage of the uterine cavity; this operation is very traumatic and disrupts the processes of thrombus formation in the vessels of the placental area.

Hypo- and atonic bleeding in the early postpartum period

In most cases, in the early postpartum period, bleeding begins as hypotonic, and only subsequently does uterine atony develop.

One of the clinical criteria for distinguishing atonic bleeding from hypotonic is the effectiveness of measures aimed at enhancing the contractile activity of the myometrium, or the lack of effect from their use. However, such a criterion does not always make it possible to clarify the degree of impairment of uterine contractile activity, since the ineffectiveness of conservative treatment may be due to severe impairment of hemocoagulation, which becomes the leading factor in a number of cases.

Hypotonic bleeding in the early postpartum period is often a consequence of ongoing uterine hypotension observed in the third stage of labor.

It is possible to distinguish two clinical variants of uterine hypotension in the early postpartum period.

Option 1:

• bleeding is profuse from the very beginning, accompanied by massive blood loss;
• the uterus is flabby, reacts sluggishly to the introduction of uterotonic drugs and manipulations aimed at increasing the contractility of the uterus;
• Hypovolemia progresses rapidly;
• hemorrhagic shock and disseminated intravascular coagulation syndrome develop;
• changes in the vital organs of the postpartum woman become irreversible.

Option 2:

• initial blood loss is small;
• there are repeated bleedings (blood is released in portions of 150-250 ml), which alternate with episodes of temporary restoration of uterine tone with cessation or weakening of bleeding in response to conservative treatment;
• temporary adaptation of the mother to developing hypovolemia occurs: blood pressure remains within normal values, there is some pallor of the skin and slight tachycardia. So, with large blood loss (1000 ml or more) within long term the symptoms of acute anemia are less pronounced, and a woman copes with this condition better than with rapid blood loss in the same or even less quantity, when collapse and death can occur faster.

It should be emphasized that the patient’s condition depends not only on the intensity and duration of bleeding, but also on the general initial condition. If the strength of a postpartum woman’s body is depleted, and the body’s reactivity is reduced, then even a slight excess of the physiological norm of blood loss can cause a severe clinical picture if there was already a decrease in blood volume initially (anemia, gestosis, diseases of cardio-vascular system, lipid metabolism disorder).

With insufficient treatment in the initial period of uterine hypotension, disturbances in its contractile activity progress, and the response to therapeutic measures weakens. At the same time, the volume and intensity of blood loss increases. At a certain stage, the bleeding increases significantly, the condition of the woman in labor worsens, the symptoms of hemorrhagic shock quickly increase and disseminated intravascular coagulation syndrome develops, soon reaching the hypocoagulation phase.

The indicators of the hemocoagulation system change accordingly, indicating a pronounced consumption of coagulation factors:

• the number of platelets, fibrinogen concentration, and factor VIII activity decreases;
• prothrombin consumption and thrombin time increase;
• fibrinolytic activity increases;
• degradation products of fibrin and fibrinogen appear.

With minor initial hypotension and rational treatment, hypotonic bleeding can be stopped within 20-30 minutes.

With severe uterine hypotension and primary disorders in the hemocoagulation system in combination with disseminated intravascular coagulation syndrome, the duration of bleeding increases and the prognosis worsens due to the significant complexity of treatment.

With atony, the uterus is soft, flabby, with poorly defined contours. The fundus of the uterus reaches the xiphoid process. The main clinical symptom is continuous and heavy bleeding. The larger the area of ​​the placental area, the greater the blood loss during atony. Hemorrhagic shock develops very quickly, the complications of which (multiple organ failure) are the cause of death.

A postmortem examination reveals acute anemia, hemorrhages under the endocardium, sometimes significant hemorrhages in the pelvic area, edema, congestion and atelectasis of the lungs, dystrophic and necrobiotic changes in the liver and kidneys.

Differential diagnosis of bleeding due to uterine hypotension should be carried out with traumatic injuries to the tissues of the birth canal. In the latter case, bleeding (of varying intensity) will be observed with a dense, well-contracted uterus. Existing damage to the tissues of the birth canal is identified during examination with the help of speculum and eliminated accordingly with adequate pain relief.

Treatment of Bleeding in the afterbirth and early postpartum periods:

Management of the succession period during bleeding

• You should adhere to expectant-active tactics for managing the afterbirth period.
• The physiological duration of the afterbirth period should not exceed 20-30 minutes. After this time, the probability of spontaneous separation of the placenta decreases to 2-3%, and the possibility of bleeding increases sharply.
• At the moment of eruption of the head, the woman in labor is administered intravenously 1 ml of methylergometrine per 20 ml of 40% glucose solution.
• Intravenous administration of methylergometrine causes long-term (for 2-3 hours) normotonic contractions of the uterus. In modern obstetrics, methylergometrine is the drug of choice for drug prophylaxis during childbirth. The time of its administration should coincide with the moment of uterine emptying. Intramuscular administration of methylergometrine to prevent and stop bleeding does not make sense due to the loss of the time factor, since the drug begins to be absorbed only after 10-20 minutes.
• Bladder catheterization is performed. In this case, there is often increased contraction of the uterus, accompanied by separation of the placenta and discharge of the placenta.
• Intravenous drip administration of 0.5 ml of methylergometrine along with 2.5 units of oxytocin in 400 ml of 5% glucose solution is started.
• At the same time, infusion therapy is started to adequately replenish pathological blood loss.
• Determine the signs of placenta separation.
• When signs of placental separation appear, the placenta is isolated using one of the known methods (Abuladze, Crede-Lazarevich).

Repeated and repeated use of external methods for releasing the placenta is unacceptable, as this leads to a pronounced disruption of the contractile function of the uterus and the development of hypotonic bleeding in the early postpartum period. In addition, with weakness of the ligamentous apparatus of the uterus and its other anatomical changes, the rough use of such techniques can lead to inversion of the uterus, accompanied by severe shock.

• If there are no signs of separation of the placenta after 15-20 minutes with the introduction of uterotonic drugs or if there is no effect from the use of external methods for releasing the placenta, it is necessary to manually separate the placenta and release the placenta. The appearance of bleeding in the absence of signs of placental separation is an indication for this procedure, regardless of the time elapsed after the birth of the fetus.
• After separation of the placenta and removal of the placenta, the internal walls of the uterus are examined to exclude additional lobules, remnants of placental tissue and membranes. At the same time, parietal blood clots are removed. Manual separation of the placenta and discharge of the placenta, even if not accompanied by large blood loss (average blood loss 400-500 ml), lead to a decrease in blood volume by an average of 15-20%.
• If signs of placenta accreta are detected, attempts to manually separate it should be stopped immediately. The only treatment for this pathology is hysterectomy.
• If the tone of the uterus is not restored after the manipulation, additional uterotonic agents are administered. After the uterus contracts, the hand is removed from the uterine cavity.
• IN postoperative period monitor the state of uterine tone and continue administering uterotonic drugs.

Treatment of hypotonic bleeding in the early postpartum period

The main feature that determines the outcome of labor during postpartum hypotonic hemorrhage is the volume of blood lost. Among all patients with hypotonic bleeding, the volume of blood loss is mainly distributed as follows. Most often it ranges from 400 to 600 ml (up to 50% of observations), less often - before Uzbek observations, blood loss ranges from 600 to 1500 ml, in 16-17% blood loss ranges from 1500 to 5000 ml or more.

Treatment of hypotonic bleeding is primarily aimed at restoring sufficient contractile activity of the myometrium against the background of adequate infusion-transfusion therapy. If possible, the cause of hypotonic bleeding should be determined.

The main tasks in the fight against hypotonic bleeding are:

• stop bleeding as quickly as possible;
• prevention of the development of massive blood loss;
• restoration of the BCC deficit;
• preventing blood pressure from falling below a critical level.

If hypotonic bleeding occurs in the early postpartum period, it is necessary to adhere to a strict sequence and phasing of the measures taken to stop the bleeding.

The scheme for combating uterine hypotension consists of three stages. It is designed for ongoing bleeding, and if the bleeding was stopped at a certain stage, then the effect of the scheme is limited to this stage.

First stage. If blood loss exceeds 0.5% of body weight (on average 400-600 ml), then proceed to the first stage of the fight against bleeding.

The main tasks of the first stage:

• stop bleeding without allowing more blood loss;
• provide infusion therapy adequate in time and volume;
• carry out accurate accounting of blood loss;
• do not allow a deficit of blood loss compensation of more than 500 ml.

Measures of the first stage of the fight against hypotonic bleeding

• Emptying the bladder with a catheter.
• Dosed gentle external massage of the uterus for 20-30 s every 1 min (during massage, rough manipulations leading to a massive entry of thromboplastic substances into the mother’s bloodstream should be avoided). External massage of the uterus is carried out as follows: through the anterior abdominal wall, the fundus of the uterus is covered with the palm of the right hand and circular massaging movements are performed without using force. The uterus becomes dense, blood clots that have accumulated in the uterus and prevent its contraction are removed by gently pressing on the fundus of the uterus and massage is continued until the uterus contracts completely and bleeding stops. If after the massage the uterus does not contract or contracts and then relaxes again, then proceed to further measures.
• Local hypothermia (applying an ice pack for 30-40 minutes at intervals of 20 minutes).
• Puncture/catheterization of great vessels for infusion-transfusion therapy.
• Intravenous drip administration of 0.5 ml of methyl ergometrine with 2.5 units of oxytocin in 400 ml of 5-10% glucose solution at a rate of 35-40 drops/min.
• Replenishment of blood loss in accordance with its volume and the body’s response.
• At the same time, a manual examination of the postpartum uterus is performed. After treating the external genitalia of the mother and the surgeon’s hands, under general anesthesia, with a hand inserted into the uterine cavity, the walls of the uterus are examined to exclude injury and lingering remnants of the placenta; remove blood clots, especially wall clots, which prevent uterine contractions; carry out an audit of the integrity of the walls of the uterus; a malformation of the uterus or a tumor of the uterus should be excluded (myomatous node is often the cause of bleeding).

All manipulations on the uterus must be carried out carefully. Rough interventions on the uterus (massage on the fist) significantly disrupt its contractile function, lead to extensive hemorrhages in the thickness of the myometrium and contribute to the entry of thromboplastic substances into the bloodstream, which negatively affects the hemostatic system. It is important to assess the contractile potential of the uterus.

During a manual examination, a biological test for contractility is performed, in which 1 ml of a 0.02% solution of methylergometrine is injected intravenously. If there is an effective contraction that the doctor feels with his hand, the treatment result is considered positive.

The effectiveness of manual examination of the postpartum uterus decreases significantly depending on the increase in the duration of the period of uterine hypotension and the amount of blood loss. Therefore, it is advisable to perform this operation at an early stage of hypotonic bleeding, immediately after the lack of effect from the use of uterotonic drugs has been established.

Manual examination of the postpartum uterus has another important advantage, as it allows timely detection of uterine rupture, which in some cases may be hidden by the picture of hypotonic bleeding.

• Inspection of the birth canal and suturing of all ruptures of the cervix, vaginal walls and perineum, if any. Apply a catgut transverse suture to back wall cervix close to the internal os.
• Intravenous administration of a vitamin-energy complex to increase the contractile activity of the uterus: 100-150 ml of 10% glucose solution, ascorbic acid 5% - 15.0 ml, calcium gluconate 10% - 10.0 ml, ATP 1% - 2.0 ml, cocarboxylase 200 mg.

You should not count on the effectiveness of repeated manual examination and massage of the uterus if the desired effect was not achieved the first time they were used.

To combat hypotonic bleeding, such treatment methods as applying clamps to the parametrium to compress the uterine vessels, clamping the lateral parts of the uterus, uterine tamponade, etc. are unsuitable and insufficiently substantiated. In addition, they do not belong to pathogenetically substantiated methods of treatment and do not provide reliable hemostasis, their use leads to loss of time and delayed use of truly necessary methods to stop bleeding, which contributes to increased blood loss and the severity of hemorrhagic shock.

Second phase. If the bleeding does not stop or resumes again and amounts to 1-1.8% of body weight (601-1000 ml), then you should proceed to the second stage of the fight against hypotonic bleeding.

The main tasks of the second stage:

• stop the bleeding;
• prevent greater blood loss;
• avoid a shortage of blood loss compensation;
• maintain the volume ratio of injected blood and blood substitutes;
• prevent the transition of compensated blood loss to decompensated;
• normalize the rheological properties of blood.

Measures of the second stage of the fight against hypotonic bleeding.

• 5 mg of prostin E2 or prostenon is injected into the thickness of the uterus through the anterior abdominal wall 5-6 cm above the uterine os, which promotes long-term effective contraction of the uterus.
• 5 mg of prostin F2a diluted in 400 ml of crystalloid solution is administered intravenously. It should be remembered that long-term and massive use of uterotonic agents may be ineffective if massive bleeding continues, since the hypoxic uterus (“shock uterus”) does not respond to the administered uterotonic substances due to the depletion of its receptors. In this regard, the primary measures for massive bleeding are replenishment of blood loss, elimination of hypovolemia and correction of hemostasis.
• Infusion-transfusion therapy is carried out at the rate of bleeding and in accordance with the state of compensatory reactions. Blood components that replace plasma oncotically are administered active drugs(plasma, albumin, protein), colloidal and crystalloid solutions, isotonic to blood plasma.

At this stage of the fight against bleeding, with blood loss approaching 1000 ml, you should open the operating room, prepare donors and be prepared for emergency transsection. All manipulations are carried out under adequate anesthesia.

When the bcc is restored, intravenous administration of a 40% solution of glucose, korglykon, panangin, vitamins C, B1, B6, cocarboxylase hydrochloride, ATP, and antihistamines(diphenhydramine, suprastin).

Third stage. If the bleeding has not stopped, blood loss has reached 1000-1500 ml and continues, the general condition of the postpartum mother has worsened, which manifests itself in the form of persistent tachycardia, arterial hypotension, then it is necessary to proceed to the third stage, stopping postpartum hypotonic bleeding.

Feature this stage is a surgical intervention to stop hypotonic bleeding.

The main tasks of the third stage:

• stopping bleeding by removing the uterus before hypocoagulation develops;
• prevention of a shortage of compensation for blood loss of more than 500 ml while maintaining the volume ratio of administered blood and blood substitutes;
• timely compensation of respiratory function (ventilation) and kidneys, which allows stabilizing hemodynamics.

Measures of the third stage of the fight against hypotonic bleeding:

In case of uncontrolled bleeding, the trachea is intubated, mechanical ventilation is started and transection is started under endotracheal anesthesia.

• Removal of the uterus (extirpation of the uterus with fallopian tubes) is performed against the background of intensive complex treatment with the use of adequate infusion and transfusion therapy. This volume of surgery is due to the fact that the wound surface of the cervix can be a source of intra-abdominal bleeding.
• In order to ensure surgical hemostasis in the surgical area, especially against the background of disseminated intravascular coagulation syndrome, ligation of the internal iliac arteries is performed. Then the pulse pressure in the pelvic vessels drops by 70%, which contributes to a sharp decrease in blood flow, reduces bleeding from damaged vessels and creates conditions for the fixation of blood clots. Under these conditions, hysterectomy is performed under “dry” conditions, which reduces the overall amount of blood loss and reduces the entry of thromboplastin substances into the systemic circulation.
• During surgery, the abdominal cavity should be drained.

In exsanguinated patients with decompensated blood loss, the operation is performed in 3 stages.

First stage. Laparotomy with temporary hemostasis by applying clamps to the main uterine vessels (ascending part of the uterine artery, ovarian artery, round ligament artery).

Second phase. An operational pause, when all manipulations in the abdominal cavity are stopped for 10-15 minutes to restore hemodynamic parameters (increase in blood pressure to a safe level).

Third stage. Radical stopping of bleeding - extirpation of the uterus with fallopian tubes.

At this stage of the fight against blood loss, active multicomponent infusion-transfusion therapy is necessary.

Thus, the basic principles of combating hypotonic bleeding in the early postpartum period are the following:

• start all activities as early as possible;
• take into account the patient’s initial health status;
• strictly follow the sequence of measures to stop bleeding;
• all treatment measures taken must be comprehensive;
• exclude the repeated use of the same methods of combating bleeding (repeated manual entries into the uterus, repositioning of clamps, etc.);
• apply modern adequate infusion-transfusion therapy;
• use only the intravenous method of administering medications, since under the current circumstances, absorption in the body is sharply reduced;
• resolve the issue of surgical intervention in a timely manner: the operation must be carried out before the development of thrombohemorrhagic syndrome, otherwise it often no longer saves the postpartum woman from death;
• do not allow blood pressure to drop below a critical level for a long time, which can lead to irreversible changes in vital organs (cerebral cortex, kidneys, liver, heart muscle).

Ligation of the internal iliac artery

In some cases, it is not possible to stop bleeding at the incision site or pathological process, and then there is a need to ligate the main vessels supplying this area at some distance from the wound. In order to understand how to perform this manipulation, it is necessary to recall anatomical features the structure of those areas where ligation of vessels will be performed. First of all, you should focus on ligating the main vessel that supplies blood to the woman’s genitals, the internal iliac artery. The abdominal aorta at the level of the LIV vertebra is divided into two (right and left) common iliac arteries. Both common iliac arteries run from the middle outward and downward along the inner edge of the psoas major muscle. Anterior to the sacroiliac joint, the common iliac artery divides into two vessels: the thicker, external iliac artery, and the thinner, internal iliac artery. Then the internal iliac artery goes vertically downward, to the middle along the posterolateral wall of the pelvic cavity and, reaching the greater sciatic foramen, divides into anterior and posterior branches. From the anterior branch of the internal iliac artery depart: the internal pudendal artery, uterine artery, umbilical artery, inferior vesical artery, middle rectal artery, inferior gluteal artery, supplying blood to the pelvic organs. The following arteries depart from the posterior branch of the internal iliac artery: iliopsoas, lateral sacral, obturator, superior gluteal, which supply blood to the walls and muscles of the pelvis.

Ligation of the internal iliac artery is most often performed when the uterine artery is damaged during hypotonic bleeding, uterine rupture, or extended hysterectomy with appendages. To determine the location of the internal iliac artery, a promontory is used. Approximately 30 mm away from it, the boundary line is crossed by the internal iliac artery, which descends into the pelvic cavity with the ureter along the sacroiliac joint. To ligate the internal iliac artery, the posterior parietal peritoneum is dissected from the promontory downwards and outwards, then using tweezers and a grooved probe, the common iliac artery is bluntly separated and, going down it, the place of its division into the external and internal iliac arteries is found. Above this place stretches from top to bottom and from outside to inside a light cord of the ureter, which is easily recognized by its pink color, ability to contract (peristalt) when touched and make a characteristic popping sound when slipping from the fingers. The ureter is retracted medially, and the internal iliac artery is immobilized from the connective tissue membrane, ligated with a catgut or lavsan ligature, which is brought under the vessel using a blunt-tipped Deschamps needle.

The Deschamps needle should be brought in very carefully so as not to damage the accompanying internal iliac vein, passing in this place from the side and under the artery of the same name. It is advisable to apply the ligature at a distance of 15-20 mm from the site of division of the common iliac artery into two branches. It is safer if not the entire internal iliac artery is ligated, but only its anterior branch, but isolating it and placing a thread under it is technically much more difficult than ligating the main trunk. After placing the ligature under the internal iliac artery, the Deschamps needle is pulled back and the thread is tied.

After this, the doctor present at the operation checks the pulsation of the arteries for lower limbs. If there is pulsation, then the internal iliac artery is compressed and a second knot can be tied; if there is no pulsation, then the external iliac artery is ligated, so the first knot must be untied and the internal iliac artery again looked for.

The continuation of bleeding after ligation of the iliac artery is due to the functioning of three pairs of anastomoses:

• between the iliopsoas arteries, arising from the posterior trunk of the internal iliac artery, and the lumbar arteries, branching from the abdominal aorta;
• between the lateral and median sacral arteries (the first arises from the posterior trunk of the internal iliac artery, and the second is an unpaired branch of the abdominal aorta);
• between the middle rectal artery, which is a branch of the internal iliac artery, and the superior rectal artery, which arises from the inferior mesenteric artery.

With proper ligation of the internal iliac artery, the first two pairs of anastomoses function, providing sufficient blood supply to the uterus. The third pair is connected only in case of inadequately low ligation of the internal iliac artery. Strict bilaterality of anastomoses allows for unilateral ligation of the internal iliac artery in case of uterine rupture and damage to its vessels on one side. A. T. Bunin and A. L. Gorbunov (1990) believe that when the internal iliac artery is ligated, blood enters its lumen through the anastomoses of the iliopsoas and lateral sacral arteries, in which the blood flow takes the opposite direction. After ligation of the internal iliac artery, anastomoses immediately begin to function, but the blood passing through small vessels loses its arterial rheological properties and its characteristics approach venous. In the postoperative period, the anastomotic system ensures adequate blood supply to the uterus, sufficient for the normal development of subsequent pregnancy.

Prevention of bleeding in the afterbirth and early postpartum periods:

Timely and adequate treatment of inflammatory diseases and complications after surgical gynecological interventions.

Rational management of pregnancy, prevention and treatment of complications that arise. When registering a pregnant woman at the antenatal clinic, it is necessary to identify a high-risk group for the possibility of bleeding.

A full examination should be carried out using modern instrumental (ultrasound, Doppler, echographic functional assessment of the state of the fetoplacental system, CTG) and laboratory research methods, as well as consult pregnant women with related specialists.

During pregnancy, it is necessary to strive to maintain the physiological course of the gestational process.

Women at risk for bleeding preventive actions in an outpatient setting consist of organizing a rational regime of rest and nutrition, conducting health procedures aimed at increasing the neuropsychic and physical stability of the body. All this contributes to a favorable course of pregnancy, childbirth and the postpartum period. The method of physiopsychoprophylactic preparation of a woman for childbirth should not be neglected.

Throughout pregnancy, careful monitoring of the nature of its course is carried out, and possible violations are promptly identified and eliminated.

All pregnant women at risk for the development of postpartum hemorrhage, in order to carry out the final stage of comprehensive prenatal preparation, 2-3 weeks before birth, must be hospitalized in a hospital, where a clear plan for the management of labor is developed and appropriate pre-examination of the pregnant woman is carried out.

During the examination, the condition of the fetoplacental complex is assessed. Using ultrasound, the functional state of the fetus is studied, the location of the placenta, its structure and size are determined. On the eve of delivery, an assessment of the state of the patient’s hemostatic system deserves serious attention. Blood components for possible transfusion should also be prepared in advance, using autodonation methods. In the hospital, it is necessary to select a group of pregnant women to perform a caesarean section as planned.

To prepare the body for childbirth, prevent labor anomalies and prevent increased blood loss closer to the expected date of birth, it is necessary to prepare the body for childbirth, including with the help of prostaglandin E2 preparations.

Qualified management of childbirth with a reliable assessment of the obstetric situation, optimal regulation of labor, adequate pain relief (prolonged pain depletes the body's reserve forces and disrupts the contractile function of the uterus).

All deliveries should be carried out under cardiac monitoring.

During the process of vaginal delivery, it is necessary to monitor:

• the nature of contractile activity of the uterus;
• correspondence between the sizes of the presenting part of the fetus and the mother’s pelvis;
• advancement of the presenting part of the fetus in accordance with the planes of the pelvis in various phases of labor;
• condition of the fetus.

If anomalies of labor occur, they should be eliminated in a timely manner, and if there is no effect, the issue should be resolved in favor of operative delivery according to appropriate indications on an emergency basis.

All uterotonic drugs must be prescribed strictly differentiated and according to indications. In this case, the patient must be under the strict supervision of doctors and medical personnel.

Proper management of the afterbirth and postpartum periods with timely use of uterotonic drugs, including methylergometrine and oxytocin.

At the end of the second stage of labor, 1.0 ml of methylergometrine is administered intravenously.

After the baby is born, the bladder is emptied with a catheter.

Careful monitoring of the patient in the early postpartum period.

When the first signs of bleeding appear, it is necessary to strictly adhere to the stages of measures to combat bleeding. An important factor in providing effective care for massive bleeding is a clear and specific distribution of functional responsibilities among all medical personnel in the obstetric department. All obstetric institutions must have sufficient supplies of blood components and blood substitutes for adequate infusion and transfusion therapy.

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Bleeding from the genital tract in the early postpartum period (in the first 2 hours after birth of the placenta) can be caused by:

Retention of part of the placenta in the uterine cavity;

Hypotony and atony of the uterus;

Hereditary or acquired defects of hemostasis (see Disturbances of the hemostatic system in pregnant women);

Rupture of the uterus and soft tissues of the birth canal (see Maternal birth trauma).

Postpartum hemorrhage occurs in 2.5% of all births.

Retention of parts of the placenta in the uterine cavity. Bleeding that begins after the birth of the placenta often depends on the fact that part of it (lobules of the placenta, membrane) is retained in the uterus, thereby preventing its normal contraction. The reason for the retention of parts of the placenta in the uterus is most often partial placenta accreta, as well as inept management of the placenta (excessive activity). Diagnosis of retention of parts of the placenta in the uterus is not difficult. This pathology is detected immediately after the birth of the placenta, during its careful examination, when a tissue defect is determined.

If there is a defect in the tissues of the placenta, membranes, torn placenta, as well as vessels located along the edge of the placenta and torn off at the point of their transition to the membranes (the possibility of having a detached additional lobule lingering in the uterine cavity), or even if there is doubt about the integrity of the placenta, it is necessary to urgently perform manually examine the uterus and remove its contents. This operation for defects in the placenta is also performed in the absence of bleeding, since the presence of parts of the placenta in the uterus eventually leads to bleeding, as well as infection, sooner or later.

Hypotony and atony of the uterus. The most common causes of bleeding in the early postpartum period are hypotension and atony of the uterus, in which postpartum hemostasis is disrupted and constriction of ruptured vessels in the placental area does not occur. Hypotonia of the uterus is understood as a condition in which there is a significant decrease in its tone and a decrease in contractility; the muscles of the uterus react to various stimuli, but the degree of these reactions is inadequate to the strength of the irritation. Hypotension is a reversible condition (Fig. 22.7).

Rice. 22.7.

The uterine cavity is filled with blood.

With atony, the myometrium completely loses its tone and contractility. The muscles of the uterus do not respond to stimuli. A kind of “paralysis” of the uterus occurs. Uterine atony is extremely rare, but it can be a source of massive bleeding.

Hypotonia and atony of the uterus are predisposed by excessively young or old age of women in labor, neuroendocrine insufficiency, uterine malformations, fibroids, dystrophic changes in muscles (previous inflammatory processes, the presence of scar tissue, a large number of previous births and abortions); hyperextension of the uterus during pregnancy and childbirth (multiple pregnancy, polyhydramnios, large fetus); rapid or prolonged labor with weak labor and prolonged activation by oxytocin; the presence of an extensive placental area, especially in the lower segment. When several of the above reasons are combined, severe uterine hypotension and bleeding are observed.

Severe forms of uterine hypotension and massive bleeding are usually combined with hemostasis disorders occurring as disseminated intravascular coagulation (DIC syndrome). In this regard, a special place is occupied by bleeding that appears after shock of various etiologies (toxic, painful, anaphylactic), collapse associated with compression syndrome of the inferior pudendal vein, or against the background of acid aspiration syndrome (Mendelssohn syndrome), with amniotic fluid embolism. The cause of uterine hypotension in these pathological conditions is the blockade of contractile proteins of the uterus by fibrin degradation products (fibrinogen) or amniotic fluid (more often embolism is associated with the penetration of a small amount of amniotic fluid, the thromboplastin of which triggers the mechanism of DIC).

Massive bleeding after childbirth can be a manifestation of multiple organ failure syndrome, observed with gestosis and extragenital pathology. At the same time, against the background of microcirculatory insufficiency, ischemic and dystrophic changes and hemorrhages develop in the muscles of the uterus, characterizing the development of shock uterine syndrome. There is a relationship between the severity of a woman’s general condition and the depth of damage to the uterus.

Measures to stop bleeding in case of impaired contractility of the uterus

All measures to stop bleeding are carried out against the background of infusion-transfusion therapy in the following sequence.

1. Emptying the bladder with a catheter.

2. If blood loss exceeds 350 ml, an external massage of the uterus is performed through the anterior abdominal wall. Putting your hand on the bottom of the uterus, begin to make light massaging movements. As soon as the uterus becomes dense, using the Crede-Lazarevich technique, the accumulated clots are squeezed out of it. At the same time, uterotonic drugs (oxytocin, methylergometrine) are administered. The domestic drug oraxoprostol has proven itself well. An ice pack is placed on the lower abdomen.

3. If bleeding continues and blood loss exceeds 400 ml or if the bleeding rate is high, it is necessary to perform a manual examination of the uterus under anesthesia, during which its contents (membranes, blood clots) are removed, after which an external-internal massage of the uterus is performed on the fist (Fig. 22.8). The hand located in the uterus is clenched into a fist; on a fist, as on a stand, with the outer hand through the anterior abdominal wall, successively massage different parts of the uterine wall, while at the same time pressing the uterus to the pubic symphysis. Simultaneously with manual examination of the uterus, oxytocin (5 units in 250 ml of 5% glucose solution) with prostaglandins is administered intravenously. After the uterus contracts, the hand is removed from the uterus. Subsequently, the tone of the uterus is checked and drugs that contract the uterus are administered intravenously.

4. If bleeding continues, the volume of which is 1000-1200 ml, the issue of surgical treatment and removal of the uterus. You cannot rely on repeated administration of oxytocin, manual examination and uterine massage if they were not effective the first time. Losing time when repeating these methods leads to increased blood loss and deterioration of the mother's condition: the bleeding becomes massive, hemostasis is disrupted, hemorrhagic shock develops and the prognosis for the patient becomes unfavorable.

In the process of preparing for surgery, a number of measures are used to prevent blood flow to the uterus and cause ischemia, thereby increasing uterine contractions. This is achieved by pressing the abdominal aorta to the spine through the anterior abdominal wall (Fig. 22.9). To enhance uterine contractions, you can apply clamps to the cervix according to Baksheev. For this purpose, the cervix is ​​exposed with mirrors. 3-4 abortionists are placed on its sides. In this case, one branch of the clamp is placed on the inner surface of the neck, the second - on the outer surface. By pulling the handles of the clamps, the uterus is moved down. A reflex effect on the cervix and possible compression of the descending branches of the uterine arteries help reduce blood loss. If the bleeding stops, the abortion collets are gradually removed. Surgery in case of uterine hypotension, it should be carried out against the background of intensive complex therapy, infusion-transfusion therapy using modern anesthesia, and artificial ventilation. If the operation is performed quickly with blood loss not exceeding 1300-1500 ml, and complex therapy made it possible to stabilize the functions of vital systems, we can limit ourselves to supravaginal amputation of the uterus. If bleeding continues with a clear violation of hemostasis, development of disseminated intravascular coagulation syndrome and hemorrhagic shock, hysterectomy is indicated. During the operation (extirpation or amputation), the abdominal cavity should be drained; after extirpation, the vagina is additionally left unsutured. Ligation of the vessels of the uterus as an independent surgical method of stopping bleeding has not become widespread. After extirpation of the uterus against the background of a developed picture of disseminated intravascular coagulation syndrome, bleeding from the vaginal stump is possible. In this situation, it is necessary to ligate the internal iliac arteries. The method of stopping bleeding by embolization of the uterine vessels seems promising.

Clinical picture. The main symptom of uterine hypotension is bleeding. Blood is released in clots of various sizes or flows out in a stream. Bleeding may have a wave-like character: it stops, then resumes again. Subsequent contractions are rare and short. Upon examination, the uterus is flabby, large in size, its upper border reaches the navel and above. When performing an external massage of the uterus, blood clots are released from it, after which the tone of the uterus can be restored, but then hypotension is possible again.

With atony, the uterus is soft, doughy, its contours are not defined. The uterus seems to spread across the abdominal cavity. Its bottom reaches the xiphoid process. Continuous and heavy bleeding occurs. If timely assistance is not provided, the clinical picture of hemorrhagic shock quickly develops. Pallor of the skin, tachycardia, hypotension, and coldness of the extremities appear. The amount of blood lost by a postpartum woman does not always correspond to the severity of the disease. The clinical picture largely depends on the initial condition of the postpartum woman and the rate of bleeding. With rapid blood loss, hemorrhagic shock can develop in a matter of minutes.

Diagnostics. Taking into account the nature of the bleeding and the condition of the uterus, diagnosing uterine hypotension is not difficult. At first, the blood is released with clots, but subsequently it loses its ability to clot. The degree of impairment of uterine contractility can be clarified by inserting a hand into its cavity during a manual examination. With normal motor function of the uterus, the force of uterine contractions is clearly felt by a hand inserted into its cavity. With atony there are no contractions, the uterus does not respond to mechanical stimulation, while with hypotension there are weak contractions in response to mechanical stimulation.

Differential diagnosis is usually made between uterine hypotension and traumatic injuries of the birth canal. Severe bleeding with a relaxed large uterus poorly contoured through the anterior abdominal wall indicates hypotonic bleeding; bleeding with a dense, well-contracted uterus indicates damage to the soft tissues, cervix or vagina, which are definitively diagnosed by examination using vaginal speculum. Measures to stop bleeding.

Prevention. In the postpartum period, prevention of bleeding includes the following.

1. Timely treatment of inflammatory diseases, the fight against induced abortions and miscarriages.

2. Rational management of pregnancy, prevention of gestosis and pregnancy complications, complete psychophysiological and preventive preparation for childbirth.

3. Rational management of labor: correct assessment of the obstetric situation, optimal regulation of labor, pain relief during labor and timely resolution of the issue of surgical delivery.

4. Rational management of the afterbirth period, prophylactic administration of medications that cause uterine contractions, starting from the end of the expulsion period, including the afterbirth period and the first 2 hours of the early postpartum period.

5. Increased contractility of the postpartum uterus.

Emptying the bladder after the birth of the child, ice on the lower abdomen after the birth of the placenta, periodic external massage of the uterus, careful recording of the amount of blood lost and an assessment of the general condition of the postpartum woman are mandatory.

Bleeding in the afterbirth (in the third stage of labor) and in the early postpartum periods may occur as a result of disruption of the processes of separation of the placenta and discharge of the placenta, decreased contractile activity of the myometrium (hypo- and atony of the uterus), traumatic damage to the birth canal, and disturbances in the hemocoagulation system.

Blood loss of up to 0.5% of body weight is considered physiologically acceptable during childbirth. A volume of blood loss greater than this indicator should be considered pathological, and blood loss of 1% or more is classified as massive. Critical blood loss is 30 ml per 1 kg of body weight.

Hypotonic bleeding is caused by a condition of the uterus in which there is a significant decrease in its tone and a significant decrease in contractility and excitability. With uterine hypotension, the myometrium reacts inadequately to the strength of the stimulus to mechanical, physical and medicinal influences. In this case, periods of alternating decrease and restoration of uterine tone may be observed.

Atonic bleeding is the result of a complete loss of tone, contractile function and excitability of the neuromuscular structures of the myometrium, which are in a state of paralysis. In this case, the myometrium is unable to provide sufficient postpartum hemostasis.

However, from a clinical point of view, the division of postpartum hemorrhage into hypotonic and atonic should be considered conditional, since medical tactics primarily depend not on what kind of bleeding it is, but on the massiveness of blood loss, the rate of bleeding, the effectiveness of conservative treatment, and the development of DIC syndrome.

What provokes / Causes of Bleeding in the afterbirth and early postpartum periods:

Although hypotonic bleeding always develops suddenly, it cannot be considered unexpected, since each specific clinical observation reveals certain risk factors for the development of this complication.

• Physiology of postpartum hemostasis

The hemochorionic type of placentation determines the physiological volume of blood loss after separation of the placenta in the third stage of labor. This volume of blood corresponds to the volume of the intervillous space, does not exceed 0.5% of the woman’s body weight (300-400 ml of blood) and does not negatively affect the condition of the postpartum woman.

After separation of the placenta, an extensive, richly vascularized (150-200 spiral arteries) subplacental area opens, which creates a real risk of rapid loss of a large volume of blood. Postpartum hemostasis in the uterus is ensured both by contraction of the smooth muscle elements of the myometrium and thrombus formation in the vessels of the placental site.

Intense retraction of the muscle fibers of the uterus after separation of the placenta in the postpartum period contributes to compression, twisting and retraction of the spiral arteries into the thickness of the muscle. At the same time, the process of thrombus formation begins, the development of which is facilitated by the activation of platelet and plasma coagulation factors, and the influence of the elements of the fetal egg on the hemocoagulation process.

At the beginning of thrombus formation, loose clots are loosely bound to the vessel. They easily come off and are washed out by the blood flow when uterine hypotension develops. Reliable hemostasis is achieved 2-3 hours after the formation of dense, elastic fibrin blood clots, firmly connected to the vessel wall and covering their defects, which significantly reduces the risk of bleeding in the event of decreased uterine tone. After the formation of such blood clots, the risk of bleeding decreases with a decrease in myometrial tone.

Consequently, an isolated or combined violation of the presented components of hemostasis can lead to the development of bleeding in the afterbirth and early postpartum periods.

• Disorders of postpartum hemostasis

Disturbances in the hemocoagulation system can be caused by:

• changes in hemostasis that existed before pregnancy;
• disorders of hemostasis due to complications of pregnancy and childbirth (antenatal death of the fetus and its prolonged retention in the uterus, gestosis, premature placental abruption).

Disorders of myometrial contractility, leading to hypo- and atonic bleeding, are associated with various causes and can occur both before the onset of labor and occur during childbirth.

In addition, all risk factors for the development of uterine hypotension can be divided into four groups.

• Factors determined by the characteristics of the patient’s socio-biological status (age, socio-economic status, profession, addictions and habits).
• Factors determined by the premorbid background of the pregnant woman.
• Factors determined by the peculiarities of the course and complications of this pregnancy.
• Factors associated with the characteristics of the course and complications of these births.

Consequently, the following can be considered prerequisites for a decrease in uterine tone even before the onset of labor:

• Ages 30 years and older are the most at risk for uterine hypotension, especially for primiparous women.
• The development of postpartum hemorrhage in female students is facilitated by high mental stress, emotional stress and overexertion.
• Parity of birth does not have a decisive influence on the frequency of hypotonic bleeding, since pathological blood loss in primigravidas is observed as often as in multiparous women.
• Dysfunction of the nervous system, vascular tone, endocrine balance, water-salt homeostasis (myometrial edema) due to various extragenital diseases (presence or exacerbation of inflammatory diseases; pathology of the cardiovascular, bronchopulmonary systems; kidney diseases, liver diseases, thyroid diseases, diabetes diabetes), gynecological diseases, endocrinopathies, lipid metabolism disorders, etc.
• Dystrophic, cicatricial, inflammatory changes in the myometrium, which caused the replacement of a significant part of the muscle tissue of the uterus with connective tissue, due to complications after previous births and abortions, operations on the uterus (the presence of a scar on the uterus), chronic and acute inflammatory processes, tumors of the uterus (uterine fibroids).
• Insufficiency of the neuromuscular apparatus of the uterus against the background of infantilism, abnormal development of the uterus, and ovarian hypofunction.
• Complications of this pregnancy: breech presentation of the fetus, FPN, threatened miscarriage, previa or low location of the placenta. Severe forms of late gestosis are always accompanied by hypoproteinemia, increased permeability of the vascular wall, extensive hemorrhages in tissues and internal organs. Thus, severe hypotonic bleeding in combination with gestosis is the cause of death in 36% of women in labor.
• Overdistension of the uterus due to a large fetus, multiple pregnancy, polyhydramnios.

The most common causes of dysfunction of the myometrium that arise or worsen during childbirth are the following.

Depletion of the neuromuscular apparatus of the myometrium due to:

• excessively intense labor (quick and rapid labor);
• discoordination of labor;
• protracted labor (weakness of labor);
• irrational administration of uterotonic drugs (oxytocin).

It is known that in therapeutic doses, oxytocin causes short-term, rhythmic contractions of the body and fundus of the uterus, does not have a significant effect on the tone of the lower segment of the uterus and is quickly destroyed by oxytocinase. In this regard, to maintain the contractile activity of the uterus, its long-term intravenous drip administration is required.

Long-term use of oxytocin for labor induction and labor stimulation can lead to blockade of the neuromuscular apparatus of the uterus, resulting in its atony and subsequent immunity to drugs that stimulate myometrial contractions. The risk of amniotic fluid embolism increases. The stimulating effect of oxytocin is less pronounced in multiparous women and women over 30 years of age. At the same time, hypersensitivity to oxytocin was noted in patients with diabetes mellitus and with pathology of the diencephalic region.

Surgical delivery. The frequency of hypotensive bleeding after surgical delivery is 3-5 times higher than after vaginal delivery. In this case, hypotensive bleeding after surgical delivery can be due to various reasons:

• complications and diseases that caused surgical delivery (weakness of labor, placenta previa, gestosis, somatic diseases, clinically narrow pelvis, anomalies of labor);
• stress factors in connection with the operation;
• the influence of painkillers that reduce myometrial tone.

It should be noted that operative delivery not only increases the risk of developing hypotonic bleeding, but also creates the preconditions for the occurrence of hemorrhagic shock.

Damage to the neuromuscular apparatus of the myometrium due to the entry into the vascular system of the uterus of thromboplastic substances with elements of the fertilized egg (placenta, membranes, amniotic fluid) or products of the infectious process (chorioamnionitis). In some cases, the clinical picture caused by amniotic fluid embolism, chorioamnionitis, hypoxia and other pathology may be blurred, abortive in nature and manifested primarily by hypotonic bleeding.

The use of medications during childbirth that reduce myometrial tone (painkillers, sedatives and antihypertensive drugs, tocolytics, tranquilizers). It should be noted that when prescribing these and other medications during childbirth, as a rule, their relaxing effect on myometrial tone is not always taken into account.

In the afterbirth and early postpartum period, a decrease in myometrial function under other of the above circumstances can be caused by:

• rough, forced management of the afterbirth and early postpartum period;
• dense attachment or placenta accreta;
• retention of parts of the placenta in the uterine cavity.

Hypotonic and atonic bleeding can be caused by a combination of several of these reasons. Then the bleeding takes on its most dangerous character.

In addition to the listed risk factors for the development of hypotonic bleeding, their occurrence is also preceded by a number of shortcomings in the management of pregnant women at risk both in the antenatal clinic and in the maternity hospital.

Complicating prerequisites for the development of hypotonic bleeding during childbirth should be considered:

• discoordination of labor (more than 1/4 of observations);
• weakness of labor (up to 1/5 of observations);
• factors leading to hyperextension of the uterus (large fetus, polyhydramnios, multiple pregnancy) - up to 1/3 of observations;
• high traumatism of the birth canal (up to 90% of observations).

The opinion that death due to obstetric hemorrhage is unpreventable is deeply erroneous. In each specific case, a number of preventable tactical errors associated with insufficient observation and untimely and inadequate therapy are noted. The main errors leading to the death of patients from hypotonic bleeding are the following:

• incomplete examination;
• underestimation of the patient's condition;
• inadequate intensive care;
• delayed and inadequate replacement of blood loss;
• loss of time when using ineffective conservative methods of stopping bleeding (often repeatedly), and as a result - a late operation - removal of the uterus;
• violation of surgical technique (long operation, injury to neighboring organs).

Pathogenesis (what happens?) during Bleeding in the afterbirth and early postpartum periods:

Hypotonic or atonic bleeding, as a rule, develops in the presence of certain morphological changes in the uterus that precede this complication.

In histological examination of preparations of uteruses removed due to hypotonic bleeding, almost all observations show signs of acute anemia after massive blood loss, which are characterized by pallor and dullness of the myometrium, the presence of sharply dilated gaping blood vessels, the absence of blood cells in them or the presence of leukocyte accumulations due to blood redistribution.

A significant number of specimens (47.7%) revealed pathological ingrowth of chorionic villi. At the same time, chorionic villi covered with syncytial epithelium and single cells of chorionic epithelium were found among the muscle fibers. In response to the introduction of elements of the chorion, foreign to muscle tissue, lymphocytic infiltration occurs in the connective tissue layer.

The results of morphological studies indicate that in a large number of cases, uterine hypotension is functional in nature, and bleeding was preventable. However, as a result of traumatic labor management, prolonged labor stimulation, repeated

manual entry into the postpartum uterus, intensive massage of the “uterus on a fist”, a large number of red blood cells with elements of hemorrhagic impregnation, multiple microtears of the uterine wall are observed among the muscle fibers, which reduces the contractility of the myometrium.

Chorioamnionitis or endomyometritis during childbirth, found in 1/3 of cases, have an extremely adverse effect on the contractility of the uterus. Among the irregularly located layers of muscle fibers in the edematous connective tissue, abundant lympholeukocyte infiltration is noted.

Characteristic changes are also edematous swelling of muscle fibers and edematous loosening of the interstitial tissue. The persistence of these changes indicates their role in the deterioration of uterine contractility. These changes are most often the result of a history of obstetric and gynecological diseases, somatic diseases, and gestosis, leading to the development of hypotonic bleeding.

Consequently, often defective contractile function of the uterus is caused by morphological disorders of the myometrium, which arose as a result of inflammatory processes and the pathological course of this pregnancy.

And only in isolated cases does hypotonic bleeding develop as a result of organic diseases of the uterus - multiple fibroids, extensive endometriosis.

Symptoms of Bleeding in the afterbirth and early postpartum periods:

Bleeding in the afterbirth period

Hypotony of the uterus often begins already in the afterbirth period, which at the same time has a longer course. Most often, in the first 10-15 minutes after the birth of the fetus, no intense contractions of the uterus are observed. On external examination, the uterus is flabby. Its upper border is at the level of the navel or significantly higher. It should be emphasized that sluggish and weak contractions of the uterus with its hypotension do not create the proper conditions for retraction of muscle fibers and rapid separation of the placenta.

Bleeding during this period occurs if partial or complete separation of the placenta has occurred. However, it is usually not permanent. Blood is released in small portions, often with clots. When the placenta separates, the first portions of blood accumulate in the uterine cavity and vagina, forming clots that are not released due to the weak contractile activity of the uterus. Such accumulation of blood in the uterus and vagina can often create a false impression that there is no bleeding, as a result of which appropriate therapeutic measures may be started late.

In some cases, bleeding in the afterbirth period may be due to retention of the separated placenta due to incarceration of part of it in the uterine horn or cervical spasm.

Cervical spasm occurs due to a pathological reaction of the sympathetic part of the pelvic nerve plexus in response to injury to the birth canal. The presence of the placenta in the uterine cavity with normal excitability of its neuromuscular system leads to increased contractions, and if there is an obstacle to the release of the placenta due to spasm of the cervix, bleeding occurs. Removing cervical spasm is possible by using antispasmodic drugs followed by release of the placenta. Otherwise, under anesthesia, manual removal of the placenta with inspection of the postpartum uterus should be performed.

Disturbances in the discharge of the placenta are most often caused by unreasonable and rough manipulations of the uterus during a premature attempt to discharge the placenta or after the administration of large doses of uterotonic drugs.

Bleeding due to pathological attachment of the placenta

The decidua is a functional layer of the endometrium that changes during pregnancy and in turn consists of the basal (located under the implanted fertilized egg), capsular (covers the fertilized egg) and parietal (the rest of the decidua lining the uterine cavity) sections.

In the basal decidua there are compact and spongy layers. The basal lamina of the placenta is formed from the compact layer located closer to the chorion and the cytotrophoblast of the villi. Individual chorionic villi (anchor villi) penetrate into the spongy layer, where they are fixed. During the physiological separation of the placenta, it is separated from the wall of the uterus at the level of the spongy layer.

Violation of the separation of the placenta is most often caused by its tight attachment or accretion, and in more rare cases, ingrowth and germination. These pathological conditions are based on a pronounced change in the structure of the spongy layer of the basal decidua or its partial or complete absence.

Pathological changes in the spongy layer can be caused by:

• previously suffered inflammatory processes in the uterus after childbirth and abortion, specific lesions of the endometrium (tuberculosis, gonorrhea, etc.);
• hypotrophy or atrophy of the endometrium after surgical interventions (caesarean section, conservative myomectomy, uterine curettage, manual separation of the placenta in previous births).

It is also possible to implant the fertilized egg in areas with physiological endometrial hypotrophy (in the area of ​​the isthmus and cervix). The likelihood of pathological attachment of the placenta increases with malformations of the uterus (septum in the uterus), as well as in the presence of submucosal myomatous nodes.

Most often, there is a tight attachment of the placenta (placenta adhaerens), when the chorionic villi firmly grow together with the pathologically altered underdeveloped spongy layer of the basal decidua, which entails a violation of the separation of the placenta.

There is a partial dense attachment of the placenta (placenta adhaerens partialis), when only individual lobes have a pathological nature of attachment. Less common is complete dense attachment of the placenta (placenta adhaerens totalis) - over the entire area of ​​the placental area.

Placenta accreta is caused by the partial or complete absence of the spongy layer of the decidua due to atrophic processes in the endometrium. In this case, the chorionic villi are adjacent directly to the muscular layer or sometimes penetrate into its thickness. There are partial placenta accreta (placenta accreta partialis) and complete placenta accreta totalis.

Much less common are such serious complications as ingrowth of villi (placenta increta), when chorionic villi penetrate into the myometrium and disrupt its structure, and ingrowth (placenta percreta) of villi into the myometrium to a considerable depth, right up to the visceral peritoneum.

With these complications, the clinical picture of the process of separation of the placenta in the third stage of labor depends on the degree and nature (complete or partial) of disruption of the placenta.

With partial tight attachment of the placenta and with partial placenta accreta due to its fragmented and uneven separation, bleeding always occurs, which begins from the moment the normally attached areas of the placenta are separated. The degree of bleeding depends on the disruption of the contractile function of the uterus at the placenta attachment site, since part of the myometrium in the projection of the unseparated parts of the placenta and in nearby areas of the uterus does not contract to the proper extent, as required to stop bleeding. The degree of contraction weakening varies widely, which determines the clinical picture of bleeding.

The contractile activity of the uterus outside the placenta insertion usually remains at a sufficient level, as a result of which bleeding for a relatively long time may be insignificant. In some women in labor, a violation of myometrial contraction can spread to the entire uterus, causing hypo- or atony.

With complete tight attachment of the placenta and complete accretion of the placenta and the absence of its forced separation from the uterine wall, bleeding does not occur, since the integrity of the intervillous space is not violated.

Differential diagnosis of various pathological forms of placenta attachment is possible only during its manual separation. In addition, these pathological conditions should be differentiated from the normal attachment of the placenta in the tubal angle of the bicornuate and double uterus.

If the placenta is tightly attached, as a rule, it is always possible to completely separate and remove all parts of the placenta by hand and stop the bleeding.

In the case of placenta accreta, heavy bleeding occurs when attempting to manually separate it. The placenta comes off in pieces and is not completely separated from the wall of the uterus; some of the placenta lobes remain on the wall of the uterus. Atonic bleeding, hemorrhagic shock, and disseminated intravascular coagulation syndrome develop rapidly. In this case, to stop the bleeding, only removal of the uterus is possible. A similar way out of this situation is also possible with the ingrowth and growth of villi into the thickness of the myometrium.

Bleeding due to retention of parts of the placenta in the uterine cavity

In one option, postpartum bleeding, which usually begins immediately after the discharge of the placenta, may be due to the retention of its parts in the uterine cavity. These may be lobules of the placenta, parts of the membrane that prevent normal contractions of the uterus. The reason for the retention of parts of the placenta is most often partial placenta accreta, as well as improper management of the third stage of labor. Upon careful examination of the placenta after birth, most often, without much difficulty, a defect in the tissues of the placenta, membranes, and the presence of ruptured vessels located along the edge of the placenta are revealed. Identification of such defects or even doubt about the integrity of the placenta serves as an indication for an urgent manual examination of the postpartum uterus with removal of its contents. This operation is performed even if there is no bleeding when a defect in the placenta is detected, since it will certainly appear later.

It is unacceptable to perform curettage of the uterine cavity; this operation is very traumatic and disrupts the processes of thrombus formation in the vessels of the placental area.

Hypo- and atonic bleeding in the early postpartum period

In most cases, in the early postpartum period, bleeding begins as hypotonic, and only subsequently does uterine atony develop.

One of the clinical criteria for distinguishing atonic bleeding from hypotonic is the effectiveness of measures aimed at enhancing the contractile activity of the myometrium, or the lack of effect from their use. However, such a criterion does not always make it possible to clarify the degree of impairment of uterine contractile activity, since the ineffectiveness of conservative treatment may be due to severe impairment of hemocoagulation, which becomes the leading factor in a number of cases.

Hypotonic bleeding in the early postpartum period is often a consequence of ongoing uterine hypotension observed in the third stage of labor.

It is possible to distinguish two clinical variants of uterine hypotension in the early postpartum period.

Option 1:

• bleeding is profuse from the very beginning, accompanied by massive blood loss;
• the uterus is flabby, reacts sluggishly to the introduction of uterotonic drugs and manipulations aimed at increasing the contractility of the uterus;
• Hypovolemia progresses rapidly;
• hemorrhagic shock and disseminated intravascular coagulation syndrome develop;
• changes in the vital organs of the postpartum woman become irreversible.

Option 2:

• initial blood loss is small;
• there are repeated bleedings (blood is released in portions of 150-250 ml), which alternate with episodes of temporary restoration of uterine tone with cessation or weakening of bleeding in response to conservative treatment;
• temporary adaptation of the mother to developing hypovolemia occurs: blood pressure remains within normal values, there is some pallor of the skin and slight tachycardia. Thus, with large blood loss (1000 ml or more) over a long period of time, the symptoms of acute anemia are less pronounced, and the woman copes with this condition better than with rapid blood loss in the same or even smaller quantities, when collapse and death can develop faster.

It should be emphasized that the patient’s condition depends not only on the intensity and duration of bleeding, but also on the general initial condition. If the strength of a postpartum woman’s body is depleted and the body’s reactivity is reduced, then even a slight excess of the physiological norm of blood loss can cause a severe clinical picture if there was already a decrease in blood volume initially (anemia, preeclampsia, diseases of the cardiovascular system, impaired fat metabolism).

With insufficient treatment in the initial period of uterine hypotension, disturbances in its contractile activity progress, and the response to therapeutic measures weakens. At the same time, the volume and intensity of blood loss increases. At a certain stage, the bleeding increases significantly, the condition of the woman in labor worsens, the symptoms of hemorrhagic shock quickly increase and disseminated intravascular coagulation syndrome develops, soon reaching the hypocoagulation phase.

The indicators of the hemocoagulation system change accordingly, indicating a pronounced consumption of coagulation factors:

• the number of platelets, fibrinogen concentration, and factor VIII activity decreases;
• prothrombin consumption and thrombin time increase;
• fibrinolytic activity increases;
• degradation products of fibrin and fibrinogen appear.

With minor initial hypotension and rational treatment, hypotonic bleeding can be stopped within 20-30 minutes.

With severe uterine hypotension and primary disorders in the hemocoagulation system in combination with disseminated intravascular coagulation syndrome, the duration of bleeding increases and the prognosis worsens due to the significant complexity of treatment.

With atony, the uterus is soft, flabby, with poorly defined contours. The fundus of the uterus reaches the xiphoid process. The main clinical symptom is continuous and heavy bleeding. The larger the area of ​​the placental area, the greater the blood loss during atony. Hemorrhagic shock develops very quickly, the complications of which (multiple organ failure) are the cause of death.

A postmortem examination reveals acute anemia, hemorrhages under the endocardium, sometimes significant hemorrhages in the pelvic area, edema, congestion and atelectasis of the lungs, dystrophic and necrobiotic changes in the liver and kidneys.

Differential diagnosis of bleeding due to uterine hypotension should be carried out with traumatic injuries to the tissues of the birth canal. In the latter case, bleeding (of varying intensity) will be observed with a dense, well-contracted uterus. Existing damage to the tissues of the birth canal is identified during examination with the help of speculum and eliminated accordingly with adequate pain relief.

Treatment of Bleeding in the afterbirth and early postpartum periods:

Management of the succession period during bleeding

• You should adhere to expectant-active tactics for managing the afterbirth period.
• The physiological duration of the afterbirth period should not exceed 20-30 minutes. After this time, the probability of spontaneous separation of the placenta decreases to 2-3%, and the possibility of bleeding increases sharply.
• At the moment of eruption of the head, the woman in labor is administered intravenously 1 ml of methylergometrine per 20 ml of 40% glucose solution.
• Intravenous administration of methylergometrine causes long-term (for 2-3 hours) normotonic contractions of the uterus. In modern obstetrics, methylergometrine is the drug of choice for drug prophylaxis during childbirth. The time of its administration should coincide with the moment of uterine emptying. Intramuscular administration of methylergometrine to prevent and stop bleeding does not make sense due to the loss of the time factor, since the drug begins to be absorbed only after 10-20 minutes.
• Bladder catheterization is performed. In this case, there is often increased contraction of the uterus, accompanied by separation of the placenta and discharge of the placenta.
• Intravenous drip administration of 0.5 ml of methylergometrine along with 2.5 units of oxytocin in 400 ml of 5% glucose solution is started.
• At the same time, infusion therapy is started to adequately replenish pathological blood loss.
• Determine the signs of placenta separation.
• When signs of placental separation appear, the placenta is isolated using one of the known methods (Abuladze, Crede-Lazarevich).

Repeated and repeated use of external methods for releasing the placenta is unacceptable, as this leads to a pronounced disruption of the contractile function of the uterus and the development of hypotonic bleeding in the early postpartum period. In addition, with weakness of the ligamentous apparatus of the uterus and its other anatomical changes, the rough use of such techniques can lead to inversion of the uterus, accompanied by severe shock.

• If there are no signs of separation of the placenta after 15-20 minutes with the introduction of uterotonic drugs or if there is no effect from the use of external methods for releasing the placenta, it is necessary to manually separate the placenta and release the placenta. The appearance of bleeding in the absence of signs of placental separation is an indication for this procedure, regardless of the time elapsed after the birth of the fetus.
• After separation of the placenta and removal of the placenta, the internal walls of the uterus are examined to exclude additional lobules, remnants of placental tissue and membranes. At the same time, parietal blood clots are removed. Manual separation of the placenta and discharge of the placenta, even if not accompanied by large blood loss (average blood loss 400-500 ml), lead to a decrease in blood volume by an average of 15-20%.
• If signs of placenta accreta are detected, attempts to manually separate it should be stopped immediately. The only treatment for this pathology is hysterectomy.
• If the tone of the uterus is not restored after the manipulation, additional uterotonic agents are administered. After the uterus contracts, the hand is removed from the uterine cavity.
• In the postoperative period, the state of uterine tone is monitored and the administration of uterotonic drugs is continued.

Treatment of hypotonic bleeding in the early postpartum period

The main feature that determines the outcome of labor during postpartum hypotonic hemorrhage is the volume of blood lost. Among all patients with hypotonic bleeding, the volume of blood loss is mainly distributed as follows. Most often it ranges from 400 to 600 ml (up to 50% of observations), less often - before Uzbek observations, blood loss ranges from 600 to 1500 ml, in 16-17% blood loss ranges from 1500 to 5000 ml or more.

Treatment of hypotonic bleeding is primarily aimed at restoring sufficient contractile activity of the myometrium against the background of adequate infusion-transfusion therapy. If possible, the cause of hypotonic bleeding should be determined.

The main tasks in the fight against hypotonic bleeding are:

• stop bleeding as quickly as possible;
• prevention of the development of massive blood loss;
• restoration of the BCC deficit;
• preventing blood pressure from falling below a critical level.

If hypotonic bleeding occurs in the early postpartum period, it is necessary to adhere to a strict sequence and phasing of the measures taken to stop the bleeding.

The scheme for combating uterine hypotension consists of three stages. It is designed for ongoing bleeding, and if the bleeding was stopped at a certain stage, then the effect of the scheme is limited to this stage.

First stage. If blood loss exceeds 0.5% of body weight (on average 400-600 ml), then proceed to the first stage of the fight against bleeding.

The main tasks of the first stage:

• stop bleeding without allowing more blood loss;
• provide infusion therapy adequate in time and volume;
• carry out accurate accounting of blood loss;
• do not allow a deficit of blood loss compensation of more than 500 ml.

Measures of the first stage of the fight against hypotonic bleeding

• Emptying the bladder with a catheter.
• Dosed gentle external massage of the uterus for 20-30 s every 1 min (during massage, rough manipulations leading to a massive entry of thromboplastic substances into the mother’s bloodstream should be avoided). External massage of the uterus is carried out as follows: through the anterior abdominal wall, the fundus of the uterus is covered with the palm of the right hand and circular massaging movements are performed without using force. The uterus becomes dense, blood clots that have accumulated in the uterus and prevent its contraction are removed by gently pressing on the fundus of the uterus and massage is continued until the uterus contracts completely and bleeding stops. If after the massage the uterus does not contract or contracts and then relaxes again, then proceed to further measures.
• Local hypothermia (applying an ice pack for 30-40 minutes at intervals of 20 minutes).
• Puncture/catheterization of great vessels for infusion-transfusion therapy.
• Intravenous drip administration of 0.5 ml of methyl ergometrine with 2.5 units of oxytocin in 400 ml of 5-10% glucose solution at a rate of 35-40 drops/min.
• Replenishment of blood loss in accordance with its volume and the body’s response.
• At the same time, a manual examination of the postpartum uterus is performed. After treating the external genitalia of the mother and the surgeon’s hands, under general anesthesia, with a hand inserted into the uterine cavity, the walls of the uterus are examined to exclude injury and lingering remnants of the placenta; remove blood clots, especially wall clots, which prevent uterine contractions; carry out an audit of the integrity of the walls of the uterus; a malformation of the uterus or a tumor of the uterus should be excluded (myomatous node is often the cause of bleeding).

All manipulations on the uterus must be carried out carefully. Rough interventions on the uterus (massage on the fist) significantly disrupt its contractile function, lead to extensive hemorrhages in the thickness of the myometrium and contribute to the entry of thromboplastic substances into the bloodstream, which negatively affects the hemostatic system. It is important to assess the contractile potential of the uterus.

During a manual examination, a biological test for contractility is performed, in which 1 ml of a 0.02% solution of methylergometrine is injected intravenously. If there is an effective contraction that the doctor feels with his hand, the treatment result is considered positive.

The effectiveness of manual examination of the postpartum uterus decreases significantly depending on the increase in the duration of the period of uterine hypotension and the amount of blood loss. Therefore, it is advisable to perform this operation at an early stage of hypotonic bleeding, immediately after the lack of effect from the use of uterotonic drugs has been established.

Manual examination of the postpartum uterus has another important advantage, as it allows timely detection of uterine rupture, which in some cases may be hidden by the picture of hypotonic bleeding.

• Inspection of the birth canal and suturing of all ruptures of the cervix, vaginal walls and perineum, if any. A catgut transverse suture is applied to the posterior wall of the cervix close to the internal os.
• Intravenous administration of a vitamin-energy complex to increase the contractile activity of the uterus: 100-150 ml of 10% glucose solution, ascorbic acid 5% - 15.0 ml, calcium gluconate 10% - 10.0 ml, ATP 1% - 2.0 ml, cocarboxylase 200 mg.

You should not count on the effectiveness of repeated manual examination and massage of the uterus if the desired effect was not achieved the first time they were used.

To combat hypotonic bleeding, such treatment methods as applying clamps to the parametrium to compress the uterine vessels, clamping the lateral parts of the uterus, uterine tamponade, etc. are unsuitable and insufficiently substantiated. In addition, they do not belong to pathogenetically substantiated methods of treatment and do not provide reliable hemostasis, their use leads to loss of time and delayed use of truly necessary methods to stop bleeding, which contributes to increased blood loss and the severity of hemorrhagic shock.

Second phase. If the bleeding does not stop or resumes again and amounts to 1-1.8% of body weight (601-1000 ml), then you should proceed to the second stage of the fight against hypotonic bleeding.

The main tasks of the second stage:

• stop the bleeding;
• prevent greater blood loss;
• avoid a shortage of blood loss compensation;
• maintain the volume ratio of injected blood and blood substitutes;
• prevent the transition of compensated blood loss to decompensated;
• normalize the rheological properties of blood.

Measures of the second stage of the fight against hypotonic bleeding.

• 5 mg of prostin E2 or prostenon is injected into the thickness of the uterus through the anterior abdominal wall 5-6 cm above the uterine os, which promotes long-term effective contraction of the uterus.
• 5 mg of prostin F2a diluted in 400 ml of crystalloid solution is administered intravenously. It should be remembered that long-term and massive use of uterotonic agents may be ineffective if massive bleeding continues, since the hypoxic uterus (“shock uterus”) does not respond to the administered uterotonic substances due to the depletion of its receptors. In this regard, the primary measures for massive bleeding are replenishment of blood loss, elimination of hypovolemia and correction of hemostasis.
• Infusion-transfusion therapy is carried out at the rate of bleeding and in accordance with the state of compensatory reactions. Blood components, plasma-substituting oncotically active drugs (plasma, albumin, protein), colloid and crystalloid solutions isotonic to blood plasma are administered.

At this stage of the fight against bleeding, with blood loss approaching 1000 ml, you should open the operating room, prepare donors and be prepared for emergency transsection. All manipulations are carried out under adequate anesthesia.

When the bcc is restored, intravenous administration of a 40% solution of glucose, corglycon, panangin, vitamins C, B1, B6, cocarboxylase hydrochloride, ATP, as well as antihistamines (diphenhydramine, suprastin) is indicated.

Third stage. If the bleeding has not stopped, blood loss has reached 1000-1500 ml and continues, the general condition of the postpartum mother has worsened, which manifests itself in the form of persistent tachycardia, arterial hypotension, then it is necessary to proceed to the third stage, stopping postpartum hypotonic bleeding.

A feature of this stage is surgical intervention to stop hypotonic bleeding.

The main tasks of the third stage:

• stopping bleeding by removing the uterus before hypocoagulation develops;
• prevention of a shortage of compensation for blood loss of more than 500 ml while maintaining the volume ratio of administered blood and blood substitutes;
• timely compensation of respiratory function (ventilation) and kidneys, which allows stabilizing hemodynamics.

Measures of the third stage of the fight against hypotonic bleeding:

In case of uncontrolled bleeding, the trachea is intubated, mechanical ventilation is started and transection is started under endotracheal anesthesia.

• Removal of the uterus (extirpation of the uterus with fallopian tubes) is performed against the background of intensive complex treatment using adequate infusion and transfusion therapy. This volume of surgery is due to the fact that the wound surface of the cervix can be a source of intra-abdominal bleeding.
• In order to ensure surgical hemostasis in the surgical area, especially against the background of disseminated intravascular coagulation syndrome, ligation of the internal iliac arteries is performed. Then the pulse pressure in the pelvic vessels drops by 70%, which contributes to a sharp decrease in blood flow, reduces bleeding from damaged vessels and creates conditions for the fixation of blood clots. Under these conditions, hysterectomy is performed under “dry” conditions, which reduces the overall amount of blood loss and reduces the entry of thromboplastin substances into the systemic circulation.
• During surgery, the abdominal cavity should be drained.

In exsanguinated patients with decompensated blood loss, the operation is performed in 3 stages.

First stage. Laparotomy with temporary hemostasis by applying clamps to the main uterine vessels (ascending part of the uterine artery, ovarian artery, round ligament artery).

Second phase. An operational pause, when all manipulations in the abdominal cavity are stopped for 10-15 minutes to restore hemodynamic parameters (increase in blood pressure to a safe level).

Third stage. Radical stopping of bleeding - extirpation of the uterus with fallopian tubes.

At this stage of the fight against blood loss, active multicomponent infusion-transfusion therapy is necessary.

Thus, the basic principles of combating hypotonic bleeding in the early postpartum period are the following:

• start all activities as early as possible;
• take into account the patient’s initial health status;
• strictly follow the sequence of measures to stop bleeding;
• all treatment measures taken must be comprehensive;
• exclude the repeated use of the same methods of combating bleeding (repeated manual entries into the uterus, repositioning of clamps, etc.);
• apply modern adequate infusion-transfusion therapy;
• use only the intravenous method of administering medications, since under the current circumstances, absorption in the body is sharply reduced;
• resolve the issue of surgical intervention in a timely manner: the operation must be carried out before the development of thrombohemorrhagic syndrome, otherwise it often no longer saves the postpartum woman from death;
• do not allow blood pressure to drop below a critical level for a long time, which can lead to irreversible changes in vital organs (cerebral cortex, kidneys, liver, heart muscle).

Ligation of the internal iliac artery

In some cases, it is not possible to stop the bleeding at the site of the incision or pathological process, and then it becomes necessary to ligate the main vessels supplying this area at some distance from the wound. In order to understand how to perform this manipulation, it is necessary to recall the anatomical features of the structure of those areas where ligation of the vessels will be performed. First of all, you should focus on ligating the main vessel that supplies blood to the woman’s genitals, the internal iliac artery. The abdominal aorta at the level of the LIV vertebra is divided into two (right and left) common iliac arteries. Both common iliac arteries run from the middle outward and downward along the inner edge of the psoas major muscle. Anterior to the sacroiliac joint, the common iliac artery divides into two vessels: the thicker, external iliac artery, and the thinner, internal iliac artery. Then the internal iliac artery goes vertically downward, to the middle along the posterolateral wall of the pelvic cavity and, reaching the greater sciatic foramen, divides into anterior and posterior branches. From the anterior branch of the internal iliac artery depart: the internal pudendal artery, uterine artery, umbilical artery, inferior vesical artery, middle rectal artery, inferior gluteal artery, supplying blood to the pelvic organs. The following arteries depart from the posterior branch of the internal iliac artery: iliopsoas, lateral sacral, obturator, superior gluteal, which supply blood to the walls and muscles of the pelvis.

Ligation of the internal iliac artery is most often performed when the uterine artery is damaged during hypotonic bleeding, uterine rupture, or extended hysterectomy with appendages. To determine the location of the internal iliac artery, a promontory is used. Approximately 30 mm away from it, the boundary line is crossed by the internal iliac artery, which descends into the pelvic cavity with the ureter along the sacroiliac joint. To ligate the internal iliac artery, the posterior parietal peritoneum is dissected from the promontory downwards and outwards, then using tweezers and a grooved probe, the common iliac artery is bluntly separated and, going down it, the place of its division into the external and internal iliac arteries is found. Above this place stretches from top to bottom and from outside to inside a light cord of the ureter, which is easily recognized by its pink color, ability to contract (peristalt) when touched and make a characteristic popping sound when slipping from the fingers. The ureter is retracted medially, and the internal iliac artery is immobilized from the connective tissue membrane, ligated with a catgut or lavsan ligature, which is brought under the vessel using a blunt-tipped Deschamps needle.

The Deschamps needle should be inserted very carefully so as not to damage the accompanying internal iliac vein with its tip, which passes in this place from the side and under the artery of the same name. It is advisable to apply the ligature at a distance of 15-20 mm from the site of division of the common iliac artery into two branches. It is safer if not the entire internal iliac artery is ligated, but only its anterior branch, but isolating it and placing a thread under it is technically much more difficult than ligating the main trunk. After placing the ligature under the internal iliac artery, the Deschamps needle is pulled back and the thread is tied.

After this, the doctor present at the operation checks the pulsation of the arteries in the lower extremities. If there is pulsation, then the internal iliac artery is compressed and a second knot can be tied; if there is no pulsation, then the external iliac artery is ligated, so the first knot must be untied and the internal iliac artery again looked for.

The continuation of bleeding after ligation of the iliac artery is due to the functioning of three pairs of anastomoses:

• between the iliopsoas arteries, arising from the posterior trunk of the internal iliac artery, and the lumbar arteries, branching from the abdominal aorta;
• between the lateral and median sacral arteries (the first arises from the posterior trunk of the internal iliac artery, and the second is an unpaired branch of the abdominal aorta);
• between the middle rectal artery, which is a branch of the internal iliac artery, and the superior rectal artery, which arises from the inferior mesenteric artery.

With proper ligation of the internal iliac artery, the first two pairs of anastomoses function, providing sufficient blood supply to the uterus. The third pair is connected only in case of inadequately low ligation of the internal iliac artery. Strict bilaterality of anastomoses allows for unilateral ligation of the internal iliac artery in case of uterine rupture and damage to its vessels on one side. A. T. Bunin and A. L. Gorbunov (1990) believe that when the internal iliac artery is ligated, blood enters its lumen through the anastomoses of the iliopsoas and lateral sacral arteries, in which the blood flow takes the opposite direction. After ligation of the internal iliac artery, anastomoses immediately begin to function, but the blood passing through small vessels loses its arterial rheological properties and its characteristics approach venous. In the postoperative period, the anastomotic system ensures adequate blood supply to the uterus, sufficient for the normal development of subsequent pregnancy.

Prevention of bleeding in the afterbirth and early postpartum periods:

Timely and adequate treatment of inflammatory diseases and complications after surgical gynecological interventions.

Rational management of pregnancy, prevention and treatment of complications that arise. When registering a pregnant woman at the antenatal clinic, it is necessary to identify a high-risk group for the possibility of bleeding.

A full examination should be carried out using modern instrumental (ultrasound, Doppler, echographic functional assessment of the state of the fetoplacental system, CTG) and laboratory research methods, as well as consult pregnant women with related specialists.

During pregnancy, it is necessary to strive to maintain the physiological course of the gestational process.

In women at risk for the development of bleeding, preventive measures in an outpatient setting include organizing a rational rest and nutrition regimen, conducting health procedures aimed at increasing the neuropsychic and physical stability of the body. All this contributes to a favorable course of pregnancy, childbirth and the postpartum period. The method of physiopsychoprophylactic preparation of a woman for childbirth should not be neglected.

Throughout pregnancy, careful monitoring of the nature of its course is carried out, and possible violations are promptly identified and eliminated.

All pregnant women at risk for the development of postpartum hemorrhage, in order to carry out the final stage of comprehensive prenatal preparation, 2-3 weeks before birth, must be hospitalized in a hospital, where a clear plan for the management of labor is developed and appropriate pre-examination of the pregnant woman is carried out.

During the examination, the condition of the fetoplacental complex is assessed. Using ultrasound, the functional state of the fetus is studied, the location of the placenta, its structure and size are determined. On the eve of delivery, an assessment of the state of the patient’s hemostatic system deserves serious attention. Blood components for possible transfusion should also be prepared in advance, using autodonation methods. In the hospital, it is necessary to select a group of pregnant women to perform a caesarean section as planned.

To prepare the body for childbirth, prevent labor anomalies and prevent increased blood loss closer to the expected date of birth, it is necessary to prepare the body for childbirth, including with the help of prostaglandin E2 preparations.

Qualified management of childbirth with a reliable assessment of the obstetric situation, optimal regulation of labor, adequate pain relief (prolonged pain depletes the body's reserve forces and disrupts the contractile function of the uterus).

All deliveries should be carried out under cardiac monitoring.

During the process of vaginal delivery, it is necessary to monitor:

• the nature of contractile activity of the uterus;
• correspondence between the sizes of the presenting part of the fetus and the mother’s pelvis;
• advancement of the presenting part of the fetus in accordance with the planes of the pelvis in various phases of labor;
• condition of the fetus.

If anomalies of labor occur, they should be eliminated in a timely manner, and if there is no effect, the issue should be resolved in favor of operative delivery according to appropriate indications on an emergency basis.

All uterotonic drugs must be prescribed strictly differentiated and according to indications. In this case, the patient must be under the strict supervision of doctors and medical personnel.

Proper management of the afterbirth and postpartum periods with timely use of uterotonic drugs, including methylergometrine and oxytocin.

At the end of the second stage of labor, 1.0 ml of methylergometrine is administered intravenously.

After the baby is born, the bladder is emptied with a catheter.

Careful monitoring of the patient in the early postpartum period.

When the first signs of bleeding appear, it is necessary to strictly adhere to the stages of measures to combat bleeding. An important factor in providing effective care for massive bleeding is a clear and specific distribution of functional responsibilities among all medical personnel in the obstetric department. All obstetric institutions must have sufficient supplies of blood components and blood substitutes for adequate infusion and transfusion therapy.

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Bleeding in the afterbirth and early postpartum period is the most dangerous complication of childbirth.

Epidemiology
The frequency of bleeding in the afterbirth period is 5-8%.

BLEEDING DURING THE FOLLOW-UP PERIOD
Causes of bleeding in the afterbirth period:
- violation of the separation of the placenta and the release of the placenta (partial tight attachment or accreta of the placenta, strangulation of the separated placenta in the uterus);

- hereditary and acquired hemostasis defects;

Violation of separation of the placenta and placenta discharge
Violation of placental separation and placenta discharge is observed when:
- pathological attachment of the placenta, tight attachment, ingrowth of chorionic villi;
- uterine hypotension;
- anomalies, structural features and attachment of the placenta to the wall of the uterus;
- strangulation of the placenta in the uterus;

Etiology and pathogenesis
Anomalies, features of the structure and attachment of the placenta to the wall of the uterus, often contribute to the disruption of separation and discharge of the placenta.

For separation of the placenta, the area of ​​contact with the surface of the uterus is important.

With a large area of ​​attachment, a relatively thin or leathery placenta (placenta membranacea), the insignificant thickness of the placenta prevents its physiological separation from the walls of the uterus. Placentas, shaped like blades, consisting of two lobes, with additional lobules, are separated from the uterine wall with difficulty, especially with uterine hypotension.

Violation of the separation of the placenta and the discharge of the placenta may be due to the placenta’s attachment site; in the lower uterine segment (with a low location and presentation), in the corner or on the side walls of the uterus, on the septum, above the myomatous node. In these places, the muscles are defective and cannot develop the force of contraction necessary to separate the placenta. Strangulation of the placenta after separation of the placenta occurs when it is retained in one of the uterine angles or in the lower segment of the uterus, which is most often observed during discoordinated contractions in the placenta.

Impaired discharge of the birth placenta can be iatrogenic if the postpartum period is not managed correctly.

An untimely attempt to release the placenta, massage of the uterus, including according to Crede-Lazarevich, pulling on the umbilical cord, and the administration of large doses of uterotonic drugs disrupt the physiological course of the third period, the correct sequence of contractions of various parts of the uterus. One of the reasons for impaired separation of the placenta and discharge of the placenta is uterine hypotension.

With uterine hypotension, afterbirth contractions are either weak or absent for a long time after the birth of the fetus. As a result, both the separation of the placenta from the uterine wall and the release of the placenta are disrupted; in this case, it is possible that the placenta may be strangulated in one of the uterine angles or the lower uterine segment of the uterus. Succession period characterized by a protracted course.

Clinical picture
The clinical picture of impaired separation of the placenta and discharge of the placenta depends on the presence of areas of separated placenta. If the placenta does not separate throughout, then the absence of signs of placental separation for a long time and the absence of bleeding are clinically determined.

More common is partial separation of the placenta, when one or another section is separated from the wall, and the rest remains attached to the uterus. In this situation, muscle contraction at the level of the separated placenta is not enough to compress the vessels and stop bleeding from the placental site. The main symptoms of partial separation of the placenta are the absence of signs of placental separation and bleeding. Bleeding occurs a few minutes after the baby is born. The blood is liquid, mixed with clots of various sizes, and flows out in spurts and unevenly. Retention of blood in the uterus and vagina often creates a false impression of the cessation or absence of bleeding, as a result of which measures aimed at stopping it may be delayed. Sometimes blood accumulates in the uterine cavity and vagina, and then is released in clots after external signs of placental separation are detected. On external examination there are no signs of separation of the placenta. The fundus of the uterus is at the level of the navel or above, deviated to the right. The general condition of the woman in labor depends on the degree of blood loss and changes quickly. In the absence of timely assistance, hemorrhagic shock occurs. The clinical picture of impaired discharge of the strangulated placenta is the same as in the case of impaired separation of the placenta from the uterine wall (also accompanied by bleeding).

Diagnostics
Complaints of bleeding of varying intensity. Laboratory tests for bleeding in the afterbirth period:
- clinical blood test (Hb, hematocrit, red blood cells);
- coagulogram;
- in case of massive blood loss, CBS, blood gases, plasma lactate level
- blood chemistry;
- electrolytes in plasma;
- Analysis of urine;

Physical examination data:
- absence of signs of placental separation (Schroeder, Küstner-Chukalov, Alfelts);
- when manually separating the placenta with physiological and tight attachment of the placenta (placenta adhaerens), strangulation, as a rule, you can remove all lobes of the placenta by hand.

With true chorionic ingrowth, it is impossible to separate the placenta from the wall without violating its integrity. Often, true placenta accreta is established only by histological examination of the uterus, which was removed due to suspected hypotension and massive bleeding in the postpartum period.

Instrumental methods. It is possible to accurately determine the type of pathological attachment with targeted ultrasound during pregnancy and manual separation of the placenta in the afterbirth period.

Birth canal injuries
Bleeding from ruptures of the soft tissues of the birth canal can be severe when blood vessels are damaged. Cervical ruptures are accompanied by bleeding when the integrity of the descending branch of the uterine artery is disrupted (with lateral cervical ruptures). With low placental attachment and pronounced vascularization of the tissues of the lower segment of the uterus, even minor injuries to the cervix can lead to massive bleeding. In case of vaginal injuries, bleeding occurs from ruptures of varicose veins, a. vaginalis or its branches. Bleeding is possible with high tears involving the fornix and base of the broad uterine ligaments, sometimes a. uterinae. When the perineum ruptures, bleeding occurs from the branches of a. pudendae. Ruptures in the clitoral area, where a network of venous vessels is developed, are also accompanied by severe bleeding.

Diagnostics
Diagnosis of bleeding from soft tissue ruptures is not difficult, with the exception of damage to the deep branches of a. vaginalis (bleeding can simulate uterine bleeding). About the gap a. vaginalis may indicate hematomas of the soft tissues of the vagina.

Differential diagnosis
In differential diagnosis, the following signs of bleeding from soft tissue ruptures are taken into account:
- bleeding occurs immediately after the birth of the child;
- despite the bleeding, the uterus is dense and well contracted;
- the blood does not have time to clot and flows out of the genital tract in a liquid stream of bright color.

Hemostasis defects
Features of bleeding with hemostasis defects are the absence of clots in the blood flowing from the genital tract. Treatment and tactics of management of pregnant women with pathology of the third stage of labor The goal of treatment is to stop bleeding, which is carried out by:
- separation of the placenta and placenta discharge;
- suturing ruptures of soft tissues of the birth canal;
- normalization of hemostasis defects.

Sequence of measures in case of retained placenta and absence of blood discharge from the genitals:
- bladder catheterization (often causes increased uterine contractions and separation of the placenta);
- puncture or catheterization of the ulnar vein, intravenous administration of crystalloids in order to adequately correct possible blood loss;
- administration of uterotonic drugs 15 minutes after expulsion of the fetus (oxytocin IV drip 5 units in 500 ml of 0.9% sodium chloride solution);
- when signs of placenta separation appear, release the placenta using one of the accepted methods (Abuladze, Crede-Lazarevich);
- in the absence of signs of placenta separation within 20-30 minutes against the background of the introduction of contracting agents, manual separation of the placenta and placenta discharge is performed. If epidural anesthesia was used during childbirth, manual separation of the placenta and release of the placenta are performed before the anesthetic wears off. If pain relief was not used during childbirth, this operation is performed against the background of intravenous painkillers (propofol). After removal of the placenta, the uterus usually contracts, tightly clasping the arm. If the tone of the uterus is not restored, additional uterotonic drugs are administered and bimanual compression of the uterus is performed by inserting the right hand into the anterior vaginal fornix;
- if true placenta accreta is suspected, the attempt at separation must be stopped to avoid massive bleeding and perforation of the uterus.

Sequence of measures for bleeding in the third stage of labor:
- catheterization of the bladder. Puncture or catheterization of the ulnar vein with the connection of intravenous infusions;
- determination of signs of placental separation (Schroeder, Küstner-Chukalov, Alfelts);
- if there are positive signs of separation of the placenta, an attempt is made to isolate the placenta according to Crede-Lazarevich, first without pain relief, then against the background of pain relief;
- if there is no effect from external methods of releasing the placenta, it is necessary to manually separate the placenta and release the placenta.

In the postoperative period, it is necessary to continue the intravenous administration of uterotonic drugs and from time to time, carefully, without excessive pressure, perform external massage of the uterus and squeeze out blood clots from it. Bleeding due to ruptures of the cervix, clitoris, perineum and vagina is stopped by immediate suturing and restoration of tissue integrity. Sutures are placed on breaks in the soft birth canal after the placenta is released. The exception is ruptures of the clitoris, the integrity of which can be restored immediately after the birth of the child. Visible bleeding from the vessels of the perineal wound after episiotomy is stopped by applying clamps, and after removing the placenta from the uterus - by suturing. If a soft tissue hematoma is detected, it is opened and sutured. If a bleeding vessel is identified, it is ligated. Hemostasis is normalized. In case of bleeding caused by impaired hemostasis, it is corrected.

Prevention
Rational management of childbirth; use of regional anesthesia. Careful and correct management of the third stage of labor. Elimination of unreasonable pulling on the umbilical cord of the uterus.

BLEEDING IN THE EARLY POSTPARTUM PERIOD
Epidemiology
The incidence of bleeding in the early postpartum period is 2.0-5.0% of the total number of births. Based on the time of occurrence, early and late postpartum hemorrhage are distinguished. Postpartum hemorrhage that occurs within 24 hours after birth is considered early or primary; after this period it is classified as late or secondary.

Bleeding within 2 hours after birth occurs for the following reasons:
- retention of parts of the placenta in the uterine cavity;
- hereditary or acquired hemostasis defects;
- hypotension and atony of the uterus;
- injuries of the soft birth canal;
- uterine inversion (see chapter on traumatism);

To determine a general understanding of the etiology of bleeding, you can use the 4T diagram:
- “tissue” - decreased uterine tone;
- “tone” - decreased tone of the uterus;
- “trauma” - ruptures of the soft birth canal and uterus;
- “blood clots” - impaired hemostasis.

Retention of parts of the placenta in the uterine cavity
The retention of parts of the placenta in the uterine cavity prevents its normal contraction and compression of the uterine vessels. The reason for the retention of parts of the placenta in the uterus may be partial tight attachment or accretion of placenta lobules. The retention of membranes is most often associated with improper management of the postpartum period, in particular, with excessive acceleration of the birth of the placenta. Retention of the membranes is also observed during intrauterine infection, when their integrity is easily damaged. It is not difficult to determine the retention of parts of the placenta in the uterus after its birth. When examining the placenta, a defect in the placental tissue, absence of membranes, and torn membranes are revealed.

The presence of parts of the placenta in the uterus can lead to infection or bleeding, both in the early and late postpartum period. Sometimes massive bleeding occurs after discharge from the maternity hospital on days 8-21 of the postpartum period (late postpartum hemorrhage). Detection of a defect in the placenta (placenta and membranes), even in the absence of bleeding, is an indication for manual examination and emptying of the uterine cavity.

Classification
Uterine hypotension is a decrease in the tone and contractility of the uterine muscles. Reversible condition. Uterine atony is a complete loss of tone and contractility. Currently, it is considered inappropriate to divide bleeding into atonic and hypotonic. The definition of “hypotonic bleeding” is accepted.

Clinical picture: main symptoms of uterine hypotension;
- bleeding;
- decreased uterine tone;
- symptoms of hemorrhagic shock.

With uterine hypotension, blood is first released with clots, usually after external massage of the uterus. The uterus is flabby, the upper border can reach the navel and above. The tone may be restored after external massage, then decrease again, bleeding resumes. In the absence of timely assistance, blood loses its ability to clot. In accordance with the amount of blood loss, symptoms of hemorrhagic shock arise (pallor of the skin, tachycardia, hypotension, etc.).

Diagnostics
Diagnosis of hypotonic bleeding is not difficult. Differential diagnosis should be made with trauma to the uterus and genital tract.

Treatment
The goal of treatment is to stop bleeding. Stopping bleeding in case of hypotension should be carried out simultaneously with measures to correct blood loss and hemostasis.

If blood loss is within 300-400 ml after confirming the integrity of the placenta, an external massage of the uterus is performed, while uterotonic drugs are administered (oxytocin 5 units in 500 ml NaCl solution 0.9%) or carbetocin 1 ml (slow IV), misoprostol (mirolut) 800-1000 mcg per rectum once. An ice pack is placed on the lower abdomen.

If blood loss exceeds 400.0 ml or if there is a placenta defect, under IV anesthesia or ongoing epidural anesthesia, a manual examination of the uterus is performed, and, if necessary, bimanual compression of the uterus. To help stop bleeding, the abdominal aorta can be pressed against the spine through the abdominal wall. This reduces blood flow to the uterus. Subsequently, the tone of the uterus is checked using external methods and uterotonics continue to be administered intravenously.

In case of bleeding of 1000-1500 ml or more, a woman’s pronounced reaction to less blood loss, embolization of the uterine vessels or laparotomy is necessary. The most optimal option at present, if conditions exist, should be considered embolization of the uterine arteries using the generally accepted method. If there are no conditions for embolization of the uterine arteries, laparotomy is performed.

As an intermediate method in preparation for surgery, a number of studies suggest intrauterine tamponade with a hemostatic balloon. The algorithm for using a hemostatic balloon is presented in the Appendix. If there is heavy uterine bleeding, you should not waste time on inserting a hemostatic balloon, but proceed to laparotomy, or, if possible, to UAE. During laparotomy, at the first stage, if there is experience or a vascular surgeon, the internal iliac arteries are ligated (the technique for ligating the internal iliac arteries is presented in the Appendix). If there are no conditions, then sutures are placed on the uterine vessels or the uterus is compressed using hemostatic sutures according to one of the methods of B-Lynch, Pereira, Hayman. Cho, V.E. Radzinsky (see appendix for technique). If the lower segment is overstretched, tightening sutures are placed on it.

The effect of suture lasts 24-48 hours. If bleeding continues, hysterectomy is performed. During laparotomy, a machine is used to reinfuse blood from the incisions and abdominal cavity. Timely implementation of organ-preserving methods allows achieving hemostasis in most cases. In conditions of ongoing bleeding and the need to proceed to radical intervention, they help reduce the intensity of bleeding and the total volume of blood loss. Implementation of organ-preserving methods to stop postpartum hemorrhage is a prerequisite. Only the lack of effect from the above measures is an indication for radical intervention - hysterectomy.

Organ-preserving methods of surgical hemostasis do not lead to the development of complications for the majority. After ligation of the internal iliac and ovarian arteries, blood flow in the uterine arteries is restored in all patients by the 4-5th day, which corresponds to physiological values.

Prevention
Patients at risk for bleeding due to uterine hypotension are given intravenous oxytocin at the end of the second stage of labor.
With hereditary and birth defects hemostasis, the labor management plan is outlined jointly with hematologists. The principle of treatment is the administration of fresh frozen plasma and glucocorticoids. Information for the patient

Patients at risk of bleeding should be warned about the possibility of bleeding during childbirth. In case of massive bleeding, hysterectomy is possible. If possible, instead of ligating blood vessels and removing the uterus, embolization of the uterine arteries is performed. It is very advisable to transfuse your own blood from the abdominal cavity. In case of ruptures of the uterus and soft birth canal, suturing is performed, and in case of hemostasis disturbance, correction is performed.

Therapy methods
During childbirth, physiological blood loss is 300-500 ml - 0.5% of body weight; for caesarean section - 750-1000 ml; for planned caesarean section with hysterectomy - 1500 ml; for emergency hysterectomy - up to 3500 ml.

Major obstetric hemorrhage is defined as a loss of more than 1000 ml of blood, or >15% of circulating blood volume, or >1.5% of body weight.

Heavy life-threatening bleeding is considered:
- loss of 100% of circulating blood volume within 24 hours, or 50% of circulating blood volume in 3 hours;
- blood loss at a rate of 15 ml/min, or 1.5 ml/kg per minute (for more than 20 minutes);
- immediate blood loss of more than 1500-2000 ml, or 25-35% of the circulating blood volume.

Determination of blood loss volume
Visual assessment is subjective. The underestimation is 30-50%. Less than average volume is overestimated, and large volume losses are underestimated. In practical activities, determining the volume of blood lost is of great importance:
- using a measuring container makes it possible to take into account the blood that has been shed, but does not allow you to measure the remaining blood in the placenta (approximately 153 ml). Inaccuracy is possible when blood is mixed with amniotic fluid and urine;
- gravimetric method - determining the difference in the mass of surgical material before and after use. Napkins, balls and diapers must be of standard size. The method is not free from errors when mixing amniotic fluid. The error of this method is within 15%.
- acid-hematine method - calculation of plasma volume using radioactive isotopes, using labeled red blood cells, is the most accurate, but is more complex and requires additional equipment.

Due to the complexity precise definition blood loss, the body's reaction to blood loss is of great importance. Taking these components into account is fundamental to determining the volume of infusion required.

Diagnostics
Due to an increase in circulating blood volume and CO, pregnant women are able to tolerate significant blood loss with minimal changes in hemodynamics until a late stage. Therefore, in addition to taking into account lost blood, indirect signs of hypovolemia are of particular importance. Pregnant women retain compensatory mechanisms for a long time, and they are able, with adequate therapy, to endure, unlike non-pregnant women, significant blood loss.

The main sign of decreased peripheral blood flow is the capillary refill test, or white spot sign. It is performed by pressing the nail bed, raising thumb or another part of the body for 3 seconds until a white color appears, indicating the cessation of capillary blood flow. After finishing pressing, the pink color should be restored in less than 2 seconds. An increase in the recovery time of the pink color of the nail bed of more than 2 seconds is noted when microcirculation is impaired.

A decrease in pulse pressure and shock index is an earlier sign of hypovolemia than systolic and diastolic blood pressure assessed separately.

Shock index is the ratio of heart rate to systolic blood pressure, which changes with blood loss of 1000 ml or more. Normal values ​​are 0.5-0.7. Decreased urine output during hypovolemia often precedes other signs of circulatory impairment. Adequate diuresis in a patient not receiving diuretics indicates sufficient blood flow in the internal organs. To measure the rate of diuresis, 30 minutes is enough:
- insufficient diuresis (oliguria) - less than 0.5 ml/kg per hour;
- reduced diuresis - 0.5-1.0 ml/kg per hour;
- normal diuresis - more than 1 ml/kg per hour.

Respiratory rate and state of consciousness should also be assessed before performing mechanical ventilation.

Intensive care of obstetric hemorrhage requires coordinated actions, which should be rapid and, if possible, simultaneous. It is carried out jointly with an anesthesiologist and resuscitator against the background of measures to stop bleeding. Intensive therapy (resuscitation) is carried out according to the ABC scheme: airways (Aigway), breathing (Breathing), blood circulation (Cigculation).

After assessing breathing, adequate oxygen supply is ensured: intranasal catheters, mask spontaneous or artificial ventilation. After assessing the patient’s breathing and starting oxygen inhalation, obstetricians - gynecologists, midwives, operating nurses, anesthesiologists-resuscitators, nurse anesthetists, an emergency laboratory, and a blood transfusion service are notified and mobilized for the upcoming joint work. If necessary, a vascular surgeon and angiography specialists are called. At the same time, reliable venous access is ensured. 14Y (315 ml/min) or 16Y (210 ml/min) peripheral catheters are used.

In case of collapsed peripheral veins, venesection or catheterization of the central vein is performed. At hemorrhagic shock or blood loss of more than 40% of the circulating blood volume, catheterization of the central vein (preferably the internal jugular vein), preferably with a multilumen catheter, is indicated, which provides additional intravenous access for infusion and allows monitoring of central hemodynamics. In conditions of blood coagulation disorders, access through the cubital vein is preferable. When installing a venous catheter, it is necessary to take a sufficient amount of blood to determine the initial parameters of the coagulogram, hemoglobin concentration, hematocrit, platelet count, and conduct compatibility tests for possible blood transfusion. Bladder catheterization should be performed and minimal monitoring of hemodynamic parameters should be provided: ECG, pulse oximetry, non-invasive blood pressure measurement. All measurements should be documented. Blood loss must be taken into account. In the intensive care of massive bleeding, infusion therapy plays a leading role.

The goal of infusion therapy is to restore:
- volume of circulating blood;
- tissue oxygenation;
- hemostasis systems;
- metabolism.

In case of an initial violation of hemostasis, therapy is aimed at eliminating the cause. During infusion therapy, the optimal combination of crystalloids and colloids, the volume of which is determined by the amount of blood loss.

The speed of administration of solutions is important. Critical pressure (60-70 mmHg) should be achieved as quickly as possible. Adequate blood pressure values ​​are achieved when I.T. >90 mmHg. In conditions of decreased peripheral blood flow and hypotension, do not invasive measurement blood pressure may be inaccurate, in these cases invasive blood pressure measurement is preferred.

Initial replacement of circulating blood volume is carried out at a rate of 3 liters for 515 minutes under the control of ECG, blood pressure, saturation, capillary refill test, CBS of blood and diuresis. Further therapy can be carried out either in discrete doses of 250500 ml over 10-20 minutes with assessment of hemodynamic parameters, or with continuous monitoring of central venous pressure. Negative values central venous pressure indicate hypovolemia, however, they are also possible with positive values ​​of central venous pressure, therefore the response to volume load, which is carried out by infusion at a rate of 1020 ml/min for 10-15 minutes, is more informative. An increase in central venous pressure of more than 5 cm of water. Art. indicates heart failure or hypervolemia; a slight increase in central venous pressure values, or its absence, indicates hypovolemia. To obtain a filling pressure sufficient to restore tissue perfusion in the left chambers of the heart, rather high values ​​of central venous pressure (10-12 cm H2O and higher) may be required.

The criterion for adequate replenishment of fluid deficiency in the circulation is central venous pressure and hourly diuresis. Until the central venous pressure reaches 12-15 cm of water. Art. and hourly urine output does not become >30 ml/h, the patient requires I.T.

Additional indicators of the adequacy of infusion therapy and tissue blood flow are:
- mixed saturation venous blood, target values ​​70% or more;
- positive test filling capillaries;
- physiological values ​​of blood CBS. Lactate clearance: it is desirable to reduce its level by 50% within 1 hour; IT. continue until lactate level is less than 2 mmol/l;
- sodium concentration in urine less than 20 mol/l, urine/blood plasma osmolarity ratio more than 2, urine osmolarity more than 500 mOsm/kg - signs of ongoing impaired renal perfusion.

During intensive care, avoid hypercapnia, hypocapnia, hypokalemia, hypocalcemia, fluid overload, and overcorrection of acidosis with sodium bicarbonate. Restoring the oxygen transport function of the blood.

Indications for blood transfusion:
- hemoglobin concentration 60-70 g/l;
- blood loss of more than 40% of the circulating blood volume;
- unstable hemodynamics.

In patients weighing 70 kg, one dose of packed red blood cells increases the hemoglobin concentration by approximately 10 g/l and the hematocrit by 3%. To determine the required number of doses of red blood cells (n) with ongoing bleeding and a hemoglobin concentration of 60-70 g/l, an approximate calculation using the formula is convenient:

N=(100x/15,

Where n is the required number of doses of red blood cells,
- hemoglobin concentration.

During blood transfusion, it is advisable to use a system with leukocyte filters, which helps reduce the likelihood of immune reactions caused by leukocyte transfusion. An alternative to red blood cell transfusion: intraoperative hardware reinfusion of blood (transfusion of red blood cells collected during surgery and washed). A relative contraindication for its use is the presence of amniotic fluid. To determine the Rh-positive blood factor in newborns, the Rh-negative mother must be administered an increased dose of human anti-Rhesus immunoglobulin Rho[D], since using this method may introduce fetal red blood cells.

Correction of hemostasis. During the treatment of a patient with bleeding, the function of the hemostatic system is most often affected by the influence of drugs for infusion, with coagulopathy of dilution, consumption, and loss. Dilution coagulopathy is clinically significant when more than 100% of the circulating blood volume is replaced and is manifested by a decrease in the content of plasma coagulation factors. In practice, dilutional coagulopathy is difficult to distinguish from disseminated intravascular coagulation syndrome. To normalize hemostasis, the following drugs are used.

Fresh frozen plasma. Indications for transfusion of fresh frozen plasma are:
- APTT >1.5 from the initial level with ongoing bleeding;
- bleeding of III-IV class (hemorrhagic shock).

The initial dose is 12-15 ml/kg, repeated doses are 5-10 ml/kg. The transfusion rate of fresh frozen plasma is at least 1000-1500 ml/h; when coagulation parameters stabilize, the rate is reduced to 300-500 ml/h. It is advisable to use fresh frozen plasma that has undergone leukoreduction. Cryoprecipitate containing fibrinogen and factor VIII is indicated as an additional agent for the treatment of hemostatic disorders with a fibrinogen content of 1 g/l.

Thromboconcentrate. The possibility of platelet transfusion is considered in the following cases:
- platelet count less than 50,000/mm3 due to bleeding;
- platelet count less than 20-30,000/mm3 without bleeding;
- with clinical manifestations of thrombocytopenia or thrombocytopathy (petechial rash). One dose of platelet concentrate increases platelet levels by approximately 5000/mm3. Usually 1 unit/10 kg (5-8 packets) is used.

Antifibrinolytics. Tranexamic acid and aprotinin inhibit plasminogen activation and plasmin activity. The indication for the use of anti-fibrinolytics is pathological primary activation of fibrinolysis. To diagnose this condition, use the euglobulin clot lysis test with activation by streptokinase or 30-minute lysis with thromboelastography.

Antithrombin III concentrate. When the activity of antithrombin III decreases to less than 70%, restoration of the anticoagulant system is indicated by transfusion of fresh frozen plasma or antithrombin III concentrate. Antithrombin III activity must be maintained within 80-100%. Recombinant activated factor VIIa was developed for the treatment of bleeding episodes in patients with hemophilia A and B. As an empirical hemostatic agent, the drug has been successfully used in a variety of conditions associated with uncontrolled severe bleeding. Due to the insufficient number of observations, the role of recombinant factor VII A in the treatment of obstetric hemorrhage has not been definitively determined. The drug can be used after standard surgical and medical means of stopping bleeding.

Conditions of use:
- Hb >70 g/l, fibrinogen >1 g/l, platelets >50,000/mm3;
- pH >7.2 (correction of acidosis);
- warming the patient (preferably, but not required).

Possible application protocol (according to Sobeszczyk and Breborowicz);
- initial dose - 40-60 mcg/kg intravenously;
- with ongoing bleeding - repeated doses of 40-60 mcg/kg 3-4 times every 15-30 minutes.
- when the dose reaches 200 mcg/kg and there is no effect, it is necessary to check the conditions for use;
- only after correction can the next dose of 100 mcg/kg be administered.

Adrenergic agonists. Used for bleeding according to the following indications:
- bleeding during regional anesthesia and sympathetic blockade;
- hypotension when installing additional intravenous lines;
- hypodynamic, hypovolemic shock.

In parallel with replenishing the volume of circulating blood, a bolus injection of 5-50 mg of ephedrine, 50-200 mcg of phenylephrine or 10-100 mcg of epinephrine is possible. It is better to titrate the effect by intravenous infusion:
- dopamine - 2-10 mcg/(kg x min) or more, dobutamine - 2-10 mcg/(kg x min), phenylfarine - 1-5 mcg/(kg x min), epinephrine - 1-8 mcg/min.

The use of these drugs increases the risk of vascular spasm and organ ischemia, but is justified in a critical situation.

Diuretics. Loop or osmotic diuretics should not be used in acute period during IT. Increased urine output caused by their use will reduce the value of monitoring urine output or volume replenishment. Moreover, stimulation of diuresis increases the likelihood of developing acute pyelonephritis. For the same reason, the use of solutions containing glucose is undesirable, since noticeable hyperglycemia can subsequently cause osmotic diuresis. Furosemide (5-10 mg IV) is indicated only to accelerate the onset of fluid mobilization from the interstitial space, which should occur approximately 24 hours after bleeding and surgery.

Maintaining temperature balance. Hypothermia impairs platelet function and reduces the rate of reactions of the blood coagulation cascade (10% for every degree Celsius decrease in body temperature). In addition, the condition of the cardiovascular system, oxygen transport (shift of the Hb-Ch dissociation curve to the left), and elimination of drugs by the liver worsen. It is essential to warm both the IV fluids and the patient. The central temperature should be kept close to 35°.

Position of the operating table. In case of blood loss, the horizontal position of the table is optimal. The reverse Trendelenburg position is dangerous due to the possibility of an orthostatic reaction and a decrease in MV, and in the Trendelenburg position, the increase in CO is short-lived and is replaced by its decrease due to an increase in afterload. Therapy after bleeding has stopped. After stopping the bleeding, I.T. continue until adequate tissue perfusion is restored.

Goals:
- maintaining systolic blood pressure more than 100 mm Hg. (with previous hypertension more than 110 mm Hg);
- maintaining the concentration of hemoglobin and hematocrit at a level sufficient for oxygen transport;
- normalization of hemostasis, electrolyte balance, body temperature (>36°);
- restoration of diuresis more than 1 ml/kg per hour;
- increase in CO;
- reverse development of acidosis, decrease in lactate concentration to normal.

Conducts prevention, diagnosis and treatment possible manifestations multiple organ failure. With further improvement of the condition to moderate, the adequacy of replenishment of circulating blood volume can be checked using an orthostatic test. The patient lies quietly for 2-3 minutes, then blood pressure and heart rate are noted. The patient is asked to stand up (the option with standing up is more accurate than with sitting down in bed). If symptoms of cerebral hypoperfusion appear, that is, dizziness or lightheadedness, the test should be stopped and the patient should be placed in bed. If there are no indicated symptoms, heart rate readings are noted 1 minute after rising. The test is considered positive when the heart rate increases to more than 30 beats/min or symptoms of cerebral perfusion are present. Due to the small variability, changes in blood pressure are not taken into account. An orthostatic test can detect a deficit in circulating blood volume of 15-20%. It is not necessary and dangerous if there is hypotension in a horizontal position and signs of shock.