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Complications during childbirth and how to deal with them. postpartum hemorrhage

It is known that both normal childbirth and postpartum period accompany bloody issues. The placenta (baby place) is attached to the uterus with the help of villi and is connected to the fetus by the umbilical cord. When it is naturally rejected during childbirth, capillaries and blood vessels rupture, which leads to blood loss. If everything is in order, then the volume of lost blood does not exceed 0.5% of body weight, i.e. for example, a woman weighing 60 kg should not have more than 300 ml of blood loss. But with deviations from the normal course of pregnancy and childbirth, bleeding that is dangerous to the health and even the life of a woman can occur, in which the volume of blood loss exceeds the permissible norms. Blood loss of 0.5% of body weight or more (more than 300–400 ml on average) is considered pathological, and 1% of body weight or more (1000 ml) is already massive.

All obstetric bleeding can be divided into two groups. The first combines bleeding that occurs in late pregnancy and in the first or second stage of labor. The second group includes those bleeding that develop in the third stage of labor (when the placenta departs) and after the baby is born.

Causes of bleeding in the first and second stages of labor

It should be remembered that the onset of labor can provoke bleeding, which is by no means the norm. The exception is streaks of blood in the mucous plug, which is released from the cervical canal a few days before childbirth or with the onset of labor. The waters that have departed during childbirth should be transparent, have a yellowish tint. If they are stained with blood, an emergency is needed. health care!
Why does bleeding start? The causes of blood loss can be different:

Bleeding in the third stage of labor and after them

Bleeding in the third stage of labor(when the afterbirth is separated) and after childbirth arise due to anomalies of attachment and separation of the afterbirth, as well as due to disruptions in the functioning of the uterine muscle and the blood coagulation system.

How to avoid bleeding?

Despite the diversity causes of bleeding, it is still possible to reduce the risk of their occurrence. First of all, of course, you need to regularly visit an obstetrician-gynecologist during pregnancy, who closely monitors the course of pregnancy and, in case of problems, will take measures to avoid complications. If something worries you on the part of the “female” organs, be sure to inform your doctor, and if you have been prescribed treatment, be sure to bring it to the end. It is very important to tell your doctor if you have had any injuries, surgeries, abortions, or sexually transmitted diseases. Such information cannot be hidden, it is necessary to prevent the development of bleeding. Do not avoid ultrasound: this study will not cause harm, and the data obtained will help prevent many complications, including bleeding.

Follow the recommendations of doctors, especially if prenatal hospitalization is necessary (for example, with placenta previa), do not decide on home birth - after all, in the event of bleeding (and many other complications), immediate action is needed, and help may simply not be in time! Whereas in a hospital setting, doctors will do everything possible to cope with the problem that has arisen.

First aid for blood loss

If you notice the appearance of spotting (most often this happens when visiting the toilet) - do not panic. Fear increases uterine contractions, increasing the risk of miscarriage. To assess the amount of discharge, thoroughly blot the perineal area, change a disposable pad, or put a handkerchief in your panties. Lie down with your legs up or sit with your feet up on a chair. call ambulance. Try not to move until the paramedics arrive. In the car, it is also better to ride lying down with your legs elevated. At profuse bleeding(when underwear and clothes are completely wet) put something cold on the lower abdomen - for example, a bottle of cold water or something from the freezer (a piece of meat, frozen vegetables, ice cubes wrapped in a plastic bag and a towel).

Bleeding, which began in the first stage of labor, may increase in the third and immediately after childbirth. Bleeding that begins in the third period often continues into the early postpartum period: Distinguish between compensated and decompensated blood loss.

Acute massive blood loss causes a number of changes in the body: in the central nervous system, on the part of respiration, hemodynamics, metabolism and endocrine organs. After acute massive blood loss, a decrease in the mass of circulating blood occurs without changing the number of erythrocytes and the percentage of hemoglobin. Then, in the next 1-2 days, the volume of circulating blood is restored with its simultaneous dilution.

The reaction of a woman in labor to bleeding is individual. In some cases, blood loss of 700-800 ml can lead to lethal outcome. At the same time, with blood loss in the range of 800 ml and even more than 1000 ml, a decrease in blood pressure may not occur, but more often acute blood loss leads to a decrease in blood pressure.

It is practical to distinguish between the following degrees of hypotension: I degree - with a maximum blood pressure of 100-90 mm Hg. Art., II degree - with a maximum blood pressure between 90 and 70 mm Hg. Art., III degree - 70-50 mm Hg. Art. and preagonal state.

Systematic monitoring of the level of blood pressure is absolutely necessary for every bleeding in childbirth.

In the first stage of labor, bleeding is more common with placenta previa, and also due to premature detachment of a normally attached placenta. Bleeding is common consecutive period. They may be due to delayed separation of the placenta, its tight attachment, or the so-called true accreta of the placenta. After the birth of the placenta, hypotonic and atonic bleeding can be observed. Clinically, with hypotonic and atonic bleeding during childbirth, the uterus contracts poorly, increases in size, its bottom rises above the navel, sometimes approaches the hypochondrium; during massage, a significant amount of blood clots is squeezed out of the uterus, the uterus contracts, but after 10-15 minutes. again dissolves and loses its tone. The cause of bleeding can be birth trauma, retention of a piece of the placenta and hypo- or atony of the uterus. Therefore, with each bleeding, the child's place and cervix should be carefully examined. Need to produce outdoor massage uterus, after lightly rubbing the bottom of the uterus, blood clots are squeezed out of it according to the Krede-Lazarevich method (see Postpartum period).

Since the contraction of the bladder reflexively leads to an increase in the tone of the uterus, urine descends by a catheter. If there is doubt about the integrity of the child's place, it is necessary to immediately conduct a manual examination of the uterine cavity. In the collective farm at home and in the local hospital (in the absence of a doctor), the midwife should perform a manual examination of the uterine cavity immediately without anesthesia. If, after external massage of the uterus, the bleeding does not stop, then with the integrity of the child's place, you should enter the uterus with your hand and massage the uterus on your fist with the other hand. At the same time, intramuscularly, ergotine (1 ml) and pituitrin (2 ml) should be administered intramuscularly, or oxytocin at a dose of 0.2 ml (1 ED) in 20 ml of 40% glucose solution should be injected simultaneously; oxytocin (5 IU) can be infused into a transfused ampoule, 3 IU of oxytocin can be injected into the cervix. With insufficient contraction of the uterus, the Genter method can be applied. At the same time, the puerperal is given the position of Trendelenburg; the obstetrician stands on the left side, grabs the uterus with his left hand in the region of the lower segment (above the womb), pushes it as high as possible and presses it against the spine, with his right hand produces light massage the bottom of the uterus. Instead of the previously used pressing of the abdominal aorta with a fist, it was proposed to press on the aorta with the fingers, with the fingers of one hand located between the fingers of the other; pressing is done first with one, then with the other hand. If the bleeding does not stop, a suture should be applied according to V. A. Lositskaya (the operation is performed by a doctor); for this, the cervix is exposed with wide mirrors, the back lip is captured with bullet (or better hemorrhoidal) forceps and pulled down; two fingers of the left hand are inserted into the neck and slightly protrude its posterior commissure. At the place of transition of the posterior fornix to the neck in the transverse direction from the fornix to the cervical canal, a thick catgut thread is passed with a needle; then, at a distance of 4-4.5 cm, the needle is passed in the opposite direction - from the canal to posterior fornix; the thread is tied tightly. The resulting longitudinal fold reflexively increases the tone of the uterus. Tamponade of the uterus is ineffective.

A positive assessment was received by the method of terminaling the parameter, the technique of which is as follows. After catheterization of the bladder, the cervix is exposed with wide vaginal mirrors and, having captured it with Musée forceps, is reduced as much as possible and pulled to the right; the same forceps are applied perpendicular to the neck in the left arch, while capturing the muscular wall of the neck; do the same on the right side. As a result, the uterus is relegated, which helps to stop the bleeding. The clamps must be applied strictly in the lateral arches, since if they are located anteriorly, the bladder may be damaged.

A similar effect can be obtained by applying 8-10 Muset forceps to both lips of the cervix until the pharynx is completely closed, followed by lowering the cervix.

Simultaneously with stopping bleeding in childbirth, acute anemia is treated. The head of the puerperal is lowered, taking out a pillow from under it. Blood loss should be immediately replaced by adequate blood transfusion. Blood loss should be precisely taken into account; to do this, collect and measure all the spilled blood. Blood transfusion is desirable for each blood loss exceeding 500 ml; it is absolutely necessary in every case of lowering blood pressure, even I degree. In acute blood loss, rapid and complete blood replacement is necessary, with a decrease in maximum blood pressure below 70 mm Hg. Art. shows intra-arterial injection. When collapsed, it is shown intravenous administration norepinephrine (1 ml) and hydrocortisone mg).

Prevention of bleeding during childbirth consists in their proper management, rational application stimulation of labor activity with its weakness, in the correct management of the afterbirth period (see) and relentless monitoring of the puerperal in the first 2 hours after childbirth. In order to prevent hypotonic bleeding at the end of the second period, it was proposed to administer intramuscularly pituitrin (1 ml) to the woman in labor. After the placenta has passed, it is proposed to inject cobalt chloride intramuscularly (2% solution, not more than 2 ml).

Bleeding during childbirth

Everyone knows that childbirth is accompanied by bleeding. If everything goes according to plan, then the body itself copes with it. If events develop differently, then you can’t do without the help of doctors. So in what situations is bleeding during childbirth a threat and what methods can be used to stop it?

In the event that childbirth proceeds without problems (read about childbirth problems here), then physiological bleeding usually begins at the moment the placenta passes, 5-10 minutes after the birth of the baby. A woman loses ml of blood (approximately 0.5% of body weight). This blood loss is considered normal.

During pregnancy, the volume of circulating blood increases by 30%, including in order to compensate for blood loss.

During the discharge of the placenta, a protective mechanism is triggered: the walls of the uterus contract and, shrinking, overlap blood vessels. Blood clots immediately form in the vessels, which close the lumen. Along with this, the vessels narrow very strongly and go deep into the body.

If a woman loses more than 400 ml of blood, then doctors talk about pathological obstetric bleeding, which is already regarded as a complication.

The so-called risk group includes women who have already had C-section(after surgery, a scar remains on the uterus, so the risk of rupture during natural childbirth increases), as well as pregnant women expecting twins or a large child.

Other hazards include polyhydramnios, uterine diseases (chronic endometritis, tumors), serious non-gynecological chronic diseases ( diabetes, kidney failure, hepatitis) and bleeding disorders.

The age of a pregnant woman (late pregnancy) can also influence the scale of blood loss: if she is over 35 years old, then the risk of weakening labor activity and reducing the contractility of the uterus muscles increases.

During childbirth, bleeding can be the result of problems with the placenta, rupture of the uterus, or rupture of the birth canal.

In the first hours after childbirth, the complication most often occurs due to hypotension of the uterus, when its muscles lose their tone and contractility.

In each individual case, doctors act differently, but the goal is always the same - to stop the bleeding as soon as possible.

Abundant blood loss can be provoked by premature detachment of the placenta, which most often develops against the background of such complications of pregnancy as preeclampsia. This disease can be accompanied by sudden changes in blood pressure, during which the vessels in the area of attachment of the placenta to the wall of the uterus break ahead of time, which causes severe bleeding.

The actions of doctors will depend on where exactly this attachment point is located. Normally, the placenta is attached to the upper part of the uterus, on its front or back wall. But it happens otherwise. For example, if the placenta is located on the edge, then opening the fetal bladder (amniotomy) can sometimes stop the bleeding.

When the amniotic fluid is poured out, the baby's head, sinking to the pelvic floor, presses the exfoliated area of the placenta and the vessels that burst prematurely. If the placenta is attached to the uterus in the center, then it is necessary to carry out an urgent caesarean section.

If the birth was prolonged, then in the first 2 hours after the birth of the baby, hypotonic bleeding may develop. The muscles of the uterus get very tired and do not respond to oxytocin, do not contract, therefore, bursting vessels are not pinched.

If an additional dose of oxytocin does not give the expected effect, then the doctor performs a manual examination of the walls of the uterus in order to cause its reflex contractions.

If the bleeding still cannot be stopped in this case, then the anterior abdominal wall and ligate the iliac arteries.

Interesting materials:

If you want to know everything about pregnancy and childbirth, as well as everything connected with it, then all necessary information you can find on the portal for parents cynepmama.ru.

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Natural blood loss during childbirth. Good to know

During childbirth, a woman loses about 200 ml of blood, which is normal for this process. This loss has no effect on the state of the mother's body. Throughout pregnancy, the body has already prepared for this slight loss.

The volume of blood has already increased over these 9 months in order to wash organs and tissues smoothly, and most importantly to supply necessary substances for the fetus. The closer to childbirth, the more blood coagulates, as if protecting the body from bleeding. After the appearance of the baby, the body inhibits blood flow automatically. The obstetrician has some knowledge of how to deliver with the least amount of blood loss.

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Uterine bleeding during childbirth

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I had a premature birth. At the 30th week, water with blood broke at home. I was frightened in earnest myself and my husband almost gave an oak. We arrived at the hospital at five in the morning. They put me in the ward, gave the midwife to look after me, who turned off the light and safely collapsed onto the next bed. Until 7 in the morning she slept well, I gave birth quietly, did not scream. At 7.20 I gave birth to a son weighing 2100, without pathologies and healthy. The doctors were shocked. After the birth, they did not understand where the blood came from and why the child is absolutely mature at such a time. The placenta was without disturbances, after childbirth there was no pathological bleeding. Here is such a strange birth we had. Now my son is 18 years old. A great guy has grown up.

My contractions were terribly painful, it pressed on the bottom like a tide, plus there was also blood. Ele did it! Doctors (who should support) did not even put painkillers. 4 hours of pain. In general, the attitude was terrible! A daughter was born, a beauty, and this is the main thing! At such moments, the support of doctors is needed, and they are so swine. Horror.

What happens during childbirth is probably of little interest to the woman in labor. In this case, the main thing is to give birth to a healthy baby and enjoy his birth. And bleeding fades into the background, although this women Health and must be followed.

Blood loss during childbirth

Let's start with the fact that for the entire time of childbirth, expectant mothers lose about 200 ml of blood (about 0.5% of body weight). Is it a lot or a little? Absolutely normal! Nature provided for these "expenses", and they do not affect the condition of the young mother in any way. The fact is that all 9 months of pregnancy, the woman's body is preparing for future "expenditure". Firstly, it increases the volume of circulating blood to ensure an uninterrupted supply of the organs and tissues of mother and baby with the necessary nutrients.

Secondly, as the birth approaches, the body increases blood clotting, insuring itself against large “spending”. Thirdly, already at the time of the birth of the baby, our body “starts” a mechanism that stops bleeding. Add to that different methods control of blood loss, which are available to obstetricians, and you will understand that there is nothing to worry about.

What events can be associated with these losses?

First of all, with the birth of the placenta (that is, the placenta, membranes and umbilical cord), when, after the baby is born, the placenta begins to separate from the wall of the uterus and a wound appears in the place where it was located. During this period (it lasts 5–30 minutes), the same mechanism for controlling blood loss comes into play.

As soon as the placenta leaves the uterus, the latter immediately begins to contract and, shrinking, closes off its blood vessels; immediately clots form in them - and the bleeding stops. The vessels themselves are “designed” in such a way that when their walls are compressed, the lumen in them immediately disappears. To help the tired muscles of the uterus, the obstetrician injects the patient with a drug that stimulates her ability to contract. Problems appear only if the muscles of the uterus suddenly relax or a piece of the placenta is retained inside it.

The next stage is the period after the end of childbirth, it lasts 2 hours. At this time, the uterus should contract and shrink. Now it is important that she does not relax. Then an ice pack is placed on the stomach of a young mother: under the influence of cold, the muscles contract.

There are situations when blood loss is more than expected:

Premature detachment of a normally located placenta - it is called serious problems with the health of the expectant mother.
Injury to the cervix occurs if a woman begins to push ahead of time, when the baby's head has not yet moved to the exit. Another reason is that the expectant mother has inflammation of the walls of the vagina and cervix.
The villi of the placenta are attached to the wall of the uterus so tightly that the first cannot separate from the second itself.
A piece of the placenta lingers in the uterus, "sticking", as in the previous case, to its wall. Stuck lump problems are commonly found in women with chronic inflammation of the uterus and appendages.
Decreased tone of the uterus. Bleeding can begin after the end of childbirth if the uterus of a young mother relaxes. The cause of her fatigue is most often a protracted or difficult birth.
Violation of the blood coagulation system, DIC appear as a result of some serious complication of pregnancy (preeclampsia, premature detachment of the placenta).

Among the complications that occur during childbirth and immediately after their completion, bleeding is one of the first places. In the process of giving birth, they are associated with problems in the attachment or separation of the placenta, trauma to the uterus and genital tract of the expectant mother. And with the birth of a child, their cause is a violation of uterine contraction and the formation of blood clots in the vessels of the site from which the placenta separated.

Bleeding is considered to be a blood loss equal to 500 ml (that is, more than 0.5% of body weight), although this definition is approximate. To prevent such problems, doctors are helped by a prognosis based on the characteristics of the condition of each expectant mother and her history: did she have abortions, a large number of pregnancies, a scar on the uterus after a cesarean section, tumors and problems in its structure, serious chronic diseases. Does the woman have problems with the blood coagulation system, has she taken drugs that affect her work, is the baby expected to be large, are there twins or triplets, does the expectant mother have excess amniotic fluid (polyhydramnios), and so on .

It is important for obstetricians not only to recognize the cause of bleeding, but also to determine the amount of blood that has come out. The most common way to determine the amount of blood loss: to the volume of blood collected in the tray during the birth of a child, add the mass of blood that has poured out onto the diapers. During a caesarean section, the blood lost is counted by summing up the amount of blood in the vacuum aspirator bank (this device sucks blood from abdominal cavity) and the volume found on the diapers. If a vacuum aspirator is not used during the operation, blood loss is calculated only according to the last indicator.

Since 2006, it has been customary to use a special Cell saver 5+ Haemonetics apparatus in Moscow maternity hospitals during operations with an expected large blood loss. Collecting blood from the abdominal cavity, he filters it from the amniotic fluid, and the specialists return the lost volume to the woman's bloodstream. And with the development of vascular surgery, the creation of blood transfusion units in large hospitals and mobile hematology and resuscitation teams, doctors have new opportunities to help women during caesarean section.

In an effort to preserve the ability of patients to become a mother in the future, obstetricians prefer to bandage to stop serious bleeding. large arteries(more precisely, the internal iliac). And one of the most modern and effective methods stop uterine bleeding was the embolization of the arteries of the uterus itself. This is a complex and delicate operation, during which they are clogged with emboli - a special substance, precisely “fitted” to the size of the vessels. This method has been successfully used by the doctors of our Center for several years now.

It is advisable not to terminate the first pregnancy.
When planning the birth of a child, you must first undergo an examination, and if the doctor detects cycle disorders and inflammation (of the vagina, uterus and cervix, appendages), also a course of treatment.
Those who are considering the option of home birth should think about their safety and, having weighed all the pros and cons, still go to the hospital.
Ask for the baby to be put to the breast immediately after birth and even before the midwife ties the umbilical cord - this will help the uterus to contract well. The sucking movements of the baby stimulate the production of the hormone oxytocin in the mother.

Bleeding during childbirth

Childbirth is the most long-awaited moment in the life of every woman. However, complications can overshadow the joy of meeting with the baby. Among them, postpartum hemorrhage should be highlighted, the frequency of which is 2-8% of the total number of births. Why childbirth is complicated by bleeding and how to prevent it, I will discuss in this article.

Blood loss during childbirth: norm and deviations

Sufficient contractility of the uterus (equal to that in the 1st stage of labor);

The activity of the processes of formation of blood clots.

surgical interventions ( manual separation placenta in previous births, caesarean section, conservative myomectomy, curettage of the uterus);

Malformations of the uterus (septum);

Submucosal myomatous node.

The introduction of ergometrine and oxytocin to stimulate uterine contractions;

Identification of signs of separation of the placenta.

Prevention of the development of massive blood loss;

Restoration of the deficit of circulating blood volume (BCC);

Prevention sharp drop blood pressure.

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Emergency: Bleeding during childbirth

Blood loss during childbirth associated with uterine ruptures and placental problems. What is dangerous bleeding. Methods for stopping bleeding.

The birth of a baby is a joyful event that you don’t want to overshadow with anxious thoughts. But knowledge about the complications that may accompany childbirth is necessary - first of all, in order not to get confused at a critical moment and meet them fully armed. After all, the calmer a woman behaves, and the better she realizes her condition, the greater the likelihood of a successful outcome of childbirth for both mother and child. In this article we will talk about one of the most formidable complications - bleeding. It can develop during childbirth, in the early postpartum period, and even on recent weeks pregnancy. The onset of bleeding is serious danger for the health (and sometimes for life) of the mother and the unborn child.

Causes of bleeding

Most often, the immediate cause of bleeding are problems associated with the condition of the placenta. Predisposing factors for them are:

Chronic inflammatory diseases of the uterine mucosa (endometritis), especially untreated or undertreated.
"Old" injuries of the pelvic organs and scars on the uterus (regardless of their origin).
A large number of abortions, miscarriages and (or) childbirth in a woman's life, especially if they were complicated by inflammation. (If we take all cases of placenta previa as 100%, then 75% of them occur in multiparous women and only 25% in primiparas).
Violations hormonal background, endocrine diseases.
Uterine fibroids and other diseases of the internal genital organs.
Severe cardiovascular diseases, some diseases of the kidneys and liver.
Injury during pregnancy.
The woman is over 35 years of age.

So, what are the placental problems that can cause bleeding?

Abnormal separation of a normally located placenta
1. Premature detachment of a normally located placenta. Placental abruption can occur at various sites. If the placenta exfoliates from the edge, then the blood flows out of the external genital tract. In other words, in this case external bleeding takes place; in such a situation, pain in the lower abdomen is insignificant or absent altogether. Detachment of the placenta can also occur in the middle, then the blood accumulates between the placenta and the wall of the uterus and a hematoma is formed; in this case pain syndrome more pronounced.
Premature detachment of a normally located placenta is accompanied by signs of blood loss: heart rate increases, blood pressure decreases, cold sweat. Since this sharply reduces the amount of blood supplied to the fetus, fetal hypoxia develops, therefore this situation can be life-threatening for both mother and child.
Depending on the period of childbirth, the condition of the woman and the fetus, childbirth can be completed through the natural birth canal or with the help of a caesarean section.
Difficulty in independent and timely separation of the placenta in the third stage of labor (tight attachment or accretion of the placenta - in whole or in part). Normally, after the birth of the baby, the placenta separates and is born. With the separation of the placenta in the uterus, an extensive wound surface is formed, from which blood begins to ooze. This physiological (normal) bleeding stops very quickly due to the contraction of the walls of the uterus and the clamping of the vessels located in them, from which, in fact, the blood flowed. If the process of placental rejection is disturbed, then bleeding begins from the surface of the mucosa, which has already been freed from the placenta, and tightly attached fragments of the placenta do not allow the uterus to contract and compress the vessels. This is an operation that is performed under general anesthesia. If the placenta cannot be separated manually, they speak of its increment. In this case, an emergency removal of the uterus is performed.

Incorrect location of the placenta:

Placenta previa, when they partially or completely overlap the internal os of the cervix.
The low location of the placenta, when its edge is closer than 5-6 cm from internal os cervix.
Cervical placenta previa is a rather rare location of the placenta, when, due to the ajar internal pharynx of the cervix, it can partially attach to the mucous membrane of the cervix.

With the onset of childbirth (if not earlier, even during pregnancy), the incorrect location of the placenta unequivocally develops into its premature detachment. This is due to the more intense stretching of the lower (compared to the upper and middle segments) sections of the uterus as pregnancy develops and their rapid contraction when the cervix opens during childbirth. Complete and cervical placenta previa are more complex and severe complications. The lower parts of the uterus are less adapted by nature to fully provide the baby with everything necessary. The developing fetus suffers more from a lack of oxygen in the first place and, naturally, nutrients. With complete or cervical attachment of the placenta, bleeding can begin spontaneously as early as the second trimester of pregnancy and be extremely intense. It should be emphasized that with complete placenta previa, talking about independent childbirth it is not necessary at all, since the placenta tightly blocks the “exit”, i.e. cervix.

In this case, a planned caesarean section is performed at the 38th week of pregnancy. If there is bleeding, then an emergency caesarean section is performed. With marginal placenta previa of full labor activity, mild bleeding and good condition mother and the child being born, it is possible to carry out childbirth through the natural birth canal. However, the decision on the form of delivery always remains with the doctor. In rare forms of placenta previa, when it affects areas of the cervix, cesarean section is preferred; moreover, this situation may even end with the removal of the uterus, since such an arrangement of the placenta is PURELY combined with its ingrowth into the wall of the cervix.

Bleeding is accompanied by another, more rare complication - uterine rupture. This is extremely serious condition can occur both during pregnancy and directly during childbirth.

Obstetricians specifically determine for themselves the temporal characteristics of the gap (threatening, begun and completed gap) and its depth, i.e. how much damage to the uterine wall is (it can be a crack, incomplete rupture, or the most dangerous - complete, when a through defect forms in the uterine wall with penetration into the abdominal cavity). All these conditions are accompanied by varying degrees of severe bleeding, sharp pain that does not stop between contractions. The contractions themselves become convulsive or, conversely, weaken; the shape of the abdomen changes, signs of hypoxia of the child increase, the fetal heartbeat changes. At the moment of complete rupture of the uterus, the pain increases sharply, becomes "dagger", but the contractions stop completely. There may be a false impression of a decrease in bleeding, since the blood no longer flows out so much as through the gap into the abdominal cavity. The deformity of the abdomen persists, the child is no longer palpable in the uterus, but next to it, he has no heartbeat. This is a critical condition: only immediate surgery and resuscitation can save the mother and baby (if he is still alive). The operation usually ends with the removal of the uterus, since it is almost impossible to sew up the torn, thinned, blood-soaked walls of the uterus.

The risk group for the likely occurrence of uterine rupture include:

Pregnant women with an existing scar on the uterus (regardless of its origin: trauma, caesarean section, removed fibroids, etc.). It should be noted that modern methods of caesarean section are not aimed at minimizing the risk of the above complications during repeated pregnancies. For this, a special technique is used to cut the body of the uterus (transverse, in the lower segment), which creates good conditions for subsequent wound healing and minimal blood loss with a possible rupture in childbirth.
Multiparous women with complicated course of previous births.
Women who have had multiple abortions.
Women with complications after an abortion.
Patients with chronic endometritis.
Women in labor with a narrow pelvis.
Pregnant women with large fetuses.
pregnant with wrong position fetus in uterus
Women in labor with discoordinated labor activity (a condition where, instead of a one-time contraction during a contraction, each fragment of the uterus contracts in its own mode).

If a woman knows that she belongs to one of these categories, she must warn both her doctor in the antenatal clinic and the obstetricians in the maternity hospital about this.

What is dangerous bleeding

Why obstetric bleeding remains so dangerous today, despite all the advances modern medicine, the development of resuscitation techniques and a sufficiently large arsenal of means to replenish blood loss?

First, bleeding is always a secondary complication of an obstetric problem that has already arisen. In addition, it very quickly becomes massive, that is, in a relatively short period of time, a woman loses a large amount of blood. This, in turn, is explained by the intensity of uterine blood flow, which is necessary for normal fetal development, the vastness of the bleeding surface. What can be more successfully shut off by hand when the valve is torn off: a single tap of water or a fan shower? Approximately the same can be said about bleeding, for example, from a damaged artery in the arm and bleeding during childbirth. After all, it is in this situation that doctors find themselves trying to save a woman in labor, when blood gushing from a large number of small damaged vessels of the uterus.

Of course, the body of a pregnant woman is “preparing for a normal small loss of blood in childbirth. The blood volume increases (although this primarily meets the needs of the developing fetus, which needs more and more nutrition every day). The blood coagulation system is put on “combat alert”, and in the event of bleeding, all its forces, without exception, “rush into battle”. At the same time, the increased coagulation ability of the blood develops into complete exhaustion - coagulopathy, there are no elements (special proteins) in the blood that can form a blood clot and “close the hole”. The so-called DIC syndrome develops. All this is aggravated by severe metabolic disorders due to the main obstetric complication (rupture of the uterus, premature detachment of the placenta or tight attachment, etc.). And until this primary complication is corrected, it is unlikely to cope with bleeding. In addition, a woman's strength is often already running out due to pain and physical stress.

Features of childbirth

In the event of bleeding during childbirth, work is carried out in several directions at the same time. The anesthesiologist begins infusion through large veins of special blood-substituting solutions and blood products. Thanks to this, substances and proteins responsible for blood clotting enter the bloodstream. To improve blood clotting, they begin to infuse fresh frozen plasma, then, depending on the volume of blood loss, an erythrocyte mass is infused into another vein, sometimes these blood products are administered in parallel into different vessels. The patient is also injected with hemostatic drugs and pain medications. Obstetricians determine the cause of bleeding and the type of upcoming surgery.

To maintain a normal supply of oxygen to tissues, inhalation of humidified oxygen through a mask is used.

The patient is connected to a monitor that constantly monitors her blood pressure, heart rate, blood oxygen saturation (saturation) and continuously takes an ECG. Simultaneously with the above activities, quick introduction the patient is placed under anesthesia for further surgical treatment and the transfer of the woman to artificial lung ventilation breathing apparatus. Practice has proven that blood transfusion in patients under anesthesia is safer than in patients who are conscious.

Of course, the transfusion of blood and solutions will be successful only when the initial complication that caused bleeding is eliminated. Therefore, the task of obstetricians is to identify this complication and determine a plan for therapeutic manipulations, whether it be manual examination of the uterus, emergency caesarean section, removal of the uterus, etc.

After the blood has been stopped, the woman is transferred to the intensive care unit of the maternity hospital or to a specialized intensive care unit of the hospital under constant supervision. medical staff.

Remember that bleeding in pregnant women can occur not only during childbirth in a hospital, but also at home. When obstetric bleeding occurs, time becomes decisive, and in the case of childbirth outside the hospital, it, alas, works against us. Therefore, when planning a trip somewhere in the last weeks of pregnancy or home birth, calculate in advance how long you can be in the hospital. Remember that with obstetric bleeding, a condition very quickly sets in when, despite ongoing intensive therapy and performing external clamping of the abdominal aorta (and this is very difficult for pregnant women), the ambulance team and even the medical helicopter team may not take the patient to hospitals are alive, since the main method of treatment against the background of intensive care remains surgery.

Can bleeding be avoided?

Significantly reduce the risk of bleeding can be with regular monitoring by a doctor in the antenatal clinic. If you have had injuries of the pelvic organs - tell your doctor about it; if something worries you from the "female" organs - also be sure to notify your doctor; if you are sick - get cured to the end. Do not avoid ultrasound: it will not cause harm, but it will help the doctor to identify the problem in time. Try to fight unwanted pregnancies not with abortions, but with more “peaceful” means: this will save you from big troubles in the future. And don't go for a home birth.

senior physician of the operational department

Emergency Medical Center

Moscow Health Committee

The first pregnancy at the age of 29 (mild), condition without pathologies, I do not belong to risk groups. Birth at term in the Center for Labor and Development in August 2002. Bleeding, manual separation of part of the child's place under general anesthesia. For six months there were health problems, weakness, the stitches did not heal, in general, a nightmare. How likely is it that the second pregnancy will end in such a birth? Would it be better, given the age of 32 and the problematic first birth, to plan a future caesarean to avoid complications? I really don't want to take risks. And giving birth is scary, but I want a second child.

And, perhaps, for some, this information will be a powerful reasonable counter-argument AGAINST home birth. After reading the article, you will understand whether you belong to the risk group. And if it turns out that yes, then there is nothing to look for problems on your head.

The Russian project "Dancing Chair" received 11 awards and prizes

Russian innovative project The “Dancing Chair” received eleven awards and professional quality awards at domestic and international professional exhibitions. Nowadays, the Russian invention includes such industry awards as: the gold medal “The Best Product for a Healthy Family”, the gold medal Russian Academy natural sciences gold medal of the international salon "New time" Large European medal order "For professionalism and business.

How to survive the “stormy rush” of milk for a nursing mother?

How to survive the “stormy rush” of milk for a nursing mother? Immediately after childbirth and during the first 2-3 days, colostrum is produced in the breast. It stands out in small quantities, and the mother practically does not feel it. Then, by the end of the 3rd, the beginning of the 4th day after childbirth, the breast begins to increase in size, become more dense and tense. These changes indicate the beginning of the milk arrival process. Often they are accompanied by pain, a slight increase in local temperature.

How did the brush get into the girl's brain?

According to VN. ru , in Biysk in the Novosibirsk region, a young 3-year-old artist ended up on the operating table because of an unsuccessful game with a box of brushes and pencils, as a result of which, after a fall, she developed a hematoma near her eye and blood. How all this happened, my mother did not know, because she was in another room and heard only a roar. And when she entered the room, her daughter was lying on the floor and crying. A visit to the Altai hospital ended with a diagnosis of meningitis. Girl in the evening.

Why are women giving birth often anemic?

Anemia is the most common problem during pregnancy, in which the amount of hemoglobin in the blood decreases. Among pregnant women, in the vast majority of cases, anemia occurs from a lack (deficiency) of iron in the body. First, the level of iron in the depot decreases, due to this, at first, the hemoglobin level may still be within the normal range. However, later, without adequate therapy, the level of hemoglobin begins to decline sharply and iron deficiency anemia develops.

A question from a member of the group: “I learned about hepatitis during pregnancy, a classic of the genre (unfortunately, I infected the child during childbirth, now there are a lot of questions. We had a pediatric infectious disease specialist, she didn’t really say anything. Our district pediatrician only looks away and also nothing Daughter is 5 months old, hepatitis C genotype 3ab, tell me what to do, what are my further actions must be? What to demand from doctors? Additional examination, testing, what treatment should be.

Natural childbirth or caesarean section for hepatitis C?

At present, the optimal mode of delivery for infected women has not been fully determined. To make a decision, the doctor needs to know the results of a comprehensive virological study. natural childbirth include a whole range of measures aimed at adequate pain relief, prevention of fetal hypoxia and early rupture of amniotic fluid, reduction of injuries of the birth canal in the mother and skin of the baby. Only when all preventive measures are observed.

How do children become infected with hepatitis B?

The probability of infection of children with viral hepatitis B in the perinatal period and in the first year of life is quite high, and during the first year of life, leads to the formation of chronic hepatitis B in 80% of cases. Often, it is the mothers of children with chronic hepatitis B who are carriers, or they themselves suffer from chronic hepatitis B. From which, we can conclude that the virus is transmitted vertically from mother to child. Most often, infection occurs during childbirth. But, the cause of infection.

Adoption of a baby with hepatitis C and healthy children at home

Good night, share your experience. We have two children, we want to adopt another baby, the only problem is that the baby has hepatitis C, I am not afraid of this disease, I worry about healthy children. Just kids, they are kids, they can hit each other, bite each other, etc. Here's how to be? Constantly fear and watch the children in both eyes? The baby we want to adopt has sunk into our souls, but I cannot but take into account that the other two children are healthy and naturally I am worried.

What is viral hepatitis B and C in children?

Viral hepatitis B and C, considered a disease of the liver, these viruses can lead to cirrhosis. In children viral hepatitis B and C, unites a common route of transmission - parenteral. The parenteral route of transmission is the route of transmission, roughly speaking "blood to blood". For infection, it is necessary for the patient's blood to enter the blood healthy person. The virus can enter the bloodstream: - through medical instruments, if they are poorly disinfected (syringes, needles), during dental procedures.

Dad's presence at birth

Honestly, I don’t even know if I want my husband to be present at the birth or not. When I gave birth for the first time, I definitely did not want to. And now I'm thinking, why not? But our dad will never voluntarily agree to such a thing. He never even went to ultrasound with me, but I never insisted. Offer - offered, but did not ask. Yesterday, in a conversation, I touched on the topic of the presence of the pope at childbirth. I haven't seen so much confusion in his eyes in a long time. Answered something close to what I have in mind at all.

But we have been married for more than 10 years, we are already not afraid of childbirth together)))

Thoughts of suicide in a 7 year old

Hello! Tell me what to do: my son is 7 years old, then he told his grandmother that sometimes he doesn’t want to live, when my mother offends me (I’ll scream for something or slap), I’m sitting in the room, and I have a voice in my head “kill yourself ", after all, you can jump off the roof or from the stairs (we have a Swedish wall at home) to jump onto something sharp. Grandmother tells him, “Dimochka, you will die then,” and he answers her: “Grandma, but the soul will remain.” I am shocked how to talk properly and rid my son of these thoughts.

This discrepancy is expressed aloud by her child.

Sex during pregnancy

If the pregnancy is normal, it is possible for future parents to have sex, it will not harm the child, and with the approach of the due date, it is even advisable to do this. The ban on having sex during pregnancy, if imposed, is most often temporary, and it is better to check with your doctor how long you need to maintain abstinence. Doctors of antenatal clinics usually warn expectant mothers if sex is contraindicated for them, and when everything goes well, they do not always explain that intimate relationships are not dangerous.

Sex: what they don't teach in school

Sex is an extremely entertaining business, even if you don't do it. After all, how many wonderful discoveries it allows us to make in the field of sciences so non-erotic at first glance, like physics, chemistry or anatomy. On school lessons You certainly weren't told about this! Physics If it were not for the force of friction, we would not know the joys of sex. But pleasure is not the only pleasant moment sexual relations, because there is also extremely beneficial effect burning kilocalories. Scientists have established: during the half-hour.

My daughter's birthday, what happened before and what happened after. Part 3: Childbirth

And flew. 4:30 They shake me by the leg, spread their arms with the word "Everything." I don't understand anything yet, because I'm dying to sleep after a sleepless night of wallpapering. Somehow I wake up. Alenka explains to me that the mucus plug has finally come off and she is having contractions. In general, the fact that the cork has finally departed is a harbinger, but it can still calmly take a few days before the birth. Yes, and contractions may well be trial (by the way, we have already been sitting with such trials in the country for an hour since.

My daughter's birthday, what happened before and what happened after. Part 1: Pregnancy and fears

The day we heard this news It's been a long time. But there are still some things I remember from that day. I remember there was another delay, but somehow I wasn’t really scared, because a couple of “delays” ago I decided that worrying every time was wasting my nerves. Moreover, there is no sense from the experience :-) So I was sent for the test. Went and bought, and he. showed nothing - it turned out to be defective (before that they were always normal, but here.). And I went for the second one. I'm back, we're waiting. At Alenka.

Daddy, thank the guardian angel that nothing happened to your wife and child!

Cheaper is not cheaper. Damn saved.

Just like a quote from Shrek. "Maybe the wife or baby will die in a home birth, but that's the sacrifice I'm going to make."

Home diagnosis of conditions threatening pregnancy

In addition to the joyful expectation of the birth of a baby, 9 months of pregnancy also bring a lot of worries and worries about his condition. But is he comfortable in his stomach, will he be born on time, and what do all the changes that occur throughout this time with a woman's body mean? Which of them can be attributed to normal, and which ones signal danger and require immediate medical intervention? All these and many other questions worry pregnant women, forcing some.

Anesthesia during childbirth. anesthesia methods

How can doctors help? General anesthesia. When using these types of anesthesia, pain sensitivity of all parts of the body is lost. Along with the loss of pain sensitivity during general anesthesia, medications also affect consciousness. Endotracheal anesthesia. Held general anesthesia with artificial lung ventilation. The method provides a long-term effect. In this case, a whole combination of drugs is used, and the anesthetic itself enters through the trachea into the lungs.

last month of waiting

Prepare everything in advance First, finally decide in which maternity hospital you will give birth. Notify the doctor of the antenatal clinic about your decision, get Required documents, an exchange card for a pregnant woman (if for some reason she is still not in your hands), a referral to the maternity hospital. Re-test if necessary. Second, check if you have newborn care literature. Third, keep in mind that the last month of pregnancy at any time.

Pregnancy shortly after cesarean. What to do?

Emergency: bleeding during childbirth. Pregnant women with an existing scar on the uterus (regardless of its origin: trauma, caesarean section, removed fibroids, etc.). It should be noted that modern methods of caesarean section of Women.

As for me personally (this is by no means positive example for imitation :)), then I just on Friday, finally, went on maternity leave, the whole pregnancy worked to its fullest, dragging bags, so, today I carried my child in my arms in the park for half an hour (well, she asked for her arms! :) - 15 kg live weight). So, of course, you don’t need to do it, it’s better to rest more, if possible. The doctor who will manage your pregnancy will closely monitor the suture, that's all :))

And the children will have a small difference, and they will be interested together! :)

Is it possible to forgive?

Emergency: bleeding during childbirth. Features of conducting childbirth. Can bleeding be avoided? Women with complications after an abortion. Patients with chronic endometritis.

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Uterine bleeding that develops during pregnancy, in the postpartum period or during childbirth is very dangerous due to its unpredictability and swiftness. In the structure of mortality in the population of even developed countries, obstetric postpartum hemorrhage occupies a high place, which indicates the urgency of the problem. Very dangerous for the life of the fetus and mother are blood loss during pregnancy associated with pathological placentation.

In childbirth, a woman can lose up to 500 ml of blood within the physiological limits, it is for such losses that the body prepares during pregnancy. During caesarean section, blood loss up to 1000 ml is permissible. Everything in the above numbers is pathological and disrupts the processes of cell oxygenation and requires immediate correction.

Causes of bleeding during pregnancy:

The main causes of uterine bleeding after childbirth form several groups, which among clinicians are called the 4T rule:

"Tissue" - the presence of remnants of the placenta or membranes in the uterus after childbirth.
"Tone" - atony or hypotension of the uterus.
"Trauma" - breaks, incisions of the birth canal.
"Thrombi" - a violation of blood clotting.

There are a number of risk factors that can lead to the above reasons and provoke bleeding in the postpartum period. They should be ungrouped in this way.

Factors that lead to impaired uterine contractility: prolonged use of Oxytocin in childbirth, a significant number of births, chorioamnionitis, general anesthesia, multiple pregnancy, polyhydramnios, large fetus, uterine fibroids; as well as conditions leading to uterine inversion - these are excessive traction for the umbilical cord, a short umbilical cord, the placenta is attached to the bottom of the uterus.
Injury to the genital tract during childbirth. This is facilitated by rapid delivery, operative delivery through the vagina, episiotomy, ruptures of the uterus, cervix, vagina.
Retention of parts of the placenta in the uterine cavity. This leads to the formation of additional lobules of the placenta, as well as its fragmentation during childbirth and retention inside.
Congenital or acquired bleeding disorder. During pregnancy, it is necessary to take into account such syndromes and symptoms in order to identify a risk factor: preeclampsia, hereditary disorders of hemostasis, infection and sepsis, premature detachment of a normally located placenta, amniotic fluid embolism, treatment with antithrombotic drugs during pregnancy, intrauterine fetal death, fever, detection on the body of a woman causeless petechiae, hemorrhages, bruises.

In accordance with these factors, it is necessary to stratify the pregnant woman according to risk before delivery.

low risk	Medium risk	high risk
Singleton pregnancy	Scars on the uterus	Placenta previa, tight attachment, or placenta accreta
Less than 4 births	More than 4 births	Hematocrit less than 30
Unoperated uterus	Multiple pregnancy	Already had obstetric bleeding
No history obstetric bleeding	Magnesia therapy	Blood clotting disorder
	Long-term administration of oxytocin	On admission bleeding
	Myoma large sizes	Unstable hemodynamics - hypotension, tachycardia

Classification

Obstetric bleeding, depending on the time of onset, is divided into:

During gestation: in early pregnancy and prenatal (miscarriage, placenta previa, chorionepithelioma, cervical pregnancy).
During childbirth or caesarean section.
Early postpartum hypotonic bleeding - no later than 2 hours after birth; late, or secondary, occur after 2 hours and up to 12 weeks after birth.

According to the volume of blood lost, bleeding is divided as shown in the table below.

Symptoms

Excretion of blood from the genital tract more than allowed in childbirth and the postpartum period - the main symptom of hypotonic uterine bleeding.

Nonspecific signs are:

On examination, the doctor reveals pale skin with cold sweat, the symptom of a "white spot" can be positive: significant hypotension - the spot from pressing a finger on the forehead disappears after 2 seconds. Tachycardia, tachypnea is detected.

What to do when bleeding at home

If a woman during pregnancy or after discharge from the hospital notes pathological spotting from the genital tract, then this may be a miscarriage, placental abruption, as well as late subsequent bleeding (up to 12 weeks after birth).

How to stop bleeding at home? You cannot do this on your own. If there is a slight spotting, then you need to contact the gynecologist of the antenatal clinic, who can prescribe hemostatic drugs (Tranexam, Etamzilat, Aminocaproic acid). Most often, the patient is sent to the hospital where therapy is performed.

If a woman has profuse bleeding, it is urgent to call an ambulance, lay her down, raise her legs, put cold on her stomach.

First aid and hospitalization

Upon arrival of the ambulance, an assessment of blood loss and preservation of vital functions is carried out. In an ambulance, venous access is performed in 2 or more veins, an antifibrinolytic agent is injected, for example, Aminocaproic acid, Tranexam, Dicinon. Crystalloid solutions are poured in. Cardiac arrest requires cardiopulmonary resuscitation.

Urgent Care

Emergency care should be as quick as possible. The first step is to assess the blood loss. At the same time, intravenous access is performed with a catheter with a maximum diameter, if it is not already installed. An intravenous infusion of crystalloid solutions is started immediately.

To determine the volume of blood loss, a visual method is used, weighing the surgical material (gravimetric), calculated using the Algover shock index - heart rate is divided by systolic pressure. The normal shock index for obstetrics is considered to be 0.5-0.9. If it exceeds 1, then the transfusion of blood components is mandatory. Taking into account the deficiency of BCC, infusion-transfusion therapy is carried out.

Simultaneously with intensive care, laboratory tests are performed:

Medical hemostasis is mandatory for hypotonic postpartum hemorrhage. Hemostatic drugs for uterine bleeding are used simultaneously with the started infusion therapy and laboratory research. In order to stop uterine bleeding, you need to enter such drugs.

Uterotonics - Oxytocin, Methylergometrine.
Antifibrinolytics - Tranexam (Cyclohemal) - 1 g intravenously, Aminocaproic acid. Dicynon (Etamsylate) is not included in the emergency protocol.
Calcium preparations - gluconate or chloride.
Fresh frozen plasma to compensate for the deficiency of fibrinogen, coagulation factors.
Cryoprecipitate - 1 dose / 10 kg of body weight.
Octaplex is a concentrate of clotting factors.
Recombinant coagulation factor Ⅶ - NovoSeven.

Synthetic vitamin K - Vikasol, is not an emergency drug for stopping uterine hypotonic bleeding. Its action begins only 24 hours after administration, so its administration can serve as a prevention of bleeding in pregnant women and puerperas who have reduced blood clotting after taking Warfarin.

Surgical hemostasis

In order to stop bleeding, surgical hemostasis is the most effective, which must be carried out without delay when making a diagnosis of hypotonic uterine bleeding. The implementation of hemostasis is based on the principles of phasing and organ preservation:

examination of the genital tract and suturing of wounds and tears;
manual examination of the uterus in order to remove the remnants of the placenta;
vacuum aspiration and curettage of the uterine cavity;
balloon tamponade, combined uterine and vaginal tamponade according to Zhukovsky;
compression sutures on the uterus in the area of the placental site;
ligation of the uterine arteries;
ligation of the iliac arteries;
removal of the uterus - hysterectomy.

The extension of the operation to a hysterectomy is most often associated with the following conditions:

intractable hypotension;
uterine fibroids;
true accreta of the placenta.

Conservative hemostasis algorithm for massive blood loss

To stop the blood in a conservative way, there are only three components:

blood components;
clotting factors;
antifibrinolytics.

With massive uterine bleeding, the following transfusion protocol is used:

15-20 ml/kg fresh frozen plasma;
3-4 dose of erythromass;
1 dose per 10 kg body weight of thrombomass;
1 dose/10 kg cryoprecipitate;
Tranexam (Cyclohemal) 10-15 mg/kg bolus + infusion 1-5 mg/kg/hour during the day;
prothrombin complex - 50 IU / kg;
Eptacog alfa (coagulation factor 7) - 90 mcg / kg, the same repeated dose after 2 hours in the absence of effect.

Prevention of obstetric bleeding

During pregnancy, it is very important to maintain a hematocrit value of more than 30. In order to treat anemia in pregnant women, iron preparations are prescribed, of which there are a lot on the market. Proved the development of severe postpartum hemorrhage in women with initial hemoglobin less than 90 g/l.

Prevention during childbirth and after:

light traction of the umbilical cord to assess the separation of the placenta, avoid intense movements;
clamping the umbilical cord not earlier than 1 minute after birth;
the introduction of drugs that reduce the uterus in the afterbirth;
in women without risk, 10 units of Oxytocin intramuscularly in the third stage of labor is sufficient;
during a caesarean section, for prevention, it is sufficient to administer 5 units of Oxytocin slowly intravenously;
after caesarean section, 1 ml of Oxytocin is injected intramuscularly after 6 hours once;
in women with an increased risk, administer Tranexam 0.5-1 g intravenously;
Methylergometrine is used as a backup drug at high risk;
in women at high risk, bolus and prolonged administration of Oxytocin is used.

Blood loss in a pregnant woman or puerperal is associated with high mortality, so this problem is given great attention by clinicians.

- Bleeding from the birth canal that occurs in the early or late postpartum period. Postpartum hemorrhage is most often the result of a major obstetric complication. The severity of postpartum hemorrhage is determined by the amount of blood loss. Bleeding is diagnosed during examination of the birth canal, examination of the uterine cavity, ultrasound. Treatment of postpartum hemorrhage requires infusion-transfusion therapy, the introduction of uterotonic agents, suturing ruptures, and sometimes hysterectomy.

ICD-10

O72

General information

The danger of postpartum hemorrhage is that it can lead to the rapid loss of a large volume of blood and death of the woman in labor. Abundant blood loss is facilitated by the presence of intense uterine blood flow and a large wound surface after childbirth. Normally, the body of a pregnant woman is ready for a physiologically acceptable blood loss during childbirth (up to 0.5% of body weight) due to an increase in intravascular blood volume. In addition, postpartum hemorrhage uterine wound it is prevented by increased contraction of the muscles of the uterus, compression and displacement into the deeper muscle layers of the uterine arteries with simultaneous activation of the blood coagulation system and thrombosis in small vessels.

Early postpartum hemorrhage occurs in the first 2 hours after birth, later ones can develop in the period from 2 hours to 6 weeks after the birth of the child. The outcome of postpartum hemorrhage depends on the volume of blood lost, the rate of bleeding, the effectiveness of conservative therapy, and the development of DIC. Prevention of postpartum hemorrhage is an urgent task of obstetrics and gynecology.

Causes of postpartum hemorrhage

Postpartum hemorrhage often occurs due to a violation of the contractile function of the myometrium: hypotension (decreased tone and insufficient contractile activity of the muscles of the uterus) or atony (complete loss of uterine tone, its ability to contract, lack of myometrial response to stimulation). The causes of such postpartum hemorrhage are fibroids and uterine fibroids, cicatricial processes in the myometrium; excessive stretching of the uterus during multiple pregnancy, polyhydramnios, prolonged labor with a large fetus; the use of drugs that reduce the tone of the uterus.

Postpartum hemorrhage can be caused by a delay in the uterine cavity of the remains of the placenta: placental lobules and parts of the membranes. This prevents the normal contraction of the uterus, provokes the development of inflammation and sudden postpartum bleeding. Partial accretion of the placenta, improper management of the third stage of labor, discoordinated labor, spasm of the cervix leads to a violation of the separation of the placenta.

Factors provoking postpartum hemorrhage can be malnutrition or atrophy of the endometrium due to previously performed surgical interventions- caesarean section, abortion, conservative myomectomy, curettage of the uterus. The occurrence of postpartum hemorrhage can be facilitated by impaired hemocoagulation in the mother, due to congenital anomalies, taking anticoagulants, the development of DIC - syndrome.

Often, postpartum bleeding develops with injuries (ruptures) or dissection of the genital tract during childbirth. There is a high risk of postpartum hemorrhage with gestosis, placenta previa and premature detachment, threatened miscarriage, fetoplacental insufficiency, breech presentation of the fetus, the presence of endometritis or cervicitis in the mother, chronic diseases of the cardiovascular and central nervous system, kidneys, liver.

Symptoms of postpartum hemorrhage

The clinical manifestations of postpartum hemorrhage are determined by the amount and intensity of blood loss. With an atonic uterus that does not respond to external medical manipulations, postpartum bleeding is usually profuse, but can also be undulating, sometimes subside under the influence of drugs that reduce the uterus. Objectively determined arterial hypotension, tachycardia, skin pallor.

The volume of blood loss up to 0.5% of the body weight of the woman in labor is regarded as physiologically acceptable; with an increase in the volume of blood lost, they speak of pathological postpartum hemorrhage. The amount of blood loss exceeding 1% of body weight is considered massive, more than this - critical. With critical blood loss, it can develop hemorrhagic shock and DIC with irreversible changes in vital organs.

In the late postpartum period, a woman should be alerted by intense and prolonged lochia, bright red discharge with large blood clots, bad smell pulling pains in the lower abdomen.

Diagnosis of postpartum hemorrhage

Modern clinical gynecology conducts an assessment of the risk of postpartum hemorrhage, which includes monitoring during pregnancy of hemoglobin levels, the number of erythrocytes and platelets in the blood serum, bleeding time and blood clotting, the state of the blood coagulation system (coagulograms). Hypotension and atony of the uterus can be diagnosed during the third stage of labor by flabbiness, weak contractions of the myometrium, and a longer course of the afterbirth period.

Diagnosis of postpartum hemorrhage is based on a thorough examination of the integrity of the discharged placenta and fetal membranes, as well as examination of the birth canal for trauma. Under general anesthesia, the gynecologist carefully performs a manual examination of the uterine cavity for the presence or absence of tears, the remaining parts of the placenta, blood clots, existing malformations or tumors that prevent the contraction of the myometrium.

An important role in the prevention of late postpartum hemorrhage is played by ultrasound of the pelvic organs on the 2nd-3rd day after birth, which makes it possible to detect the remaining fragments in the uterine cavity. placental tissue and fruit membranes.

Treatment of postpartum hemorrhage

When postpartum hemorrhage is paramount is to establish its causes, extremely quick stop and prevent acute blood loss, restore the volume of circulating blood and stabilize the level of blood pressure. Important in the fight against postpartum hemorrhage A complex approach with the use of both conservative (drug, mechanical) and surgical methods treatment.

To stimulate the contractile activity of the muscles of the uterus, catheterization and emptying of the bladder, local hypothermia (ice on the lower abdomen), gentle external massage of the uterus, and if there is no result, intravenous administration of uterotonic agents (usually methylergometrine with oxytocin), injections of prostaglandins into the cervix. To restore the BCC and eliminate the consequences of acute blood loss during postpartum hemorrhage, infusion-transfusion therapy with blood components and plasma-substituting drugs is carried out.

If ruptures of the cervix, vaginal walls and perineum are detected during examination of the birth canal in the mirrors, they are sutured under local anesthesia. In case of violation of the integrity of the placenta (even in the absence of bleeding), as well as in case of hypotonic postpartum hemorrhage, an urgent manual examination of the uterine cavity is performed under general anesthesia. During the revision of the walls of the uterus, manual separation of the remnants of the placenta and membranes, removal of blood clots are performed; determine the presence of ruptures of the body of the uterus.

In case of uterine rupture, an emergency laparotomy, wound closure, or removal of the uterus is performed. If signs of placenta accreta are found, as well as in case of intractable massive postpartum hemorrhage, subtotal hysterectomy is indicated (supravaginal amputation of the uterus); if necessary, it is accompanied by ligation of the internal iliac arteries or embolization of the uterine vessels.

Surgical interventions for postpartum hemorrhage are carried out simultaneously with resuscitation measures: compensation for blood loss, stabilization of hemodynamics and blood pressure. Their timely implementation before the development of thrombohemorrhagic syndrome saves the woman in labor from fatality.

Prevention of postpartum hemorrhage

Women with an unfavorable obstetric and gynecological history, coagulation disorders, taking anticoagulants, have a high risk of developing postpartum hemorrhage, therefore they are under special medical supervision during pregnancy and are sent to specialized maternity hospitals.

In order to prevent postpartum hemorrhage, women are given drugs that promote adequate contraction of the uterus. The first 2 hours after childbirth, all women in labor spend in the maternity ward under the dynamic supervision of medical personnel to assess the volume of blood loss in the early postpartum period.

ICD-10 code

Prevention of obstetric bleeding

Prevention of obstetric bleeding includes several principles.

Pregnancy planning, timely preparation for it (detection and treatment of chronic diseases before pregnancy, prevention of unwanted pregnancy).

Timely registration of a pregnant woman in a antenatal clinic (up to 12 weeks of pregnancy).

Regular visit obstetrician-gynecologist(1 time per month in the 1st trimester, 1 time in 2-3 weeks in the 2nd trimester, 1 time in 7-10 days in the 3rd trimester).

Removal of increased muscle tension of the uterus during pregnancy with the help of tocolytics (drugs that reduce muscle tension of the uterus).

Timely detection and treatment of complications during pregnancy:

preeclampsia(a complication of the course of pregnancy, accompanied by edema, increased blood pressure and impaired renal function);
placental insufficiency(violation of the functioning of the placenta due to insufficient blood supply to the "womb-placenta" system);
arterial hypertension(persistent increase in blood pressure).

Control of blood sugar levels with a glucose tolerance test (the pregnant woman is given 75 g of glucose and an hour later her blood sugar level is measured).

Compliance with a pregnant diet (with a moderate content of carbohydrates and fats (excluding fatty and fried foods, starchy foods, sweets) and sufficient protein content (meat and dairy products, legumes)).

Therapeutic exercise for pregnant women (minor physical exercise 30 minutes a day - breathing exercises, walking, stretching).

Rational management of childbirth:

assessment of indications and contraindications for childbirth through the natural birth canal or with the help of a caesarean section;
adequate use of uterotonics (drugs that stimulate uterine contractions);
exclusion of unreasonable palpations of the uterus and pulling on the umbilical cord in the afterbirth period of childbirth;
carrying out an episio- or perineotomy (dissection by a doctor of a woman's perineum (tissues between the entrance to the vagina and anus) as a prevention of perineal rupture);
examination of the discharged placenta (placenta) for integrity and the presence of tissue defects;
the introduction of uterotonics (drugs that stimulate muscle contractions of the uterus) in the early postpartum period.

Successful prevention and treatment of bleeding requires:

Identify risk groups for the development of bleeding, which will allow a number of preventive measures to be taken to reduce the incidence of obstetric bleeding and reduce the severity of post-hemorrhagic disorders.

Currently, the main risk groups for the occurrence of massive coagulopathic bleeding in obstetrics are presented (A. D. Makatsaria et al., 1990).

I. Pregnant women and women in labor with preeclampsia and extragenital diseases (diseases of the cardiovascular system, kidneys, diathesis, venous insufficiency, etc.) In this group, 4 types of hemostasis disorders were found in DIC:

1) hypercoagulation and hyperaggregation of platelets with thrombinemia;

2) hypercoagulability and consumption thrombocytopathy;

3) isocoagulation or hypocoagulation and platelet hyperaggregation;

4) isocoagulation or hypocoagulation and consumption thrombocytopathy.

The probability of bleeding during childbirth and the postpartum period is especially high with types 2, 3 and 4 of hemostasis disorders, with type 4 there is a 100% chance of coagulopathy bleeding.

II. Pregnant women with hereditary and congenital defects in coagulation and platelet hemostasis.

III. Pregnant women and women in labor with disadaptation of hemostasis - hypo- or isocoagulation in the third trimester of pregnancy, uncharacteristic for this period of pregnancy. Disadaptation of hemostasis is often observed in patients with recurrent miscarriage, endocrine disorders, and infectious diseases. In the absence of preventive measures in this group (administration of FFP), bleeding occurs in every third woman.

IV. Iatrogenic disorders (untimely start of infusion-transfusion therapy, insufficient pace and volume of administered solutions, incorrect choice of the qualitative and quantitative composition of solutions, homeostasis correction errors, incorrect choice of means and methods for stopping bleeding).

V. Parturients and puerperas with the circulation of specific and non-specific inhibitors of blood coagulation.

A specific and effective algorithm for predicting, monitoring and intensive care in the prevention of obstetric bleeding was proposed by O. I. Yakubovich et al. (2000): according to the authors, the application of the developed program made it possible to increase by 13.4% the number of women whose childbirth ended without pathological blood loss.

Hemostasiological indicators were determined that have the greatest information content in terms of predicting pathological blood loss in childbirth and its estimated volume - the number of platelets, fibrinogen, fibrinogen B, thrombin time, the K parameter of thromboelastogram under conditions of high-contact activation of hemocoagulation and the level of D-dimers, a number of regression equations and a scheme for the management of pregnant women has been developed, starting from the first visit of a woman to a antenatal clinic.

In the I and II trimesters, 2 indicators are determined - the level of fibrinogen and thrombin time, the function F is determined:

F = 0.96a - 0.042b - 2.51,

where a is the concentration of fibrinogen in plasma, g/l;

b - thrombin time, s.

If the value of the function F>0.31, physiological blood loss is predicted, the woman continues to be observed in the antenatal clinic and the hemostasis indicators are re-monitored in the III trimester.

With a value of F<-0,27, когда прогнозируется патологическая кровопотеря или при значении функции F в диапазоне от -0,27... до 0,31, что составляет зону неопределенного прогноза, пациентку направляют в стационар одного дня, где проводят углубленное комплексное исследование системы гемостаза и в зависимости от результата рекомендуют лечение в амбулаторных или стационарных условиях.

As a rule, in the first trimester of pregnancy, pathology of the vascular-platelet hemostasis link is detected and therapy is aimed at stabilizing endothelial function and reducing the aggregation ability of platelets: metabolic therapy (riboxin, magnesium, vitamin B6), herbal medicine, antiplatelet agents (aspirin) for 10- 14 days.

In the II trimester, given the more pronounced dysfunction of vascular-platelet hemostasis and the tendency to intravascular coagulation, this therapy is supplemented with prophylactic doses of low molecular weight heparins - fraxiparin at a dose of 7500 IU. When registering an isolated activation of fibrinolysis, Essentiale, lipoic acid, vikasol are additionally prescribed, the dosage of riboxin is increased. In the absence of positive dynamics from the side of the hemostasiogram, fibrinolysis inhibitors are connected in prophylactic doses. The effectiveness of treatment is assessed 10 days after the start of therapy by re-determining the prognosis - function F.

In the III trimester, pathological blood loss is predicted using the following parameters:

F \u003d -0.89a - 0.59b + 0.014c + 0.012d - 1.14,

where a is the concentration of fibrinogen B in plasma, g/l;

b - D-dimers, ng/ml;

c is the number of platelets, 109/l;

d - parameter K of the thromboelastogram (TEG) under conditions of high-contact activation of hemocoagulation, mm.

If the value of the function F>0.2, physiological blood loss is predicted, and the woman continues to be observed in the consultation.

With a value of F<-0,2 прогнозируется патологическая кровопотеря, значения F от -0,2... до 0,2 составляют зону неопределенного прогноза и в этих случаях беременной проводится комплексное исследование системы гемостаза и в зависимости от выраженности гемостазиологических нарушений назначается терапия.

To resolve the issue of the volume of intensive care, you can use the algorithm for predicting the estimated volume of blood loss. For this, two discriminant functions are calculated:

F1 \u003d -1.012a - 0.003b - 0.038c + 4.16

F2 \u003d -0.36a + 0.02b + 0.03c - 4.96,

where a is the level of fibrinogen B, g/l;

b is the number of platelets, 10 to 9 degrees/l;

c - parameter K TEG in conditions of high-contact hemocoagulation, mm.

With the values of the functions F, >0.2 and F2 >0.5, one can expect a blood loss of less than 500 ml; if F1 > 0.2 and F2< -0,2, ожидается объем кровопотери от 500 до 1000 мл и женщина может проходить лечение в акушерском стационаре. Если F1 < -0,5, a F2 >0.2, then more than 1000 ml of blood loss is assumed, and the woman should be treated in the intensive care unit.

In the III trimester, patients with a prognosis of pathological blood loss during childbirth, as a rule, already have profound disorders of all links of hemostasis, up to the development of a typical pattern of DIC blood. In this contingent of pregnant women, therapy includes low molecular weight heparin, fresh frozen plasma (antithrombin-III concentrate), if DIC occurs, the deficiency of anticoagulants (antithrombin-III, protein C and S) is replenished, vascular-platelet hemostasis is corrected using dicynone and ATP, coagulation the potential is replenished with supernatant donor plasma, cryoprecipitate in combination with fibrinolysis inhibitors.

The next step in solving the problem of combating bleeding is the use of modern methods of replenishing blood loss and preventing bleeding in women of "high risk" bleeding groups. It's about about the types of autohemo- and plasma donation, which include: preoperative preparation of blood components, controlled hemodilution and intraoperative blood reinfusion (V.N. Serov, 1997, V.I. Kulakov et al., 2000).

Preoperative preparation of blood components

Procurement of erythrocyte mass in obstetrics is not used. Erythrocyte sampling from gynecological patients in the amount of 200-300 ml is carried out 2-7 days before surgery for 1 and 2 exfusions with compensation with colloid and crystalloid solutions in a ratio of 2:1. The erythromass is stored at a temperature of +4°C. Harvesting of autoerythrocytes is indicated with an estimated blood loss of 1000-1200 ml (20-25% of the BCC), with difficulties in the selection of donor erythrocytes, transfusion reactions, and a high risk of thromboembolic complications in the postoperative period.

The following contraindications to the harvesting of autoerythrocytes have been identified: anemia (Hb less than 110 g/l and Ht less than 30%), various forms of hemoglobinopathies, hypotension (BP less than 100/60 mm Hg), cardiovascular decompensation, sepsis, septic conditions, ARI, exhaustion, hemolysis of any origin, chronic renal failure with azotemia, liver failure, severe atherosclerosis, cancer cachexia, severe hemorrhagic syndrome and thrombocytopenia (platelet count less than 50 10 in 9 degrees / l).

When harvesting autoerythrocytes, venipuncture, infusion of 200-300 ml of 0.9% NaCl, exfusion of the calculated blood volume, taking into account body weight, initial Hb and Ht (usually 15% BCC) and centrifugation of blood (speed 2400 rpm for 10 min) are performed ). Additionally, 0.9% NaCl is administered and autoplasma retransfusion. For one procedure, when performing two exfusions, 200-450 ml of erythroconcentrate are obtained. The optimal period for harvesting autoerythrocytes before surgery is usually 5-8 days, provided that the main hemodynamic parameters are stable, after harvesting autoerythrocytes, the decrease in Ht is not allowed to be less than 30%, respectively, the level of Hb is not less than 100 g / l.

If the need for erythrocytes exceeds 15% of the BCC, which cannot be prepared in one procedure, the “jumping frog” method is used: stage I - exfusion of 400-450 ml of blood, stage II - after 5-7 days, infusion of blood prepared at stage I, exfusion 800-900 ml of blood, stage III - 5-7 days after stage II, exfusion of blood in a volume of 1200-1400 ml with an infusion of 800-900 ml of blood harvested at stage II. The method allows to prepare 1200-1400 ml of autologous blood of short shelf life with high rates of oxygen transport function.

During obstetric operations, the woman's body needs to replenish blood coagulation factors, fibrinogen, antithrombin-III, the deficiency of which is due to the subclinical course of DIC during pregnancy. The main source of clotting factors is FFP. The preparation of autoplasma is carried out by the method of discrete plasmapheresis in the amount of 600 ml for 2 exfusions with an interval of a week for 1-2 months before the expected date of delivery.

Indications for autoplasma donation in pregnant women are abdominal delivery according to absolute indications (uterine scar, high myopia, placenta previa, anatomically narrow pelvis), or according to the sum of relative indications with a predicted blood loss of no more than 1000 ml (no more than 20% of BCC), the estimated during surgery by hypocoagulation, with an initial content of Hb at the level of 100-120 g/l, total protein not less than 65 g/l.

Harvesting of autoplasma is contraindicated in case of low content of total protein - less than 65 g/l, albumin content less than 30 g/l, in case of pulmonary, renal, hepatic or cardiovascular insufficiency, septic conditions, hemolysis of any genesis, severe disorders of coagulation and thrombocytopenia (less than 50 10 to the 9th degree/l).

2 stages of plasmapheresis are carried out to obtain 800-1200 ml of plasma. 400-500 ml of blood is exfuse simultaneously, centrifugation is carried out at a speed of 2800 rpm for 10 minutes or 2200 rpm for 15 minutes. After compensation (1:1) with isotonic solutions and reinfusion of erythrocytes, the next 400-500 ml of blood is taken. The total volume of plasma obtained is determined by the condition of the patient, the initial content of total protein and albumin, the calculated value of the VCP. The content of total protein after plasmapheresis should be at least 60 g/l, more often 0.25 VCP is exfused. Plasma replacement is carried out with colloid or crystalloid solutions in a ratio of 2:1. Plasma is stored at a temperature of -18 ° C, transfused - during cesarean section in order to stabilize coagulation and hemodynamic parameters and protein parameters (M. M. Petrov, 1999).

Another modern method replenishment of operational blood loss is controlled hemodilution. There are normovolemic and hypervolemic hemodilutions.

Normovolemic hemodilution is indicated during operations in gynecological patients. After the introduction of anesthesia, the patient is exfused with 500-800 ml of blood with simultaneous replacement with colloids in an equal volume. The blood harvested in this way is reinfused after achieving surgical hemostasis. A contraindication to the method is the initial anemia, severe coronary pathology, obstructive pulmonary disease, severe hypertension, cirrhosis of the liver, defects in the hemostasis system (hypocoagulation), endogenous intoxication, mitral heart disease, renal failure.

In obstetrics, during a caesarean section, the hypervolemic hemodilution technique is used, which consists in the preliminary transfusion of solutions with high colloid osmotic pressure or osmolarity. As a result, there is an improvement in microcirculation, in particular, in the uteroplacental zone, normalization of the rheological properties of blood, a decrease in the risk of thrombotic and purulent-septic complications, and an increase in lactation. For hypervolemic hemodilution, solutions of albumin, rheopolyglucin, hydroxyethyl starch are used, which are well tolerated, improve tissue perfusion, circulate for a long time in the vascular bed, and do not pose a risk to the pregnant woman and the fetus. The method is contraindicated in severe anemia, mitral heart disease, renal failure, hypocoagulation, intrauterine fetal suffering.

The presence of modern equipment "Cell-saver" firms "Haemonetics", "Althin", "Dideco" has made a promising and safe method such as intraoperative blood reinfusion. At the same time, blood from the surgical wound is aspirated using a sterile pump into a special container with an anticoagulant, then it enters the separator, where it is washed with saline during rotation, hemoconcentration occurs, and the end product is an erythrosuspension with Ht of about 60%, which is returned to the patient.

Blood reinfusion is used in gynecological operations, when the estimated blood loss is more than 500 ml, and is the method of choice in patients with rare group blood burdened by allergic and blood transfusion history.

The use of reinfusion during cesarean section is promising, however, it is necessary to remember the presence of thromboplastic substances in the amniotic fluid and the possibility of their transfer into the patient's vascular bed. Therefore it is necessary:

1) amniotomy before surgery,

2) use of a second pump immediately after extraction to aspirate amniotic fluid, cheese grease and meconium,

3) the use of a special mode of high-quality washing of erythrocytes with a large amount of solution.

The presence in the abdominal cavity of liquids such as furatsilina solution, small amounts of alcohol, iodine, cyst contents, is not a contraindication to reinfusion, because. these substances will be washed away during washing at high speed.

Indications for intraoperative reinfusion in obstetrics are repeated caesarean section, caesarean section and conservative myomectomy, caesarean section followed by amputation (extirpation) of the uterus, varicose veins of the uterus, hemangiomas of the pelvic organs.

An absolute contraindication to reinfusion is the presence of intestinal contents and pus in the abdominal cavity. A relative contraindication is the presence of a malignant neoplasm in a patient.

The use of the above methods, taking into account indications and contraindications to them, in most cases allows for timely, effective and safe prevention of the development of hemorrhagic shock. At the same time, the use of donor blood decreases, i.e. the risk of developing blood transfusion complications, HIV infection and hepatitis is excluded, maternal morbidity and mortality are reduced (Methodological recommendations No. 96/120 of the Ministry of Health of the Russian Federation “Prevention and treatment of bleeding in obstetrics and gynecology”, 1997).

A feature of obstetric bleeding is their acute onset and massive blood loss, therefore important role the implementation of a set of organizational measures plays a role in reducing maternal mortality from bleeding. According to the definition of V. N. Serov (1993), the survival of patients with massive obstetric bleeding is determined by the help started in the first 30 minutes and carried out in the first 3 hours from the onset of obstetric bleeding, 75% of the lost blood volume should be replenished in the first 1-2 hours from the onset of bleeding.

Organizational activities include the following points (E. N. Zarubina, 1995, I. B. Manukhin et al., 1999):

1. The suddenness of the onset of a critical situation and the diversity of actions at the time of bleeding determine the attitude to childbirth, as to a surgical operation. This approach involves a preliminary examination of the woman by an anesthesiologist and her preoperative preparation, including emptying the intestines, bladder, creating psychological comfort, etc. During childbirth, the presence of an anesthetic team is recommended, which organizes anesthesia for childbirth and provides the entire volume and quality of infusion therapy in the event of bleeding.

2. An important point is the creation in the obstetric institution of stocks of blood components, consisting of FFP, washed erythrocytes, erythromass, thrombus mass, albumin, plasma-substituting solutions, systems for emergency blood sampling.

3. It is necessary to have a 24-hour express laboratory, whose function includes clinical and biochemical examination of blood and the hemostasis system. It should be emphasized the need to determine the initial parameters of hemostasis, monitoring them during the onset of bleeding and in the process of infusion therapy.

4. Before the onset of the active phase of labor, each woman in labor is catheterized with a peripheral vein and the blood group is determined by the ABO and Rh system in case of possible blood transfusion.

5. Therapy of obstetric bleeding is carried out in the operating room or in the delivery room, where there is everything necessary to ensure intensive treatment and, if necessary, surgical intervention. The time required to deploy the operating room should not exceed 5-7 minutes.

6. The duty team should include a specialist who knows all methods of stopping obstetric bleeding, including performing hysterectomy and ligation of the internal iliac arteries.

7. With the development of bleeding, the main task of the obstetrician is the timely use of the most effective and reliable methods of stopping it before the onset of hemorrhagic shock. Delay leads to the fact that we have to fight not only with bleeding, but also with multiple organ failure that occurs in the post-resuscitation period. When bleeding, the main task is to stop them. It implies an examination of the birth canal, the elimination of traumatic injuries, the use of mechanical methods to stop bleeding, the introduction of uterotonic agents.

Lysenkov S.P., Myasnikova V.V., Ponomarev V.V.