The significance of the problem caused by obstetric bleeding is due to the fact that this pathology acts as the main and immediate cause of death in 60-70% of women. It follows that postpartum hemorrhage is one of the most important places in the system of maternal mortality. By the way, it is noted that the leading role among obstetric hemorrhages is occupied by hypotonic ones, which opened after childbirth in the first 4 hours.
Possible causes
The main causes of possible hypotonic bleeding can be: atony and hypotension of the uterus, poor blood clotting, part of the child's place that has not left the uterine cavity, injury to the soft tissues in the birth canal.
What is uterine hypotension
Hypotension of the uterus is a condition in which the tone and its ability to contract sharply decrease. Thanks toactivities and under the influence of drugs that excite the contractile function, the muscle begins to contract, although often the strength of the contractile reaction is not equal to the strength of the impact. For this reason, hypotonic bleeding develops.
Atonia
Uterine atony is a condition in which funds aimed at stimulating the uterus are not able to have any effect on it. The apparatus of the neuromuscular system of the uterus is in a state of paralysis. This condition does not happen often, but can cause severe bleeding.
Provoking bleeding factors
The causes of hypotonic and atonic bleeding may be different. One of the main reasons is the weakening of the body, i.e. the central nervous system weakens due to prolonged and painful childbirth, persistent labor activity weakens, in addition, rapid labor and the use of oxytocin can be the cause. Also, the causes include severe gestosis (nephropathy, eclampsia) and hypertension. Postpartum hypotonic bleeding is very dangerous.
The next reason may be the inferiority of the uterus at the anatomical level: poor development and malformations of the uterus; various fibroids; the presence of scars on the uterus after previous operations; diseases caused by inflammation or abortion, replacing a significant part of the muscle with connective tissue.
In addition, the consequences of hypotonic bleeding in the early postpartum period are: uterine dysfunction, i.e.its strong stretching as a result of polyhydramnios, the presence of more than one fetus, if the fetus is large; placenta previa and low insertion.
Hypotonia or atony
Bleeding of a hypotonic and atonic nature may result from a combination of several of the above causes. In this case, bleeding becomes more dangerous. Based on the fact that at the first symptoms it can be difficult to find the difference between hypotonic bleeding and atonic, it will be correct to use the first definition, and diagnose uterine atony if the measures taken have been ineffective.
What causes bleeding to stop
The stoppage of bleeding, which was caused by placental abruption and the birth of the placenta, as a rule, is explained by two main factors: myometrial retraction and thrombus formation in the vessels of the placental site. The increased retraction of the myometrium leads to the fact that the venous vessels are compressed and twisted, and the spiral arteries are also drawn into the thickness of the uterine muscle. After this, thrombus formation begins in the vessels of the uterus, which is facilitated by the process of blood clotting. The process of blood clots formation can last quite a long time, sometimes several hours.
Women in labor at high risk for early postpartum hypotonic hemorrhage should be carefully anesthetized because contractions that are accompanied by severe pain lead to disruption of the central nervous system andnecessary relationships between subcortical formations and, accordingly, the cerebral cortex. As a result, a violation of the generic dominant is possible, which is accompanied by equivalent changes in the uterus.
Clinically, such bleeding is manifested in the fact that it can often begin in the afterbirth period, and then turn into bleeding in the early postpartum period.
Clinical variants of hypotension
M. A. Repina (1986) identified two clinical variants of uterine hypotension. According to this theory, in the first variant, bleeding is abundant from the very beginning, blood loss is huge. The uterus becomes flabby, atonic, shows a weak reaction to the introduction of drugs that contribute to its reduction. Hypovolemia rapidly develops, hemorrhagic shock sets in, and disseminated intravascular coagulation (DIC) often occurs.
In the second version of the theory, blood loss is insignificant, the clinical picture is characteristic of a hypotonic state of the uterus: repeated blood loss alternates with a short-term regeneration of myometrial tone and a temporary stop of bleeding as a result of conservative treatment (such as the introduction of reducing agents, external massage of the uterus). As a result of relatively small repeated blood loss, a woman begins to temporarily become accustomed to progressive hypovolemia: blood pressure decreases slightly, the appearance of pallor of the skin and visible mucous membranes is observed, and an insignificanttachycardia.
As a result of compensated fractional blood loss, the onset of hypovolemia often goes unnoticed by medical professionals. When treatment at the initial stage of uterine hypotension was ineffective, its impaired contractile function begins to progress, responses to therapeutic effects become short-lived, and the amount of blood loss increases. At some stage, bleeding begins to increase significantly, leading to a sharp deterioration in the patient's condition and all signs of hemorrhagic shock and DIC syndrome begin to develop.
Determining the effectiveness of the activities of the first stage should be relatively fast. If for 10-15 minutes. the uterus shrinks poorly, and hypotonic bleeding in the postpartum period does not stop, then manual examination of the uterus should be carried out immediately and uterine massage on the fist should be applied. Based on practical obstetric experience, a timely manual examination of the uterus, cleaning it of accumulated blood clots, and then massaging it on the fist helps to ensure correct uterine hemostasis and prevent severe blood loss.
Significant information that necessitates an appropriate hand examination of the uterus in the event of hypotonic bleeding in the early postpartum period is given by M. A. Repina in her own monograph "Bleeding in obstetric practice" (1986). According to her observations, in those who died from it, the approximate time from the onset of bleeding to manual examination of the uterine cavityaverages 50-70 minutes. In addition, the lack of effect of this operation and the invariance of the hypotonic state of the myometrium indicate not only that the operation was performed late, but also about the unlikely prognosis of stopping bleeding even with the use of other conservative methods of treatment.
Terminating method according to N. S. Baksheev
During the activities of the second stage, it is necessary to use techniques that contribute to at least the slightest decrease in blood flow to the uterus, which can be achieved with the help of finger pressure on the aorta, clamping of parametria, ligation of the main vessels, etc. Today, among the many of these methods The most popular is the method of clamping according to N. S. Baksheev, thanks to which in many cases it was possible to stop hypotonic uterine bleeding, which in turn helped to do without surgery to remove the uterus.
N. S. Baksheev's method is used when the volume of blood loss is not too large (no more than 700-800 ml). The duration of the presence of the terminals on the parameters should not be more than 6 hours. In cases where, in the presence of superimposed terminals, the bleeding does not stop, at least in small quantities, it is necessary to be puzzled in time by the question of removing the uterus. This operation is called supravaginal amputation or extirpation of the uterus. Surgery to remove the uterus, done on time, is the most reliable method to stop hypotonicbleeding after childbirth.
Timely and necessary action
This is due to the risk of bleeding disorders. Thus, in the fight against uterine hypotension, as well as to restore hemodynamics, it is necessary to carefully monitor the nature of the blood clots formed in the patient, which follows from the genital tract, as well as the occurrence of petechial skin hemorrhages, especially at the injection site.
If the slightest symptoms of hypofibrinogenemia appear, they begin the urgent administration of drugs that increase the coagulating properties of the blood. When in this case the question arises of the mandatory operation to remove the uterus, extirpation is required, and not amputation of the uterus. This is explained by the fact that probably the remaining stump of the cervix can serve as a continuation of the frolicking pathological process, if there is a violation of blood clotting. And stopping hypotonic bleeding should be timely.
