Significance of the problem that is caused by obstetricbleeding, due to the fact that this pathology acts as the main and immediate cause of death of 60-70% of women. It follows that postpartum hemorrhages are on 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, which opened after giving birth in the first 4 hours.
Possible reasons
Главными причинами возможного гипотонического bleeding can be: atony and hypotension of the uterus, poor blood clotting, part of the children's place that has not left the uterus, trauma of soft tissues in the birth canal.
What is hypotension uterus
Hypotension of the uterus is called a condition whenwhich sharply decreases the tone and its ability to decline. Thanks to the measures taken and under the action of means that stimulate the contractile function, the muscle begins to contract, although often the force of the contractile reaction is not equal to the force of the action. For this reason, hypotonic bleeding develops.
Atony
Atony uterus is a condition in whichFunds aimed at the excitation of the uterus, are not able to have any impact on her. 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.
Provocative bleeding factors
Causes of hypotonic bleeding andatonic nature may be different. One of the main reasons is the weakening of the body, i.e. the central nervous system weakens due to long and painful childbirth, persistent labor is weakened, in addition, the reason may be fast delivery and use of oxytocin. The causes also include severe gestosis (nephropathy, eclampsia) and hypertension. Postpartum hypotonic bleeding is very dangerous.
The next reason could be inferiority.uterus at the anatomical level: poor development and malformations of the uterus; various fibroids; the presence of scars on the uterus after operations performed earlier; diseases caused by inflammation or abortion, replacing a significant part of the muscle with connective tissue.
In addition, the consequences of hypotonicearly postpartum bleeding are: uterine dysfunction, i.e. its strong stretching as a result of polyhydramnios, the presence of more than one fruit, if the fetus is large in size; previa and low attachment of the placenta.
Hypotension or Atonia
Bleeding hypotonic and atonicnature may result from a combination of several of the above reasons. In this case, the bleeding becomes more dangerous. Based on the fact that at the first symptoms it is difficult to find the difference between hypotonic bleeding and atonic, it is correct to use the first definition, and to diagnose uterine atony, if the rendered measures were ineffective.
What is the reason for stopping bleeding
The bleeding stop that was caused bythat placental abruption occurred and the birth of the afterbirth, as a rule, explains two main factors: myometrial retraction and thrombus formation in the vessels of the placenta area. Enhanced retraction of the myometrium leads to the fact that the venous vessels contract and twist, and the spiral arteries are drawn into the thickness of the uterus. After this, thrombus formation begins in the uterus vessels, which is facilitated by the blood coagulation process. The process of blood clots can take a long time, sometimes several hours.
Women who are at high risk inin relation to early postpartum hypotonic bleeding, pain relief is necessary, because contractions, which are accompanied by severe pain, lead to disruption of the central nervous system and the necessary relationship between the subcortical structures 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 what can often begin in a sequential period, and then go into the bleeding of the early postpartum period.
Clinical hypotension options
М. А.Repina (1986) performed the isolation of two clinical variants of uterine hypotension. According to this theory, in the first embodiment, the bleeding is abundant from the very beginning, the blood loss is huge. The uterus becomes flabby, atonic, shows a weak reaction to the introduction of funds that contribute to its reduction. Hypovolemia develops rapidly, hemorrhagic shock begins, and the syndrome of disseminated intravascular coagulation often occurs (DIC).
In the second version of the theory of blood lossinsignificant, the clinical picture is characterized by hypotonic state of the uterus: repeated blood loss alternates with short-term regeneration of myometrial tone and temporary cessation of bleeding as a result of conservative treatment (such as the introduction of reducing means, external uterine massage). As a result of comparatively small repeated blood loss, a temporary habituation of a woman to progressive hypovolemia begins: blood pressure decreases slightly, pallor of the skin and visible mucous membranes is observed, insignificant tachycardia occurs.
В результате компенсированных дробных кровопотерь the onset of hypovolemia often goes unnoticed by medical professionals. When treatment at the initial stage of hypotonia of the uterus was ineffective, its impaired contractile function begins to progress, the reactions to the therapeutic effect become short-lived, and the volume of blood loss increases. At some stage, the bleeding begins to increase significantly, leading to a sharp deterioration in the patient’s condition and all signs of hemorrhagic shock and DIC begin to develop.
Определение эффективности мероприятий первого Stage must be relatively fast. If for 10-15 minutes. the uterus is not well reduced, and hypotonic bleeding in the postpartum period does not stop, you must immediately carry out a manual examination of the uterus and apply a massage of the uterus on the fist. Based on practical obstetric experience, a timely manual examination of the uterus, clearing it of accumulated blood clots, and then made her massage on the fist, help to ensure accurate uterine hemostasis and prevent severe blood loss.
Significant information that causesthe need for appropriate examination of the uterus with hand when hypotonic bleeding arises in the early postpartum period, results M. A. Repin in his own monograph “Bleeding in obstetric practice” (1986). According to her observations, for those who died from him the estimated time from the appearance of bleeding to the manual examination of the uterine cavity is on average 50-70 minutes. In addition, the fact that there is no effect from this operation and the invariance of the hypotonic state of the myometrium indicate not only that the performed operation was performed late, but also the unlikely forecast of cessation of bleeding even with the use of other conservative treatment methods.
Clamping method according to N. S. Baksheev
Во время мероприятий второго этапа необходимо use techniques that contribute to at least the slightest decrease in blood flow to the uterus, which can be achieved with the aid of finger pressing of the aorta, parameterization, ligation of great vessels, etc. Today, among the many methods available, N.Sheksheev's method of clamping is the most popular , due 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.
Method N. S.Baksheyev is used when the volume of blood loss is not too large (no more than 700-800 ml). The duration of the presence of terminals on the parametriums should not be more than 6 hours. In cases where the presence of overlaid terminals does not stop the bleeding, at least in small quantities, it is required to take time to confuse the question of how to remove the uterus. This operation is called supravaginal amputation or hysterectomy. A surgery to remove the uterus, done on time, is the most reliable method to stop hypotonic bleeding after delivery.
Timely and necessary measures
This is due to the risk of coagulability.blood. Thus, in the control of uterine hypotonia, as well as to restore hemodynamics, it is necessary to carefully monitor the nature of the blood clots that form in the patient, which results from the genital tract, as well as the appearance of petechial skin hemorrhages, especially at the injection site.
If you have the slightest symptomshypofibrinogenemia, proceed to the immediate introduction of drugs that increase the coagulating properties of blood. When in this case the question arises about the necessity of the operation to remove the uterus, an extirpation is required, not an amputation of the uterus. This is explained by the fact that the likely remaining cervical stump may serve as a continuation of the sporting pathological process, if there is a violation of blood clotting. A stop hypotonic bleeding should be timely.
