Hypotonic and atonic postpartum

hemorrhage
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As mentioned, the cause of bleeding after the birth of the placenta is, first of all, reduction of the
uterus. The result is expressed retraction reduce the placental site with a bleeding blood vessels
and the lumen of the vessels. The second reason that provides hemostasis immediately after
delivery is fast clots in the placental site. Only if the aggregate of these two reasons you may
stop bleeding after childbirth. Conversely, if one of the mechanisms violated, early postpartum
period is complicated by uterine bleeding. The most common cause of bleeding is the contractile
ability of the uterus. Disorder of the blood coagulation system also can cause severe, even fatal
bleeding, but this disease is more often secondary and occurs much less frequently.
The bleeding is due to low contractile ability Oxytocics, called hypotonic. If the uterine
musculature not able to shrink, bleeding is called atopic. With atony of the uterus wall of her
flabby, flat, doesn't react on any irritation. Atonic bleeding is very rare. In the early postpartum
period is generally the case hypotonic hemorrhage. Spending childbirth, women, never forget
that even the most insignificant uterine bleeding in the postpartum period in the absence of
attention to it and timely assistance can go to catastrophic.
Hypotonic postpartum hemorrhage occurs frequently, its frequency is 4-6%. This serious defect
requires early diagnosis and rapid treatment measures.
One frequent cause hypotension uterus after delivery is delayed in the uterus parts of the
placenta. Even small slices of the placenta prevent the normal reduction in placental site. In this
regard, the examination of the placenta must always be carried out very carefully. At the slightest
suspicion on a defect placental tissue is necessary to perform a manual examination of the uterus
to remove the rear part of the placenta.
To hypotonic postpartum bleeding predispose the hyperextension of the uterus in connection
with the birth of large fruit, multiple births, mnogovodnee, low placentation, underdevelopment
and malformation of the uterus (for example, bicornuate uterus), uterine sites fibromyoma,
moved past inflammatory diseases, and artificial spontaneous miscarriages, prolonged labour,
endometritis in childbirth, endocrine diseases of women. On the frequency of occurrence
hypotonic hemorrhages also influenced the elderly woman.
Diagnostics hypotonic condition of the uterus and related bleeding does not pose special
difficulties. Soon after the birth of the placenta and the uterus becomes loose, stretched, the
contours of her work are defined through the abdominal wall. In connection with the relaxation
of the wall of the uterus, its hypotension capacity of the uterus grows, it may accumulate a large
quantity of liquid and blood clots. External bleeding if hypotension uterus can be quite strong,
flowing blood flows broad stream. Diagnostics in these cases, as a rule, is timely.
However, sometimes the blood clots that are stuck in the uterus, hinder the outflow of liquid
blood, the external bleeding as a result may not exist or be very small. The absence of external
bleeding is often the cause of late diagnosis rich blood loss that is caused by incorrect
observation of such child-birth.
Observing the overall condition of postpartum women and adolescent girls within the first hour

after birth, it is necessary not only to monitor quantity of the flowing and collected in a basin of
blood, but always at hand to check the height of standing of the fundus of the uterus and its
width. The increase in the transverse size of the uterus or the definition of the fundus of the
uterus above the level at which it was after the birth of the placenta, testifies to the congestion in
the uterus blood.
A woman's body responds differently to blood loss. This difference of reaction depends not only
on the number of loose blood, but also on the speed of blood loss that with hypotonic
hemorrhage must always be considered. In connection with non-refunded in a timely manner
acute massive blood loss may develop a whole number of serious complications, such as the
status of hemorrhagic shock, Hypo or afibrinogenemia, acute renal failure and possible death
postpartum women and adolescent girls from severe anemia. Therefore, by diagnosing hypotonic
postpartum hemorrhage, must be treated in two directions: 1) control of bleeding, 2)
replenishment of circulating blood volume.
In conditions where the midwife working independently, in the event of hypotonic hemorrhage
must immediately call a physician, telling him about the reason for the call, and the blood group
and rhesus facilities postpartum women and adolescent girls.
A very important issue for uterine postpartum hemorrhage is the accounting of blood loss. Leaky
blood should be collected in a vessel or in a bowl and pour into a graduated container. In
addition, after stopping bleeding, you must weigh all linen and all the bandages soaked with
blood. From these values need to subtract the weight of a dry linen. The resulting difference and
will be a lot of lost woman's blood. For translation mass in volumetric units - milliliters and liters
- you should know that 100 ml of blood weigh about 120, All of these calculations is absolutely
necessary for the correct filling of blood loss.
Measures to combat bleeding should be aimed at improving the contractility of the uterus. The
sequence of events is essential.
First of all it is necessary to release the urine catheter and manufacture of outdoor massage of
the uterus. For this Palmar surface of the fingers do in the bottom of the uterus light circular
motion. In response, the uterus contracts, consistency it becomes dense. When uterine
contractions of her cavity exiled liquid blood clots, after which the size of the uterus decrease.
Sometimes these simple actions is enough to stop the bleeding. In such cases addition is an
intramuscular injection of 1-2 ml metilargometrina, 5 ml of 3% solution of pahikarpin, or 1-2 ml
of oxytocin.
Applying reduce the uterus funds. If the event has been ineffective and bleeding continues, it is
necessary to intravenous injection, 1 ml metilargometrina or 1 ml (5 UNITS) oxytocin, diluted in
20 ml of 40% glucose solution. If hypotension uterus introduction one of these funds is causing a
reduction in the response of the muscles of the uterus, and therefore the cessation of bleeding. In
this case, you must immediately go for a long (not less than one hour) drip intravenous oxytocin,
which 2 ml (10 IU) oxytocin throw in 250-300 ml of 5% glucose solution or physiological
solution and impose a speed of 20-30 drops per 1 min.
In the absence of uterine contractions after intravenous oxytocin or metilargometrina need to

think about atonic hemorrhage, or that in the uterine cavity there are remnants of placental tissue.
Therefore, it is necessary immediately to produce a manual examination of the uterus, delete
scraps membranes, blood clots, and the remains of placental tissue. Then, without removing his
hands, to make massage of the uterus on his fist.
To the manual examination of the uterus to prepare necessary as to the manual separation of the
placenta. At that time, while operating prepares hand, someone else has to make another attempt
to stop the bleeding by pressing the abdominal aorta. For this we need to stand by the side of
postpartum women and adolescent girls and fingers of both hands, placing one hand over the
other, to press the ventral portion of the aorta to the spine. The same can be done with a fist right
hand (Fig. 38). This decreases the blood flow to the uterus and in response to anemisation the
uterus contracts.

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For manual examination of the uterus hand is introduced into the uterine cavity as well as for
manual separation of the placenta, and then it is necessary internal hand turn to examine all of
the uterus. Outer arm locks through the abdominal wall and the bottom of the uterus, slightly
pushing him (Fig. 39). Find protruding soft cloth, it should be separated from the uterine wall
and delete. Conducting a manual examination of the uterus to remove the rear parts of the
placenta, it is necessary to simultaneously pay attention to the integrity of the walls of the Uterus.
Making sure that all of the uterus intact and their surface is smooth, without removing his hands
from the uterus, it is necessary to stop bleeding apply the external-internal uterine massage. The
hand that are in the uterus, is compressed in a fist, and the outer one hand produces a circular
motion at the bottom of the uterus. If the uterus during massage decreasing, then the cavity it
decreases and the inner hand feels like the uterus begins to cover denser and denser. After
stopping bleeding massage stops on the lower abdomen travaileth put an ice pack.

If the bleeding is associated with uterine atony, despite the ongoing massage, uterus remains as
flabby and stretched. In this situation it is necessary to hurry with the beginning of the operation,
which sometimes comes down to bandaging of major vessels supplying the uterus blood (Fig.
40). Taped at first with one and then with the other hand ascending part uterine artery, own a
bunch of ovarian and round uterine ligament. Once the wall of the uterus toned, reduced and
becomes firm to the touch, it is possible at this stage to stop the operation, make sure that the
uterus is no longer relaxes and sew up the abdominal wall. Left uterus, despite the ligation of
vessels, continues to function normally. Women at the end of the postnatal period resumed
menstruation, and further some even get pregnant.

40. Ligation of vessels in Tsitsishvili.

1 - body of the uterus, 2 - fallopian tube. 3 - ovary, 4 - cervix, 5 - ligature imposed on its own
bunch of ovary, 6 - ligature imposed on the uterine artery, 7 - round uterine ligament.
In that case, when after ligation of vessels uterus remains atonic, is supracervical her
amputation.
Unusual bleeding can be so strong that soon leads to a sharp bleeding postpartum women and
adolescent girls. Therefore, women with Hypo - and atonic bleeding is not transportable. In those
conditions, where the midwife one works and where to call medical team (obstetriciangynecologist and the anesthesiologist) takes time, the midwife must produce tight tamponade of
the uterus. To do this, in the delivery room you should constantly keep Bix with sterile bandages
width 15-20 cm or with strips of gauze length of 12 - 15 m and a width of 30 cm, folded three
times. The cervix is grasped bullet forceps and widely disclosed. Long tweezers bandage is put
into the uterus to the bottom of her and laid a small folds, performing pipe corners and all the

cavity, and then all the vagina. Swab can remain in the uterus 2-3 h and more. Plugging should
be very tight. Only then can we expect to temporarily stop bleeding. When loose tamponade
pressure vessels does not happen, the bleeding will continue, and just outside the blood will not
go up until the entire entered bint not saturated by it (Fig. 41).

41. Plugging of the uterus, as is the right; b is wrong.

Besides the listed ways of dealing with hypotonic hemorrhage used in the first place, there are a
number of measures to help tone the muscles of the uterus and its reduction.

The seam along Lositskiy superimposed on the back lip of the cervix. To do this, the cervix is
exposed through vaginal mirrors. On the back lip of the cervix are imposed bullet forceps, for
which the cervix is drawn to the fold. In the cervical canal entered two fingers (index and
middle) of the left hand, which protrudes slightly back wall of the cervix. From the posterior
vaginal fornix left of the middle line a large needle, charged thick catgut, pierced the back wall
of the cervix with Mykola in the cervical canal. Then, at a distance of 3-4 cm from Mykola, the
needle is in the opposite direction - from the cervical canal in the posterior vaginal vault of the
right of midfield. Catgut tied and cut (Fig. 42). As a result, on the back lip of the cervix produces
longitudinal crease. Imposed ligature provides mechanical irritation of the zone of the cervix,
where a large number of nerve endings. In the result of irritation reflex called the uterus.

42. The seam along Lositskiy.

Method of Arendt is that after the inspection of the cervix on the front and back of her lips
impose several pairs bullet forceps that the neck is pulled maximum down, and then released.
Such stretching produced within 3-5 minutes, reflex causes uterine contractions.
The use of a tampon with ether, widely spread, also gives good therapeutic effect in hypotonic
hemorrhage. Anaesthetic ether, easily evaporating, has a cold stimulation on the uterus, in answer
to which it reduces. Loose, well-ether-soaked swab is inserted after the examination of the cervix
in the posterior vaginal vault. While the cervix during imposed on her bullet forceps, it is
advisable to tighten down. Inserting tampons with air in the cavity gipotonica uterus is very
dangerous because of the possibility of embolism pairs of ether.
Method Of Genera. Stand to the side of postpartum women and adolescent girls, one hand it is
necessary to shift the uterus up, capturing the lower segment of it so that four fingers lay on one
side of the cervix and the thumb on the other, to shrink the lower segment of the uterus and
pressed it to his spine. This reduces the blood supply to the fibroids. The onset of ischemia
(reduced blood) causes uterine contractions (Fig. 43).

43. Method Of Genera.

Method Baksheev based on a combination of reflex mechanism of pressure on the uterus and
mechanical. With hypotonic hemorrhage of lateral departments of the lower uterine segment are
superimposed on each side for 3-4 aborting or fenestrated clip. One of the branches of the clip is
introduced into the uterus and is located on the inner surface of the side wall of the uterus, and
the other is imposed by the side of the vault of the vagina. After the imposition of abortando
several of them tighten down.
The imposition of clips on Henkel-Tikanadze through the side arches of the vagina on the
parametrium with the purpose compression uterine vessels not widespread. However, when
properly used, this method is quite effective. The technique of its realization is the following: the
cervix is exposed through vaginal mirrors, front and rear her lips are imposed bullet forceps that
the neck is pulled down and to one side. Lift exposed the opposite side of the vault of the vagina.
If the cervix has sent down to the back and to the right, then to expose have left the vault and
Vice versa. Through the side of the arch on the area of the parametrium perpendicular to the side
surface of the uterus are imposed intestinal clips, capturing the entire thickness parametrium
passing it uterine vessels. To reduce the possibility of injury vaginal wall on the ends of the
branches of the clip to put on a rubber tube in the form manzhetok. After clamping on the one
hand the same is done with the other hand. Reduced blood supply to the uterus, as a rule, causes
of its decline. The clamps can stay for periods of up to 12 or even 20 hours
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The drawback of this method is the risk of damage to the ureters, if they are squeezed together
with the parametric fibre branches clips.
Simultaneously with the implementation of measures to combat bleeding should start
Antianemic events, so in the treatment of puerperas with hypotonic uterine bleeding should
involve at least two people.
Timely applied in the complex therapy directed on increase of contractile uterine activity and to
restore the circulating blood volume, usually effective.
The task midwives, leading childbirth and watching postpartum women after childbirth, is to

prevent the development of the woman severe (decompensated) hemorrhagic shock, as in severe
stage of hemorrhagic shock resulting loss of large quantities of blood comes tissue hypoxia,
disturbed microcirculation in vital organs and develops an acute cardiovascular insufficiency. In
puerperas in a state of hemorrhagic shock often there are changes of the blood coagulation
system. And although in the future in the fight for the lives of women included team of doctors,
midwives, anaesthetists, hematologists, even now it is not always possible to save the woman if
treatment was started with a delay.
About the severity of the condition postpartum women and adolescent girls with continued Hypo
- or atopic bleeding can be judged on the basis of pulse frequency, numbers, blood pressure, skin
colour, the behavior of women, the number of discharge of urine.
In moderate stage of hemorrhagic shock noted paleness of skin, cold sweat, restless behavior
postpartum women and adolescent girls, consciousness saved, tachycardia 100-120 beats per 1
min, systolic (maximum) blood pressure no higher than 90-100 mm RT. Art., pulse pressure (the
difference between systolic and diastolic pressure) is reduced. At this stage of shock there is
reduction of the Department of urine - oliguria.
Serious stage of hemorrhagic shock is characterized by a more severe clinical picture: skin
sharply pale limbs cold, consciousness retarded, pulse frequent (more than 120 beats per 1 min)
weak filling, sometimes filiform, systolic blood pressure below 60 mm RT. Art., may not be
detected.
Moderate and even severe hemorrhagic shock can develop in postpartum women and adolescent
girls with hypotonic postpartum hemorrhage very quickly, as this condition uterine blood poured
out in great numbers and with great speed. Therefore, in any maternity ward, both big and small
staff should always be ready to fight with hypotonic hemorrhage. In a maternity hospital, where
the clock has a duty doctor-obstetrician, midwife conduct the necessary treatment. In those
conditions, where the midwife working independently, it must call medical team, and before
arrival of doctors to act independently, inviting the other midwives or nurses.
When helping the woman with the blood issue of great importance are the issues of organization
of this assistance and the distribution of responsibilities. In this critical situation should not be
panic and rush.
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Antianemic measures begin primarily to replenish the volume of circulating blood. For this
purpose various plazmozameschayuschie solutions and, of course, the blood. From
plazmozameniteli solutions good poliglyukin, rheopolyglucin, neocompsa etc. depending on the
state of postpartum women and adolescent girls (stopped if bleeding or it continues its intensity),
the solutions are poured into one or two of Vienna, drip or struino. In the maternity ward, where
there are stocks of banked blood, already blood loss of more than 0.5% in relation to body
weight postpartum women and adolescent girls, should begin to blood transfusion. The more
blood, the faster we should start a blood transfusion, while following all the necessary rules (see
main 15). When conducting intravenous infusion therapy should monitor the numbers of blood
pressure, trying to keep it on the level close to normal. If within 5-10 min blood pressure in
postpartum women and adolescent girls is not specified, then even such a short period of time is
enough to irreversible changes in vital organs and for the occurrence of disorders of blood
coagulation. That is why transfusion therapy should be initiated promptly and carried out with
the necessary intensity, depending on the speed losing blood.

To apply a means of improving the tone of the vascular wall, and hence arterial blood pressure
(epinephrine, norepinephrine, mezaton) contraindications to replenish blood loss, as these
substances, causing a sharp reduction in vascular walls, bring on the background of anemia to
more violations of peripheral blood circulation. Consequently, in vital organs such as kidneys,
the brain, liver, increasing hypoxia, part of the fabric of these bodies may die.
During massive blood loss, except intravenous solutions, postpartum women need to breathe
humidified oxygen, which is given through the rubber catheters, entered into the nasal passages
and reinforced adhesive tape to the face. Omit the head end of the bed.
As one of the most frequent complications from childbirth, after hemorrhagic shock, is acute
renal failure after stopping bleeding should very carefully monitor renal function by typing this
purpose a permanent catheter into the bladder. The number of escaping urine, measured per unit
time, is also monitoring the effectiveness of the treatment. Diuresis, equal to 3-4 ml in 1 min,
indicates normal kidney function and the effectiveness of therapy. In other words, this means that
the blood volume and blood pressure at this stage sufficient to ensure filtration function of
kidneys.
To compensate for massive blood loss should transfusion single-group of donor blood at once in
two of Vienna. First, the blood should flow at a fast pace, which is sometimes used rubber bulb
from the office of Riva rocci, through which the blood is poured under pressure. After
improvement of the patient and stabilize blood pressure pace replenish blood loss slows down.
When the massive hemorrhage to fill it with excess on 20-30% in relation to the number of the
lost blood. The most valuable qualities necessary for a patient in a state of hemorrhagic shock,
has a warm blood. For its stabilization used heparin in the amount of 2500 IU, diluted in 50 ml of
physiological solution for every 400 ml of blood. Along with the blood intravenously injected
fibrinogen 2-3 g, dry divorced plasma in the amount of 250-500 ml
When deriving postpartum women and adolescent girls from the state of hemorrhagic shock of
great importance anesthesia. The heavier the condition of the patient, the faster it is necessary to
translate it into controlled breath. Artificial ventilation is carried out under high pressure,
improves gas exchange and is a kind of heart massage. So anesthesiologist must take part in the
rescue of the patient.
Due to the fact that during massive blood loss increased need of the body in the hormones of the
adrenal cortex, the puerperium is used intravenously prednisolone 40-50 mg or hydrocortisone in
the amount of 250-300 mg Introduction of these drugs is shown after stopping bleeding and
krovopoteri.
At insufficiency of kidney function for improving the circulation apply diafillin 2,4% -10,0 ml
0.25% solution novokaina in the amount of 100-150 ml. In the future, to enhance diuresis - lasix
40-60 mg or mannitol in the amount of 1 g per 1 kg of weight postpartum women and adolescent
girls.
After stopping bleeding, replenish blood loss, improve postpartum women and adolescent girls
and stabilization within 30-40 minutes of hemodynamics (pulse rate - not more than 90 beats per
1 minute, systolic blood pressure below 100 mm RT. Art.) the patient can be transferred to an
independent breathing.
Hypotonic treatment of postpartum hemorrhage is a difficult and very responsible task that
require speed, organization and sequencing of activities. In this regard, in any maternity ward
should always be ready dressed system for intravenous infusion. Life shows that in the alarming
situation when postpartum women and adolescent girls occurs profuse bleeding and when every

minute delay with the beginning of treatment may cost the patient's life, any usual manipulation
requires much more time. For example, an experienced midwife or operating sister in a relaxed
atmosphere fills system for intravenous infusion for 3-5 minutes, and in a state of agitation and
anxiety on the same action is spent sometimes 10 to 15 minutes more.
Maternity ward should always have an adequate supply of blood, plasma and plazmozameniteli
solutions. In addition, in the maternity ward should have a list of backup donors from the staff of
the maternity ward or hospital. In this list it is necessary to have data on the blood group and
rhesus toiletries employee, his address and phone number. In those rare cases when you need
fresh donor blood, need to use this form of donation.
The midwife, watching the woman during pregnancy, must ensure that every pregnant in
advance were defined group of blood and RH affiliation. If for some reason during pregnancy,
this was not done, it is necessary in the maternity ward to determine in advance the group and
RH affiliation blood woman. In that case, when there are indications for blood transfusion, it is
necessarily test the compatibility of donor blood with blood postpartum women and adolescent
girls. For this sample desired serum of the patient. In order not to waste time on getting the
serum by centrifugation blood, each woman in advance, i.e. immediately after its admission to
the maternity ward, we have to take a test tube 8-10 ml of blood. Gradually, during the time that
continue childbirth, in vitro asserted serum.
If a pregnant woman is based on history, data, objective research, or the characteristics of the
course delivery can be expected hypotonic hemorrhage, it is advisable to make a venipuncture
and start intravenous drip or physiological solution, or 5% glucose solution. This preventive
action is necessary because in bleeding time to get to Vienna more difficult, especially if they are
thin, deeply and are collapsed. If it is impossible to make a puncture of a vein have to go to
venesection. This operation requires much more time and completely distracts one doctor.

Prevention hypotonic postpartum haemorrhage