The significance of the problem, which is caused by obstetric bleeding, is due to the fact that this pathology acts as the main and immediate cause of the deaths of 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 reasons
The main causes of possible hypotonic bleeding can be: atony and hypotension of the uterus, poor blood coagulation, part of the child's place that has not left the uterine cavity, soft tissue injuries in the birth canal.
What is uterine hypotension
Uterine hypotension is a condition in which the tone and its ability to contract are sharply reduced. Thanks to the measures taken and under the action of drugs that stimulate contractile function, the muscle begins to contract, although often the strength of the contractile reaction is not equal to the strength of the effect. For this reason, hypotonic bleeding develops.
Atony
Atony of the uterus is a condition in which means aimed at stimulating the uterus are not able to exert 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 bleeding hypotonic and atonic in nature can be different. One of the main reasons is the depletion of the body, i.e. the central nervous system is weakened due to prolonged and painful childbirth, persistent labor is weakened, in addition, the cause may be a quick birth and the use of oxytocin. Other 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 operations done earlier; diseases caused by inflammation or abortion, replacing a significant portion of muscle tissue with connective tissue.
In addition, the consequences of hypotonic bleeding in the early postpartum period are: uterine dysfunction, i.e. its strong stretch as a result of polyhydramnios, the presence of more than one fetus, if the fetus is large; placenta previa and low attachment.
Hypotension or atony
Hypotonic and atonic bleeding can occur as a result of a combination of several of the above reasons. In this case, the bleeding becomes more dangerous. Based on the fact that with 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 were ineffective.
What is the reason for stopping bleeding
The stoppage of bleeding, which was caused by placental abruption and placenta, is usually explained by two major factors: myometrial retraction and thrombosis in the vessels of the placenta site. Enhanced retraction of the myometrium leads to the fact that the venous vessels are compressed and twisted, and the spiral arteries are retracted into the thickness of the uterus muscle. After this, thrombosis in the vessels of the uterus begins , which is facilitated by the process of blood coagulation. The process of blood clots can last quite a long time, sometimes several hours.
Mothers at high risk for early postpartum hypotonic bleeding must be carefully anesthetized because contractions accompanied by severe pain lead to disruption of the central nervous system and the necessary relationships between the 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 subsequent period, and then go into the bleeding of the early postpartum period.
Clinical options for hypotension
M. A. Repin (1986) conducted the selection of two clinical variants of uterine hypotension. According to this theory, in the first version, bleeding is plentiful 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 is rapidly developing, hemorrhagic shock begins, and disseminated intravascular coagulation syndrome (DIC) often occurs .
In the second version of the theory, hemorrhage is insignificant, the clinical picture is characteristic of the hypotonic state of the uterus: repeated blood loss alternates with short-term regeneration of the myometrial tone and temporary stopping of bleeding as a result of conservative treatment (such as the introduction of contractions, external massage of the uterus). As a result of relatively small repeated bleeding, a woman becomes temporarily addicted to progressive hypovolemia: blood pressure decreases slightly, pale skin and visible mucous membranes appear, insignificant tachycardia occurs.
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, short-term reactions to the therapeutic effect become, and the volume 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 quick. If for 10-15 minutes. Since the uterus does not contract well, and hypotonic bleeding in the postpartum period does not stop, you should immediately perform a manual examination of the uterus and apply uterine massage on your fist. Based on practical obstetric experience, a timely manual examination of the uterus, cleansing it of accumulated blood clots, and then massage her on a fist, help ensure correct uterine hemostasis and prevent severe blood loss.
Significant information that necessitates an appropriate examination by the hand of the uterus in case of hypotonic bleeding in the early postpartum period is given by M. A. Repin in his own monograph “Bleeding in obstetric practice” (1986). According to her observations, in those who died from him, the approximate time from the appearance of bleeding to a 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 constancy of the hypotonic state of the myometrium indicate not only that the operation was performed late, but also about the unlikely prognosis of stopping the bleeding, even using other conservative treatment methods.
Clamping method according to N. S. Baksheev
During the events 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 pressing of the aorta, clamping of parametres, ligation of the great vessels, etc. To date, the method of clamping is most popular among the set of these methods. 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 for removal uw uterus.
The method of N. S. Baksheev 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 bleeding does not stop, even in small amounts, when the terminals are applied, it is necessary to be puzzled by the question of removing the uterus in time. This operation is called supravaginal amputation or hysterectomy. On-time surgery to remove the uterus is the most reliable method to stop hypotonic bleeding after childbirth.
Timely and necessary measures
This is due to the risk of bleeding disorders. Thus, in the fight against uterine hypotension, as well as in order to restore hemodynamics, it is necessary to carefully monitor the nature of the formed blood clots 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, proceed to 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, not uterine amputation. This is explained by the fact that probably the remaining stump of the cervix can serve as a continuation of the frolic pathological process, if there is a violation of blood coagulation. And stopping hypotonic bleeding should be timely.