Topic. Bleeding during pregnancy, childbirth and postpartum period.

I. Scientific and methodological substantiation of the topic

Maternal bleeding during pregnancy, childbirth and early postpartum period occupy a
leading place among various types of severe obstetric pathology and the first among the causes
of maternal mortality. The frequency of obstetric bleeding is from 8 to 11% and has no tendency
to decrease. The urgency of the topic is determined by the high frequency of maternal and
perinatal mortality due to obstetric bleeding. The most massive and dangerous bleeding occurs in
childbirth and early postpartum period. This type of pathology requires the provision of urgent
qualified assistance. A doctor of any specialty should be able to properly organize measures to
combat bleeding.
The priority direction of the modern organization of health care is the preservation of
women's reproductive health by improving the quality and effectiveness of health care, including
organ-saving surgical interventions and measures to prevent possible complications (massive
blood loss, hemorrhagic shock, DIC, multiple organ failure) due to providing effective help in
case of obstetric bleeding.

II. Education goals

For the formation of skills the student must identify:
1. Classification and causes of obstetric bleeding.
2. Clinic, diagnosis and treatment of placenta previa, premature placental ablation, and
obstetric bleeding in the third period of labor and postpartum period.
3. Differentiate the causes of bleeding during pregnancy, childbirth and the postpartum
period.
4. Methods of stopping the bleeding.
5. Pharmacological means for the treatment of obstetric bleeding.

As a result of conducting classes students should be able to:

1. Differentiate the causes of bleeding during pregnancy, childbirth and the postpartum
period.
2. Know the methods of preventing bleeding in the presence of the placenta or its premature
detachment.
3. To master the algorithm of the physician's action in case of premature detachment of a
normally located placenta, to compile and substantiate an individual plan of degeneration
in the presence of the placenta.
4. Know the methods of prevention of obstetric bleeding.
5. Demonstrate a phantom operation of manual examination of the walls of the uterus.
6. Demonstrate a phantom operation of the manual placement of the placenta and allocation
of litter.
7. To demonstrate on a phantom massage of the uterus on the fist.
8. Demonstrate on phantom methods of stopping hypotonic bleeding.

III. Output and basic knowledge

1. Physiology of blood circulation.
2. Features of vascularization of the pregnant uterus.
3. The main phases of blood clotting.
4. Definition of group and individual blood compatibility.
5. Influence of pregnancy and amniotic fluid on the blood coagulation system.
6. Effect of blood loss on the vital functions of the body of the mother and
the fetus
 7. Mechanisms of regulation of hemodynamics.
8. Objectively assess the obstetric situation with bleeding.

IV. Content of education material

Classification of obstetric bleedings:

 Bleeding in the first half of pregnancy: involuntary miscarriage, ectopic pregnancy
(including cervical pregnancy), trophoblastic disease.
 Bleeding in the second half of pregnancy: placenta previa, premature detachment of a
normally located placenta, uterine rupture.
 Bleeding during childbirth:

I period - placenta previa, premature detachment of a normally located placenta, uterine rupture,
cervical dilatation;
II period - premature detachment of normally located placenta, uterine rupture;
III period - pathology of attachment of the placenta, delay, placental jamming, rupture of soft
tissues of the delivery path.

Postpartum hemorrhage: atonic / hypotonic bleeding, delayed parts of the uterus / blood
convections, trauma (rupture of soft tissue of the birth canal, uterine rupture, uterus eruption,
coagulopathic bleeding (including embolism with amniotic fluid).
Bleeding in the late postpartum period: placental polyp, endomyometritis,
chorionepitelioma.
Non-pregnancy-related bleeding: cervical cancer, cervical erosion, cervical cancer.

Involuntary miscarriage
Classification:
- The threat of abortion (threat of miscarriage);
- The mischief that began;
- Miscarriage in progress;
- Incomplete involuntary miscarriage;
- Total involuntary miscarriage;
- Miscarriage that has not happened.

Clinical and diagnostic criteria:

Symptoms of abortion: pain syndrome (pain associated with uterine contraction),
increased uterine tone, bleeding of varying degrees of intensity, structural changes in the cervix.
The last two symptoms are based on differential diagnosis of stages of abortion.
At the threat of interruption there is no bleeding and structural changes in the cervix.
Bleeding occurs during spontaneous miscarriage, miscarriage that began, miscarriage in
progress, incomplete involuntary miscarriage.

Diagnostics:
- Assessment of the general condition of the pregnant woman;
- Overview of the cervix in the mirrors, bimanual study;
- Estimation of the amount of blood loss.

Treatment:
- Instrumental emptying of the uterus under intravenous anesthesia (obligatory histological
examination of the obtained material);
- Preparations for reducing the uterus (10 OD oxytocin intravenously or 0.5 mkg
methylergobrevin intravenously or intramuscularly);
- If the bleeding continues, 800 micrograms of misoprostol per rectum;
- Restoration of the size of blood loss on the testimony;
- Antibacterial therapy on the testimony.

An algorithm for emergency care during bleeding in the first half of pregnancy.
1. Urgent hospitalization.
2. Establishing the cause of bleeding:
2.1. Impersonal abortion (in progress) - instrumental pain, contraceptive drugs, infusion therapy
on the testimony.
2.2. Ectopic pregnancy:
2.2.1. Pipe - laparotomy or laparoscopy, hemostasis, tubectomy or organ-saving operations on
the fallopian tube.
2.2.2. Abdomen - laparotomy, removal of the fetus.
2.2.3. Cervical pregnancy - laparotomy, extirpation of the uterus without appendages.
2.3. Polyp of the cervix during pregnancy - local hemostatic therapy and observation under
cytological control, in the absence of effect - unscrewed polyp with histological examination,
preserving pregnancy therapy.
2.4. Cervical cancer - Tactics of pregnancy and treatment is determined with the oncologist.
2.5. Cystic mole - instrumental uterine emptying, observation with control of the level of
chorionic gonadotropin in blood plasma.

Pre-natal bleeding is a bleeding occurring from the 22-nd week, during pregnancy and before
childbirth. Pre-natal bleeding is 3-5% of the total number of pregnancies and is one of the first
places among the causes of maternal and perinatal mortality around the world. The birth of more
than ¼ of prematurely infected children is due to pre-natal bleeding. Association of pre-natal
bleeding with cerebral palsy can be explained by premature birth. The causes of pre-natal
bleeding include: placenta prevalence - 20%, premature detachment of normally located placenta
- 40%, and bleeding from the vulva, vagina or cervix - 5%, unspecified pre-natal bleeding - 35%.

Urgent organizational measures:

- Skidding to the hospital, transportation with the possibilities of providing intensive care;
- Posting the obstetrician, to which the patient is referred. Assistance to a multidisciplinary team
(obstetrician, gynecologist, midwife, anesthetist, neonatologist, laboratory assistant, operating
personnel, blood transfusion unit);
- Hospitalization to hospital.

Clinical evaluation:
- Assessment of anamnesis (in the case of a woman's stable condition, a detailed study of the
anamnesis is conducted, in the case of a woman's unconscious condition - a survey of relatives);
- Estimation of the volume and nature of discharge (fresh or outdated blood);
- An urgent assessment of the severity of the bleeding and the treatment needed by the pregnant
woman.

The amount of blood loss in the case of pre-natal bleeding is defined as:
- Blotting - stains of blood on linen and sanitary napkins;
- Small bleeding - blood loss is estimated at 250 ml, which has stopped;
- Large bleeding - Blood loss estimated from 250 ml to 1000 ml, which stopped, in the absence
of signs of hemorrhagic shock;
- Massive bleeding - blood loss greater than 1000 ml and / or signs of hemorrhagic shock;
- Repeated pre-natal bleeding or relapse of bleeding - the term is used if the episode pre-natal
bleeding occurred more than once.
General examination (in the absence of massive bleeding):
- Estimation of height of standing of the bottom of the uterus (compliance with the period of
gestation);
- Fetal position and presentation: the high position of the presenting part and / or the false
position of the fetus indicate a possible placenta previa;
- Palpation of the abdomen;
- Ultrasound. A review in the mirrors in the operating conditions (except for cases of placenta
pre-placement, established ultrasound) to detect the source of bleeding, assessment of the state of
the cervix and its disclosure;
- In the case of the exclusion of the placenta previa according to ultrasound data, the vaginal
examination is carried out in the operating room: after the deployment of the operative, the
training of the brigade before the operation and the preparation of blood for transfusion;
- Listening to the heart rate of the fetus with the help of a stethoscope, CTG - in the case of
insignificant pre-natal bleeding and a stable mother's condition or after stabilization of the
mother's condition for determining the method of delivery. Ultrasound - to detect fetal heartbeat.

Laboratory research:
- General blood test;
- Blood group, Rh, blood for compatibility;
- For women with an Rh (-) factor, the administration of anti-rhesus immunoglobulin.

General provisions for the provision of assistance in the case of prenatal bleeding
depending on the size of the discharge:
- All women with continued blotting and small bleeding should be in the hospital until the
bleeding has stopped;
- Careful monitoring of the condition of the mother and the fetus (CTG, fetal movement test)
within the next 24 hours, taking into account the risk of bleeding recovery;
- Antenatal steroids - for all women with pre-natal bleeding in the case of a stable mother and /
or fetus in the period of 24-34 weeks of pregnancy, given the risk of premature birth;
- The use of tocolytics is possible in the case of blotting or minor bleeding and the appearance of
a prime in women with placenta previa and gestational age of up to 34 weeks of gestation in
conditions of the perinatal center of the third level. Do not use calcium antagonists with pre-natal
bleeding (risk of hypotension). Such tactics are contraindicated in the case of premature
detachment of a normally located placenta;
- Antianemic therapy according to indications (hemoglobin level below 110 g/l);
- In the event of termination of bleeding in a pregnant woman with placenta previa -
hospitalization to the term of delivery, planned delivery by CS in 38-39 weeks of pregnancy;
- In the case of a relapse of bleeding in a woman with placenta previa - an urgent cesarean
section regardless of the period of pregnancy;
- In the event of termination of bleeding in pregnant women with suspicion on the premature
detachment of a normally located placenta - in the absence of pain syndrome and increased tone
of the uterus - observation, evaluation of the state of the fetus. Childbirth incidence;
- Large blood loss (estimated from 250 to 1000 ml) - indications for urgent delivery by caesarean
section;
- Urgent organizational measures + order blood components and preparations. Assessment and
correction of vital functions;
- General inspection, laboratory research and monitoring.

Available Symptoms:
- Pathological changes in the cardiac rhythm of the fetus. Hemorrhagic shock;
- Significant abdominal pain or increased tone of the uterus;
- Bleeding may be external or internal.
Organizational events:
- Urgent call and urgent mobilization of all personnel to help (according to local distribution
protocol for urgent states);
- Message from the responsible administrator;
- The team leader (responsible obstetrician-gynecologist or anaesthesiologist) assigns a task and
identifies the member of the team that documented the event.

Estimation and correction of vital functions:

In case of massive blood loss, support for motherhood and resuscitation should start
immediately. Mother's condition is a priority and it should be stabilized until the condition of the
fetus is established.
- Respiratory tract, respiration;
- Fixation in documents of vital signs every 5 minutes;
- Prevention of aorto-cavernous compression - turn 15 ° to the left;
- 100% oxygen supply;
- Restoration of blood loss.

Anesthesia:
The dose and type of anesthetic depend on the severity of the pain syndrome. Premature
detachment of a normally located placenta may require the appointment of opiates (promedol).

Observation:
- Non-invasive measurement of blood pressure;
- Pulse oximetry;
- Renal function assessment: Reducing the volume of less than 30 ml/h needs special
attention.

Intrauterine fetal death:

- Talk with a woman about a care plan, given the severity of bleeding bleeding and
mother's condition;
- The longer the fetus will be in utero - the greater the risk of developing DIC syndrom.

Caesarean section:
- Regardless of the condition of the fetus (presence of fetal heart rate or fetal death), after
stabilization of the mother's condition, degeneration is shown by an urgent cesarean section with
general anesthesia (exclusion - premature detachment of a normally located placenta in the
second period of childbirth).
- In the presence of heart rate of the fetus - a neonatal resuscitation physician should be
present during the operation.
- Readiness for massive postpartum hemorrhage.
- Catetrazation of the central vein to assess the CVP - set by the anesthesiologist.
- In order to preserve the uterus immediately after the removal of the child used
uterotonic agents (oxytocin or ergometrine, carbetocin, prostaglandin E1 and E2) and
vasoconstrictors - terlipressin (locally 2 ampoules (400 mcg) diluted in a ratio of 162
physiological solution to 10 ml, shave the uterus. the effect comes in 5-7 minutes).
- In the case of excessive blood loss, surgical hemostasis is applied step by step: partial
uterine devascularisation, compression sutures, bilateral imposition of ligatures on the internal
iliac arteries, and in case of ineffectiveness, uterine extirpation with uterine tubes.
 PLACENTA PRAEVIA

Placenta praevia is a complication of pregnancy, in which the placenta is located in the

lower segment of the uterus below the prefrontal part of the fetus, covering completely or
partially the inner cervix of the uterus. In physiological pregnancy, the lower edge of the
placenta does not reach 7 cm at the internal part of cervix. Placenta praevia occurs in 0,2-0,8% of
the total number of childbirth.

Classification for placental placement:

1. Complete prejection (central – pl.praeviacentralis) - the placenta completely overlaps
the internal part of cervix.
2. Incomplete presentation - the placenta partly overlaps the internal part of cervix:
A) Lateral Pregnancy (pl.praevia lateralis) - the cervical internal part is covered by 2/3 of
its area;
B) Cervical presentation (pl.praevia marginalis) - the cervical internal part is covered by
1/3 of its area.
3. Low placental attachment - placenta placement in the lower segment below 7 cm from
the internal cervical part without its overlap.
Due to the migration of the placenta or its spread, the type of pre-delivery may change
with an increase in the period of pregnancy.

Clinical and diagnostic criteria:

Women who have suffered from placenta previa include:
- endometritis with subsequent scar and dystrophic changes in the endometrium;
- Pregnancy placenta previa;
- previous Caesarean section;
- many births;
- age of a woman - over 40 years old;
- multiple pregnancy;
- smoking;
- abortions, especially complicated with inflammatory processes;
- benign tumors of the uterus, in particular submucous myomatous nodes;
- action on the endometrium of chemical preparations;
- women with hypoplastic uterus;
- auxiliary reproductive technologies.

Clinical symptoms:
Pathognomonic symptom - mandatory bleeding, which can be repeated periodically
during the period of pregnancy from 12 to 40 weeks, arises spontaneously or after physical
activity, becomes threatening in nature:
- With the beginning of contractions of the uterus in any period of pregnancy;
- Not accompanied by pain;
- Not accompanied by increased tone of the uterus.
The severity will be due to the amount of blood loss:
- With full prelocation - massive;
- When incomplete - it can vary from small to massive.
Anesthesia as a result of repeated bleeding. With this pathology, the lowest content of
hemoglobin and erythrocytes in comparison with other complications of pregnancy,
accompanied by bleeding.
Frequently, the fetal position is incorrect: oblique, transverse, pelvic holding, incorrect
insertion of the head.
Preterm labor is possible.
 Diagnostics:
1. Anamnesis.
2. Clinical manifestations - occurring repetitive bleeding, and not accompanied by
pain and increased uterine tone.

Obstetric analysis:
A) External analysis;
- high standing of the front part;
- spit, transverse fetal position;
- the tone of the uterus is not elevated.
B) Internal analysis (performed only in conditions of expanded operational):
- tartness of the tissues of the vault, pastoseness, pulsation of vessels;
- impossibility to palpate the adjacent part through the vaults.
In the case of a bleeding, clarification of the nature of the presentation does not make
sense because obstetric tactics are determined by the volume of blood loss and the
condition of the pregnant woman.
Ultrasound scans are important for locating the placenta and establishing the correct
diagnosis.
Placental placement with bleeding is an urgent indication for hospitalization in a hospital.

The algorithm of examination at the arrival of a pregnant woman with bleeding to a

hospital.
1. Diagnostic algorithm for bleeding in pregnant women with placenta previa:
• in case of suspicion of placental prostatitis - hospitalization to the obstetric department;
• clarification of anamnesis;
• assessment of the general condition, volume of blood loss;
• general clinical examinations (blood group, rhesus factor, general blood test,
coagulogram);
• external obstetric examination;
• An overview of the cervix using vaginal mirrors with the expanded surgical and
evaluation of excretions to exclude other causes of bleeding (polyp, erosion, cervical cancer,
varicose vein rupture, and others).
• Additional methods of examination (ultrasound) on the testimony provided no urgent
need to resolve.
2. The algorithm of conducting bleeding in pregnant women with the presence of a
placenta:
Tactics of driving depends on the volume of blood loss, pregnancy and fetal, the nature of
the pregnancy, the period of pregnancy, the maturity of the fetal lungs.
• With insignificant blood loss (up to 250 ml), absence of symptoms of hemorrhagic
shock, fetal distress, absence of labor activity, immature matrix of the lung of the fetus during
pregnancy up to 37 weeks - Expectant tactics;
• When bleeding is stopped - ultrasound, preparation of a surfactant system of the
pulmonary fetus. Target of Expectant Tactics - Prolongation of pregnancy to the term of fetal
vitality;
• With progressive uncontrolled bleeding (over 250 ml), which is accompanied by
symptoms of hemorrhagic shock, fetal distress, irrespective of the period of pregnancy and the
condition of the fetus - immediate urgency.
3.Clinical options:
3.1. Loss of up to 250 ml, no symptoms of hemorrhagic shock, fetal distress, pregnancy
up to 37 weeks:
• Hospitalization.
• Tocolytic therapy for indications.
 • Accelerated maturation of the sweetening system of the lung of the fetus to 34 weeks of
pregnancy (betamethasone (dexamethasone) 6 mg in 12 hours for two days).
• Monitor the state of the fetus and the pregnant woman.
• With the progression of bleeding - a roodropsis operation through a cesarean section.
3.2. Bleeding is significant (more than 250 ml) in preterm pregnancy - regardless of the
degree of pregnancy - urgent delivery by operation of a cesarean section.
3.3. Blood circulation 250 ml in case of full-term pregnancy, provided that there is an
advanced surgical procedure - the degree of presentation is specified:
• With partial presence of the placenta, the possibility of achieving amniotic membranes
and the main presentation of the fetus, active contractions of the uterus, amniotomy is performed.
When stopping bleeding, births are conducted through natural birth lines. When bleeding is
restored - Caesarean section.
• With full or incomplete placenta previa, false position - cesarean section;
• If incomplete placenta previa, a dead fetus is possible amniotomy, at stopping a
bleeding - a childbirth through natural birth lines.
3.4. Blood loss is more than 250 ml in case of congenital pregnancy regardless of the
degree of pregnancy - an urgent cesarean section.
3.5. Complete preheating without bleeding - admission to the term of moderate
resolution, cesarean section in the period of 37-38 weeks.
In the early postpartum period - careful monitoring of the state of pregnancy. When
restoring bleeding after cesarean section surgery and achieving a blood loss of more than 1% of
body weight - urgent relaparotomy, extirpation of the uterus without supplements, and, if
necessary, ligation of internal iliac arteries by a specialist who owns this operation.
Restoring the size of blood loss, treating hemorrhagic shock and DIC syndrom is based
on indications.

PREMATURE DETACHMENT OF NORMALLY LOCATED PLACENTA.

(Separatio placentae normaliter inserte spontanea) - detachment of the placenta diluted

outside the lower segment of the uterus during pregnancy or in the 1st to 2nd periods of labor.
Occurs in 0,4-0,8% of cases.

Classification:
• Complete detachment (detachment of the entire placenta).
• Partial detachment.
• Croatian
• Central.

Clinical and diagnostic criteria for premature detachment of normally located

placenta:
Premature detachment of a normally located placenta may occur in pregnant women in
the event of the following pathology:
• Preeclampsia
• Diseases of the kidneys
• An isoimmune conflict between mother and fetus
• Overturning the uterus (polyhydramnios, multiple fertility, large fruit)
• Diseases of the vascular system
• Diabetes
• Disease of the connective tissue
• Inflammatory processes of the uterus, placenta
• Anomalies of development or tumor of the uterus (submucosal, intramuscular fibroids)
The immediate cause may be:
 • Physical injury
• Mental injury
• Sudden decrease in the volume of amniotic fluid
• Absolutely or relatively short umbilical cord
• Pathology of contractile activity of the uterus

Depending on the type of bleeding, there are three forms:

1. External, or visible, bleeding, in which the allocation of blood from the genital tract is
marked.
2. Internal, or hidden, bleeding, in which the blood is placed between the placenta and the
uterine wall (retroplacental hematoma).
3. Combined or mixed bleeding, in which the bleeding is partially visible and partly
hidden.

Clinical picture:
1. The bleeding from the genital tract may vary depending on the degree of severity and
nature (marginal or central detachment) from the insignificant to the massive.
2. Pain syndrome: acute pain in the projection of placental localization, which then
spreads across the uterus, across, back, and becomes diffuse. The pain is most pronounced in the
central detachment and may not be expressed in marginal detachment. When detachment of the
placenta, which is located on the back wall, the pain may imitate the renal colic.
3. Hypertonus of the uterus up to tetany, which is not removed by antispasmodics, such
as the classics.
4. Fetal distress.

Diagnostics:
1. Evaluation of the condition of the pregnant woman, which will depend on the size of
detachment, volume of blood loss, the appearance of symptoms of hemorrhagic shock or DIC.
2. External obstetric examination:
• Hypertonus of the uterus;
• The uterus can be deformed with a local protrusion if the placenta is located on the front
wall;
• Pain in pain;
• Difficulty or impossibility of palpation and auscultation of fetal heartbeat;
• The appearance of symptoms of fetal distress or death.
3. Internal midwifery study
• The tenseness of the productive bladder
• When digestion of amniotic fluid - their blood coloring is possible
• Bleeding of different intensities from the uterus
4. U.S. research (echo-negative center between the uterus and the placenta), but this
method can not be an absolute diagnostic criterion, as the hypoechogenic zone can be visualized
in patients and without detachment.
In the absence of external bleeding, the diagnosis of premature detachment of the
placenta is based on increased uterine tone, local pain, deterioration of the fetus. The blood from
the retroplacental hematoma impregnates the uterine wall and forms the uterus of the covealer
(utero-placental apoplexy), which loses its ability to contract, leading to the development of
bleeding with massive blood loss due to coagulopathy and hypotension.

An algorithm for emergency treatment in premature placental ablation.

Undue delayed delivery results in fetal death, Caveller's uterine development, massive
blood loss, hemorrhagic shock and DVS-syndrome, loss of reproductive function of a woman.
 1.In the case of progressive premature detachment of the placenta during pregnancy or in
the 1st period of labor, with the appearance of symptoms of hemorrhagic shock, DIC, signs of
fetal distress, regardless of the term of pregnancy - urgent childbirth by operation of a cesarean
section. In the presence of signs of uterine queveler - extirpation of the uterus without
appendages.
2. Restoration of blood loss, treatment of hemorrhagic shock and DIC-syndrome.
3.If non-progressing placental detachment is possible, dynamic observation in the
preterm pregnancy up to 34 weeks (therapy for maturation of the surfactant system of the
pulmonary fetus) in facilities where there is a round-the-clock duty of qualified doctors
obstetricians-gynecologists, anesthetists, neonatologists. Monitoring is conducted on the
condition of pregnant and fetal, CTG, ultrasound in dynamics.
4. With premature detachment of the placenta in the second period of labor, amniotomy is
carried out, at the main presentation of the fetus, an overlay of obstetric forceps is used, and
pelvic extraction of the fetus is performed at the pelvic end.
At a transverse position of the second fetus with a twin - obstetric rotation with extraction
of the fetus;
Manual placental separation and removal of litter;
Manual revision of the walls of the uterus, removal of blood convections;
Uterotonics (oxytocin 10 units per 500 ml of physiological solutin intravenuosly , 60
drops per minute, ergometrin 0.5 mg, misoprostol 800 mkg per rectum, if available - carbetocin
100 mkg / in jet;
Dynamic careful monitoring of the condition of the uterus in the postpartum period.

Features of Caesarean section:

• Postoperative amniotomy surgery (if any)
• Obligatory revision of the walls of the uterus (especially the outer surface) in order to
exclude uterine placental apoplexy
• In the case of diagnosis of Caveller's uterus - extirpation of the uterus without
appendages
• With a small area of apoplexy - 2-3 focuses of small diameter 1-2 cm, or one - up to 3
cm) and the ability of the uterus to reduce, lack of bleeding and signs of the DIC syndrome, if
necessary, to preserve the reproductive function (first birth, dead fetus) , the consilium solves the
issue of preserving the uterus. Surgeons observe for some time (10-20 min.) with an open
abdominal cavity on the condition of the uterus and, in the absence of bleeding, drains the
abdominal cavity to control hemostasis. Such tactics, in exceptional cases, is allowed only in
institutions, in what is n clear clock duty doctors, obstetrician-gynecologist, anesthetist.
In the early postoperative period, careful monitoring for next 6 hours.

POSTPARTUM BLEEDING

The most dangerous complications of the subsequent period are bleeding. Bleeding that
exceeds 0.5% of body weight (250-400 ml) is considered pathological, and 1000 ml and more
(1% or more of body weight) is considered to be massive.

Types of postpartum bleeding:

1. Bleeding in the serum period.
2. Primary (early) postpartum, occurring in the early postpartum period or within 24
hours after delivery.
3. Secondary (late) postpartum bleeding that occurs after 24 hours and up to 6 weeks after
childbirth.
Etiology
1. Aggravating somatic anamnesis:
 cardiovascular pathology (hypotension, hypertension, heart disease, hypertonic disease);
 diseases of the hematopoiesis (anemia, thrombocytopenia);
 diseases of the endocrine organs.
 chronic DIC-syndrome.
2. Obsessed and gynecological history:
 history of abortion (medical and involuntary);
 leiomyoma of the uterus;
 Scar on the uterus (cesarean section, perforation apertures, enucleation of nodes).
 Bleeding in previous childbirth.

Complications of pregnancy:
1. Preeclampsia.
2. Rhesus-conflict.
3. Placental placement.
4. Premature detachment of normally located placenta.
5. Big fetus.
6. Bagatovoddy.
7. Multiple pregnancy.
8. Antenatal fetal death.

Complications during childbirth:

1. Weakness of labor activity.
2. Premature amalgamation of amniotic fluid.

At physiological deliveries hemostasis in the postpartum period is mainly carried out by

two mechanisms:
- Myotamponade. The vessels of the uterus are compressed by the muscles during its
contraction and the bleeding stops as a result of the mechanical factor.
- Thrombotamponad as a result of hypercoagulation of blood in the uterine vessels.
Causes of bleeding in the III-th period of childbirth:
- dense attachment of the placenta (placenta adhaerens);
- true growth of the placenta (placenta accreta, increta, percreta);
- Improvement of the litter in the area of the internal cell;
- Remnants of placental tissue in the uterine cavity.

Clinical manifestations:
1. There are no signs of separation of the placenta for 30 minutes without significant
blood loss - pathology of attachment or germination of the placenta.
2. Bleeding begins immediately after the birth of the feces - delayed parts of the placenta.
3. Bleeding begins after the birth of the child without separation of the placenta - scarring
of the placenta, incomplete enlargement of the placenta.

An algorithm for providing emergency care for blood loss associated with delay,
pathological attachment or pinching of the placenta
1. Catheterization of the peripheral or central vein, depending on the size of blood loss and the
state of pregnant women.
2. Catheterization of the bladder.
3. Inspection of signs of placental secretion and selection of serum by manual methods.
4. When imprisonment of the litter is external massage, external methods of allocation of the
litter.
5. When delayed parts of the placenta or membranes - manual revision of the walls of the uterus
cavity under in / out anesthesia.
6. In violation of the mechanism of separation of the placenta and the absence of bleeding -
waiting for 30 minutes, (in pregnant women at risk - 15 minutes), manual placental separation
and removal of the litter.
7. When bleeding occurs - urgent manual placement of the placenta and removal of the suction
under v / v anesthesia.
8. Introduction of endothelial drugs - 10-20 OD oxytocin IV / 400 ml of physiological solution
drip.
9. In the true growth of the placenta - laparotomy, extirpation of the uterus without appendages.
10. Estimation of volume of blood loss and restoration of bcc.

Early (primary) postpartum hemorrhage.

Reasons:
- delay in the cavity of the uterus of the parts of the litter;
- atony and hypotension of the uterus (in 90% of cases);
- traumas of soft tissues of the delivery path;
- Disruption of blood coagulation (coagulopathy).
Hypotonia of the uterus - a condition of the uterus, in which there is a significant reduction in its
tone and decrease contractile ability. The muscles of the uterus thus react to various stimuli, but
the degree of these reactions is inadequate to the effect of irritation. Hypotonia - the state of the
inverse. Atony of the uterus - a condition at which myometrium completely loses the ability to
reduce and tone. The uterus does not respond to irritation. There is a so-called "paralysis" of the
uterus
The main causes of hypotonia / atony of the uterus:
 - organic, dystrophic changes in the uterus, resulting from septic abortion, the presence of
fibromatous nodes in the uterus, a large number of abortions in history;
 - stretching of the walls of the uterus in the abdomen, multiple pregnancy, large size of the fetus,
pregnancy;
 - progesterone unit;
 - prolonged anesthesia;
 - unsystematic multiple stimulation of labor activity;
 - diseases of the cardiovascular system, blood system, vitamin deficiency, stress.

In case of violation of the tone of the uterus:

1. Introduction of uterotonics (oxytocin 10 units / 500 ml of physiological solution at a rate of 60
drops / min.)
2. External massage of the uterus, if the bleeding has stopped, and then proceeded - manual
examination of the uterine cavity under I / P anesthesia, if the bleeding stopped, and then
proceeded - use of uterotonics of the 2 nd - 3 rd line (ergometrin, prostaglandins, carbetocin), in
the case of bleeding - bimanual compression of the uterus or compression of the aorta, if the
bleeding has stopped, and then proceeded - under the operating conditions of the balloon
tamponade and the appointment of tranexamic acid (1 g, repeat after 30 minutes, if necessary), if
the cr umbrella continues - with a blood loss 1.5% or more of the body weight - laparotomy (the
use of organo-preserving technologies - ligation of major vessels (turn-based partial vaginal
devascularization), compression sutures on the uterus, bleaching of the internal iliac (gipogastric)
arteries having a specialist who has the technique of manipulation, or with the encouragement of
vascular surgeons), hysterectomy without the use of uterus.
If the uterus is not defined, or has an irregular shape, or is observed outside the vagina - it
is diagnosed by eradicating the uterus. In the case of an outflow - the uterus is returned to its
normal position. Do not apply uterotonics and do not attempt to remove the placenta to restore
the position of the uterus. Apply in / to anesthesia or narcotic analgesics. In the case of luck -
manual separation and allocation of the placenta, the appointment of uterotonics, preventive
antibiotic therapy. In case of failure - hysterectomy.
 If the uterus is dense - eliminate injury: manual examination of the uterus to prevent uterine
rupture. In case of uterine rupture - immediate laparotomy;
- Careful examination to exclude injuries (perineum, vagina, cervix). In the presence of trauma -
the sewing of gaps with the subsequent appointment of tranexamic acid (1 g, repeat after 30
minutes if necessary).
In the absence of injury, blood coagulation may be disturbed.
Hypo - and afibrizogenemia - lowering the fibrinogen content in the blood. Normally, fibrinogen
levels in pregnant women are 0.4-0.6 g / l. Reducing it to 0.15 g / l indicates a severe form of
hypofibrinogenemia. At a level of 0,1 g / l (afibrinogenemia) the blood does not collapse. There
are two forms of hypofibrinogenemia - congenital and acquired.
The main causes of acquired (secondary) hypofibrinogenemia:
 loss of 1000 ml of blood and more;
 detachment and placenta previa;
 Amniotic embolism;
 dead fetus, preeclampsia, Rh-conflict;
 chronic DIC-syndrome;
 Severe labor damages.

Basic clinical and laboratory manifestations:

Bleeding can be of 2 types:
• Bleeding begins immediately after birth, massive (in a few minutes> 1000 ml); the
uterus remains hypotonic, does not shrink, rapidly develops hypovolemia, hemorrhagic shock;
• Bleeding begins after uterine contraction, the blood is released in small portions, blood
loss increases gradually. Typically, alternation of the hypotonia of the uterus with the restoration
of tone, stopping and prolonging bleeding.

EMERGENCY MEDICAL CARE ALGORITHM

1. Overview of the pregnant women:

• estimation of blood loss;
• assessment of the condition of the woman: complaints, blood pressure, heart rate, color
of the skin and mucous membranes, the amount of urine, the presence and stage of hemorrhagic
shock.
2. Terminal laboratory examination: hemoglobin level, hematocrit, time of coagulation,
coagulogram, blood group, Rh factor, blood biochemistry.
3.Cateterization of the peripheral or central vein, depending on the degree of blood loss
and the condition of the woman.
4. Bladder catheterization.
5. Introduction of uterotonics: 10-20 OD oxytocin / drops into 400 ml of physiological
solution, in the absence of the effect of 800 mcg misoprostol per rectum.
6. Perform manual revision of the walls of the uterine cavity under v / v anesthesia
(evaluation of the integrity of the walls of the uterus, especially the left uterine wall, removal of
convective blood or residues of the placenta or membranes). If bleeding continues - use of
uterotonics of the 2 nd - 3 rd line (ergometrine , prostaglandins, carbetocin).
In the case of bleeding, bimanual compression of the uterus or compression of the aorta,
if the bleeding stops, and then continues - in the operating conditions of the balloon tamponade
and the appointment of tranexamic acid (1g, repeat after 30 minutes, if necessary), if the
bleeding continues - with the amount of blood loss 1,5% or more by weight of the body -
operative treatment: laparotomy (application of organo-preserving technologies - ligation of
major vessels (turn-by-turn partial devascularization), compression sutures on the uterus,
bilateral dressing of internal iliac (gipogastric) arteries (in the presence of a specialist who has
 the technique of manipulation, or with the encouragement of vascular surgeons), hysterectomy
without the use of uterus.
7. Review of the birth canals and restore their integrity.
8. Restoration of bcc and blood loss.

Mechanical methods of stopping uterine bleeding (when transported to the

operating system):
 Pressing the abdominal aorta with a fist.
 Clamping of the aorta with the uterus in the lower segment to the spine by the method of Genter
G.G.
 Clamping the uterus using the Gubarev-Rachinsky method (the uterus is removed from the
pelvic cavity and pushed to the lonar symphysis for 5-6 minutes).
 Breaking the cervix by the method of Baksheyev, Henkel-Tikikinadze.

POSTPARTUM SECONDARY (LATE) BLEEDING

Late postpartum bleeding is one that occurs after 1 day after delivery and more (up to 42
days). Only one day after delivery in the cavity of the uterus, solid posterior thrombi, which
close the lumen of the uterine vessels, are formed. Bleeding occurs due to delay in the uterine
cavity of the lobules of the placenta or membranes.
Obstetric hemorrhages can occur as a result of a violation of the blood coagulation
system (coagulopathic bleeding). Such abnormalities arise in the dead fetus, premature
detachment of the normally located placenta, embolism with amniotic fluid, after massive blood
loss that occurs in the postpartum or postpartum periods, with septic conditions. There is a DIC -
a syndrome. Traumatic damage to the birth canal can result in massive bleeding.

The main causes of late postpartum bleeding:

• Delay of placenta or litter parts;
• Departure of necrotic tissues after delivery;
• Seizures and wounds of the uterus (after cesarean section or uterine rupture).
Most often late postpartum bleeding occurs 7-12 days after childbirth.

An algorithm for emergency care during bleeding in the late postpartum period
1. Estimation of the amount of blood loss by accessible methods.
2.Cateterization of the peripheral or central vein.
3.Manual (electric) revision (vacuum-aspiration) of the uterus cavity under the
anesthesia. Antibiotic therapy.
4. In the case of bleeding against the background of postpartum endometritis -
immediately begin antibiotic therapy with drugs of the 1st line (ampicillin + gentamicin +
metronidazole, or cephalosporins 1-2 generations) after the rapid introduction of the Ringer
solution.
5. Overview of the birth paths.
6. Haemorrhages in the vagina may require immediate surgical intervention, including
bleaching of the internal iliac (hypogastric) arteries.
7. Bleeding due to the difference in seams and wounds of the uterus requires immediate
laparotomy.
Violation of blood clotting (postpartum afibrinogenemia, fibrinolysis):
- Restoration of the CBC volume;
- Correction of hemostasis.

Methods of evaluation of blood loss

 Alghero-Burri Index: Determined by dividing the pulse rate by the magnitude of systolic
pressure.

Alghero-Burri Index Volume of blood loss (in% VBC)

0,8 and less 10
0,9-1,2 20
1,3-1,4 30

Indices of red blood vary within 2-3 hours from the onset of bleeding.

Degrees of blood loss

Tests
Easy Average Hard
Deficit VBC Up to 20 % 20-30 % 30 % and more
The number of red blood cells 12
4,410 /л 3,51012/л 2,51012/л
Hemoglobin More that 100г/л 85-100 г/л Less than 85 г/л
Hematocrit More than 30% 25-30 % Less than 25 %

Infusion - transfusion therapy in pathological blood loss.

The amount of Total volume of Blood substitutes and volume of blood
blood loss transfusion transfusion
(% of body weight) (% of blood loss) (% of blood loss)
Blood substitutes: reopoliglyukin, crystalloid
0,6 - 0,8 80 – 100
solutions and their combination
0,8 - 1,0 130 – 150 Blood substitutes, hemotransfusion 50-60%
Blood substitutes, poliglyukin in combination
1,0 – 1,5 150 – 180 with other solutions, albumin, hemotransfusion
70-80%
Blood substitutes, plasma, albumin, fibrinogen,
1,5 – 2,0 180 – 200 with a decrease in its concentration in blood,
blood transfusion 90-100%
Blood substitutes, plasma, albumin, fibrinogen,
More that 2,0 More that 250 hemotransfusion 110-120%. Direct blood
transfusion

Compression of the abdominal aorta:

- Application of descending pressure by the fist of the abdominal aorta directly through
the abdominal wall;
- The point of pressure is located directly above the navel and slightly to the left;
- In the early postpartum period, the aortic pulsation can be easily determined through the
anterior abdominal wall;
- The second finger palpates the pulse on the femoral artery to assess the effectiveness of
compression;
- If the pulse is determined, then the pressure is measured by the fist as insufficient and
vice versa.

Bimanual compression of the uterus.

One hand is inserted into the vagina and pressed against the body of the uterus. Another
hand on the inner side of the palm is placed on the stomach at the bottom of the uterus and pump
the uterus to the womb as shown in the picture. Such bimanual compression prevents
prolongation of postpartum bleeding by increasing the tone of the uterus and makes it possible to
significantly reduce blood loss. In addition, it allows the removal of blood convections from the
uterine cavity and to establish the presence of signs of uterine retinopathy, to decide on the need
for manual examination of the uterine cavity.
Balloon tamponade of the uterus.
A special cylinder or rubber glove attached to the urological catheter is introduced into
the cavity of the uterus using a final closure (outside the cervical eye). With a syringe, a cylinder
(glove) is filled with a sterile physiological solution in the amount of 300-500 ml to provide
counter-pressure to stop bleeding. Infusion of oxytocin lasts for 24 hours. In the case of
continued bleeding - additionally injected solution in the balloon. In the event that the bleeding
has stopped and the woman complains of pain – with draw 50-100 ml of solution. Assign an
antibiotic. The balloon is left for 24 hours. Then, gradually remove the solution for 2 hours, after
which the balloon is removed. In case of recovery of bleeding during deflation of the bottle - fill
it again with the solution and leave for the next 24 hours.
The full balloon provides the effect of tamponade. Success is estimated by reducing
blood loss from the cervix. Monitor monitoring of vital functions of the organism is shown.
Continued administration of oxytocin is necessary to keep the uterus abbreviated. The average
length of use of such a method of tamponade is 24 hours. Gradually reducing the volume of the
cylinder provides a reduction in the risk of bleeding recovery. The effectiveness of balloon
tamponade is 77.5-88.8%, that in most cases, this method prevents further surgical treatment. In
the case of continued bleeding after tamponade - carefully reassess the presence of injuries, or
other causes not related to the atony of the uterus.
Surgical hemostasis.
The removal of the uterus in order to stop the bleeding is performed only in the case of
ineffectiveness of the use of previous organ-saving methods and the continuation of bleeding or
in the case of diagnosis of true growth of the placenta.
Methods of surgical hemostasis:
1. Two-way dressing of the uterine vessels.
2. Two-way dressing of the ovarian vessels.
3. Injection of compression seams on the uterus.
4. Bialateral dressing of internal iliac (hypogastric arteries).
5. Radical operations (subtotal or total hysterectomy).
Overlays of ligatures on uterine and ovarian vessels are effective methods of stopping
massive postpartum bleeding. There are several ways to conduct this operation. A separate or
compatible dressing of the uterine artery and veins may be possible. In the case of continued
bleeding, and ineffectiveness of the first ligature overlay, it is possible to overlay the second
ligature below, in order to bandage the lower branch of the uterine artery. But in this case, one
should keep in mind the anatomic closeness of the ureters, which is parametrically at a distance
of 1.5 - 2.0 cm at the level of the internal uterus and has an intersection with the common trunk
of the uterine artery. One-sided overlay of ligatures is ineffective. To enhance the morphological
effect, it is expedient to impose ligatures on the ovarian vessels on both sides, along with the
bleaching of the uterine vessels.
Square stitches for Cho.

B-Lynch Compression Seams.

The effectiveness of compression sutures is 70-90%.

Indications for hysterectomy.

According to WHO, the rate of hysterectomy in postpartum hemorrhages is 1 case per 1000
births.
1. Placental pathology (placenta previa, placenta accreta, increta, percreta).
2.Periodic placement of a normally located placenta with intermucosal hemorrhage and blood
immiscible myometrium and development of uterine Coveller.
 3.Atonia of the uterus is not sensitive to uterotonic drugs and in the absence of the effect of
balloon tamponade, compression sutures, bandaging of the major vessels of the uterus.
4. Breaking the uterus with the separation of the uterine vessels and massive bleeding.
Over-the-top amputation of the uterus (subtotal hysterectomy) is performed only in the case of
the true enlargement of the placenta without significant blood loss and DIC-syndrome.

Tissue of internal iliac (gipogastral) arteries.

Indication:
 After hysterectomy - when blood loss continues.
 In the complex therapy of coagulopathic bleeding.
 Bleeding from under the leaves of a wide ligament of the uterus, pelvic wall, parametric
cellulose.
 Diffuse bleeding from the site without a clear definition of the source of bleeding and vessel bed.
 Uterus rupture with uterine artery detachment.
 Deep cramps of the cervix and cavities of the vagina with the technical difficulties of their
stitching.

The main stages of the operation tethering the internal iliac arteries with intraperitoneal
access:
1. Laparotomy - lower-median or intra-ical incision.
2. Longitudinal incision of the posterior parietal peritoneum.
3.Disection of the internal iliac artery.
4. Submission of ligature under artery.
5. Ligation of ligature on hypogastric artery.

Bleeding after extirpation of the uterus.

The most common cause of bleeding after a hysterectomy is coagulopathic disturbances or
inadequate hemostasis after the previous operation. The need for relaparotomy is due to
iatrogenic causes, which are related to incomplete volume of surgical hemostasis, technical
defects of the operation. During relaparotomy it is necessary to provide local hemostasis, to
perform tight tamponade of the small pelvis and vagina with the subsequent correction of
coagulopathic disorders by conducting infusion-transfusion therapy and the administration of the
appropriate preparations. According to testimony, if possible, the lining of the internal iliac
arteries is performed.
Prevention of postpartum bleeding:
1. During pregnancy:
- assessment of the risk factors for the occurrence of bleeding;
- Diagnosis and treatment of anemia;
- Hospitalization in the hospital with the readiness to render assistance to a pregnant woman
from a group of high risk of occurrence of bleeding, which was: prenatal bleeding, bleeding in
the previous childbirth, have a multifamily, multiple pregnancy, large fruit.
2. During childbirth:
- anesthesia of labor;
- avoiding long births;
- active conduct of the third period of labor;
- use of uterotonic drugs in the third period of childbirth;
- routine examination and evaluation of the integrity of the placenta and membranes;
- Prevention of traumatism during childbirth.
3. After childbirth:
- examination and review of delivery paths;
- careful supervision within 2 hours after delivery;
- in pregnant women at risk of intravenous drip administration of 20 U of oxytocin within 2
hours postpartum.

V. The plan of organization of classes

Introduction 2% of study time;
Topic motivation 3% of study time;
Control the source level of knowledge 20% of study time;
Independent work of student 35% of study time;
Control of the final level of knowledge 20% of study time;
Assessment of student knowledge 15% of study time;
Узагальнення викладача, завдання 5% of study time;
додому Generalization of a topic, a task at home

VI. Basic stages of the class

1. Preparatory stage - motivation of the topic, control of the basic and basic level of knowledge,
assignment of the task for independent work.
2. The main stage - the independent work of students under the control of a teacher: work with
educational literature with a low level of basic knowledge, as well as with teaching aids. Cure for
pregnant women and childbirth. Independent solving of situational tasks and their compilation.
Argumentation of the plan and prognosis of labor and postpartum period.
3. Final stage - control of the final level of knowledge, generalization, evaluation of the work of
each student. Tasks home.

VII Methodical support

The venue for the occupation is the maternity hall, the operating room, the postpartum
department, the department of blood transfusion.
Equipments - tables, slides, stories of illnesses of pregnant women, dummies.

VIIІ. Control questions and tasks

1. Blood supply of the internal genital organs of a woman.
2. Causes of bleeding in the first half of pregnancy.
3. Normal placement and attachment of the placenta.
4. Etiological factors and degrees of placenta previa.
5. Methods of diagnosis, the course of pregnancy and doctor's tactics in childbirth in the placenta
previa. Methods of prevention.
6. Reasons, clinical picture, diagnostics and tactics of the doctor during premature detachment of
a normally placed placenta. Methods of prevention.
7. Causes of bleeding in the 3rd period of childbirth.
8. Anatomic-histological features of placenta in different types of pathological attachment.
9. The algorithm of stopping a bleeding in the III-th period of childbirth. The course of the
operation of the manual placenta of the placenta and the allocation of litter.
10. Causes of bleeding in the early postpartum period. An algorithm for stopping hypotonic
bleeding.
11. Methods of stopping uterine bleeding. Methods of evaluation of blood loss.

Recommended literature:
Basic:

1. Бенюк В.А., Усевич И.А., Дындарь Е.А. Акушерский фантом – К. Библиотека

«ЗдоровьеУкраины»”,2015.С. 8-37.
2. Бенюк В.А. Алгоритмы в акушерстве и гинекологии. – К. Библиотека
«ЗдоровьеУкраины»,2015.С. 8-37.
3. Справочник семейноговрача по акушерству и гинекологии./ Под редакциейпроф.
В.А. Бенюка. – Киев: «Доктор-медиа», 2015.- 622 с.

Additional:
1. Obstetrics: підручник англійською мовою (editby I.B. Ventskivska).- K.:
Medicine,2008.-334 p.
2. Акушерство: підручник (за ред. Б.М.Венцківського, Г.К.Степанківської,
В.П.Лакатоша).- К.: ВСВ Медицина, 2012.- 648 с.
3. Запорожан В.М., Чайка В.К., Маркін Л.Б. Акушерство і гінекологія (у 4-х томах):
національний підручник: 2013.
4. Акушерство і гінекологія (у 2-х книгах): підручник (за ред. Грищенко В.І.,
Щербини М.О.)// Книга І Акушерство.-К.: Медицина, 2011.- 422 с
5. Наказ МОЗ України від 24.05.2014 №205. Клінічний протокол «Акушерські
кровотечі».