Bleeding in the afterbirth and early postpartum period is the most dangerous complication of childbirth.
Epidemiology
The frequency of bleeding in the afterbirth period is 5-8%.
BLEEDING DURING THE FOLLOW-UP PERIOD
Causes of bleeding in the afterbirth period:
- violation of the separation of the placenta and the release of the placenta (partial tight attachment or accreta of the placenta, strangulation of the separated placenta in the uterus);
- hereditary and acquired hemostasis defects;
Violation of separation of the placenta and placenta discharge
Violation of placental separation and placenta discharge is observed when:
- pathological attachment of the placenta, tight attachment, ingrowth of chorionic villi;
- uterine hypotension;
- anomalies, structural features and attachment of the placenta to the wall of the uterus;
- strangulation of the placenta in the uterus;
Etiology and pathogenesis
Anomalies, features of the structure and attachment of the placenta to the wall of the uterus, often contribute to the disruption of separation and discharge of the placenta.
For separation of the placenta, the area of contact with the surface of the uterus is important.
With a large area of attachment, a relatively thin or leathery placenta (placenta membranacea), the insignificant thickness of the placenta prevents its physiological separation from the walls of the uterus. Placentas, shaped like blades, consisting of two lobes, with additional lobules, are separated from the uterine wall with difficulty, especially with uterine hypotension.
Violation of the separation of the placenta and the discharge of the placenta may be due to the placenta’s attachment site; in the lower uterine segment (with a low location and presentation), in the corner or on the side walls of the uterus, on the septum, above the myomatous node. In these places, the muscles are defective and cannot develop the force of contraction necessary to separate the placenta. Strangulation of the placenta after separation of the placenta occurs when it is retained in one of the uterine angles or in the lower segment of the uterus, which is most often observed during discoordinated contractions in the placenta.
Impaired discharge of the birth placenta can be iatrogenic if the postpartum period is not managed correctly.
An untimely attempt to release the placenta, massage of the uterus, including according to Crede-Lazarevich, pulling on the umbilical cord, and the administration of large doses of uterotonic drugs disrupt the physiological course of the third period, the correct sequence of contractions of various parts of the uterus. One of the reasons for impaired separation of the placenta and discharge of the placenta is uterine hypotension.
With uterine hypotension, afterbirth contractions are either weak or absent for a long time after the birth of the fetus. As a result, both the separation of the placenta from the uterine wall and the release of the placenta are disrupted; in this case, it is possible that the placenta may be strangulated in one of the uterine angles or the lower uterine segment of the uterus. The succession period is characterized by a protracted course.
Clinical picture
The clinical picture of impaired separation of the placenta and discharge of the placenta depends on the presence of areas of separated placenta.
If the placenta does not separate throughout, then the absence of signs of placental separation for a long time and the absence of bleeding are clinically determined.
More common is partial separation of the placenta, when one or another section is separated from the wall, and the rest remains attached to the uterus. In this situation, muscle contraction at the level of the separated placenta is not enough to compress the vessels and stop bleeding from the placental site. The main symptoms of partial separation of the placenta are the absence of signs of placental separation and bleeding. Bleeding occurs a few minutes after the baby is born. The blood is liquid, mixed with clots of various sizes, and flows out in spurts and unevenly. Retention of blood in the uterus and vagina often creates a false impression of the cessation or absence of bleeding, as a result of which measures aimed at stopping it may be delayed. Sometimes blood accumulates in the uterine cavity and vagina, and then is released in clots after external signs of placental separation are detected. On external examination there are no signs of separation of the placenta. The fundus of the uterus is at the level of the navel or above, deviated to the right. The general condition of the woman in labor depends on the degree of blood loss and changes quickly. In the absence of timely assistance, hemorrhagic shock occurs. The clinical picture of impaired discharge of the strangulated placenta is the same as in the case of impaired separation of the placenta from the uterine wall (also accompanied by bleeding).
Diagnostics
Complaints of bleeding of varying intensity. Laboratory tests for bleeding in the afterbirth period:
- clinical blood test (Hb, hematocrit, red blood cells);
- coagulogram;
- in case of massive blood loss, CBS, blood gases, plasma lactate level
- blood chemistry;
- electrolytes in plasma;
- Analysis of urine;
Physical examination data:
- absence of signs of placental separation (Schroeder, Küstner-Chukalov, Alfelts);
- when manually separating the placenta with physiological and tight attachment of the placenta (placenta adhaerens), strangulation, as a rule, you can remove all lobes of the placenta by hand.
With true chorionic ingrowth, it is impossible to separate the placenta from the wall without violating its integrity. Often, true placenta accreta is established only by histological examination of the uterus, which was removed due to suspected hypotension and massive bleeding in the postpartum period.
Instrumental methods. It is possible to accurately determine the type of pathological attachment with targeted ultrasound during pregnancy and manual separation of the placenta in the afterbirth period.
Birth canal injuries
Bleeding from ruptures of the soft tissues of the birth canal can be severe when blood vessels are damaged. Cervical ruptures are accompanied by bleeding when the integrity of the descending branch of the uterine artery is disrupted (with lateral cervical ruptures). With low placental attachment and pronounced vascularization of the tissues of the lower segment of the uterus, even minor injuries to the cervix can lead to massive bleeding. In case of vaginal injuries, bleeding occurs from ruptures of varicose veins, a. vaginalis or its branches. Bleeding is possible with high tears involving the fornix and base of the broad uterine ligaments, sometimes a. uterinae. When the perineum ruptures, bleeding occurs from the branches of a. pudendae. Ruptures in the clitoral area, where a network of venous vessels is developed, are also accompanied by severe bleeding.
Diagnostics
Diagnosis of bleeding from soft tissue ruptures is not difficult, with the exception of damage to the deep branches of a. vaginalis (bleeding can simulate uterine bleeding). About the gap a. vaginalis may indicate hematomas of the soft tissues of the vagina.
Differential diagnosis
In differential diagnosis, the following signs of bleeding from soft tissue ruptures are taken into account:
- bleeding occurs immediately after the birth of the child;
- despite the bleeding, the uterus is dense and well contracted;
- the blood does not have time to clot and flows out of the genital tract in a liquid stream of bright color.
Hemostasis defects
Features of bleeding with hemostasis defects are the absence of clots in the blood flowing from the genital tract. Treatment and tactics of management of pregnant women with pathology of the third stage of labor The goal of treatment is to stop bleeding, which is carried out by:
- separation of the placenta and placenta discharge;
- suturing ruptures of soft tissues of the birth canal;
- normalization of hemostasis defects.
Sequence of measures in case of retained placenta and absence of blood discharge from the genitals:
- bladder catheterization (often causes increased uterine contractions and separation of the placenta);
- puncture or catheterization of the ulnar vein, intravenous administration of crystalloids in order to adequately correct possible blood loss;
- administration of uterotonic drugs 15 minutes after expulsion of the fetus (oxytocin IV drip 5 units in 500 ml of 0.9% sodium chloride solution);
- when signs of placenta separation appear, release the placenta using one of the accepted methods (Abuladze, Crede-Lazarevich);
- in the absence of signs of placenta separation within 20-30 minutes against the background of the introduction of contracting agents, manual separation of the placenta and placenta discharge is performed. If epidural anesthesia was used during childbirth, manual separation of the placenta and release of the placenta are performed before the anesthetic wears off. If pain relief was not used during childbirth, this operation is performed against the background of intravenous painkillers (propofol). After removal of the placenta, the uterus usually contracts, tightly clasping the arm. If the tone of the uterus is not restored, additional uterotonic drugs are administered and bimanual compression of the uterus is performed by inserting the right hand into the anterior vaginal fornix;
- if true placenta accreta is suspected, the attempt at separation must be stopped to avoid massive bleeding and perforation of the uterus.
Sequence of measures for bleeding in the third stage of labor:
- catheterization of the bladder. Puncture or catheterization of the ulnar vein with the connection of intravenous infusions;
- determination of signs of placental separation (Schroeder, Küstner-Chukalov, Alfelts);
- if there are positive signs of separation of the placenta, an attempt is made to isolate the placenta according to Crede-Lazarevich, first without pain relief, then against the background of pain relief;
- if there is no effect from external methods of releasing the placenta, it is necessary to manually separate the placenta and release the placenta.
In the postoperative period, it is necessary to continue the intravenous administration of uterotonic drugs and from time to time, carefully, without excessive pressure, perform external massage of the uterus and squeeze out blood clots from it. Bleeding due to ruptures of the cervix, clitoris, perineum and vagina is stopped by immediate suturing and restoration of tissue integrity. Sutures are placed on breaks in the soft birth canal after the placenta is released. The exception is ruptures of the clitoris, the integrity of which can be restored immediately after the birth of the child. Visible bleeding from the vessels of the perineal wound after episiotomy is stopped by applying clamps, and after removing the placenta from the uterus - by suturing. If a soft tissue hematoma is detected, it is opened and sutured. If a bleeding vessel is identified, it is ligated. Hemostasis is normalized. In case of bleeding caused by impaired hemostasis, it is corrected.
Prevention
Rational management of childbirth; use of regional anesthesia. Careful and correct management of the third stage of labor. Elimination of unreasonable pulling on the umbilical cord of the uterus.
BLEEDING IN THE EARLY POSTPARTUM PERIOD
Epidemiology
The incidence of bleeding in the early postpartum period is 2.0-5.0% of the total number of births. Based on the time of occurrence, early and late postpartum hemorrhage are distinguished. Postpartum hemorrhage that occurs within 24 hours after birth is considered early or primary; after this period it is classified as late or secondary.
Bleeding within 2 hours after birth occurs for the following reasons:
- retention of parts of the placenta in the uterine cavity;
- hereditary or acquired hemostasis defects;
- hypotension and atony of the uterus;
- injuries of the soft birth canal;
- uterine inversion (see chapter on traumatism);
To determine a general understanding of the etiology of bleeding, you can use the 4T diagram:
- “tissue” - decreased uterine tone;
- “tone” - decreased tone of the uterus;
- “trauma” - ruptures of the soft birth canal and uterus;
- “blood clots” - impaired hemostasis.
Retention of parts of the placenta in the uterine cavity
The retention of parts of the placenta in the uterine cavity prevents its normal contraction and compression of the uterine vessels. The reason for the retention of parts of the placenta in the uterus may be partial tight attachment or accretion of placenta lobules. The retention of membranes is most often associated with improper management of the postpartum period, in particular, with excessive acceleration of the birth of the placenta. Retention of the membranes is also observed during intrauterine infection, when their integrity is easily damaged. It is not difficult to determine the retention of parts of the placenta in the uterus after its birth. When examining the placenta, a defect in the placental tissue, absence of membranes, and torn membranes are revealed.
The presence of parts of the placenta in the uterus can lead to infection or bleeding, both in the early and late postpartum period. Sometimes massive bleeding occurs after discharge from the maternity hospital on days 8-21 of the postpartum period (late postpartum hemorrhage). Detection of a defect in the placenta (placenta and membranes), even in the absence of bleeding, is an indication for manual examination and emptying of the uterine cavity.
Classification
Uterine hypotension is a decrease in the tone and contractility of the uterine muscles. Reversible condition. Uterine atony is a complete loss of tone and contractility. Currently, it is considered inappropriate to divide bleeding into atonic and hypotonic. The definition of “hypotonic bleeding” is accepted.
Clinical picture: main symptoms of uterine hypotension;
- bleeding;
- decreased uterine tone;
- symptoms of hemorrhagic shock.
With uterine hypotension, blood is first released with clots, usually after external massage of the uterus. The uterus is flabby, the upper border can reach the navel and above. The tone may be restored after external massage, then decrease again, bleeding resumes. In the absence of timely assistance, blood loses its ability to clot. In accordance with the amount of blood loss, symptoms of hemorrhagic shock arise (pallor of the skin, tachycardia, hypotension, etc.).
Diagnostics
Diagnosis of hypotonic bleeding is not difficult. Differential diagnosis should be made with trauma to the uterus and genital tract.
Treatment
The goal of treatment is to stop bleeding. Stopping bleeding in case of hypotension should be carried out simultaneously with measures to correct blood loss and hemostasis.
If blood loss is within 300-400 ml after confirming the integrity of the placenta, an external massage of the uterus is performed, while uterotonic drugs are administered (oxytocin 5 units in 500 ml NaCl solution 0.9%) or carbetocin 1 ml (slow IV), misoprostol (mirolut) 800-1000 mcg per rectum once. An ice pack is placed on the lower abdomen.
If blood loss exceeds 400.0 ml or if there is a placenta defect, under IV anesthesia or ongoing epidural anesthesia, a manual examination of the uterus is performed, and, if necessary, bimanual compression of the uterus. To help stop bleeding, the abdominal aorta can be pressed against the spine through the abdominal wall. This reduces blood flow to the uterus. Subsequently, the tone of the uterus is checked using external methods and uterotonics continue to be administered intravenously.
In case of bleeding of 1000-1500 ml or more, a woman’s pronounced reaction to less blood loss, embolization of the uterine vessels or laparotomy is necessary. The most optimal option at present, if conditions exist, should be considered embolization of the uterine arteries using the generally accepted method. If there are no conditions for embolization of the uterine arteries, laparotomy is performed.
As an intermediate method in preparation for surgery, a number of studies suggest intrauterine tamponade with a hemostatic balloon. The algorithm for using a hemostatic balloon is presented in the Appendix. If there is heavy uterine bleeding, you should not waste time on inserting a hemostatic balloon, but proceed to laparotomy, or, if possible, to UAE. During laparotomy, at the first stage, if there is experience or a vascular surgeon, the internal iliac arteries are ligated (the technique for ligating the internal iliac arteries is presented in the Appendix). If there are no conditions, then sutures are placed on the uterine vessels or the uterus is compressed using hemostatic sutures according to one of the methods of B-Lynch, Pereira, Hayman. Cho, V.E. Radzinsky (see appendix for technique). If the lower segment is overstretched, tightening sutures are placed on it.
The effect of suture lasts 24-48 hours. If bleeding continues, hysterectomy is performed. During laparotomy, a machine is used to reinfuse blood from the incisions and abdominal cavity. Timely implementation of organ-preserving methods allows achieving hemostasis in most cases. In conditions of ongoing bleeding and the need to proceed to radical intervention, they help reduce the intensity of bleeding and the total volume of blood loss. Implementation of organ-preserving methods to stop postpartum hemorrhage is a prerequisite. Only the lack of effect from the above measures is an indication for radical intervention - hysterectomy.
Organ-preserving methods of surgical hemostasis do not lead to the development of complications for the majority. After ligation of the internal iliac and ovarian arteries, blood flow in the uterine arteries is restored in all patients by the 4-5th day, which corresponds to physiological values.
Prevention
Patients at risk for bleeding due to uterine hypotension are given intravenous oxytocin at the end of the second stage of labor.
In case of hereditary and congenital hemostasis defects, a labor management plan is outlined together with hematologists. The principle of treatment is the administration of fresh frozen plasma and glucocorticoids. Information for the patient
Patients at risk of bleeding should be warned about the possibility of bleeding during childbirth. In case of massive bleeding, hysterectomy is possible. If possible, instead of ligating blood vessels and removing the uterus, embolization of the uterine arteries is performed. It is very advisable to transfuse your own blood from the abdominal cavity. In case of ruptures of the uterus and soft birth canal, suturing is performed, and in case of hemostasis disturbance, correction is performed.
Therapy methods
During childbirth, physiological blood loss is 300-500 ml - 0.5% of body weight; for caesarean section - 750-1000 ml; for planned caesarean section with hysterectomy - 1500 ml; for emergency hysterectomy - up to 3500 ml.
Major obstetric hemorrhage is defined as a loss of more than 1000 ml of blood, or >15% of circulating blood volume, or >1.5% of body weight.
Severe life-threatening bleeding is considered to be:
- loss of 100% of circulating blood volume within 24 hours, or 50% of circulating blood volume in 3 hours;
- blood loss at a rate of 15 ml/min, or 1.5 ml/kg per minute (for more than 20 minutes);
- immediate blood loss of more than 1500-2000 ml, or 25-35% of the circulating blood volume.
Determination of blood loss volume
Visual assessment is subjective. The underestimation is 30-50%. Less than average volume is overestimated, and large volume losses are underestimated. In practical activities, determining the volume of blood lost is of great importance:
- using a measuring container makes it possible to take into account the blood that has been shed, but does not allow you to measure the remaining blood in the placenta (approximately 153 ml). Inaccuracy is possible when blood is mixed with amniotic fluid and urine;
- gravimetric method - determining the difference in the mass of surgical material before and after use. Napkins, balls and diapers must be of standard size. The method is not free from errors when mixing amniotic fluid. The error of this method is within 15%.
- acid-hematine method - calculation of plasma volume using radioactive isotopes, using labeled red blood cells, the most accurate, but more complex and requires additional equipment.
Due to the difficulty of accurately determining blood loss, the body's response to blood loss is of great importance. Taking these components into account is fundamental to determining the volume of infusion required.
Diagnostics
Due to an increase in circulating blood volume and CO, pregnant women are able to tolerate significant blood loss with minimal changes in hemodynamics until a late stage. Therefore, in addition to taking into account lost blood, indirect signs of hypovolemia are of particular importance. Pregnant women retain compensatory mechanisms for a long time, and they are able, with adequate therapy, to endure, unlike non-pregnant women, significant blood loss.
The main sign of decreased peripheral blood flow is the capillary refill test, or white spot sign. It is performed by pressing the nail bed, eminence of the thumb or other part of the body for 3 seconds until a white color appears, indicating the cessation of capillary blood flow. After finishing pressing, the pink color should be restored in less than 2 seconds. An increase in the recovery time of the pink color of the nail bed of more than 2 seconds is noted when microcirculation is impaired.
A decrease in pulse pressure and shock index is an earlier sign of hypovolemia than systolic and diastolic blood pressure assessed separately.
Shock index is the ratio of heart rate to systolic blood pressure, which changes with blood loss of 1000 ml or more. Normal values are 0.5-0.7. Decreased urine output during hypovolemia often precedes other signs of circulatory impairment. Adequate diuresis in a patient not receiving diuretics indicates sufficient blood flow in the internal organs. To measure the rate of diuresis, 30 minutes is enough:
- insufficient diuresis (oliguria) - less than 0.5 ml/kg per hour;
- reduced diuresis - 0.5-1.0 ml/kg per hour;
- normal diuresis - more than 1 ml/kg per hour.
Respiratory rate and state of consciousness should also be assessed before performing mechanical ventilation.
Intensive care of obstetric hemorrhage requires coordinated actions, which should be rapid and, if possible, simultaneous. It is carried out jointly with an anesthesiologist and resuscitator against the background of measures to stop bleeding. Intensive therapy (resuscitation) is carried out according to the ABC scheme: airways (Aigway), breathing (Breathing), blood circulation (Cigculation).
After assessing breathing, adequate oxygen supply is ensured: intranasal catheters, mask spontaneous or artificial ventilation. After assessing the patient’s breathing and starting oxygen inhalation, obstetricians - gynecologists, midwives, operating nurses, anesthesiologists-resuscitators, nurse anesthetists, an emergency laboratory, and a blood transfusion service are notified and mobilized for the upcoming joint work. If necessary, a vascular surgeon and angiography specialists are called. At the same time, reliable venous access is ensured. 14Y (315 ml/min) or 16Y (210 ml/min) peripheral catheters are used.
In case of collapsed peripheral veins, venesection or catheterization of the central vein is performed. In case of hemorrhagic shock or blood loss of more than 40% of the circulating blood volume, catheterization of the central vein (preferably the internal jugular vein), preferably with a multilumen catheter, is indicated, which provides additional intravenous access for infusion and allows monitoring of central hemodynamics. In conditions of blood coagulation disorders, access through the cubital vein is preferable. When installing a venous catheter, it is necessary to take a sufficient amount of blood to determine the initial parameters of the coagulogram, hemoglobin concentration, hematocrit, platelet count, and conduct compatibility tests for possible blood transfusion. Bladder catheterization should be performed and minimal monitoring of hemodynamic parameters should be provided: ECG, pulse oximetry, non-invasive blood pressure measurement. All measurements should be documented. Blood loss must be taken into account. In the intensive care of massive bleeding, infusion therapy plays a leading role.
The goal of infusion therapy is to restore:
- volume of circulating blood;
- tissue oxygenation;
- hemostasis systems;
- metabolism.
In case of an initial violation of hemostasis, therapy is aimed at eliminating the cause. During infusion therapy, the optimal combination of crystalloids and colloids, the volume of which is determined by the amount of blood loss.
The speed of administration of solutions is important. Critical pressure (60-70 mmHg) should be achieved as quickly as possible. Adequate blood pressure values are achieved when I.T. >90 mmHg. In the setting of decreased peripheral blood flow and hypotension, noninvasive blood pressure measurement may be inaccurate; in these cases, invasive blood pressure measurement is preferred.
Initial replacement of circulating blood volume is carried out at a rate of 3 liters for 515 minutes under the control of ECG, blood pressure, saturation, capillary refill test, CBS of blood and diuresis. Further therapy can be carried out either in discrete doses of 250500 ml over 10-20 minutes with assessment of hemodynamic parameters, or with continuous monitoring of central venous pressure. Negative values of central venous pressure indicate hypovolemia, however, they are also possible with positive values of central venous pressure, therefore the response to volume load, which is carried out by infusion at a rate of 1020 ml/min for 10-15 minutes, is more informative. An increase in central venous pressure of more than 5 cm of water. Art. indicates heart failure or hypervolemia; a slight increase in central venous pressure values, or its absence, indicates hypovolemia. To obtain a filling pressure sufficient to restore tissue perfusion in the left chambers of the heart, rather high values of central venous pressure (10-12 cm H2O and higher) may be required.
The criterion for adequate replenishment of fluid deficiency in the circulation is central venous pressure and hourly diuresis. Until the central venous pressure reaches 12-15 cm of water. Art. and hourly urine output does not become >30 ml/h, the patient requires I.T.
Additional indicators of the adequacy of infusion therapy and tissue blood flow are:
- mixed venous blood saturation, target values 70% or more;
- positive capillary refill test;
- physiological values of blood CBS. Lactate clearance: it is desirable to reduce its level by 50% within 1 hour; IT. continue until lactate level is less than 2 mmol/l;
- sodium concentration in urine is less than 20 mol/l, urine/blood plasma osmolarity ratio is more than 2, urine osmolarity is more than 500 mOsm/kg - signs of ongoing impaired renal perfusion.
During intensive care, avoid hypercapnia, hypocapnia, hypokalemia, hypocalcemia, fluid overload, and overcorrection of acidosis with sodium bicarbonate. Restoring the oxygen transport function of the blood.
Indications for blood transfusion:
- hemoglobin concentration 60-70 g/l;
- blood loss of more than 40% of the circulating blood volume;
- unstable hemodynamics.
In patients weighing 70 kg, one dose of packed red blood cells increases the hemoglobin concentration by approximately 10 g/l and the hematocrit by 3%. To determine the required number of doses of red blood cells (n) with ongoing bleeding and a hemoglobin concentration of 60-70 g/l, an approximate calculation using the formula is convenient:
N=(100x/15,
Where n is the required number of doses of red blood cells,
- hemoglobin concentration.
During blood transfusion, it is advisable to use a system with leukocyte filters, which helps reduce the likelihood of immune reactions caused by leukocyte transfusion. An alternative to red blood cell transfusion: intraoperative hardware reinfusion of blood (transfusion of red blood cells collected during surgery and washed). A relative contraindication for its use is the presence of amniotic fluid. To determine the Rh-positive blood factor in newborns, the Rh-negative mother must be administered an increased dose of human anti-Rhesus immunoglobulin Rho[D], since using this method may introduce fetal red blood cells.
Correction of hemostasis. During the treatment of a patient with bleeding, the function of the hemostatic system is most often affected by the influence of drugs for infusion, with coagulopathy of dilution, consumption, and loss. Dilution coagulopathy is clinically significant when more than 100% of the circulating blood volume is replaced and is manifested by a decrease in the content of plasma coagulation factors. In practice, dilutional coagulopathy is difficult to distinguish from disseminated intravascular coagulation syndrome. To normalize hemostasis, the following drugs are used.
Fresh frozen plasma. Indications for transfusion of fresh frozen plasma are:
- APTT >1.5 from the initial level with ongoing bleeding;
- bleeding of III-IV class (hemorrhagic shock).
The initial dose is 12-15 ml/kg, repeated doses are 5-10 ml/kg. The transfusion rate of fresh frozen plasma is at least 1000-1500 ml/h; when coagulation parameters stabilize, the rate is reduced to 300-500 ml/h. It is advisable to use fresh frozen plasma that has undergone leukoreduction. Cryoprecipitate containing fibrinogen and factor VIII is indicated as an additional agent for the treatment of hemostatic disorders with a fibrinogen content of 1 g/l.
Thromboconcentrate. The possibility of platelet transfusion is considered in the following cases:
- platelet count less than 50,000/mm3 due to bleeding;
- platelet count less than 20-30,000/mm3 without bleeding;
- with clinical manifestations of thrombocytopenia or thrombocytopathy (petechial rash). One dose of platelet concentrate increases platelet levels by approximately 5000/mm3. Usually 1 unit/10 kg (5-8 packets) is used.
Antifibrinolytics. Tranexamic acid and aprotinin inhibit plasminogen activation and plasmin activity. The indication for the use of anti-fibrinolytics is pathological primary activation of fibrinolysis. To diagnose this condition, use the euglobulin clot lysis test with activation by streptokinase or 30-minute lysis with thromboelastography.
Antithrombin III concentrate. When the activity of antithrombin III decreases to less than 70%, restoration of the anticoagulant system is indicated by transfusion of fresh frozen plasma or antithrombin III concentrate. Antithrombin III activity must be maintained within 80-100%. Recombinant activated factor VIIa was developed for the treatment of bleeding episodes in patients with hemophilia A and B. As an empirical hemostatic agent, the drug has been successfully used in a variety of conditions associated with uncontrolled severe bleeding. Due to the insufficient number of observations, the role of recombinant factor VII A in the treatment of obstetric hemorrhage has not been definitively determined. The drug can be used after standard surgical and medical means of stopping bleeding.
Conditions of use:
- Hb >70 g/l, fibrinogen >1 g/l, platelets >50,000/mm3;
- pH >7.2 (correction of acidosis);
- warming the patient (preferably, but not required).
Possible application protocol (according to Sobeszczyk and Breborowicz);
- initial dose - 40-60 mcg/kg intravenously;
- with ongoing bleeding - repeated doses of 40-60 mcg/kg 3-4 times every 15-30 minutes.
- when the dose reaches 200 mcg/kg and there is no effect, it is necessary to check the conditions for use;
- only after correction can the next dose of 100 mcg/kg be administered.
Adrenergic agonists. Used for bleeding according to the following indications:
- bleeding during regional anesthesia and sympathetic blockade;
- hypotension when installing additional intravenous lines;
- hypodynamic, hypovolemic shock.
In parallel with replenishing the volume of circulating blood, a bolus injection of 5-50 mg of ephedrine, 50-200 mcg of phenylephrine or 10-100 mcg of epinephrine is possible. It is better to titrate the effect by intravenous infusion:
- dopamine - 2-10 mcg/(kg x min) or more, dobutamine - 2-10 mcg/(kg x min), phenylfarine - 1-5 mcg/(kg x min), epinephrine - 1-8 mcg/min.
The use of these drugs increases the risk of vascular spasm and organ ischemia, but is justified in a critical situation.
Diuretics. Loop or osmotic diuretics should not be used in the acute period during IT. Increased urine output caused by their use will reduce the value of monitoring urine output or volume replenishment. Moreover, stimulation of diuresis increases the likelihood of developing acute pyelonephritis. For the same reason, the use of solutions containing glucose is undesirable, since noticeable hyperglycemia can subsequently cause osmotic diuresis. Furosemide (5-10 mg IV) is indicated only to accelerate the onset of fluid mobilization from the interstitial space, which should occur approximately 24 hours after bleeding and surgery.
Maintaining temperature balance. Hypothermia impairs platelet function and reduces the rate of reactions of the blood coagulation cascade (10% for every degree Celsius decrease in body temperature). In addition, the condition of the cardiovascular system, oxygen transport (shift of the Hb-Ch dissociation curve to the left), and elimination of drugs by the liver worsen. It is essential to warm both the IV fluids and the patient. The central temperature should be kept close to 35°.
Position of the operating table. In case of blood loss, the horizontal position of the table is optimal. The reverse Trendelenburg position is dangerous due to the possibility of an orthostatic reaction and a decrease in MV, and in the Trendelenburg position, the increase in CO is short-lived and is replaced by its decrease due to an increase in afterload. Therapy after bleeding has stopped. After stopping the bleeding, I.T. continue until adequate tissue perfusion is restored.
Goals:
- maintaining systolic blood pressure more than 100 mm Hg. (with previous hypertension more than 110 mmHg);
- maintaining the concentration of hemoglobin and hematocrit at a level sufficient for oxygen transport;
- normalization of hemostasis, electrolyte balance, body temperature (>36°);
- restoration of diuresis more than 1 ml/kg per hour;
- increase in CO;
- reverse development of acidosis, decrease in lactate concentration to normal.
They carry out prevention, diagnosis and treatment of possible manifestations of multiple organ failure. With further improvement of the condition to moderate, the adequacy of replenishment of circulating blood volume can be checked using an orthostatic test. The patient lies quietly for 2-3 minutes, then blood pressure and heart rate are noted. The patient is asked to stand up (the option with standing up is more accurate than with sitting down in bed). If symptoms of cerebral hypoperfusion appear, that is, dizziness or lightheadedness, the test should be stopped and the patient should be placed in bed. If there are no indicated symptoms, heart rate readings are noted 1 minute after rising. The test is considered positive when the heart rate increases to more than 30 beats/min or symptoms of cerebral perfusion are present. Due to the small variability, changes in blood pressure are not taken into account. An orthostatic test can detect a deficit in circulating blood volume of 15-20%. It is not necessary and dangerous if there is hypotension in a horizontal position and signs of shock.
The afterbirth period (third stage of labor) begins with the birth of the fetus and ends with the birth of the placenta. Usually the placenta separates on its own within 5-20 minutes after the birth of the fetus. You should not try to isolate the placenta before the placenta is separated. The succession period is characterized by the appearance of afterbirth contractions, which lead to the gradual separation of the placenta from the walls of the uterus. Separation of the placenta from the walls of the uterus can occur in two ways - from the center (central placenta compartment) and from the peripheral parts of the placenta (marginal placenta compartment).
Signs of placental separation. Before checking contact signs, you need to check non-contact signs:
1) the umbilical cord lengthens (positive Alfeld sign);
2) the umbilical cord is retracted with a deep breath (Dovzhenko’s sign);
3) the fundus of the uterus takes on a rounded shape, becomes denser to the touch and rises higher and to the right of the navel (Schroeder’s sign);
4) bloody discharge from the genital tract appears;
5) the outer section of the umbilical cord lengthens;
6) when pressing with the edge of the palm on the abdominal wall slightly above the pubis, the umbilical cord does not retract into the vagina, but, on the contrary, comes out even more.
Bleeding in the afterbirth period may occur as a result of a violation of the separation of the placenta and the discharge of the placenta.
Violation of the process of separation of the placenta. It may be associated with weakness of labor, with tight attachment and true placenta accreta.
Violation of placenta discharge occurs with spasm of the internal pharynx, hypotonicity of the uterus.
If blood loss remains within normal limits, it is necessary to monitor the condition of the woman in labor and administer uterotonics for another 30–40 minutes.
If the blood loss is pathological, then it is necessary:
1) clarify the woman’s condition;
2) compensate for blood loss:
a) if blood loss is 400–500 ml, administer gelatinol,
saline solution, oxytocin intravenously;
b) if blood loss exceeds 500 ml, hemodynamic disturbances occur and blood transfusion is necessary.
If there are no signs of placental separation, you must:
1) assess the general condition of the woman in labor and the amount of blood loss;
2) give intravenous anesthesia and begin or continue the administration of uterotonics, having previously performed an external massage of the uterus;
3) proceed with the operation of manual separation of the placenta and release of the placenta.
Manual separation of the placenta and release of the placenta is performed if there are no signs of placenta separation within 30 minutes after anesthesia.
Inspection of the placenta. The placenta is examined for the presence of all its lobules and the membranes are examined. If broken vessels are present, there may be additional lobules that remain in the uterine cavity. In cases of pathological changes, the placenta is sent for histological examination.
1. Bleeding due to pathological attachment of the placenta
· dense attachment of the placenta - attachment of the placenta in the basal layer of the uterine mucosa;
· true placenta accreta - ingrowth of the placenta into the muscular layer of the uterus;
· anomalies, structural features and attachment of the placenta to the wall of the uterus.
2. Impaired discharge of placenta
· pinching of the placenta in the area of the internal pharynx (spasm of the pharynx)
Pathological attachment of the placenta includes:
1) tight attachment of the placenta (placenta adhaerens);
2) accretion of the placenta to the muscle layer (placenta accreta);
3) ingrowth of the placenta into the muscle layer (placenta increta);
4) germination of the placenta (placenta percreta).
Pathological attachment of the placenta can be observed throughout (full) or in one place ( incomplete).
Etiology and pathogenesis. Normally, the placenta is formed in the functional layer of the mucous membrane, which transforms into the decidua and consists of a compact and spongy layer. The separation of the placenta from the uterine wall in the third stage of labor occurs at the level of the spongy layer of the decidua.
In case of inflammatory diseases or dystrophic changes in the endometrium, the spongy layer undergoes scar degeneration, as a result of which independent separation of the tissue along with the placenta in the third stage of labor is impossible. This condition is called tight attachment. With atrophy of the functional and basal layer of the mucous membrane, one or more cotyledons of the developing placenta reach the muscular layer or grow into it (true ingrowth).
Pathological attachment of the placenta is caused by either changes in the uterine mucosa or characteristics of the chorion. The following diseases lead to changes in the uterine mucosa that contribute to disruption of trophoblast formation:
ü nonspecific and specific inflammatory lesions of the endometrium (chlamydia, gonorrhea, tuberculosis, etc.);
ü excessive curettage during removal of the fertilized egg or diagnostic procedures;
ü postoperative scars on the uterus (CS and myomectomy).
Violation of trophoblast attachment or ingrowth also contributes to increased proteolytic activity of chorionic villi. The increased proteolytic ability of the chorion can lead to the ingrowth of villi into the compact layer of the falling membrane as a whole, and in some cases to growth into the muscular layer of the uterus up to the serous membrane.
Anomalies, structural features and attachment of the placenta to the wall of the uterus often contribute to the disruption of separation and discharge of the placenta. For separation of the placenta, the area of contact with the surface of the uterus is important. With a large area of attachment, a relatively thin or leathery placenta (placenta membranacea), the slight thickness of the placenta prevents physiological separation from the walls of the uterus. Placentas, shaped like lobes, consisting of two lobes, with additional lobules, are separated from the walls of the uterus with difficulty, especially with uterine hypotension.
Impaired separation of the placenta and placenta discharge may be due to the placenta insertion site: in the lower uterine segment (with a low location and presentation), in the corner or on the side walls of the uterus, on the septum, above the myomatous node. In these areas, the muscles are defective and cannot develop the contractile force necessary to separate the placenta.
CLINICAL PICTURE. The clinical picture of impaired separation of the placenta and discharge of the placenta depends on the presence of areas of separated placenta. Only with partial true accretion or partial tight attachment is bleeding possible.
The classification depends on the degree of penetration of chorionic villi into the layers of the uterine wall.
There are:
Dense attachment of the placenta (complete and partial)
· True placenta accreta (complete and partial).
Tight attachment of the placenta- a pathology in which the chorionic villi do not extend beyond the basal layer, but are tightly connected to it.
True placenta accreta a severe pathology in which chorionic villi penetrate the muscle layer, growing through it and reaching the serous membrane of the uterus.
If the placenta does not separate all the way ( complete pathological attachment), clinically determined no signs of placental separation and no bleeding.
More often observed partial separation of the placenta (incomplete attachment), when one or another section is separated from the wall, and the rest remains attached to the uterus. In this situation, muscle contraction at the level of the separated placenta is not enough to compress the vessels and stop bleeding from the placental site.
The main symptoms of partial separation of the placenta are: no signs of placental separation and bleeding.
Clinic for partial separation of the placenta. Bleeding 10-15 minutes after the birth of the baby. There are no signs of separated placenta. The blood is liquid, mixed with clots of various sizes, and flows out in spurts and unevenly. On external examination there are no signs of separation of the placenta. The fundus of the uterus is located at the level of the navel or above. The general condition of the woman in labor depends on the degree of blood loss and changes quickly. In the absence of timely assistance, hemorrhagic shock occurs.
DIAGNOSTICS. It is possible to accurately determine the type of pathological attachment of the placenta with targeted ultrasound and manual separation of the placenta.
Determine true accretion or fetal attachment It is possible only with manual separation of the placenta. During manual separation of the placenta when it's tight attachment (placenta adhaerens), as a rule, can be removed by hand all shares placenta. At true ingrowth chorionic villi impossible separate the placenta from the wall without violating its integrity.
SCREENING. Ultrasound of patients with a burdened obstetric history.
PREVENTION. Prevention of pathological attachment of the placenta consists of reducing the frequency of abortions and inflammatory diseases leading to degenerative changes in the uterine mucosa.
INFRINGEMENT OF THE SEPARATE PLACENTA . Bleeding 10-15 minutes after the baby is born. Presence of signs of placenta separation. If the internal os is spasmed or blocked by the detached placenta and the outflow of blood to the outside stops, the uterus increases in volume, takes on a spherical shape and is sharply tense. Help. Under anesthesia, try to extract the placenta using external methods; if that fails, then manually extract the placenta.
SEQUENCE OF MEASURES FOR DELAYED PLACENTA AND NO BLOOD DISCHARGE FROM THE GENITAL ORGANS.
1) Catheterization of the bladder (often causes increased contractions of the uterus and separation of the placenta).
2) Puncture or catheterization of the ulnar vein, intravenous administration of crystalloids in order to adequately correct possible blood loss.
3) Administration of uterotonic drugs 15 minutes after expulsion of the fetus (oxytocin intravenously 5 units in 500 ml of 0.9% sodium chloride solution). In order to prevent bleeding in women with advanced pregnancy, the administration of oxytocin should begin in the second stage of labor.
4) If signs of placenta separation appear, release the placenta using one of the accepted methods (Abuladze, Genter, Crede-Lazarevich)
5) If there are no signs of separation of the placenta within 30 minutes against the background of the introduction of reducing agents, the placenta is manually separated and the placenta is released.
6) After removal of the placenta, the uterus usually contracts; if the tone of the uterus is not restored, additional uterotonic drugs are administered intravenously and methylergometrine is administered simultaneously (2 ml in 20 ml of isotonic solution).
7) If true placenta accreta is suspected, it is necessary stop the attempt to secede to avoid massive bleeding and perforation of the uterus. Preparing a woman for emergency surgery.
8) Examine the soft birth canal and repair the damage.
9) Assess the general condition of the woman in labor and the amount of blood loss.
10) Compensate for blood loss by administering blood substitutes and blood products (depending on the volume of blood loss, hemoglobin and hematocrit).
11) Continue intravenous drip administration of uterotonics for at least 1 hour after surgery.
12) Carry out constant monitoring of the height of the uterine fundus, its tone and the volume of external blood loss.
13) Transfer the postpartum woman to the postpartum department after normalization of hemodynamic parameters and replenishment of blood loss.
The afterbirth period (third stage of labor) begins with the birth of the fetus and ends with the birth of the placenta. The placenta includes the placenta, membranes and umbilical cord. Usually the placenta separates on its own within 5–20 minutes after the birth of the fetus. You should not try to isolate the placenta before the placenta is separated. The succession period is characterized by the appearance of afterbirth contractions, which lead to the gradual separation of the placenta from the walls of the uterus. Separation of the placenta from the walls of the uterus can occur in two ways - from the center (central placenta compartment) and from the peripheral parts of the placenta (marginal placenta compartment). With the central separation of the placenta, blood released from the uteroplacental vessels accumulates between the placenta and the uterine wall, forming a retroplacental hematoma. The formation of a retroplacental hematoma, together with afterbirth contractions increasing in strength and frequency, contributes to the separation of the placenta and membranes from the walls of the uterus and the birth of the placenta. The marginal separation of the placenta begins from its peripheral parts, as a result of which the blood released from the uteroplacental vessels does not form a hematoma, but immediately flows between the wall of the uterus and the amniotic membranes to the outside. By the time the placenta and membranes are completely separated from the walls of the uterus and the placenta is lowered into the lower uterine segment and uterine vagina, the woman in labor begins to struggle, as a result of which the placenta is born within 2–3 minutes. When the placenta is separated from the center, the placenta is born with the fetal surface facing outward; when separated from the periphery, the maternal surface of the placenta will be located on the outside. In some cases, the placenta may separate from the wall of the uterus, but not be released from the birth canal. The separated placenta continues to remain in the uterus, thereby preventing its contraction. The separated placenta should be removed using external techniques, but it is first necessary to determine whether the placenta has separated.
Tactics for managing the afterbirth period. The basic principle: “hands off the uterus!”
Signs of placental separation. Before checking contact signs, you need to check non-contact signs:
1) the umbilical cord lengthens (positive Alfeld sign);
2) the umbilical cord is retracted with a deep breath (Dovzhenko’s sign);
3) the fundus of the uterus takes on a rounded shape, becomes denser to the touch and rises higher and to the right of the navel (Schroeder’s sign);
4) bloody discharge from the genital tract appears;
5) the outer section of the umbilical cord lengthens;
6) when pressing with the edge of the palm on the abdominal wall slightly above the pubis, the umbilical cord does not retract into the vagina, but, on the contrary, comes out even more.
After separation of the placenta, a gentle massage of the uterine fundus is performed while simultaneously pulling the umbilical cord. It is recommended to use the Brandt-Andrews maneuver: after emptying the bladder through the catheter, pull the umbilical cord with one hand, and with the other move the anterior wall of the uterus in the opposite direction (to prevent uterine inversion).
Bleeding in the afterbirth period may occur as a result of a violation of the separation of the placenta and the discharge of the placenta.
Violation of the process of separation of the placenta. It may be associated with weakness of labor, with tight attachment and true placenta accreta.
The placenta is considered to be firmly attached if the chorionic villi do not extend beyond the compact layer of the decidua. It can be complete or incomplete depending on the length.
With true accretion, the villi penetrate the muscular lining of the uterus up to the serous lining and sometimes cause uterine rupture. Occurs in 1 case per 10,000 births. It can be complete or incomplete depending on the length.
With complete true accretion and complete tight attachment, no bleeding is observed, since the entire placental area adjoins or grows into the muscle wall.
With true partial placenta accreta, part of it can separate, and then bleeding occurs in the afterbirth period.
When parts of the placenta are retained, bleeding may also develop in the postpartum period, when part of the placenta is separated and released, but several lobules or a piece of the membrane remain, which interferes with the contraction of the uterus.
Violation of placenta discharge occurs with spasm of the internal pharynx, hypotonicity of the uterus. Spasm may be the result of irrational use of contractile agents in the afterbirth period.
If bleeding occurs during the postpartum period, the first task of the obstetrician is to determine whether there are signs of placental separation.
If there are signs of placental separation, it is necessary to immediately isolate the placenta externally, assess blood loss, introduce or continue administration of uterotonics, put ice and weight on the stomach, clarify the condition of the woman in labor and the amount of blood loss; examine the afterbirth and the integrity of its tissues.
If blood loss remains within normal limits, it is necessary to monitor the condition of the woman in labor and administer uterotonics for another 30–40 minutes.
If the blood loss is pathological, then it is necessary:
1) clarify the woman’s condition;
2) compensate for blood loss:
a) if blood loss is 400–500 ml, administer gelatinol, saline solution, oxytocin intravenously;
b) if blood loss exceeds 500 ml, hemodynamic disturbances occur and blood transfusion is necessary.
If there are no signs of placental separation, you must:
1) assess the general condition of the woman in labor and the amount of blood loss;
2) give intravenous anesthesia and begin or continue the administration of uterotonics, having previously performed an external massage of the uterus;
3) proceed with the operation of manual separation of the placenta and release of the placenta.
Manual separation of the placenta and placenta release performed in the absence of signs of placental separation within 30 minutes after anesthesia. Infectious complications after this intervention are quite rare.
Operation technique. Holding the body of the uterus with one hand, with the other gloved hand they penetrate the uterine cavity and carefully separate the placenta from its walls, then remove the placenta and massage the fundus of the uterus through the anterior abdominal wall to reduce bleeding.
Inspection of the placenta. The placenta is examined for the presence of all its lobules and the membranes are examined. If broken vessels are present, there may be additional lobules that remain in the uterine cavity. The umbilical cord is examined in cases where one umbilical artery is missing; other anomalies are possible. In cases of pathological changes, the placenta is sent for histological examination.
Further tactics depend on the result of the operation.
When stopping bleeding during surgery, it is necessary to assess the amount of blood loss and begin to replace it, acting as in normal childbirth.
In cases of continued bleeding due to accreta, placenta attachment, etc., this bleeding continues into the early postpartum period.
Before manual separation of the placenta, no diagnosis can be made - dense attachment or true placenta accreta. A definitive diagnosis can only be made through surgery.
In cases of tight attachment of the placenta, you can separate the decidua from the underlying muscle tissue by hand; with true accreta, this is impossible. You must be very careful to avoid severe bleeding.
With true accreta, there is a need to remove the uterus by amputation or extirpation, depending on the location of the placenta and obstetric history. Surgery is the only option to stop bleeding.
Prevention of hypotonic bleeding. The causes of bleeding in the postpartum period can be hypotension and uterine atony. To prevent hypotension and atony, gentle massage of the uterus and the administration of oxytocin are used, the latter is administered either at the birth of the anterior shoulder (10 units intramuscularly), or, better, after the birth of the placenta (20 units in 1000 ml of 5% glucose solution intravenously, with at a rate of 100 drops per minute). When administered intravenously, oxytocin can cause severe arterial hypotension. In cases of ineffectiveness of oxytocin, methylergometrine is administered - 0.2 mg intramuscularly. Methylergometrine is contraindicated in arterial hypertension, as well as in arterial hypotension (constriction of peripheral vessels during hypovolemic shock can be accompanied by severe complications). If bleeding continues, carboprost promethamine is prescribed - 0.25 mg intramuscularly.
Restoring the integrity of the soft tissues of the birth canal
Soft tissue ruptures. To diagnose soft tissue ruptures, the lateral walls and vaults of the vagina, as well as the labia minora and the external opening of the urethra are examined. The palm of one hand is inserted into the vagina and the cervix and anterior lip are examined, which is then pulled up and the rest of the cervix is examined. Soft tissue ruptures are repaired by suturing with continuous or interrupted sutures.
Absorbable suture material 2/0 or 3/0 is applied to the perineum after perineo- or episiotomy. Interrupted sutures are placed on the perineal muscles. The vaginal mucosa is sutured with a continuous suture, capturing the apex of the tear, after which an intradermal cosmetic suture is applied.
If the external anal sphincter ruptures, which is the third degree of perineal rupture, interrupted sutures are applied. A double-row intestinal suture must be applied to the rupture of the anterior wall of the rectum (fourth degree rupture of the perineum), after which the perineum is sutured.
Surgical delivery. Surgical delivery can be performed by caesarean section, forceps or vacuum extraction if spontaneous vaginal delivery is not possible.
Previously, people died from these bleedings.
The normal afterbirth period lasts 2 hours (within 2 hours the afterbirth should separate from the walls of the uterus). The placenta is normally located along the posterior wall of the uterus with a transition to the side (or bottom). Separation of the placenta occurs in the first 2-3 contractions after the birth of the fetus, although it can separate from the walls during the birth of the fetus.
In order for the placenta to separate, the contractility of the uterus must be high (that is, equal to that in the 1st period).
The placenta is separated due to the fact that there is a discrepancy between the volume of the uterine cavity and the placental site. Separation most often occurs in the first 10-15 minutes after the birth of the fetus (in classical obstetrics, the placenta can separate within 2 hours after birth).
^ MECHANISM OF HEMOSTASIS IN THE UTERUS.
These assumptions are correct because violations occur when:
Normal blood loss is no more than 400 ml, anything higher is pathology (no more than 0.5% of body weight).
Separation of the placenta occurs from the center (formation of a retroplacental hematoma) or from the edge, hence the clinical difference during the period:
^ GROUPS AT RISK FOR BLEEDING (IN GENERAL).
I. If we assume that muscle retraction is the main mechanism of hemostasis, then we can distinguish 3 risk groups:
Women whose contractility of the uterus is impaired during childbirth.
III risk group. These are women who have disrupted processes of attachment and separation of the placenta and abnormalities in the location of the placenta:
That is, risk groups are women with extragenital pathology, with complications of pregnancy, with complications of childbirth.
^ BLEEDING IN THE FOLLOW-UP PERIOD.
Caused by disruption of the processes of separation of the placenta and discharge of the placenta.
There are 2 phases during the period:
True accretion - villi penetrate the muscular lining of the uterus up to the serosa and sometimes cause uterine rupture. Occurs in 1/10,000 births. It can be complete or incomplete depending on the length.
If there is complete true accretion and complete tight attachment, then there will never be bleeding, that is, when the entire placental area adjoins or grows into the muscle wall.
With true partial accreta, part of the placenta separates and bleeding occurs in the afterbirth period.
Bleeding in the placenta can develop when parts of the placenta are retained, when part of the placenta is separated and released, but several lobules remain or a piece of the membrane remains and interferes with the contraction of the uterus.
^ Impaired discharge of placenta.
Violation when:
^ TACTICS OF FOLLOW-UP PERIOD.
Principle: hands off the uterus!
Before checking contact signs, you need to check non-contact signs: look at the umbilical cord, which is lengthening (positive Alfeld sign). The uterus deviates to the right, upwards and flattens (Schroeder's sign), the umbilical cord retracts with a deep breath (Dovzhenko's sign).
^ IT IS NECESSARY TO START SEPARATION OF THE AFTERMISSION IMMEDIATELY AS SOON AS SIGNS OF ITS SEPARATION APPEAR.
| There are signs of placenta separation. | There are no signs of placental separation. |
|
|
| If the blood loss is pathological, then you need to do:
|
^ OPERATION OF MANUAL SEPARATION OF THE PLACENTA AND DISCHARGE OF THE AFTERMISSION.
With complete true growth and complete tight attachment, there is no bleeding (according to classical laws, wait 2 hours). In modern conditions, the rule is to separate the placenta 30 minutes after the birth of the fetus, if there are no signs of placental separation and no bleeding. Performed: operation of manual separation of the placenta and release of the placenta.
Further tactics depend on the result of the operation:
^ BLEEDING IN THE EARLY POSTPARTUM PERIOD.
Most often it is a continuation of complications in all stages of labor.
The main reason is the hypotonic state of the uterus.
^ RISK GROUP.
Also causes of bleeding in the early postpartum period may be:
Variants of hypotonic bleeding.
Objectives of the ROPM operation:
^ SEQUENCE OF ACTIONS IN STOPING HYPOTONIC BLEEDING.
Obstetricians also distinguish atonic bleeding (bleeding in the complete absence of contractility - Couveler's uterus). They differ from hypotonic bleeding in that the uterus is completely inactive and does not respond to the administration of uterotonics.
If hypotonic bleeding does not stop with ROPM, then further tactics are as follows:
Massive blood loss is considered to be blood loss during childbirth of 1200 - 1500 ml. Such blood loss dictates the need for surgical treatment - removal of the uterus.
When starting the hysterectomy operation, you can try another reflex method to stop bleeding:
^ PREVENTION OF BLEEDING.
Bleeding can and should be predicted based on risk groups:
Administration of uterotonics depending on the risk group.
The first stage of labor is 3-5 minutes.
The second stage of labor is 1-3 minutes.
Third period 1-3 minutes.
^ NORM ACCORDING TO LEE-WHITE.
The first period is 6-7 minutes.
Third period 5 minutes.
Early postpartum period 4 minutes.
A woman at risk should be provided with blood substitutes and blood before going into labor.
^ LECTURE No. 17.
TOPIC: BIRTH INJURIES.
Uterine rupture.
Uterine rupture during pregnancy and childbirth is the most severe manifestation of obstetric trauma. Its frequency is 0.015-0.1% of the total number of births. The mortality rate for uterine rupture is high - 12.8-18.6%. This is associated with extensive trauma, massive blood loss, shock, purulent-septic complications, which always requires qualified surgical intervention, targeted resuscitation measures and long-term intensive care.
The classification of uterine ruptures, developed by L.S. Persianinov in 1964, has now been refined and modified by M.A. Repina, taking into account the features of modern obstetrics.
1. By pathogenesis.
Spontaneous uterine rupture: 1) with morphological changes in the myometrium; 2) with mechanical obstruction to the birth of the fetus; 3) with a combination of morphological changes in the myometrium and mechanical obstacles to the birth of the fetus.
Forced uterine rupture: 1) clean (during vaginal delivery operations, external trauma); 2) mixed (with different combinations of a violent factor, morphological changes in the myometrium, mechanical obstacles to the birth of a child). 2. According to the clinical course. Risk of uterine rupture. Threatening uterine rupture. Completed uterine rupture. 3. By the nature of the damage. Incomplete uterine rupture (not penetrating into the abdominal cavity).
Complete uterine rupture (penetrating into the abdominal cavity). 4. By localization.
Rupture in the lower segment of the uterus: 1) rupture of the anterior wall; 2) lateral tear; 3) rupture of the posterior wall; 4) separation of the uterus from the vaginal vault.
Rupture in the body of the uterus: 1), rupture of the anterior wall, 2) rupture of the posterior wall. Rupture in the fundus of the uterus.
The practical significance of the above classification dictates the need to identify a risk group for the occurrence of uterine rupture. It is formed:
Pregnant women with scars on the uterus after a cesarean section, conservative myomectomy, uterine perforation during an induced abortion;
Pregnant women with a burdened obstetric history (multiparous, had several abortions, complicated course of the post-abortion period);
Pregnant women and women in labor who are at risk due to a clinical discrepancy between the fetal head and the mother’s pelvis (large fetus, narrow pelvis, incorrect insertion of the fetal head, fetal hydrocephalus);
Pregnant women with multiple pregnancy, polyhydramnios, transverse position of the fetus;
Women in labor with labor anomalies and unreasonable use of labor-stimulating therapy.
Features of uterine ruptures at the present stage include a decrease in the frequency of spontaneous uterine ruptures due to mechanical reasons. Violent ruptures (severe trauma, illiterate obstetric interventions, inappropriate use of birth-stimulating drugs) are rare. However, the role of uterine ruptures caused by cicatricial changes in its wall has grown. This is due to an increase in the frequency of cesarean sections to 9-10% in our country and up to 20% abroad, a large number of abortions, often complicated by uterine perforation, in the inflammatory process of the uterus, as well as an increase in the number of conservative plastic surgeries for fibroids in young people women.
Etiology and pathogenesis. Structural changes in the uterus will be considered as a predisposing factor,
And a mechanical obstacle is a revealing factor. The clinical picture of uterine rupture depends on the relationship of these factors and the predominance of one or the other.
According to Bandl's theory, uterine rupture is a consequence of hyperextension of its lower segment, associated with the presence of a mechanical obstacle to the passage of the fetal head (narrowing of the pelvis, large fetus, hydrocephalus, incorrect insertion of the fetal head, incorrect position of the fetus, cicatricial changes in the cervix or vagina, exostoses tumors of the ovary or uterus fixed in the pelvis).
The histopathic nature of the ruptures is due to the inferiority of the myometrium due to scars on the uterus, infantilism, malformations, damage to the myometrium during abortion, and metroendometritis.
In recent years, new factors have been identified, called “biochemical trauma of the uterus.” This condition occurs during prolonged labor, discoordinated labor, when, due to disruption of energy metabolism and the accumulation of under-oxidized compounds, the muscle becomes flabby and easily tears.
Clinic and diagnostics. The clinical picture of uterine rupture will depend on the cause leading to the rupture, stage, location, and nature of the damage. The speed and severity of the development of hemorrhagic shock (the main cause of death of patients) is influenced by the background against which the uterine rupture occurred: concomitant chronic diseases of parenchymal organs, toxicosis of pregnant women, depletion of the physical and spiritual strength of the woman in labor, and the addition of infection.
Clinic for threatening uterine rupture.
The mechanical rupture of the uterus described by Bandle is called typical and is characterized by the following symptoms: the woman in labor is very restless, screams in pain, which hardly decreases between contractions, the face is hyperemic and expresses fear. Tachycardia, slightly elevated temperature, dry tongue. The contractions are violent, taking on the character of pushing. The uterus does not relax between contractions, is elongated, the contraction ring is located at the level of the navel, or above the uterus has an unusual hourglass shape, palpation
Tense, painful in the lower parts, round ligaments are sharply stretched. Parts of the fetus, as a rule, cannot be felt. Fetal heart rate is measured or absent. There is swelling of the external genitalia due to pinching of the anterior lip of the cervix, which, due to the inexperience of the doctor, can be regarded as incomplete dilatation. The birth tumor on the fetal head is pronounced, making it difficult to determine the nature of the insertion of the head.
The current widespread use of anesthesia during childbirth and antispasmodic drugs can lead to delayed diagnosis of impending uterine rupture, since the symptoms of the rupture become unclear. Therefore, the basis for the diagnosis of impending uterine rupture should be signs of disproportion between the fetus and the mother’s pelvis, risk factors for uterine incompetence.
Diagnosis of threatening uterine rupture of a histopathic nature in the presence of a scar on the uterus is greatly facilitated by knowledge of the fact of the operation and the condition of the scar based on anamnesis. Signs of a defective scar are as follows:
Caesarean section was performed less than 2 years before the actual pregnancy;
Postoperative course with fever;
Suppuration of the sutures of the anterior abdominal wall in the postoperative period;
Scar after corporal caesarean section;
The presence of abdominal pain and scanty bleeding long before childbirth, diagnosis is facilitated by ultrasound.
During childbirth, characteristic signs are: 1) pain in the area of the postoperative scar, on the uterus or in the lower abdomen, persisting beyond the contraction; 2) soreness of the entire uterine scar or its sections, thinning, presence of niches; 3) the mother’s anxiety, which is not adequate to the strength of the contraction; 4) ineffective labor; 5) the appearance of unproductive attempts with a high-standing head.
Clinical manifestations of the threat of uterine rupture with other structural changes in the wall are similar to those with ruptures along the scar. In such cases, uterine rupture is preceded by weakness of labor, which is a functional reflection of morphological changes in the uterus, and labor stimulation (intravenous drip administration of oxytocin and the unreasonable prescription of labor stimulation are especially dangerous).
Clinic of completed uterine rupture.
With a typical uterine rupture, a “calm” occurs after a stormy clinical picture: contractions suddenly stop, pain subsides. Before our eyes, the shape of the abdomen and the contours of the uterus change (irregular shape), bloating of the intestines gradually develops, and the abdomen becomes painful, especially in the lower sections. When the uterus is completely ruptured and the fetus is expelled into the abdominal cavity, its parts are easily palpated, the fetus becomes mobile, and the fixed head moves upward. A contracted uterus can be felt next to the fetus. The fetal heartbeat disappears. Symptoms of shock and anemia as a result of bleeding increase.
In the pathogenesis of shock during uterine rupture, blood loss, pain and traumatic components are important. Bleeding can be external, internal or combined. With incomplete ruptures, a subperitoneal hematoma is formed, located on the side of the uterus, displacing it upward and in the opposite direction. In some cases, hematomas spread far upward, involving the perinephric area. In this case, the hematoma is palpated as a painful tumor of doughy consistency, with uneven contours merging with the walls of the pelvis.
Increased bleeding is associated with a hypotonic state of the uterus and the development of disseminated intravascular coagulation syndrome. Blood loss can immediately be very significant and lead to the rapid death of the patient. More often, blood loss and hemorrhagic shock increase slowly, since the source of bleeding is often small-caliber vessels feeding this area of the uterus. Less commonly, the source of bleeding is the uterine artery or its branches.
Uterine rupture may occur at the end of labor, and its symptoms may be erased. The following symptoms will help to suspect a uterine rupture: bleeding during childbirth of unknown origin, signs of fetal hypoxia, deterioration of the mother's condition immediately after the birth of the child. In this case, a manual examination of the uterine cavity should be performed. In order to exclude uterine rupture, this operation must also be performed after fetal destruction operations, combined obstetric rotation of the fetus, after childbirth in a woman with a scar on the uterus. Clinical signs of a completed uterine rupture along the scar are as follows: 1) rapid increase in existing pain in the scar and soreness; 2) bloody discharge from the vagina; 3) the addition of pain and a feeling of heaviness in the epigastrium, nausea, vomiting 4) short-term fainting, slight intestinal paresis, vague symptoms of peritoneal irritation; 5) changes in the fetal heartbeat.
The clinical picture may not be burdened by shock and anemia if the rupture is limited to the area of the old scar or may be erased due to the adhesive process in the scar area, with only minor pain in the lower abdomen.
Treatment of uterine rupture depends on the stage of the process (threatened or completed), but it is always immediate transection.
If there is a scar on the uterus, the tactics are the same - immediate abdominal surgery, since it is impossible to reliably distinguish between the clinic of a threatening rupture and a completed rupture. First, the contractile activity of the uterus is removed.
In case of uterine rupture of mechanical origin, medical tactics are somewhat different for threatening and completed uterine rupture. Thus, if there is a threat of uterine rupture, the doctor’s task is to prevent the onset of rupture, which is achieved in the following ways:
Immediate removal of contractile activity of the uterus. For this purpose, inhalation anesthesia with ftorotan is used, which must be quite deep (an overdose of ftorotan can provoke atonic uterine bleeding);
Urgent delivery by abdominal cesarean section or by fetal-destroying surgery (if the fetus is dead or its viability is questionable) if conditions exist for its implementation.
Treatment of a completed uterine rupture consists of the simultaneous implementation of the following measures: 1) surgical intervention, 2) adequate anesthesia, 3) infusion-transfusion therapy, adequate blood loss and the severity of the patient’s condition, 4) correction of hemocoagulation disorders.
Surgery is performed immediately after diagnosis using endotracheal anesthesia with mechanical ventilation. Purpose of surgical treatment:
a) elimination of the source of bleeding, b) restoration of anatomical relationships disturbed by injury, c) elimination of the entrance gate for the introduction of infection into the abdominal cavity and retroperitoneal space. Only a lower median laparotomy is performed, the fetus, placenta and blood and amniotic fluid are removed from the abdominal cavity using electric suction, the nature of the damage is determined and hemostasis is performed.
The scope of the operation is strictly individual and is selected depending on the severity of the patient’s condition, the location of the damage, the size of the damage, the presence of infection, etc. In the absence of contraindications and the presence of appropriate conditions, one should strive to preserve menstrual and reproductive function.
The minimum scope of the operation is suturing the rupture. It can be performed under the following conditions: no signs of infection, a short anhydrous interval, the presence of a fresh linear rupture (especially along an old scar), and preservation of uterine contractility. First, the edges of the wound are refreshed.
Expanding the scope of the operation to supravaginal amputation of the uterus or its extirpation is necessary in the presence of an extensive wound with torn, crushed edges, a complex rupture, significant hemorrhage into the uterine wall,
The maximum volume of surgery - hysterectomy - is selected in cases of: gross damage to the lower segment, transition of the rupture to the cervix, separation of the uterus from the vaginal vault, peritonitis. In addition to hysterectomy, drainage of the retroperitoneal space is carried out in case of extensive hematomas reaching the perinephric region, and the abdominal cavity after its thorough sanitation in case of peritonitis.
During all operations for uterine rupture, it is advisable to leave nipple drains in the abdominal cavity for the administration of antibiotics.
Adequate anesthetic care must be provided at all stages: during transportation of the patient, during manual examination of the uterine cavity if a uterine rupture is suspected - and continue when the diagnosis of uterine rupture is confirmed. When changing combined general anesthesia.
Infusion-transfusion therapy is adequate to the blood loss and the severity of the patient's condition. Carrying out correction of hemocoagulation disorders.
Cervical ruptures (CC).
The incidence of cervical cancer is 25% among all complications of childbirth. Cervical cancer requires suturing, since this can be followed by: immediately after a rupture - bleeding (sometimes profuse), and in the long term - cervicitis, spread of inflammation to the internal genitalia, formation of ectropion of the cervix, erosion and other precancerous diseases.
ETIOLOGY AND PATHOGENESIS. Cervical cancer can be spontaneous during normal spontaneous labor and violent during forced or operative delivery in case of incomplete dilatation of the uterine pharynx.
The risk group includes pregnant women and women in labor if they have:
CLASSIFICATION.
There are 3 degrees of cervical cancer on one or both sides:
1st degree - a rupture up to 2 cm long, 2nd degree - a rupture more than 2 cm long and not reaching 1 cm from the vaginal vault, 3rd degree - a rupture reaching the vault or involving the vault.
In most cases, cervical cancer is linear in shape, corresponding to the longitudinal axis, and in location it is lateral, one- or two-sided.
^ CLINIC AND DIAGNOSTICS.
The main symptom of cervical cancer is bleeding from the birth canal of varying intensity with a well-contracted uterus. The final diagnosis is established after examining the cervix in a speculum: after completion of the succession period, subject to the rules of asepsis and antisepsis, without prior anesthesia, a sequential examination of the cervix is performed clockwise. Inspection is carried out by alternately applying hemorrhoidal or bullet forceps to the edges of the pharynx, stretching the edges of the pharynx with them.
It consists of suturing grade 1-3 tears with separate catgut sutures (catgut No. 3-4), without involving the mucous membrane of the cervical canal. The first suture is placed above the apex of the tear to ligate the bleeding vessel. Next, the seams are placed from top to bottom at a distance of 1.5 - 2 cm, the injection and puncture are done at a distance of 1 - 1.5 cm from the edge of the tear.
Prevention of cervical cancer consists of rational management of labor (use of antispasmodics, regulation of labor) and competent surgical delivery.
^ LECTURE No. 18. PART 2.
CROTCH RUPTURE.
This is the most common type of maternal birth trauma and complications of childbirth, more often found in first-time mothers. Consequences of perineal rupture:
The causes of perineal tears are:
The RP mechanism (sequence of changes) is as follows.
The sequence of tissue damage during spontaneous ruptures (from outside to inside):
posterior commissure, skin, perineal muscles, vaginal wall. When obstetric forceps are applied, the rupture begins from the vaginal side, but the skin may remain intact.
CLASSIFICATION.
There are spontaneous and violent ruptures, and according to degree - 3 degrees of perineal rupture:
^ CLINIC AND DIAGNOSTICS.
Any rupture of the perineum is accompanied by bleeding. Diagnosed by examining the soft birth canal. If a third degree perineal rupture is suspected, it is necessary to insert a finger into the rectum. An intact sphincter creates resistance when a finger is inserted into the rectum. A rupture of the intestinal wall is easily determined by the specific appearance of the inverted intestinal mucosa.
If there is significant bleeding from the perineal tissue, a clamp is applied to the bleeding tissue without waiting for the birth of the placenta.
TREATMENT. Treatment of all ruptures consists of suturing them after the birth of the placenta.
^ SEQUENCE OF URGENT ACTIONS.
^ SEQUENCE OF MEASURES FOR 3 DEGREE PERINEAL RUPTURE.
Prevention of perineal ruptures consists of rational management of labor, qualified delivery, and timely perineotomy in case of threat of perineal ruptures.
^ UTERUS EVERION.
The frequency of this complication is 1 in 45 - 450 thousand births. The essence of uterine inversion is that the fundus of the uterus from the side of the abdominal covering is pressed into its cavity more and more, but complete inversion of the uterus will not occur. The uterus turns out to be located in the vagina with the endometrium facing outwards, and from the side of the abdominal cavity the wall of the uterus forms a deep funnel, lined with a serous covering, into which the uterine ends of the tubes, round ligaments and ovaries are drawn.
CLASSIFICATION.
There are complete and incomplete (partial) inversion of the uterus. Sometimes complete inversion of the uterus is accompanied by inversion of the vagina. Eversion can be acute (fast) or chronic (slowly occurring). Acute inversions are more common, with 3/4 of them occurring in the afterbirth and 1/4 in the first day of the postpartum period. According to the etiological factor, uterine inversion is divided into forced and spontaneous, although at the end of the 19th century it was proven that uterine inversion is always spontaneous and is associated with uterine pathology. Violent is understood as an inversion that occurs when the umbilical cord is pulled or the Lazarevich-Crede maneuver is roughly applied - with a relaxed uterus.
ETIOPATHOGENESIS.
The main reason is relaxation of all parts of the uterus, loss of elasticity of its myometrium. In this condition, even an increase in intra-abdominal pressure during pushing, coughing, or sneezing can lead to inversion of the uterus. The predisposing factor is the fundal attachment of the placenta, as well as large submucosal fibroids arising from the fundus of the uterus.
CLINIC. Clinic of acute uterine inversion: sudden severe pain in the lower abdomen, shock, uterine bleeding. It can begin before uterine inversion due to atony and continues after its occurrence.
Complete inversion of the uterus may or may not be accompanied by vaginal inversion. In the first case, the uterus and placenta are located outside the vulva. In the second, the uterus is determined in the vagina when examined in the speculum. In both cases, upon palpation there is no uterus above the womb.
With incomplete uterine reversal, the general condition does not change so quickly and severely. For differential diagnosis with other complications (for example, uterine rupture), a bimanual examination is performed, which determines the unusually low location of the upper edge of the uterus for the placenta and early postpartum period and the presence of a funnel-shaped depression at the site of the uterine fundus.
The prognosis if emergency assistance is not provided is the patient’s death from shock and blood loss, and in the following days from infection (peritonitis, sepsis). Spontaneous correction of inversion does not occur.
Reduction of the uterus under anesthesia with preliminary manual removal of the placenta.
^ SEQUENCE OF EMERGENCY MEASURES WHEN REPOSITION OF THE UTERUS BY MANUAL TECHNIQUES:
PREVENTION.
Prevention of uterine inversion consists of proper management of the placenta, releasing the placenta externally if there are signs of placental separation without pulling on the umbilical cord.
^ HEMATOMA OF THE VULVA AND VAGINA.
Localization - below and above the main pelvic floor muscle (mm. Levator ani) and its fascia. More often, a hematoma occurs below the fascia and spreads to the vulva and buttocks, less often - above the fascia and spreads along the paravaginal tissue retroperitoneally up to the perinephric region.
Etiopathogenesis. The main cause of hematomas is changes in the vascular wall. Occurs with varicose veins of the external genitalia and pelvis, hypovitaminosis C, hypertension, chronic glomerulonephritis, gestosis in pregnant women. Against this background, a hematoma is formed not only as a result of complicated labor (long or rapid, with a narrow pelvis, application of obstetric forceps, extraction by the pelvic end), but also during spontaneous uncomplicated labor.
Hematomas are more often formed on the left, which is associated with the asymmetry of the development of the venous system and the more frequent formation of 1 position with the longitudinal position of the fetus.
Clinic and diagnostics. The size of hematomas can vary, and the severity of clinical manifestations depends on this. Symptoms of a hematoma of significant size: pain and a feeling of pressure at the site of localization (tenesmus due to compression of the rectum), as well as anemia with an extensive hematoma. When examining postpartum women, a tumor-like formation of a blue-purple color is discovered, protruding outward towards the vulva or into the lumen of the vaginal opening, deforming it. On palpation, the hematoma fluctuates. Diagnosis of vaginal hematoma is more difficult. It is necessary to use vaginal examination, speculum examination and rectal examination to determine the size and topography of the hematoma. If the hematoma spreads to the parametrial tissue vaginally, a vaginal examination reveals the uterus pushed to the side and between it and the pelvic wall an immobile and painful tumor-like formation. In this situation, it is difficult to differentiate a hematoma from an incomplete uterine rupture in the lower segment.
Treatment of hematoma - conservative or surgical; it depends on its location, size and clinical course. Small, non-progressive hematomas of the vagina and vulva, which gradually resolve, are treated conservatively. Emergency surgical treatment is required if the hematoma rapidly increases in size with signs of anemia; with a hematoma that produces profuse external bleeding; with a large hematoma that occurred before the onset of labor and in the first period. The latter will create an obstacle to the birth of a child and contribute to additional trauma and crushing of tissues.
The operation is performed under general anesthesia and consists of the following stages: incision of tissue above the tumor; removing blood clots; ligation of bleeding vessels or stitching with 8-shaped catgut sutures; closing and draining the hematoma cavity. A hematoma of the broad uterine ligament requires transection, opening of the peritoneum between the round ligament of the uterus and the infundibulopelvic ligament, removal of the blood tumor, and ligation of damaged vessels. The operation is limited to this unless the uterus ruptures.
Prevention of vaginal hematomas consists of the treatment of diseases that affect the condition of the vascular wall, as well as the qualified management of labor and delivery operations.
^ OBSTETRIC FISTULAS.
This concept includes genitourinary and enterogenital fistulas. They arise as a result of severe birth trauma and lead to permanent loss of ability to work, disorders of a woman’s sexual, menstrual and generative functions. Fistulas contribute to the development of ascending infection of the genital organs and urinary system.
Classification. Based on the nature of their occurrence, fistulas are divided into spontaneous and violent. According to localization, vesicovaginal, cervicovaginal, urethrovaginal, ureterovaginal, and enterovaginal fistulas are distinguished.
Etiology and pathogenesis. Spontaneous fistulas are more common, and according to localization - vesicovaginal. The formation of fistulas is associated with necrosis of a section of the walls of the bladder or rectum when blood circulation in them is impaired as a result of prolonged (more than 3-4 hours) compression of tissues by the fetal head. This is observed with a functionally narrow pelvis or with severe weakness of labor. Fistulas of a violent nature are rarely formed and occur during childbirth operations (fetal destruction operations, obstetric forceps, cesarean section). Rectovaginal fistulas can form as a result of unsuccessful suturing of a 3rd degree perineal tear.
^ CLINIC AND DIAGNOSTICS.
With genitourinary fistulas, urine leaks from the vagina of varying intensity, and with entero-genital fistulas, gas and feces are released. The time at which these symptoms appear is of diagnostic importance: injury to adjacent organs is indicated by the appearance of these symptoms in the first hours after surgical delivery. When a fistula forms as a result of tissue necrosis, these symptoms appear 6-9 days after birth. The final diagnosis is made by examining the vagina in a speculum, as well as using urological and radiological diagnostic methods.
TREATMENT.
Treatment of fistulas is only surgical. If adjacent organs are injured by instruments and there is no tissue necrosis, the operation is performed immediately after childbirth; in case of fistula formation as a result of tissue necrosis - 3-4 months after birth. Small fistulas sometimes close as a result of conservative local treatment.
PREVENTION.
^ LECTURE No. 20.
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