The diagnosis and management of postpartum hemorrhage I. Definition of postpartum hemorrhage is called postpartum hemorrhage if the amount of bleeding exceeds 500ml within 24 hours after delivery of the fetus, and is the primary cause of maternal death.
(2) Etiology and diagnostic points (a) weak contraction: bleeding due to inability to effectively close the uterine blood sinus at the site of placental attachment and thrombosis disorder 1. Clinical manifestations 1) paroxysmal increase of vaginal bleeding after delivery of placenta, indistinct and soft uterine contour, large amount of blood clots discharged by pressing the fundus; 2) sometimes vaginal bleeding is not much, but large amount of blood clots accumulate in the uterine cavity, and it is too late when the mother is in shock.
2, factors affecting uterine contraction 1) twin fetuses, excessive amniotic fluid, huge children; 2) prolonged labor, stalled labor causing maternal failure; 3) excessive use of sedatives and anesthetics during labor; 4) systemic acute and chronic diseases; 5) severe anemia, hypertension, uteroplacental stroke; 6) uterine dysplasia, infection, malformation, myoma; 7) overfilled bladder; (b) placental factors 1, placental retention: fetal delivery 30 minutes after delivery, the placenta has not yet been delivered (weak contractions, overfilled bladder); 2, placenta entrapment: uterine cavity operation or improper use of contraction agents, local formation of a narrow ring in the uterus or contraction of the cervical opening, the aborted placenta cannot be delivered; 3, incomplete placental abruption: due to weak contractions, or excessive squeezing of the uterus too early after delivery of the fetus, rough pulling of the umbilical cord; 4, partial adhesion of the placenta: part of the placenta has been The placenta is partially detached and partially adhered to the uterine wall and cannot be detached and bleed on its own. It is common after multiple abortions and multiple births; 5. partial implantation of placenta: the placenta is partially implanted and the other part has separated from the uterine wall causing hemorrhage; 6. placental residue: after delivery of the placenta, there is a lot of bleeding that lasts, check the placenta has a stump, or the placenta remains in the uterine cavity and causes bleeding; (c) soft birth canal injury persistent vaginal bleeding of bright red blood after delivery of the fetus, good contraction of the uterus and intact placenta-fetal membranes. There is laceration at the perineum, vagina or cervix with active bleeding.
1.Progress of labor is too fast, the fetus is too large, some have laceration and bleeding before the fetus is delivered; 2.The opening of the uterus is not fully opened, and the premature use of abdominal pressure causes laceration; 3.Improper protection of perineum or improper operation of assisted labor; 4.Perineal incision is too early resulting in excessive bleeding from the incision, and bleeding from laceration of too small perineal incision; 5.Uterine rupture is not detected in time and gradual shock; (d) Coagulation dysfunction postpartum bleeding, blood does not clot. It should be combined with medical history, physical signs and laboratory tests to confirm the diagnosis.
(E) bleeding problems of cesarean section 1, in addition to placental abruption bleeding, there are still surgical incision bleeding, anesthesia, etc., and the risk of postpartum bleeding is high; 2, the placenta praevia is planted in the anterior wall of the lower uterine segment, and the placenta is easily damaged when the uterus is incised here; 3, the placenta is stripped immediately after the delivery of the fetus; 4, after the delivery of the fetus and placenta, the uterus lacks strong contraction because of the thin lower uterine segment and the rich vascularity of the placenta planting site; 5 If amniotic fluid enters the uterine blood sinus through the trauma, acute DIC hemorrhage occurs; 6. Uterine incision injury; incision position is too low or too high, incision curvature is not large; fetal head is deeply embedded in the pelvis or high floating; incorrect technique, violent delivery of the fetal head; fetal malposition; huge fetus; causing the incision to tear to both sides (left side is more common). It may extend to the broad ligament, down to the cervix, vaginal vault or upper l/3 of the vagina, involving the vascular plexus of the parametrium or vaginal wall, and uncontrollable bleeding occurs.
Postpartum bleeding measurement methods (a) Commonly used postpartum bleeding measurement methods.
1, visual method: that is, the naked eye estimation method, based on experience, the estimated blood volume is often half of the actual bleeding volume.
2, area method: wetting the area of two layers of dressings to estimate, such as 5 × 5cm2 blood volume 2ml; 10 × 10cm2 blood volume 5ml; 15 × 15cm2 blood volume 10ml, etc.. Affected by the different water absorption of the dressing, often only approximate estimates.
3.Volume method: Use curved disc, graduated blood accumulator to measure, more accurate.
4.Weighing method.
Bleeding volume (ml) = (weight of the item after use – weight of the item before use) ÷ 1,055, volume method + weighing method bleeding volume (ml) = volume method measurement of bleeding volume ＋ [(weight of the item after use – weight of the item before use) ÷ 1,05 ]
(B) Precautions for measuring bleeding volume.
1.2 hours after delivery is an important period for observation and timely treatment of postpartum hemorrhage; 2.The standard of postpartum hemorrhage is set at ≥500ml, however, it is too late to deal with it when the bleeding has reached 500ml, and when the bleeding reaches 200ml, the cause should be found and actively dealt with; 3.Pay attention to vaginal bleeding at the same time, pay attention to the amount of bleeding from perineal incision, abdominal incision of cesarean section, uterine incision, gauze and dressings on 4. In vaginal bleeding, it is dangerous to have violent bleeding, but it is more dangerous to have small amount of continuous bleeding, i.e. “long flow” type of bleeding; 5.
Preventive measures 1. closely observe the labor process, apply labor chart to monitor the progress of labor, promptly find out the factors causing prolonged labor and promptly refer to the doctor; 2. strictly grasp the indications and timing of cesarean section and perineal incision, and pay attention to stopping bleeding; 3. correctly apply contraction agents to prevent postpartum bleeding. After delivery of the fetal shoulder, inject 20U of contractin into the uterine muscle. 500ml of 5% glucose solution was added to 20U of contractin for sedation. Misoprostol 400μg chewed orally; 4.Check the soft birth canal for laceration after delivery and suture to stop bleeding; 5.Get the signs of placental abruption, violent pushing on the uterus and pulling the umbilical cord are strictly prohibited before the placenta is completely aborted; 6.If the placenta is not delivered 10-15 minutes after delivery, find the reason and deal with it timely; 7.Check the soft birth canal for laceration after vaginal midwifery; 8.Check the integrity of the placenta-fetal membrane after delivery. Check the integrity of the placenta and membranes carefully after delivery, and remove the suspected placenta and membranes in time; 9. Stay in the delivery room for 2 hours after delivery to observe the mother, observe the blood pressure, pulse, general condition, vaginal bleeding and contractions. Encourage the mother to drink, eat and urinate. Encourage the newborn to breastfeed early and suckle early to promote uterine contraction; 10. Collect and measure the amount of postpartum bleeding accurately; if the bleeding amount reaches 200ml or more, find the cause and deal with it in time. Pay high attention to the amount of bleeding within 2 hours after delivery; 11, especially vigilant to identify signs of hemorrhagic shock: such as panic, fast and thin pulse; dizziness, pale face, wet and cold skin, etc., early detection and early treatment; V. Treatment (a) weak uterine contraction The principle is to promote uterine contraction 1, contraction agents: contraction 10-20u intramuscular injection or added to the drip, ergot 0, 2mg intramuscular injection. Misoprostol 400μg chewed orally; 2, those who cannot urinate by themselves, sterile catheterization; 3, massage the uterus: A, transabdominal massage uterus method; B, abdominal-vaginal two-handed pressure massage uterus method; 4, placental detachment surface bleeding, can be “8” suture; 5, B-lynch suture; 6, uterine artery ligation, internal iliac (7) placental factors: the principle is to help deliver the placenta 1, to clarify whether the placenta is detached, if it is detached, to assist the delivery of the placenta.
2, push saline 10~20ml + contraction 20U through umbilical vein.
3.Perform manual placental extraction (manual placental abruption).
4.If the placenta is partially retained, remove it by hand and perform scraping if necessary to prevent perforation of the uterus.
5.If the placenta is implanted, remove the implanted part. Or perform subtotal hysterectomy, do not forcibly dig out by hand.
(c) Soft birth canal laceration Suture to stop bleeding.
(iv) Coagulation dysfunction The principle is timely referral, transfusion of fresh whole blood, platelets and coagulation factors.
VI. Monitoring of obstetric hemorrhagic shock (a) general clinical manifestations 1. early stage of shock; restlessness, thirst, decreased blood pressure, rapid pulse, pale or mild cyanosis, wet and cold extremities; 2. aggravation of shock: indifferent expression, delayed reaction, continued decrease in blood pressure, slowed pulse, dilated pupils, white swollen face, no urine; (b) monitoring indicators.
1, shock index (shock index) to estimate the amount of bleeding.
Formula: shock index = heart rate ÷ systolic blood pressure normal value of 0, 5 table: shock index and blood loss relationship ________________________________________ shock index estimated blood loss blood loss as a percentage of the total ________________________________________1, 0 1000 20~301,5 1500 30~402,0 2000 40~50_________________________________________【Example】heart rate 120 beats/min,systolic blood pressure 80mmHg, shock index=120÷80=1,5, the estimated amount of bleeding is about 1500ml2, blood pressure: systolic blood pressure <90mmHg, or In the original basis to drop 20 ~ 30mmHg is an important indicator of shock. Pulse pressure difference < 20mmHg in general, systolic blood pressure < 80mmHg , the estimated bleeding has been > 1000ml.
3, the mean arterial pressure measurement: MAP = diastolic pressure-1/3 (pulse pressure difference).
Normal MAP=90±5mmHg; <65mmHg is abnormal.
4, pulse or heart rate: >100 times/min; 5, urine volume: oliguria: <25~30ml/h, <400ml/24h; 6, central venous pressure VII, first aid and treatment of obstetric hemorrhagic shock (a) comprehensive measures 1, immediate hemostasis; 2, care, comfort, spiritual support; 3, position: autotransfusion position (lying position, lower limbs elevated 20o. In case of respiratory distress, head and shoulders also elevated 4, respiratory support: oxygen administration, to ensure that the blood has sufficient oxygen-carrying capacity; 5, the establishment of 2-3 intravenous channels, the placement of urinary catheters; (B) replenish blood volume, unblock microcirculation, replenish extracellular fluid 1, the principle: first more, then less, first fast, then slow, first salt, then sugar; 2, rapid replenishment of adequate blood volume (the total amount of more than two times the amount of blood loss): A, the preferred balance of fluid: sugar and salt.)
A. Preferred balance fluid: sugar saline, lactate Ringer’s solution (close to extracellular fluid); B. Plasma bulking agent: dextrose, 706 plasma substitute. It can improve microcirculation; C. Blood transfusion: 1/3~2/3 of blood loss is replenished.
Transfusion of whole blood volume: fluid volume = 1:3 whole blood (fresh is best ): contains red blood cells, white blood cells, platelets, plasma. Red blood cells have oxygen-carrying capacity; plasma (FFP): a colloidal solution to expand blood volume, containing all coagulation factors; concentrated red blood cells: containing only red blood cells, supplementing blood oxygen-carrying capacity transfusion rate (HCT ≤ 25-30%); platelets: mostly used for coagulation disorders; 3. Transfusion rate.
Systolic blood pressure mmHg blood input within 1h ml<90 500<80 1000<60 1500 Note: for every 3000 ml of whole blood transfusion, supplement 1 g of calcium (c) correction of acidosis: mild acidosis does not require treatment; (d) application of diuretics: such as basic correction of blood volume, low urine volume (<25 ml/h), tachyphylaxis (40 mg, intravenous), mannitol (250 ml, within half an hour, intravenous); (e) application of cardiac and Vasoactive drugs; severe shock, myocardial hypoxia, cardiac insufficiency, available Cetiran 0, 2 ~ 0, 4mg (P>120 times / min); short time application of vasoconstrictor drugs, boosting blood pressure, to buy time to replenish blood volume; dobutamine: increase cardiac output, reduce peripheral resistance, weak hypertensive effect, dilate renal blood vessels Usage: 5 ~ 20mg% IV m-hydroxylamine ephedrine: after the estimated expansion of satisfactory Use, can raise blood pressure, dosage of half, immediately stop after blood pressure recovery (f) the application of naloxone opioid peptide cardiac, dilate coronary arteries, stabilize the cell membrane, maintain blood pressure Usage: 10μg ~ 4mg/kg intravenous drip effect is good, safe and less side effects, shock early application is better (g) anti-infection (h) indicators of hemorrhagic shock correction 1, systolic blood pressure > 90mmHg; 2, central Venous pressure back to normal; 3, pulse pressure difference > 30mmHg; 4, pulse < 100bpm; 5, urine volume > 30ml/h; 6, blood gas analysis is normal; 7, general condition: warm, red skin, venous filling, strong pulse.
Referral (a) Referral indications 1. For pregnant women with risk of postpartum hemorrhage, they should be transferred to hospitals with blood transfusion conditions near the expected date of delivery or at the early stage of labor; 2. For women with postpartum hemorrhage, they should be transferred as soon as possible while actively carrying out emergency treatment; 3. If the placenta is partially implanted, the uterine cavity should be stuffed with gauze and then transferred; (2) the treatment of the referral process 1, the mother to take a flat position, pay attention to warmth, avoid violent vibration, and closely observe the vital signs; 2, keep the fluids flowing, give contractions and antibiotics; 3, pay attention to contractions and vaginal bleeding at any time during the referral, massage the uterus at any time, and give contractions; 4, the referral should be in place at one time, to avoid repeated referrals Avoid repeated referrals; 5. Accompany the doctor and nurse throughout the whole process.