Definition of postpartum hemorrhage
Postpartum hemorrhage refers to vaginal bleeding exceeding 500ml within 24 hours after delivery of the fetus, commonly known as postpartum hemorrhage or postpartum hemorrhage. Postpartum hemorrhage is a serious complication during delivery, ranking first among the four major causes of maternal death in China. The incidence of postpartum hemorrhage accounts for 2%-3% of the total number of deliveries. Due to the subjective factors of measuring and collecting blood volume, it is usually estimated that the blood loss is only half of the actual blood loss, so the actual incidence rate is high.
What is the difference between postpartum hemorrhage and late postpartum hemorrhage?
1, bleeding time is different.
Postpartum hemorrhage occurs within 24 hours after delivery, and the amount of bleeding exceeds 500ml, and 80% occurs within 2 hours after delivery. Compared with late postpartum hemorrhage, postpartum hemorrhage is also called early postpartum hemorrhage. Late postpartum hemorrhage refers to a large amount of uterine bleeding in the puerperium 24 hours after delivery, and the amount of bleeding exceeds 500ml. More common in postpartum 1-2 weeks, but also as late as 6 weeks postpartum. Also known as postpartum hemorrhage.
2. The causes of bleeding are different.
The four main causes of postpartum hemorrhage are uterine inertia, abnormal delivery of placenta and fetal membrane, laceration of soft birth canal and coagulation dysfunction. The main cause of late postpartum hemorrhage is residual placental fragments.
In recent years, with the increase of cesarean section rate in various places, the incidence of late postpartum hemorrhage has an upward trend. Among them, uterine incision dehiscence caused by improper handling during cesarean section is one of the important reasons for late postpartum hemorrhage.
Causes of postpartum hemorrhage
The causes of postpartum hemorrhage are uterine inertia, placental factors, laceration of soft birth canal and coagulation dysfunction in turn. These factors can cause and effect each other and influence each other.
1, uterine atony
The most common cause of postpartum hemorrhage. All factors affecting uterine contraction can cause postpartum hemorrhage caused by uterine atony. Common factors are:
(1) Systemic factors: The parturient is extremely nervous, excessively afraid of delivery, especially lacking sufficient confidence in vaginal delivery; Excessive use of sedatives, anesthetics or uterine contraction inhibitors after delivery; Combined with chronic systemic diseases; Physical weakness can cause uterine contraction weakness.
(2) Obstetric factors: Prolonged labor, excessive physical exertion or accelerated delivery can cause uterine atony. Obstetric complications and complications such as placenta previa, placental abruption, hypertensive disorder complicating pregnancy, intrauterine infection, etc. It may be uterine weakness caused by uterine muscle edema or oozing blood.
(3) Uterine factors: dysplasia of uterine muscle fibers, such as uterine malformation or hysteromyoma; Excessive stretching of uterine fibers, such as macrosomia, multiple pregnancies and polyhydramnios; Coin collection of damaged uterus, such as cesarean section, uterine perforation and other uterine surgery history; Too many births and times can cause uterine atony.
2. Placental factors
According to placental abruption, the types of postpartum hemorrhage caused by placental factors are:
(1) Placenta retention: After the fetus is delivered, the placenta should be delivered out of the body within 30 minutes. If it is still not discharged, it will affect the closure of blood sinus on the surface of placental abruption, leading to postpartum hemorrhage.
(2) Placenta adhesion: refers to that the placenta adheres to the uterine wall in whole or in part, and cannot be peeled off by itself. Repeated induced abortion, endometritis or decidual dysplasia are common causes. If it is a complete calendar year, there is generally no bleeding; If there is partial adhesion, the blood sinus on the surface of partial placental detachment will open, and the placenta retention will affect uterine contraction and cause postpartum hemorrhage.
(3) Placental implantation: Placental villi are implanted into the myometrium of uterus. The implanted sinus is partially open, and the bleeding is not easy to stop.
(4) Placenta-fetal membrane residue: Most placental lobules or accessory placentas remain in the uterine cavity, and sometimes some placentas fall off and blood sinuses are open, and the placenta retention affects uterine contraction, causing postpartum hemorrhage.
3, soft birth canal laceration
The characteristic of hemorrhage is that it occurs after the delivery of the fetus, which is different from postpartum hemorrhage caused by uterine fatigue. The blood flowing from the soft birth canal laceration can coagulate itself. If the laceration damages the arteriole, the color of the blood is bright red. Rupture of the birth canal during delivery is usually related to the following factors:
(1) The elasticity of vulva tissue is poor;
(2) urgent labor, excessive productivity and huge children;
(3) The operation of guiding operation and midwifery is not standardized;
(4) When the perineum is cut and sutured, the bleeding is not completely stopped, and the laceration of the cervix or vaginal vault can be found in time.
4. Coagulation dysfunction
Maternal coagulation dysfunction can be seen in:
(1) Complications related to obstetrics, such as amniotic fluid embolism, hypertensive disorder complicating pregnancy, placental abruption and stillbirth, can all be complicated with DIC.
(2) Maternal women with hematological diseases, such as aplastic anemia. Because of coagulation disorder, it can cause uncontrollable bleeding of postpartum incision and uterine sinus, which is characterized by blood coagulation.
Clinical manifestations of postpartum hemorrhage
Postpartum hemorrhage is mainly manifested as complications such as shock and anemia caused by vaginal bleeding or excessive blood loss.
1, vaginal bleeding increased.
There may be no sudden massive bleeding, but continuous bleeding until severe hypoxemia occurs. Or it may lead to massive blood loss within a few hours. The clinical manifestations of postpartum hemorrhage with different causes are different.
Laceration of birth canal: vaginal bleeding and bright red immediately after delivery of the fetus, which may be laceration of birth canal.
Placental factors: the fetus began to bleed a few minutes after delivery, and the color was dark, which may be caused by placental factors.
Uterine atony or placenta and fetal membrane residue: bleeding occurs after placenta delivery, mainly due to uterine atony or placenta and fetal membrane residue.
Coagulation dysfunction: If the vagina continues to bleed and the blood does not coagulate, it may be postpartum hemorrhage caused by coagulation dysfunction.
2. The uterus is big and soft.
Within 24 hours after delivery, the uterus should be ellipsoid; The height of the uterine fundus is at or below the umbilicus and at the midline of the abdomen. If the uterus is weak, it is not easy to touch the uterus or feel that the uterus is very soft; During massage, the uterus is in a hard state. Once the massage is stopped, the uterus will lose its tension.
3. The heartbeat is faster and the blood pressure is lower.
When bleeding, the heart beats faster first, and after continuous bleeding, the blood pressure drops. When the pulse accelerates to 100- 120 beats/min and the systolic blood pressure is lower than 90- 100mmHg, the blood loss usually reaches 25-35% of the whole body blood volume.
4. Symptoms of shock
The influence of bleeding largely depends on the blood volume during non-pregnancy, the increase of blood volume during pregnancy and the degree of anemia during delivery. If the amount of vaginal bleeding is more or less for a long time, the parturient may have shock symptoms, such as dizziness, pallor, rapid pulse and decreased blood pressure.
Postpartum hemorrhage examination
Because there are several major causes of postpartum hemorrhage, when postpartum hemorrhage occurs, we can find it from the following aspects:
1, to judge whether the uterine contraction is normal.
After the placenta is delivered, the uterus contracts to the level of umbilical cord or the next finger of umbilical cord. The uterus is spherical and hard. All the blood is sealed. The bleeding stopped. If the uterus is weak in contraction, the bottom of the uterus will bulge, and the uterus will become soft and appear as a water sac.
2. Check whether the placenta is delivered normally.
The placenta is not delivered in normal time, and a large amount of vaginal bleeding is abnormal. Furthermore, placental residue can also lead to postpartum hemorrhage, so after the placenta is delivered, it is necessary to carefully check whether the placenta and fetal membrane are complete.
3. Check whether the soft birth canal is damaged.
In the case of the Third Great Wall and climate bleeding, especially in the case of good contractions, we should consider the soft birth canal and check it carefully. Such as cervical laceration, vaginal laceration, vaginal wall hematoma and perineal laceration.
4. Blood test
If it is postpartum hemorrhage caused by coagulation dysfunction, it is characterized by persistent vaginal bleeding, blood coagulation and difficulty in stopping bleeding, and systemic lesions can occur at the same time.
Postpartum hemorrhage is easy to diagnose, but it is often less clinically estimated by visual inspection. The following methods for detecting blood loss are objective, but there will be some errors due to different operators.
1. weighing method: divide the dressing used after delivery into different markets, and the weight of dressing before delivery is the blood loss.
2. Volumetric method: Use a special postpartum blood container to measure the collected blood with a cup.
3. Area method: calculate the blood wetted area as 10cm× 10cm and 10ml.
4. Shock index method: shock index = heart rate/systolic blood pressure (mmHg). 0.5 is normal, if it is 1, it is mild shock; 1.0- 1.5, and the amount of bleeding is about 20%-30%; 1.5-2, severe shock with a bleeding volume of about 30%-50%; ≥2.0, severe shock, bleeding volume above 50%.
Flow chart of postpartum hemorrhage rescue
The treatment principle of postpartum hemorrhage is to stop bleeding quickly, replenish blood volume to correct shock and prevent infection.
(1) Quickly and effectively replenish blood volume. Seize the opportunity of rescue, establish two-way venous access, use indwelling needle as much as possible, and closely monitor the changes of vital signs such as blood pressure, pulse, breathing, skin color and expression. Grasp the correct speed of intravenous infusion according to the condition, pay attention to the conscious symptoms of lying-in women while infusion quickly, and avoid acute pulmonary edema caused by excessive infusion. Keep the respiratory tract unobstructed, take oxygen effectively and timely, and it is best to give oxygen through a mask with a flow rate of 4-6L/min. Observe the effect of oxygen therapy, such as rosy complexion, nails and smooth breathing.
(2) Postpartum hemorrhage is prone to shock. In case of shock, the nursing staff must be calm and report to the doctor while keeping warm, taking oxygen and actively promoting the involution of uterus, so as to ensure that the rescue work is carried out in an orderly manner, immediately check the blood type and collect blood, make up the blood loss in a short time, closely observe the vital signs, accurately measure the blood loss and make detailed records.
(3) Massage the bottom of the uterus with bare hands to stimulate uterine contraction and close the blood sinus of the uterine wall. Assist doctors to improve various examinations and actively prevent complications.
(4) After stopping bleeding and correcting shock, we should comfort the parturient to rest quietly, encourage and assist in eating, and closely observe the blood pressure, pulse, uterine recovery and vaginal bleeding of the parturient. After 2 hours of observation in the delivery room, if there is no abnormality, you can return to the ward.
Postpartum hemorrhage rescue flow chart:
Nursing measures for postpartum hemorrhage
If pregnant women have postpartum hemorrhage, correct nursing is particularly important at this time. Maternal women must always check their physical condition, maintain emotional stability, and avoid bad mental stimulation such as anxiety and anger, which is more conducive to recovery.
1, puerperium is the period of reproductive organ recovery, because of the weakness of qi and blood, it is particularly easy to cause wind-cold invasion and form blood stasis. Because the formation of blood stasis is mostly caused by cold, we should pay attention to keep warm after delivery, avoid taking cold as the wind, avoid cold stimulation and prevent the invasion of cold evil.
2. Encourage the lying-in women to get out of bed as soon as possible and increase the amount of exercise day by day, which is more conducive to the discharge of lochia and congestion and promote the involution of uterus. Conditional can learn to do postpartum health gymnastics, strengthen the whole body exercise, as soon as possible to restore physical strength.
3. Actively prevent infection and keep the environment clean. Indoor ventilation for 30 minutes, twice a day, regular disinfection. Keep the sheets clean and dry, change sanitary napkins frequently, scrub the vulva with 10% strong iodine cotton ball twice a day, keep the perineum clean and use effective antibiotics.
4. Provide psychological support. Although the maternal life can be saved after massive hemorrhage, due to massive blood loss, there may be serious secondary anterior pituitary blood necrosis, decreased function and decreased levels of various hormones, which is called Sheehan syndrome. Maternal women face problems such as poor physical strength, lack of activity endurance and difficulties in taking care of themselves. In the above situation, pregnant women should be encouraged to express their feelings, provide psychological comfort and help to pregnant women and their families in time, guide them on how to strengthen nutrition, effectively correct anemia, gradually increase the amount of activity, and promote their early recovery.
Matters needing attention after caesarean section: an interesting talk about the influence of caesarean section on postpartum hemorrhage.
The influence of postpartum hemorrhage on parturient is mainly determined by the amount of blood loss and the situation of parturient. If the amount of bleeding is small or the maternal body is strong and tolerant, it can be cured after treatment without leaving any serious sequelae.
On the contrary, if there is a large amount of bleeding in a short period of time, and the pregnant woman has anemia or poor coagulation function, the consequences will be serious, and she may feel dizzy, flustered, cold limbs, syncope and shock, and at the same time lose a lot of coagulation substances during blood loss, leading to coagulation dysfunction and even death. Although some doctors tried their best to save their lives, due to massive blood loss, ischemia and hypoxia of important organs such as heart, brain and kidney caused tissue cell damage and organ function damage.
In addition, postpartum hemorrhage may lead to Sheehan syndrome. The disease is caused by massive hemorrhage and shock, which leads to ischemic necrosis of the anterior pituitary gland in brain tissue, and its secretion of gonadotropin decreases, which reduces the secretion of female estrogen and progesterone by ovaries, leading to amenorrhea, emaciation, lack of milk, atrophy of breasts and external genitalia, which will cause great physical and psychological trauma to parturient.
In addition, puerperal women with postpartum hemorrhage are prone to puerperal infection due to blood loss and anemia, resulting in decreased body resistance. Maternal blood loss, malnutrition, mental stress and anxiety will also affect the secretion of milk, which is not conducive to breastfeeding. Therefore, delivery should go to a regular hospital with rescue facilities to avoid postpartum hemorrhage and ensure the health of mother and baby.
How to prevent postpartum hemorrhage
How to prevent postpartum hemorrhage? Strengthening perinatal health care, closely observing and correctly handling the Great Wall can reduce the incidence of postpartum hemorrhage.
1, pay attention to prenatal care
(1) Strengthen women's health care before and during pregnancy. Patients with coagulation dysfunction and diseases that may affect coagulation dysfunction should be actively treated before pregnancy and terminate pregnancy if necessary.
(2) Pregnant women with risk factors for postpartum hemorrhage. If pregnant women have anemia, blood system diseases or other abnormal conditions, they should be treated and corrected in time. If it is twins, polyhydramnios, pregnancy complicated with hypertension syndrome or a history of postpartum hemorrhage, you should be hospitalized as soon as possible.
(3) Increase women's understanding of reproductive knowledge and reduce the number of induced abortions.
2. Improve the quality of delivery
Help the parturient to get rid of worries, actively rest and eat during the uterine contraction, avoid excessive physical exertion, guide the correct delivery mode, and make the parturient give birth smoothly and naturally.
3. Strengthen postpartum observation
In order to prevent bleeding after delivery 12 hours, midwives should observe uterine contraction and vaginal bleeding 2 hours after delivery, whether the bladder expands to avoid affecting uterine contraction, and pay attention to the changes of blood pressure and pulse. After 2 hours, if there is no abnormality, you can go back to the maternal and child room to rest.
4, early postpartum breastfeeding can stimulate uterine contraction and reduce vaginal bleeding.
What is good for postpartum hemorrhage?
Diet should be light, digestible and nutritious. Usually you can eat more alkaline foods, such as tofu, kelp, milk and various fruits and vegetables.
1, the uterus contraction should eat more lily, sheep blood, eggs, swim bladder, leek, lotus leaf pedicle, vinegar, carp, hippocampus and shepherd's purse.
2, placenta retention or congestion should eat more rape, sheep blood, brown sugar, arrowhead, rabbit meat and so on.
3. People with birth canal injury or blood fever should eat more loach, black beans, dried winter vegetables, bayberry, shepherd's purse, day lily, beet, crucian carp and so on.
4. All kinds of bleeding should eat foods rich in vitamin E, such as vegetable oil such as wheat malt oil, cottonseed oil, peanut oil and soybean oil, whole grains such as millet and corn, green vegetables such as spinach, lettuce, cabbage, milk, eggs, animal liver, heart, kidney, meat, fish, carrots, sweet potatoes, potatoes, cream, green beans, tomatoes and bananas.
Medicinal diet for postpartum hemorrhage:
1, ginseng porridge
50g of rice, ginseng powder 10g, ginger juice 10g. Rice porridge, add ginseng powder and ginger juice and stir well; Breakfast and dinner.
2. Persimmon porridge
Persimmon and yellow wine are suitable. Persimmons are burnt into powder with charcoal. 6 grams each time, yellow wine is delivered. Sheng Di Mu Yi soup: 200ml of yellow rice wine, 6g of radix rehmanniae, and 0/0g of motherwort/kloc. Put the medicine into a porcelain cup, steam for 20 minutes and then take the medicine soup; Take 50 ml of warm clothes for several days.
3. Black egg drink
3 black eggs, 1 cup of vinegar and wine. Remove the egg skin, stir them together, boil them in a cup and take them twice; Daily 1 dose, 5 ~ 7 doses continuously.
Postpartum hemorrhage is harmful to both body and mind, so family members should accompany and enlighten them more. The above three kinds of medicated diets can be made for parturient in daily diet.
Healthy nourishing dessert sweet glutinous lotus seed lily red bean porridge red jujube lily steamed pumpkin postpartum hemorrhage late.
Late postpartum hemorrhage refers to massive postpartum uterine bleeding within 24 hours after delivery. More common in postpartum 1-2 weeks, but also as late as 42 days after delivery. The clinical manifestations are persistent or intermittent vaginal bleeding, and sometimes a large amount of vaginal bleeding suddenly appears, which can cause hemorrhagic shock. Late postpartum hemorrhage is often accompanied by chills and low fever.
In recent years, with the increase of cesarean section rate in various places, the incidence of late postpartum hemorrhage has an upward trend. The statistics of Beijing Shanghai Grand Hospital are 0. 17% ~ 0.4%. Rupture of uterine incision caused by improper handling during cesarean section is one of the important causes of late postpartum hemorrhage.
Distinguish postpartum hemorrhage (early postpartum hemorrhage) The time of late postpartum hemorrhage is within 24 hours after delivery-within 42 days after delivery. The common occurrence time is within 2 hours after delivery 6- 10/0 days. Postpartum causes include uterine inertia, laceration of birth canal, placenta debris residue, disseminated coagulation disorder, infection, surgical wound dehiscence, tumor symptoms, vaginal bleeding exceeding 500ml, pallor, shock and chills, and low fever.