Treatment of hypotonic bleeding is directed to on the rapid restoration of the normal contractile function of the uterus and the fight against acute anemia. When the delay of the afterbirth or its parts in the uterine cavity, suspicion of tight attachment of the placenta, it is necessary to perform manual removal of the afterbirth and examination of the uterine cavity. You can not repeatedly and rudely apply the techniques of secrete afterburn, as this leads to a breach of the contractile activity of the uterus and the prolongation of bleeding. In the presence of hypotension, it is necessary to carry out an external-internal massage of the uterus on the fist. The operation is performed under anesthesia.
Technique of operation: with one hand (usually left), the labia are bred, the right hand in the form of a cone is inserted into the uterus, compressed into a fist and moves the uterus up and forward. With the second hand, through a sterile diaper, gentle massage is performed by stroking it through the anterior abdominal wall. Rough mechanical irritation can lead to hemorrhage, a violation in the coagulation system and increased bleeding. With partial preservation of the motor function of the uterus, there is a contraction of muscles, and with atony, there are no contractions.
For the treatment of bleeding arising in connection with the uterine hypotonia, are successively used.
1. Emptying the bladder;
2. Overview of litter and birth canal;
3. External massage of the uterus;
4. Local hypothermia (cold to the bottom of the abdomen);
5. Introduction 1ml methylergometrine or 1ml of oxytocin, replenishment of bcc by the introduction of rheopolyglucin, polyglucin, blood.
6. Manual examination of the uterine cavity and uterine massage on the fist (under anesthesia).
7. With the continuation of bleeding, the following methods are used, based on increasing the contractility of the uterus by irritating its receptors: cold on the abdomen, suturing the back of the cervix with VA Lositsky or circular for OT Mikhailenko, a tampon with ether in posterior vaginal arches, application of clamps to parameters by Genkel-Tikanadze (perpendicular to cervical ribs) or M.S. Bakseevim (length of cervix). It is possible to use an electro-toner - ZA Chiladze's method.
8. In the absence of the effect of the above measures and the continuation of bleeding, it is more than 1000 ml with the signs of ICE, it is necessary to proceed quickly to laparotomy for ligation of uterine vessels or supravaginal amputation or extirpation of the uterus.
To temporarily stop bleeding, when transporting the patient to the operating room, the following procedures should be used:
- Pressing the abdominal aorta;
- Clamping of the uterus to the frontal articulation.
When atony of the uterus, its extirpation is shown (complete removal of the uterus).
With uterine bleeding in the consecutive and early postpartum periods, simultaneously with measures to stop bleeding, the struggle with acute anemia is being conducted. Blood loss is considered compensated, if it does not exceed 1% of body weight, the deficit of BCC is not more than 15%. Decompensated is considered a blood loss, which is 1.5% of body weight, a deficit of bcc more than 15%. Hemorrhagic shock is accompanied by a deficit of BCC more than 25%, a drop in blood pressure, development of hypoxia in all organs. Shock can develop with less blood loss when exhausted, overworked and late toxicosis of pregnancy.
Assessment of blood loss is based on determining the filling and pulse rate, blood pressure, central venous pressure, hourly diuresis, hematocrit, hemoglobin, shock index. The latter is determined by dividing the pulse rate by the maximum blood pressure, normally it is 054.
Blood loss to 500ml is restored only by blood substitutes (polyglucin, reopolyglucin). The blood loss of 500-1000 ml is restored by solutions of colloids and blood in a ratio of 2: 1. Blood loss 1000-1500ml is restored by solutions of colloids and blood in a ratio of 1: 1 blood loss of 1500-3000ml - solutions of colloids and blood with blood substitutes in the ratio 2: 3. Restoration of large blood loss should be carried out only by one-group, preferably fresh, donor blood. Vasopressors (mezaton, adrenaline) are used only in the phase of restored blood loss. Glucocorticoids are prescribed for suspected adrenocortical insufficiency. It is advisable to introduce cardiac glycosides (strophanthin), oxygen therapy, warming of the patient, in terminal conditions - intubation and connection of the ventilator, indirect cardiac massage, intracardiac adrenaline injection.