OBSTETRICS : - etiology, pathogenesis, symptoms and course of, recognition, prediction and prevention



What is the HYPOTONIA OF THE UTERUS, HYPOTONIC BLEEDING and how it is treated?



Hypotonia of the uterus, hypotonic bleeding - lowering ability of the muscles of the uterus to contract, leading to insufficient clamping of the vessels of the uterus and as a result to bleeding in succession and the postpartum period.

Causes of hypotonic condition of the uterus: hypoplasia of the uterus, birth in elderly primiparae giving birth women with a history of a large number of abortions; hyperextension of the uterus when polyhydramnios and multiple pregnancy, the presence of myomatous nodes in the uterus, intoxication with feverish childbirth. To hypotonia of the uterus may cause overfilling of the bladder and rectum. The main and most frequent cause of hypotonic hemorrhage is incorrect management succession period, kneading and massage of the abdominal wall and uterus to the placenta, giving the mother at this time reduces the uterus funds, especially preparations of ergot. In rare cases, the cause of hypotonic hemorrhage in succession period are anomalies of the placenta (incremental slice, the ring shape of the placenta, the increment of the placenta and other).



In practical terms, it is convenient to divide hypotonic hemorrhage in bleeding in the presence of the placenta in the uterus and bleeding after the birth of the whole or the greater part of the placenta from the genital tract.

  1. Bleeding in the presence of the placenta in the uterus: bleeding in 600 ml or more. Bleeding in late maternity care can reach dangerous proportions and lead to death;
  2. the uterus is softened, its boundaries are not distinct, the uterus is blurred in width; its bottom is above the level of the navel, reaching hypochondrium.



The recognition is based on these symptoms. It is important to distinguish between hypotonic bleeding from bleeding caused by the rupture of the cervix and vagina (see).



Prevention involves the proper management of labour, in particular the succession period.


The treatment has two objectives:

  1. to empty the uterus;
  2. to cause a good and stable reduction.

To achieve this, the physician with the following activities:

  1. the emptying of the bladder,
  2. light stroking of the uterus. In case of failure indicated by the reception to resort
  3. the squeezing of the placenta by way of the Vendor or Geiter; when the futility of the last reception start
  4. the squeezing of the placenta by the Vendor or Gentaro under General anesthesia or, if necessary, the immediate cessation of bleeding)
  5. produce manual separation of the placenta using a sleeve Oceanica;
  6. upon separation of the placenta with the same hand without removing it from the uterus, produce a manual examination of the uterus to make sure that the uterus intact and free from the remnants of the placenta and blood clots;
  7. assign pituitrin 1 ml subcutaneously, arguin 1 ml subcutaneously or extract of ergot 30 - 40 drops inside the ice on his stomach; periodic monitoring of uterine contractions and moderate massage of the uterus with its tendency to lose its tone;
  8. transfusion of blood and krovezamenauschie liquids. Drip enema of saline solution mixed with streamed blood, lifting the foot end of the bed.

Bleeding after the birth of the whole or the greater part of the placenta from the genital tract depends on detention in the uterus part of the placenta, overflow it with blood clots or true hypotension uterus.

Treatment. Vigorous uterine contractions by applying ergotine, pituitrin. In order to more vigorous action they can enter into the tissue of the cervix. With the same purpose apply massage of the uterus. With the failure of these measures, and at the slightest suspicion on the possibility of leaving in the uterus part of the placenta (data examination of the placenta, torn, crushed placenta, megadelta placenta) requires manual examination of the uterus and removing the existing placental debris and blood clots. The uterus is then usually well reduced, and the bleeding stops. The tone of the uterus to support the appointment of ergotine, pituitrin, aqueous extract of ergot and periodic massage of the uterus. With the failure of the specified treatment that depends on the true hypotension uterus, which are associated with neuromuscular structure and functional condition of the uterus, it is necessary to apply the most energetic means to immediately stop the bleeding:

  1. the pressure of the abdominal part of the aorta to the lumbar part of the spine fist through the abdominal integuments or rubber harness-tube for 30 minutes;
  2. lift through the abdominal integuments up the body of the uterus and tightly pressed her bosom, that it leads to bleeding. This position of the uterus can to keep fixation on the fundus of the uterus thick roll of rolled sheets.

Achieving these techniques at least a temporary cessation of bleeding, in a more relaxed atmosphere to prepare everything for persistent bleeding.

For upcoming events, if they will need include:

  • a) lavage of the uterus through the long uterine tip hot (up to 50º) sterile weak solution of boric acid or boiling water. Vagina reveal mirrors; the cervix bullet forceps brought to the entrance of the vagina (to avoid infection) and keep the canal of the cervix wide open, to provide a reverse flow of liquid. To this end you can use the tip with dual outflow. The amount of liquid required for washing, can reach from 1 to 3 - 4 l;
  • b) tamponade of the uterus and vagina: the uterine cervix is to relegate bullet forceps to the entrance of the vagina and long tweezers or by hand tightly sataminijet the entire uterine cavity, starting from the angles of the pipes and the bottom, a long, wide gauze bandage or linked to each other gauze napkins; at the end of tamponade of the uterus plugging tight vaults and vagina; the swab is left for 12 hours; the pressure side of the abdomen bandage;
  • C) pressing of the uterine vessels clips: cervix is reduced, as described above, to the entrance of the vagina. On both sides, without the bloody separation of tissues, through the side arches impose long strong clamps on the side of the cervix at the level of the internal OS to clamp the terminals of the uterine artery. To avoid injury, you can put on the end clamps rubber tubing of the appropriate diameter. Clamps wrap in cheesecloth and leave for 12 to 24 hours;
  • g) removal of the uterus (rarely gives success).

After stopping atonic bleeding postpartum women should remain under close medical supervision for at least 2 - 4 hours, as bleeding may recur. To prevent the possible development of an infection shows the use of penicillin (25 000 units 3 hours for 2 to 3 days, a total of 400 000 - 600 000 units) and sulfa drugs. When developed postpartum infection - treatment by the General rules (see Postpartum infectious diseases).