Obstetrics and gynecology. Treatment for bleeding (most important)

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Obstetrics and gynecology. Treatment for bleeding (most important)

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37. Treatment for bleeding

If a placental defect is suspected and detected, a manual examination of the uterus is done, the remnants of the placental tissue are removed. At the same time, myotonics are administered. With hypotonic bleeding, a complex of therapeutic measures is carried out without delay, aimed at stopping bleeding and replenishing blood loss. With the ineffectiveness of conservative treatment, it is necessary to immediately begin surgical treatment. These can be operations of abdominal surgery and extirpation of the uterus. All actions to stop bleeding are aimed at enhancing the contractility of the uterus and are carried out in a certain order:

1) emptying the bladder using catheterization;

2) the introduction of uterine contracting agents (1 ml of oxytocin intravenously slowly);

3) external massage of the uterus: with the palm of the right hand through the anterior abdominal wall, they cover the bottom of the uterus and make light circular massaging movements. In this case, the uterus becomes dense. With gentle pressure on the bottom of the uterus, blood clots that prevent contraction are removed from its cavity. Massage is continued until the uterus is completely contracted and bleeding stops. If, after the massage, uterine contraction does not occur or occurs incompletely, and then the uterus relaxes again, then proceed to further measures;

4) an ice pack on the lower abdomen;

5) if the bleeding has not stopped, a manual examination of the uterus is performed, it is massaged on the fist. The external genital organs and hands of the doctor are treated with disinfectants and under general anesthesia the uterine cavity, its walls are examined by hand in order to exclude the presence of trauma and retained placental remnants. Remove existing blood clots that prevent uterine contraction. If after this the contraction of the uterus is insufficient, then it is massaged on the fist. The fist is located in the region of the bottom of the uterus, with the other hand through the anterior abdominal wall, a light massage of the uterus is performed, with an increase in tone, the uterus tightly covers the fist, the bleeding stops. The hand is carefully removed from the uterus. Rough manipulations with the use of force can lead to multiple hemorrhages in the myometrium. Simultaneously with the massage of the uterus on the fist, agents that reduce the uterus (oxytocin, prostaglandins) are injected;

6) to enhance the effect of stopping bleeding, a transverse catgut suture can be applied to the posterior lip of the cervix according to V. A. Lositskaya;

7) introduction of a tampon moistened with ether into the posterior fornix of the vagina.

The lack of effect from all the measures taken indicates in favor of the presence of atonic bleeding, which requires emergency surgical intervention. In order to preserve the uterus, if circumstances permit, after opening the abdominal cavity, catgut ligatures are applied to the uterine and ovarian arteries on both sides, wait some time. In some cases, this leads to uterine contraction (hypoxia of the myometrium leads to reflex contraction), bleeding stops, and the uterus is preserved. If this does not happen, especially if there are signs of coagulopathy, then the bleeding cannot be stopped. In such a situation, the only method of saving the life of the puerperal is amputation or extirpation of the uterus.

Author: Ivanov A.I.

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