Акушерские кровотечения

Obstetric bleeding
от «30» января 2023 года
Протокол №178
• Классификация:

• Classification:
•  early postpartum bleeding: during the first
24 hours after birth;
•  late postpartum hemorrhage: after 24 hours
to 42 days postpartum. Late-onset PPH is
usually associated with placental remnants
and/or postpartum infection
• Diagnostic criteria:
• Complaints:
•  bleeding from the genital tract;
•  pain in the lower abdomen;
•  general weakness and dizziness.
• Physical examination: assessment of the general
condition of the postpartum woman, pulse,
blood pressure, respiratory rate, respiratory rate,
uterine tone, speculum examination data,
volume of blood loss.
• Postpartum hemorrhage is blood loss of 500
ml or more for vaginal delivery, 1000 ml or more
for cesarean section, or any blood loss that
results in hemodynamic instability within 42
days of delivery.
• The amount of blood loss causing hemodynamic
instability depends on the woman’s previous
condition (anemia, preeclampsia, etc.).
• Early postpartum bleeding: in the first 24
hours after birth. Late postpartum
bleeding: after 24 hours up to 42 days
postpartum.
Диагностика
• Pain in the lower abdomen, weakness, dizziness Physical
examination: Assessment of the postpartum mother’s condition:
• · pulse more than 100 beats per minute; · Blood
pressure less than/equal to 100/60 mmHg; · O2 saturation
less than 95%; · decreased uterine tone. Examination of the
cervix on speculum: · ruptures of the birth canal.
• Determination of the volume of blood loss: ·
bleeding from the genital tract in the afterbirth/early
postpartum/postoperative period in a volume of 500 ml or more
during vaginal birth; · 1000 ml or more during cesarean
section, and/or clinical signs of hypoxia of tissues and organs;
• For any degree of risk, determine the blood type
and Rh
• If the risk is high: · review the PPH
protocol; · ensure that 2 doses of EM and
FFP are available in the blood office/center;
•· notify anesthesiologists; · notify
the management of the medical organization
Hospital
•· assessment of the condition and hemodynamic
parameters of the postpartum woman every 5-10 minutes
(blood pressure, pulse, temperature, respiratory rate,
diuresis) with mandatory documentation in the birth
history; · mobilization of personnel: an experienced
obstetrician-gynecologist, a second midwife,
anesthesiologist, anesthetist, laboratory assistant; ·
catheterization and bladder emptying; ·
catheterization of 2 peripheral veins with catheters No.
14-16:
Hospital
• one vein for oxytocin infusion; the second vein is for taking blood
for tests (Hb, Ht, platelets, clotting time, coagulogram,
compatibility with blood products) and subsequent infusion of
crystalloids at a rate of 1000.0 ml (20 ml/kg) in 15 minutes in a
ratio of 3:1 to the volume of blood loss; · warming a woman:
a blanket, changing wet underwear to dry; · supply of
humidified oxygen; · determination of the volume of blood
loss every 5-10 minutes; · order 2 doses of EM and FFP;
• NB! Priority measures must be carried out within 5-10 minutes!
NB! При эффективности первоочередных мероприятий и
стабилизации состояния – продолжить интенсивный
послеродовый уход и наблюдение
Hospital

• Prevention of postpartum hemorrhage: Active

management of the third stage of labor consists of 3
components: routine administration of oxytocin,
uterine massage, controlled traction on the umbilical
cord [1, 3, 4, 8, 9].
• FIGO confirms the recommendation for oxytocin
as the first choice drug for the prevention of
PPH during vaginal birth and caesarean section. For
vaginal birth, 10 IU of oxytocin
intramuscularly at the birth of the anterior
shoulder of the fetus or within the first minute after
birth of the newborn.
• If you are at high risk of PPH:  For vaginal birth, 10 IU of
oxytocin intramuscularly (UD-IA) or oxytocin 10 IU in saline
0.9%-10.0 bolus (iv, stream, slow) at birth of the anterior
shoulder of the fetus or within the first minute after birth
newborn (UD-IIB) [1, 3, 10, 11].  During a cesarean section
after removing the newborn, a bolus of either oxytocin 10 IU in
saline 0.9%-10.0 (UD-IA) or carbetocin 100 mcg (if cost-
effective) (UD - IB) [1, 2, 10, 28].
• Early cord clamping (before 1 minute after birth) is not
recommended unless the newborn requires immediate
resuscitation or if the mother has an Rh antibody titer [1, 4, 9].
 Controlled traction by the umbilical cord during the birth of
the placenta with simultaneous counterpressure on the uterus
during contractions (the body of the uterus is moved away from
the symphysis pubis by hand in the direction of the navel).
•  Postpartum assessment of uterine tone is
recommended for all women: external uterine
massage for at least 15 seconds every 15 minutes
during the first hour after birth, every 30
minutes during the second hour. NB! Prolonged
uterine massage is not recommended as an
intervention to prevent postpartum hemorrhage
in women receiving prophylactic oxytocin [1, 4,
9, 12].
• Constant assessment of the amount of blood lost:
•  assessment of the volume of blood loss before
the birth of the placenta;
•  assessment of the volume of blood loss after the
birth of the placenta;
•  use of informative methods for determining the
volume of blood loss using graduated containers,
weighing materials soaked in blood (1 gram = 1
ml).
• When visually accounting for blood loss, the error
from the actual volume of blood loss is 30%.
•
If you are at high risk of PPH:
•  review the PPH protocol;
•  make sure that 2 doses of packed red blood cells, fresh frozen
plasma, cryoprecipitate (CRIO) are available in the blood
office/center;
•  notify anesthesiologists;
•  notify the management of the medical organization.

Laboratory research:
•  general blood test (including Hb, Ht, platelets);
•  determination of blood group according to the ABO system;
•  determination of blood Rh factor;
•  coagulogram (fibrinogen)
•  thromboelastography/thromboelastometry
• Instrumental research:
•  Ultrasound of the pelvic organs;
•  ECG.
Indications for consultation with
specialists:
•  angiosurgeon, if necessary, ligation of the
internal iliac arteries;
•  consultation of specialized specialists in the
presence of somatic pathology and obstetric
complications.
• Continuous assessment of vital signs: blood
pressure, heart rate, respiratory rate, SI, hourly
diuresis.
• Continue monitoring during the first 24 hours
after birth, with mandatory documentation in
the birth history .
•  Early breastfeeding.
TONE Injury Tissue THROMBIN
external examination on •inspection of the massive
massage of the mirrors and uterine cavity, transfusion of
uterus; • suturing of manual packed red blood
uterotonics; • ruptures and separation and cells, fresh frozen
bimanual uterine hematomas of the removal of plasma, platelet
compression; • birth canal; • retained parts of mass,
balloon uterine inversion the placenta if prothrombin
tamponade of the anesthesia, there is a complex
uterus; • relaxation and suspicion of concentrate,
surgical reposition of the placenta remains recombinant
hemostasis uterus in the and its growth clotting factor VII
operating room;
• uterine rupture
– laparotomy.
• PRIORITY ACTIONS For PPH
• STEP 1 - PRIORITY MEASURES
• For PPH should be carried out within 5-10 minutes! The
PRK checklist is activated
• assessment of the condition, color of the skin,
hemodynamic parameters of the postpartum woman (BP,
pulse, temperature, respiratory rate, blood pressure,
diuresis), determination of the volume of blood loss every
5-10 minutes with mandatory documentation;
• mobilization of personnel: an experienced obstetrician-
gynecologist, a second midwife, an anesthesiologist, an
anesthetist, and a laboratory assistant;
• supply of humidified oxygen;
• catheterization and bladder emptying;
•  catheterization of 2 peripheral veins with
catheters No. 14 or 16: one vein for oxytocin
infusion (bolus 5 IU in 0.9%-10.0 NaCl and
intravenous drip, taking into account the tone of
the uterus 10-40 IU in 0.9% -500.0-1000.0
NaCl, at least 2 hours);
• the second vein is for taking blood for tests (Hb,
Ht, platelets, coagulogram, compatibility with
blood products) and infusion of warmed
crystalloids (preferably Ringer's lactate instead).
•  For PPH without clinical shock (blood loss 500.0-
1000.0), infusion of warmed crystalloids in a ratio of 2:1
to the initial volume of blood loss.
• Administration of the initial dose: 500.0 isotonic
crystalloids intravenously over 30 minutes, and
subsequent doses of 500.0 isotonic crystalloids
intravenously over 60 minutes [4, 11, 21].
•  In all cases of PPH, regardless of the cause of
bleeding and method of delivery, administer
tranexamic acid 1000 mg (100 mg/ml) IV at a rate
of 1 ml/min as soon as possible, but no later than 3
hours after delivery, i.e. within 10 minutes
•  warming a woman: blanket, changing wet underwear
to dry;
•  check the availability of 2 doses of EM, FFP
and CRYO. NB! If priority measures are effective
and the condition is stabilized, continue
intensive postpartum care and observation
(Appendix 5); if bleeding continues, see STEP 2.
• Uterine atony is the most common cause of PPH
(70%). Emergency interventions for atonic PPH
include uterine massage, uterine and bladder
emptying[1].
• If PPH is associated with retained placenta or
parts thereof, they should be removed and a
single dose of antibiotics given. If ruptures in the
birth canal are detected on the speculum, they
should be sutured
• STEP 3 - METHODS FOR TEMPORARILY
STOPING BLEEDING
• For the treatment of atonic PPH after vaginal
delivery, the use of bimanual uterine
compression ,
• abdominal aortic compression (Fig. 2) or
intrauterine balloon tamponade (Fig. 3)
• is recommended as a temporary measure until
surgical intervention
• NB! Balloon tamponade of the uterus is performed only after exclusion of
retained products of conception or uterine rupture .

• NB! While using methods to temporarily stop bleeding, the administration

of uterotonics (oxytocin diluted in isotonic crystalloids) and a second
dose of tranexamic acid should be continued.

• Conducting intensive transfusion therapy together with an

anesthesiologist-resuscitator.
• To select the volume of infusion therapy for PPH, a central venous catheter
(UD-IA) should not be used.
• Transfusion criteria include assessment of blood loss, hemodynamic
situation, hemoglobin, hematocrit, tissue oxygenation (lactate) level and
prediction of PPH severity.
• If bleeding continues and/or blood loss is 1000 ml or more, surgical
hemostasis is recommended (see STEP 4).
• https://
www.youtube.com/watch?v=40dYms_v4YM
volume of operation indication
compression hemostatic sutures to B. ineffectiveness of drug treatments for
Lynch atonic PPH without signs of disseminated
intravascular coagulation syndrome

ligation of the uterine arteries according ineffectiveness of drug treatments for

to Oliri atonic PPH without signs of disseminated
intravascular coagulation syndrome,
when compression seams do not work

ligation of the internal iliac arteries one of the options for quick control of
PRН
subtotal hysterectomy atonic bleeding without signs of
coagulopathy, no cervical trauma,
ineffectiveness of compression sutures
total hysterectomy atonic bleeding without signs of
coagulopathy, no cervical trauma,
ineffectiveness of compression sutures
true accretion of a normally located
placenta
Algover shock index for PPH
blood loss up to 1000 ml 1000-2000 2000-3000 more than 3000

infusion- crystalloids •Crystalloids •Crystalloids •Crystalloids

transfusion •red blood cell •red blood cell •red blood cell
therapy mass mass mass
•fresh frozen •fresh frozen •fresh frozen
plasma for plasma for plasma for
coagulopathy coagulopathy coagulopathy
•cryo •Colloids •platelet mass
•Albumin •cryo
•cryo •Colloids
•Albumin

note ratio of start red blood ratio of red blood product

crystalloids to cell transfusion blood cells :to ratio with
initial blood loss ratio of fresh frozen massive PPH of
2:1 crystalloids to plasma:platelets red blood
colloids 2:1 / cells :to fresh
1:1:1 frozen
plasma:platelets
/
1:1:1