Postpartum hemorrhage

      The causes of late postpartum hemorrhage are multifaceted, and excessive bleeding often leads to shock, anemia, and even life-threatening conditions. Late postpartum hemorrhage is often due to Qi deficiency, blood stasis, infection with pathogenic toxins, or poor uterine involution.

　　One of the main causes of late postpartum hemorrhage is improper handling of the uterine incision during cesarean section. In recent years, due to the increase in pathologic conditions of pregnancy and social factors, as well as the high level of attention to the fetus and the fear of pain in women, the cesarean section rate has gradually increased, and postoperative complications have also increased. The skill level of the operator during cesarean section is related to the rate of late postpartum hemorrhage.

　　1. Inappropriate choice of uterine incision: The incision should be as close to the lower segment of the uterus as possible to avoid being too high or too low. If the incision is too high, it is located at the junction of the body and the lower segment, and the upper and lower tissues of the incision edge are uneven in thickness, which can cause poor uterine incision healing; if the incision is too low, it is close to the cervix, where there is a lot of connective tissue and poor blood supply, which can also cause poor uterine incision healing. Moreover, it is easy to cause incision tearing when delivering the fetal head.

　　2. Inadequate incision method: Cutting with a surgical knife or scissors throughout the process or cutting, causing the arcuate vessels of the uterine wall to break, resulting in excessive bleeding and affecting healing.

　　3. Incision tearing during delivery of the fetal head:粗暴动作或遇巨大儿，畸形儿，前置胎盘时，易发生切口撕裂。Due to the movement of the gravid uterus by the sigmoid colon, the uterus rotates to the right, so the left angle of the incision is prone to tearing, involving the uterine artery, causing massive hemorrhage. At this time, the operator is often nervous, repeatedly suture and ligate the hemorrhage at the site of tearing, which can lead to vascular obstruction at the uterine cornual wound, making it prone to necrosis, cracking, and hemorrhage.

　　4. Improper suturing: Too close needle spacing, excessive and tight sutures can affect local blood circulation, leading to poor incision healing. Moreover, if the endometrium is sutured outward into the muscular layer during suturing, it is also one of the reasons affecting uterine incision healing.

　　Infections that occur before delivery, such as premature rupture of membranes, prolonged labor, repeated vaginal examinations, artificial rupture of membranes, water balloon induction, or use of balloons to promote cervical ripening, can lead to vaginal and intrauterine infections in women with pathologic conditions such as severe anemia during pregnancy, severe pregnancy-induced hypertension, and diabetes. Additionally, failure to maintain proper vaginal hygiene after delivery, fear of pain, and failure to clean the perineum can also result in infections, leading to poor uterine involution or poor incision healing and late postpartum hemorrhage.

　　Incomplete uterine involution can be caused by incomplete intrauterine infection and a small amount of placental and amniotic membrane residue.

　　Four, if there is residual placenta or amnion during the delivery of placental polyps, the residual tissue in the uterus will necrose and become organized, with fibrin deposition on the surface, forming polyps.

　　Five, other endometritis, infection of submucosal uterine fibroids, choriocarcinoma, which can also cause late postpartum hemorrhage.

　　Six, injury to the soft birth canal. Overlarge or malformed fetus, malpresentation, rapid delivery of the fetus, improper use of instrumental delivery, etc., can cause lacerations of the perineum, vagina, cervix, or lower uterine segment, leading to postpartum hemorrhage.

　　Seven, postpartum uterine trophoblastic tumors or submucosal uterine fibroids. They can also lead to continuous or massive bleeding of the uterus.

　　Eight, not checking the placenta and amnion carefully during delivery, especially when there is a placenta accreta or velamentous placenta, a small amount of placental and amnion retention can lead to incomplete restoration of the attachment site of the placenta, the uterus cannot be normally contracted, and uterine contraction is poor. With the local thrombus shedding, sinus opening appears, leading to late postpartum hemorrhage. Partial or complete shedding of placental polyps causes sinus opening at the attachment site, leading to late postpartum hemorrhage.

　　Late postpartum hemorrhage is a serious complication during the puerperium, often causing severe anemia in patients due to persistent or intermittent vaginal bleeding and sudden massive bleeding, which can even lead to hemorrhagic shock and infection. If not treated correctly and effectively in a timely manner, it can lead to maternal death.

　　Late postpartum hemorrhage is related to the condition during delivery. Therefore, understanding the labor process, such as prolonged labor, placental retention, the situation of uterine incision suture on both sides during cesarean section, and the presence of infection factors, has certain reference value for diagnosis. The main clinical symptoms of late postpartum hemorrhage include vaginal bleeding, postpartum defecation, fever, and abdominal pain, etc.

　　1. Vaginal bleeding:It often recurs and can also suddenly bleed a large amount. Bleeding caused by residual placental tissue usually occurs around 10 days after delivery, with bleeding often being large and sudden. In cases where the attachment site of the uterus and placenta is not fully restored, sudden bleeding usually occurs between 10 to 20 days after delivery, with less bleeding. Postpartum hemorrhage after cesarean section often occurs between 4 to 6 weeks after the operation, with more bleeding.

　　2. Fever and abdominal pain:Recurrent bleeding with infection can lead to fever and lower abdominal pain. The signs and symptoms of late postpartum hemorrhage patients include more and acute bleeding, which can often cause anemia in patients, and severe hypovolemia can lead to shock, such as blood pressure drop, profuse cold sweat, weak and unclear pulse, and even loss of consciousness; abdominal palpation can show an enlarged and soft uterus with tenderness.

　　Proper pregnancy health care and appropriate handling of the labor process can significantly reduce the occurrence of postpartum hemorrhage. Those with a history of postpartum hemorrhage, multiple induced abortions, placental retention, twins, polyhydramnios, and prolonged labor should be vigilant, and good antenatal, intrapartum, and postpartum care should be provided. At the same time, inform the mother-to-be in detail to obtain cooperation and prevent the occurrence of late postpartum hemorrhage. Properly handle the second and third stages of labor, and deliver the head and shoulders slowly to protect the perineum and prevent laceration of the soft birth canal. After delivery, closely observe uterine contractions and vaginal bleeding volume, and press the fundus to promote the expulsion of clots.

　　Strictly follow the indications for cesarean section, strengthen the publicity of normal physiological delivery methods, and reduce the influence of social factors. For those with indications for cesarean section, the uterine incision should be made in the lower segment of the uterus, a small incision should be made first, and then torn by hand to the appropriate length, the head should be delivered gently, the appropriate suture should be chosen, the needle distance should not be too close, hemostasis should be thorough, and antibiotics should be used to prevent infection after surgery.

      Late postpartum hemorrhage is a serious complication during the puerperium. The main examinations required include gynecological examination, ultrasound examination, laparotomy, and blood test.

　　1. Gynecological examination:Vaginal examination shows that there is a lot of blood clots mixed with blood, or mixed with placental and amniotic membrane tissue, the cervix is relaxed and open, or mixed with placental tissue; during bimanual examination, the uterus is large and soft, or unclear in shape, there may be mild tenderness, which can be more obvious during infection; in some cases after cesarean section, the lower segment of the uterus can be palpated as being significantly softer; in some cases of trophoblastic tumor,转移nodules may be found in the birth canal.

　　2. Ultrasound examination:There are residual tissues and clotted blood in the uterine cavity, poor uterine involution, or laceration of the uterine muscular wall.

　　3. Laparotomy:For those suspected of having a uterine wall incision rupture, emergency laparotomy should be performed to clarify the diagnosis and provide rescue treatment.

　　4. Blood test:When bleeding is severe, hemoglobin and total red blood cell count decrease, showing signs of anemia due to hemorrhage; when complications of infection occur, the total white blood cell count and neutrophils increase. Due to the different amount of blood loss, the blood Hb often decreases to varying degrees, and when infection factors are present, WBC can exceed 15.0X109/L, and neutrophils are greater than 0.80-0.85.

      In addition to other treatment methods, late postpartum hemorrhage can also be strengthened by nutrition and correction of anemia. The following dietary therapy can also effectively alleviate the concurrent symptoms of late postpartum hemorrhage.

　　1. Dangshen and huangqi stewed chicken:30g of dangshen, 30g of huangqi, 25g of yam, 20 red dates, and 1 hen. Remove the internal organs of the hen and place them with the above herbs in a pot, add yellow wine and water to cook until done, and eat it in several doses, 3-5 doses in a row.

　　2. Ejiao and wuxi zi paste:10g of ejiao and wuxi zi, 30g of rice powder. First, grind wuxi zi with water, add ejiao and rice powder to cook into a paste, eat it, once a day, and take it for several days in a row.

 　　The treatment of postpartum hemorrhage in the late stage mainly uses uterotonics and antibiotics, and appropriate measures should be taken according to the different causes of postpartum hemorrhage. In case of necessity, curettage or laparotomy can be performed, and active resuscitation should be carried out when shock occurs.

　　1. Application of uterine contraction agents and antibiotics The application of uterine contraction agents and antibiotics is the first choice for the treatment of postpartum hemorrhage in late stage. Oxytocin 10-20U can be given, three times a day, intramuscularly. The frequency of injection can be increased if necessary. When there is a lot of bleeding, oxytocin 10-20U can be injected intravenously immediately, and then oxytocin 10-20U can be added to a 10% glucose solution for intravenous infusion to promote uterine contraction and achieve hemostasis. Due to massive blood loss, or prolonged bleeding time, or retained products in the uterus, it is easy to have complications such as infection. Therefore, antibiotics such as penicillin, cefalexin, gentamicin, erythromycin, ciprofloxacin, and josamycin can be given routinely, and the route of administration can be chosen according to the specific situation, such as oral, intramuscular, or intravenous, to prevent and control the occurrence and spread of infection.

　　2. Curettage: For those who still have fresh blood discharge or sudden massive bleeding after the use of uterine contraction agents and antibiotics, or those who suspect the retention of placental or amniotic membrane tissue, curettage should be performed immediately to remove the retained tissue, promote uterine contraction, and most cases can be effective.

　　3. Laparotomy: For postpartum hemorrhage after cesarean section, if there is a suspicion of uterine incision rupture, laparotomy should be performed, and hysterectomy may be necessary if necessary.

　　4. Correction of anemia and anti-shock Long-term repeated bleeding or massive bleeding can cause the body to be in a state of anemia, acute hemorrhage can cause a sudden drop in blood volume and lead to shock, which should be corrected. During shock, expansion of blood volume and raising blood pressure, and improving the state of microcirculation should be the main measures, and blood and its substitutes such as blood substitute, blood stabilizer, normal saline, glucose, and low molecular weight dextran can be given. The amount of fluid can be determined according to the condition. For anemia caused by chronic hemorrhage, fresh blood can be transfused in small amounts multiple times, or iron preparations can be supplemented.

　　Postpartum hemorrhage in late stage is a serious complication during the puerperium. It often causes severe anemia and even hemorrhagic shock due to persistent or intermittent vaginal bleeding and sudden massive bleeding, and if it cannot be treated correctly and effectively in time, it can lead to maternal death. According to the statistics of national maternal and child mortality data from 1996 to 1997, the number of maternal deaths caused by postpartum hemorrhage accounted for 3.4% of the total number of maternal and child deaths. The prognosis of postpartum hemorrhage in late stage is closely related to medical conditions, and factors such as blood source and transportation are also important factors.