Complications during labor

　　The main reasons for the occurrence of perinatal complications in pregnant women are mainly due to the following 2 points:

　　1. Uterine atony
　　Factors that affect the contraction and involution of the postpartum uterus can all cause postpartum hemorrhage. Common factors include:
　　Systemic factors:Maternal excessive tension, excessive use of sedatives and anesthetics during labor, prolonged labor or difficult labor, maternal exhaustion of physical strength; combined with acute and chronic systemic diseases, etc.
　　Local factors:Overly dilated uterus, such as twin pregnancy, macrosomia, polyhydramnios, poor development of uterine muscle fibers, uterine muscle edema and hemorrhage, such as pregnancy-induced hypertension, severe anemia, placental abruption, placenta previa

　　2. Placental factors
　　According to the condition of placental detachment, the types of postpartum hemorrhage caused by placental factors include: incomplete placental detachment, retained placenta after detachment, placental impaction, placental adhesion, placental implantation, and/or retained placenta and/or amniotic membrane.

　　The main diseases caused by perinatal complications include:

　　1. Complications of amniotic fluid embolism

　　1. Onset before or during childbirth.

　　It is common in cases of strong uterine contractions or rupture of the amniotic membrane, mainly with pulmonary hypertension and shock. Patients may show symptoms such as restlessness, difficulty breathing, cyanosis, convulsions, coma, blood pressure drop, and shock; a few cases may only scream once and then stop breathing and die; some may have a mild onset, first showing symptoms such as chills, restlessness, coughing, and chest tightness, followed by cyanosis, difficulty breathing, and then entering a state of convulsions, coma, and shock; some may die after this period due to dysfunction of blood coagulation or acute renal failure.

　　2. Postpartum illness is mainly characterized by bleeding and shock, with mild symptoms of cardiac and pulmonary dysfunction.

　　3. Organ failure If the condition is not controlled and continues to worsen, it will eventually develop into multiple organ failure, with acute renal failure as the complication, which is life-threatening.

　　2. Postpartum hemorrhage complications

　　1. The complications of postpartum hemorrhage are hemolytic shock, heart failure, and electrolyte imbalance, leading to death.

　　2. Reproductive tract infection Postpartum hemorrhage can cause anemia in women, lower resistance, and increased opportunities for uterine cavity operations, which increases the risk of postpartum infection. Therefore, it is advisable to use broad-spectrum antibiotics for the prevention and treatment of reproductive tract infections.

　　3. In severe postpartum hemorrhage caused by Sheehan syndrome, the patient may develop ischemic necrosis of the anterior pituitary due to circulatory failure, leading to disrupted endocrine function. The patient lacks prolactin, resulting in no milk secretion, and lacks thyroxine,

　　Postpartum hemorrhage and amniotic fluid embolism are severe complications of childbirth that pose a serious threat to the lives of women, and their clinical symptoms are as follows:

　　1. Postpartum hemorrhage Postpartum hemorrhage is defined as bleeding exceeding 500ml within 24 hours after the fetus is delivered, which includes the period from the delivery of the fetus to the delivery of the placenta, from the delivery of the placenta to 2 hours after delivery, and from 2 hours after delivery to 24 hours. Most bleeding occurs in the first two periods. Postpartum hemorrhage is the leading cause of maternal death in China.

　　1. Bleeding before the placenta is delivered
　　When the fetus is delivered or after delivery, active bright red blood starts to flow from the vagina, which is mostly caused by injury to the soft birth canal.
　　If there is intermittent dark red blood discharge mixed with clots, delayed delivery of the placenta, it often belongs to placental factors and should be delivered rapidly.

　　2. Bleeding after the placenta is delivered
　　Examine the integrity of the placenta and amniotic membrane, palpate the uterus to find it soft, even indistinct in contour. After massaging the uterus, uterine contraction improves, bleeding decreases significantly or stops, indicating uterine atony; if the soft birth canal is not damaged, the placenta is delivered completely, uterine contraction is good, and there is still persistent vaginal bleeding that is difficult to coagulate, consider the dysfunction of blood coagulation and further examination of blood coagulation function is needed.

　　Two: The typical clinical course of amniotic fluid embolism can be divided into three stages:
　　1. Shock It can cause heart failure and acute respiratory and circulatory failure due to pulmonary hypertension, or anaphylactic shock caused by an allergic reaction. Initially, the mother may present with symptoms such as restlessness, chills, nausea, vomiting, dyspnea, etc.; followed by coughing, difficulty breathing, cyanosis, moist rales at the base of the lung, increased heart rate, pale complexion, cold extremities, and decreased blood pressure.

　　2. Bleeding caused by DIC (Disseminated Intravascular Coagulation) After patients pass the first stage, they may develop uncontrollable widespread bleeding, with a large amount of vaginal bleeding, incision leakage, hemorrhage of the skin and mucous membranes, hematuria, and even massive hemorrhage in the gastrointestinal tract. The mother may die of hemorrhagic shock.

　　3. Acute renal failure Patients with amniotic fluid embolism in the late stage may present with oliguria or anuria and symptoms of uremia. This is mainly due to renal ischemia caused by circulatory failure and thrombosis in the early stage of disseminated intravascular coagulation (DIC) blocking the small renal blood vessels, leading to renal ischemia and hypoxia, causing organic damage to the kidneys.

　　The preventive methods for the main complications during the period of delivery are as follows:

　　One: Prevention of postpartum hemorrhage

　　1. Do a good job of pre-pregnancy and antenatal health care, start prenatal examination and monitoring in the early stage of pregnancy, and terminate pregnancy in a timely manner for those who are not suitable for pregnancy.

　　2. Prepare for early treatment for mothers with a high risk of postpartum hemorrhage. This type of mother includes: ① Women with multiple pregnancies, multiple deliveries, and those with multiple uterine cavity surgeries; ② Elderly primiparas or young primigravidas; ③ Women with a history of myomectomy; ④ Underdeveloped or malformed reproductive organs; ⑤ Pregnancy-induced hypertension; ⑥ Concurrent diabetes, hemopathy, etc.; ⑦ Uterine atony leading to prolonged labor; ⑧ Assisted delivery using instruments such as vacuum extraction and forceps, especially when combined with uterotonics, more attention is needed; ⑨ Stillbirth, etc.

　　3. Closely observe the condition of the mother during the first stage of labor, pay attention to the supplementation of water and nutrition, avoid excessive fatigue of the mother, and can consider intramuscular injection of Demerol if necessary to give the mother a chance to rest.

　　4. Pay attention to the management of the second stage of labor, guide the mother to use abdominal pressure appropriately and correctly. For those who may develop postpartum hemorrhage, it is necessary to arrange a physician with high professional level to be on standby. For those with indications, perform perineal midcut or perineal median incision at an appropriate time and degree. The operation of delivery technique should be standardized, correctly guide the head, shoulders, and head of the fetus to be delivered smoothly. For those with uterine atony, after the shoulders of the fetus are delivered, inject 10U oxytocin intramuscularly, followed by intravenous infusion of oxytocin to enhance uterine contraction and reduce bleeding.

　　5. Properly handle the third stage of labor, accurately collect and measure the amount of postpartum hemorrhage, after the natural detachment of the placenta appears, gently press the lower segment of the uterus and gently pull the umbilical cord to help the placenta and amniotic membrane be completely discharged, and carefully check the placenta and amniotic membrane for integrity, check for lacerations or hematoma in the soft birth canal, check the uterine contraction condition, and massage the uterus to promote uterine contraction.

　　6. After the placenta is delivered, the mother should stay in the delivery room for observation for 2 hours, because about 80% of postpartum hemorrhage occurs within 2 hours after delivery, so close observation should be focused on, closely observe the general condition, vital signs, vaginal bleeding, and uterine contractions, but also cannot ignore the bleeding after 12 hours, attention should be paid to inform the mother of the precautions, medical staff should regularly patrol, and problems should be handled early.

　　7. For those with excessive bleeding but without signs of shock, early blood volume replacement is necessary, which is much better than replacing the same amount of blood after shock occurs.

　　8. Early breastfeeding can stimulate uterine contractions and reduce vaginal bleeding.

　　II. Prevention of amniotic fluid embolism

　　If the following items are paid attention to, it is beneficial for the prevention of amniotic fluid embolism.

　　1. Prohibit artificial amniotomy, and artificial amniotomy by needle puncture during the intercontraction period.

　　2. Avoid hypertonic uterine contractions

　　(1) Avoid the irregular operation of pressing the fundus to force the fetus out.

　　(2) Strictly control the indications for oxytocin induction, medication should start with a small dose (2mU/min),专人监护，专用记录，according to uterine contractions, fetal condition, cervical dilation, and maternal pelvis relationship, adjust the concentration of medication, maximum dose

　　(3) Small dose misoprostol (25-50μg) to promote cervical ripening and planned delivery, if necessary, repeat 1-2 times every 6 hours, and closely monitor the labor process.

　　3. Master the indications for vaginal assistance, standardized operation, if bleeding, blood does not coagulate, difficult to control, it should be vigilant for amniotic fluid embolism.

　　4. If uterine contractions are too strong after labor or membrane rupture, and obstructive dystocia is excluded, and it is estimated that delivery cannot be completed in a short time, pethidine can be injected intramuscularly, or magnesium sulfate can be administered by点滴 to weaken the strength of uterine contractions.

　　5. Strictly control the indications for cesarean section, standardized operation, gentle, and after incising the uterus, the amniotic fluid should be aspirated first and then the placenta should be delivered. If there is a large blood sinus exposed, it should be clamped and closed.

　　6. During the second-trimester cesarean section, it should be broken first, the amniotic fluid should be drained, and then the amniotomy should be performed.

　　7. For situations such as stillbirth and early placental abruption, close observation should be made.

　　8. Avoid injuries during delivery, uterine rupture, cervical laceration, etc.

　　Doctors can master the basic conditions of pregnant women, fetal conditions, and timely diagnosis of complications through the following examination items.

　　I. General examination

　　1. Oral examination: Current research shows a close correlation between periodontitis and infectious preterm delivery, therefore, the maintenance of oral health during pregnancy is very important, of course, it is very important to treat oral diseases thoroughly before planning pregnancy.

　　2. Auscultation of the heart and lungs: Understanding the presence of heart murmurs and lung base lesions, especially for pregnant women with a history of heart and lung diseases, the burden during pregnancy is significantly increased, and further assessment of cardiovascular function is required.

　　3, Edema of the lower limbs: Normal pregnant women often have edema below the knees, which subsides after rest. If it does not disappear and is accompanied by excessive weight gain, one should be vigilant about the occurrence of pregnancy-induced hypertension.

　　Second, obstetric examination

　　1, Measurement of fundal height and abdominal circumference: Fundal height refers to the distance from the superior margin of the pubic symphysis to the bottom of the uterus. When the fundal height exceeds the normal gestational age range, it is necessary to consider whether it is a twin pregnancy, macrosomia, or polyhydramnios, especially in cases of fetal malformation causing abnormal increase in amniotic fluid volume. A small abdomen needs to be checked for the possibility of intrauterine growth restriction or fetal malformation.

　　2, Fetal heart sound auscultation: Fetal heart sounds are often clearer when auscultated on the fetal back side. For those with sensitive uterine wall or obesity and other factors that make fetal position assessment difficult, it can be helpful.

　　3, Vaginal and cervical examination: Vaginal examination is often performed during the early pregnancy period from 6 to 8 weeks, and attention should be paid to routine cervical cytological examination for pregnant women without pre-pregnancy examination to exclude cervical lesions. If there are abnormalities in cervical cytology, a colposcopy should be performed accordingly. In the late pregnancy period, pelvic measurement should be performed at the same time as vaginal examination, and the most important diameter in pelvic measurement is the intertrochanteric diameter, that is, the transverse diameter of the pelvic outlet plane. If the outlet plane is normal, vaginal trial delivery can be chosen.

　　Pregnant and postpartum women's diet should be rich in sugar, protein, vitamins, and easy to digest. They can choose a variety of foods according to their own preferences, such as cakes, soup, porridge, meat porridge, lotus root starch, snacks, milk, fruit juice, apples, watermelons, etc. Eat 4-5 times a day, and eat less and more often.

　　1, Chocolate is a 'labor assistant'

　　Currently, many nutritionists and doctors advocate for chocolate, believing that it can act as a 'labor assistant'. Reasons: First, because chocolate is rich in nutrition, containing a large amount of high-quality carbohydrates, and can be digested, absorbed, and utilized by the human body in a short time, producing a large amount of heat energy for the body to consume; secondly, due to its small size, high heat, and sweet taste, it is very convenient to eat. Therefore, eating a few pieces of chocolate during labor can be expected to shorten the labor process and have an easy delivery.

　　2, Only after 5 days of childbirth can chicken soup be drunk

　　After childbirth, the body is weak, the gastrointestinal function has not been fully restored, and a large amount of water is lost during the childbirth process. Therefore, on the first day after childbirth, one should eat liquid food and drink more high-calorie drinks, such as brown sugar water, red bean soup, lotus root starch, almond tea, etc. On the second day, one can eat some soft semi-liquid food, such as water eggs, soft eggs, etc.

　　It is particularly important to note that many people believe that postpartum, one should drink old hen soup immediately, which is both nutritious and beneficial for physical recovery. In fact, this is a big misconception. Because old hens contain a lot of estrogen, drinking it will reduce the production of prolactin, which in turn affects milk secretion. Therefore, old hen soup should not be drunk early, but should be started after 5 days of childbirth. In addition, one can also drink more crucian carp soup, pork rib soup, beef soup, pork trotter soup, etc., and eat more lean meat, eggs, milk, pork liver, pork kidney, soy products, fresh vegetables and fruits every day, which is conducive to body recovery and milk secretion.

　　The treatment methods for main delivery complications are as follows:

　　First, the treatment methods of amniotic fluid embolism

　　The key to the successful rescue of amniotic fluid embolism lies in early diagnosis, early treatment, early use of heparin, and early treatment of pregnancy uterus. It can be summarized into the following aspects.

　　1. Correction of hypoxia: Oxygen mask supply, in case of severe cyanosis, tracheal intubation and positive pressure oxygen supply should be guaranteed to ensure effective oxygen supply. If conditions permit, artificial respirator can be used, oxygen supply can reduce pulmonary edema, improve brain hypoxia and other tissue hypoxia.

　　2. Correction of pulmonary artery hypertension: Oxygen supply can only solve alveolar oxygen pressure, but not pulmonary blood flow hypoperfusion. It is necessary to relieve pulmonary artery hypertension as soon as possible to fundamentally improve hypoxia, prevent acute right heart failure, peripheral circulation failure, and acute respiratory failure. Commonly used drugs include the following:

　　(1) Aminophylline: It has the effects of relieving pulmonary vascular spasm, dilating coronary arteries, and diuresis, as well as relieving bronchial smooth muscle spasm. The dose is 0.25 to 0.5 g added to 20 ml of 10% to 25% glucose solution, intravenous injection.

　　(2) Papaverine: It has a dilating effect on coronary vessels and pulmonary and cerebral vessels, and is an ideal drug for relieving pulmonary artery hypertension. The dose is 30 to 60 mg added to 20 ml of 25% glucose solution, intravenous injection.

　　(3) Atropine: To relieve pulmonary vascular spasm, it can also inhibit the secretory function of the bronchus, and improve microcirculation. The dose is 0.5 to 1 mg, intravenous injection, once every 10 to 15 minutes until symptoms improve.

　　(4) Phentolamine: To relieve pulmonary vascular spasm, the dose is 20 mg added to 250 ml of 10% glucose solution, intravenous infusion, at a rate of 10 drops/min, adjust the concentration or add dosage according to symptoms and blood pressure changes.

　　(5) Dopamine: 20 to 40 mg added to 100 to 200 ml of glucose solution, infused slowly.

　　3. Antiallergic:

　　(1) Hydrocortisone, 500 to 1000 mg intravenous injection, repeat every 6 hours.

　　(2) Dexamethasone, 20 to 40 mg intravenous infusion, repeat administration as appropriate.

　　4. Antishock: The shock caused by amniotic fluid embolism is relatively complex, related to various factors such as allergy, pulmonary, cardiac, and DIC. Therefore, comprehensive consideration must be given during treatment.

　　(1) Blood volume expansion: There is always an insufficient effective blood volume during shock, and it should be expanded as soon as possible, but improper use is prone to induce heart failure. Those with conditions are best to use pulmonary artery floatation catheter, measure pulmonary capillary wedge pressure (PCWP), and supplement blood volume while monitoring cardiac load. If there is no condition to measure PCWP, the central venous pressure can guide fluid infusion. Regardless of which monitoring method is used, 5 ml of blood should be drawn at the same time as the catheter insertion, and a blood sedimentation test should be performed, smears stained to find amniotic fluid components, and relevant DIC laboratory tests should be conducted. The choice of fluid for expansion, initially, dextran-40 is often used.

　　500 to 1000 ml, intravenous infusion, those with bleeding should supplement fresh blood and balanced solution.

　　13) Correcting acidosis: The initial dose can be 100 to 200ml of 5% sodium bicarbonate, or calculated according to the formula: sodium bicarbonate (g) = (55 - measured CO2CP) × 0.026 × body weight. Half to two-thirds of the calculated amount should be injected first. It is best to perform arterial blood gas and acid-base testing and administer medication according to the imbalance.

　　12) Adjusting vascular tone: For those with acute and severe shock symptoms or those with unstable blood pressure despite adequate blood volume replacement, vasoactive drugs can be selected. Dopamine 20 to 40mg is commonly used, added to 500ml of glucose solution, and administered intravenously to ensure blood supply to vital organs.

　　11. DIC treatment: Once the diagnosis of amniotic fluid embolism is established, anticoagulant therapy should be started as soon as possible to inhibit intravascular coagulation and protect renal function. The initial dose of heparin is 1mg/kg (about 50mg), added to 100ml of normal saline, and administered intravenously over 1 hour. The thrombin time test can be used for monitoring to determine whether to repeat the medication. Maintaining the coagulation time at about 20 minutes is desirable. Amniotic fluid embolism can occur before, during, or after delivery. It is necessary to be vigilant for severe postpartum hemorrhage. The safest measure is to transfuse fresh blood on the basis of heparin administration, and supplement fibrinogen, platelet suspension, and fresh frozen plasma, etc., to supplement coagulation factors and stop postpartum hemorrhage.

　　10. Prevention of cardio-renal failure: If the heart rate is increased (≥120 times/min), 0.4mg of digitoxin (cedilanidine) should be added to 20ml of 25% glucose solution and injected intravenously. According to the condition, 0.2 to 0.4mg should be injected again 2 to 4 hours later. Urine output is less (

　　9. Prevention of infection: Use large doses of broad-spectrum antibiotics and avoid drugs with nephrotoxicity.

　　8. Obstetric management: After the respiratory and circulatory function of the mother is improved after treatment, timely removal of the cause is the key to successful obstetric management and rescue.

　　7) If it is not possible to deliver vaginally, an immediate cesarean section should be performed to end the delivery.

　　6) If the disease occurs during the second stage of labor or shortly thereafter, the cervix is fully dilated, and if there is a condition for vaginal delivery, the birth should be assisted by forceps.

　　5) If there is not much postpartum hemorrhage, conservative treatment can be used to preserve the uterus. If the hemorrhage is severe and difficult to control, the uterus should be removed in a timely manner to eliminate the focus and save the life.

　　4) For patients without children or those with stillbirths in the uterus, comprehensive treatment should be carried out actively, and after the condition is stable, an experienced physician should perform a cesarean section through the vagina to perform an abortive operation (such as craniotomy).

　　3. In summary, once the symptoms of amniotic fluid embolism occur, every second counts, and immediate rescue should be carried out. The focus is on hypoxemia and respiratory and circulatory failure caused by allergic reactions to pulmonary artery hypertension, and the prevention of secondary DIC and renal failure.

　　2. Treatment methods for postpartum hemorrhage

　　1. Coagulation dysfunction: If it occurs in the early stage of pregnancy, induced abortion should be performed as soon as possible under the collaboration of a physician in the department of internal medicine to terminate pregnancy. For those discovered in the middle and late stages of pregnancy, active treatment should be carried out in collaboration with a physician in the department of internal medicine to remove the cause of the disease or significantly improve the condition. During labor, treatment for the cause should be carried out at the same time, and treatment should be given as soon as there is slight bleeding, using drugs to improve the coagulation mechanism, transfusing fresh blood, and actively preparing for anti-shock and acidosis correction and other rescue work.

　　In the treatment of postpartum hemorrhage, while stopping the bleeding, it is necessary to actively treat hemorrhagic shock and strive to improve the patient's condition as soon as possible. Antibiotics should be used to control infection.

　　2. Placental factors: The key to treatment is early diagnosis and prompt removal of this factor. Partially detached placentas, retained placentas, and adherent placentas can all be manually stripped and removed. For those with some residual parts that cannot be removed by hand, a large spoon can be used to scrape off the residual material. If it is difficult to distinguish the attachment boundary when manually stripping the placenta, it is strictly forbidden to use fingers to separate the placenta with force, as it is very likely that the placenta is implanted. In this case, the uterus should be incised and examined by laparotomy, and if diagnosed, it is advisable to perform subtotal hysterectomy. For placenta impaction above the uterine narrow ring, ether anesthesia should be used, and the placenta can be removed by hand after the uterine narrow ring is relaxed.

　　3. Laceration of the soft birth canal: The effective measure for hemostasis is to repair and suture in a timely and accurate manner. Generally, severe cervical lacerations can extend to the fornix and even into adjacent tissues. Those suspected of having cervical lacerations should expose the cervix under disinfection, use two oval forceps side by side to clasp the anterior lip of the cervix and pull it towards the vaginal orifice, moving the oval forceps in a clockwise direction step by step, observing the condition of the cervix directly. If lacerations are found, they should be sutured with catgut, starting the first stitch slightly above the top of the laceration, and the last stitch should stop 0.5cm from the lateral end of the cervix. If the suture reaches the outer edge, it may lead to stenosis of the cervical orifice in the future. The suture of vaginal lacerations should pay attention to suture to the bottom to avoid leaving dead space, and pay attention to achieving good tissue approximation and hemostasis after suture. The process of vaginal suture should avoid the suture thread passing through the rectum, and the suture taken perpendicular to the direction of blood vessels can be more effective in hemostasis. The perineal laceration can be sutured according to the anatomical location, suture the muscular layer and submucosal layer, and finally suture the vaginal mucosa and perineal skin.

　　4. Uterine Inertia: Strengthening uterine contractions is the fastest and most effective hemostatic method for treating uterine inertia. The midwife quickly places one hand at the bottom of the uterus, with the thumb on the anterior wall and the other four fingers on the posterior wall, performing uniform massage on the uterine bottom. After massage, the uterus begins to contract. It is also possible to place one fist at the anterior fornix of the vagina, pressing against the anterior wall of the uterus, while the other hand presses on the posterior wall of the uterus from the abdominal wall, causing the uterus to flex forward. Both hands press on the uterus tightly and perform massage. If necessary, place the other hand at the superior margin of the pubic symphysis, pressing on the midline of the lower abdomen, pushing the uterus upwards. Emphasize using the hand to hold the uterine body, so that it is higher than the pelvic cavity, and perform rhythmic and gentle massage. The pressing time should be until the uterus returns to normal contraction and can maintain the contraction state, so that it is higher than the pelvic cavity, with rhythmic and gentle massage. The pressing time should be until the uterus returns to normal contraction and can protect the contraction state. While massaging, 10U of oxytocin can be injected intramuscularly or slowly injected intravenously (mixed with 20ml of 10% to 25% glucose solution), followed by intramuscular or intravenous injection of ergometrine 0.2mg (for those with heart disease), and then 10 to 30U of oxytocin is added to 500ml of 10% glucose solution for intravenous infusion to maintain the uterus in a good state of contraction. Through such treatment, it can usually cause uterine contraction and stop bleeding quickly. If it still does not work, the following measures can be taken:

　　(1) Filling the Uterine Cavity: In modern obstetrics, it is rare to use gauze strips to fill the uterine cavity for the treatment of uterine hemorrhage. If this operation is necessary, it should be done as soon as possible, and if the patient's condition is poor, the effect is often not good, mainly because the uterine muscle may have very poor contraction. The method is to fix the fundus of the uterus with one hand in the abdomen, and use the other hand or a round clamp to insert a 2cm wide gauze strip into the uterine cavity. The gauze strip must be filled from the fundus, from the inside to the outside, and should be filled tightly. After filling, there is generally no more bleeding. After the patient has been treated for shock, the condition can gradually improve. If it is possible to use gauze wrapped with non-fat cotton to make an intestinal-shaped substitute for the gauze strip, the effect is better. The gauze strip should be slowly withdrawn after 24 hours, and oxytocin, ergometrine, and other uterine contraction agents should be injected intramuscularly before withdrawal. After filling the uterine cavity with gauze strips, the general condition and vital signs such as blood pressure and pulse should be closely observed, and attention should be paid to the changes in the height of the fundus and the size of the uterus. Be vigilant about the false appearance of hemostasis due to loose filling, where the gauze strip is only filled in the lower segment of the uterus, and there is continued bleeding in the uterine cavity, but no bleeding is seen in the vagina.

　　(2) Ligation of the Uterine Artery: If the massage fails or if the uterus cannot be contracted after 30 minutes of massage, the ligation method of the superior uterine artery on both sides through the vagina can be performed. After disinfection, use two long mouse teeth forceps to clasp the anterior and posterior lips of the cervix, gently pull downward, suture the bilateral walls at the upper end of the cervix in the vagina with 2号线 silk, about 0.5cm deep into the tissue. If ineffective, the abdomen should be opened quickly, and the superior uterine artery should be ligated, that is, at the level of the internal os of the cervix, 1cm from the lateral wall of the cervix, the ureter should be palpated without puncturing, and the lateral wall of the cervix should be ligated, entering the cervix tissue about 1cm, and the same treatment should be given on both sides. If uterine contraction is seen, it is effective.

　　(3) Ligation of the Internal Iliac Artery: If the above treatment is still ineffective, the origins of the bilateral internal iliac arteries can be separated, ligated with 7号线, and after ligation, the uterine contraction is generally good. This measure can preserve the uterus, preserve fertility, and is easy to perform during cesarean section.

　　(4) Hysterectomy: If the ligation of blood vessels or the filling of the uterine cavity is still ineffective, an immediate subtotal hysterectomy should be performed, and there should be no hesitation to miss the opportunity for rescue.

　　5. Genital Tract Infections: Postpartum hemorrhage can cause anemia and low resistance in women, and with the increased opportunity for intrauterine manipulation, the probability of postpartum infection increases. Therefore, it is advisable to use broad-spectrum antibiotics to prevent and treat genital tract infections.