After the baby is delivered, excessive bleeding from the uterus is a major concern.
Ordinarily, the woman loses about 1 pint of blood during and after vaginal delivery. Blood is lost because some blood vessels are opened when the placenta detaches from the uterus. The contractions of the uterus help close these vessels until the vessels can heal. Typically, cesarean delivery results in about twice the blood loss as vaginal delivery, partly because delivery requires an incision in the uterus, and a lot of blood is pumped to the uterus during pregnancy.
Blood loss is considered excessive if one of the following occurs within 24 hours of delivery:
Excessive blood loss usually occurs soon after delivery but may occur as late as 1 month afterward.
The most common cause of excessive bleeding at delivery is
When the uterus does not start contracting after delivery, the blood vessels that were opened when the placenta detached continue to bleed.
Contractions may be impaired in the following situations:
When labor was prolonged, abnormal, or rapid
When a woman has delivered five or more babies
When a muscle-relaxing anesthetic was used during labor and delivery
When the membranes around the fetus are infected (called intra-amniotic infection)
Excessive bleeding can also result when the following occurs:
When the vagina or cervix is torn during delivery
When the cut made during an episiotomy extends too far
When a woman has a bleeding disorder that interferes with clotting
When intra-amniotic infection leads to infection of the uterus (called endometritis)
When a piece of the placenta remains inside the uterus after delivery
Excessive bleeding after one delivery may increase the risk of excessive bleeding after subsequent deliveries.
Fibroids in the uterus may also increase the risk.
The diagnosis of postpartum hemorrhage is based on close observation of the amount of bleeding. The vagina and perineum are examined to check for tears that may need to be repaired. Doctors gently press on the woman's abdomen to feel the uterus and determine whether it is firm. A soft uterus may mean that the uterus is not contracting as it should and blood is collecting inside the uterus.
Monitoring the woman's vital signs, such as blood pressure and heart rate, can help doctors determine whether blood loss is excessive. A drop in blood pressure or a rapid heart rate may indicate excessive bleeding.
Before a woman goes into labor, doctors take steps to prevent or to prepare for excessive bleeding after delivery. For example, they determine whether the woman has any conditions that increase the risk of bleeding (such as too much amniotic fluid or a bleeding disorder). These conditions are treated if possible.
If the woman has an unusual blood type, doctors make sure that her blood type is available.
Delivery should be slow and as gentle as possible. Doctors usually give the woman oxytocin through an intravenous line or inject it into a muscle. Oxytocin helps the uterus contract and helps reduce blood loss.
When the placenta is delivered, doctors check it to determine whether it is complete. If it is incomplete, fragments that remain in the uterus (which can cause bleeding) are removed by hand.
After delivery of the placenta, the woman is monitored for at least 1 hour to make sure that the uterus has contracted and to assess bleeding.
If excessive bleeding occurs, the woman's uterus is massaged by pressing on her abdomen, and she is given oxytocin continuously through an intravenous line. These measures help the uterus contract. The woman is also given fluids intravenously to help restore the amount of fluid in the bloodstream. If bleeding continues, another drug that helps the uterus contract is also given. These drugs can be injected into a muscle, placed as a tablet in the rectum, or, during cesarean delivery, injected into the uterus.
The woman may need a blood transfusion.
Doctors look for the cause of excessive bleeding. The uterus may be examined to see whether any fragments of the placenta remain. Any fragments that remain in the uterus are removed by hand. Rarely, dilation and curettage is needed to remove these fragments. In this procedure, a small, sharp instrument (curet) is passed through the cervix (which is usually still open from the delivery). The curet is used to remove the retained fragments. This procedure requires an anesthetic. The cervix and vagina are examined for tears.
If the uterus cannot be stimulated to contract and bleeding continues, the arteries supplying blood to the uterus may have to be compressed to stop blood flow. Procedures that may be used include the following:
A balloon may be inserted into the uterus and inflated.
Packing may be inserted into the uterus
A doctor may place stitches (sutures) around the bottom of the uterus—a procedure that requires abdominal surgery.
A device that applies gentle suction to the uterus and thus helps the uterus contract may be placed in the uterus.
The procedures used usually do not cause infertility, abnormalities in menstruation, or other lasting problems.
Sometimes the arteries supplying blood to the uterus must be blocked surgically or by inserting material through catheters into the arteries.
Removal of the uterus (hysterectomy) is rarely necessary to stop the bleeding.
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