The key measure for both cases is to determine the cause of bleeding, and start the appropriate overlap. We will review the following issues related to the diagnosis of postpartum haemorrhage and treatment methods.
Reasons:
Causes of PPH after caesarean section as follows:
1 - atony (inaction) of the uterus.
2 - adherent placenta.
3 - implanted placenta.
4 - deep placental implantation.
5 - retained placenta.
6 - an incision in the uterus or extend the tear.
Could be a case of uterine atony isolated or associated with one or more of the causes of previous bleeding.
Injuries occur cervix and vagina, typically after a long labor with the expansion of full or almost full. Can occur these wounds spontaneously during the application of forceps by the surgeon or during the extraction aspiration vacuum extraction, and can also occur during the Caesarean section when you attempt the surgeon remove the baby's head tucked deep in the pelvis. Happen bleeding dangerous as a result of expansion profile which in turn results in excessive pull to remove the fetus through an incision too small.
Assess the diagnosis:
Are routinely remove the placenta after assessing the amount of bleeding and to identify its sources, and as explained above, can be associated with severe bleeding womb of a weak muscle tension and (or) associated with the ruptures and fissures, or focal abnormalities in the muscle of the uterus.
Uterine atony by definition is a situation which does not restore uterine tension after a massage or give the factors that increase the tension of the uterus. Can be verified from the bleeding caused by the expansion of both sides of the incision so easily and preview this part, and similarly we admire uterine cavity in search of remaining fragments of the placenta. Can indicate the difficulty of separation of the placenta adherent to the placenta, even if the placenta was taken out completely.
Bleeding usually occurs in the area of implantation in the lower uterine segment, you may not notice the presence of tears in the cervix and the lower part of the way the reproductive to occur vaginal bleeding after the surgery, which leads us to an immediate examination of the reproductive system through the bottom. We must examine the perineum in the operating room to confirm the presence of vaginal bleeding effectively and if we found vaginal lacerations must be repaired.
Primary treatment:
1 - give blood and fluids for recovery.
2 - We conduct laboratory tests to estimate the volume of blood lost and detect coagulopathy and patterning and Almassalbh with several units of packed red blood cells.
3 - If we confirm the presence of uterine atony or we expected when we massage the bottom of the uterus and the use of medications that increase the tension of the uterine muscle contraction to help him.
4 - Surgical bleeding: You can control bleeding from a wound or incision easily by ligament surgery. We preview the angle of accidental injury to make sure that each container has been linked to shrinking.
Likely to be linked to the ureter located on the same side of bleeding by mistake, so you must specify the ureter by the control of the bleeding, if possible, and after control.
Interactions during the surgery:
There are many procedures useful during the surgery to control with PPH, On the practitioner to use clinical trial to decide whether to spend the time to experience one or more of the interventions on a patient suffering from severe bleeding or that it is best to use the time in the hysterectomy hysterectomy ..
Linked to uterine arteries, uterine and ovarian:
Link has now become a two-sided veins, uterine first action taken when opening the abdomen to control uterine bleeding, preferably linked to internal iliac artery, which makes access to the vascular uterine easier, this procedure is easy technically does not carry any significant risk to adjacent vessels or the uterus.
Is linked to uterine artery procedure, first and foremost if the hemorrhage caused by rupture of the uterus or ovarian artery, although it might reduce the bleeding caused by other reasons. Although this procedure is unable to control bleeding caused by uterine atony or placenta adherens, but it may reduce bleeding, which allows us to apply other measures.
After selecting the ureter we be passed sewing needle with chromic catgut measure 0 # or string several Skarede through the brutal piece of uterine lower as close as possible from the cervix and then back across the broad ligament and a brutal blood vessels, and the goal of this procedure is the pressure on these vessels. If the above does not work to control the bleeding, then we connect uterine ovarian arcade are similarly a century away from the uterus and the ligament be passed through the uterine muscle forget the blood vessels and then back across the broad ligament and a brutal blood vessels and then connect to pressure it.
Showed a two-sided connection of arteries and veins (uterine uterine and ovarian) successful in controlling bleeding in more than 90% of patients. As for complications has been registered cases of necrosis of uterine or the failure of placental Kachtlatat in pregnancies later, however; was registered one case of lack of ovarian development of adhesions iris within the uterine after ligation of the artery uterine and uterine ovarian and ovarian for the management of PPH associated with Bonnie uterus.
Uterine artery internal iliac:
Was used to link the offender to a bilateral iliac arteries of the cavernous (Algeslah arteries) to control uterine bleeding mechanism of blood pressure, reduce the current in the uterine vessels. Facing these technical difficulties, including: the uterus and the large incision and occasional small tub full of blood and the surgeon with little experience in the operations of the space behind the peritoneum in the pelvis, so it was replaced by this technology linking the uterine artery.
Electrode pressure on the uterus:
This method is effective in reducing bleeding on the state of atony of the uterus. Was recorded some complications of this procedure Ktnkr erosion and suppuration of the uterus, but remain rare. Showed limited control of women have undergone this procedure that there are no negative effects on future pregnancies.
The surgeon will determine the place of the pole during the surgery, which requires diligence in it. In general, the use of longitudinal pole is easier and more secure than the transverse pole. But things are not always this way, if the situation continued uterine atony despite the use of medicines, tonic tension of the uterus and, despite the application of electrode pressing, it becomes a hysterectomy is necessary.
Qutb is the B-Lynch technique most common in the intrauterine pressure has been explained several types of them.
Pole B-Lynch:
The cordon and intrauterine pressure and achieve results similar to the pressure of the hand, showed a series of cases recorded that this technique might work in the management of bleeding caused by atony uterus when the failure of other mechanisms, and is described as easy to learn and safe and preserve the possibility of procreation in the future, and keep use restricted to cases of atony the uterus, did not succeed in the management of bleeding due to adherent placenta.
Used needle Mayo needle with chromic catgut measure # 2 where it is entered and removed from the uterine cavity laterally within the segment uterine bottom, is a pole major surgery to avoid their destruction, and the speed of absorption important to avoid herniation of intestine through the bonds of sutures after healing of the uterus.
Is a pole surgery above the bottom of the uterus, and then entered again in the inner lower segment of the uterus through the back wall, and then passed to the opposite side of the lower part of the uterus, to come out through the back wall again and held above the bottom of the uterus to enter back into the front face side of a piece of uterine lower In return for a parallel to the initial occlusion.
Pulls the free ends of the string and carefully linked to the pressure of the uterus, with the help of manual pressure.
This technique is used alone and in association with KD balloon, called this post as "Alsnduwihh uterine uterine sandwish"
Other techniques:
Other techniques are used in some cases and include:
Pole surgical method of B-Lynch suture.
The method is described based on the set 2 to 4 pole operation of the compressed vertical front wall to the back wall of the uterus without hysterectomy hysterotomy.
Pole can be placed Brzachah transverse cervical surgery when needed to control bleeding in the lower segment of the uterus. Another way is through the application of a set of surgical pole longitudinal and transverse yarns made up of several slow absorption without the need to enter the cavity of the uterus, which placed two rows or three rows of the pole in each hand and wrapped so that pressing the uterus completely. Longitudinal pole start and end tied to the pole by the transverse cervical.
When the transverse movement of the pole through the broad ligament should be drawn to the need to avoid damage blood vessels and ureters, fallopian tubes.
Should start with hand pressure on the muscle of the uterus before the surgical application of the pole, in order to facilitate the greatest possible pressure.
Technology is one of the squares and rectangles, the amendments to the surgery.
KD balloon:
Show your father use a technique by balloon Bakritamponade or BT-Cath success in bridging the bleeding from the uterine cavity after vaginal delivery.
For tools, blow the balloon to control bleeding while, but continued heavy bleeding Fidel on the ineffectiveness of this procedure.
Your father is applied in the cesarean delivery balloon during the surgery where the surgeon can see the uterus directly, but the reports that show information about the results of the few overlap.
Hysterectomy:
A last resort, but it is not being late for women who need to control rapid bleeding to save their lives.
Survey after open abdomen:
With the end of the process of opening the abdomen to be a survey of the surgical work area with caution and in search of any area in need of hemostasis, as bleeding from tiny vessels are often controlled through the application of topical agents Almriqih.
Must examine the bladder and determine the status of the ureters, and if there is a possibility of rupture of the bladder can introduce 200 ml of a mixture of solution of saline (salt solution) with 5 ml of tincture Alandago Carmen (indigo carmine) into the bladder through the catheter Foley, where they are to ensure the safety of bladder failure leak serous fluid through the layer of the bladder.
Must assess the state of the ureters in general, before closing the abdomen, either through the optical property of permeability through the broad ligament or direct vision during the dissection area behind the peritoneum. Is directed horizontally through the peritoneum so that is about 1-5 cm from the ovarian vessels, and can be easily detected as it passes abdominally to the forest common iliac artery.
Ureters must be survey to ensure their safety, through the injection Ombolten (10 ml) of tincture Alandago Carmen (indigo carmine) and intravenously, as the torn ureter, Paul will present a blue color within the basin during the 10-15 minutes. If connecting the ureter Cystoscopy or direct view of the ureter through the bladder shows a couple of the passage of urine through an opening only one of the two openings of the ureters, and can pass the network to locate the ureteral obstruction.
Measures to gain time:
Aortic pressure:
Can bleeding severe that threatens to drain rapidly over several minutes, so must the surgeon that the feeling the aorta at a higher level of the eaves of sacral few centimeters and then clicking near the branching, which leads to reduce the size of the bleeding and gives a better chance to find the source of bleeding and control it.
Treatment rescuer blood transfusion during the surgery:
Through the liquidation of white blood cells and self-transport of blood, which is an additional option, and that there is a theoretical concern about leaking amniotic fluid and cause stigma Omenyusah, but this method is still under study did not take place only once.
Pelvic filling:
May enter the patient infected with severe and persistent bleeding in the fatal downward spiral characterized by low temperature, coagulopathy, and metabolic acidosis.
Criteria for the diagnosis of this deadly situation include: PH less than 7.30 and temperatures below 35 degrees Celsius and the total time refresher procedural more than 90 minutes with a mechanical bleeding and the need to transport more than 10 units of packed red blood cells.
To stop this sequence is filling the area well and cover the bandage with the wound left open, then transported the patient to the intensive care unit for follow-up surveillance, and appropriate blood product replacement and correction of physiological imbalance. This is useful to stop the spiral overlap and reduce the risk of abdominal syndrome spaces.
Difficult to determine the syndrome spaces abdomen after birth because the pressure inside the abdomen after a Caesarean section is usually higher than the pressure in the cases of surgeries and other public, especially when women with a rise in the value of body mass index, or suffer from disorders lead to high blood pressure.
Is the use of a sufficient amount of gauze to bind the two ends together to encapsulate the basin is well Odk the bleeding, but the rest of the free end of a piece of gauze will be accessible outside the body (in a letter Z) through the main wound. Closing of the peritoneum and the muscles and fascia in the traditional way but with a prominent piece of gauze from the end of the wound. Leave a layer of the skin and under skin Admdan wide open, and more gauze.
There are different ways and few surgeons in the practice of this procedure, one of these ways is to fill a sterile plastic bag (Kalgueta which is used in the packaging of X-ray films) or gauze cloth, and set it against the patient pool. This cover is paid through the vagina and provides links so that the weight of the power to drag in the application of pressure according to self on the floor of the pelvis.
The need for the transfer of two or more units of red blood cells stacked in time for a period of 3 hours is considered an important sign of a bleeding effectively requires overlap surgical fast or embolization arterial arterial embolization using a doctor-rays, or returned to the patient to the operating room to be subject to the attention of surgical critical period of 48 hours.
Open wound under general anesthesia and still gauze gently withdrawn, so allow time to correct Alkhthrey morbidity. Tells the tub to clean saline solution free clots and other waste is not being any violent survey of the basin in case of not noticing any blood clots. Then assess the situation of the wound in the traditional way.
Effective recombinant factor VII (rFVIIa):
Has been approved by the Food and Drug Administration to treat people who suffer from bleeding as a result of injury Bnaaour A and B inhibitor and inhibitor syndrome, and want congenital factor VII, was also used successfully without the consent in order to control the bleeding in the other cases Kalnsv Almand associated with a lack of tonic uterine after birth, or adherent placenta or rupture of the uterus, and it seems this type of treatment is promising in the case of failure of traditional treatment.
Using doses of 16.7 - 120 mg as a single dose is injected rapidly in a few minutes every two hours until the access to the state of slaves and are often control the bleeding during 10-40 minutes after the first dose.
However, the appropriate dose of rFVIIa may vary greatly, depending on the levels of clotting factors in the other. For example, there hemorrhage persists despite giving rFVIIa for hemorrhage following for PPH treatment failure was due to the low level of fibrinogen (less than 60 mg / dL). Where it is proposed that the treatment is full of traditional blood components before starting to rFVIIa.
Medicine is expensive (about $ 1 per 1 mg), and it may raise the risk of thromboembolism, so should be used in cases of bleeding and morbidity Alkhthrey Almand.
Uterine bleeding after surgery:
And can not be appreciated before closing the abdomen or the transfer of the patient outside the operating room, pretending to have a copious vaginal bleeding or hypotension and speed up the heart and / or the product of a low-poly due to decrease. Hypovolemia blood volume
In case of heavy vaginal bleeding; must examine the cervix and vagina and repair tears enough. Diagnosed uterine atony in the event of the uterus was boggy.
The primary treatment for uterine atony after cesarean delivery are similar to those conducted after vaginal delivery include the following:
1 - Massage the bottom of the uterus to increase Gulwsath.
2 - give the drugs increase the uterine muscle tension.
3 - fluids for recovery.
4 - We conduct laboratory tests to estimate the volume of blood lost and detect coagulopathy and patterning and Almassalbh with several units of packed red blood cells.
If heavy bleeding continues, the uterine artery embolization is a good option for patients who have settlements served and can be maintained to have the case of volumetric appropriate pending the completion of this procedure (about two hours).
The bleeding 24 hours after the situation is called postpartum bleeding secondary secondary PPH.
Conclusion and recommendations:
Include primary treatment of postpartum hemorrhage after Caesarean section, the following:
Massage the bottom of the uterus and give medicines to tonic muscle tension for the management of uterine atony of the uterus, fluids for resuscitation, laboratory tests to estimate the volume of blood loss and morbidity Alkhthrey, and the investigation of uterine ruptures, cracks and restoration. Adherent placenta abnormalities require additional interventions.
If these measures had not controlled the bleeding; the first surgical step suggests linking the uterine artery.
If you do not control the bleeding caused by uterine atony uterine artery linking; proposes the use of electrode pressure on the uterus.
Hysterectomy is the last resort, but it is not being late for women who need to control rapid bleeding to save their lives.
May enter the patient infected with severe and persistent bleeding in the fatal downward spiral characterized by low temperature, coagulopathy, and metabolic acidosis.
To stop this sequence is filling the area well and cover the bandage with the wound left open, then transported the patient to the intensive care unit for follow-up surveillance, and appropriate blood product replacement and correction of physiological imbalance.
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