Update: October 2018
Uterine bleeding after childbirth – such a “term” puerperal
call any bleeding from the genital tract after
completion of labor. And many of the women who gave birth start to panic,
not knowing how much bleeding after delivery should last, what
its intensity and how to distinguish the rate from the pathology.
In order to avoid such situations, an obstetrician on the eve of discharge from
Maternity Hospital conducts a conversation with a woman, explaining all the features
postpartum period, its duration and assigns attendance to
женскую консультацию (как правило, через 10 дher).
Features of the postpartum period
How long after birth the so-called bleeding lasts, i.e.
AT норме интенсивные кровянистые выделения продолжаются
не более 2 – 3 дней. This is a natural process and
such discharge is called lochia.
As you know, after the birth of the fetus there is a separation or
roughly speaking, the separation of the children’s place (placenta) from the inner
оболочки uterus. At the same time, a sufficiently large wound is formed.
a surface that takes time to heal. Lochia is not
which is a wound secret, which is represented by a discharge from
AT первые сутки после родоразрешения лохии состоят из крови и
pieces of decidual shell. Then, as the uterus contracts and
returning it to the normal “pre-pregnant” size to the secret
blood plasma and tissue fluid join the discharge, and
also particles of the decidual shell that continue to fall off,
mucus with leukocytes. Therefore, a couple of days after discharge
become blood-serous, and then serous. Color them too
varies, from bright red to brown, and at the end yellowish.
Along with the coloring of the secretions, their intensity also changes.
(decrease). The process of discharge ends by 5-6 weeks. AT
If the discharge is delayed, or becomes bloody and
more intense, should consult a doctor.
Ofменения матки и шейки
The cervix and the uterus itself also undergo a stage of change. AT послеродовом
a period that, on average, lasts about 6 to 8 weeks, i.e.
up to 42 days, the uterus is reduced (reduced) in size, and its
�”Internal wound” heals. In addition, the neck is formed
The most pronounced phase of the reverse
development or involution of the uterus occurs in the first 14 days after
childbirth. By the end of the first postpartum day, the bottom of the uterus is palpable on
navel location, and then, subject to its normal contraction of the uterus
every day drops 2 cm or 1 transverse finger.
As the height of the uterus floor decreases, other
masterbatch sizes. The uterus becomes flatter and narrower in
across. About 10 days after delivery the bottom of the uterus
descends beyond the pubic bones and is no longer palpable through
anterior abdominal wall. When conducting a gynecological examination
You can determine the uterus in size from 9 to 10 weeks of pregnancy.
Параллельно формируется и шейка uterus. Gradually tapering
cervical canal. After 3 days, we pass for 1 finger. At first
there is a closure of the internal pharynx, and after – external.
Completely internal shed closes to 10 days, while outer to
16 – 20 days.
What is called postpartum bleeding?
Postpartum hemorrhages include intense blood loss.
up to 0.5% and more of the puerperal body mass and are directly related to
- If bleeding after birth has occurred after 2 hours or more (in
the next 42 days), it is called late.
- If intense blood loss is recorded immediately after delivery
or within two hours, it is called early.
Postpartum bleeding is considered a formidable obstetric.
complication, and can lead to the death of the puerperal.
Тяжесть кровотечения устанавливается по объему blood loss. Have
a healthy parturient woman the estimated amount of blood loss in childbirth is not
more than 0.5% of body weight, whereas with preeclampsia, anemia or
coagulopathy, it is reduced to 0.3%. If in the early postpartum
period, the woman lost more blood than expected, then
talking about early postpartum bleeding that requires taking
immediate action, sometimes up to surgery.
Causes of postpartum hemorrhage
Causes of heavy bleeding, both in early and late
The postpartum period is varied:
Atonia or hypotonia of the uterus
This is one of the leading factors that contributes to
bleeding. Hypotonia of the uterus is called its state, with
which reduced both the tone and its contractility. With
atony of the uterus, the tone and contractile activity are sharply reduced or
completely absent, and the uterus is in “paralyzed”
condition. Atonia, fortunately, is extremely rare, but dangerous
massive, not amenable to conservative treatment, bleeding.
Bleeding, связанное с нарушенным тонусом матки, развивается в
early postpartum period. Decrease and loss of uterine tone
contributes to one of these factors:
- excessive overstretching of the uterus that observed at
polyhydramnios, multiple fetuses or large fruit;
- marked fatigue of muscle fibers, aided by
prolonged labor, irrational use of reducing, rapid
either quick delivery;
- loss of myometrium ability to normally reduce when it
cicatricial, inflammatory or degenerative changes.
The following factors predispose to the development of hypo or atony:
- young age;
- pathological conditions of the uterus:
- myomatous nodes;
- postoperative uterus;
- structural dystrophic changes (inflammation, large
number of births);
- overstretching of the uterus during gestation (polyhydramnios,
- pregnancy complications;
- anomalies of generic forces;
- abnormalities of the placenta (presentation or detachment);
- gestosis, chronic extragenital diseases;
- DIC syndrome of any origin (hemorrhagic shock,
anaphylactic shock, amniotic fluid embolism.
Violation of the placenta
After a period of exile the fetus comes third or successive
the period of labor during which the placenta is separated from the uterine
wall and stands out. As soon as the placenta was born,
the early postpartum period begins (remember that it continues
2 hours). This period most requires attention, as the puerperal
and medical staff. After the birth of the placenta, it is examined on the subject.
integrity, if any lobule remains in the uterus, it can
provoke massive blood loss is usually similar
bleeding begins one month after delivery, amid complete
health of the woman.
Withмер из практики: ATызвали меня ночью в
surgery, a young woman was admitted with a monthly baby who
got sick. While the child was operated, the woman opened
bleeding, and so intense that the nurses on duty themselves,
without a doctor (the surgeon was on surgery), called a gynecologist. Of
Conversation with the patient, I found out that the birth happened a month ago,
and during that time her discharge was normal,
corresponded to the postpartum period, and she felt good.
At the reception in the antenatal clinic was, as expected, after 10
days and a month later, and (in the patient’s opinion) I was nervous about
child, here and there was a heavy bleeding. When gynecological
examination: the uterus is soft, increased to 9 – 10 weeks of pregnancy,
sensitive to palpation. Appendages without features. Of
cervical canal, freeing one finger, abundant
spotting with pieces of placental tissue. Woman
I had to quickly scrape, during the procedure was removed
lobule afterbirth. After scraping the uterus, the patient received
infusion therapy, antibiotics and iron preparations (in the blood,
naturally, significantly reduced hemoglobin). Written in
What I want to mention. Unfortunately, such bleeding,
which suddenly begin a month later and more after giving birth, do not
rarity. Of course, to blame the doctor who took delivery. Looked
that the placenta lacks lobules, or maybe it was
additional lobule (separate from the placenta), and did not take
appropriate measures (manual control of the uterus). But how
obstetricians say: “There is no such placenta that cannot be folded.” Thats
there is, the absence of a lobule, especially the extension, is easy to overlook, but
the doctor is a man, not an x-ray. In good maternity hospitals at discharge
the puerperal woman performs a mandatory ultrasound of the uterus, but, as it is not sad,
not everywhere ultrasonic apparatus is available. And bleeding sooner or later
this patient would still start, only in a similar situation
he was spurred on by severe stress.
Trauma to the birth canal
Far from the last role in the occurrence of postpartum
bleeding (usually in the first 2 hours) plays obstetric
injury In case of heavy bleeding from
genital tract obstetrician, first of all, should exclude
damage to the birth canal. Impaired integrity may be at:
Sometimes cervical tears are found so much
long (3-4 degrees) that go to the vaults of the vagina
и нижний сегмент uterus. Breaks can happen like
spontaneously during the expulsion of the fetus (for example, rapid
childbirth), and due to medical manipulations used in
fetal extraction (application of obstetric forceps,
After cesarean section, bleeding may be due
violation of suturing techniques (for example, missed, unstitched
vessel and divergence of stitches on the uterus). In addition, in the postoperative
period it can trigger the appointment of antiplatelet agents
(blood thinners) and anticoagulants (reduce it
Predisposing factors contribute to uterine rupture:
- uterine scars after previous surgical
- scraping and abortion;
- use of intrauterine contraceptives;
- obstetric manipulations (external rotation of the fetus or
- birth stimulation;
- narrow pelvis.
Various blood diseases associated with the violation of her
clotting should also be considered as a factor
the possible bleeding. These include:
- von Willebrand disease;
- hypofibrinogenemia and others.
Also, the development of bleeding and diseases
liver (as it is known, many coagulation factors are synthesized in
Early postpartum hemorrhage, as already noted, is associated with
violation of the tone and contractility of the uterus, so the woman is 2 hours
after childbirth remains under the supervision of medical staff in the birth hall.
Every woman who has just become a mother should remember that in these 2
hours she can not sleep. Heavy bleeding may open
suddenly, and it is likely that next to the puerperal will not be
doctor or midwife. Hypo- and atonic bleeding can
proceed in two ways:
- Bleeding immediately becomes massive, “pouring like a tap.”
At the same time the uterus is very relaxed and flabby, its borders are not
are determined. No effect from external massage, manual control
uterus and reducing drugs. In view of the high risk of development
complications (DIC and hemorrhagic shock) puerperal
- Bleeding is wave-like. The uterus is sometimes
relaxes, then shrinks, so blood is expelled in portions
150 – 300 ml. The positive effect of reducing drugs and
наружного массажа uterus. But at some point the bleeding
increases, and the woman’s condition deteriorates, join
the above complications.
But how to determine the pathology, if the woman is already at home? AT
First of all, it is worth remembering that the total volume of Lochium for the entire period
recovery (6 – 8 weeks) is 0.5 – 1.5 liters. Any
abnormalities indicate pathology and require immediate treatment
to the doctor:
Unpleasant smell of discharge
Purulent and sharp “aroma” of discharge, and even mixed with blood
either bloody after 4 days after delivery indicates
the development of inflammation in the uterus or endometritis. In addition to secretions may
alert the rise in temperature and pain below
The appearance of such secretions, especially after the lochia has become
grayish or yellow, should alert the woman. Bleeding
may be simultaneous, or repeated periodically, in
secretions may be present or absent blood clots.
The blood itself can change color – from bright scarlet to dark. Suffers and
general condition of the mother. Her pulse and breathing quickens, appears
weakness and dizziness, a woman may constantly feel cold.
Similar signs speak about the remains of an afterbirth in a uterus.
If bleeding has started, and is massive enough, it is necessary
urgently call an ambulance. Determine yourself
the intensity of bleeding young mother is not difficult –
A change of several shims per hour is required. To the doctor in like
do not have to be able to go independently, since the risk of loss is high
consciousness on the street.
Termination of discharge
Such an option as the sudden disappearance is not excluded.
discharge, which is also not the norm and requires the provision of
Bleeding после родов длится (в норме) не более 7 дней и
similar to heavy menstruation. If the period of bleeding
dragged on, it should alert the young mother.
After the birth of the afterbirth a number of events are held,
warning of the occurrence of early postpartum
The puerperal remains in the delivery room
Finding a woman in the delivery room for the next 2 hours
End of delivery is necessary to take emergency measures in case
the possible bleeding. AT этот промежуток времени за женщиной
observes the medical staff, who assesses blood pressure and pulse,
skin color and amount of blood secreted. What already
indicated, the permissible blood loss in labor should not exceed
0.5% of the woman’s weight (on average up to 400 ml). AT противном случае
blood loss is regarded as early postpartum hemorrhage, and
measures are being taken to stop it.
Immediately upon completion of labor, urine is removed by a catheter, which is necessary
to empty the filled bladder and prevent it
pressure on the uterus. AT противном случае полный мочевик будет давить
to the uterus, which will prevent it from contracting normally and can
After the birth of a baby, compulsory obstetrician
with the midwife, they examine it and decide on the integrity
placenta, the presence / absence of additional lobules, their separation and
delay in the uterine cavity. AT случае сомнения целостности плаценты
manual examination of the uterus is performed (under general anesthesia). ATо время
examination of the uterus doctor produces:
- eliminates uterine trauma (rupture);
- removes remnants of the placenta, membranes and blood clots;
- conducts a manual (with caution) massage of the uterus on the fist.
Once the placenta was born, intravenously, less intramuscularly
uterine-reducing drugs are introduced (oxytocin, methylergometrine).
These drugs prevent uterine atony and strengthen it.
Inspection of the birth canal
AT недавнем прошлом осмотр родовых ways after childbirth was carried out
only in primiparous women. This is currently a manipulation.
All mothers, regardless of the number of births. AT
the inspection process establishes the integrity of the cervix and
vagina, soft tissue of the perineum and clitoris. Upon detection
ruptures are carried out (under local anesthesia).
Measures in the development of early postpartum hemorrhage
AT случае усиления кровянистых выделений в первые 2 часа после
the end of the delivery (500 ml or more), the doctors conduct the following
- Bladder emptying (если это не было проведено
- ATведение утеротоников внутривенно в повышенной дозировке.
- Холод на низ belly.
- External massage of the uterus
Having established a hand at the bottom of a uterus, carefully squeeze and unclench it
до полного сокращения uterus. The procedure for a woman is not very
pleasant, but quite tolerable.
- Manual massage of the uterus
It is performed as indicated above under general anesthesia. AT матку
a hand is inserted and after examining its walls, the hand is squeezed into a fist.
With the other hand, massage the uterus outside.
- Tamponade of the posterior vaginal fornix
AT задний влагалищный свод вводится тампон, пропитанный эфиром,
что вызывает рефлекторное сокращение uterus.
If all these measures have not had a positive effect,
bleeding increased and reached 1 liter or more, the issue is resolved
about operative intervention. Intravenous is simultaneously administered.
administration of solutions, blood and plasma preparations for replenishment
blood loss. Of операций применяются:
- amputation or extirpation of the uterus (depending on
- ligation of the arteries of the uterus;
- ligation of ovarian arteries;
- ligation of the iliac artery.
Stop Late Postpartum Bleeding
Later postpartum hemorrhage, as already indicated,
arises about the delay of parts of the placenta and membranes, less often
blood clots in the uterine cavity. Assistance scheme
- immediate hospitalization of a woman to the department
- preparation for curettage of the uterus (holding
infusion therapy, the introduction of reducing);
- performing emptying (curettage) of the uterus and removal
residues of the ovum and clots (under anesthesia);
- bladder with ice for 2 hours on the lower abdomen;
- continued infusion therapy, if necessary
- antibiotic prescription;
- prescription of uterotonics, iron preparations and vitamins.
What can a woman do
To prevent bleeding in late
postpartum young mom recommended to follow simple
It is necessary to urinate regularly, avoiding urinary overflow
bladder, especially in the first days after birth. Bye woman
is in the hospital, to go to the toilet every 3 hours, even when
no desire. Houses also do not forget about timely
emptying the bladder.
Baby feeding on demand
Frequent attachment of the baby to the chest not only sets and
reinforces the physical and psychological contact between mom and
baby Nipple irritation causes exogenous excretion.
(native) oxytocin, which stimulates uterine contraction, and
also enhances discharge (emptying the uterus).
Lie on your stomach
AT горизонтальном положении на животе не только способствует
increase uterine contractility, but also the outflow of discharge from it.
Cold on the lower abdomen
If possible, a young mother should put on the lower abdomen
ice pack (preferably up to 4 times per day). Cold stimulates
contractile activity of the uterus and reduces open uterine
vessels on its inner shell.