Hemorrhage of the delivery

The hemorrhage of the delivery is defined by WHO like a Hémorragie of uterine origin, occurring in the 24 hours following the Accouchement, and person in charge of a blood loss estimated at least 500 millilitres. It is a frightening complication of the childbirth which relates to 5% of the women, and is the first cause of maternal death during the pregnancy in France .

Physiopathology

The delivery represents the expulsion of the Placenta out of the Utérus after the childbirth, normally into 15 to 30 minutes. When it is empty, the uterus contracts (it has a muscular layer, made up of smooth muscle fibers: the Myomètre) in order to ensure the Hémostase (the occlusion of the vessels which bleeds after the separation of the placenta) mechanical: the uterine contraction involves the occlusion of the Artère S remained open and makes it possible to dry up the bleeding. In the event of hemorrhage of the delivery, this hémostase mechanical does not occur and involves an abundant bleeding and potentially mortal. This hemorrhage becomes complicated after (intravascular Coagulation disseminated) which is responsible for the bleeding (or which worsens another cause). The physiological delivery must respect 4 points:
  • complete Delivery of the placenta and its membranes
  • Utérus empties
  • satisfactory uterine Rétraction
  • Absence of disorders of coagulation

Causes

Uterine inertia

A dull uterus is a uterus which does not retract well after the childbirth: during the examination of the Abdomen, one finds a large soft uterus instead of a uterine sphere closes, under Ombilic Al the lifelessness involves bad a hémostase mechanical and a prolonged bleeding of the uterine vessels. It is caused by a too prolonged work having exhausted the myometer (or on the contrary a very fast work), a uterine distension during the Grossesse (multiple pregnancy, hydramnios, Macrosomie, bulky Fibrome S under mucous), a high number of pregnancy (multiparity), the advanced maternal age, a recent Tocolyse, a major Anesthésie by halogenous.

Placental retention

The uterus cannot retract if it is not completely empty. It is the case when the natural delivery was not done, or when the delivery is incomplete (presence of fragments of placenta or membranes in the uterus in spite of the delivery). This one is diagnosed by the systematic examination of delivers by the Sage-femme or the obstetrician in the search of a Cotylédon lack or nonjust membranes. With the slightest doubt, one carries out a uterine revision (the hand is plunged in the uterus and explores it completely, under aseptie strict and sometimes general anesthesia).

Disorders of coagulation

They are dominated by coagulation will intra vascular disseminated and the Fibrinolyse. They can involve a hemorrhage of the delivery alone.

Uterine hypertonicity

Cervical and vaginal lesions

Assumption of responsibility and treatment

Treatment of first intention

The hemorrhage of the delivery is a therapeutic urgency, the speed of the installation of an effective cure conditions the vital prognosis.
  • If the delivery did not take place, manual delivery then uterine revision. In the case of a natural delivery, checking of the entirety of the placenta, and systematic uterine revision.
  • Examination of the genital die under valves in the search of a cervical wound, Vagina ale, or périnéale. Joining of all Wound, even tiny.
  • Perfusion the oxytocic ones in order to support the uterine retraction, associated with a uterine massage.
  • Measurements of Reanimation:
    • Installation of a second venous way of good gauge,
    • biological Assessment: Hémogramme, assessment of hémostase, Blood group, Group Rhesus, SPOKE,
    • Search for signs of bad hemodynamic tolerance (signs of Shock hypovolemic), installation of a scopic monitoring of the vital constants (Pulse, blood Pressure, electrocardiogram),
    • nasal Oxygen treatment, perfusion of macromolecules, Colloids frozen fresh Plasma and globular base in the event of disorder of coagulation,
  • Monitoring of the bleeding, the uterine sphere, the maternal tolerance.

In the event of failure

  • Perfusion of Prostaglandins (in the absence of counter-indications)
  • Research and treatment of an anomaly of uterine coagulation
  • Tamponnade

In last intention

In the cataclysmic hemorrhages resistant to the treatment, a surgical or radio-interventionnelle sanction must be considered:
  • surgical Binding of the uterine arteries (see even binding of the hypogastric arteries)
  • Embolisation of the uterine arteries by microparticles during a Arteriography (only possible treatment in the hospitals equipped with a technical plate of interventionnelle radiology)
  • Hystérectomie of hémostase (ablation of the uterus) in ultimate intention, when all the other possible methods failed.

Prevention

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