In obstetrics, uterine atony or atonic rebleeding refers to the weakness of contraction ( atony ) of the uterus, i.e. the lack of or insufficient ability of the uterine muscles to contract after the birth of the child and the incompletely or completely born uterine cake . This weak contraction results in profuse or life-threatening bleeding that requires immediate intervention. Uterine atony is one of the most common causes of maternal mortality .
Increased rebleeding before the placenta is born
If there is increased rebleeding before the birth of the placenta , there are usually disorders of placental abruption and anatomical reasons, in particular an adhesion of the placenta with the uterine wall, caused by damage to the uterine lining after a previous caesarean section or endometritis .
The uterus can be felt softly under the abdominal wall; the mother feels pressure from outside as painful. In addition, there is increased vaginal bleeding, which, depending on the loss of blood, is associated with increasing circulatory instability of those affected.
If there is increased rebleeding before the birth of the placenta, it must first be checked whether the bleeding is due to possible birth injuries. If this can be ruled out, the mother is first given medication to promote labor. If the injection does not work, the uterus is rubbed lightly after the mother's bladder has been emptied, briefly exposed to a cold stimulus and, if necessary, the Credé handle is carried out. If these measures also remain unsuccessful, the placenta must be removed manually. The obstetrician inserts his hand into the uterus and loosens the placenta from the wall of the uterus. Depending on the general condition of the woman, further measures to stabilize the circulation are taken.
Atonic rebleeding after the birth of the placenta
After the birth of the mother cake, there is gush-like bleeding , accompanied by rapid circulatory instability of the mother up to signs of shock . The uterus is soft, tender and is often well above the navel.
Various factors can be considered as possible causes of atonic rebleeding, including
- surgical births in which the uterine volume has decreased too quickly, especially if delivered by caesarean section
- the overstretching of the uterus due to multiple pregnancy , an above-average amount of amniotic fluid or an above-average weight child
- the relaxation of the uterus after anesthesia and the administration of anticonvulsant medication as well as in the case of a rapid pregnancy result and frequent women with more than three children
- Labor weakness
- lumpy changes in the uterus, e.g. B. in uterine myomatosus or endometriosis
- Malformations of the uterus
- Consumption coagulopathy in amniotic fluid embolism
If the placenta was incompletely born, i.e. if there are tissue fields or skin remnants left in the uterus, they must be removed with a scraping immediately after the diagnosis , as only a completely emptied uterus can effectively contract.
If atonic rebleeding occurs in spite of a fully born placenta, the procedure is initially similar to the situation mentioned above. There is accordingly a drug treatment by giving contraction agents ( uterotonics ) such as oxytocin , sulprostone or methylergometrine , which is followed by expressing the contents of the uterus. After the mother's bladder has been emptied and the cold is stimulated by the application of an ice bladder, the uterus is permanently compressed from the outside using the Credé handle if the bleeding continues. Under certain circumstances, instrumental follow-up palpation of the uterine cavity is indicated to remove blood clots .
If this does not lead to success either, the uterus is compressed with the help of the Hamilton handle (also known as the vaginal fist handle or punching ball handle ). This involves inserting a hand into the mother's vagina and clenching it into a fist so that the knuckles are directed towards the front wall of the uterus. The outer hand also exerts pressure on the body of the uterus from the maternal abdominal wall by erecting the organ and pressing it against the inner fist and pubic symphysis . The front and back walls of the uterus are pressed against each other in this way, so that the compression of the large vessels is supported and the uterine cavity is prevented from bleeding through the whole body. A massage performed at the same time can also trigger after-pains. If the Hamilton handle is carried out long enough, it almost always leads to the goal. However, in severe cases, regular after-pains can take an hour or two to appear.
If, in extremely rare cases, atonic rebleeding is not manageable despite external aortic compression and surgical ligation of the uterine arteries, surgical removal of the uterus is the last possible solution . Depending on the mother's blood loss, intensive medical care with the transfer of plasma expanders and blood transfusions is necessary.
According to the amount of blood loss, the following degrees can be distinguished:
- Grade I: 500 - 1000 ml
- Grade II: 1000 - 1500 ml
- Grade III: over 1500 ml