Postpartum hemorrhage

Introduction to postpartum hemorrhage Postpartum hemorrhage (postpartum hemorrhage) is called when the vaginal bleeding exceeds 500ml within 24 hours after delivery. This is a serious serious complication of obstetrics and is one of the obstetrical diseases. Special attention should be paid. The main reason is weak uterine contractions, clinical manifestations of hemorrhage in the birth canal, and a large amount of bleeding, or a small amount of bleeding, severe shock can occur. At the same time can be accompanied by dizziness, fatigue, lethargy, loss of appetite, diarrhea, edema, breast milk, hair loss, chills and so on. basic knowledge Probability ratio: 5% of special population Susceptible population: more than 1 pregnancy, prolific and had multiple intrauterine surgery 2 elderly primipara or young pregnant women Mode of infection: non-infectious Complications: hemorrhagic shock anemia ischemic necrosis

Causes of postpartum hemorrhage

Weak uterine contractions (30%):

After the fetus is delivered, the placenta is exfoliated and excreted from the uterine wall, and the sinusoidal opening of the maternal wall is caused by hemorrhage. Under normal circumstances, due to the shrinkage of the postpartum uterine cavity, the contraction of the muscle fibers is strengthened, so that the blood vessels in the uterine wall interwoven between the muscle fibers are compressed and hemostasis. At the same time, the sinusoids are closed, the bleeding stops, and the blood of the maternal woman is hypercoagulable. The platelets on the endothelial collagen fibers that damage the blood vessels after the placenta is detached form a large amount of thrombus, and fibrin deposits on the platelet plugs. Large blood clots effectively block the uterine blood vessels, so that when the muscle fibers contract, they will no longer bleed. If the uterus fails to contract and shrink after the baby is delivered, the sinus is not open and the fashion is not open. Hemorrhage occurs. If the placenta is partially peeled off or peeled off, the uterine atony can not effectively close the sinus of the uterine wall of the placenta attachment and cause excessive bleeding, which is the main cause of postpartum hemorrhage.

(1) systemic factors: such as maternal physique weakness, acute and chronic medical history, long labor, delayed labor, nervousness, excessive use of sedatives or deep anesthesia.

(2) Local factors: 1 excessive expansion of uterine muscle wall, excessive extension of muscle fibers, affecting muscle fiber contraction, such as excessive amniotic fluid, multiple pregnancy, giant children, huge placenta, -thalassemia, fetal edema syndrome, etc., more than 2 women Repeated pregnancy and childbirth, uterine muscle fiber damage, connective tissue increased, degenerative changes, 3 uterine dysplasia or surgical scar, 4 placental factors affect uterine contraction, such as placenta previa, early placental stripping, decidual necrosis Bleeding, myometrial oozing, postpartum hematoma, etc., 5 bladder, over-filling of the rectum can affect uterine contractions.

Soft birth canal tear (25%):

During pregnancy, the soft birth canal is rich in blood vessels and hyperemia. If a soft birth canal laceration occurs during childbirth, the amount of blood loss can be very large. Especially when the laceration involves the upper part of the vagina, the cervix and the uterus, hemostasis is often difficult, and the soft birth canal is torn. There are several reasons for this:

(1) Urgent production: due to excessive productivity or excessive maternal exertion during emergency delivery, the perineum has not been fully expanded, and the delivery of the fetus can cause heavier soft birth canal laceration.

(2) Huge fetus: the prenatal assessment of the size of the fetus is insufficient, no perineal incision or incision is not large enough, can cause soft birth canal laceration.

(3) Obstetric surgery: such as forceps, hand-turning fetal head, destructive fetal, internal reversal or shoulder dystocia can cause perineum, vagina, cervix or even lower uterine laceration leading to postpartum hemorrhage, a district in Shanghai has counted postpartum hemorrhage The cause is that up to 37.9% of postpartum hemorrhage due to improper operation of obstetric vaginal surgery is associated with unskilled operation techniques of young obstetricians.

(4) The elasticity and stretchability of the perineum itself: such as congenital dysplasia of the perineum, vulvovaginal inflammation, white lesions, etc.

(5) Hematoma formation: If the injury involves the blood vessels, and the mucosa of the birth canal, the skin remains intact, or the suture is not completely sutured when the wound is sutured, or the cervix, the vaginal foramen rupture extends upward to tear the blood vessels in the broad ligament. Hematoma, at this time, there may not be more external bleeding, but the hemorrhage in the hematoma can cause a lot of shock.

Placental factor (20%):

Postpartum hemorrhage caused by placental factors, including placental insufficiency, retention after placental dissection, placental incarceration, placental adhesions, placental implantation, placenta and/or residual fetal membranes.

Partial dissection of the placenta and retention after dissection may be caused by uterine contraction. Placental incarceration occurs after the use of oxytocin or ergometrine causes spasm contraction near the internal cervix, forming a narrow ring, embedding the finished placenta In the uterine cavity, to prevent the contraction and bleeding, this narrow ring can also occur in the rough massage of the uterus, the bladder overfilling can also hinder the discharge of the placenta and increase bleeding.

The placenta adheres to the uterine wall in whole or in part and cannot be peeled off by itself. It is called placental adhesion. Some adhesions may cause bleeding. Many artificial abortions may cause endometrial damage and endometritis. Endometritis may also be caused by Caused by other causes of infection, endometritis can cause placental adhesions.

Placental implantation refers to the implantation of the myometrium in the placental villus, uterine dysplasia, etc. It is rare in clinical practice. According to the placental implant area, it can be divided into complete and partial.

Placental residue is more common, can be caused by premature traction of the umbilical cord, premature force to squeeze the uterus, placental residue can be part of the placenta leaflet or para-placental residue adhere to the uterine wall, affecting contractions and bleeding, placental residue can be Including the residual part of the membrane.

Coagulopathy (20%):

Reasons for less frequent postpartum hemorrhage, such as blood diseases (thrombocytopenia, leukoemia, coagulation factor VII, VIII reduction, aplastic anemia, etc.) are pre-pregnancy, for pregnancy contraindications, severe hepatitis, intrauterine Dead tires stay too long, placental abruption, severe pregnancy-induced hypertension and amniotic fluid embolism, etc., can affect blood coagulation or diffuse intravascular coagulation, causing blood clots, postpartum bleeding blood does not condense, not easy to stop bleeding.

Pathogenesis

Rapid blood loss in a short period of time, the main pathophysiological change is a sharp decrease in blood volume, causing a lack of cardiovascular filling, collapse, irreversible shock or death. The early compensation mechanism of acute blood loss is through the adjustment of cardiovascular dynamics. And adrenergic stimulation, increased heart rate, increased cardiac output, redistributed circulating blood volume, vasoconstriction of skin, muscles and spleen, blood vessels with high tolerance to hypoxia such as kidneys and gastrointestinal tracts Contraction also occurs, thereby ensuring the vital organ organization and blood supply to hypoxic sensitive organs such as heart, lung, liver and brain tissue. During this period, since red blood cells and plasma are proportionally lost, hemoglobin and hematocrit can be measured at this time. Still in the normal range, no anemia occurs, the main clinical manifestation is insufficient blood volume, which is the first phase of acute blood loss, generally lasting 2 to 3 days.

Since then, the recovery of blood volume mainly depends on the expansion of plasma volume, that is, mainly relying on water, electrolytes and albumin mobilized from the outside of the blood vessels into the plasma, the blood is diluted, the viscosity is reduced, the blood flow is accelerated, and thus the organ tissue is more ingested. On the other hand, due to blood thinning, hemoglobin concentration and hematocrit decrease continuously, and anemia occurs. When a large amount of bleeding reaches about 20% of the total blood volume, it takes 20 to 60 hours to restore the normal blood volume. After 2 to 3 days of hemorrhage, when the blood volume returns to normal or close to normal, the main problem is excessive red blood cell loss and acute hemorrhagic anemia. This is the second stage of acute blood loss. If the total amount of blood loss is still large, However, the speed is not fast, the compensatory mechanism of plasma volume expansion is sufficient, the hemorrhagic shock performance is not obvious, and acute hemorrhagic anemia is the main performance, healthy adult young patients can tolerate 50% to 60% of red blood cell capacity loss, and Patients with coronary heart disease can cause organ hypoxia when the red blood cell volume is lost by less than 30%.

Acute blood loss caused by tissue hypoxia can stimulate the production of erythropoietin in the kidney. After 6 hours of acute blood loss, the plasma erythropoietin concentration is increased and negatively correlated with hemoglobin concentration. Erythropoietin can not only promote the proliferation of erythroid progenitor cells in the bone marrow. And the maturation of young red blood cells can also promote the release of immature reticulocytes from the bone marrow into the circulating blood. Because it is immature red blood cells, it contains more ribonucleic acid and ribosome particles, so it is on the retort blood smear. It is a polychromatic red blood cell. It can be seen 6 to 12 hours after acute blood loss. After several days, the bone marrow production increases, and the polychromatic red blood cells can increase significantly. On the second day after acute bleeding, the bone marrow red blood cells begin to proliferate. However, it takes 2 to 5 days for the maturation of the red blood cells to mature. After 5 days of acute blood loss, the proliferation of the red blood cells reaches a peak, and the ratio of the red pigment is reversed. The maximum rate of red blood cell formation reaches 10 days after acute blood loss, and the red blood cell volume loss reaches 10% to 20%. Bone marrow hyperplasia can be 2 to 3 times higher than that of normal healthy people, and hematocrit is less than 30%, suggesting that red blood cell loss is about 25%, plasma The level of erythropoietin is even higher. At this time, if the supply of iron is sufficient, the bone marrow hyperplasia is 5 times larger than that of normal healthy people. If iron storage is insufficient, it is impossible to reach this level. Therefore, acute hemorrhagic anemia bone marrow compensatory hyperplasia The ability depends on factors such as whether the bone marrow hematopoietic function is sound, the erythropoietin reaction and the iron supply are sufficient, such as the original bone marrow disease, the kidney disease reduces the production of erythropoietin, or the disease such as inflammation or tumor, interferes with erythropoietin. The role of the original iron storage is not sufficient, it will affect the ability of bone marrow compensatory hyperplasia, 2,3-diphosphoglycerate (2,3-DPG) content in the new red blood cells, can make hemoglobin and oxygen The affinity is reduced, and thus the release of oxygen in the tissue is increased, and the hypoxic state is alleviated.

Postpartum hemorrhage prevention

To prevent postpartum hemorrhage, the incidence can be greatly reduced, and prevention should be carried out in the following links.

1, do a good job of pre-pregnancy and pregnancy health care, early pregnancy start prenatal care monitoring, not suitable for pregnancy in the early pregnancy to terminate the pregnancy.

2, for the preparation of early maternal treatment of women with higher risk of postpartum hemorrhage, such maternal include: more than 1 pregnancy, prolific and had multiple intrauterine surgery; 2 older primipara or younger pregnant women; 3 History of uterine fibroids removal; 4 genital hypoplasia or malformation; 5 pregnancy-induced hypertension; 6 with diabetes, blood disease, etc.; 7 uterine contraction fatigue prolonged labor; 8 rows of fetal head suction, forceps and other midwifery surgery midwifery, especially combined use More uterine contractions need to pay attention; 9 dead tires and so on.

3, the first stage of labor close observation of maternal conditions, pay attention to the supplement of water and nutrition, to avoid excessive maternal fatigue, if necessary, can be used to inject muscle cold, so that the mother has a chance to rest.

4, pay attention to the second stage of labor treatment, to guide the maternal timely and correct use of abdominal pressure, for those who may have post-production bleeding, should be arranged to have a higher level of practice of the physicians on the scene, there are indicators to timely moderate or perineal cut or perineal cut Open, the technical operation of the production should be standardized, the fetal head is correctly guided, the shoulder and the fetal head are delivered smoothly, and those who have had uterine atony, when the shoulder is delivered, the intramuscular injection of oxytocin 10U, followed by intravenous infusion In order to enhance uterine contractions and reduce bleeding.

5. Correctly handle the third stage of labor, accurately collect and measure the amount of postpartum hemorrhage. After the signs of natural exfoliation of the placenta appear, gently press the lower part of the uterus and gently pull the umbilical cord to help the placenta, completely discharge the membrane, and carefully check the placenta, whether the membrane is intact. Check the soft birth canal for tear or hematoma, check the uterine contraction, massage the uterus to promote uterine contraction.

6, after delivery of the placenta, the mother should continue to stay in the delivery room for 2 hours, because 80% of postpartum hemorrhage occurs within 2 hours after delivery, so should focus on monitoring, close observation of general conditions, vital signs, vaginal bleeding and contractions, However, we should not ignore the bleeding after 12 hours. We should explain the precautions to the mothers, and the medical staff will regularly inspect and find problems early.

7, more blood loss, there are no signs of shock, should be early to replenish blood volume, the effect is far better than the shock after the supplement of the same amount of blood is better.

8, early breastfeeding can stimulate uterine contractions, reducing vaginal bleeding.

Application of postpartum hemorrhage score table: According to the presence or absence of pregnancy-induced hypertension, the number of history of abortion, fetal size, platelet count, prenatal bleeding history and other factors that may cause postpartum hemorrhage, a postpartum hemorrhage score table is established, and corresponding preventive measures are taken according to the score. Can significantly reduce the incidence of postpartum hemorrhage.

The total score of the score sheet is 29 points. Maternal women with 5 points tend to be prone to postpartum hemorrhage. They should be alert and take preventive measures in time to reduce the amount of bleeding. For medical conditions, hospitals with poor blood transfusion conditions should treat pregnant women with high postpartum hemorrhage scores. Transfer to the hospital in time.

Postpartum hemorrhage complications Complications, hemorrhagic shock, anemia, ischemic necrosis

1. Complications of postpartum hemorrhage are hemorrhagic shock, heart failure, water and electrolyte disorders and death.

2. Genital tract infections

Postpartum hemorrhage causes maternal anemia, low resistance, increased chances of intrauterine operation, and increased postpartum infection. Therefore, broad-spectrum antibiotics should be used to prevent reproductive tract infections.

3. Xi Han syndrome

Severe postpartum hemorrhage caused by circulatory failure can be secondary to anterior pituitary avascular necrosis, endocrine function is destroyed, patients lack prolactin without milk secretion, lack of thyroxine, so there is chills, weight gain, basal metabolic rate Lower, glucose tolerance test increased.

Symptoms of postpartum hemorrhage Common symptoms Hemorrhagic tendency nausea and lochia not postpartum abdominal pain out cold sweaty birth canal laceration blood pressure drop heart rate irregular postpartum fever coagulopathy

The main clinical manifestations of postpartum hemorrhage are excessive vaginal bleeding. The bleeding volume exceeds 500ml within 24 hours after delivery. Following hemorrhagic shock and prone to infection, the clinical manifestations vary with the cause, which may be a sudden large amount of bleeding. The mother is quickly in a state of shock, maternal chills, dizziness, nausea, vomiting, yawning, shortness of breath, irritability, examination can be found that the maternal pale, cold sweat, cold limbs, blood pressure, pulse speed; can also be expressed as Continuous small or medium amount of bleeding; sometimes postpartum uterine relaxation, uterine bleeding stay in the uterine cavity and vagina, the bottom of the uterus is soft, unclear, such as massage the uterus and push down, showing a lot of blood, blood clots.

Postpartum hemorrhage

Blood picture

(1) Red blood cells: The change of red blood cells after acute blood loss varies with time. In the early stage of bleeding, red blood cells flow out of the blood vessels in proportion to plasma. Although the blood volume decreases sharply, the concentration of red blood cells and hemoglobin per unit volume does not decrease; The reflexive contraction of blood vessels, the redistribution of blood, and the concentration of blood trapped in the organs into the circulating blood, so that hematocrit and hemoglobin can be slightly increased, so the amount of hemoglobin is measured during the first few hours of acute blood loss. Hematocrit can not be used to estimate the amount of blood loss. At this time, symptoms and signs should be used to estimate the amount of blood loss. After 2 to 3 days after acute blood loss, the recovery of blood volume is based on the expansion of plasma volume. In the first 24 hours, the mobilization of body fluids and electrolytes from the outside of the blood vessels into the blood vessels, the expansion of the plasma of the active patients is very slow, mainly by mobilizing extravascular albumin into the blood vessels, due to blood dilution, hematocrit and hemoglobin concentration Only gradually decline, this change is most significant in 2 to 3 days after hemorrhage, anemia Normal cells and normal pigmentation, the number of reticulocytes in peripheral blood begins to increase within 3 to 5 days after acute blood loss, and the increase is proportional to the amount of bleeding, reaching the highest peak from 6 to 11 days, generally up to 5%. ~10%, no more than 14%, the early stage of reticulocyte elevation is to reflect the role of erythropoietin in premature release of renin reticulocytes into peripheral blood, and later to reflect compensatory hyperplasia of bone marrow, new red blood cells Released into the blood, the morphology of red blood cells is mostly normal at first, but when the reticulocytes increase, it can be seen that polychromatic red blood cells and red blood cells increase, and MCV is transiently elevated. If it is checked at this time, it can be misdiagnosed as hemolytic anemia. However, acute hemorrhagic anemia, unless bleeding occurs in the body cavity or interstitial space, no increase in serum bilirubin, severe blood loss caused by shock or tissue hypoxia, peripheral blood smear may also appear a small amount of nucleated red blood cells, the peripheral blood red blood cells The hyperplasia disappears within 10 to 15 days, otherwise the bleeding is still continuing.

(2) white blood cells: leukocytes increase rapidly within 2 to 5 hours after acute blood loss, up to (10 ~ 20) × l09 / L, up to 35 × 109 / L, the mechanism of leukocytosis is partly due to the action of adrenaline granulocytes From the side pool into the circulation pool, and at the same time caused by the release of blood into the storage pool in the bone marrow, the classification count shows that the increased white blood cells are mainly neutrophils, and the left nucleus shift phenomenon can be seen. In severe cases, neutral late granules can appear. Even in neutral myelocytes, the majority of white blood cells return to normal after 3 to 5 days, and persistent leukocytosis often indicates the presence of bleeding or other complications.

(3) platelets: in the short time after hemorrhage or bleeding, the number of platelets, clotting time and plasma fibrinogen can be temporarily lowered, and return to normal 15 minutes after hemostasis, and the number of platelets rises rapidly after 1 to 2 hours. The number of platelets can reach 500×109/L or even 1000×109/L. If severe shock occurs, diffuse intravascular coagulation may occur. The thrombocytopenia generally gradually returns to normal within 3 to 5 days after the bleeding stops.

2. Bone marrow

On the 2nd day after acute blood loss, the bone marrow can be hyperplasia. After 5 days, the red blood cell hyperplasia reaches a peak. The ratio of red pigment can be reversed in a ratio of 1:1 or red, and the morphology of young red blood cells is normal. The majority of young red blood cells are in hemorrhage. 10 to 14 days after the cessation, the immature red blood cell hyperplasia disappeared. Iron staining showed that the extracellular iron in the bone marrow mostly disappeared, and the iron granule cells were significantly reduced or disappeared. The above-mentioned storage iron deficiency often appeared in the late stage of acute hemorrhagic anemia.

3. Other

Such as acute hemorrhage in the blood, blood into the body cavity, cysts and interstitial space, often due to red blood cell destruction, elevated bilirubin, serum lactate dehydrogenase increased, globin decreased, plus retinoblastia increased, similar to hemolytic Anemia, acute gastrointestinal blood loss, blood urea nitrogen can be elevated, which may be due to reduced renal blood flow or due to the digestion and absorption of a large number of blood proteins in the digestive tract.

According to the condition, the clinical performance is selected to do electrocardiogram and ultrasound examination.

Diagnosis and diagnosis of postpartum hemorrhage

diagnosis

1. Accurately detect the amount of bleeding

There are many methods for measuring postpartum hemorrhage, such as visual estimation, basin connection, area method, weighing method and colorimetric method. It is generally considered that the visually estimated blood loss is often inconsistent with the actual amount of bleeding, often 50% less, acidic. The methemoglobin colorimetric method is more accurate, but the operation is more complicated, and the reagents are expensive. It is not suitable for clinical application. Currently, the commonly used methods in clinical practice are:

(1) Weighing method: Before the delivery, the dressings and disinfection sheets used by the mothers and the towels are weighed. After the birth, the dressings will be weighed by blood, and the towels will be weighed. If the initial weight is reduced, the blood loss will be determined. 1.05g is converted to 1ml.

(2) Volumetric method: The measuring cup is used to measure the curved plate or the special post-harvest blood receiving container, and then the collected blood measuring cup is measured.

(3) Area method: Calculated according to the blood-wet area of 10 cm × 10 cm measured in advance, 10 ml, 15 cm × 15 ml is 15 ml.

The above three methods are compared with the colorimetric method and are relatively accurate measurement methods.

2. Looking for the cause of postpartum hemorrhage

Obvious external hemorrhage, diagnosis is not difficult, but bleeding is a common phenomenon, and the causes of bleeding are different, so in addition to close observation of bleeding and accurate measurement of bleeding, the key is to find out the cause of postpartum hemorrhage, early diagnosis.

(1) uterine contraction should be alert to the fact that sometimes the placenta has been discharged, the uterus is slack, a large amount of blood accumulates in the uterine cavity, and vaginal bleeding is only a small amount, the maternal symptoms of excessive blood loss, so in addition to pay close attention to vaginal bleeding after delivery, Should pay attention to the uterine contraction.

The visual measurement of vaginal bleeding is much less than the actual blood loss. Therefore, it must be collected and measured with a curved disc. There is uterine atony before the delivery. The placenta is delivered and the bleeding is too much after delivery. The diagnosis is not difficult, but the above-mentioned hidden postpartum should be guarded. Bleeding may occur at the same time as the birth canal laceration or placental factors.

(2) Cervical laceration of soft birth canal is mostly on both sides, and may also be petal-like. If the laceration is heavier and affects the cervical vessels, it will produce a lot of bleeding. The cervical laceration can be broken to the lower part of the uterus.

Vaginal laceration is mostly in the vaginal side wall, posterior wall and perineum, and most of them are irregular laceration. If the vaginal laceration affects the deep tissue, due to the rich blood supply, it can cause severe bleeding. At this time, the uterine contraction is good, and the vaginal examination can be clear. The location of the laceration and the severity of the laceration.

According to the degree of perineal laceration can be divided into 3 degrees, I degree refers to the perineal skin and vaginal entrance mucosal tear, not reaching the muscular layer, generally bleeding is not much, II degree refers to the laceration has reached the perineal muscle layer, involving the vagina The posterior wall mucosa, even the sulcus on both sides of the posterior wall of the vagina, tears upward, the laceration can be irregular, the original anatomical tissue is not easy to identify, the bleeding is more, the third degree anal external sphincter has broken, and even the vaginal rectum and part of the rectal anterior wall There is a laceration, although the situation is serious, but the amount of bleeding is not necessarily a lot.

(3) Placental factors Placental insufficiency and retention of the placenta after detachment of the uterus, clinically seen in the uterine contraction, the placenta failed to deliver and the amount of bleeding, placental incarceration can be found in the lower part of the uterus narrow ring, placenta and wall Adhesion is prone to incomplete detachment, and the retained placenta affects uterine contraction, and the sinus opening of the placenta is removed. The placenta of all adhesions is not peeled off on time. When the placenta is peeled off by hand, it is found that the placenta is firmly attached to the uterine wall. To make a diagnosis, part of the placenta value can occur without partial implantation and bleeding, often confused with placenta adhesion. When the placenta is peeled off by hand, it is found that all or part of the placenta is integrated with the uterine wall, and it is difficult to peel off and diagnose the placenta. Residues are often routinely examined after the placenta is delivered. When the placenta is intact, it is found that there is a defect in the body surface of the placenta or a defect in the membrane and the blood vessels at the edges are broken, indicating the presence of placental tissue or para-placenta. Make a diagnosis.

(4) Coagulation dysfunction has a tendency to bleed easily before or during pregnancy, and when there is damage to the placenta or the birth canal, hemorrhagic dysfunction.

First of all, we must judge the postpartum hemorrhage and make a diagnosis of the cause of postpartum hemorrhage. Only the diagnosis of the cause of postpartum hemorrhage can be treated accordingly. It can be diagnosed according to clinical manifestations, symptoms, signs and necessary laboratory tests.

Differential diagnosis

The diagnosis of postpartum hemorrhage is not difficult to make. The key point and difficulty of diagnosis is to find the cause of bleeding. According to the treatment, it can stop bleeding quickly. Therefore, there are four major causes of postpartum hemorrhage: uterine contraction, placental factors, soft birth canal injury and blood coagulation. Mechanism disorders are used for differential diagnosis.

1. Patients with uterine contraction and fatigue have a history of uterine contraction fatigue during labor, postpartum hemorrhage is mostly dark red blood, blood clots are visible, blood is rare; massage the bottom of the palace, the uterus is soft or even like a bag, after the massage, a large amount of blood can flow out of the vagina. There was no abnormality in the soft birth canal examination; the amount of bleeding after the contraction was strengthened.

2. Placental retention, partial adhesion, partial implantation and other placental abnormalities caused by abnormal postpartum hemorrhage, more common in the placenta after the delivery of the fetus, no signs of placenta stripping; abdominal examination sometimes in the inferion of the placenta in the lower part of the uterus to form a narrow ring, free to peel the placenta It was found that the placenta was stuck to the uterine wall or difficult to separate.

3. Soft birth canal laceration occurs after the baby is delivered, the bleeding is bright red, no blood clots but self-coagulation; the uterine contraction is found to be good, and the soft birth canal examination can clearly identify the location and severity of the laceration.

4. Coagulation dysfunction can have chronic systemic hemorrhage before delivery. Patients can have multiple sites such as uterus, soft birth canal, and blood. It is difficult to diagnose blood coagulation function according to platelet count.

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