As one of the critical obstetric emergencies, the diagnosis and treatment of postpartum hemorrhage are directly related to maternal and infant safety, and also a key focus in current obstetric and gynecological clinical practice. To further promote academic exchanges in this field and help obstetric and gynecological colleagues improve their diagnosis and treatment capabilities, Obstetrics and Gynecology Network has specially invited Professor Li Zhi from Peking University International Hospital to elaborate on the details of hemorrhage prevention at various stages of labor, explain cesarean section optimization techniques and rapid intervention protocols for refractory hemorrhage, provide practical decision-making ideas for obstetric medical staff, enhance the accuracy and effectiveness of treatment, and ensure maternal and infant safety.
Obstetrics and Gynecology Network:
Prevention is more important than treatment for postpartum hemorrhage, especially in labor management. In your opinion, during the monitoring of the first and second stages of labor, which detailed interventions (such as uterine contraction regulation, perineal protection, etc.) can effectively reduce the risk of postpartum hemorrhage? How to accurately implement "preventive hemostatic measures" for high-risk pregnant women?
Professor Li Zhi:
Postpartum hemorrhage is a common obstetric complication and remains the leading cause of maternal death worldwide. Even in Beijing, it has dropped to the fifth place, but nationwide, it is still a challenging issue requiring focused attention. Compared with treatment, prevention is more effective in reducing the risk of postpartum hemorrhage, and measures need to be implemented throughout the prepartum, intrapartum, and postpartum periods, which can be refined according to labor stages:
I. Prepartum: Conduct Comprehensive High-Risk Factor Assessment and Intervention
It is crucial to accurately identify high-risk factors in pregnant women during the prepartum period, including polyhydramnios, twin pregnancy, hypertension, diabetes, and prenatal anemia, all of which increase the incidence of postpartum hemorrhage. In prenatal care, on one hand, standardized interventions should be adopted to prevent such complications; on the other hand, for pregnant women with existing high-risk factors, personalized postpartum hemorrhage prevention plans during childbirth should be formulated in advance to lay a foundation for precise intervention during labor.
II. Intrapartum: Implement Stage-Specific Detailed Interventions
1. First Stage of Labor: Focus on Uterine Contraction Regulation to Ensure Orderly Labor Progression
The core of the first stage of labor is to prevent abnormal uterine contractions (uterine atony or hypertonic uterine contractions), which is key to reducing the risk of postpartum hemorrhage.
Intervention for uterine atony: Timely detection and correction are essential. Uterotonic agents (such as oxytocin) can be used to adjust contraction intensity, or uterine contraction modulators and spasmolytics to ensure effective contractions. Failure to promptly correct uterine atony not only increases postpartum blood loss but also may lead to fetal distress, neonatal asphyxia, and other complications.
Prevention of hypertonic uterine contractions: Avoid unnecessary augmentation of uterine contractions and inhibit existing hypertonic contractions. Hypertonic contractions may cause precipitous labor, leading to birth canal lacerations and subsequent increased risk of postpartum hemorrhage.
Labor progression management: Ensure labor progresses in accordance with normal timelines without blind intervention, maintaining a stable labor rhythm.
2. Second Stage of Labor: Standardize Delivery Operations and Strengthen Perineal Protection
The second stage of labor, from fetal descent to delivery, focuses on three aspects to prevent postpartum hemorrhage: uterine contraction management, reduction of excessive intervention, and standardized perineal protection.
Uterine contraction management: Uterine atony may still occur at this stage. The cause (e.g., persistent atony from the first stage, maternal fatigue, or oxytocin induction) should be identified first, followed by targeted correction. Meanwhile, hypertonic contractions should be prevented to avoid birth canal injury.
Reduction of excessive intervention: Avoid premature or frequent vaginal examinations and fetal position manipulation. Fetal head internal rotation is mostly completed in the mid-late stage of labor; premature rotation or frequent examinations can cause birth canal edema and increased fragility, raising the risk of lacerations and postpartum hemorrhage. The natural labor process should be respected without forced intervention in fetal delivery rhythm.
Standardized perineal protection: Proper perineal protection can reduce postpartum blood loss by 50-100 ml, and the correct method should be mastered:
Protection technique: Use the thenar eminence (not the tiger's mouth) to focus on protecting the perineal body and levator ani muscle, rather than just the vaginal orifice.
Timing of protection: Apply pressure during contractions and release during intervals, but keep the hand in place to avoid lacerations from sudden contractions.
Auxiliary perineal care: Qualified maternity institutions can perform perineal massage to enhance elasticity and reduce lacerations.
Shoulder dystocia prevention: Continue perineal protection until fetal shoulders are delivered to avoid shoulder dystocia or perineal lacerations caused by premature relaxation.
3. Third Stage of Labor: Scientific Placental Management and Wait for Spontaneous Separation
The third stage of labor (5-15 minutes) focuses on placental separation and uterotonic use, avoiding blind manipulation.
Prophylactic uterotonic administration: For high-risk women (e.g., twins, intrapartum uterine atony), appropriate uterotonics should be administered after fetal delivery and stable respiration, based on maternal complications.
Placental separation management: Adhere to the principle of "no hasty intervention." If there is no bleeding, observe for 5 minutes to allow spontaneous placental separation. During this period, uterine myometrial fibers shorten and thicken due to contraction, compressing uterine sinuses and reducing bleeding. If the placenta fails to separate after 5 minutes, ultrasound should first be used to identify the cause (e.g., placental adhesion or accreta) before formulating a separation plan, avoiding incomplete separation and increased bleeding caused by blind manual removal.
4. Fourth Stage of Labor (2-Hour Postpartum Observation Period): Continuous Monitoring to Prevent Delayed Hemorrhage
Three key measures are required to prevent hemorrhage during this period:
Encourage maternal urination to avoid bladder distension, which increases bleeding risk.
Closely monitor uterine contractions. Uterine massage can be performed at any time after placental delivery; if the uterus becomes soft, timely massage to stimulate contractions, and promote uterine involution through breastfeeding.
Screen for occult bleeding. Observe for vaginal hematomas or birth canal laceration bleeding. For suspected bleeding without obvious symptoms, colposcopy should be performed promptly to confirm the presence of hematomas.
III. High-Risk Pregnant Women: Precise Implementation of Preventive Hemostatic Measures
For high-risk pregnant women (e.g., complicated with hypertension, diabetes, twins, placenta previa), "precision prevention" should be strengthened throughout the process:
Prepartum: Develop personalized plans for specific high-risk factors, such as blood pressure and blood glucose control, correction of prenatal anemia, and assessment of placental location (e.g., surgical planning for placenta previa in advance).
Intrapartum: Prioritize targeted preventive measures, such as earlier assessment of uterine contractions and timely uterotonic administration for twin pregnancies during the third stage of labor; adequate surgical hemostasis preparation for placenta previa to avoid massive hemorrhage caused by blind manipulation.
Postpartum: Extend observation time, strengthen monitoring of vital signs and blood loss, and pre-prepare emergency resources such as blood transfusion and interventional therapy to ensure rapid intervention when bleeding signs appear.
Obstetrics and Gynecology Network:
Obstetric surgical operations are closely related to the occurrence of postpartum hemorrhage. In cesarean section, what optimized experiences do you have in uterine incision selection and suturing techniques to reduce bleeding? How to make rapid decisions and implement effective interventions for sudden refractory hemorrhage during surgery?
Professor Li Zhi:
In cesarean section, surgical techniques are crucial for preventing and controlling postpartum hemorrhage. Standardized incision selection and suturing can significantly reduce blood loss. For refractory hemorrhage, rapid management relying on multidisciplinary team (MDT) collaboration is essential. Specific experiences are as follows:
I. Cesarean Section: Optimize Operational Details to Reduce Intraoperative Hemorrhage
1. Incision Selection: Precise Localization to Balance Safety and Operability
Transverse incisions are commonly used in cesarean section. The key is to control the incision location and traction force to avoid vascular injury.
Incision localization: The uterine incision should be made 2-3 cm below the bladder reflection on the lower uterine segment. Accurate identification of anatomical landmarks is critical: ① Palpate the lower uterine segment to find the "membranous loose area" at the bladder reflection; ② Identify the physiological contraction ring (internal cervical os) and set the incision starting point 3 cm below this ring. Adjust the incision according to fetal head position: raise the incision slightly for a high fetal head and lower it slightly for a low fetal head to avoid difficult fetal head delivery and incision laceration bleeding caused by mismatched incision and fetal head position.
Incision traction technique: Subcutaneous and rectus abdominis blood vessels are longitudinally distributed. Traction should be "slow and gentle" to avoid vascular rupture due to excessive force; only traction to fully expose the incision is necessary to minimize unnecessary vascular injury.
2. Intraoperative Hemorrhage Control: Stage-Specific Management with Priority to Clamping Hemostasis
Before fetal delivery: For oozing blood (mostly venous oozing), no excessive intervention is needed; temporary compression with gauze can be used, and amniotic fluid will naturally stop bleeding after fetal delivery (amniotic fluid has hemostatic effects). For arterial bleeding, timely ligation or suture ligation should be performed to avoid increased blood loss.
After fetal delivery: Immediately clamp the edges of the incision with uterine forceps or ovum forceps to prioritize controlling incision bleeding before administering oxytocin. Due to weak uterine contractions in the lower uterine segment, relying solely on oxytocin for hemostasis has limited effect, and 200-300 ml of blood may be lost during the 30 seconds to 1 minute it takes for oxytocin to take effect. Incision clamping takes only 1 minute to achieve rapid hemostasis without affecting subsequent oxytocin use.
3. Placental Management: Wait for Spontaneous Separation and Avoid Blind Manipulation
After fetal delivery, incision clamping, and oxytocin administration, wait 5-15 minutes (third stage of labor) for spontaneous placental separation. During this period, amniotic fluid can be cleaned, and umbilical cord blood or blood gas samples can be collected. Avoid premature uterine massage or manual placental twisting to prevent increased bleeding due to incomplete placental separation. If the placenta fails to separate after waiting, the cause (e.g., adhesion or accreta) should be clarified first before formulating a separation plan.
4. Suturing Technique: Standardized Layered Suture with Targeted Management for Special Cases
Routine incision suture: Layered suture should be performed to restore anatomical structure, avoiding random tissue suturing. Reduce clamping of uterine myometrium, rectus abdominis, and other tissues to prevent hematoma or abscess formation due to tissue necrosis, which increases the risk of subsequent bleeding.
Suture for special cases (e.g., placenta previa, incision laceration): For bleeding from placenta previa, instead of relying on gauze compression (which may cause rebleeding after removal), first suture "wide-span stitches" (5-6 cm in span) to cover the placental attachment site for rapid hemostasis, then supplement with 2-3 stitches to address small bleeding points. For incision lacerations (especially in converted cesarean sections due to fetal distress, abnormal fetal position, etc.), increase personnel (e.g., three surgeons on the operating table) to fully expose the surgical field, identify the bleeding source (e.g., uterine upper glands, lower glands, main trunk of the uterine artery), and perform targeted suture ligation to ensure good tissue approximation.
II. Sudden Refractory Hemorrhage During Surgery: Rapid Decision-Making and MDT Collaborative Intervention
Refractory hemorrhage is mostly caused by unforeseen factors (e.g., placental abruption, amniotic fluid embolism, severe uterine atony) and should be managed according to the process of "rapid assessment - precise intervention - MDT collaboration":
1. Clarify Intervention Indications and Methods
Refractory hemorrhage due to uterine atony: Prioritize B-Lynch suture (performed strictly in accordance with specifications). If ineffective, combine with backpack suture, uterine artery ligation, or ascending branch ligation of the uterine artery, avoiding reliance on a single suture method.
Hemorrhage due to placental factors (e.g., placenta accreta, placental abruption): First target the placental attachment site (e.g., suture ligation of the attachment site), then administer uterotonics. If bleeding persists, promptly initiate subsequent emergency measures.
2. Rapidly Activate MDT Collaboration
The core of refractory hemorrhage management is "no solo management and timely call for help." Immediately activate department-level, hospital-level, or even regional MDT teams, collaborating with gynecology (assisting surgical hemostasis), interventional radiology (vascular embolization), anesthesiology (maintaining stable vital signs), ICU (critical care), and blood transfusion department (ensuring blood supply) to form a joint treatment force.
3. Follow Standardized Processes and Coordinate Resources
Strictly adhere to the diagnostic and treatment guidelines and operational procedures for postpartum hemorrhage. Meanwhile, rely on the Obstetric Quality Management Office (e.g., Beijing Obstetric Quality Management Office) to coordinate materials (blood, hemostatic drugs) and technical resources, ensuring an orderly and efficient treatment process to minimize the risk of maternal death.
Summary
Postpartum hemorrhage is the leading cause of maternal death. With the increasing proportion of high-risk pregnant women, a single treatment method can no longer meet clinical needs. Experts point out that primary hospitals face challenges in promoting postpartum hemorrhage treatment, such as insufficient hardware facilities, inadequate medical staff skills, and limited blood supply. It is necessary to strengthen the identification and management of high-risk pregnant women. In terms of medication, it is important to distinguish between preventive and therapeutic drugs, and adjust medication plans for special populations. Additionally, the principles of managing bleeding in scarred uteri, difficulties in early identification of postpartum hemorrhage, and medication strategies and coagulation function management during amniotic fluid embolism are discussed, providing references for obstetric medical staff to carry out clinical work, helping improve the level of postpartum hemorrhage treatment, and ensuring maternal and infant safety.
Expert Introduction
Professor Li Zhi
Master of Medicine, Chief Physician, Professor of Peking University, Deputy Director of Obstetrics and Gynecology, and Director of Obstetrics at Peking University International Hospital.
Research Projects and Publications: Has participated in multiple research projects at various levels, including the Beijing Municipal Science and Technology Commission Fund, the Ministry of Health Projects, and the National Tenth Five-Year Plan Key Projects. Has published 46 academic papers and over 30 popular science articles, and edited or co-edited 9 books, including serving as the Deputy Editor-in-Chief of Practical Atlas of Obstetric and Gynecological Surgery.
Academic Appointments:
Member of the Obstetrics and Gynecology Professional Committee of the China International Exchange and Promotion Association for Medical and Healthcare;
Member of the China Fertility and Health Professional Committee;
Member of the Obstetrics and Gynecology Branch of the Beijing Medical Association;
Director of the Obstetrics and Gynecology Physicians Branch of the Beijing Medical Doctor Association;
Member of the Hospital Infection Control Professional Committee of the China Maternal and Child Health Association;
Vice Chairman of the Multidisciplinary Comprehensive Intervention Professional Committee of Obstetric and Gynecological Vascular Diseases, Chinese Chapter of the International Union of Angiology (IUA-CC);
Chairman of the Critical Obstetrics Professional Committee of the Beijing Chaoyang District Preventive Medicine Association;
Editorial Board Member and Reviewer of Chinese Journal of Osteoporosis and Chinese Journal of Minimally Invasive Surgery;
Expert of the Invited Expert Group of Mommy Pregnancy Magazine.
Professional Competence and Clinical Innovation:
With 36 years of experience in obstetrics and gynecology, Professor Li has extensive clinical expertise in the diagnosis and treatment of complex gynecological diseases, maternal and child health care, cephalic dystocia, and high-risk pregnancy. He is proficient in unprotected natural childbirth, standardized minimally invasive cesarean section, extraperitoneal cesarean section, and forceps delivery, with unique insights, methods, and techniques in managing pregnancy complicated with uterine fibroids, placenta previa, and postpartum hemorrhage. He regularly organizes clinical skills training courses and academic activities.
With societal development, the increase in advanced-age pregnant women and cesarean section scar pregnancies has led to more high-risk pregnancies, including those complicated with internal and surgical diseases, uterine fibroids, hypertensive disorders of pregnancy, gestational diabetes, preterm birth, placenta previa, placenta accreta, and multiple pregnancies. Based on rich clinical experience, Professor Li has made multiple unique innovations and established new technologies and methods to significantly reduce bleeding in critical cases, even avoiding bleeding, and greatly reducing clinical risks:
Squeezing Method for Myomectomy: For pregnant women with uterine fibroids, the unique "squeezing method" is used for myomectomy during cesarean section, which can safely and effectively remove fibroids without increasing postpartum hemorrhage or causing postpartum infection.
Internal Compression Suture Technique: Placenta previa is a common cause of antepartum and postpartum hemorrhage. Especially for central placenta previa, bleeding is often difficult to control. The self-developed compression suture technique can significantly reduce postpartum blood loss, with most cases not requiring blood transfusion, ensuring maternal safety and reducing the rate of hysterectomy.
Ultrasound-Guided Abdominal Aortic Occlusion in Pernicious Placenta Previa: Under ultrasound guidance, an abdominal aortic balloon is placed, and blood flow is temporarily occluded after laparotomy. The uterus is quickly incised to deliver the fetus, followed by hemostasis with internal compression suture. The entire operation can be completed in a few minutes, significantly reducing intraoperative bleeding and avoiding the need for X-ray machine transportation and radiation protection.
Editor-in-Charge: Lily
