Early Postpartum Hemorrhage Research Articles

High-Fidelity Environment Effect on Early Postpartum Haemorrhage Management

Objective: In order to compare outcomes of a simulation of early postpartum haemorrhage management through a medium-fidelity mannequin in a high-fidelity environment before clinical practicums with those after clinical practicums in nursing students. Methods: This quasi-experimental study was performed on second-year nursing students (n=61). After the simulation, the students were asked to perform postpartum haemorrhage control in clinical practicums. Data were collected with the State-Trait Anxiety Inventory, Student Satisfaction and Self-Confidence in Learning Scale, Educational Practices Questionnaire, and Student Self-Evaluation Form. Results: The mean satisfaction, self-confidence, and Educational Practices Questionnaire scores after the simulation were high. The mean scores for feeling competent in involution, haemorrhage control, fundus massage, perineal care, andestablishing appropriate communication with patients and their relatives were 19.18±5.70 after the simulation and 23.83±5,03 after the clinical practicums. Conclusion: The medium-fidelity simulation in a high-fidelity environment of early postpartum haemorrhage management enhanced the students’ learning satisfaction and self-confidence. This helped them to feel more competent in the clinical practicums.

HEMORRAGIA PÓS-PARTO: FATORES DESENCADEANTES E IMPLICAÇÕES PARA À PRÁTICA CLÍNICA: UMA REVISÃO NARRATIVA DA LITERATURA

Postpartum hemorrhage (PPH) is a critical obstetric condition characterized by excessive blood loss after childbirth. It can occur immediately after delivery or develop within the first 24 hours, referred to as early postpartum hemorrhage, or up to 12 weeks after childbirth, known as late postpartum hemorrhage. This study is a bibliographic research, configured as a narrative review of the literature related to postpartum hemorrhage, focusing on its main triggering factors and clinical practice implications, aiming to synthesize published research on this topic. The final review sample consisted of 20 articles, after the exclusion of 133 during the full reading and application of inclusion and exclusion criteria. Initially, the screening of titles and abstracts reduced the sample from 346 to 153 articles, with 193 excluded at this stage. The original sample, obtained after applying the descriptors, included 483 articles, but was reduced to 346 after the removal of 137 duplicates. In the literature found, all studies were categorical in presenting the main triggering factors for postpartum hemorrhage. In this sense, the authors mainly discuss the "4Ts" as key risk factors associated with this obstetric emergency, a serious complication and one of the leading causes of maternal mortality worldwide. The term "4Ts" refers to four potential causes of postpartum hemorrhage: Tone, Trauma, Tissue, and Thrombin. In summary, postpartum hemorrhage is a complex and multifactorial condition that requires a multidisciplinary approach.

Development and Piloting of Implementation Strategies to Support Delivery of a Clinical Intervention for Postpartum Hemorrhage in Four sub-Saharan Africa Countries.

Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality. A new clinical intervention (E-MOTIVE) holds the potential to improve early PPH detection and management. We aimed to develop and pilot implementation strategies to support uptake of this intervention in Kenya, Nigeria, South Africa, and Tanzania. Implementation strategy development: We triangulated findings from qualitative interviews, surveys and a qualitative evidence synthesis to identify current PPH care practices and influences on future intervention implementation. We mapped influences using implementation science frameworks to identify candidate implementation strategies before presenting these at stakeholder consultation and design workshops to discuss feasibility, acceptability, and local adaptations. Piloting: The intervention and implementation strategies were piloted in 12 health facilities (3 per country) over 3 months. Interviews (n=58), case report forms (n=1,269), and direct observations (18 vaginal births, 7 PPHs) were used to assess feasibility, acceptability, and fidelity. Implementation strategy development: Key influences included shortages of drugs, supplies, and staff, limited in-service training, and perceived benefits of the intervention (e.g., more accurate PPH detection and reduced PPH mortality). Proposed implementation strategies included a PPH trolley, on-site simulation-based training, champions, and audit and feedback. Country-specific adaptations included merging the E-MOTIVE intervention with national maternal health trainings, adapting local PPH protocols, and PPH trollies depending on staff needs. Piloting: Intervention and implementation strategy fidelity differed within and across countries. Calibrated drapes resulted in earlier and more accurate PPH detection but were not consistently used at the start. Implementation strategies were feasible to deliver; however, some instances of limited use were observed (e.g., PPH trolley and skills practice after training). Systematic intervention development, piloting, and process evaluation helped identify initial challenges related to intervention fidelity, which were addressed ahead of a larger-scale effectiveness evaluation. This has helped maximize the internal validity of the trial.

Novel insights into causal effects of maternal nonalcoholic fatty liver disease on adverse pregnancy outcomes: evidence from Human Genetics and Mendelian Randomization Study.

Observational studies have associated nonalcoholic fatty liver disease (NAFLD) with adverse pregnancy events, but findings show heterogeneity, leaving the causal direction and mediating pathways unclear. We aimed to investigate the causal relation between NAFLD and various pregnancy events, and to elucidate the underlying mediating pathways while determining the proportion of this correlation that is mediated through these pathways. A genome-wide association study involving over 6 million participants employing Mendelian randomization (MR) and mediation analysis was performed. The study used genetically predicted NAFLD as exposures and cardiometabolic traits as mediators, with various adverse pregnancy events as outcomes. The main analysis was performed using the inverse variance weighted (IVW) approach, while sensitivity analyses included the weighted median, weighted mode, MR-Egger, and MR-PRESSO methods. Mediation analyses were performed using a two-step MR framework. In this MR cohort study, NAFLD was found to be strongly associated with elevated risks of GDM (P = 0.019 for the discovery dataset, P < 0.001 for the discovery dataset) and HDPs, including any HDP (P < 0.001 for the both datasets), gestational hypertension (P = 0.007 for the discovery dataset, P < 0.001 for the discovery dataset), and pre-eclampsia or eclampsia (P = 0.040 for the discovery dataset, P < 0.001 for the discovery dataset). However, no significant associations were found with hemorrhage in early pregnancy, postpartum hemorrhage, preterm birth, or offspring birthweight for both datasets. Cardiometabolic traits played a significant mediating role in these associations, rather than solely acting as confounding factors. This study provided evidence supporting a correlation between NAFLD and a higher risk of adverse pregnancy events and introduces some new insights. These findings may inform preventions and interventions for remediating adverse pregnancy outcomes attributable to NAFLD.

Genome-wide association meta-analysis identifies five loci associated with postpartum hemorrhage

Bleeding in early pregnancy and postpartum hemorrhage (PPH) bear substantial risks, with the former closely associated with pregnancy loss and the latter being the foremost cause of maternal death, underscoring the severe impact on maternal–fetal health. We identified five genetic loci linked to PPH in a meta-analysis. Functional annotation analysis indicated candidate genes HAND2, TBX3 and RAP2C/FRMD7 at three loci and showed that at each locus, associated variants were located within binding sites for progesterone receptors. There were strong genetic correlations with birth weight, gestational duration and uterine fibroids. Bleeding in early pregnancy yielded no genome-wide association signals but showed strong genetic correlation with various human traits, suggesting a potentially complex, polygenic etiology. Our results suggest that PPH is related to progesterone signaling dysregulation, whereas early bleeding is a complex trait associated with underlying health and possibly socioeconomic status and may include genetic factors that have not yet been identified.

The effect of the feedback method on the obstetrics-gynecology residents’ learning in the management of early postpartum hemorrhage

Background: Simulation training, a novel learning method, provides medical students with opportunities to practice managing stressful situations as if they were experiencing them in reality. Recently, there has been increased recognition of the value of simulation-based education. This study aimed to evaluate the most effective approach for providing feedback during a simulation program. Methods: In this interventional study, a total of 43 obstetrics and gynecology residents were recruited and stratified into three groups based on their residency stage. These residents participated in a simulation-based program focused on the management of post-partum hemorrhage (PPH). The program involved handling a PPH scenario, during which they received feedback either during the task (in-task; IT) or after completing the task (end-task; ET). Following the simulation, a post-test was administered, and the results were compared between the IT and ET feedback groups. Results: Demographic variables did not differ significantly between the ET and IT groups. Generally, there were no significant differences in secondary knowledge (P=0.232) or secondary performance (P=0.196) following the simulation program between the two groups. However, Among second-year residents, the change in primary and secondary performance was not significant in either the ET (P=0.76) or IT (P=0.74) group, while the IT group showed a significant improvement in knowledge (P=0.04). For third-year residents, the point change in primary and secondary knowledge and performance was not statistically significant in either the ET or IT groups. Conclusion: The final knowledge and performance following simulation programs do not significantly differ between the IT and ET groups. However, second-year residents experienced an improvement in knowledge.

Lower Uterine Segment Corrugated Sutures in Hemorrhage during Cesarean Section because Previal and/or Placenta Accreta Spectrum: Case Reports Series and Literature Review.

We present the original technique of compression hemostatic sutures on the lower uterine segment due to early postpartum hemorrhage during cesarean section, with a literature review. A retrospective clinical case study was conducted at the tertiary perinatal center. Twelve patients had nine planned and three urgent cesarean sections due to antenatally verified placenta previa and/or placenta accreta spectrum and defined early postpartum hemorrhage > 1000 mL during cesarean section. As the use of uterotonics failed to produce any effect and hemorrhage persisted, compression sutures of the lower uterine segment were made by our own technique, as follows: below the hysterotomy, a horizontal corrugated suture is placed from the right to the left corner and after 2-3 cm vertically and backwards at several sites from the left to the right corner, where it is tightened. Seven patients had one cesarean section, three patients had two cesarean sections, and seven patients had pregnancy from the in vitro fertilization procedure in their history. There were six patients with placenta previa and six patients with anterior invasive placenta accreta or increta. Original hemostatic procedure was applied successfully in ten cases, and after placement of O'Leary suture and persistent bleeding in two cases. In this group, no hysterectomy was performed, and patients received blood transfusion of 440-880 mL. Three patients later had spontaneous pregnancies. Our own hemostatic method with a simple technique, fast learning, and minimal logistics contributes to successful management of this currently global problem of morbidly adherent placenta previa.

Long-term outcomes of uterine artery embolization in patients with early hypotonic postpartum hemorrhage

Introduction. Obstetric haemorrhage remains the number one cause of maternal death globally. Today, the frequency of hypotonic postpartum hemorrhage (PPH) reaches 80% in the obstetric hemorrhage profile.Objective. To evaluate the long-term outcomes of uterine artery embolization (UAE) for the treatment of early hypotonic postpartum hemorrhage (PPH).Material and methods. 136 patients were examined 2–8 years after UAE performed for early hypotonic postpartum hemorrhage. A survey was conducted for everyone. Ultrasound of the pelvic organs on the 5th–7th day of the menstrual cycle with an assessment of endometrial thickness, ovarian volume, number of antral follicles, and also Dopplerography were performed in 34 patients. Hormonal status was studied in 34 patients, that were examined in the first phase of the menstrual cycle, with an assessment of serum levels of anti-Mullerian hormone (AMH), follicle-stimulating (FSH) and luteinizing (LH) hormones.Results. 19.1% (26/136) of patients planned pregnancy. Pregnancy occurred in 61.5% (16/26). Term delivery occurred in 38.5% (10/26), PPH recurrence occurred in 30% (3/10), placenta accretion was not detected. 23.1% (6/26) patients were pregnant at the time of the survey. Neither morphological nor functional changes of the ovaries were detected in patients 2–8 years after UAE.Conclusions. Uterine artery embolization is a safe method of therapy of early hypotonic postpartum hemorrhage.

Prognosis of subsequent pregnancy in uterine necrosis after uterine artery embolization.

In an 8-year period at two medical center, 138 patients underwent uterine artery embolization, and 11 of them were diagnosed with uterine necrosis. Among them, three were successfully conceived. However, one of them developed an arteriovenous malformation after an artificial abortion, and another experienced complications, including placenta previa and placenta accreta spectrum, which resulted in early preterm delivery and recurrent postpartum hemorrhage, necessitating subtotal hysterectomy. Therefore, it is crucial to prepare for potential adverse pregnancy outcomes in subsequent pregnancies for patients with a history of uterine necrosis.

Blood loss monitoring chart, a game changer in postpartum hemorrhage detection and treatment: A direct observation study in 7 E-MOTIVE trial hospitals in Kenya

Background: Every six minutes, a mother dies of postpartum hemorrhage (PPH) in low-resource countries. PPH, defined as blood loss of more than 500 ml, is the leading cause of maternal death worldwide, accounting for 27% of maternal deaths. The WHO published “Recommendations for the Prevention and Treatment of Postpartum Hemorrhage” in 2012 to provide evidence-informed recommendations for managing PPH. However, adherence to these recommendations is currently limited by several challenges, including poor maternal care where despite guideline dissemination, many health care providers (HCPs) do not provide effective care such as proper monitoring of vital signs which is key in hemodynamic assessments that can prompt early intervention. The E-MOTIVE trial supported 14 health facilities in Kenya, 7 intervention and 7 control sites. The trial introduced a blood loss monitoring chart to support HCPs in assessing women after delivery of the placenta and enabling early detection and treatment of PPH. Methods: Blood loss monitoring tool/Trigger chart was developed by the University of Birmingham. This tool was implemented in seven hospitals in Kenya with the capacity for comprehensive emergency obstetric care, including blood transfusion and cesarean delivery. In these hospitals, labor, delivery, and postpartum care are primarily provided by nurse-midwives and students. More senior clinicians, including medical officers and consultant physicians such as obstetrician, gynecologists and pediatricians, make periodic rounds and are available on-call to assist in emergencies. Data were collected from August 2021 to December 2021. Observations were conducted by the trial implementation midwives with the support of the on-site research midwives for two weeks in each of the study hospitals. Observations occurred 24 hours a day. Patients were observed from the second stage up to two hours after placental delivery. All data were collected on paper forms and then entered into a digital database using RedCap. Results: A total of 734 deliveries were observed cumulatively during the study period. All women received four clinical observations within the first hour using the blood loss monitoring chart. The frequency of observing blood loss in the calibrated drapes during monitoring by HCPs was 94%. There was 100% detection of PPH using the blood loss monitoring chart. Conclusion: Efforts to increase the rates of early PPH detection and treatment should emphasize improvements in the quality of care, with a particular focus on PPH blood loss monitoring. The blood loss monitoring chart is easy to use and can be easily adopted and scaled in low-resource settings.

Risk factors for early postpartum hemorrhage: A retrospective, population-based, cohort analysis.

To identify risk factors for developing early postpartum hemorrhage (PPH) and to examine whether risk factors vary according to severity and mode of delivery. A population-based cohort study was conducted in which all deliveries at a tertiary medical center were included. Risk factors for developing early PPH were compared based on the severity of bleeding as well as the mode of delivery. Multiple logistic regression models were used to control for confounders. Among 322 497 deliveries included in the analysis, early PPH complicated 1811 (0.56%) of all deliveries. Among all cases of early PPH, 505 deliveries (28%) were complicated with severe PPH. Using a logistic regression model, invitro fertilization (IVF) pregnancy, previous cesarean delivery (CD), pre-eclampsia, placental abruption, and uterine rupture were independently associated only with severe early PPH, while non-progressive second stage of labor, induction of labor, and large for gestational age were independently associated with both severe and mild early PPH. When applying an additional logistic regression model, whereas IVF pregnancy, pre-eclampsia, and large for gestational age were independently associated with early PPH among vaginal deliveries only, placenta previa was independently associated with early PPH among CD only. Independent risk factors for developing severe PPH solely include IVF pregnancy, previous CD, pre-eclampsia, placental abruption, and uterine rupture. IVF pregnancy, pre-eclampsia, and large for gestational age are independent risk factors for early PPH following vaginal delivery, while placenta previa is independently associated with early PPH after CD only. Due to the recognition of the importance of both the provider and institutional planning and preparation for PPH, the study's results should be viewed within the scope of its retrospective cohort design.

Pregnancy outcome in patients with non-alcoholic fatty liver disease: a prospective cohort study.

The purpose of this investigation was to examine the potential association between non-alcoholic fatty liver disease (NAFLD) and adverse maternal and perinatal outcomes during pregnancy. Gaining insights into the effect of NAFLD on pregnancy outcomes is essential to ensure the health and well-being of mothers and infants. This prospective cohort study was conducted at Imam Khomeini and Razi hospitals of Ahvaz City in 2022. Totally, 180 pregnant women in the NAFLD group to 180 in the control group. In this study, a researcher-made checklist was used to collect the background information, medical history, and lab data during their initial visit using. Follow-up continued until one week after delivery, with pregnancy outcomes assessed. Statistical analysis used student's t-test and the Chi-Square test for group comparisons. Significant differences were observed between the NAFLD, and control groups in terms of age (P=0.003), BMI (P=0.016), ALT and AST measures (P<0.001), and hypertensive complications (P=0.044). The NAFLD group had higher rates of gestational diabetes (P<0.001) and gestational hypertension (P=0.003). However, no significant differences were found in gestational age at delivery, early postpartum hemorrhage rates, birth weight, and neonatal Apgar scores (P>0.05). The pregnant women with NAFLD may be at risk for various complications during pregnancy, including a higher prevalence of gestational diabetes, elevated liver enzymes, and higher blood pressure compared to healthy pregnant women. However, the research failed to identify any statistically significant disparities between infants born to mothers with NAFLD and those delivered to healthy mothers in relation to birth weight, Apgar scores, or neonatal mortality.

Pregnancy outcomes of fetal reduction in patients with intrauterine haematoma following double embryo transfer

Research questionIs there an association between intrauterine hematoma(IUH) and pregnancy outcomes in patients receiving fetal reduction(FR) after double embryo transfer? What is the relationship between IUH-related characteristics and pregnancy outcomes? DesignClinical information and pregnancy outcomes of women receiving FR after double embryo transfer were analyzed. Patients with other systematic diseases, ectopic pregnancy or heterotopic pregnancy, monochorionic twin pregnancies and incomplete data were excluded. Stratification of IUH pregnancies was done according to IUH-related characteristics. The main outcome measures included incidence of fetal demise(<24 weeks) while other adverse pregnancy outcomes were considered as secondary outcomes. Result(s)34 IUH patients and 136 non-IUH patients receiving FR after double embryo transfer(DET) were included based on 1:4 match for age, cycle type and fertilization method. IUH patients had higher incidence of early fetal demise(20.6% vs. 7.4%, p=0.048), threatened abortion(48.1% vs. 10.3%, p<0.001) and postpartum hemorrhage(14.8% vs. 4.0%, p=0.030)after FR compared with non-IUH patients, whereas IUH was an independent risk factor for early fetal demise(OR 3.34 95%CI 1.14-9.77) and threatened abortion(OR 8.61, 95%CI: 3.28-22.61) after adjusting for potential confounders. IUH pregnancies undergoing FR resulted in miscarriage had larger IUH volumes and earlier diagnosis. However, IUH characteristics(i.e. volume, changing pattern, presence or absence of cardiac activities) were not correlated with fetal demise and threatened abortion. Conclusion(s)Fetal reduction should be performed with caution in IUH pregnancies after double embryo transfer since the risks of fetal demise is relatively high. Special attention should be given to IUH patients after FR noticing the early signs of threatened abortion and inevitable fetal demise.

The effect of date fruit consumption on early postpartum hemorrhage: a randomized clinical trial

BackgroundPostpartum hemorrhage, anemia, and iron deficiency are important health problems. Using safe, cheap, and available methods to reduce the amount of hemorrhage after childbirth can be effective for the mother's health during this period. Therefore, this study was conducted to determine the effect of date fruit consumption on the amount of hemorrhage after natural childbirth.MethodsThis randomized clinical trial was conducted on 98 women referred to the maternity ward of Al-Zahra Hospital in Rasht using the available sampling method. The primary outcome was postpartum hemorrhage, measured using the Pictorial Blood Loss Assessment Chart (PBLAC). Two hours after delivery, 100 g of date fruits were given to the intervention group, and the amount of hemorrhage was recorded during the first 24 h. Comparison between the two groups was done with the Mann–Whitney test with the Hodges–Lehmann estimator and corresponding exact conditional nonparametric confidence interval (CI) as effect estimate. A P < 0.05 was considered significant.ResultsThe median of postpartum hemorrhage after normal delivery in the date and control groups was 35.0 [interquartile range (IQR): 22.0 to 39.8] and 39.0 [IQR: 27.5 to 64.5], respectively. Using the Hodges–Lehmann estimator, on average, the median postpartum hemorrhage in the date group was 9.0 (95% CI: 2.00–18.0) units lower than the control group (P = 0.009).ConclusionConsumption of dates effectively reduces the amount of hemorrhage after natural childbirth; thus, consuming this fruit during postpartum period is recommended. Also to confirm the findings, it is recommended to conduct similar studies in this field.Trial registrationThis trial was registered with the Iranian Registry of Clinical Trials; https://www.irct.ir/trial/59197 (IRCT20210607051505N2) on 31/10/2021.

Retrospective Study of First Trimester Metrorrhagia: Pregnancy Follow-Up and Relationship with the Appearance of Gestational Complications.

Background and Objectives: The purpose of this study was to describe and evaluate the bleeding that occurs during the first weeks of gestation and its implications throughout pregnancy. Secondarily, we assessed the associated complications in order to identify potential risk factors that could be used to select women at higher risk of adverse outcomes that could benefit from an early diagnosis and improved monitoring. Materials and Methods: We made a selection of all the women who consulted in the Emergency Department of the Hospital QuirónSalud in Malaga on 2015 presenting with first trimester metrorrhagia. We refer to first trimester metrorrhagia as that which occurs until week 12 + 6. Once these pregnant women were identified, we studied several variables not related to the gestation and some others associated with it and its natural course. Results: The average age of the patients assessed was 34.1. Associated gestational complications were metrorrhagia in the second trimester (6.3%), threatened preterm labor (7.4%), preeclampsia (2.5%), gestational diabetes (7.4%), late abortion (1.2%), and early postpartum hemorrhage (1.8%). We sought associations to assess possible risk factors, establishing an increased maternal age as an aggravating factor for the development of complications. We also studied gestational complications, finding a higher prevalence of them in older women, such as prematurity (33.11 vs. 34.48 years), gestational diabetes (33.11 vs. 36.06 years), and preeclampsia (33.25 vs. 35 years). Conclusions: Maternal age is a risk factor for first-trimester spontaneous miscarriage and for the development of complications of pregnancy. It is crucial to perform a correct screening of different pathologies throughout the pregnancy to anticipate potential complications.

Risk factors for early severe post-partum hemorrhage

Risk factors for early severe post-partum hemorrhage

Risk factors for early postpartum hemorrhage: differences between vaginal and cesarean deliveries

Risk factors for early postpartum hemorrhage: differences between vaginal and cesarean deliveries

Частота встречаемости, основные факторы риска и эффективность лечения пациенток с послеродовыми кровотечениями

Aim: to evaluate the frequency of postpartum hemorrhage (PPH) in a high risk hospital, to conduct a comparative assessment of the clinical, historical and laboratory features of patients with PPH, and the effectiveness of the algorithm of PPH management after vaginal birth (VB) and caesarean section (CS). Design: retrospective study. Material and methods. The study included 15,480 patients. The frequency of early PPH and the effectiveness of applying a local stepwise algorithm for management of PPH were evaluated. Clinical historical and laboratory data were obtained by copying from the primary documentation. Results. The incidence of PPH in a high risk hospital is 0.67%. The most significant risk factor for PPH is the induction of labor, but more than a third of women do not have significant risk factors. The volume of blood loss after CS was 1218.29 ± 728.15 ml, after VB — 784.12 ± 304.44 ml (p&lt;0.001). Uterine balloon tamponade was used in 28 (44.4%) women with PPH after VB and in 27 (65.9%) after CS (χ2 = 4.600; p = 0.142). Compression sutures on the uterus were used in 12 (29.3%) patients after CS and in 3 (2.9%) puerperas after VB (χ2 = 2.8; p = 0.001). Hysterectomy was performed in 4 (9.8%) cases only after CS. Conclusion: The existing algorithms for management PPH are highly effective and allow avoiding hysterectomy in VB in 100% of cases, in CS — in 90.2%. Keywords: postpartum hemorrhage, uterotonics, controlled balloon tamponade, complex compression haemostasis.

Obstetrics injuries during shoulder dystocia in a tertiary perinatal center

ObjectivesThis study will present our results in management of fetal shoulder dystocia with special consideration of maternal and neonatal outcome.Study design.A retrospective study was performed at a university tertiary perinatal center. The study included data of singleton vaginal term deliveries in the period of 15 years (2006–2020). Analized informations include: obstetrics maternal and neonatal data and outcomes. ResultsThis period included 45,687 deliveries with diagnosed shoulder dystocia in 254 (0.7 %) cases in vaginal deliveries. Most of the deliveries were spontaneous births 69.7 %, induced deliveries 30.3 %, 47.2 % primiparas and preexisting or gestational diabetes in 21.7 %. The delivery was managed by vacuum extraction in 13.8 %, mediolateral episiotomy in 48.0 % of births, most of the shoulder dystocia were unilateral anterior, while only two cases were diagnosed as more difficult bilateral and 5 cases were recurrent. 87.4 % cases were resolved by McRobert's maneuver, 7.8 % by Barnum's 3.9 % by Wood's maneuver and one case was managed by Menticoglou and by Bourgoise-Siegemundin maneuver. 4.3 % injuries were classified as OASIS of III/IV degree, early postpartum hemorrhage due in 1.6 %. 54.3 % of newborns were male sex, 61.0 % of newborns had birth weight of above 4000 g (mean 4071 g). Maximal Apgar scores were atributed to 92.5 % in first and to 97.2 % in fifth minute, one case that requaired resuscitation. Clavicle fracture was found in 9.5 %, humerus fracture in 0.4 %, transient form of Duchenne Erb obstetrics brachial palsy was diagnosed in only in 7.5 % newborns, while we have not found any case of permanent brachial palsy. ConclusionsOur results confirmed that strategy of prompt identification of shoulder dystocia accompanied by cessation of axial fetal head traction decrease the risk of brachial plexus strain, injury or tear, while performance of exact obstetrical maneuvers resulted in decanceration of fetal shoulders without permanent obstetrics brachial palsy or cerebral morbidity. We think that our good results corelate with our opinion that the performance of external obstetrical manoeuvres should be done without one minute postpone since efforts should be put in sooner shoulder liberation decreasing the time of fetal hypoxia.

Transvaginally surgically treatment of early postpartum hemorrhage caused by lower uterine segment atony.

Prove the success of transvaginal hemostatic procedures in treatment of the early postpartum hemorrhage caused by lower uterine segment atony. We have conducted a retrospective, clinical study during a 10-year period (2010-2019) in our institution that is tertiary perinatal university center. This particular study enrolled total number of 29,543 deliveries with 215 cases of early postpartum hemorrhage (0.72%). Lower uterine segment atony was diagnosed in 44 cases (29.93%) in all uterine atony cases of early postpartum hemorrhage. Hemostatic ligation procedures according to authors: Losickaja in two cases, Hebisch-Huch in 13 cases, Habek in seven cases, Hebisch-Huch+Losickaja in 10 cases. According to our results, hemostatic ligation procedures alone (32 cases; 72.72%) or combined with gauze or ballon tamponade (five cases, 11.36%), have shown to be highly effective in 37 cases (84.09%). Lower uterine segment atony should definitely be identified and understood as a clinical entity. Transvaginal hemostatic approach for surgical treatment of lower uterine segment atony is accessible, minimally invasive, feasible, successful and lifesaving. All of the above-mentioned methods are of great importance in the prevention and treatment of obstetric shock, multiorgan failure, postpartum hysterectomy and finally vital for fertility preservation.