Trauma includes vaginal, cervical, or perineal lacerations. In a postpartum patient, a narrowing of the pulse pressure (the difference between the systolic and diastolic blood pressure) may be a sign of compensated hemorrhage and an early sign of a serious problem. A full bladder can also prevent the uterus from contracting (see Figure 17-1). Overstretching may cause a lack of efficiency of the smooth muscle cells to contract. Extreme uterine distention (e.g., multifetal gestations, hydramnios) can cause uterine atony. Mechanical factors that contribute to the inability of muscles to contract include retained placental fragments or large blood clots. Uterine atony is the most common cause of early postpartum hemorrhage and occurs during the first hours after birth. Without this contraction, the vessels at the placental implantation site cannot close and begin to heal. Uterine atony (hypotonic uterus) is the inability of the myometrium muscle (middle muscle, which has interlacing “figure eight” fibers) of the uterus to contract and stay contracted around the open blood vessels.
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