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  1. 1. TOG11_4_231-238.qxd 9/30/09 6:09 PM Page 231 The Obstetrician & Gynaecologist 10.1576/toag. 2009;11:231–238 Review Review The surgical approach to postpartum haemorrhage Author Philip J Steer Key content: • Pharmaceutical treatment of postpartum haemorrhage is well defined. • Physical methods for controlling postpartum haemorrhage that conserve the uterus include intrauterine balloons if the abdomen is closed or, at laparotomy, uterine compression sutures, uterine artery ligation, internal iliac artery ligation and aortic compression. • If the above measures fail, hysterectomy should be undertaken sooner rather than later. • In cases of uterine inversion, the ventouse can be used either vaginally or abdominally to help reduce the inversion. • Surgery for placenta praevia/accreta should be planned carefully in advance. Learning objectives: • To understand the range of physical techniques available for controlling postpartum haemorrhage. • To learn about a variety of ways to correct uterine inversion. • To understand how to prepare for and conduct surgery for placenta praevia/accreta. Ethical issues: • Prior informed consent for hysterectomy can be problematic in an emergency situation. • Operations for placenta praevia/accreta need to be especially carefully planned if a woman declines the use of blood transfusion. • There is little authoritative information to give women about the benefits and disadvantages of the various surgical techniques. Keywords hysterectomy / intrauterine tamponade balloon / placenta accreta / placenta praevia / postpartum haemorrhage / uterine artery ligation / uterine compression suture Please cite this article as: Steer PJ. The surgical approach to postpartum haemorrhage. The Obstetrician & Gynaecologist 2009;11:231–238. Author details Philip J Steer BSc MD FRCOG Emeritus Professor of Obstetrics and Gynaecology Faculty of Medicine, Imperial College London, London SW7 2AZ, UK; and Consultant Obstetrician Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK Email: (corresponding author) © 2009 Royal College of Obstetricians and Gynaecologists 231
  2. 2. TOG11_4_231-238.qxd 9/30/09 6:09 PM Page 232 Review 2009;11:231–238 The Obstetrician & Gynaecologist Introduction surgeon and their assistants to take turns at Postpartum haemorrhage (PPH) has always been a 5-minute intervals, if satisfactory compression is to major cause of maternal mortality and morbidity; be maintained. If this is insufficient, compression of its incidence is rising for reasons that remain the lower abdominal aorta against the spinal obscure.1 Fortunately, techniques for dealing with it column at the level of L2–4 can produce an have improved so that mortality from this cause additional reduction in bleeding by reducing blood continues to decline. Some PPHs are traumatic flow to the uterus. Such compression can be (vaginal and uterine lacerations). The primary produced by an additional assistant, providing the approach to dealing with these is surgical correction mother is not grossly obese. Special ‘anti-shock’ of the defect; the techniques required are as varied as garments have been produced which combine the lacerations themselves. This article deals with aortic and uterine compression with compression the surgical approach to the more generic causes of of the lower limbs, both to reduce bleeding and to PPH, namely uterine atony, and the less common maintain venous return (Figure 1 and Figure 2).3–5 conditions of uterine inversion, placenta praevia and placenta accreta. It should be noted that, as with If bimanual compression appears effective, but many emergency surgical procedures, there are very bleeding recommences when compression is few systematic studies of their use and no stopped, a traditional approach is to pack the uterus. randomised trials of efficacy. Long-term follow-up Although its effectiveness has been questioned, a data are also very few. Inevitably, therefore, this recent review6 has concluded that, performed article relies substantially on anecdote and the properly, this can work well. The key to most author’s personal experience and this should be effective use is to insert wide ribbon gauze firmly, borne in mind if any of the techniques are adopted making sure that it is placed initially at the fundus by the reader. using a sponge holder and then fed systematically into the uterus. Each layer must be pressed firmly home before the next layer is placed. However, Uterine atony probably more convenient than packing with gauze Failure of the uterus to contract effectively is the use of an intrauterine balloon. This technique following the delivery of the baby is the commonest was described independently in 2001 by Johanson cause of massive PPH. There is no accepted et al.7 and Bakri et al.8 The capacity of the balloon definition of massive PPH; for the purposes of this needs to be up to 500 ml, so small balloons such as article I have defined it as any case with continuing those found on Foley catheters are insufficient. haemorrhage despite the ‘usual’ treatment, such as Bakri balloons are now commercially available intravenous oxytocin (Syntocinon®, Alliance in the UK and are manufactured by Cook Ireland Pharmaceuticals Ltd, Chippenham, Wilts, UK) Ltd (Limerick, Republic of Ireland). They contain a 10 iu, ergometrine 0.5 mg ϫ 2, carboprost 0.25 mg central lumen which ends above the balloon, so that intramuscularly (up to ϫ 6) and misoprostol any blood still being lost above the level of the 200 micrograms ϫ 5 rectally. (The use of activated uterine tamponade can drain and be measured. In VIIa is controversial and currently not supported the absence of a balloon specifically designed for the by controlled trials.2) The surgical techniques that purpose, similar tamponade can be obtained using can then be employed are listed in Box 1, in the the stomach balloon of the Sengstaken catheter, order in which they are commonly tried. which is stocked in many hospitals for the management of bleeding oesophageal varices Bimanual compression, with one hand (made into (although the Sengstaken catheter is effective, the a fist) in the vagina and the other compressing the Bakri balloon is cheaper and simpler to use). Once uterus using the other hand to press downwards inserted fully into the uterus, the balloon should onto the uterus through the mother’s abdomen, be inflated with sterile saline until the bleeding is is often effective at staunching the flow, at least controlled; commonly, ~300 ml is needed. There temporarily. It allows a respite during which blood have been no randomised trials of balloon use, can be crossmatched and other resources but in a series of 23 cases unresponsive to medical marshalled. It is tiring to maintain adequate therapy reported by Dabelea et al.,9 bleeding was compression and it is usually necessary for the arrested in 21, with only two needing to proceed to hysterectomy. Box 1 Surgical techniques for controlling • Uterine compression and massage If the cervix is fully dilated, there is sometimes postpartum haemorrhage • Packing/balloon insufficient resistance in the lower segment and • Uterine compression suture vagina for a pack or balloon to be retained when it • Uterine artery ligation is fully inserted/inflated. This can be countered by • Hysterectomy putting in a cervical cerclage (using Prolene® or • Logethotopulos pack Mersilene® [both made by Ethicon Ltd., Livingston, • Internal iliac ligation UK]) and tightening it to a diameter of ~3 cm; this • Arterial embolisation provides a platform which maintains the 232 © 2009 Royal College of Obstetricians and Gynaecologists
  3. 3. TOG11_4_231-238.qxd 9/30/09 6:09 PM Page 233 The Obstetrician & Gynaecologist 2009;11:231–238 Review pack/balloon securely in the body of the uterus so Figure 1 that it can compress the uterus effectively against Non-inflatable garment for the control of postpartum haemorrhage. its elastic limit. Balloons can also be used for Reproduced with permission from tamponade in the vagina when there is bleeding Miller et al.5 from multiple vaginal lacerations.10 Uterine compression sutures If packing or balloon tamponade are ineffective, the next step is to consider direct uterine compression suturing. The first suggestion of this approach was by Christopher B-Lynch, of Milton Keynes Hospital in the UK, who in 1997 published an account of five cases11 where compression of the uterus was achieved following caesarean section using the technique shown in Figure 3. It requires that the uterus is opened; the suture compresses the upper Figure 2 segment but the lower segment remains open. If the Noninflatable garment for the uterus has not previously been opened (e.g. at control of postpartum haemorrhage. Reproduced with permission from caesarean section), a simplified suture can be Miller et al.5 inserted, such as square suturing (Figure 4).12 However, there is concern that the square suture may completely occlude the blood supply to the uterine muscle within the square, leading to ischaemic necrosis and subsequent complications (see below). An important principle is, therefore, to avoid sutures that apply compression both Figure 3 B-Lynch suture. Reproduced with vertically and horizontally, but instead use sutures permission from Lynch et al.11 that are compressive, whether transversely, e.g. multiple horizontal sutures as recently described by Hackethal et al.13 (Figure 5) or horizontally as with the simpler loop suture inserted through the lower segment and tied at the fundus, as described by Hayman et al.14 (Figure 6). As with balloons, there are no randomised controlled trials of compression sutures, but in a recent series of 11 cases where the Hayman suture was used, hysterectomy was only necessary in one.15 In another series of 31 519 births, uterine compression sutures were applied in 28 cases; they were successful in 23 whereas 5 still required hysterectomy.16 A particular problem is dealing with bleeding from the lower segment of the uterus. This can be dealt with by square suturing,12 by a simple horizontal14 or vertical17 loop suture, opposing the anterior to the posterior walls of the lower segment. An A series of five such cases was reported by Nelson ingenious variant of this, if the cervix is not fully and O’Brien20 and this method was effective in all dilated, is to invert the lower segment upon itself cases without complications. before suturing it, thus compressing the bleeding surfaces without occluding the uterine cavity18 All effective interventions have complications and (Figure 7). these are now being reported with all the approaches described above. An important Another possibility is to combine the compression practical point is that all compression sutures suture with an intrauterine balloon.19 The suture should be absorbable.21 The reason for this is that as must be inserted first: clearly, inserting a suture the uterus involutes, the sutures will become loose after the balloon risks puncturing it. Moreover, and, if they are nonabsorbable and do not produce once the suture has been inserted, the balloon can an inflammatory reaction making them adhere to be used to apply counter pressure more effectively. the uterine surface, there is always the risk that © 2009 Royal College of Obstetricians and Gynaecologists 233
  4. 4. TOG11_4_231-238.qxd 9/30/09 6:09 PM Page 234 Review 2009;11:231–238 The Obstetrician & Gynaecologist Figure 4 apposition of the anterior and posterior walls of Cho square haemostatic suture12 the uterus, which can impede drainage of lochia, resulting in pyometra22 or, in the longer term, in the formation of synechiae.23 Moreover, if the sutures are placed too tightly, or result in an area of the uterus being totally deprived of blood supply (for example, if there is placement of both vertical and horizontal compression sutures), ischaemic necrosis will result.24 Even with the B-Lynch suture, which does not occlude the uterine cavity, necrosis of the entire uterine corpus has been reported25 and reports of partial necrosis are becoming more common.26–28 The outcome in subsequent pregnancies has been little studied, but in seven reported pregnancies following prior use of uterine compression sutures, pregnancy and birth was uncomplicated.16 Figure 5 The needles and suture material used vary Multiple U-suture. Reproduced with permission from Hackethal et al.13 according to the report. The first paper by B-Lynch11 describes the use of a 70 mm round- bodied hand needle with a number 2 chromic catgut suture. Cho et al.12 describe the use of number 7 or 8 straight needles with number 1 atraumatic chromic catgut. However, catgut is now rarely used in obstetrics because of its relative lack of strength and durability. Hayman et al.14 report the use of either polyglycolic acid (Dexon®, Covidien, Gosport, UK) or Vicryl® (Ethicon Ltd., Livingston, UK) (number 1 or 2 sutures). They also mention the use of a straight needle; in fact I usually bend this manually to a shallow curve, which makes it easier to insert in the depths of the pelvis while avoiding puncture of the structures immediately behind the lower segment. The needle should ideally be у6 cm long so as to exceed the combined thickness of the anterior and posterior lower segment. A shallow curved needle with this Figure 6 dimension is available commercially. On the other Hayman suture. Reproduced with permission from Ghezzi et al.15 hand, Hackethal et al. describe the use of an XLH needle (in conjunction with 0 Vicryl) in which the curve had been straightened! Ghezzi et al.15 also recommend using a straight needle with a number 2 polyglactin suture. Uterine artery ligation If use of a simple compression suture is unsuccessful, then ligation of the uterine arteries can be tried next29 and is often effective. Indeed, one suspects that uterine artery ligation is sometimes performed inadvertently when a lower segment incision extends during a difficult delivery (for example, of a large baby) and extensive suturing into the broad ligament is necessary to control the resultant bleeding. There appear to be no consequences for future pregnancies of such ligation, presumably because loops of free suture will result. This can allow bowel a collateral circulation develops from other to become entangled in the loops, resulting in vessels (particularly the ovarian arteries) to obstruction. Square suturing results in tight compensate. 234 © 2009 Royal College of Obstetricians and Gynaecologists
  5. 5. TOG11_4_231-238.qxd 9/30/09 6:09 PM Page 235 The Obstetrician & Gynaecologist 2009;11:231–238 Review Internal iliac artery ligation Figure 7 Dawlatly suture for control of bleeding and aortic compression from the lower segment of the uterus. Reproduced with permission from There has long been controversy about when ligation Dawlatly et al.18 of the internal iliac artery should be attempted.30 It is a difficult manoeuvre because of the proximity of the internal iliac vein, which can be torn during mobilisation of the artery and is difficult to repair, and the external iliac artery, which if ligated in error results in an ischaemic leg. A practical point is that when the artery is mobilised using an artery clamp, this should be done laterally to medially, so that the tip of the clamp points away from, rather than into, the internal iliac vein. In the hands of experts who perform the procedure regularly, the results can be good.31 In the UK, it should probably not be undertaken by the obstetrician who performs it, for example, only once every 5 years, but instead the assistance of a gynaecological oncologist or vascular surgeon should be sought. If there is a delay in obtaining assistance from such an expert, direct compression of the aorta against the spinal column can reduce bleeding by ~40% and this can be life- saving in some cases. Complete occlusion of the aorta by clamping below the renal arteries is even identification of the cervix and therefore reduces the more effective and flow to the legs can be completely chance of taking a pedicle too low and including the stopped for 4 hours or more without irreversible ureter. Once the bleeding is controlled, any damage. However, analogous to the problem with temptation to remove more tissue, for example, the ligating the internal iliac artery, damage to the vena cervix, should be resisted, as this may simply restart cava can be catastrophic and so such clamping the bleeding. Any specific bleeding sites should be should only be applied by an experienced vascular oversewn, even if it seems possible that the ureter surgeon. may be obstructed. This can always be rectified at a later date, once the woman is no longer at risk of Hysterectomy death from haemorrhage. Even complete occlusion In women wishing to retain their fertility, of the ureter for several days will not result in caesarean hysterectomy is the procedure of last permanent damage to renal function, which will resort; but, as has been repeatedly emphasised in resume once the obstruction is relieved. If bleeding the Confidential Enquiries into Maternal and continues following hysterectomy, it becomes Child Health, it should not be left until the woman mandatory to include surgeons with additional is in extremis, but instead should be carried out experience of dealing with major haemorrhage, promptly if the previously described procedures such as a gynaecological oncologist or vascular prove to be ineffective and there are signs of surgeon. In the meantime, pelvic tamponade with a impending cardiovascular decompensation. Logethotopulos pack32 will usually staunch the flow Anaesthetists will be the people most in touch with (Figure 8). The principle is straightforward. A the woman’s condition and if they declare that the flexible plastic bag larger than the pelvic cavity is pulse rate is continuing to rise and the blood filled with gauze swabs or anything similar to hand. pressure to fall despite conservative measures, The neck is firmly tied to a length of tubing, which is hysterectomy becomes inevitable. The precise passed from the pelvis out through the vagina and timing of this intervention must, of course, always then attached to a litre bag of fluid which is allowed remain a matter of clinical judgment. to hang freely over the end of the bed. This applies a steady tamponade which moulds itself to the pelvic The topic of caesarean hysterectomy really requires cavity and will stop all but the most major arterial an article to itself, but the experience of this author bleeding (especially as the woman is likely to be over the years suggests that it is often a good idea quite hypotensive by this stage). I have had personal to do subtotal hysterectomy first. This is often communications from obstetricians who have sufficient to arrest the bleeding if the main cause is found this manoeuvre to be life-saving in extremis. an atonic corpus, because the two major pedicles clamped, cut and tied include both the ovarian and Special situations the uterine arteries. Even if there is continuing Uterine inversion bleeding, removing the body of the uterus improves This is a rare cause of PPH, but it is important to access to and visibility of the pelvic floor. It allows recognise it promptly as the situation will not be © 2009 Royal College of Obstetricians and Gynaecologists 235
  6. 6. TOG11_4_231-238.qxd 9/30/09 6:09 PM Page 236 Review 2009;11:231–238 The Obstetrician & Gynaecologist Figure 8 abdominal probe, together with colour flow Logethotopulos pack32 (power) Doppler. This can reveal the presence of large blood-filled spaces between the fetus/amniotic fluid of the lower uterus and the mother’s urinary bladder, with loss of the normal myometrium. The presence of large blood vessels with pulsatile flow in the bladder wall is a likely indicator of placental invasion. In such cases, operative delivery is necessary but is often accompanied by profuse haemorrhage and appropriate preparations must be made. The likelihood of hysterectomy is significantly increased to an odds ratio of 5.6 when there have been five or more caesarean sections.38 Placenta accreta is almost exclusively seen in association with placenta praevia, it can sometimes develop as resolved until the inversion is corrected. If the pregnancy progresses and it never resolves with woman has had adequate analgesia, prompt advancing gestational age. manual correction of the inversion is feasible and will be effective in many cases. If the placenta is still Practical aspects of preparation and care in the adherent to the uterus, it should be left in situ until operating theatre when placenta accreta is suspected the uterus has been replaced. If there is a delay while The average blood loss in cases of placenta accreta the woman is resuscitated and anaesthesia is 3–51,39 so proper prior liaison with the provided, then hydrostatic replacement (the haematologist to ensure an appropriate supply of O’Sullivan technique) may be necessary. Several crossmatched blood is essential. It is probably litres of warmed Hartmann’s solution instilled into advisable to have at least 4 units of packed red the vagina is usually enough to stretch the cervix blood cells in the operating theatre, with ready and generate enough pressure to push the uterus access to further supplies, before commencing the back into a normal position. Traditionally, the operation. It is also wise to arrange access to lower vagina was plugged with the accoucheur’s supplies of clotting factors, including fresh frozen hand, but a better seal can be obtained using a plasma. Adequate intravenous access is important, silicone vacuum extractor (ventouse).33 with two wide-bore venous lines inserted and an arterial line to measure the blood pressure More complicated methods have been described, accurately if there is major blood loss and including applying manual upward pressure on the hypotension. In appropriate cases autologous cervix balanced by counter pressure on the uterus transfusion may be appropriate (e.g. some via a laparoscopy probe34 and reducing the Jehovah’s Witnesses will accept replacement of their inversion at laparotomy using a vacuum extractor own blood, but will not accept it from other to suck out the fundus into its correct position.35 people). Up to 1 unit per week can be removed for storage during pregnancy without causing a Placenta praevia and accreta significant drop in haemoglobin concentration, With the considerable rise in the rate of caesarean so up to 6 units can be collected in total: the bone section in recent years, the incidence of marrow can increase production of red cells to placenta praevia and placenta accreta has risen compensate. Normovolaemic haemodilution substantially. The risk of placenta praevia in a first (taking off 250 ml of whole blood at a time and pregnancy is only about 1 in 400, but it rises to 1 in replacing it with crystalloid) can also be used to 160 after one caesarean section, 1 in 60 after two, obtain a further 2 units immediately before 1 in 30 after three and 1 in 10 after four.36 If the surgery.40 Cell savers can also be used to recycle placenta is over the lower segment scar, then there some of the woman’s own blood and they are now is an attendant risk that the placenta will invade routinely used in some units for this type of into (or occasionally through) the myometrium. surgery.41, 42 This risk is about 1 in 50 if there has been one caesarean section, 1 in 6 after two, 1 in 4 after three, One needs to ensure adequate numbers of 1 in 3 after three or four and 1 in 2 after five.37 Thus, experienced and well-trained supporting staff in the presence of a placenta praevia in a woman with the operating theatre, plus appropriate equipment. a previous caesarean section should always raise It is wise to have at least two suction devices with the suspicion of a placenta accreta. This should be bottles in reserve. The deleterious tissue perfusion investigated using ultrasound, supplemented if effects of blood loss are exacerbated by a drop in possible with magnetic resonance imaging. body temperature, so the operating theatre should Ultrasound is probably the most sensitive method, be kept warm, as should the woman (using, for especially if a vaginal probe is used as well as an example, a Bair Hugger® warming blanket). 236 © 2009 Royal College of Obstetricians and Gynaecologists
  7. 7. TOG11_4_231-238.qxd 9/30/09 6:09 PM Page 237 The Obstetrician & Gynaecologist 2009;11:231–238 Review Instruments for bowel and bladder resection uterine compression sutures and intrauterine should be available if needed, as should a vascular tamponade balloons. These are now widely used surgery set. Preoperative cystoscopy and stent and are effective in ~90% of cases. However, reports placement is helpful to ascertain bladder of both short- and long-term complications are involvement and make any necessary bladder now appearing and it is important not to reduce the surgery easier. Urological and vascular surgeons perfusion of the uterus so much that it becomes should be available if needed. Packing of the vagina devitalised. Uterine artery ligation can be carried with multiple gauze bandages to elevate the lower out safely by an obstetrician, but internal iliac uterine segment can make surgery easier if there is a artery ligation should be carried out only by a lot of bleeding and pelvic surgery becomes surgeon familiar with this procedure, for example, necessary, as this elevates the pelvic floor and a gynaecological oncologist or vascular surgeon. facilitates identification of the cervix.43 Hysterectomy still has an important place. If bleeding continues after the uterus has been For the delivery, general endotracheal anaesthesia is removed, the Logethotopulos pack can be used to preferred in combination with lumbar (thoracic) stabilise the situation and arterial embolisation can epidural catheter placement preoperatively for be life-saving. With the increasing incidence of postoperative pain control. Intra-operative calf caesarean section, the possibility of placenta accreta compression (e.g. with Flowtron® boots) helps to should always be considered in the next pregnancy guard against deep vein thrombosis if the operation and ultrasound/magnetic resonance imaging are and recovery time is prolonged. important. Anticipation and careful preparation of the operating theatre, facilities, blood products and The most appropriate abdominal incision is a surgeons remain the key to successful management. midline, which gives the best access in case of heavy bleeding (mass closure with a nylon suture gives the Acknowledgement lowest dehiscence rates). It is a good idea to scan The author is grateful for the assistance of Professor directly onto the uterus, using a sterile sleeve for the Michael Belfort of the Utah Valley Regional transducer, to define the placental site precisely Medical Center (USA) for helping with the before making the uterine incision. This incision development of the lecture upon which this article should be away from the placenta, often fundal, so is based. as to allow delivery of the baby before there is any attempt at removing the placenta. We have developed a technique in our unit of giving References 1 Joseph KS, Rouleau J, Kramer MS, Young DC, Liston RM, Baskett TF. oxytocics (such as an intravenous infusion of Investigation of an increase in postpartum haemorrhage in Canada. BJOG 2007;114:751–9. doi:10.1111/j.1471-0528.2007.01316.x oxytocin and 1000 micrograms of misoprostol 2 Franchini M, Lippi G, Franchi M. The use of recombinant activated factor rectally) once the baby is safely delivered and then VII in obstetric and gynaecological haemorrhage. BJOG 2007;114:8–15. doi:10.1111/j.1471-0528.2006.01156.x waiting to see if the placenta separates. If it does, 3 Hensleigh PA. Anti-shock garment provides resuscitation and and there is good uterine retraction with minimal haemostasis for obstetric haemorrhage. BJOG 2002;109:1377–84. doi:10.1046/j.1471-0528.2002.02197.x bleeding, then once the placenta is extruded by 4 Brees C, Hensleigh PA, Miller S, Pelligra R. A non-inflatable anti-shock uterine contraction the uterus can be closed. If the garment for obstetric hemorrhage. Int J Gynaecol Obstet 2004;87:119–24. doi:10.1016/j.ijgo.2004.07.014 placenta does not separate spontaneously within 10 5 Miller S, Hamza S, Bray EH, Lester F, Nada K, Gibson R, et al. First aid minutes (this interval is arbitrary), we do not make for obstetric haemorrhage: the pilot study of the non-pneumatic anti-shock garment in Egypt. BJOG 2006;113:424–9. any attempt to separate it provided there is no doi:10.1111/j.1471-0528.2006.00873.x bleeding, but instead we close the uterus and wait 6 Hsu S, Rodgers B, Lele A, Yeh J. Use of packing in obstetric hemorrhage of uterine origin. J Reprod Med 2003;48:69–71. for the placenta to discharge spontaneously in the 7 Johanson R, Kumar M, Obhrai M, Young P. Management of massive puerperium (some authorities have suggested using postpartum haemorrhage: use of a hydrostatic balloon catheter to avoid laparotomy. BJOG 2001;108:420–2. doi:10.1111/j.1471-0528.2001.00102.x methotrexate to speed placental involution). If, 8 Bakri YN, Amri A, Abdul JF. Tamponade-balloon for obstetrical bleeding. Int J however, there is substantial bleeding, then we Gynaecol Obstet 2001;74:139–42. doi:10.1016/S0020-7292(01)00395-2 9 Dabelea V, Schultze PM, McDuffie RS, Jr. Intrauterine balloon tamponade proceed straight to hysterectomy without making it in the management of postpartum hemorrhage. Am J Perinatol worse by trying to remove the placenta piecemeal. 2007;24:359–64. doi:10.1055/s-2007-984402 10 Tattersall M,.Braithwaite W. Balloon tamponade for vaginal lacerations Persistent bleeding can often be arrested by arterial causing severe postpartum haemorrhage. BJOG 2007;114:64–8. embolisation but this technique is outwith the doi:10.1111/j.1471-0528.2007.01278.x 11 Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical scope of this article. The article by Boulleret et al.44 technique for the control of massive postpartum haemorrhage: an is recommended to readers as a good account of alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol 1997;104:372–5. recent techniques. 12 Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol 2000;96:129–31. Conclusion doi:10.1016/S0029-7844(00)00852-8 13 Hackethal A, Brueggmann D, Oehmke F, Tinneberg HR, Zygmunt MT, For most of the last century, the management of Muenstedt K. Uterine compression U-sutures in primary postpartum hemorrhage after Cesarean section: fertility preservation with a simple major PPH relied upon the use of oxytocic agents, and effective technique. Hum Reprod 2008;23:74–9. followed by hysterectomy if these failed. However, doi:10.1093/humrep/dem364 14 Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: the last 10 years has seen the introduction of many surgical management of postpartum hemorrhage. Obstet Gynecol useful additional surgical procedures, in particular 2002;99:502–6. doi:10.1016/S0029-7844(01)01643-X © 2009 Royal College of Obstetricians and Gynaecologists 237
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