Postpartum Hemorrhage / 4T's Plus Model / Lower Uterine Segment Compression (LUSC)

2. The New Chapter of PPH
4T’s is not enough
Why?

3. Objectives
• To show the importance of lower uterine segment to PPH
• To propose a new idea regarding the mechanism of PPH which
is 4T’s plus model
• To propose a new management of PPH with lower uterine
segment compression (LUSC) maneuver
• To further build on the existing knowledge about PPH

4. Major causes of mortality
Causes of maternal mortality Causes of newborn and child mortality

5. World Health Organization
(WHO)
Millennium Development Goal; MDG5 (1990-2015)
Target  MMR ¾ by the year 2015 (5.5 per year)
Result = 2.3 per year
2015 - MMR (Developing Country) = 239/100,000 LB
- MMR (Developed County) = 12/100,000 LB

6. From Millenium to Sustainable Development Goals. Global Strategy for Women,
Children and Adolescents’ Health 2016-2030

7. United Nations General Assembly 2015, in New York, UN
Secretary General Ban Ki-moon launched the Global Strategy for
Women’s, Children’s and Adolescents’ Health, 2016-2030. The
Strategy is a road map for the post-2015 agenda as described by
the Sustainable Development Goals.
Sustainable Development Goal 3
Target  MMR 70/100,000 LB by the year 2030 with no country having
MMR more than twice (140/100,000 LB)
Sustainable Development Goals (SDG)

10. Atonic PPH
Ref. Knight M, Callaghan WM, Berg C et al Trends in postpartum hemorrhage in high resource
countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group
pregnancy and Childbirth 9, Article number: 55 (2009)

11. Why is Atonic PPH important?
• 80-90 % of total PPH cases are Atonic PPH.
• The exact cause of Atonic PPH remains unknown. Meanwhile,
the effect of the known risk factors is only around 10%.
• Atonic PPH has the highest mortality rate and morbidity rate
due to its large proportion to all PPH cases.
• Most importantly, the incidence rate of Atonic PPH is still going
up without any sign of stopping.

12. The prevention and treatment of postpartum haemorrhage:
what do we know, and where do we go to next?
Ref. A Weeks The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go
to next? BJOG 2015
As a result, many questions still remain unanswered
about the management of PPH:
What do we know, and where do we go to next?

14. AMTSL (2012)
• A uterotonic, preferably oxytocin, 10 IU IM immediately after all
births, including caesarean sections (recommended)
• Delayed (1-3 minutes after birth) cord clamping (recommended)
• Controlled cord traction for delivery of the placenta (optional)
• Fundal massage (optional)
• Regular and frequent assessment of uterine tone by palpation of the
uterine fundus after delivery of the placenta (recommended)
Now Known to be almost all due to the uterotonics
Prevention of PPH
Ref. World Health Organization. WHO Recommendations for the PPH prevention and treatment of postpartum
hemorrhage. Geneva: WHO; 2012.
also see Ref. Escobar MF, Nassar AH, Theron G, et al. FIGO recommendations on the management of postpartum
hemorrhage 2022 . FIGO Safe Motherhood and Newborn Health Committee ; 2022.

16. PPH treatment
Medication : Uterotonics
: Hemostatic drugs
Surgical Intervention
: Uterine tamponade
: Bimanual uterine compression
: Artery ligation
: Compression suture
: Radiologic embolisation
: Hysterectomy
Compression device
: Non-pneumatic anti-shock garment (NASG)

17. Figure 1. Routine third stage management
(im= intramuscular; imm= intramyometrial; iv= intravenous)
Ref. A Aflaifel. Postpartum heamorrhage : new insights from poblished trials and the development of novel management options. University of Liverpool. 2015

19. Figure 2. The treatment of atonic PPH
(E= Ergometrine; Ox= Oxytocin; E/OX= Syntometrine; PG= prostaglandin; im
= intramuscular; iv= intravenous; imm= intramyometrial)

21. PPH management guideline
Prevention : AMTSL (Active management
of third stage of labor)
Treatment : Medications
Mechanical
Surgery
Rescue Zone
Killing Zone
“Atony is too late”
“Prevention is better than cure”

23. Prevention of PPH by AMTSL did not achieve
adequate reduction in Atonic PPH incidence
“4T’s Plus Model”
Can manage and completely eliminate Atonic PPH

24. The turning point
Uterine atony must be separated into 2 types
1. Flaccid uterus is a result of uterine overdistension or from
medication which will happen immediately after delivery.
2. Hypoxic uterus is a result of uterine hypoperfusion which
persists until uterine muscle becomes hypoxic, followed by
its relaxation.

25. 4T’s Plus Model
What is the add on 5th?
Lower uterine segment bleeding or lower uterine segment
atony (LUSA) is the cause of hypoxic uterine atony, which is
also the origin of the problem of uterine atony that we see
everyday.

27. Etiology of lower uterine segment bleeding
Body
Lower segment
Body
Lower segment
Normal bleeding more bleeding more bleeding

28. 4T’s Plus Model
Ref. Chantrapitak W, Anansakunwat W, Suwikrom S, Wattanaluangarun R. The correlation of lower uterine segment atony after
delivery with atonic postpartum hemorrhage. Journal of Charoenkrung Pracharak Hospital 2019;115: 1-13.
.
PPH with Associated Risk Factors 10%
PPH without Associated Risk Factors 90%
Tone
(Flaccid Uterus)
Thrombin
Trauma
Tissue
Lower Uterine Segment Bleeding
LUS placenta implantation / LUS atony
Extraordinary Bleeding
Continuous Excessive Bleeding
Uterine Hypoxia
Uterine Atony
PPH
Uterine Hypoxia Uterine Atony

30. Vicious Cycle of PPH
The mechanism of hypoxic uterine atony cycle is as followed:
1. Excessive bleeding after placental delivery - LUSA (despite good
uterine contraction)
2. Persistent bleeding until >1000 ml
3. Uterine muscle hypoxia from hypoperfusion resulting in uterine
muscle relaxation and complete the cycle of PPH

31. Ref. Michael J Taggart ,Susan Wray. Hypoxia and smooth muscle function: key regulatory events during
metabolic stress. J Physiol. 1998 Jun 1; 509(Pt 2): 315–325.
Changes in uterine force and myosin
phosphorylation with cyanide

33. Management of LUSA
Since we know the origin of the problem which is PPH, what can we do
to deal with this? Lower uterine segment has thin muscle layer and
thus cannot achieve adequate contraction in case of low placental
attachment, resulting in profuse bleeding after delivery of the
placenta (lower uterine segment bleeding) and start off the vicious
cycle of [ bleeding  hypoxia  atony ] in which oxytocics and
uterine massage become ineffective
Hence, Mechanical compression directly on the bleeding site is the only
effective solution such as bimanual uterine compression or
compression suture .....etc.

35. Both Bimanual uterine compression and compression suture are used
to treat PPH which can already be considered late.
This is because we should prevent PPH in the first place, and what
can help us in this is “lower uterine segment compression maneuver
(LUSC)”
LUSC is directly beneficial in preventing PPH caused by lower uterine
segment atony (LUSA)
Lower Uterine Segment Compression Maneuver (LUSC)

36. Tip
“Use LUSC immediately in case of abnormally
profuse bleeding after placental delivery”
The incidence rate of LUSA is low normally.
Therefore, it is not necessary to use LUSC in cases without
abnormal bleeding after delivery
(which also means that there is no LUSA).

38. 1. Chantrapitak W, Srijanteok K, Puangsa-art S. Lower uterine segment compression for management of early postpartum
hemorrhage after vaginal delivery at Charoenkrung Pracharak Hospital. J Med Assoc Thai. 2009 May; 92(5): 600-5.
2. Chantrapitak W, Srijuntuek K, Wattanaluangarun R. The efficacy of lower uterine segment compression for prevention of early
postpartum hemorrhage after vaginal delivery. J Med Assoc Thai. 2011 June; 94(6): 649-56.
3. Anansakunwat W, Iamurairat W, Boonyoung P. Lower Uterine Segment Compression for 20 Minutes to Prevent Early Postpartum
Hemorrhage. J Med Assoc Thai 2018; 101 (9): 1151-6.
4. Chantrapitak W, Anansakunwat W, Suwikrom S, Wattanaluangarun R, Puangesaart S. Postpartum Hemorrhage Outcome in
Lower Uterine Segment Compression Maneuver: A 20-Year Experience in Charoenkrung Pracharak Hospital. J Med Assoc Thai
2018; 101 (4): 495-500.
5. Hongranai S, Sopajaree C , Ruangrit P, Dongnit W. Effect of Duration of Lower Uterine Segment Compression Immediately after
Placental Delivery on Amount of Blood Loss in Normal Delivery. Thai red cross nursing journal 2019;12(2)
6. Chantrapitak W, Anansakunwat W, Suwikrom S, Wattanaluangarun R. The correlation of lower uterine segment atony after
delivery with atonic postpartum hemorrhage. Journal of Charoenkrung Pracharak Hospital 2019;115: 1-13.
7. Chantrapitak W, Suwikrom S, Khemarangsan V, Boonyoung N, Wattanaluangarun R. The relationship between cervical tear, lower
uterine segment bleeding and lower uterine segment compression maneuver in pregnant women with primary
postpartum hemorrhage. Journal of Charoenkrung Pracharak Hospital . 2021;17(2):10-21
Evidence base of LUSC

40. The technique of applying
compression is essential,
and it can be
learned easily even for
nonprofessional personnel.
The main principles are:

41. 1. The compression should be precisely on lower uterine
segment.
It locates above suprapubic and below the body of the uterus. In
some cases the uterus can be very flexible and sits way above pubic
symphysis, so another hand has to be used to push the uterus down,
preventing it from shifting away. The pressing hand then has to
palpate the underside of the body of uterus. Some patients may
possess wide abdomens, making the uterus possibly be shifted either
to the right or to the left. In those cases, two hands are then again
used; one positioning the uterus in the medial plane and another
compressing it.

42. 2. Apply sufficient pressure.
While pronating towards the uterus, use all 4 fingertips to
apply pressure. Apply as much force as possible but the patient
should not be showing any sign of pain. The person who carries
out the compression will feel that the uterus is being compressed
tightly together. The pressure applied to the uterus should be
similar to that applied to stop bleeding in other parts of the body.

43. 3. Keep the compression consistent.
This is to allow enough time for the blood at the end of blood
vessel to clot. Hence it is important to maintain a strong and
consistent compression. (If the pressing hand gets tired, the other
hand can help with the compression or the hands can be switched
without losing the force of compression.) The result should be
observed after 10 minutes (as minimum). If the bleeding has not
stopped, the compression should be continued. The time used to
check if the bleeding has stopped should be as short as possible.

44. 4. Be swift.
When large amount of blood is observed postpartum,
immediate compression will result in decreased blood loss. The
sooner, the better.

45. 1. As soon as large amount of blood is observed, apply
compression immediately. Only after that then assistance should be
called for. During the compression, the bleeding will stop, allowing
other procedures to be done; preparing drugs or calling assistant team
for examples. In addition, while compressing the uterus, doctors can
examine whether the birth canal has any tear. Another benefit is that when
uterus is pushed cranially, the upper section of vagina will be bloated
(tenting) and the resulting cavity allows for easy detection for any damage.
With much spaces and absence of blood obstructing field of vision, any
wound found can be easily sutured.
Other techniques on how to perform
Lower Uterine Segment Compression

46. 2. If the uterus still feels soft during the compression, the non-
compressing hand should massage the fundus simultaneously.
This will allow quick identification of the location of the uterus
and its lower segment if uterus contracts.

47. 3. Some mothers may have stretchy tummy after giving birth, particularly if
they are slim or gave birth to many children. In such cases, the non-
compressing hand should push the fundus towards the lower segment of
uterus. Some mothers may have tight tummy or thick tummy wall,
particularly if they are primipara or overweight. This will make palpation of
fundus difficult. In such cases, the focus should be on compression of lower
uterine segment alone. However, the force of pressure required is much
more than for slimmer patients with thinner tummy wall, so both hands may
be needed for the compression.

48. It has been decades since the fight against PPH has
started worldwide. Even if the situation has seemed to
improved for the better, it still remains a major problem for
obstetricians which causes loss of many maternal lives.
When we have 4T’s plus model, this may be the
starting point in eliminating Atonic PPH in the near future.
Conclusion

49. We would like to thank every patient, every colleague, and
Charoenkrung Pracharak hospital for helping us in this
endeavor in reaching this conclusion.
We also would like to thank the authors of every research
and article for their data and insight especially those that have
been referenced to in this presentation.
Thank you