Uterine brace sutures are a uterine-sparing surgical technique for treating postpartum hemorrhage when pharmacological methods and other interventions have failed. The document discusses various uterine brace suture techniques including B-Lynch suture, Cho suture, Hayman suture, and Pereira suture. It notes that the ideal uterine brace suture provides even compression of the uterus without transfixing the uterine walls to control bleeding while minimizing risks of infection and effects on future fertility. The document calls for a large randomized controlled trial to directly compare uterine artery ligation to uterine brace sutures and establish their long-term impacts.

1. Uterine Brace Sutures:
The solution before the last!!!
Mahmoud Abdel-Aleem
Assistant Professor of Obstetrics and
gynecology

3. • What is the role of uterine brace?
• What is the type of uterine brace suture to be
done?
• What is the ideal uterine brace suture?
What do we need to discuss?

4. INTRODUCTION

5. • Postpartum hemorrhage (PPH) is a nightmare
for every obstetrician regardless of the level of
obstetrician, patient condition or place of
delivery.
• The hierarchy for management for PPH is
preset throughout the world.

6. • What makes the outcomes different in cases of
PPH is the readiness of the obstetrician and the
place of delivery to manage promptly these cases.
• Obstetricians should start by combined physical
and pharmacological methods. If these fail, first
exclude genital trauma, and retained contents.
• If neither is present, then surgery should have its
place without delay.

7. • Surgery is either:
– Uterine sparing surgery
• Vascular ligations
• Uterine Brace sutures.
– Hysterectomy.

8. Uterine Sparing Surgery
Uterine artery ligation Uterine brace
Experience Requires experience Relatively little experience.
How old? 60 years old 15 years old
Techniques Same; no modifications Lynch
Cho
Ouahba et al…………..
Immediate risks May be risky
Not as rapid as brace
Without risk of vessel or
ureter injury
Intermediate risks Free Free
Remote risks Well-studied and well
documented not to affect
the fertility potential.
?????

9. • Uterine artery ligation versus uterine brace
sutures
– Former is well-studied and well documented not to
affect the fertility potential.
– Later is still needed to be evaluated.
• Uterine artery ligation, which is a well-assessed
procedure, and as simple, rapid, and effective as B-
Lynch suture, should currently be the first line
uterine-sparing surgical procedure for postpartum
hemorrhage.

10. Is it important to learn uterine brace
suture?
Yes
• The Confidential Enquiry into maternal deaths in UK has
recommended the use of B-Lynch suture.
• The CEMACH report has recommended formal training for B-
Lynch technique.
• The high success rate of various sutures warrants including
this type of procedure in controlling PPH in curriculum for
trainees.
• It has the advantage of being applied easily and rapidly, and
should be taught to all trainees in obstetrics.

11. Aim of uterine sparing surgery
• The aim is not only to control PPH with the lowest
morbidity but also to preserve a theoretically
functional uterus that will not compromise the
patients’ subsequent fertility and obstetric
outcome
• To leave a functioning uterus:
– Menses.
– Fertility.
– Carrying a baby to term.

12. • Immediate desirable effect.
– Control of PP hemorrhage.
• Mid-term effects.
– Normal shape of the uterine cavity.
• ??? Hysteroscopy.
• Long-term effects
– Fertility.
– Obstetric outcome.

13. UTERINE BRACE SUTURE

14. Uterine brace
sutures
With opening
of the cavity
B-lynch
Nelson
B-hal
Marasinghe
Without opening
of the cavity
With transfixing
Targeted:
Cho
Transverse:
Quabha
Vertical:
Hyeman
With no
transfixing
Mixed:
Piererra
Horizontal:
Hackethal

15. Lynch Involves lower uterine incision to check for emptiness of cavity and
brace suture to the uterus without transfixing the anterior and posterior
uterine walls
CHO Multiple square suturing to approximate anterior and posterior
uterine walls especially in areas of heavy bleeding
Hayman Two vertical sutures are place over the fundus effectively sewing
the anterior and posterior walls together and one cervicoisthmic
suture anteroposteriorly
Pereira Multiple sutures applied longitudinally and transversely around the
uterus. Placement of sutures involved a series of bites inserted
superficially, taking only the serous membrane and the subserous
myometrium without penetrating the uterine cavity
Ouahba Four sutures placed on the uterus with one transverse suture in the
middle of the fundus, one transverse suture in the lower segment and
one suture on each horn
Hackethal Uterine compression using 6–16 horizontal interrupted U-sutures
Bhal Variation of B-Lynch sutures using two sutures.
Nelson Sandwich technique with concomitant use of Bakri balloon in addition to
B-Lynch suture.

16. Results of uterine brace suture
74/ 7 72/74

18. Uterine Brace Suture
B-Lynch C, Coker A, Lawal AH,
Abu J, Cowen MJ. The B-
Lynch surgical technique
for the control of massive
postpartum haemorrhage:
an alternative to
hysterectomy? Five cases
reported. Br J Obstet
Gynaecol 1997;104:372–5.

19. Principles of B-lynch operation
1- Correct positioning of the patient in Lloyd Davis (or Frog Legged) position is
essential.
2- After the uterus is exteriorised, bimanual compression should be done to
test for potential success.
3- A transverse lower segment incision made and the uterine cavity checked,
explored and evacuated if required.
4- The B-Lynch suture is applied correctly with even tension, taking care that
there is no shouldering. This should allow free drainage of blood, debris
and inflammatory material.
5- Once haemostasis is achieved and the vagina is checked, the abdomen can
be closed.

20. A No 1 polyglecaprone-25 suture is placed in the uterus 3 cm below the right lower edge of the uterine
incision and 3 cm from the right lateral border of the uterus (chromic catgut was used in the
original study).
The suture is then threaded through the uterine cavity and emerges at the upper incision margin 3 cm
above and approximately 4 cm from the lateral border (because the uterus widens from below
upwards).
The suture (now visible) is passed over to compress the uterine fundus approximately 3–4 cm from the
right cornual border. It is then fed posteriorly and vertically to enter the posterior wall of the
uterine cavity at the same level as the upper anterior entry point.
The suture is pulled under moderate tension assisted by manual compression exerted by the first
assistant and then passed back posteriorly in a horizontal direction through the same surface
marking as for the right side.
Then it is fed through posteriorly and vertically over the fundus to lie anteriorly and vertically
compressing the fundus on the left side as occurred on the right. The needle is passed in the same
fashion on the left side through the uterine cavity and out approximately 3 cm anteriorly and below
the lower incision margin on the left side.
The two lengths of suture are pulled taut assisted by bi-manual compression.
A polyglecaprone-25 suture is recommended because it is user and tissue friendly with uniform tension
distribution and is easy to handle.

21. Some reported effects
1- A thin fibrous band between the anterior and
posterior wall of the uterine cavity in the
lower uterine segment in one case.
2-The possible marks of a previous B-Lynch
procedure, i.e. fundal grooves, that did not
interfere with the pregnancy.
3-Some oligo-hypomenorrhea.

22. Bhal
Two instead of one
suture
The reason for
modification of B-Lynch
approach was due to
the reduction in use of
catgut and the ease of
using two rather than
one suture to achieve
compression.

23. Marasinghe modification
of B-Lynch

24. Nelson operation
(uterine sandwich)
• B-lynch + intrauterine balloon.

25. Cho suture
It involves piercing the uterus
multiple times (in one case the
uterus was pierced 32 times) and
also it involves suturing the anterior
and posterior wall together.
The drawback of this technique is
the possibility of pyometra and
Asherman’s syndrome was reported
in one case.
The efficiency of these techniques
may be less than the B-Lynch
technique

26. Cho
1. An arbitrary point in the heavily bleeding area is selected and the
entire uterine wall from the serosa of the anterior wall to the
serosa of the posterior wall, through the uterine cavity, is sutured.
2. Another arbitrary point 2–3 cm lateral above or below the first
suture point is selected, and the entire uterine wall from the
posterior to the anterior is sutured again. From another point in
the heavily bleeding area, 2–3 cm lateral above or below the
second suture point, uterine cavity walls are penetrated again, this
time from the anterior to posterior.
3. Then, from the third suture point, another point is set so the
points form a square and penetrate the uterine walls from the
posterior to the anterior. Finally, a knot is tied as tightly as
possible.

27. Hayman
It is quicker to perform but
does not allow for
exploration of the uterine
cavity under direct vision.
Four vertical sutures are
inserted passing the needle
from front to back above the
bladder reflection in the line
where a lower segment
incision would have been
made and tied anteriorly.

28. Pereira
Series of longitudinal and
transverse sutures around
the uterus.
Placement of the sutures
involved a series of bites
inserted superficially taking
only the serous membrane
and the sub serous
myometrium without
penetrating the uterine
cavity.

29. • This technique does not involve penetrating uterine
cavity and therefore decreases the risk of infection.
• The risk of a loop of bowel or omentum coming
between the uterus and the suture with puerperal
involution is reduced.
• Each suture is made up of a succession of small bites of
the uterus, it results in distributing the pressure more
evenly and therefore more effective compression.

30. Quahba
Four sutures placed on
the uterus with one
transverse suture in the
middle of the fundus,
one transverse suture
in the lower segment
and one suture on each
horn

31. Modified U suturing technique (Hackethal)
It involved placing 6–16 horizontal
interrupted sutures starting at the
fundus and ending at the cervix.
The average time taken was 8.4
min.
It provides more effective
compression during uterine
involution because several areas
are compacted and that if one
suture fails, the remainder is not
affected.

32. TAKE HOME MESSAGE

33. The ideal Uterine Compression Suture
1- Pre-test; successful bimanual compression test.
2- Timing: don’t be late in doing it, also don’t be
late in awaiting results. Look for vaginal bleeding.
3- Opening the cavity?
4- Using Monocryl suture.
5- Avoid shouldering. i.e. even compression.
6-Not transfixing the uterus.
6- Guarding against infection.

34. RESEARCH AGENDA

35. • Conducting an RCT to address differences
between uterine artery ligation and uterine
brace sutures. This study will provide an
evidence-based answer about the efficacy and
differences in long term effects. This has to be
powered enough with definite outcomes with
the share of many centers.