Simple and easy to learn quick procedures for surgical management of PostPartum Haemorrhage

1. Dr. Rakhi Gajbhiye
MBBS,MD (MGIMS Sevagram)
Director Mauli Women’s
Hospital,Nagpur
Published 9 papers in various journals
Contributed a chapter in the Hands on
hysterscopy book published in 2016
Delivered talks in various conferences
Member of
IMA,FOGSI,NOGS,IMS,AMF,ISAR,MSR

2. Surgical management of PPH
3.11.17
3.11.17

7. SURGICAL MANAGEMENT OF PPH

8. Surgical Interventions
A wide range of Surgical interventions have
been reported to control PPH that is
unresponsive to medical or mechanical
interventions

9. • Compression sutures
B Lynch suture
Hayman suture
CHO sutures and U sutures
• Ligation of uterine,ovarian,ant.div. int. iliac
vessel
• hysterectomy

10. B Lynch suture
• Christopher B Lynch developed it in 1997
• Objective-To compress the uterus without
occluding the UA or the uterine cavity.
• Ind: Atonic PPH,PPH with coagulopathy
• Suture: absorbable-Polyglactin ,Chromic .
• Procedure: A compression test is done and if
the uterus responds this suture is attempted.

11. B-Lynch suture
Procedure:Take a suture 3cm below the incision line and
come out 3cm above the line.
Take the suture over the fundus and come posteriorly.
Now take a horizontal suture in the lower segment of uterus
posteriorly.
Take this suture over the fundus and come anteriorly.
Insert a suture again 3cm above the incision ,then come out
3cm below the incision .
Tell the assistant to compress the uterus while u tie the knot.

14. Hayman Compression suture
Ind: Atonic PPH,PPH with coagulopathy.
Easy to perform.
Does not require an incision on the uterus.
Pair of vertical compression sutures passed
anteriorly to posterior uterine wall and tied
over the fundus.

15. • Procedure:A delayed absorbable suture like
polyglactin on a straight and blunt needle is
used to transfix the uterus from anterior
uterine wall to the posterior uterine wall half
an inch medial to the angle just above the
reflection of the bladder.
• The assistant compresses the uterus while you
tie a knot at the fundus . The walls get
compressed and help to achieve homeostasis
by effectively producing tamponade.

18. Hayman suture

19. CHO sutures
Indications:Atonic PPH,placental bed bleeding
Procedure: Square stitches are taken by
introducing the needle through anterior uterine
wall at or opposite to the site of bleeding sinuses
and brought out through post wall,reinserted
postero-anteriorly and tied,approximating the two
uterine walls thereby closing large sinuses.

22. Complications of
compression sutures
Even though there are no large published data , there
are several small observational studies and case reports
of the complications .

23. Complications of
compression sutures
Short term consequences:
• Haemorhage due to cut through of sutures
• Haematometra,Pyometra
• Partial or complete uterine wall necrosis due to ischaemia.
Long term consequences:
• Bowel herniation and Int. obstr. due to dog ear loop of
suture
• Asherman’s syndrome- quoted risk-1 in 4

24. Ligation of vessels
Uterine artery ligation
Ligation of anastomosis of Ovarian
and uterine artery.
ligation of ant. div.of internal iliac
artery

25. Uterine artery
ligation(O’Leary stitch)
Procedure:Bladder is pushed down to avoid
injury to ureter.
index finger is introduced behind broad ligament
to identify avascular space
Take a bite through the avascular space 2-3cm
below the level of uterine incision ,then a bite
through the myometrium and tie it.
In case of normal del in lat ut border at the
junction of upper and lower ut segment.

26. 10-15% of bleeding will stop with U/L UA
ligation
70-90% with B/L UA ligation ,as during
pregnancy uterine artery supplies 90% of blood
to uterus.
Additional lower stitch about 2cm below the
first ligature(cervicovaginal br & ascending br)
can also be taken

27. O’Leary stitch

29. Ligation of utero-ovarian
anastomosis
Procedure:Hold the FT with babcocks
Take a bite below the ovarian ligament and
come out from avascular area below the FT
and tie

30. ligation of utero-ovarian
vessels

32. Internal iliac artery ligation
(ant branch)

33. Internal Iliac Artery
Ligation
• Ind: Before or after hysterectomy for PPH
• Continuous bleeding from the broad ligament base;
profuse bleeding from pelvic side-wall or vaginal angle
• Diffuse bleeding without clearly identifiable vascular bed
• Ruptured uterus in which uterine artery may be torn at
its origin from internal iliac artery
• Where extensive lacerations of cervix have occurred
following difficult instrumental delivery

34. Internal iliac artery ligation
(ant branch)
Procedure:Give incision from the lateral end of
round ligament to the base of infundibulo-
pelvic lig.Open broad ligament to approach
retroperitoneal space. Search for the ext iliac
vein.Ureter is seen hugging medial peritoneal
fold.Internal iliac artery is identified and
doubly ligated at least 2cm from its origin.

35. IIAL

36. Hysterectomy
• Best immediate option
• When uterine atony is unresponsive to medical and surgical
measures —Where facilities for embolization are not available —
Obstetrician not well versed with technical aspects of
conservative surgical procedures or iliac artery ligation
• Indications :
1. Uterine rupture secondary to obstructed labor , Previous
caesarean section
2. If rupture is extensive & haemorrhage cannot be stopped by
suture of ruptured area

37. MM of traumatic causes
Exploration and suturing of vaginal tears,
paraurethral tears,Cx tears
Vulval and Broad ligament haematomas

38. Summary
With so many women dying each year globally,
we should work hard at all levels to save every
mother and reduce the MMR.
In situations where medical management has
failed to control the bleeding, a prompt
decision should be taken for mechanical
interventions and if need be surgical
interventions to save life.

39. Save the life of the one who gives birth to a new life