PPH Surgical management

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The Obstetrician & Gynaecologist 10.1576/toag.11.4.231.27525 http://onlinetog.org 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: p.steer@imperial.ac.uk
(corresponding author)
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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
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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
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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.
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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
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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).
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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
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