Chapter 27 Operative Management of Postpartum Hemorrhage: Uterine Compression and Cesarean Hysterectomy

This chapter will discuss operative management of postpartum bleeding. Though the major emphasis of this lab experience is operative management of postpartum hemorrhage (PPH), a general review of the principles of diagnosis and initial medical management will also be presented.

Learning Objectives

By the end of the ASSET course, participants should be able to do the following:

1. Describe indications for operative management of postpartum hemorrhage (PPH).
2. Describe techniques for compression sutures, Bakri balloon placement, and uterine artery ligations for controlling PPH.
3. Understand indications and describe techniques for cesarean hysterectomy.
4. Demonstrate the steps in surgical exposure of the uterus, ligation of uterine arteries, and cesarean hysterectomy.

General Considerations

• PPH is a common and potentially life- threatening event most commonly defined as estimated blood loss greater than one liter after either vaginal or cesarean delivery, a decrease in hematocrit by 10 percent, and/or the need for transfusion.
• PPH is most common at the time of cesarean section.
• Identify the source of PPH:
  • Tone — The majority of cases are caused by uterine atony, and medical management largely targets this mechanism.
  • Iatrogenic — At cesarean section, extension of the uterine incision can lacerate bordering vessels. At vaginal delivery, bleeding from cervical or perineal lacerations may occur.
  • Tissue — Retained placental fragments after vaginal delivery, or an abnormal placenta (accreta, previa, etc.) encountered at the time of cesarean section, can worsen bleeding and prevent effective contraction of the uterus.
  • Thrombin — Coagulopathy, either preexisting or as a result of ongoing bleeding
• Indications for operative management:
  • Following vaginal delivery, continued bleeding that is unresponsive to medical interventions, or ongoing hemodynamic instability
  • During cesarean section, significant bleeding that is unresponsive to uterine massage or uterotonics, or bleeding resulting from vascular injury or abnormal placentation

Initial Management

• Identify the bleeding source and resuscitate the patient, activating the massive transfusion protocol to achieve balanced resuscitation.
• Identify whether the placenta is intact and perform a manual sweep of uterus, either transvaginally or through the hysterotomy, removing any remaining tissue or membrane fragments.
• Consider abdominal sonogram to evaluate for retained products.

Atony

• Atony is caused by failure of the uterus to contract around the site of placental detachment.
• First-line treatment is with bimanual uterine massage (Figure 1 for vaginal delivery, and Figure 2 for cesarean section).
• Medication management follows quickly after uterine massage (Table 1).

Table 1: Medications/Dosage for Postpartum Hemorrhage*

*Adapted from American College of OB/GYN Practice Bulletin #183: Postpartum Hemorrhage, Oct 2017

• Operative management with compression or ligation sutures is indicated for unresponsive atony, placenta previa or suspected accreta, or when used with other adjunct treatments like tamponade devices.
  • The most common suture used is 0 or 1-chromic.
• The B-Lynch Suture (Figure 3) is performed as follows:
  • The suture enters inferior to the uterine incision and exits above the superior edge of the incision.
    • In most cases, the hysterotomy will have already been closed; it is not reopened, but the sutures are placed in the same locations.
  • The suture is passed over the top of the uterus and through the posterior uterus at the same level and same side as the suture previously passed through either side of the hysterotomy.
  • The suture is passed laterally across the posterior side of the uterus and then brought back over the top of the uterus.

• The suture is then passed across the hysterotomy incision, from superior to inferior, on the side of the hysterotomy opposite to where the suture started.
• The assistant should then manually compress the uterus as the surgeon ties down the suture.
• The Hayman suture (Figure 4), which is an alternative to the B-Lynch suture, is performed as follows:
  • A straight needle is placed though the lower uterine segment from anterior to posterior, just above the bladder reflection.
  • Two to four sutures are placed and then tied across the top of the fundus to effect uterine compression.
  • If necessary, horizontal sutures can also be placed for specific problem areas.
• The O’Leary suture (Figure 5) is a rapid method for uterine artery ligation to decrease flow to the uterus and is performed as follows:
  • A suture is placed at the level of the cervical os around the uterine arteries bilaterally.
  • Two to three centimeters of myometrium should be included in the stitch, which is passed through the avascular area of the broad ligament lateral to the uterine artery. This should be done in a single pass to decrease the risk of vessel/ureter injury that comes with multiple attempts.
  • The process can be repeated at the superior portion of the uterine artery.
  • An attempt should be made to identify and avoid the ureter prior to stitch placement. If this is not possible, palpate the uterine artery, pinch and retract the tissue lateral to the artery, and then place the suture medial to your fingers to avoid the ureter.

• Intrauterine tamponade devices
  • The Bakri balloon (Figure 6) is a common tamponade device that can be placed either through the vagina during vaginal delivery or via the hysterotomy at the time of cesarean section, with the distal end pulled through the cervix and vagina.
  • The balloon is filled with 500 mL of sterile fluid, placed on tension, left in place for 12–24 hours, slowly emptied at a rate of 100 mL per hour, and then removed.
  • The balloon can be used alone or after uterine compression suture placement. The device can also be augmented with vaginal and uterine packing.
  • If the commercial device is unavailable, a “homemade” uterine tamponade balloon can be created with a condom and Foley catheter.
• Endovascular control of postpartum hemorrhage
  • Transcatheter embolization of the uterine arteries is an alternative to the techniques described above.
  • Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been increasingly used as an adjunct to hemorrhage control in postpartum hemorrhage, recognizing that this is only a temporizing measure while preparing for one of the definitive procedures previously described. The technique for REBOA is described in chapter 22 of this manual.

Peripartum Hysterectomy

• Hysterectomy should be considered when all other interventions for peripartum hemorrhage have failed.
• Hysterectomy can also be considered as a planned procedure with suspected accreta. This must be discussed with the patient, as it will result in permanent sterilization.
• Exposure via Pfannenstiel incision was discussed in chapter 26.
• A vertical incision should be considered when placental abnormalities are suspected, or in women with history of multiple cesarean sections. A self-retaining retractor should be used (Figure 7).
• If needed, control active bleeding before starting the hysterectomy by clamping the uterine arteries prior to beginning dissection (Figure 11).
• Curved Kelly clamps are placed as close to the uterus as possible across each fallopian tube and utero-ovarian ligament bilaterally (Figure 8), and the tissue is divided. Take care to avoid the vasculature that is engorged due to pregnancy. These pedicles can be sutured after the uterine arteries are secured.
• Large absorbable sutures are placed 1 cm proximal and 1 cm distal to the area of planned division of the round ligament. The round ligament is then divided, with the incision extended inferiorly into the broad ligament 1–2 cm (Figure 9).
• If a bladder flap was made as part of the cesarean section, then ensure adequate exposure for the hysterectomy. Identify the ureters in the retroperitoneal space (Figure 10).
• Open the posterior leaf of the broad ligament, with extension inferomedially toward the uterosacral ligaments.
• The uterine vessels are skeletonized, doubly clamped, and divided prior to ligation, taking care to avoid the ureter (Figure 11).
• A more efficient option for ligation of the uterine vessels is to use a surgical stapler. This must be held against the uterus to avoid the ureter.
• A supracervical technique is most often used, as the cervical os is difficult to identify in a patient who has been in labor with a dilated/effaced cervix.
  • After ligation of the uterine arteries, the uterus is amputated from the cervix, with an attempt to make the incision just above the internal cervical os. A V-cut can be made to help with closure (Figure 12).
  • The cervical stump is then closed using figure-of-eight absorbable sutures (Figure 13).

• If the patient was in advanced labor and the cervix is dilated, it can be more difficult to identify the cervical edges. In these cases, careful inspection after removal of the uterus is important to make sure you adequately close the cervical opening.
• Inspect all surrounding structures for injury.