Fetal and Maternal Medicine Review 2006; 17:2 105–123

C 2006 Cambridge University Press

doi:10.1017/S0965539506001744

THE SURGICAL MANAGEMENT OF POST PARTUM

HAEMORRHAGE

CHRISTOPHER BALOGUN-LYNCH AND NAOMI WHITELAW

Department of Obstetrics and Gynaecology, Milton Keynes Hospital NHS Trust, Milton Keynes,
United Kingdom.

INTRODUCTION

The historical background of post partum haemorrhage (PPH) dates back to the 17th
century. William Smelley published his famous treatise of the theory and practice of
midwifery in 1752. His observations sent a clear message to practitioners of the time
that haemorrhage in midwifery can be a messenger of death.
“This hazardous haemorrhage is known by the violence of the discharge, wetting
fresh cloths as fast as they can be applied; from the pulse becoming low and weak, and
the countenance turning pale; then the extremities grow cold, she sinks into faintings
and, if the discharge is not speedily stopped, or diminished, is seized with convulsions
which often terminate in death”.1
Together with the rapidity of blood loss, a loss in excess of 1000ml following
delivery is used as a clinical diagnosis of major post partum haemorrhage (PPH).2
Primary PPH occurs in approximately 4% of vaginal deliveries and 6% of caesarean
deliveries, with atony being the commonest cause (75–90%).3 In a study of 48,865
women who delivered in the London area in the United Kingdom, between 1997
and 1999, severe PPH was diagnosed in 6.7/1000 deliveries.4 The World Health
Organisation estimated 20 million annual maternal morbidities due to haemorrhage.5
In the developing world, the risk of maternal death from PPH is approximately one
in 1000 deliveries.6 PPH accounts for up to 4% of maternal deaths in the United
States.7 Moreover it played a significant role in 15 maternal deaths in the 2000–
2002 Triennial Confidential Enquiry into Maternal Deaths in the United Kingdom.8
The Trienial Report on Confidential Enquiry into Maternal Death has become a
good and reliable source of reference to understanding the efficacy of management
of PPH. In 2004 the Confidential Enquiry into Maternal and Child Health (Why
Mothers Die 2000–2002) reaffirmed that catastrophic haemorrhage is a persistent
problem.8

Christopher B-Lynch, Department of Obstetrics and Gynaecology, Milton Keynes Hospital NHS Trust,
Standing Way, Eaglestone, Milton Keynes MK6 5LD United Kingdom
106 Christopher Balogun-Lynch and Naomi Whitelaw

Table 1 Common causes of postpartum haemorrhage

Uterine overdistention, atony Disorders of placenta,

and disseminated intravascular uterine and genital tract
Pre-existing conditions coagulation (DIC) trauma

Thrombocytopenic purpura Polyhydramnios Acute uterine inversion

Hypertensive disease Multiple gestation Lower segment caesarean
section
Uterine myoma Macrosomia Operative vaginal delivery
Anticoagulation therapy Prolonged labour Precipitate delivery
Coagulation factor deficiency Chorionamnionitis Previous uterine surgery
Systemic disease of Tocolytic agents Internal podalic version
haemorrhagic nature
Consumptive coagulopathy Halogenated anesthetic agents Breech extraction
Mullerian malfusion High parity Mid-cavity forceps
Anaemia Abruptio placentae Obstructed labour
Courvelliar’s uterus Abnormal fetal presentation
Placenta previa Vacuum site extraction
Placenta accreta, increta, percreta Placental subinvolution
Retained products of
conception
Ruptured uterus

PPH remains among the top five causes of maternal death in both the developing
and developed world. It is estimated that over 125,000 women in developing countries
die of PPH each year out of 125 million births.9 In the UK, the risk of maternal
death from PPH is 1 in 100,000 deliveries.10,11 When haemorrhage occurs it can be a
sudden and potentially life threatening event, usually and frequently unpredictable in
its occurrence. Predictability, expediency and competent management protocols are
essential.
With the increasing incidence of communicable disease worldwide and the risk
of surgical contamination with blood products, it is essential that conservative
methods of treating PPH, such as the recently described brace suture techniques,
should make a significant contribution in not only life saving endeavours but
also fertility preservation and costs in managing this problem. The reduction
in maternal morbidity and mortality must be the corner-stone of good obstetric
practice. The recent confidential report on maternal death from obstetric haemorrhage
(2000-2002) shows obstetric care was substandard in 12 out of 15 (80%) of
cases.8
Table 1 illustrates some of the risk and predisposing factors to PPH.12 It is important
to note that imaging has played an important role in predicting mothers at risk of
PPH. Mothers who have had previous uterine surgery, particularly previous caesarean
section, must be scanned for abnormal placentation prior to a repeat elective caesarean
section.8,13 A key factor in the surgical management of PPH must be the awareness of
predisposing factors.2,3 With the constant awareness of risk factors coupled with the
 The surgical management of post partum haemorrhage 107

assistance of a regularly updated labour ward protocol and fire drill, significant inroads
can be made in controlling acute and chronic blood loss thereby reducing the need
for surgical intervention. Obstetricians and maternity staff must be constantly aware
of the co-existence of other risks of maternal death such as pulmonary embolus and
hypertensive disease. These can co-exist or even independently predispose to severe
PPH.
The definition of PPH is traditionally understood as an estimated loss of 500mls
or more of blood following the 3rd stage of labour. It is clear from current
publications that a more realistic estimate is a blood loss of over one litre of
blood.11 Because of the difficulty in the objective assessment of post partum blood
loss, the incidence may vary considerably. There is little doubt that with the
increasing trend towards caesarean birth there will be a simultaneous increase
in the risk of PPH. These observations make it even more imperative that the
maternity care of women who have had previous caesarean sections involves senior
obstetricians.
There are 3 commonly encountered presentations of PPH.
i the acute and significant bleed within the first 24 hours after delivery, irrespective
of mode, commonly described as primary PPH.
ii the recurrent and episodic bleeding of varying quantity that starts after the
completion of the third stage and progressively increases in quantity, not controlled
by conventional medical treatment within 24 hrs and requiring delayed surgical
intervention.
iii patients who have no primary or episodic bleeding after the third stage but
characteristically return between the 9th and 12th day post delivery with significant
or massive PPH.
This last category may represent intercurrent infection which should be treated
with appropriate antibiotics in accordance with prompt diagnosis and exploration
of the uterus if necessary. In pregnancy there is significant increase in cardiac
output in accordance with red cell mass and plasma volume which provide a
compensative reserve for acute blood loss and haemostatic response following massive
haemorrhage.
Management of emergency haemorrhage requires team work. Initially conservative
treatment such as bimanual compression of the uterus may control blood loss
whilst resuscitative measures are undertaken, according to the labour ward protocol,
involving the anaesthetists, haematologists and obstetric team. Standard measures to
control of PPH include uterotonics, such as syntocinon, syntometrine, prostaglandins
or the less commonly used ergometrine. Ergometrine should be used with caution
because of its non selective vaso-constriction effect. In a collapsed patient this can be
hazardous.14,15 Prostaglandin injection into the uterus has met with varying success.
More recently the vaginal administration of misoprostol in haemorrhage secondary
to uterine atony has proved effective.16 Bleeding from surgical incisional sites should
be identified but there are still cases where diagnosis is difficult, bleeding continues
and leads to coagulopathy and the need for more radical surgery. The Brace suture
108 Christopher Balogun-Lynch and Naomi Whitelaw

technique and the pre operative checks described reduce the chance of missing sites
of surgical trauma.17,18 The surgical management of PPH in the past has included the
use of an intra-uterine pack with or without thromboxane,19 thrombogenic uterine
pack,20 ligation of uterine arteries,21 ligation of internal iliac arteries,22 stepwise
devascularisation23 and finally sub total or total abdominal hysterectomy.24 A more
conservative procedure such as the Brace suture technique described by B-Lynch et al
in 1997,17 and selective arterial embolisation may prove more effective than radical
vascular surgery.7 These new non-radical surgical techniques have been successfully
used for the control of menacing PPH. As a last resort subtotal or total abdominal
hysterectomy should be performed.25
It is essential for all those involved in obstetric care to realise that shock may
occur from non-haemorrhagic causes, such as cardiogenic and neurogenic causes,
anaphylaxis, where there is increased permeability of small blood vessels, and finally
sepsis. Shock may also be due to trauma such as following a road traffic accident. In
such cases, the accident and emergency major incident protocol must be followed,
not just to control emergency haemorrhage but also to save the life of the mother and
baby.

SURGICAL MANAGEMENT OF OBSTETRIC HAEMORRHAGE

Treatment for PPH requires a multi-disciplinary approach. Resuscitation, uterotonics,

uterine Brace suture, tamponade, and selective radiological emoblisation of bleeding
vessels have been used successfully. However, failure of conservative management
may warrant more radical surgical intervention. The type of surgical intervention
will depend upon several factors, paramount of which is the experience of the
surgeon. Other factors include parity and desire for future children, the extent of
the haemorrhage, general condition of the patient and place of confinement. Women
at high risk of PPH should not be delivered in isolated units or units ill equipped
to manage sudden, life threatening emergencies. Immediate access to specialist
consultant care, blood products and intensive care are essential.

Bimanual compression

The technique of bi-manual compression of the uterus is shown in Figure 1. This

should be the first line approach to mechanical haemostasis. Compression in itself
may control bleeding by assisting the uterus to use its anatomical and physiological
mechanisms such as the crossover interlinked network of myometrial fibres for
vascular compression and bleeding control. The patient should be placed in stirrups
in the labour ward or in theatre whilst intravenous fluid and appropriate blood
products are replaced. However, not infrequently bimanual compression fails to
achieve haemostasis.
 The surgical management of post partum haemorrhage 109

Figure 1 Bi-manual compression of the uterus.

The B-Lynch Suture Compression Technique

The procedure was first performed in 1989 by the author at Milton Keynes General
Hospital, UK during the management of a patient with a massive PPH.17 The suture
aims to exert continuous vertical compression on the uterine vascular system.

The technique17,18

• Test for the potential efficacy of the B-Lynch suture before performing the procedure

The patient is placed in the Lloyd Davies or semi-lithotomy position. An assistant

stands between the patient’s legs and intermittently swabs the vagina to determine
the presence and extent of the bleeding. The uterus is then exteriorised and bimanual
compression performed. To do this, the bladder peritoneum is reflected inferiorly
to a level below the cervix. The whole uterus is compressed by placing one hand
posteriorly with the ends of the fingers at the level of the cervix and the other hand
anteriorly just below the bladder reflection. If the bleeding stops on applying such
compression, there is a good chance that application of the B-Lynch suture will stop
the bleeding.
110 Christopher Balogun-Lynch and Naomi Whitelaw

Figure 2 Technique of B-Lynch brace sture.

In the presence of coagulopathy, compression will control diffuse bleeding points. If

this is successful, the application of the suture will also succeed. However, application
of the B-Lynch suture is not a substitute for the medical treatment of coagulopathy.

• Suture application

Given that the criteria for the B-Lynch suture are met, the uterus remains
exteriorised until application of the suture is complete. The senior assistant takes over
in performing compression and maintains it with two hands during the placement of
the suture by the principle surgeon.
With the bladder displaced inferiorly, the first stitch is placed 3 cm below the
caesarean section/hysterotomy incision on the patient’s left side and threaded through
the uterine cavity to emerge 3 cm above the upper incision margin approximately
4 cm from the lateral border of the uterus (Figure 2a).
The suture is now carried over the top of the uterus to the posterior side. Over
the fundus the suture should be more or less vertical and lying about 4 cm from the
 The surgical management of post partum haemorrhage 111

cornu. Lateral slippage towards the broad ligament does not occur if the uterus has
been compressed.
The location on the posterior uterus where the suture is re-inserted through the
uterine wall is easy to identify being at the level of the insertion of the uterosacral
ligament (Figure 2). The senior assistant is compressing the uterus as the suture is
fed through the posterior wall into the cavity. This will enable progressive tension to
be maintained as the suture compresses the uterus. Assistant compression also helps
prevent suture slipping and uterine trauma. The suture now lies horizontally on the
cavity side of the posterior uterine wall.
The suture is then passed through the posterior wall and over the top of the fundus
onto the anterior right side of the uterus. (Figure 2) The needle re-enters the right side
of the cavity 3 cm above the incision and 4 cm from the lateral side of the uterus
through the upper incision margin, into the uterine cavity and then again through
3 cm below the lower incision margin.
The assistant maintains the compression as the suture material is milked through
to ensure uniform tension and no slippage. The two ends of the suture are put under
tension and a double throw is placed for security to maintain tension after the lower
segment incision had been closed by either the one or two layer method. The tension
on the two ends of the suture material can be maintained while the lower segment
incision is closed or the knot can be tied first, followed by closure of the lower segment.
If the latter option is chosen, it is essential that the corners of the hysterotomy incision
be identified and stay sutures placed before the knot is tied. This ensures that when
the lower segment is closed, there is no escape of the angles of the incision. Either
procedure works equally well. It is important to identify the corners of the uterine
incision to make sure there are no bleeding points left unsecured.
It is probable that the maximum haemostatic effect only lasts 24 to 48 hours.
Because the uterus undergoes its maximum involutionary process in the first week
after vaginal or caesarean section delivery, the suture probably loses some tensile
strength but haemostasis will have been achieved. There is no need for delay in closing
the abdomen after the application of the suture. The assistant standing between
the patient’s legs swabs the vagina and can confirm that the bleeding has been
controlled.

Application after normal vaginal delivery

If laparotomy is required for the management of atonic PPH, hysterotomy is warranted

to apply the B-Lynch suture. The third stage may have been incomplete or products,
debris and clots retained in the uterine cavity. B-Lynch suture application without
hysterotomy or re-opening of the caesarean section wound increases the risk of
secondary PPH, therefore confirmation that the uterine cavity is completely empty
is essential. Hysterotomy will help to explore the uterine cavity, exclude retained
products of conception, large blood clots and diagnose abnormal placentation.
Furthermore, hysterotomy ensures that the correct application of the suture will
give maximum and even distribution of compression during and after application of
112 Christopher Balogun-Lynch and Naomi Whitelaw

the B-Lynch suture. (Figure 2c) Also, it avoids blind application of the suture and
the possibility of obliteration of the cervical and/or uterine lumens that may lead to
pyometria and morbidity.17,18,26

Application for abnormal placentation

The B-Lynch suture may be beneficial in cases of placenta accreta, percreta and increta.
In a patient with placenta praevia, a figure-of-eight or transverse compression suture
of the lower anterior or posterior compartment or both to control bleeding is applied.
If this is not completely successful then in addition the longditudinal Brace suture
component may be applied for further/complete haemostasis.17

World wide experience

Over 1300 cases of the B-Lynch suture have been successfully performed worldwide
with only seven reported failures. (B-Lynch personal communication) The Indian
subcontinent has the largest number of reported successful applications, over 250,
followed by Africa, South America, North America and Europe. There have been seven
reported failures because of delay in application, defibrination syndrome and technical
difficulties. Various suture materials have been used. However a moncryl suture is
recommended because it is user and tissue friendly with uniform tension distribution
and is easy to handle. Holtsema et al27 concluded that the B-Lynch technique for
management of PPH should be an option for every obstetrician.

Post operative follow up

Three cases have had laparoscopy at various time intervals post operatively for
sterilisation, suspected pelvic inflammatory disease and appendicitis. One patient
who had a history of ileostomy for surgical reasons had laparotomy ten days after her
B-Lynch suture for suspected intestinal obstruction. The diagnosis was not confirmed
although there was a band of adhesion unrelated to the Brace suture. Magnetic
resonance imaging (MRI) and hysterosalpingography (HSG) were performed on one
patient showing no intraperitoneal or uterine sequealae.28 No complications have
been observed in the five patients from the first published series. Moreover, all have
succeeded in further pregnancy and delivery.

Other compression techniques

The Hayman technique

Hayman et al29 reported a uterine compression suture which did not require opening
the uterine cavity (Figure 3). While this technique is quicker to perform it does not
allow exploration of the uterine cavity under direct vision. The morbidity and fertility
outcome is also unknown.
 The surgical management of post partum haemorrhage 113

Figure 3 The Hayman uterine compression suture.27

The Cho technique

Cho et al30 reported an alternative suture technique involving multiple full thickness
square sutures to compress the anterior and posterior uterine walls (Figure 4). The
technique may interfere with uterine drainage and involution; Cho et al29 reported
pyometra after the procedure. Data on morbidity and future fertility are again
limited.

Conclusions

Of the compression suturing techniques described, the B-Lynch procedure has been
recommended by the Confidential Enquiry into Maternal Deaths in the UK,7 The
Royal College of Obstetricians and Gynaecologists in the UK and in the Cochrane
Database of systematic reviews. There are no reported instances of serious adverse
outcomes from the B-Lynch surgical technique. Furthermore, the latest 2000–2002
Triennial Confidential Enquiry states that no deaths were reported in women who
had had interventional radiology or B-Lynch suture in the management of PPH.7

Selective arterial embolisation

This technique was introduced following research experience around 1997.31 It is

performed usually by an interventional radiologist under fluoroscopic guidance in
the angiography suite. Regional anaesthesia is used or conscious sedation as an
114 Christopher Balogun-Lynch and Naomi Whitelaw

Figure 4 The Cho multiple square suture technique.28

alternative. A catheter is introduced via the femoral artery and directed into the
target vessel under image control. It can be passed into the hypogastric uterine or
ovarian artery. Gelform plaget coils or a balloon are used to occlude the artery.32 Both
sides of the pelvis can be accessed through a single portal. The control of PPH is
usually immediate. The technique can be highly effective in defibrination or other
coagulopathy. The duration of the procedure is approximately 30 minutes, although
this is dependent on the experience of the radiologist. Menstruation may return within
3 months and subsequent pregnancies may occur. Reported data have shown that
subsequent pregnancies may be uncomplicated, although long-term follow-up data
has yet to be published. Reported complications include infection, pain, ischaemia,
fever, haematoma, vascular perforation, uterine necrosis and sepsis. Pre-op informed
consent should be taken by the radiologist. A risk of inadvertent embolisation of
the external iliac artery instead of the hypogastric artery has been reported resulting
in leg amputation.32 The technique should be used if facilities are available in the
labour ward. However it is essential to know the time availability of the procedure
before incorporation into any obstetric guideline. The availability of this facility may
vary between day and night. If a patient is at risk of PPH, then the elective delivery
should be undertaken in the day time, as a prearranged service between the imaging
department and the obstetric team. Theatre staff should be alerted in time so the
 The surgical management of post partum haemorrhage 115

procedure is carried out quickly and before life threatening haemorrhage appears.
Patients at particular risk are those with obesity, cardiomyopathy and coagulopathy.31

POST PARTUM HAEMORRHAGE FOLLOWING GENITAL TRACT TRAUMA

Below the level of the pelvic floor

Haemorrhage and haematoma collection below the level of levator ani are accessed
through the vagina with the patient in the lithotomy position. This can be simply
evacuated in the presence of a good light source and a good assistant. The patient
should be adequately anaesthetised either with regional or general anaesthesia. Passive
drainage should be encouraged. Obvious signs of local bleeding should be identified,
transfixed and haemostased. Exploration of the pudendal vessels should be achieved,
with identification of bleeding points and transfixation haemostasis. Suturing with
non absorbable material should be avoided. A vaginal pack may enable continued and
sustained haemostasis for 24 hours and if bleeding is controlled then the pack may be
removed. Antibiotic cover should be considered if a wound/vaginal pack is retained.
There is usually no need to transfer such patients to a high dependency unit.

Bleeding above the level of the pelvic floor

In contrast, bleeding above the pelvic floor may enlarge and extend proximally
between the two layers of the broad ligament. The haematoma may be of moderate
size and contained within it to enable conservative management. In some instances
laparotomy and drainage may become necessary using a subperitoneal approach. A
proportion of these cases may follow spontaneous vaginal delivery whilst the others
follow instrumental or caesarean operations.
The time of presentation is variable and clinical features may not fit with the
cardiovascular state of the patient. Low abdominal pain, tachycardia and pallor may
be the initial clinical features. Where conservative management has failed or is
inappropriate, a laparotomy should be carried out by a surgeon of appropriate skill.
Evacuation and retro-peritoneal drainage with antibiotic cover may be necessary. A
watchful eye should be kept on such patients for secondary haemorrhage.

POST PARTUM HAEMORRHAGE FOLLOWING ACUTE UTERINE INVERSION

Acute inversion is reported in 1:2,000 deliveries and may go unrecognised or mis-

diagnosed as a uterine fibroid. Massive haemorrhage can occur resulting in shock.
There may be disturbed venous return which may affect the rate and degree of shock.
116 Christopher Balogun-Lynch and Naomi Whitelaw

The character of such acute inversion may be subtle or overt. Prompt replacement of
the uterine fundus is essential starting with the O’Sullivan technique.

The O’Sullivan technique

The patient is first resuscitated to restore vital signs including adequate blood
transfusion and blood pressure. Adequate analgesia is essential before any attempt
at repositioning without the use of uterine relaxant. If response is not imminent or
sustained, an anaesthetist should provide uterine relaxation to facilitate respos-
itioning. General anaesthesia is preferable using halothane. Digital repositioning
should be maintained to support and establish good uterine muscle tone.
O’Sullivan’s hydrostatic pressure technique involves infusing 1-2 litres of saline at
body temperature through a rubber tube placed in the posterior fornix of the vagina
whilst sealing the introitus with the obstetrician’s hand. As the vaginal wall distends,
the fundus of the uterus rises and usually the inversion is promptly corrected. Once
this is achieved fluid is allowed to slowly escape from the vagina whilst the placement
of the uterine fundus maintained.
In extremely difficult cases, especially associated with myomata, replacement may
have to be by laparotomy. This process involves placing the surgeon’s hands from
front and back at the lower segment with the finger tips between and below the level
of the inverted fundus. With progressive manual pressure the fundus is flipped up and
replaced.

INTERNAL UTERINE COMPRESSION TECHNIQUES

A series of reports have appeared advocating the use of a variety of conservative

techniques to achieve intra-uterine compression. These include an intra-uterine Foley
catheter,33 hydrostatic balloon internal compression,34 and surgical packing using a
gauze roll with or without prior soaking in thromboxane to facilitate clotting.19,20,35
In a similar manner, a Sengstaken Blakemore tube36,37 can be used for intrauterine
tamponade. These methods are successful independently or in combination with the
B-Lynch Brace suture application.38

VASCULAR SURGICAL PROCEDURES FOR LIFE THREATENING POST PARTUM HAEMORRHAGE

Anaesthetic considerations

The principal risk of PPH is that massive bleeding can rapidly lead to hypovolaemia.
The severity of this is often unrecognised and bleeding underestimated. Hypovolaemia
will present with tachycardia, hypotension and oliguria. However, hypotension may
 The surgical management of post partum haemorrhage 117

be a late manifestation because the cardiovascular system decompensates at a very

late stage in fit patients. Early involvement of a consultant anaesthetist is crucial and
often life-saving.
The choice of anaesthetic will be dictated by circumstances, the degree of blood loss
and the urgency of the situation. In most cases of significant PPH, a general anaesthetic
is preferable. However, if a patient already has a functioning regional block (spinal or
epidural) where bleeding is controlled and the cardiovascular system stable, it may be
appropriate to continue with a regional block. However the danger of a block is that
it will tend to aggravate hypotension. In these cases, early conversion to a general
anaesthetic may be indicated if instability occurs. The general anaesthetic technique
will include preoxygenation and a rapid sequence induction using either thiopentone
in a reduced dose (e.g. 4 mg/Kg) or ketamine 1 mg/kg or etomidate 0.2 mg/kg followed
by intubation after suaxmethonium. Maintenance agents will include nitrous oxide,
oxygen and either a very low concentration of isoflorane to combat awareness or
possibly opiates such as fentanyl, afentanil or remifentanil.

Stepwise devascularisation procedures

The procedure requires a gynaecological surgeon with a working knowledge of pelvic

anatomy and the vascular and neurological supply to pelvic organs.
The patient should be in the Lloyd Davis or modified lithotomy position with one
of the assistants able to access and swab the vagina to assess bleeding control. This set
of procedures takes full account of the entire blood supply to the uterus and the pelvic
organs.23 The surgical approach starts with ligature of the uterine artery39 preferably
as it emerges from crossing over the ureter or as it approaches the uterine wall.40 This
can be carried out unilaterally or bilaterally about 2cms from the uterine angle at
caesarean section or where the lower segment is opened after conservative surgery for
PPH has failed.
Next, the ovarian vascular supply to the uterus is ligatured, either unilaterally or
bilaterally. Unilateral or bilateral ligature of the internal iliac artery may become
necessary as a further step to control massive PPH.41 A skillful surgeon will aim
to ligate the anterior division of the internal iliac artery in order to achieve further
devascularisation of the uterus without compromising blood supply to the posterior
division. (Figure 5) However, ligation of the internal iliac directly could save time, life
and organ.

Potential complications of vascular surgery for post partum haemorrhage

It is essential that the internal iliac artery is identified separately from the external
iliac. It is also essential that the ureter is identified independent of the internal iliac
and uterine arteries. This avoids potential major complications such as:

i accidental ligature of the common iliac artery compromising the arterial supply
to the lower limb (white leg).
118 Christopher Balogun-Lynch and Naomi Whitelaw

Figure 5 Vascular distribution to pelvic organs. a) Posterior view, b) Lateral view.

 The surgical management of post partum haemorrhage 119

ii accidental ligature of the ureter as it crosses the bifurcation of the common

iliac artery at the level of sacral promontory or close to the uterine artery (renal
failure).
iii accidental incorporation of the anterior division of the sciatic nerve causing nerve
injury (drop foot).
iv uncontrolled haemorrhage and death.

COMPLEX RADICAL SURGERY FOR PPH

Lateral pelvic floor haemorrhage

Following difficult and complicated instrumental delivery and/or caesarean section,

vessels of the lateral compartment of the pelvis can be traumatised, transected or
torn. In the particular case of severe PPH, vascular collapse in this region may
cause difficulty in identification of the bleeding vessels. As the pelvic pulse pressure
is reduced, some traumatised vessels might go unnoticed until the pulse pressure
returns. Apart from broad ligament haematoma that may need evacuation, it might
be necessary to open the broad ligament, evacuate the clot and pack the cavity firmly
with a hot pack, in order to get maximum coagulation. This in itself may haemostase
diffuse venous bleeding. Packing may be all that is necessary and sufficient time given
for the effect of the heat coagulation to be effective before closing the abdomen with a
passive drain to monitor any further bleeding. It is usually futile to continue to apply
sutures in the hope that this will secure haemostasis. There are considerable risks
in attempts at ligature of venous plexuses since this creates more trauma to other
vessels. This is particularly true where caesarean section or forceps delivery has been
performed at full dilatation following prolonged labour where there is a significant
degree of vaso dilatation from tissue hypoxia.
It may be necessary on rare occasions to pack the lateral pelvic wall, leave the pack
in-situ and allow for a second procedure, usually 48hrs later, to remove the pack.

EMERGENCY HYSTERECTOMY

General considerations

As a last resort and when medical and conservative surgery have failed, hysterectomy
may be necessary to save maternal life. The commonest indications for this radical
procedure are abnormal placentation (praevia, accreta, increta, percreta), atonic PPH,
uterine trauma, secondary PPH and uterine rupture.24,25
Hysterectomy can be associated with significant maternal morbidity and
mortality.42 The choice between subtotal and total hysterectomy depends on the
prevailing condition and the timing of the hysterectomy. For example in PPH
120 Christopher Balogun-Lynch and Naomi Whitelaw

Table 2 Potential complications following hysterectomy for post partum haemorrhage

1. Renal insufficiency
2. Pulmonary dysfunction (adult respiratory distress syndrome)
3. Liver dysfunction
4. Pituitary ischaemia, necrosis (Sheehan’s syndrome) exhibiting features of
amenorrhoea, hypothyroidism, and adreno-cortical dysfunction.

following elective caesarean section with an undilated cervix, this may be carried
out by performing a subtotal hysterectomy. In contrast post partum haemorrhage
secondary to abnormal placentation may be best treated by total hysterectomy.
The most important requirement is that either procedure should not be delayed
unnecessarily and should be performed by a consultant obstetrician with or without
the assistance of a skilled gynaecological or vascular surgeon if required.
In term pregnancy tissue planes can be dissected bluntly because of tissue oedema.
Subtotal hysterectomy is usually quicker and safer to perform. Total hysterectomy
will be an extension of the subtotal approach but involves further distal dissection of
vascular plexus, bladder base and pelvic floor. The potential complications associated
with hysterectomy for PPH are shown in Table 2. Up to 30% of massive PPH in
primagravidae may result in hysterectomy.24 This deprives these patients of future
fertility and can cause physical and psychological damage.

SUMMARY

Post partum haemorrhage can be a menacing and life threatening condition. The
updated Confidential Enquiry into Maternal and Child Health gives the following
learning points.7

1 Catastrophic haemorrhage is a persistent problem.

2 All of the women who died with placenta previa had previous caesarean section
3 Women at high risk of haemorrhage are still delivering in isolated units ill equipped
for sudden, life threatening emergencies. These units may be without immediate
access to specialist consultant care, blood products or intensive care.
4 Women who decline blood products should be treated with respect and the
management plan in case of haemorrhage agreed with them before delivery.
5 During this trienium, 2 women who concealed their pregnancies for fear that their
babies might be taken into care, died of post partum haemorrhage at home.
6 Obstetric care was considered to be substandard in 12 out of 15 (80%) of cases
where the woman had sought treatment; anaesthetic care was considered to be
substandard for 5 cases.
7 No deaths were reported in women who had had interventional radiology or the
B-Lynch suture.
 The surgical management of post partum haemorrhage 121

KEY POINTS IN PPH MANAGEMENT

1 Identify all risk factors for PPH during the antenatal and intrapartum periods
(Table 1.)
2 Mothers with risk factors should have appropriate surveillance during labour.
3 Surgeon with appropriate seniority and experience should perform caesarean
section in cases of placenta previa and other forms of abnormal placentation.
4 When medical therapy for PPH fails conservative surgery of the B-Lynch variety
with or without intrauterine tamponade should be tried first.
5 Stepwise devascularisation or major vessel ligation may have a role if
appropriate surgical expertise is available.
6 Arterial embolisation has great potential but the logistic difficulties of arranging
interventional radiology are significant. This should follow a strict obstetric and
radiological protocol.
7 Rates of subtotal or total hysterectomy may continue to rise if the rise in
caesarean section rate is not controlled.
8 Trainees should have regular workshop and fire drill training on PPH to
include the application of the Brace Suture compression and other conservative
tamponade techniques.

ACKNOWLEDGEMENTS
We acknowledge the contribution of the following colleagues:
1 Mr. Philip Wilson for his outstanding artwork.
2 Dr. Michael Cowen, Consultant Anaesthetist for his advice and contributing text
on the anaesthetic considerations of life threatening PPH.
3 Mrs. Nora Horner for typing the manuscript.

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