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51Conservative Surgical ManagementC. B-Lynch and H. Shah

INTRODUCTION

A key factor in the surgical management of postpartumhemorrhage is the awareness of predisposing factors1–3

and the readiness of therapeutic teams consisting ofobstetric, anesthetic and hematology staff3,4.

In the past, the surgical management of postpartumhemorrhage included use of an intrauterine pack, withor without thromboxane5, thrombogenic uterinepack6, ligation of uterine arteries7, ligation of internaliliac artery8, stepwise devascularization9 and, finally,subtotal or total abdominal hysterectomy10. Most ofthese are discussed in detail in other chapters of this text.

A more conservative procedure, now colloquiallyknown as the Brace suture technique, was firstdescribed by B-Lynch and colleagues in 19973. Alongwith later modifications by Hayman and colleagues11

and Cho and colleagues12, this13 may prove moreeffective than radical surgery for the control of life-threatening postpartum hemorrhage3,11,12. Althoughsubtotal and total abdominal hysterectomy are stillavailable and indeed useful in their own right, theyshould be considered as a last resort.

Common causes of postpartum hemorrhage arelisted in Table 1, which is not to mean that additionalcauses cannot or do not exist. Most, if not all, are con-sidered in references to postpartum hemorrhage inmodern standard textbooks of obstetrics and furtherdescribed in the other chapters of this volume. Threeimportant points merit attention.

First, there is significant increase in cardiac outputin pregnancy in accordance with red cell mass andplasma volume, which provides a compensativereserve for acute blood loss and hemostatic responsefollowing massive hemorrhage14. Second, the arrange-ment of the uterine muscle fibers, vis-à-vis the courseof the uterine arteries, facilitates the use of compres-sion techniques for effective control of postpartumhemorrhage and, finally, conservative treatment suchas bimanual compression of the uterus may controlblood loss (Figure 1), whilst intensive resuscitativemeasures are undertaken according to established laborward protocols, which involve the anesthetists, hema-tologists, the obstetric team and intensive care support(see Chapters 36 and 40).

NEW DEVELOPMENTS IN THERAPEUTIC OPTIONS

The type of surgical intervention depends uponseveral factors, paramount of which is the experienceof the surgeon. Other factors include parity and desirefor future children, the extent of the hemorrhage, thegeneral condition of the patient and place of confine-ment. Women at high risk of postpartum hemorrhageshould not be delivered in isolated units or unitsill-equipped to manage sudden, life-threatening emer-gencies. Immediate access to specialist consultant care,blood products and intensive care are essential.

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Pre-existing conditionsUterine overdistention, atony and disseminatedintravascular coagulation (DIC)

Disorders of placenta, uterine andgenital tract trauma

Thrombocytopenic purpuraHypertensive diseaseUterine myomaAnticoagulation therapyCoagulation factor deficiencySystemic disease of hemorrhagic natureConsumptive coagulopathyMüllerian malfunctionAnemia

PolyhydramniosMultiple gestationMacrosomiaProlonged laborChorionamnionitisTocolytic agentsHalogenated anesthetic agentsHigh parityAbruptio placentaeCourvelliar’s uterusPlacenta previaPlacenta accreta, increta, percreta

Acute uterine inversionLower segment cesarean sectionOperative vaginal deliveryPrecipitate deliveryPrevious uterine surgeryInternal podalic versionBreech extractionMid-cavity forcepsObstructed laborAbnormal fetal presentationVacuum site extractionPlacental subinvolutionRetained products of conceptionRuptured uterus

Table 1 Common causes of postpartum hemorrhage

The B-Lynch suture compression technique

The procedure was first performed and described byMr Christopher B-Lynch, a consultant obstetrician,gynecological surgeon, Fellow of the Royal College ofObstetricians and Gynaecologists of the UK and Fellowof the Royal College of Surgeons of Edinburgh, basedat Milton Keynes General Hospital National HealthService (NHS) Trust (Oxford Deanery, UK), duringthe management of a patient with a massive postpartumhemorrhage in November 1989. This patient refusedconsent to an emergency hysterectomy3! Table 2provides an audit summary of five case histories ofother patients with severe life-threatening postpartumhemorrhage managed with this technique.

The principle

The suture aims to exert continuous vertical compres-sion on the vascular system. In the case of postpartumhemorrhage from placenta previa, a transverse lowersegment compression suture is effective.

The technique2–4

See Figures 2a (i and ii), 2b and 2c.

Surgeon’s position In outlining the steps involved, weassume that the surgeon is right-handed and standingon the right-hand side of the patient. A laparotomy isalways necessary to exteriorize the uterus. A lowersegment transverse incision is made or the recentlower segment cesarean section suture (LSCS)removed to check the cavity for retained placentalfragments and to swab it out.

Test for the potential efficacy of the B-Lynch suture beforeperforming the procedure The patient is placed in theLloyd Davies or semi-lithotomy position (frog leg).An assistant stands between the patient’s legs and inter-mittently swabs the vagina to determine the presenceand extent of the bleeding. The uterus is then exteri-orized and bimanual compression performed. To dothis, the bladder peritoneum is reflected inferiorly to alevel below the cervix (if it has been taken down for aprior LSCS, it is pushed down again). The wholeuterus is then compressed by placing one hand posteri-orly with the ends of the fingers at the level of the cer-vix and the other hand anteriorly just below thebladder reflection. If the bleeding stops on applyingsuch compression, there is a good chance that applica-tion of the B-Lynch suture will work and stop thebleeding.

Even in the presence of coagulopathy, bimanualcompression will control diffuse bleeding points. Ifthis test is successful, the application of the suture willalso succeed. However, application of the B-Lynchsuture is not a substitute for the medical treatment ofcoagulopathy, which should take place along with theoperative intervention (see Chapter 25).

Suture application Given that the test criteria for theB-Lynch suture placement are met, the uterus remainsexteriorized until application of the suture is complete.The senior assistant takes over in performing compres-sion and maintains it with two hands during the place-ment of the suture by the principal surgeon.

(1) First stitch relative to the low transverse cesarean sec-tion/hysterotomy wound. With the bladder displacedinferiorly, the first stitch is placed 3 cm below thecesarean section/ hysterotomy incision on thepatient’s left side and threaded through the uterinecavity to emerge 3 cm above the upper incisionmargin approximately 4 cm from the lateralborder of the uterus (Figure 2a(i)).

(2) The fundus The suture is now carried over the topof the uterus and to the posterior side. Once situ-ated over the fundus, the suture should be more orless vertical and lie about 4 cm from the cornu. Itdoes not tend to slip laterally toward the broadligament because the uterus has been compressedand the suture milked through, ensuring thatproper placement is achieved and maintained(Figure 2a).

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POSTPARTUM HEMORRHAGE

Figure 1 Bimanual compression of the uterus, illustrating thefirst-line approach to mechanical hemostasis. This in itself mightcontrol bleeding significantly by assisting the uterus to use itsanatomical and physiological properties such as the cross-overinterlinked network of myometrial fibers for vascular compressionand bleeding control. The patient should be placed in stirrups orfrog-legged position in the labor ward or in theater whilstintravenous fluid and/or appropriate blood product runs freely. Insome cases and commonly so, there may be failure to achievesatisfactory and lasting hemostasis by this method

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Conservative Surgical Management

Figure 2 Summary of the application of the B-Lynch procedure

(b)(a(i))

(c)

(a(ii))

(3) The posterior wall The location on the posterioruterus where the suture is placed through theuterine wall is actually easy to surface mark poste-riorly. It is on the horizontal plane at the level ofthe uterine incision at the insertion of theuterosacral ligament (Figure 2b).

(4) Role of the assistant As the operation proceeds, theassistant continues to compress the uterus as thesuture is fed through the posterior wall into thecavity. This will enable progressive tension to bemaintained as the suture begins to surround theuterus. Assistant compression will also help to pullthe suture material through to achieve maximumcompression, without breaking it, at the end ofthe procedure. Furthermore, it will prevent sutureslipping and uterine trauma. The suture now lieshorizontally on the cavity side of the posterioruterine wall.

(5) The fundus As the needle pierces the uterine cavityside of the posterior wall, it is placed over the pos-terior wall, bringing the suture over the top of the

fundus and onto the anterior right side of theuterus. The needle re-enters the cavity exactly inthe same way as it did on the left side, that is 3 cmabove the upper incision and 4 cm from the lateralside of the uterus through the upper incision mar-gin, into the uterine cavity and then out againthrough 3 cm below the lower incision margin(Figure 2a(ii)).

(6) Later role of the assistant The assistant maintains thecompression as the suture material is milkedthrough from its different portals to ensure uni-form tension and no slipping. The two ends of thesuture are put under tension and a double throwknot is placed for security to maintain tension afterthe lower segment incision has been closed byeither the one- or two-layer method.

(7) Relation to the hysterotomy incision The tension onthe two ends of the suture material can be main-tained while the lower segment incision is closed,or the knot can be tied first, followed by closure ofthe lower segment (Figure 2c). If the latter option

is chosen, it is essential that the corners of thehysterotomy incision be identified and stay suturesplaced before the knot is tied. This ensures that,when the lower segment is closed, the angles ofthe incision do not escape it. Either procedureworks equally well. It is important to identify thecorners of the uterine incision to make sure nobleeding points remain unsecured, particularlywhen most of these patients are hypotensive withlow pulse pressure at the time of the B-Lynchsuture application.

(8) Post-application and hysterotomy closure It is probablethat the maximum effect of suture tension lasts foronly about 24–48 h. Because the uterus undergoesits primary involutionary process in the first weekafter vaginal or cesarean section delivery, thesuture may have lost some tensile strength, buthemostasis would have been achieved by thattime. There is no need for delay in closing theabdomen after the application of the suture. Theassistant standing between the patient’s legs swabsthe vagina again and can confirm that the bleedinghas been controlled.

Application after normal vaginal delivery If laparotomy isrequired for the management of atonic postpartumhemorrhage, hysterotomy is necessary to apply theB-Lynch suture. Hysterotomy will also allow explora-tion of the uterine cavity, exclude retained products ofconception, evacuate large blood clots and diagnoseabnormal placentation and decidual tears, damage and

bleeding. B-Lynch suture application or any modifica-tion of it (see below) without hysterotomy orre-opening of the cesarean section wound runs thepotential risk of secondary postpartum hemorrhage.Therefore, confirmation that the uterine cavity iscompletely empty is essential. Furthermore, hystero-tomy ensures that the correct application of the sutureprovides maximum and even distribution of the com-pressive effect during and after application of theB-Lynch suture (Figures 2 and 3). Also, it avoids blindapplication of the suture and the possibility of oblitera-tion of the cervical and/or uterine cavities that maylead to clot retention, infected debris, pyometria,sepsis and morbidity3,11,12,15.

Application for abnormal placentation The B-Lynch suturemay be beneficial in cases of placenta accreta, percretaand increta. In a patient with placenta previa, a figure-of-eight or transverse compression suture to the loweranterior or posterior compartment or both is appliedto control bleeding. If this is not completely successful,then, in addition, the longitudinal Brace suturecomponent may be applied for further/completehemostasis3.

POSTOPERATIVE FOLLOW-UP

Three patients from the original series had laparoscopypostoperatively for sterilization, suspected pelvicinflammatory disease or appendicitis. One patient who

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Age(years) Parity GA

Presentingdiagnosis

Mode ofdelivery

Infant sexandweight (g)

Apgar scoreat 5 and10 min

Typeof PPH

Treatment andvolume transfused

Intensivecareadmission Outcome

28 PP 39/40 placentalabruption,PPH, DIC

spontaneousvertex

male (2800) 4, 7 primary ecbolics, 20 unitsfresh blood,8 units FFP

48 h; fullantibioticcover

good; 3 years laterspontaneous vertexdelivery; female(3890 g); noproblems

22 PP 43/40 prolongedlabor, persistingoccipitoposition?,cephalopelvicdisproportion

emergencyCS

male (4190) 7, 10 primary ecbolics, 13 unitsblood, 5 unitspacked cells, BSA


good; normal CTpelvimetry 2 yearslater; elective CS at39 weeks; female(3820 g); noproblems

23 PP(twin)

37/40 eclampsia inlabor, PPH,DIC

emergencyCS

(1) female(2735),(2) female(2430)

(1) 3, 8(2) 5, 8

primary ecbolics, 19 unitsblood, 5 units FFP,BSA


good; nocomplications

35 PP(IVF)

38/40 major placentaprevia

electiveCS

female (3370) 9, 10 secondary,9th dayreadmission

ecbolics, 15 unitsblood, 5 units FFP,BSA



30 PP 40/40 uterine atony spontaneousvertex

female (3890) 9, 10 primary ecbolics, 15 unitsblood, 7 unitspacked cells, BSA



PP, primiparous; GA, gestational age in weeks; PPH, postpartum hemorrhage; CS, cesarean section; CT, computerized tomography;DIC, disseminated intravascular coagulations; BSA, brace suture application; IVF, in vitro fertilization; FFP, fresh frozen plasma*Refused consent to emergency hysterectomy

Table 2 Audit summary of five selected case histories of patients with severe life-threatening postpartum hemorrhage treated by ecbolics and theB-Lynch brace suture application in the period 1989–1995 at Milton Keynes General Hospital, UK2

had a history of ileostomy for surgical reasons hadlaparotomy 10 days after her B-Lynch suture for sus-pected intestinal obstruction (unpublished data,B-Lynch). Magnetic resonance imaging and hystero-salpingography were performed on one patient, show-ing no intraperitoneal or uterine sequelae16 (Figure4a–c). No complications have been observed in thefive patients of the first published series2 (see Table 1).Moreover, all have succeeded in further pregnancyand delivery17,18.

Tables 3–5 lists the clinical points of the B-Lynchsurgical technique, the Hayman uterine compressionsuture (see Figure 5) and the Cho multiple squaresutures (see Figure 6).

WORLD-WIDE REPORTS

The current level of application of the B-Lynch sutureworld-wide includes over 1300 successful cases; ofthese, there are only 19 failures. The Indian subconti-nent has the largest number of reported successfulapplications, over 250, followed by Africa, South

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Figure 3 The in vivo effect of correct application of the B-Lynchsurgical technique seen immediately after successful sutureapplication. No congestion, no ischemia and no ‘shouldering’ of thesutures at the fundus

Figure 4 Normal MRI 6 months after massive postpartumhemorrhage treated by B-Lynch surgical technique followed byuneventful spontaneous vertex vaginal delivery 22 months later.(a) Sagittal view showing normal endometrial cavity and treatedcesarean incision site; (b) coronal view, with no uterine cavitysynechiae19; (c) view at level of incision for cesarean section,showing well-healed features

(a)

(b)

(c)

America, North America, Europe and other countries.The 17 reported failures were because of delay inapplication, poor technique, defibrination and in-appropriate material. Various suture materials havebeen used. However, the monocryl suture (codeWC3709) is recommended because it is user- andtissue-friendly with uniform tension distribution and iseasy to handle20. Holtsema and colleagues recentlyopined, in a review, that the B-Lynch technique forpostpartum hemorrhage should be an option for everygynecologist21. Wohlmuth and colleagues publishedoutcome of a large series with a 91% success rate(world-wide cumulative success rate 98%)22.

CONCLUSION

Of the compression suturing techniques describedabove, the B-Lynch procedure has been recom-mended by the 2000–2002 Triennial ConfidentialEnquiry into Maternal Deaths in the UnitedKingdom23, The Royal College of Obstetricians andGynaecologists in the UK, and the Cochrane Databaseof systematic reviews. To date, no serious adverseoutcomes have been associated with the B-Lynchsurgical technique3,17,20,22,24. Furthermore, the latest2000–2002 Triennial Confidential Enquiry states thatno deaths were reported in women who had had

interventional radiology or B-Lynch suture in themanagement of postpartum hemorrhage23.

It is important to remember that, if a patient is aknown or appreciated risk for postpartum hemor-rhage, then the elective delivery should be performedin the day time, with prearranged co-operationbetween the imaging department and the obstetric

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1.

2.3.4.5.6.7.8.9.

10.11.

User-friendly suture material monocryl No.1 mounted on 90-cm curved ethigard blunt needle (codeW3709) (Ethicon, Somerville, NJ). Otherrapidly absorbable sutures can be used according to the surgeon’s preference. A good length and needle are essential19

Basic surgical competence requiredUterine cavity checked, explored and evacuatedSuture bends maintain even and adequate tension without uterine trauma or ‘shouldering’Allows free drainage of blood, debris and inflammatory materialTransverse compression suture applied to the lower segment for abnormal placentation effectively controls bleedingSimple, effective and cost-savingFertility preserved and proven3

Mortality avoided3

World-wide application and successful reports (> 1300) (B-Lynch, personal data base, [email protected])Potential for prophylactic application at cesarean section when signs of imminent postpartum hemorrhage develop, e.g. placenta accreta, or whereblood transfusion is declined, e.g. placenta previa surgery on a Jehovah’s Witness

Table 3 The B-Lynch surgical technique: clinical points

1.2.3.4.5.6.

Lower uterine segment or uterine cavity not openedUterine cavity not explored under direct visionProbably quicker to applyNo feed-back data on fertility outcomeMorbidity feed-back data limitedUnequal tension leads to segmented ischemia secondary to slippageof suture – ‘shouldering’ with venous obstruction

Table 4 The Hayman uterine compression suture: clinical points

1.

2.3.4.5.6.

Multiple full-thickness square sutures applied, probablytime-consuming if many square sutures requiredUterine cavity drainage restriction – pyometra risk15

No feed-back data on fertility outcomeMorbidity feed-back data limitedRhythmic contraction not facilitated and involution impededThe production of multiple uterine senechiae (see Chapter 28)

Table 5 The Cho multiple square sutures: clinical points

Figure 5 The Hayman uterine compression suture withoutopening the uterine cavity11

Figure 6 The Cho multiple square sutures compressing anteriorto posterior uterine walls12

team. Theater staff should be alerted in time so thatconservative surgery can be carried out quickly ifneeded. Patients at particular risk are those withobesity, cardiomyopathy, coagulopathy, abnormalplacentation, polyhydramnios and specific religiousconvictions contraindicating blood transfusion.

PLACEMENT OF LIGATURES IN STEPWISEDEVASCULARIZATION

The essential requirements are not simple and may notbe available in every unit. First, there is a need for acompetent obstetrician who is conversant and compe-tent at pelvic gynecological procedures, and who has a

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Figure 7 Placement of ligatures in the process of stepwise devascularization, including ligature of the descending uterine and vaginalarteries

Figure 8 The complex vascular distribution to the pelvic organs. In this procedure of stepwise devascularization, the patient must be in theLloyd Davis or modified lithotomy position, with one of the assistants able to access and swab the vagina to assess bleeding control

working knowledge of the pelvic anatomy, includingthe vascular and neurological supply of the pelvicorgans. Second, there is a need for an obstetric anesthe-tist, as well as a vascular and/or gynecological cancersurgeon on standby. Finally, provisions must be avail-able for admission postoperatively to the intensive careunit.

This set of requirements takes full account of theextraordinarily generous blood supply to the uterusand the pelvic organs (see Figure 7). The surgicalapproach starts with ligature of the uterine artery andits distribution to the uterus, preferably as it emergesfrom crossing over the ureter or as it approaches theuterine wall to penetrate and establish its division25.This could be carried out unilaterally or bilaterallyabout 2 cm from the uterine angle at cesarean sectionor where the lower segment is opened after conserva-tive surgery for postpartum hemorrhage has failed(Figure 8).

It is absolutely essential to remember that the inter-nal iliac (hypogastric artery) gives off independentbranches that descend to the cervix and vagina (vaginalbranch), respectively (see Chapter 52). Devasculariza-tion can be achieved by independent ligation suturesapplied bilaterally to the cervix and/or vagina. Theovarian vascular supply to the uterus is also ligated,either unilaterally or bilaterally. Unilateral or bilateralligature of the internal iliac artery may become neces-sary as a further step to control massive postpartumhemorrhage. A skilful surgeon should aim to ligate theanterior division of the internal iliac artery in order toachieve further devascularization of the uterus withoutcompromising blood supply to the posterior division.However, ligation of the internal iliac directly couldbe done unilaterally or bilaterally without devascu-larizing the pelvic organs8,26. This may save time, lifeand organ.

References

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6. Bobrowski RA, Jones JB. A thrombogenic uterine pack forpost partum hemorrhage. Obstet Gynecol 1995;85:836–7

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10. Baskett TF. Surgical management of severe obstetric hemor-rhage: experience with an obstetric hemorrhage equipmenttray. J Obstet Gynaecol Can 2004;26:805–8

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15. Ochoa M, Allaire AD, Stitely ML. Pyometra after hemostaticsquare suture technique. Obstet Gynecol 2002;99:506–9

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18. Tsitpakidis C, Lalonde A, Danso D, B-Lynch C. Long termanatomical and clinical observations of the effects of theB-Lynch uterine compression suture for the management ofpost partum hemorrhage – ten years on. J Obstet Gynaecol2006; in press

19. Wu HH, Yeh GP. Uterine cavity synechiae after hemostaticsquare suturing technique. Obstet Gynecol 2005;105:1176–8

20. Price N, B-Lynch C. Technical description of the B-Lynchsuture for treatment of massive hemorrhage and review ofpublished case. Int J Fertil Womens Med 2005;50:148–63

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22. Wohlmuth C, Gumbs J, Quebral-Ivie J. B-Lynch suture, acase series. Int J Fertil Womens Med 2005;50:164–73

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