phil steer pph

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Review2009;11:231–23810.1576/toag.11.4.231.27525 http://onlinetog.orgThe Obstetrician & Gynaecologist

© 2009 Royal College of Obstetricians and Gynaecologists 231© 2009 Royal College of Obstetricians and Gynaecologists

Review The surgical approach topostpartum haemorrhageAuthor 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 ligationand 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 / placentapraevia / 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: [email protected]

(corresponding author)

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© 2009 Royal College of Obstetricians and Gynaecologists

IntroductionPostpartum haemorrhage (PPH) has always been amajor cause of maternal mortality and morbidity;its incidence is rising for reasons that remainobscure.1 Fortunately, techniques for dealing with ithave improved so that mortality from this causecontinues to decline. Some PPHs are traumatic(vaginal and uterine lacerations). The primaryapproach to dealing with these is surgical correctionof the defect; the techniques required are as varied asthe lacerations themselves. This article deals withthe surgical approach to the more generic causes ofPPH, namely uterine atony, and the less commonconditions of uterine inversion, placenta praeviaand placenta accreta. It should be noted that, as withmany emergency surgical procedures, there are veryfew systematic studies of their use and norandomised trials of efficacy. Long-term follow-updata are also very few. Inevitably, therefore, thisarticle relies substantially on anecdote and theauthor’s personal experience and this should beborne in mind if any of the techniques are adoptedby the reader.

Uterine atonyFailure of the uterus to contract effectivelyfollowing the delivery of the baby is the commonestcause of massive PPH. There is no accepteddefinition of massive PPH; for the purposes of thisarticle I have defined it as any case with continuinghaemorrhage despite the ‘usual’ treatment, such asintravenous oxytocin (Syntocinon®, AlliancePharmaceuticals Ltd, Chippenham, Wilts, UK) 10 iu, ergometrine 0.5 mg � 2, carboprost 0.25 mgintramuscularly (up to � 6) and misoprostol 200 micrograms � 5 rectally. (The use of activatedVIIa is controversial and currently not supportedby controlled trials.2) The surgical techniques thatcan then be employed are listed in Box 1, in theorder in which they are commonly tried.

Bimanual compression, with one hand (made intoa fist) in the vagina and the other compressing theuterus using the other hand to press downwardsonto the uterus through the mother’s abdomen,is often effective at staunching the flow, at leasttemporarily. It allows a respite during which bloodcan be crossmatched and other resourcesmarshalled. It is tiring to maintain adequatecompression and it is usually necessary for the

surgeon and their assistants to take turns at 5-minute intervals, if satisfactory compression is tobe maintained. If this is insufficient, compression ofthe lower abdominal aorta against the spinalcolumn at the level of L2–4 can produce anadditional reduction in bleeding by reducing bloodflow to the uterus. Such compression can beproduced by an additional assistant, providing themother is not grossly obese. Special ‘anti-shock’garments have been produced which combineaortic and uterine compression with compressionof the lower limbs, both to reduce bleeding and tomaintain venous return (Figure 1 and Figure 2).3–5

If bimanual compression appears effective, butbleeding recommences when compression isstopped, a traditional approach is to pack the uterus.Although its effectiveness has been questioned, arecent review6 has concluded that, performedproperly, this can work well. The key to mosteffective use is to insert wide ribbon gauze firmly,making sure that it is placed initially at the fundususing a sponge holder and then fed systematicallyinto the uterus. Each layer must be pressed firmlyhome before the next layer is placed. However,probably more convenient than packing with gauzeis the use of an intrauterine balloon. This techniquewas described independently in 2001 by Johanson et al.7 and Bakri et al.8 The capacity of the balloonneeds to be up to 500 ml, so small balloons such asthose found on Foley catheters are insufficient.Bakri balloons are now commercially available in the UK and are manufactured by Cook IrelandLtd (Limerick, Republic of Ireland). They contain acentral lumen which ends above the balloon, so thatany blood still being lost above the level of theuterine tamponade can drain and be measured. Inthe absence of a balloon specifically designed for thepurpose, similar tamponade can be obtained usingthe stomach balloon of the Sengstaken catheter,which is stocked in many hospitals for themanagement of bleeding oesophageal varices(although the Sengstaken catheter is effective, theBakri balloon is cheaper and simpler to use). Onceinserted fully into the uterus, the balloon should be inflated with sterile saline until the bleeding iscontrolled; commonly, ~300 ml is needed. Therehave been no randomised trials of balloon use,but in a series of 23 cases unresponsive to medicaltherapy reported by Dabelea et al.,9 bleeding wasarrested in 21, with only two needing to proceed to hysterectomy.

If the cervix is fully dilated, there is sometimesinsufficient resistance in the lower segment andvagina for a pack or balloon to be retained when itis fully inserted/inflated. This can be countered byputting in a cervical cerclage (using Prolene® orMersilene® [both made by Ethicon Ltd., Livingston,UK]) and tightening it to a diameter of ~3 cm; thisprovides a platform which maintains the

Box 1

Surgical techniques for controlling

postpartum haemorrhage

• Uterine compression and massage

• Packing/balloon

• Uterine compression suture

• Uterine artery ligation

• Hysterectomy

• Logethotopulos pack

• Internal iliac ligation

• Arterial embolisation

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pack/balloon securely in the body of the uterus sothat it can compress the uterus effectively againstits elastic limit. Balloons can also be used fortamponade in the vagina when there is bleedingfrom multiple vaginal lacerations.10

Uterine compression suturesIf packing or balloon tamponade are ineffective, thenext step is to consider direct uterine compressionsuturing. The first suggestion of this approach wasby Christopher B-Lynch, of Milton Keynes Hospitalin the UK, who in 1997 published an account of fivecases11 where compression of the uterus wasachieved following caesarean section using thetechnique shown in Figure 3. It requires that theuterus is opened; the suture compresses the uppersegment but the lower segment remains open. If theuterus has not previously been opened (e.g. atcaesarean section), a simplified suture can beinserted, such as square suturing (Figure 4).12

However, there is concern that the square suturemay completely occlude the blood supply to theuterine muscle within the square, leading toischaemic necrosis and subsequent complications(see below). An important principle is, therefore,to avoid sutures that apply compression bothvertically and horizontally, but instead use suturesthat are compressive, whether transversely, e.g.multiple horizontal sutures as recently described by Hackethal et al.13 (Figure 5) or horizontally aswith the simpler loop suture inserted through thelower segment and tied at the fundus, as describedby Hayman et al.14 (Figure 6).

As with balloons, there are no randomisedcontrolled trials of compression sutures, but in arecent series of 11 cases where the Hayman suturewas used, hysterectomy was only necessary inone.15 In another series of 31 519 births, uterinecompression sutures were applied in 28 cases;they were successful in 23 whereas 5 still requiredhysterectomy.16

A particular problem is dealing with bleeding fromthe lower segment of the uterus. This can be dealtwith by square suturing,12 by a simple horizontal14

or vertical17 loop suture, opposing the anterior tothe posterior walls of the lower segment. Aningenious variant of this, if the cervix is not fullydilated, is to invert the lower segment upon itselfbefore suturing it, thus compressing the bleedingsurfaces without occluding the uterine cavity18

(Figure 7).

Another possibility is to combine the compressionsuture with an intrauterine balloon.19 The suturemust be inserted first: clearly, inserting a sutureafter the balloon risks puncturing it. Moreover,once the suture has been inserted, the balloon canbe used to apply counter pressure more effectively.

A series of five such cases was reported by Nelsonand O’Brien20 and this method was effective in allcases without complications.

All effective interventions have complications andthese are now being reported with all theapproaches described above. An importantpractical point is that all compression suturesshould be absorbable.21 The reason for this is that asthe uterus involutes, the sutures will become looseand, if they are nonabsorbable and do not producean inflammatory reaction making them adhere tothe uterine surface, there is always the risk that

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Review2009;11:231–238The Obstetrician & Gynaecologist


Figure 1

Non-inflatable garment for the

control of postpartum haemorrhage.

Reproduced with permission from

Miller et al.5

Figure 2

Noninflatable garment for the

control of postpartum haemorrhage.


Miller et al.5

Figure 3

B-Lynch suture. Reproduced with

permission from Lynch et al.11

TOG11_4_231-238.qxd 9/30/09 6:09 PM Page 233

loops of free suture will result. This can allow bowelto become entangled in the loops, resulting inobstruction. Square suturing results in tight

apposition of the anterior and posterior walls ofthe uterus, which can impede drainage of lochia,resulting in pyometra22 or, in the longer term, in theformation of synechiae.23 Moreover, if the suturesare placed too tightly, or result in an area of theuterus being totally deprived of blood supply (forexample, if there is placement of both vertical andhorizontal compression sutures), ischaemicnecrosis will result.24 Even with the B-Lynch suture,which does not occlude the uterine cavity, necrosisof the entire uterine corpus has been reported25

and reports of partial necrosis are becoming morecommon.26–28 The outcome in subsequentpregnancies has been little studied, but in sevenreported pregnancies following prior use of uterinecompression sutures, pregnancy and birth wasuncomplicated.16

The needles and suture material used varyaccording to the report. The first paper by B-Lynch11 describes the use of a 70 mm round-bodied hand needle with a number 2 chromiccatgut suture. Cho et al.12 describe the use ofnumber 7 or 8 straight needles with number 1atraumatic chromic catgut. However, catgut is nowrarely used in obstetrics because of its relative lackof strength and durability. Hayman et al.14 reportthe use of either polyglycolic acid (Dexon®,Covidien, Gosport, UK) or Vicryl® (Ethicon Ltd.,Livingston, UK) (number 1 or 2 sutures). They alsomention the use of a straight needle; in fact Iusually bend this manually to a shallow curve,which makes it easier to insert in the depths of thepelvis while avoiding puncture of the structuresimmediately behind the lower segment. The needleshould ideally be �6 cm long so as to exceed thecombined thickness of the anterior and posteriorlower segment. A shallow curved needle with thisdimension is available commercially. On the otherhand, Hackethal et al. describe the use of an XLHneedle (in conjunction with 0 Vicryl) in which thecurve had been straightened! Ghezzi et al.15 alsorecommend using a straight needle with a number2 polyglactin suture.

Uterine artery ligationIf use of a simple compression suture isunsuccessful, then ligation of the uterine arteriescan be tried next29 and is often effective. Indeed,one suspects that uterine artery ligation issometimes performed inadvertently when alower segment incision extends during a difficultdelivery (for example, of a large baby) andextensive suturing into the broad ligament isnecessary to control the resultant bleeding.There appear to be no consequences for futurepregnancies of such ligation, presumably becausea collateral circulation develops from othervessels (particularly the ovarian arteries) tocompensate.

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Figure 4

Cho square haemostatic suture12

Figure 5

Multiple U-suture. Reproduced with

permission from Hackethal et al.13

Figure 6

Hayman suture. Reproduced with

permission from Ghezzi et al.15

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Internal iliac artery ligationand aortic compressionThere has long been controversy about when ligationof the internal iliac artery should be attempted.30 It isa difficult manoeuvre because of the proximity of theinternal iliac vein, which can be torn duringmobilisation of the artery and is difficult to repair,and the external iliac artery, which if ligated in errorresults in an ischaemic leg.A practical point is thatwhen the artery is mobilised using an artery clamp,this should be done laterally to medially, so that thetip of the clamp points away from, rather than into,the internal iliac vein. In the hands of experts whoperform the procedure regularly, the results can begood.31 In the UK, it should probably not beundertaken by the obstetrician who performs it, forexample, only once every 5 years, but instead theassistance of a gynaecological oncologist or vascularsurgeon should be sought. If there is a delay inobtaining assistance from such an expert, directcompression of the aorta against the spinal columncan reduce bleeding by ~40% and this can be life-saving in some cases. Complete occlusion of theaorta by clamping below the renal arteries is evenmore effective and flow to the legs can be completelystopped for 4 hours or more without irreversibledamage. However, analogous to the problem withligating the internal iliac artery, damage to the venacava can be catastrophic and so such clampingshould only be applied by an experienced vascularsurgeon.

HysterectomyIn women wishing to retain their fertility,caesarean hysterectomy is the procedure of lastresort; but, as has been repeatedly emphasised inthe Confidential Enquiries into Maternal andChild Health, it should not be left until the womanis in extremis, but instead should be carried outpromptly if the previously described proceduresprove to be ineffective and there are signs ofimpending cardiovascular decompensation.Anaesthetists will be the people most in touch withthe woman’s condition and if they declare that thepulse rate is continuing to rise and the bloodpressure to fall despite conservative measures,hysterectomy becomes inevitable. The precisetiming of this intervention must, of course, alwaysremain a matter of clinical judgment.

The topic of caesarean hysterectomy really requiresan article to itself, but the experience of this authorover the years suggests that it is often a good ideato do subtotal hysterectomy first. This is oftensufficient to arrest the bleeding if the main cause isan atonic corpus, because the two major pediclesclamped, cut and tied include both the ovarian andthe uterine arteries. Even if there is continuingbleeding, removing the body of the uterus improvesaccess to and visibility of the pelvic floor. It allows

identification of the cervix and therefore reduces thechance of taking a pedicle too low and including theureter. Once the bleeding is controlled, anytemptation to remove more tissue, for example, thecervix, should be resisted, as this may simply restartthe bleeding.Any specific bleeding sites should beoversewn, even if it seems possible that the uretermay be obstructed. This can always be rectified at alater date, once the woman is no longer at risk ofdeath from haemorrhage. Even complete occlusionof the ureter for several days will not result inpermanent damage to renal function, which willresume once the obstruction is relieved. If bleedingcontinues following hysterectomy, it becomesmandatory to include surgeons with additionalexperience of dealing with major haemorrhage,such as a gynaecological oncologist or vascularsurgeon. In the meantime, pelvic tamponade with aLogethotopulos pack32 will usually staunch the flow(Figure 8). The principle is straightforward.Aflexible plastic bag larger than the pelvic cavity isfilled with gauze swabs or anything similar to hand.The neck is firmly tied to a length of tubing, which ispassed from the pelvis out through the vagina andthen attached to a litre bag of fluid which is allowedto hang freely over the end of the bed. This applies asteady tamponade which moulds itself to the pelviccavity and will stop all but the most major arterialbleeding (especially as the woman is likely to bequite hypotensive by this stage). I have had personalcommunications from obstetricians who havefound this manoeuvre to be life-saving in extremis.

Special situationsUterine inversionThis is a rare cause of PPH, but it is important torecognise it promptly as the situation will not be

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Figure 7

Dawlatly suture forcontrol ofbleeding

from the lowersegment of the uterus.


Dawlatly et al.18

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resolved until the inversion is corrected. If thewoman has had adequate analgesia, promptmanual correction of the inversion is feasible andwill be effective in many cases. If the placenta is stilladherent to the uterus, it should be left in situ untilthe uterus has been replaced. If there is a delay whilethe woman is resuscitated and anaesthesiaprovided, then hydrostatic replacement (theO’Sullivan technique) may be necessary. Severallitres of warmed Hartmann’s solution instilled intothe vagina is usually enough to stretch the cervixand generate enough pressure to push the uterusback into a normal position. Traditionally, thelower vagina was plugged with the accoucheur’shand, but a better seal can be obtained using asilicone vacuum extractor (ventouse).33

More complicated methods have been described,including applying manual upward pressure on thecervix balanced by counter pressure on the uterusvia a laparoscopy probe34 and reducing theinversion at laparotomy using a vacuum extractorto suck out the fundus into its correct position.35

Placenta praevia and accretaWith the considerable rise in the rate of caesareansection in recent years, the incidence ofplacenta praevia and placenta accreta has risensubstantially. The risk of placenta praevia in a firstpregnancy is only about 1 in 400, but it rises to 1 in160 after one caesarean section, 1 in 60 after two,1 in 30 after three and 1 in 10 after four.36 If theplacenta is over the lower segment scar, then thereis an attendant risk that the placenta will invadeinto (or occasionally through) the myometrium.This risk is about 1 in 50 if there has been onecaesarean section, 1 in 6 after two, 1 in 4 after three,1 in 3 after three or four and 1 in 2 after five.37 Thus,the presence of a placenta praevia in a woman witha previous caesarean section should always raisethe suspicion of a placenta accreta. This should beinvestigated using ultrasound, supplemented ifpossible with magnetic resonance imaging.Ultrasound is probably the most sensitive method,especially if a vaginal probe is used as well as an

abdominal probe, together with colour flow(power) Doppler. This can reveal the presenceof large blood-filled spaces between thefetus/amniotic fluid of the lower uterus and themother’s urinary bladder, with loss of the normalmyometrium. The presence of large blood vesselswith pulsatile flow in the bladder wall is a likelyindicator of placental invasion. In such cases,operative delivery is necessary but is oftenaccompanied by profuse haemorrhage andappropriate preparations must be made. Thelikelihood of hysterectomy is significantlyincreased to an odds ratio of 5.6 when there havebeen five or more caesarean sections.38 Placentaaccreta is almost exclusively seen in associationwith placenta praevia, it can sometimes develop aspregnancy progresses and it never resolves withadvancing gestational age.

Practical aspects of preparation and care in theoperating theatre when placenta accreta is suspectedThe average blood loss in cases of placenta accreta is 3–51,39 so proper prior liaison with thehaematologist to ensure an appropriate supply ofcrossmatched blood is essential. It is probablyadvisable to have at least 4 units of packed redblood cells in the operating theatre, with readyaccess to further supplies, before commencing theoperation. It is also wise to arrange access tosupplies of clotting factors, including fresh frozenplasma. Adequate intravenous access is important,with two wide-bore venous lines inserted and anarterial line to measure the blood pressureaccurately if there is major blood loss andhypotension. In appropriate cases autologoustransfusion may be appropriate (e.g. someJehovah’s Witnesses will accept replacement of theirown blood, but will not accept it from otherpeople). Up to 1 unit per week can be removed forstorage during pregnancy without causing asignificant drop in haemoglobin concentration,so up to 6 units can be collected in total: the bonemarrow can increase production of red cells tocompensate. Normovolaemic haemodilution(taking off 250 ml of whole blood at a time andreplacing it with crystalloid) can also be used toobtain a further 2 units immediately beforesurgery.40 Cell savers can also be used to recyclesome of the woman’s own blood and they are nowroutinely used in some units for this type ofsurgery.41, 42

One needs to ensure adequate numbers ofexperienced and well-trained supporting staff inthe operating theatre, plus appropriate equipment.It is wise to have at least two suction devices withbottles in reserve. The deleterious tissue perfusioneffects of blood loss are exacerbated by a drop inbody temperature, so the operating theatre shouldbe kept warm, as should the woman (using, forexample, a Bair Hugger® warming blanket).

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Figure 8

Logethotopulos pack32

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Instruments for bowel and bladder resectionshould be available if needed, as should a vascularsurgery set. Preoperative cystoscopy and stentplacement is helpful to ascertain bladderinvolvement and make any necessary bladdersurgery easier. Urological and vascular surgeonsshould be available if needed. Packing of the vaginawith multiple gauze bandages to elevate the loweruterine segment can make surgery easier if there is alot of bleeding and pelvic surgery becomesnecessary, as this elevates the pelvic floor andfacilitates identification of the cervix.43

For the delivery, general endotracheal anaesthesia ispreferred in combination with lumbar (thoracic)epidural catheter placement preoperatively forpostoperative pain control. Intra-operative calfcompression (e.g. with Flowtron® boots) helps toguard against deep vein thrombosis if the operationand recovery time is prolonged.

The most appropriate abdominal incision is amidline, which gives the best access in case of heavybleeding (mass closure with a nylon suture gives thelowest dehiscence rates). It is a good idea to scandirectly onto the uterus, using a sterile sleeve for thetransducer, to define the placental site preciselybefore making the uterine incision. This incisionshould be away from the placenta, often fundal, soas to allow delivery of the baby before there is anyattempt at removing the placenta. We havedeveloped a technique in our unit of givingoxytocics (such as an intravenous infusion ofoxytocin and 1000 micrograms of misoprostolrectally) once the baby is safely delivered and thenwaiting to see if the placenta separates. If it does,and there is good uterine retraction with minimalbleeding, then once the placenta is extruded byuterine contraction the uterus can be closed. If theplacenta does not separate spontaneously within 10minutes (this interval is arbitrary), we do not makeany attempt to separate it provided there is nobleeding, but instead we close the uterus and waitfor the placenta to discharge spontaneously in thepuerperium (some authorities have suggested usingmethotrexate to speed placental involution). If,however, there is substantial bleeding, then weproceed straight to hysterectomy without making itworse by trying to remove the placenta piecemeal.Persistent bleeding can often be arrested by arterialembolisation but this technique is outwith thescope of this article. The article by Boulleret et al.44

is recommended to readers as a good account ofrecent techniques.

ConclusionFor most of the last century, the management ofmajor PPH relied upon the use of oxytocic agents,followed by hysterectomy if these failed. However,the last 10 years has seen the introduction of manyuseful additional surgical procedures, in particular

uterine compression sutures and intrauterinetamponade balloons. These are now widely usedand are effective in ~90% of cases. However, reportsof both short- and long-term complications arenow appearing and it is important not to reduce theperfusion of the uterus so much that it becomesdevitalised. Uterine artery ligation can be carriedout safely by an obstetrician, but internal iliacartery ligation should be carried out only by asurgeon familiar with this procedure, for example,a gynaecological oncologist or vascular surgeon.Hysterectomy still has an important place. Ifbleeding continues after the uterus has beenremoved, the Logethotopulos pack can be used tostabilise the situation and arterial embolisation canbe life-saving. With the increasing incidence ofcaesarean section, the possibility of placenta accretashould always be considered in the next pregnancyand ultrasound/magnetic resonance imaging areimportant. Anticipation and careful preparation ofthe operating theatre, facilities, blood products andsurgeons remain the key to successful management.

AcknowledgementThe author is grateful for the assistance of ProfessorMichael Belfort of the Utah Valley RegionalMedical Center (USA) for helping with thedevelopment of the lecture upon which this articleis based.

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