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31CONSERVATIVE SURGICAL MANAGEMENT

C. B-Lynch

INTRODUCTION

A key factor in the surgical management ofpostpartum hemorrhage is the awareness of pre-disposing factors1–3 and the readiness of thera-peutic teams consisting of obstetric, anestheticand hematology staff3,4.

In the past, the surgical management of post-partum hemorrhage included use of an intra-uterine pack, with or without thromboxane5,thrombogenic uterine pack6, ligation of uterinearteries7, ligation of internal iliac artery8,stepwise devascularization9 and, finally, sub-total or total abdominal hysterectomy10. Mostof these are discussed in detail in other chaptersof this text.

A more conservative procedure, now collo-quially known as the Brace suture technique,was first described by B-Lynch and colleagues

in 19973. Along with later modifications byHayman and colleagues11 and Cho and col-leagues12, this13 may prove more effective thanradical surgery for the control of life-threateningpostpartum hemorrhage3,11,12. Although sub-total and total abdominal hysterectomy are stillavailable and indeed useful in their own right,they should be considered as a last resort.

Common causes of postpartum hemorrhageare listed in Table 1, which is not to mean thatadditional causes cannot or do not exist.Most, if not all, are considered in referencesto postpartum hemorrhage in modern standardtextbooks of obstetrics and further describedin the other chapters of this volume. Threeimportant points merit attention.

First, there is significant increase in cardiacoutput in pregnancy in accordance with red cell

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Pre-existing conditions

Uterine overdistention, atonyand disseminated intravascularcoagulation (DIC)

Disorders of placenta, uterine andgenital tract trauma

Thrombocytopenic purpuraHypertensive diseaseUterine myomaAnticoagulation therapyCoagulation factor deficiencySystemic disease of hemorrhagicnatureConsumptive 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

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mass and plasma volume, which provides acompensative reserve for acute blood loss andhemostatic response following massive hemor-rhage14. Second, the arrangement of the uterinemuscle fibers, vis-à-vis the course of the uterinearteries, facilitates the use of compressiontechniques for effective control of postpartumhemorrhage and, finally, conservative treatmentsuch as bimanual compression of the uterusmay control blood loss (Figure 1), whilstintensive resuscitative measures are undertaken

according to established labor ward protocols,which involve the anesthetists, hematologists,the obstetric team and intensive care support(see Chapters 13 and 22).

NEW DEVELOPMENTS INTHERAPEUTIC OPTIONS

The type of surgical intervention dependsupon several factors, paramount of which is theexperience of the surgeon. Other factors includeparity and desire for future children, the extentof the hemorrhage, the general condition of thepatient and place of confinement. Women athigh risk of postpartum hemorrhage shouldnot be delivered in isolated units or unitsill-equipped to manage sudden, life-threateningemergencies. Immediate access to specialistconsultant care, blood products and intensivecare are essential.

The B-Lynch suture compressiontechnique

The procedure was first performed anddescribed by Mr Christopher B-Lynch, aconsultant obstetrician, gynecological surgeon,Fellow of the Royal College of Obstetriciansand Gynaecologists of the UK and Fellow of theRoyal College of Surgeons of Edinburgh, basedat Milton Keynes General Hospital NationalHealth Service (NHS) Trust (Oxford Deanery,UK), during the management of a patient with amassive postpartum hemorrhage in November1989. This patient refused consent to an emer-gency hysterectomy3! Table 2 provides an auditsummary of five case histories of other patientswith severe life-threatening postpartum hemor-rhage managed with this technique.

The principle

The suture aims to exert continuous verticalcompression on the vascular system. In thecase of postpartum hemorrhage from placentaprevia, a transverse lower segment compressionsuture is effective.

The technique2–4

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

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POSTPARTUM HEMORRHAGE

Figure 1 Bimanual compression of the uterus,illustrating the first-line approach to mechanicalhemostasis. This in itself might control bleedingsignificantly by assisting the uterus to use itsanatomical and physiological properties such as thecross-over interlinked network of myometrial fibersfor vascular compression and bleeding control. Thepatient should be placed in stirrups or frog-leggedposition in the labor ward or in theater whilstintravenous fluid and/or appropriate blood productruns freely. In some cases and commonly so, theremay be failure to achieve satisfactory and lastinghemostasis by this method



Surgeon’s position In outlining the stepsinvolved, we assume that the surgeon is right-handed and standing on the right-hand side ofthe patient. A laparotomy is always necessary toexteriorize the uterus. A lower segment trans-verse incision is made or the recent lowersegment Cesarean section suture (LSCS)removed to check the cavity for retainedplacental fragments and to swab it out.

Test for the potential efficacy of the B-Lynch suturebefore performing the procedure The patient isplaced in the Lloyd Davies or semi-lithotomyposition (frog leg). An assistant stands betweenthe patient’s legs and intermittently swabs thevagina to determine the presence and extent ofthe bleeding. The uterus is then exteriorized

and bimanual compression performed. To dothis, the bladder peritoneum is reflected inferi-orly to a level below the cervix (if it has beentaken down for a prior LSCS, it is pushed downagain). The whole uterus is then compressed byplacing one hand posteriorly with the ends ofthe fingers at the level of the cervix and the otherhand anteriorly just below the bladder reflec-tion. If the bleeding stops on applying suchcompression, there is a good chance thatapplication of the B-Lynch suture will workand stop the bleeding.

Even in the presence of coagulopathy,bimanual compression will control diffusebleeding points. If this test is successful, theapplication of the suture will also succeed.

289

Conservative surgical management

Figure 2a–c Summary of the application of the B-Lynch procedure

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However, application of the B-Lynch suture isnot a substitute for the medical treatment ofcoagulopathy, which should take place alongwith the operative intervention (see Chapter25).

Suture application Given that the test criteriafor the B-Lynch suture placement are met, theuterus remains exteriorized until applicationof the suture is complete. The senior assistanttakes over in performing compression andmaintains it with two hands during the place-ment of the suture by the principal surgeon.

(1) First stitch relative to the low transverseCesarean section/hysterotomy wound. With thebladder displaced inferiorly, the first stitchis placed 3 cm below the Cesarean section/hysterotomy incision on the patient’s leftside and threaded through the uterine cav-ity 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 overthe top of the uterus and to the posteriorside. Once situated over the fundus, thesuture should be more or less vertical andlie about 4 cm from the cornu. It does nottend to slip laterally toward the broad liga-ment because the uterus has been com-pressed and the suture milked through,ensuring that proper placement is achievedand maintained (Figure 2a).

(3) The posterior wall The location on theposterior uterus where the suture is placedthrough the uterine wall is actually easyto surface mark posteriorly. It is on thehorizontal plane at the level of the uterineincision at the insertion of the uterosacralligament (Figure 2b).

(4) Role of the assistant As the operation pro-ceeds, the assistant continues to compressthe uterus as the suture is fed through theposterior wall into the cavity. This willenable progressive tension to be maintainedas the suture begins to surround the uterus.Assistant compression will also help to pullthe suture material through to achieve max-imum compression, without breaking it,at the end of the procedure. Furthermore,

it will prevent suture slipping and uterinetrauma. The suture now lies horizontally onthe cavity side of the posterior uterine wall.

(5) The fundus As the needle pierces the uterinecavity side of the posterior wall, it is placedover the posterior wall, bringing the sutureover the top of the fundus and onto theanterior right side of the uterus. The needlere-enters the cavity exactly in the same wayas it did on the left side, that is 3 cm abovethe upper incision and 4 cm from the lateralside of the uterus through the upper inci-sion margin, into the uterine cavity andthen out again through 3 cm below thelower incision margin (Figure 2a(ii)).

(6) Later role of the assistant The assistant main-tains the compression as the suture materialis milked through from its different portalsto ensure uniform tension and no slipping.The two ends of the suture are put undertension and a double throw knot is placedfor security to maintain tension after thelower segment incision has been closed byeither the one- or two-layer method.

(7) Relation to the hysterotomy incision The ten-sion on the two ends of the suture materialcan be maintained while the lower segmentincision is closed, or the knot can be tiedfirst, followed by closure of the lower seg-ment (Figure 2c). If the latter option is cho-sen, it is essential that the corners of thehysterotomy incision be identified and staysutures placed before the knot is tied. Thisensures that, when the lower segment isclosed, the angles of the incision do notescape it. Either procedure works equallywell. It is important to identify the cornersof the uterine incision to make sure nobleeding points remain unsecured, particu-larly when most of these patients are hypo-tensive with low pulse pressure at the timeof the B-Lynch suture application.

(8) Post-application and hysterotomy closure It isprobable that the maximum effect of suturetension lasts for only about 24–48 h.Because the uterus undergoes its primaryinvolutionary process in the first week aftervaginal or Cesarean section delivery, thesuture may have lost some tensile strength,

291




but hemostasis would have been achievedby that time. There is no need for delay inclosing the abdomen after the application ofthe suture. The assistant standing betweenthe patient’s legs swabs the vagina againand can confirm that the bleeding has beencontrolled.

Application after normal vaginal delivery Iflaparotomy is required for the management ofatonic postpartum hemorrhage, hysterotomy isnecessary to apply the B-Lynch suture. Hystero-tomy will also allow exploration of the uterinecavity, exclude retained products of conception,evacuate large blood clots and diagnose abnor-mal placentation and decidual tears, damageand bleeding. B-Lynch suture application orany modification of it (see below) withouthysterotomy or re-opening of the Cesarean sec-tion wound runs the potential risk of secondarypostpartum hemorrhage. Therefore, confirma-tion that the uterine cavity is completely emptyis essential. Furthermore, hysterotomy ensuresthat the correct application of the suture pro-vides maximum and even distribution of thecompressive effect during and after applicationof the B-Lynch suture (Figures 2 and 3). Also,it avoids blind application of the suture andthe possibility of obliteration of the cervicaland/or uterine cavities that may lead to clotretention, infected debris, pyometria, sepsis andmorbidity3,11,12,15.

Application for abnormal placentation TheB-Lynch suture may be beneficial in casesof placenta accreta, percreta and increta. In apatient with placenta previa, a figure-of-eightor transverse compression suture to the loweranterior or posterior compartment or both isapplied to control bleeding. If this is notcompletely successful, then, in addition, thelongitudinal Brace suture component may beapplied for further/complete hemostasis3.

POSTOPERATIVE FOLLOW-UP

Three patients from the original series hadlaparoscopy postoperatively for sterilization,suspected pelvic inflammatory disease orappendicitis. One patient who had a history ofileostomy for surgical reasons had laparotomy

10 days after her B-Lynch suture for suspectedintestinal obstruction (unpublished data,B-Lynch). Magnetic resonance imaging andhysterosalpingography were performed on onepatient, showing no intraperitoneal or uterinesequelae16 (Figure 4a–c). No complicationshave been observed in the five patients of thefirst published series2 (see Table 1). Moreover,all have succeeded in further pregnancy anddelivery17,18.

Tables 3–5 lists the clinical points of theB-Lynch surgical technique, the Hayman uter-ine compression suture (see Figure 5) and theCho multiple square sutures (see Figure 6).

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Figure 3 The in vivo effect of correct applicationof the B-Lynch surgical technique seen immediatelyafter successful suture application. No congestion,no ischemia and no ‘shouldering’ of the sutures atthe fundus



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Figure 4a–c Normal MRI 6 months after massive postpartum hemorrhage treated by B-Lynch surgicaltechnique followed by uneventful spontaneous vertex vaginal delivery 22 months later. (a) Sagittal viewshowing normal endometrial cavity and treated Cesarean incision site; (b) coronal view, with no uterinecavity synechiae19; (c) view at level of incision for Cesarean section, showing well-healed features

(a)

(b)



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