Several balloons are available for use, with the Bakri balloon being the prototype. The balloon may cut off uterine blood flow as a mechanism of action.
Before the advent of manufactured balloons, uterine tamponade was attempted using packing with gauze and a large-bore Foley catheter.
9. How do you proceed when surgery is necessary?
OBG Management: What surgical techniques—aside from hysterectomy—may be useful in stanching hemorrhage?
Dr. Brown: The first-line surgical approach after vaginal delivery is uterine exploration to evacuate uterine clots and check for retained placental fragments. This act alone may impart improved uterine contractility. If retained placental fragments are suspected, a gentle curettage of the uterine cavity, using a large curette, is appropriate.
When it is obvious that atony is the cause of the hemorrhage, and medical management has failed, these surgical steps are appropriate:
- Uterine artery ligation, using the “O’Leary” technique, can be performed bilaterally. The utero-ovarian vessels can also be ligated (but not cut!)
- B-Lynch suture as a technique to compress the uterus. This strategy uses outside, draping, absorbable suture to collapse the uterine cavity. It can be quite successful when combined with the use of uterotonics. One study reported more than 1,000 B-Lynch procedures, with only seven failures.1 Hemostatic multiple-square compression is a surgical technique that works according to a similar principle
- Hypogastric artery ligation can be performed by an experienced surgeon but is rarely employed in severe hemorrhage owing to the risk of complications and lengthy procedure time.
OBG Management: When does hysterectomy become an option?
Dr. Brown: Hysterectomy is the last defense against morbidity and maternal death from hemorrhage due to atony.
Clearly, when hysterectomy is performed, sooner is better than later, especially if uterine artery ligation and B-Lynch suture do not appear to be controlling the hemorrhage and the patient is hemodynamically unstable.
If the patient is a young woman with low parity, the uterus should be preserved, if at all possible, unless the hemorrhage cannot be controlled and the woman’s life is jeopardized.
When a uterine rupture has occurred, usually after a VBAC attempt, it may be prudent to proceed to hysterectomy, especially if the uterus appears to be difficult to repair.
10. When do you call for help?
OBG Management: When do you call in extra help?
Dr. Brown: As soon as hemorrhage occurs, the team should be assembled. It is critical that anesthesia be notified immediately, in the event that the patient requires surgical management. The blood bank should be notified that blood and blood products are likely to be required.
We designate a nursing leader to monitor the patient and another to keep the staff and unit on alert for potential surgical intervention. If uterine rupture or an invasive placental abnormality is suspected, we assemble the surgical team, including any potential consultant surgeon. We also notify the best available surgeons so that they can be ready to perform the necessary techniques. In addition, we notify the OR and surgical intensive care unit, in case they are needed.
OBG Management: How can obstetricians and obstetric units practice the response to OB hemorrhage so that, when a hemorrhage occurs, they are at the top of their game?
Dr. Brown: Obstetric units prepare by performing drills and simulations. These drills are now considered part of most units’ quality and safety programs.
Because obstetric hemorrhage can occur on any unit at any time, the team must be prepared to respond around the clock promptly and effectively to reduce the risk of morbidity and death.
After emergent surgical management of obstetric hemorrhage, the team should be assembled again to discuss what occurred and how they performed or could have performed more effectively as a team.
OBG Management: Should all obstetricians who perform repeat cesarean delivery be able to perform a cesarean hysterectomy in the event that uncontrollable hemorrhage is encountered?
Dr. Brown: It is an absolute must that any clinician who allows VBAC be capable of performing peripartum cesarean hysterectomy and know the indications for hysterectomy, as we have discussed. In fact, any obstetrician who performs cesarean delivery should be capable of performing a cesarean hysterectomy.
11. What do you recommend for practice?
OBG Management: How would you summarize the main points of management of postpartum hemorrhage?
Dr. Brown: I would suggest that the first step is organizing the team (obstetricians, nurses, anesthesiologist), followed by:
- resuscitation of the mother with oxygen and fluids through large-bore intravenous access sites
- notification of the blood bank (with typing and cross-matching) of the possible need for 4 to 6 U of blood for trans-fusion
- liberal assessment of laboratory values, especially coagulation status (International Normalized Ratio [INR], prothrombin time, and partial thromboplastin time) and blood counts (hemoglobin and hematocrit). Values may be lower if there has been significant blood loss and aggressive fluid resuscitation. Blood products such as fresh frozen plasma and cryoprecipitate are indicated, in addition to packed RBCs, if the patient has or is developing a coagulopathy. Also give platelets if the count is low. Once it becomes apparent that surgical intervention will be necessary, begin transfusion and replace clotting factors before beginning the procedure
- monitoring of vital signs and urine output throughout resuscitation and medical and surgical intervention
- elimination of the cause of bleeding as soon as possible by whatever means necessary to prevent maternal death, beginning with conservative medical management and, if necessary, followed by surgical intervention.