Elsevier

Seminars in Perinatology

Volume 43, Issue 1, February 2019, Pages 27-34
Seminars in Perinatology

Surgical management of postpartum hemorrhage

https://doi.org/10.1053/j.semperi.2018.11.006Get rights and content

Abstract

When medical management of PPH is unsuccessful, surgical options should be utilized in a timely fashion in order to reduce maternal morbidity and mortality. This chapter describes ways of effective preparation, mobilization of resources and an organized approach to evaluation and surgical amelioration of PPH. Multiple fertility preserving surgical techniques to control PPH are described. Although a variety of conservative surgical approaches can be used in the setting of PPH, in a hemodynamically unstable patient, readiness for definitive management with a hysterectomy is necessary in order to reduce the risk of maternal mortality.

Introduction

Preparation and evaluation, as well as amelioration of risk factors for hemorrhage should be primary in postpartum hemorrhage (PPH) management. Failing the prevention, rapid assessment, medication administration with aggressive fluid and blood replacement become the next best therapies. However, surgical evaluation and treatment may need to be part of the management strategy and the team should not hesitate to prepare for and employ these while simultaneously performing other therapies.

The approach to PPH can be thought of as the “4 Ts” including Tone (atony), Trauma (lacerations), Tissue (retained), and Thrombin (coagulation).1 Surgical hemorrhage management prior to hysterectomy is concerned with improving Tone, removing Tissue and repairing Trauma, while preventing blood loss (Thrombin). These techniques fall broadly into three categories: (1) restoring uterine contractility (removing Tissue, repairing Trauma); (2) decreasing blood loss (Thrombin) while allowing time for uterotonic effect in restoring tone and (3) providing “Tone” through internal or external tamponade.

To approach the 4 T's, there are three groups of surgical techniques. The first restore uterine physiology and normal anatomy. This involves the repair of lacerations, removal of retained products, as well as restoring normal uterine anatomy after inversion. By restoring normal anatomy, these techniques aim to restore the process of uterine involution. The second group decreases uterine blood flow and decreases blood loss through surgical vascular ligation and uterine artery embolization, giving time for involution to take effect. The third group replicates vascular compression of uterine involution by tamponade through B-lynch or uterine balloon. Failing these uterine and fertility salvaging procedures, hysterectomy becomes the final method to treat post-partum hemorrhage.

Using this framework, this chapter will focus on the care and evaluation after initial medical therapies are ineffective or inadequate. There are no data as to the proper order in which to utilize these techniques, and no prospective data comparing these techniques head-to-head for effectiveness in the setting of PPH. The utilization must be based on primary assessment, findings, severity and rapidity of the hemorrhage (Box 1: commonly used algorithm “STASIS”). This chapter will not address rare pregnancy events/causes of bleeding such as liver rupture and splenic artery aneurysm. As rare complications and ruptures can occur, possibly due to the collagen vascular intimal remodeling of pregnancy, careful evaluation of the entire pelvis and abdomen when the patient's condition is out of proportion to the visible bleeding is needed.

“Stasis” surgical approach to PPH.

S: Shift

 Shift to operating room

 (with bimanual compression anti-shock garment in place if transfer is required)

T: Tissue, trauma and tamponade

 Exclude the presence of retained tissue or lacerations; proceed with tamponade (balloon)

A: Apply compression

 Apply compression sutures

S: Systematic devascularization

 Ligate uterine (O'leary), ovarian, hypogastic, quadruple

I: Interventional radiology

 Uterine artery embolization

S: Subtotal/total hysterectomy

 Proceed with hysterectomy

           Adapted from: Mukherjee et.al.1

The decision to proceed to the operating room (OR) should be made when there is a need for additional visualization, anesthesia or equipment (Box 2). Although there may be a temptation to attempt evaluation in the delivery room, if bleeding is severe or cannot be rapidly controlled, then the move to the OR should not be delayed. Conversely, the decision to move to the OR should not delay the administration of uterotonics and other portions of the hemorrhage bundle (Chapter 5: PPH Medical management).

General approach to surgical management of PPH.

General considerations

∘ Team-based closed-loop communication

∘ Assurance of enough team members

∘ Support and communication with family

∘ Code sheet and assigned scribe to record times, events & medications

Assurance of equipment and supplies

∘ Hemorrhage cart with appropriate equipment

∘ Uterotonics

∘ Uterine balloons and filling equipment

∘ Retractors- abdominal, vaginal and self-retaining, as needed

∘ Large packing sponges

∘ Long instruments

∘ Cystoscope and tower

∘ Cesarean hysterectomy tray

∘ Ultrasound

∘ D&C equipment (possibly including manual vacuum aspiration (MVAC))

Monitoring of blood loss

∘ Quantitative drapes

∘ Qualitative assessments

∘ Scale and weights of blood-soaked items

∘ “Call out” and check back of total EBL at regular intervals

Maternal hemodynamic support and anesthesia/pain control

∘ Massive transfusion and maternal care as appropriate

∘ Provision of anesthesia for maternal comfort

∘ Avoidance of hypothermia

∘ Antibiotics, re-dosed as appropriate for procedure type and after 1500-2000 cc estimated blood loss or 4 h of operative time2

Optimization of physical environment:

∘ Appropriate positioning of patient in stirrups

∘ Optimization of lighting

■ OR lights

■ Headlamps

■ Task lighting

■ Lighted specula

Full anatomic evaluation and systematic treatment

∘ Evaluation of sources of vaginal bleeding working from distal to proximal

∘ Evaluation for retained products

■ Bedside ultrasound

■ Manual exploration

∘ Evaluation and assist abdominally (if not already open)

■ Evaluation of pelvis in systematic manner

■ Evaluation of non-pelvic organs if shock out of proportion to vaginal/abdominal bleeding

When proceeding to the OR, the anesthesia team, obstetrics team and any support personnel needed should be rapidly assembled, ideally using an “obstetrics team” or code call for rapid assembly. The team should quickly “huddle” to review the patient, events, blood loss, and care thus far. The team should continually check in with blood loss, patient stability, and interventions being attempted to assure that all team members are aware of the findings and patient status. Teams should continue to use closed-loop communication techniques and best practices for care coordination (see also Chapter 2: Readiness). Administration of blood products and evaluation of coagulation cascade should continue per best practices (Chapter 8: PPH Blood Product management) and anesthesia should be provided (Chapter 7: PPH anesthesia management).

Section snippets

Laceration evaluation and repair

Thorough examination of the perineum, vaginal vault, lateral vaginal walls and cervix is vital in any PPH. Discovery of one tear does not preclude the presence of higher or multiple tears and a full evaluation is needed prior to beginning repair. Unless there is a large bleeding vessel that warrants immediate attention, repairs should proceed cephalo-caudal to avoid disruption of lower repairs while visualizing superior ones. A vaginal pack to decrease the obscuring lochia can be utilized.

Surgical interventions to decrease uterine blood flow

If bleeding continues after medical therapies for PPH, then surgical techniques that decrease uterine blood flow and pulse pressure can help decrease blood loss, thus giving time to allow for normal physiological and/or medical involution (uterotonics) to take effect. Typically, this should be completed in a stepwise fashion, interrupting blood supply to the uterus from its four main sources: the uterine artery – above and below the level of the ureter, the vaginal branch of the uterine, and

Surgical interventions to replicate uterine compression

External uterine compression and tamponade can decrease blood loss while uterotonics and resuscitation to restore normal coagulation are completed. However, they are not a replacement for definitive management in a patient with unstable continued bleeding.

Definitive surgical management – hysterectomy

Failing these uterine and fertility salvaging procedures, hysterectomy to prevent further maternal morbidity or mortality becomes the final method to treat post-partum hemorrhage. As with all other aspects of management of PPH, preparation is essential for a successful peripartum hysterectomy. Having a preset hysterectomy instrument tray and availability of self-retaining abdominal wall retractors (such as O Ring retractor) can expedite the surgical process.

Once the decision for hysterectomy is

Role of cystoscopy in surgical PPH management

Injury to the lower urinary tract is uncommon after repair of post-birth lacerations. Although there are no trials specifically evaluating the utility of cystoscopy after repair of post-birth injuries, to extrapolate from literature on unintentional injuries after urogynecologic surgery, it is reasonable to perform cystoscopy after repair of significant superior anterior or superior lateral vaginal wall injury and significant lateral or cervico-vaginal hysterotomy extensions, as well as after

Conclusions

PPH is a symptom, not a diagnosis, and therefore, the alert clinician should be searching for a cause while simultaneously managing the “4 T's”. Surgical management of PPH should not be postponed in the setting on ongoing bleeding. These techniques, when utilized in conjunction with the medical and blood therapies delineated elsewhere in this edition, have the potential to reduce maternal morbidity and mortality.

Although a variety of conservative, fertility sparing surgical approaches can be

Disclosures

The authors report no conflicts of interest regarding this manuscript.

Grant support

None

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