Compression sutures for uterine atony and hemorrhage following cesarean delivery

Postpartum hemorrhage is a common obstetric complication, and uterine atony was identified as its primary cause [1]. In 1997 B-Lynch and colleagues described a surgical technique for the control of postpartum hemorrhage, which served as an alternative to more complicated surgical procedures associated with increased patient morbidity (e.g., internal iliac artery ligation and hysterectomy) [2], [3]. Recently, Hayman et al. [4] described modifications to this technique, which include (1) placing the primary vertical compression sutures separately, and (2) placing additional sutures to control hemorrhage and prevent the primary vertical compression sutures from sliding down the sides of the uterus. In the following case series, an original method to control hemorrhage and prevent lateral slippage of the sutures is described. A 40-year-old woman, gravida 1, para 0, was admitted in active labor to the Foothills Medical Centre of Calgary, Alberta, Canada, in her 42nd week of pregnancy and cared for by the family physician on call. Eight hours later, the obstetrical service was consulted because labor was not progressing, and a cesarean section was performed. Following an uncomplicated delivery via a low transverse uterine incision and removal of the placenta, the uterus was found to be atonic and diffusely bleeding. There was minimal response to intermittent fundal massage and medical efforts to improve uterine tonicity proved unsuccessful. Although continuous bimanual compression, as recommended by B-Lynch et al. [2], appeared to control the bleeding, the patient having lost more than 1500 mL, the decision was made to place compression sutures. According to the B-Lynch technique, with the uterine incision still open, a No. 2 Vicryl suture (Ethicon Inc., Sommerville, NJ) threaded through a large needle was passed through the anterior uterine wall (A) approximately 2 cm below the uterine incision (Fig. 1). From its intrauterine position, the needle was then brought out through the anterior uterine wall, approximately 2 cm above the incision (B). At this point, the authors of the present report modified the B-Lynch technique. Rather than wrapping the suture over the fundus, from where it risks being dislodged during the return of the uterus to the abdomen or during uterine involution, the suture was passed through the fundus 3 to 4 cm medial to the cornual region of the fallopian tube and 2 to 3 cm below the superior aspect of the fundus (to pass through the fundus the needle needs to be large; a large size also decreases the possibility of a needle break and/or needle embedment in the myometrium) (C). Needle and suture are then brought back through the posterior aspect of the lower segment of the uterus and joined anteriorly, where the suture was initially passed through below the uterine incision (D). This process is repeated on the opposite side. Then, while an assistant applies bimanual compression to the uterus, the sutures are tied down in place. The uterine incision is then observed for any evidence of bleeding prior to closure. Table 1 summarizes an additional 4 cases in which this compression technique proved successful in controlling diffuse uterine bleeding. Passage of the suture through the uterus. The needle is passed through the anterior uterine wall (A). From its intrauterine position, it is then brought out through the anterior uterine wall (B), then passed through the fundus (C), and brought back through the posterior aspect of the lower segment and joined anteriorly (D). The process is repeated on the opposite side and the sutures are tied down in place while an assistant applies continuous bimanual compression to the uterus. The novelty of the technique resides with anchoring the primary sutures to the uterine fundus, which prevents the possibility of their slipping laterally during the return of the uterus to the abdomen or during uterine involution (although some may argue that this does not matter, as hemostasis is achieved by thrombosis of the vessels in just a few hours). While passing the suture through the uterine cavity may be of concern, in the authors' experience, any risk is minimal and outweighed by the benefit of preserving the patient's fertility. Furthermore, the suture material used is absorbable, and the amount in the uterus is small compared with that needed with other techniques. This technique has only been used for 18 months, and long-term fertility issues have not been addressed. This will be a topic for further study.

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