Choose suture material wisely
In the original description of the B-Lynch suture, a chromic suture was used.1 In a later report, a No. 1 poliglecaprone-25 suture (Monocryl) was utilized.6
I prefer a #1 chromic suture on a large curved needle (Ethicon GL30, 65-mm tapered needle, 30” looped suture) because the uterine compression suture only needs to maintain suture integrity for a few days to be effective. As the uterus involutes to a nonpregnant size, delayed absorption sutures may result in long “rabbit ear” loops separated from the uterus that theoretically could trap intra-abdominal tissue. It is important to ensure that the suture selected is sufficiently long to complete the encirclement of the uterus and with sufficient residual length to facilitate tying the knot.
Evaluate for postop complications
Following recovery from a PPH treated with a uterine compression suture, some women develop uterine complications such as:
- hematometra
- pyometra
- Asherman’s syndrome
- localized areas of uterine necrosis and full-thickness defects in the lower uterine segment or uterine fundus.
Some experts recommend that, for women considering a future pregnancy, the uterine cavity be evaluated, preferably with hysteroscopy.7,8 Hysterosalpingogram, hysterosonography, and MRI are alternative options for evaluating the uterus.
Sutures are effective when used
When PPH is caused by uterine atony, compression sutures have been reported to effectively manage the hemorrhage in about 80% to 90% of cases if the suture is placed in an expedient manner.9-11 The introduction of uterine compression sutures has helped to significantly reduce the number of women who undergo hysterectomy following a PPH. The uterine compression suture represents a significant advance in obstetric care. Every obstetrician should be facile in placing at least one type of compression suture.
Managing PPH following vaginal and cesarean delivery
The sequential treatment of PPH can be conveniently divided into two algorithms:
1. PPH following vaginal delivery
2. PPH at cesarean delivery.
In both situations, administration of uterotonics; uterine massage; aggressive replacement of red blood cells and clotting factors (fresh frozen plasma, cryoprecipitate, Riastap-lyophilized fibrinogen concentrate), and platelets and monitoring of coagulation effectiveness are critically important. Eliciting the aid of additional obstetricians, anesthesiologists, and nursing staff is also essential.
| Managing PPH following vaginal delivery | Managing PPH at cesarean delivery |
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