Emergent management of postpartum hemorrhage for the general and acute care surgeon

Abstract

Background: Postpartum hemorrhage is one of the rare occasions when a general or acute care surgeon may be emergently called to labor and delivery, a situation in which time is limited and the stakes high. Unfortunately, there is generally a paucity of exposure and information available to surgeons regarding this topic: obstetric training is rarely found in contemporary surgical residency curricula and is omitted nearly completely from general and acute care surgery literature and continuing medical education.

Methods: The purpose of this manuscript is to serve as a topic specific review for surgeons and to present a surgeon oriented management algorithm. Medline and Ovid databases were utilized in a comprehensive literature review regarding the management of postpartum hemorrhage and a management algorithm for surgeons developed based upon a collaborative panel of general, acute care, trauma and obstetrical surgeons' review of the literature and expert opinion.

Results: A stepwise approach for surgeons of the medical and surgical interventions utilized to manage and treat postpartum hemorrhage is presented and organized into a basic algorithm.

Conclusion: The manuscript should promote and facilitate a more educated, systematic and effective surgeon response and participation in the management of postpartum hemorrhage.

Figure 1

B-Lynch Suture Technique: The B-Lynch Suture Technique was the originally described compression suture [27], providing a simple and fertility-sparing option for treatment of post-partum hemorrhage.

Figure 2

Square Suture Technique: The Square Suture technique was created and described by Cho and colleagues [28], offering an alternative to the B-Lynch technique. This suture is considered to be a safer option as the uterine vessels do not cross the anatomy where the stitch is placed.

Figure 3

Modified B-Lynch Suture: The Modified B-Lynch Suture [29]is an adaptation of the B-Lynch suture, used for cases in which the source of bleeding is identified to be contained primarily within the fundus of the uterus.

Figure 4

Significant Uterine Vessels. The uterine artery, the anastomosis of the utero-ovarian artery and the hypogastric artery are all acceptable places to perform an arterial ligation.

Figure 5

Algorithm for Management of Post-Partum Hemorrhage. This figure provides a step-wise chart depicting timely choices for the management of post-partum hemorrhage.