If the uterus remains atonic and bleeding continues despite giving appropriate utrerotnics and removal of possible retained products. Specialist surgical techniques are necessary. The early use of physical methods to control on-going bleeding is changing the management of major obstetric hemorrhage and reduces the side effects associated with the over use of uterotonics. A hysterectomy has been considered the definitive life-saving treatment for haemorrhage, and whilst this may still be appropriate in some cases, effective alternatives are now available with which the anaesthetist needs to be familiar.
Balloon Tamponade of Uterus
Hydrostatic balloons can be used within the uterine cavity to control haemorrhage, both for atony and placenta accrete. The Rusch Baloon can be inflated with 600ml of saline and left in situ for 48 hrs, then gradually deflated over several hours. A senstaken balloon for oesophageal varices and even a condom tied over a urinary catheter and inflated with saline have been used with success in this situation. The uterus can also be packed with gauze, but this requires a more traumatic removal.
B-Lynch Brace Suture
This is a surgical technique of 'folding' the atonic uterus down on itself to provide compression haemostasis ). In the UK report into confidential Enquiries into Maternal and child health (CEMACH) 2000 - 2002, there were no deaths in patients in whom this had been used. The use of the B-Lynch suture can avoid the need for hysterectomy, and there are reports of successful pregnancies after its use.
Transfusion Alternatives Cell Salvage
Where access to a safe blood supply is not possible, this specialist technique for washing, concentrating and returning the patient's own blood can provide a useful source of red blood cells. It also reduces the patient's exposure to donor blood and conserves the blood supply in massive bleeding. It is now being used widely in the UK and USA. If blood is salvaged in this way, it does not contain clotting factors, so they will need to be given in addition.