The B-Lynch suture3 is performed with a long, rapidly absorbable suture on a large needle (FIGURE 2). We use a 60-inch #1 or #2 chromic suture on a TP-1 needle in the following steps:
- Take bites on either side of the right edge of the hysterotomy incision (A and B). Place these bites approximately 3 cm from the edge of the hysterotomy incision.
- Loop the suture around the fundus and reenter the uterus through the posterior uterine wall at point C, which is directly posterior to point B.
- Exit the posterior wall of the uterus through point D.
- Loop the suture over the uterine fundus.
- Anchor the suture in the lower uterine segment by taking bites on either side of the left edge of the uterine hysterotomy incision (points E and F).
- Pull the two ends of the suture tight while an assistant squeezes the uterus to aid compression.
- Place a surgical knot to secure the suture.
- Close the hysterotomy incision.
The B-Lynch suture was described with an open hysterotomy incision,3 which avoids closing off the lower uterine segment. We have successfully performed a modific tion on a closed uterus, taking care to not drive the lower uterine sutures through both the anterior and posterior walls.
The Hayman suture4 was proposed with two important modifications: The suture is placed through-and-through the lower uterine segment with a closed hysterotomy, and the suture can be fixed to the uterine fundus to avoid slippage. This vertical compression suture (FIGURE 3) is performed by placing two to four vertical #2 chromic sutures directly through the anterior to posterior uterine wall, tying the suture on the fundus using a 3-throw technique to minimize slippage of the first knot. In the original description, Hayman also described injecting carboprost into the uterine fundus to stimulate uterine contraction and regularly inspecting the vagina to evaluate the extent of continued bleeding.4
The Pereira sutures,5 also described on a closed uterus, combine vertical and horizontal sutures placed as a series of bites into the submucosal myometrium using #1 polyglactin 910 (Vicryl) sutures (FIGURE 4). The sutures do not enter the uterine cavity. Two to three transverse sutures are initially placed followed by two vertical sutures. When placing the transverse sutures, it is important to cross the broad ligament in an avascular area and avoid trauma to blood vessels, ureters, gonadal vessels and fallopian tubes. The vertical sutures begin and end at the level of the transverse suture closest to the cervix.
Intrauterine balloon tamponade
Many types of balloon tamponade devices have been developed, ranging from the humble condom tied to a Foley urinary catheter to the sophisticated Bakri6,7 and Belfort-Dildy8 balloon tamponade devices. Intrauterine balloon tamponade is highly effective in controlling excess bleeding following vaginal delivery and less effective when used following a CD. In one study of 226 women with postpartum hemorrhage treated with a Bakri balloon the success rate was 89% and 66% following vaginal delivery and CD, respectively.9
Continue to: When using balloon tamponade during a CD...