3.1 Intrauterine Tamponade Balloons, Compression Sutures & Surgical Hemostasis

Intrauterine Tamponade Balloons, Compression Sutures & Surgical Hemostasis

When severe postpartum hemorrhage (PPH) persists despite aggressive first-line and second-line uterotonic administration (oxytocin, methylergonovine, carboprost, misoprostol) and tranexamic acid (TXA), immediate escalation to mechanical tamponade, vacuum-assisted uterine collapse, or operative surgical hemostasis is mandatory. Delay in transitioning from medical to mechanical or surgical interventions is a leading root cause of preventable maternal hemorrhagic morbidity and mortality.

Under standardized national obstetric safety frameworks—including the American College of Obstetricians and Gynecologists (ACOG) and the California Maternal Quality Care Collaborative (CMQCC)—persistent hemorrhage with blood loss exceeding 1,000 mL or clinical vital sign instability triggers Stage 2 and Stage 3 Hemorrhage Protocols, demanding immediate mobilization of intrauterine devices or surgical intervention.

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1. Intrauterine Balloon Tamponade (Bakri, Foley & Balloon Systems)

Intrauterine balloon tamponade (IUBT) exerts hydrostatic counter-pressure against the inner myometrial surface, exceeding systemic capillary and venous pressure in the denuded placental bed. This compresses open spiral and venous sinuses to arrest hemorrhage.

+---------------------------------------------------------------------------------------+
|                      INTRAUTERINE BALLOON TAMPONADE (BAKRI PROTOCOL)                  |
|                                                                                       |
|   [Clinical Indication]                                                               |
|   - Persistent uterine atony or lower uterine segment bleeding unresponsive to drugs  |
|                                                                                       |
|   [Placement Technique]                                                               |
|   - Transvaginal or trans-hysterotomy insertion under sterile conditions               |
|   - Advance catheter into uterine cavity ensuring balloon sits above internal os      |
|                                                                                       |
|   [Fluid Instillation]                                                                |
|   - Instill 300 to 500 mL sterile isotonic saline (NEVER air, CO2, or hypotonic water)|
|                                                                                       |
|   [Counter-Pressure & Stabilization]                                                  |
|   - Place vaginal gauze pack (or vaginal balloon) to prevent downward extrusion       |
|   - Maintain continuous IV oxytocin infusion to prevent myometrial relaxation         |
|                                                                                       |
|   [The Tamponade Test (15–30 min)]                                                    |
|   +---------------------------------------+---------------------------------------+   |
|   |         POSITIVE TEST (SUCCESS)       |         NEGATIVE TEST (FAILURE)       |   |
|   | - Port drainage <50 mL/hr             | - Port drainage >50 mL/hr or brisk    |   |
|   | - Hemodynamic stabilization           | - Vaginal blood bypassing packing     |   |
|   | - Maintain in situ for max 12–24 hrs  | - ESCALATE IMMEDIATELY TO SURGERY/IR  |   |
|   +---------------------------------------+---------------------------------------+   |
+---------------------------------------------------------------------------------------+

Key Procedural Nuances for IUBT:

1. Insufflation Volume & Fluid: The standard fill volume for a Bakri balloon is 300 to 500 mL of sterile saline or water. Never fill below 250 mL (ineffective surface apposition) or exceed 500 mL (risks uterine rupture or concealed myometrial wall ischemia). Only liquid is used; gas/air poses fatal air embolism risks if the balloon ruptures.
2. Foley Catheter Alternative: In low-resource settings or when bleeding originates selectively within the lower uterine segment or endocervical canal, a large Foley catheter (or multiple Foley catheters tied together) with a 30 to 80 mL balloon can provide focal hydrostatic tamponade.
3. Vaginal Packing: A sterile vaginal gauze pack soaked in antibiotic ointment or saline, or an inflated vaginal sponge/balloon, must be placed in the vaginal fornices around the catheter shaft. Without vaginal counter-pressure, uterine contractions will displace the balloon down through the dilated cervix into the vagina, losing uterine tamponade.
4. Continuous Drainage Port Patency: The central lumen of the catheter must be connected to a graduated drainage bag and flushed periodically with 15–30 mL sterile saline to prevent blood clot occlusion. A balloon that appears to 'stop' bleeding but has an occluded port will allow massive, fatal concealed hemorrhage to collect above it.
5. The 'Tamponade Test': Following balloon inflation, the clinical team observes the drainage port for 15 to 30 minutes:
   • Positive Tamponade Test: Bleeding from the port stops or slows to minimal serosanguinous output (<50 mL/hr), and maternal hemodynamic parameters stabilize. The balloon is left in place.
   • Negative Tamponade Test: Ongoing brisk bleeding (>50 mL/15 min) through the port or bleeding leaking around the balloon into the vagina indicates arterial bleeding, deep lacerations, placenta accreta spectrum, or complete mechanical failure. The team must immediately proceed to laparotomy, surgical devascularization, or uterine artery embolization.
6. Maintenance & Uterotonic Co-Administration: An IV oxytocin infusion (20–40 units/L at 125–250 mL/hr) must be continuously maintained while the balloon is inflated. Without basal myometrial tone, the uterus will expand around the balloon rather than generating effective tissue counter-pressure.
7. Indwelling Duration & Deflation Protocol: The balloon should remain inflated for a maximum of 12 to 24 hours. Prolonged indwelling beyond 24 hours significantly increases the risk of severe endometritis, toxic shock, and myometrial pressure necrosis. Deflation is performed during regular daytime operating hours when surgical staff is fully available: deflate the balloon in stepwise increments (e.g., withdraw 100 mL every 1–2 hours, or withdraw half the volume and observe for 30 minutes). If re-bleeding occurs, reinflate immediately and mobilize the surgical team.

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2. Vacuum-Induced Uterine Hemorrhage Control Device (JADA System)

The JADA System represents a paradigm shift from outward mechanical balloon expansion to physiologic, negative-pressure uterine collapse. It utilizes regulated low-level intrauterine vacuum to rapidly evacuate pooled blood and draw the myometrial walls together, simulating and accelerating normal physiologic postpartum myometrial contraction.

+---------------------------------------------------------------------------------------+
|                     VACUUM-INDUCED HEMORRHAGE CONTROL (JADA PROTOCOL)                 |
|                                                                                       |
|   [Intrauterine Silicone Loop]                                                        |
|   - Inserted transvaginally or trans-cesarean through the cervix into the cavity      |
|                                                                                       |
|   [Cervical Seal Inflation]                                                           |
|   - Fill cervical seal with 30 mL sterile fluid (expandable up to 60 mL)              |
|   - Positions at external os to establish an airtight anatomic seal                   |
|                                                                                       |
|   [Regulated Vacuum Application]                                                      |
|   - Connect to regulated in-line suction source set at 60–90 mmHg (80 ± 10 mmHg)       |
|                                                                                       |
|   [Physiologic Response & Evacuation]                                                 |
|   - Rapid evacuation of accumulated blood/clots into calibrated canister              |
|   - Immediate collapse of myometrial walls around the silicone loop                   |
|   - Median time to clinical hemostasis: <3 to 5 minutes                               |
|                                                                                       |
|   [Maintenance & Weaning]                                                             |
|   - Maintain suction for minimum 1 hour (typically 1–24 hours, average ~3 hours)      |
|   - Turn off vacuum, deflate seal, observe 30 min for stability prior to removal      |
+---------------------------------------------------------------------------------------+

Comparison: Intrauterine Balloon vs. Vacuum-Induced Tamponade

[!IMPORTANT] Contraindications to Intrauterine Devices (Bakri / JADA):

• Suspected or confirmed uterine rupture (risk of fluid/vacuum extravasation into the peritoneal cavity)
• Active, purulent intrauterine or cervical infection
• Cervical or genital tract lacerations that have not been surgically repaired
• Retained products of conception requiring surgical evacuation prior to device placement
• Known allergy to device materials (silicone/latex)

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3. Uterine Compression Sutures

When pharmacologic therapy and intrauterine devices fail to control hemorrhage during laparotomy (either at cesarean delivery or relaparotomy following vaginal birth), uterine compression sutures offer rapid, fertility-preserving mechanical hemostasis without devascularizing the uterus.

+---------------------------------------------------------------------------------------+
|                         UTERINE COMPRESSION SUTURE TECHNIQUES                         |
|                                                                                       |
|   1. B-LYNCH SUTURE (The Classic 'Suspender' Technique)                              |
|      - Indication: Atony during open cesarean hysterotomy                             |
|      - Method: Vertical loops traversing anterior/posterior walls, hugging fundus     |
|      - Suture: No. 1 or 2 absorbable (polydioxanone, polyglactin 910, chromic gut)    |
|                                                                                       |
|   2. MODIFIED HAYMAN SUTURE (Closed Hysterotomy / Post-Vaginal Delivery)              |
|      - Indication: Laparotomy following vaginal birth (hysterotomy not opened)        |
|      - Method: Direct through-and-through anterior-to-posterior vertical transfixion  |
|      - Advantage: Faster placement; no need to incise the lower uterine segment       |
|                                                                                       |
|   3. CHO MULTIPLE SQUARE SUTURES (Cavity Obliteration)                                |
|      - Indication: Focal placental bed bleeding / localized atony                     |
|      - Method: Full-thickness transmural square/box sutures compressing walls         |
|      - Caveat: Highest risk of Asherman syndrome (uterine synechiae) and pyometra     |
+---------------------------------------------------------------------------------------+

The B-Lynch Suture Protocol:

1. Pre-placement Bimanual Compression Test: Prior to placing the suture, the surgeon manually compresses the uterus with two hands (one anterior, one posterior). If bimanual compression successfully arrests vaginal and lower segment bleeding, the B-Lynch suture has a >90% probability of success.
2. Suture Material: Heavy, absorbable monofilament or braided suture (e.g., No. 1 or 2 polyglactin 910 / Vicryl or polydioxanone / PDS) on a large blunt-tipped curved needle (e.g., 70 mm Mayo needle). Permanent sutures must NEVER be used.
3. Anatomic Pathway:
   • Needle enters the anterior uterine wall 3 cm below the hysterotomy margin and 3 cm from the lateral border.
   • Enters the uterine cavity and emerges 3 cm above the upper hysterotomy margin.
   • Loops vertically over the uterine fundus (3–4 cm medial to the cornua) to the posterior wall.
   • Enters the posterior uterine wall directly opposite the anterior hysterotomy level, traverses the cavity horizontally, and emerges on the opposite posterior side.
   • Loops back over the contralateral fundus to the anterior wall, entering above and exiting below the hysterotomy.
   • Assistant vigorously compresses the fundus while the surgeon ties the two ends snugly below the hysterotomy.
4. The Modified Hayman Technique:
   • Unlike the B-Lynch, the Hayman suture does not require opening the lower uterine segment hysterotomy. Suture passes directly from the anterior to posterior uterine wall through the full thickness of the myometrium, looping over the fundus and tying on the anterior surface.
   • It is significantly faster to perform, especially when relaparotomy is undertaken following an atonic vaginal birth.
5. Complications of Compression Sutures: Uterine ischemia/necrosis, partial fundal sloughing, hematometra/pyometra, and late intrauterine synechiae (Asherman syndrome).

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4. Stepwise Surgical Pelvic Devascularization & Uterine Artery Embolization

If uterine compression sutures fail or if hemorrhage involves deep lateral vascular pedicles, the surgeon proceeds down the stepwise pelvic devascularization cascade.

+---------------------------------------------------------------------------------------+
|                       STEPWISE SURGICAL DEVASCULARIZATION CASCADE                     |
|                                                                                       |
|   [Step 1: Bilateral Uterine Artery Ligation (O'Leary Stitch)]                        |
|   - Ligate ascending branch of uterine artery 2–3 cm below hysterotomy                |
|   - Incorporates 2–3 cm of myometrium to avoid uterine vein laceration                |
|   - Controls ~80% to 90% of pelvic arterial blood flow                                |
|                                 |                                                     |
|                                 v (if bleeding continues)                             |
|   [Step 2: Bilateral Utero-Ovarian Vessel Ligation]                                   |
|   - Transfix anastomotic branch of ovarian artery just below utero-ovarian ligament   |
|   - Eliminates high-pressure collateral flow from the ovarian arcade                  |
|                                 |                                                     |
|                                 v (if bleeding continues)                             |
|   [Step 3: Internal Iliac (Hypogastric) Artery Ligation]                              |
|   - Retroperitoneal approach: Identify ureter crossing iliac bifurcation              |
|   - Ligate anterior division of internal iliac artery 3–4 cm distal to bifurcation    |
|   - Reduces pelvic pulse pressure by 85% and blood flow by 48%                        |
+---------------------------------------------------------------------------------------+

1. Uterine Artery Ligation (O'Leary Stitch)

• Anatomy & Technique: Using a No. 1 absorbable suture on a CT-1 curved needle, a mass ligature is placed through the myometrium 2 to 3 cm below the lower uterine segment incision. The needle penetrates 2 to 3 cm medial to the lateral uterine border from anterior to posterior, passes through an avascular window in the broad ligament, and is tied anteriorly. The bite must encompass a substantial portion of the adjacent myometrium to anchor the ligature and prevent shearing the delicate uterine venous plexus.
• Physiologic Impact: Bilateral ligation reduces arterial pulse pressure and decreases overall uterine blood supply by approximately 80–90% without causing myometrial necrosis due to extensive collateral pelvic circulations.

2. Utero-Ovarian Vessel Ligation

• Technique: Suture ligation placed directly beneath the insertion of the utero-ovarian ligament at the cornua, capturing the ovarian branch of the uterine artery and the anastomotic arcades from the infundibulopelvic vessels.

3. Internal Iliac (Hypogastric) Artery Ligation

• Surgical Approach: Requires opening the retroperitoneal space by incising the posterior leaf of the broad ligament parallel to the infundibulopelvic ligament.
• Critical Surgical Landmarks:
  1. Common Iliac Bifurcation: Located over the sacroiliac joint.
  2. The Ureter: Must be directly visualized and reflected medially; the ureter crosses the bifurcation of the common iliac artery into the external and internal iliac branches ("water under the bridge").
  3. Anterior Division: The ligature (No. 0 or 1 silk/absorbable) is passed from lateral to medial around the anterior division of the internal iliac artery, strictly 3 to 4 cm distal to the common iliac bifurcation to preserve the posterior division (which supplies the superior gluteal artery and iliolumbar arteries).
• Physiologic Effect: Converts the pelvic arterial system from a high-pressure pulsatile system into a low-pressure venous-like system (reducing pulse pressure by 85% and total pelvic blood flow by 48%), facilitating native microvascular clot formation.
• Major Risks: Laceration of the thin-walled internal iliac vein (which lies directly posterior and adherent to the artery; causes massive catastrophic hemorrhage), accidental ligation of the external iliac artery (resulting in lower extremity ischemia and limb loss), and accidental ureteral ligation.

4. Uterine Artery Embolization (UAE)

• Indications: Minimally invasive catheter angiography and embolization (using Gelfoam pledgets, micro-particles, or coils) performed by Interventional Radiology (IR).
• Patient Selection: Hemodynamically stable patients with persistent slow bleeding, suspected pseudoaneurysms, arteriovenous malformations (AVMs), or cervical/broad ligament hematomas not amenable to direct surgical access.
• Contraindications: Severe hemodynamic instability or refractory massive coagulopathic hemorrhage where transfer to an IR suite introduces fatal delays.

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5. Emergent Peripartum Hysterectomy

Emergent peripartum hysterectomy is the definitive, life-saving rescue procedure for intractable obstetric hemorrhage when all medical, mechanical, and conservative surgical maneuvers fail, or as the primary planned management for advanced Placenta Accreta Spectrum (PAS).

+---------------------------------------------------------------------------------------+
|                   SUBTOTAL (SUPRACERVICAL) VS. TOTAL HYSTERECTOMY                     |
|                                                                                       |
|   +---------------------------------------+---------------------------------------+   |
|   |         SUBTOTAL HYSTERECTOMY         |           TOTAL HYSTERECTOMY          |   |
|   | (Supracervical - Cervix Retained)     | (Complete Removal of Uterus & Cervix) |   |
|   +---------------------------------------+---------------------------------------+   |
|   | - Shorter operative duration          | - Longer, more complex dissection     |
|   | - Lower blood loss during procedure   | - Mandatory for lower segment previa, |
|   | - Reduced risk of bladder/ureter injury|   focal accreta/increta in cervix,    |
|   | - Indication: Severe fundal atony in   |   or deep cervical lacerations        |
|   |   hemodynamically unstable patient    | - Eliminates risk of persistent       |
|   | - Risk: Ongoing cervical bleeding     |   bleeding from the cervical stump    |
|   +---------------------------------------+---------------------------------------+   |
+---------------------------------------------------------------------------------------+

Clinical Decision Matrix: Device & Surgical Interventions