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Uterine Compression Suture Technique in the Management of Severe Postpartum Haemorrhage as an Alternative to Hysterectomy

A massive, uncontrolled haemorrhage after childbirth is the leading cause of maternal mortality and morbidity. Uterine atony is the most common cause (28-90%) of primary postpartum haemorrhage [1, 2]. To avoid hysterectomy and stop haemorrhage the obstetricians should undertake several steps [3, 4]. These steps can be performed by a skilful and experienced obstetrician, who can bring the decision within seconds when faced with such a dramatic situation. If the haemorrhage occurs during spontaneous labour it takes some time to diagnose the atonic uterus. Immediately the obstetrician should attempt to stop bleeding by applying conservative methods in order to stimulate the construction of the uterus. If conservative methods fail (massage, tamponade, and application of oxytocic agents) the abdomen should be opened and the ligature of the uterine artery or even hypogastric artery must be done. If all these steps fail the last solution is hysterectomy. Atony during the caesarean section is more obvious. Blood loss is smaller and the obstetrician immediately applies conservative methods (massage, application of oxytocic agents, ligation of uterine artery). In order to avoid hysterectomy and preserved fertility, five years ago we started to apply compression uterine suture technique. This technique is only solution when all other haemostatic methods fail. OBJECTIVE


INTRODUCTION
A massive, uncontrolled haemorrhage after childbirth is the leading cause of maternal mortality and morbidity. Uterine atony is the most common cause (28-90%) of primary postpartum haemorrhage [1,2]. To avoid hysterectomy and stop haemorrhage the obstetricians should undertake several steps [3,4]. These steps can be performed by a skilful and experienced obstetrician, who can bring the decision within seconds when faced with such a dramatic situation. If the haemorrhage occurs during spontaneous labour it takes some time to diagnose the atonic uterus. Immediately the obstetrician should attempt to stop bleeding by applying conservative methods in order to stimulate the construction of the uterus. If conservative methods fail (massage, tamponade, and application of oxytocic agents) the abdomen should be opened and the ligature of the uterine artery or even hypogastric artery must be done. If all these steps fail the last solution is hysterectomy. Atony during the caesarean section is more obvious. Blood loss is smaller and the obstetrician immediately applies conservative methods (massage, application of oxytocic agents, ligation of uterine artery).
In order to avoid hysterectomy and preserved fertility, five years ago we started to apply compression uterine suture technique. This technique is only solution when all other haemostatic methods fail.

OBJECTIVE
The aim of this paper is to demonstrate the technique of compression uterine suture after delivery to stop excessive bleeding, and to present the gained results.

METHODS
After we have done everything to stop the bleeding and the uterus is still without contraction we apply four compression sutures. The first one we start at the back wall of the uterus from the right sacrouterine ligament, sowing posterior wall of uterus laterally up to its cornu. We skip the cornu and continue the same suture on the right front lateral wall (Scheme 1). When we reach the isthmus of uterus at the level of sascrouterine ligament, we sow through the uterine wall backwards medially of uterine artery, being careful not to pass through uterine cavity. With the needle we come at the same spot from which we began. When we tie the knot, right side of the uterus shrinks. The second suture is done symmetrically on the left side of uterus. After these two sutures only the central part of uterus is still stretched. Two more sutures are applied to press the central part of uterus and completely stop bleeding. The third suture begins also from the right sacrouterine ligament one centimetre medially of the first one. From that spot suture passes on the back wall SUMMARY Introduction One of the most dramatic conditions in obstetrics is definitely bleeding from the uterus which fails to compress. This condition is known as postpartum atony. When such a condition is diagnosed, the obstetrician has a choice of several conservative methods to stimulate the uterus to contract and several surgical methods to stop the bleeding. The most extreme measure used to save the patient's life and stop the bleeding is hysterectomy. This surgery is characterized by high morbidity, primarily by the loss of woman's fertility. In order to avoid hysterectomy, several authors have introduced the compressive uterine suture technique into gynaecological practice. Objective The aim of the paper is to demonstrate the technique of applying compressive uterine suture after delivery to stop excessive bleeding, and to present results obtained by this technique. Methods The paper explains the technique of applying compressive suture to the atonic uterus in cases when all other procedures to stop excessive bleeding after delivery fail. Since uterine atony is the main reason for excessive and uncontrollable bleeding after childbirth, the need to perform such surgery is rather common. Authors demonstrate the technique of applying four compressive sutures which prevent uterus dilation and thus stop the bleeding. Results Compressive suture technique was used by the authors eight times, seven of which during caesarean section and one after spontaneous delivery. All patients had normal postpartum period and normal involution of the uterus. Conclusion Although this surgery requires a skilful and experienced obstetrician, the authors find it rather easy to perform and it is suggested to be applied in all cases of uterine atony when excessive bleeding cannot be stopped by other any other method except hysterectomy. This surgical procedure saves the uterus and facilitates quick and easy patient's recovery. Keywords: uterine atony; compressive suture; postpartum hysterectomy

DISCUSSION
Heavy haemorrhage after delivery leads to hysterectomy in order to save the life of the mother [2]. This is a high risk surgery for the patient, and there is a loss of fertility. All authors say that the main reason for heavy haemorrhage after delivery is atony [2,[5][6][7][8]. As situation is very dramatic and serious and the life of the patient is in danger it is necessary that the most experienced obstetrician performs the surgery. Putting the sutures is not complicated, but it demands a skilful and experienced surgeon [1]. Using this technique the bleeding is stopped at high rate [6,7]. In our group of patients one became pregnant, but the pregnancy has finished by artificial abortion. As some obstetri-Scheme 2. Four sutures according to the steps they were applied    With these four sutures (Figures 1 and 2) the uterus cannot be stretched and the bleeding stops.
After drainage we close the abdomen. If the atony occurs during the caesarean section, which is usually the case, we close the opened uterus and then put the four sutures. As the uterus has no contraction, it bleeds all the time, so the assistant should hold it tight in his hands to compress it.
For this surgery we use polyglycolic acid No 2.

RESULTS
From 2004 to 2008, there were 34,229 deliveries. We performed compressive suture eight times, seven during caesarean section and one after spontaneous delivery. All patients had normal postpartum period, and normal involution of uterus. The involution was controlled by ultrasound ( Figure 3).
cians use compression suture when atony occurs, placenta accrete is becoming a leading cause of emergency hysterectomy postpartum [2]. There are different ways of compression suture techniques. It varies from author to author, from three transversal sutures [7] to different number of longitudinal sutures, but all techniques have the same goal, the uterus with compressive sutures that is not bleeding any more. Some authors said that they succeeded to stop bleeding, in atonic uterus, only by suturing uterine artery [5], but we had such experience in small rate.
With this procedure the uterus is saved as well as menstrual function and fertility [8].
Many authors point out that atony occurs during caesarean section [5][6][7][8]. That happened with our patients. Although the caesarean section rate is increasing lately, it is not the caesarean section itself that leads to atony, but the causes that lead to caesarean section. In further clinical investigations the risk factors that lead to caesarean section and atony should be defined. By preventing risk factors the caesarean section rate should decrease as well as the atony and the number of this type of surgery.

CONCLUSION
Although this surgery needs skilful and experienced obstetrician we find it rather easy to perform and it should be applied in each case of uterus with atony when excessive bleeding cannot be stopped otherwise than performing hysterectomy. With this surgical procedure we save the uterus and the patient is recovering quickly and easily.

KRATAK SADRŽAJ
Uvod Jed no od naj te žih sta wa u aku šer stvu je kr va re we iz ma te ri ce ko ja se ne ste že, po zna to pod ime nom "ato ni ja po sle po ro đa ja". Ka da se di jag no sti ku je, aku še ru je na ras po la ga wu ne ko li ko kon zer va tiv nih me to da ko ji ma se ma te ri ca pod stiče na kon trak ci ju i ne ko li ko hi rur ških me to da za za u stavqa we kr va re wa. Kraj wa me ra ko jom se spa sa va ži vot že ne i za u sta vqa kr va re we je hi ste rek to mi ja. Ova ope ra ci ja je pove za na s ve li kim mor bi di te tom, pr ven stve no gu bit kom fertil ne spo sob no sti že ne. Da bi se iz be gla hi ste rek to mi ja, neko li ci na auto ra je u gi ne ko lo škoj prak si po če la da pri mewu je kom pre siv ni šav na ma te ri ci. Ciq ra da Ciq ra da je bio da se pri ka žu teh ni ka sta vqa wa kom pre siv nog ša va na ato nič nu ma te ri cu po sle po ro đa ja, kako bi se za u sta vi lo obil no kr va re we, i po stig nu ti re zul tati le če wa. Me to de ra da Kom pre siv ni šav na ato nič noj ma te ri ci je pri me wen ka da su sve ras po lo ži ve mo guć no sti za u sta vqa wa obil nog kr va re wa po sle ro đe wa de te ta osta le bez re zul ta-ta. Ka ko je ato ni ja ma te ri ce vo de ći raz log ne kon tro li sa nog kr va re wa na kon po ro đa ja, to je po tre ba za ova kvom ope ra cijom kod ovih sta wa re la tiv no če sta. Pri ka za na je teh ni ka stavqa wa če ti ri kom pre siv na ša va ko jom se one mo gu ća va raste za we ma te ri ce, či me se za u sta vqa kr va re we. Re zul ta ti U pe ri o du 2004-2008. go di ne kom pre siv ni šav je po sta vqen kod osam po ro di qa: se dam pu ta to kom car skog reza i je dan put na kon spon ta nog po ro đa ja. Kod svih is pi ta ni ca po sto pe ra ci o ni tok je pro te kao nor mal no, a in vo lu ci ja mate ri ce je bi la uobi ča je na. Za kqu čak Iako pri me na ove ope ra ci je zah te va uve žba nog i is ku snog aku še ra, sma tra mo da je re la tiv no la ka za iz vo đewe i tre ba je pri me wi va ti u sva kom slu ča ju ato ni je ma te rice ka da kao po sled we sred stvo za u sta vqa wa kr va re wa ostaje hi ste rek to mi ja. Ovim hi rur škim po stup kom se spa sa va mate ri ca, a že ni omo gu ća va nor ma lan i brz opo ra vak.