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Editorial Robert L. Barbieri, MD Editor in Chief A stitch in time: The B-Lynch, Hayman, and Pereira uterine compression sutures All three of these uterine compression sutures are effective at treating postpartum hemorrhage caused by uterine atony—remember to use them CASE You are performing a cesarean carboprost tromethamine (Hemabate), others. Every obstetrician should be delivery for a 30-year-old G1P0 woman and methergine do not result in resolu- proficient with the placement of at who presented in labor with a breech tion of the hemorrhage. Your assistant least one uterine compression suture fetus at term. Earlier in the pregnancy suggests a uterine compression suture for the treatment of PPH caused by an external version was unsuccessful to treat the PPH. uterine atony. in achieving a cephalic presentation. What uterine compression suture The breech delivery of the newborn would you choose? Consider the hysterotomy is uncomplicated but, immediately When it’s open. When PPH caused following delivery of the placenta, he management of PPH can by uterine atony occurs at cesarean you note excessive uterine bleeding be conveniently described delivery and the hysterotomy inci- and diagnose a postpartum hemor- T using one algorithm for cases sion is open, the B-Lynch suture rhage (PPH) due to uterine atony. that follow a vaginal delivery, and ( FIGURE 1, page 8) is a common se- Manual massage of the uterus and another algorithm for PPH that lection by obstetricians. administration of oxytocin, misoprostol, occurs during cesarean delivery (see When it’s closed. When the hys- “Managing PPH following vaginal terotomy is already closed when and cesarean delivery” on page 10). PPH is noted, the Hayman or Pereira Instant Poll If PPH does not respond to initial suture(s) are often selected by obste- treatment steps, more invasive and tricians (FIGURES 2 AND 3, page 8). resource-intensive steps should be Both of these compression sutures performed quickly. Time is critical; also could be applied when the hys- delay in initiating escalating steps in terotomy is open. In your experience, what are the treatment algorithm should be the most important clinical minimized. Combination treatment pearls concerning the place- Consider combining a uterine com- ment of uterine compression PPH at cesarean: Remember pression suture with either: sutures that you would like to your suture options! • placement of an intrauterine bal- share with our readers, your In the algorithm for the treatment of loon, the so-called uterine sandwich,4 colleagues? PPH occurring at the time of cesare- or Tell us—at an delivery, the uterine compression • uterine devascularization sutures [email protected]. suture is an important option. (O’Leary ligation of branches of uter- Please include your name In 1997, Christopher B-Lynch ine artery and ligation of the uterine- and city and state. reported1 on the first widely utilized ovarian arteries). uterine compression suture. Alterna- It’s important to note that the tive compression sutures have been combination of a uterine compres- reported by Hayman,2 Pereira,3 and sion suture with devascularization 6 OBG Management | December 2012 | Vol. 24 No. 12 obgmanagement.com Editorial FIGURE 1 B-Lynch suture sutures may be associated with a higher rate of uterine ischemia and myometrial necrosis than the com- bination of compression sutures with an intrauterine balloon.5 Placing the B-Lynch suture The B-Lynch suture (figure 1) is placed with the following steps: 1) Take bites on either side of the right edge of the hysterotomy in- cision (A and B). These bites are placed approximately 3 cm from the edge of the hysterotomy incision. 2) Loop the suture around the fun- dus and reenter the uterus through the posterior uterine wall at point C, which is directly below point B. 3) Pull the suture tightly, but do not tear into the myometrium. 4) Exit the posterior wall of the uter- us through point D. 5) Loop the suture over the uterine fundus. 6) Anchor the suture in the lower uterine segment by taking bites on either side of the left edge of the uter- ine hysterotomy incision (E and F). The B-Lynch suture as seen from the anterior uterine wall. 7) Pull the two ends of the suture tight while an assistant simultaneously FIGURE 2 Hayman suture FIGURE 3 Pereira sutures management obg r O k f oc s T r ha The Pereira sutures combine longitudinal and transverse sutures A i The Hayman suture passes directly from the anterior uterine placed as a series of bites into the submucosal myometrium. The C wall through the posterior uterine wall. Two to four longitudinal sutures do not enter the uterine cavity. The longitudinal sutures r ma sutures can be placed. Two longitudinal sutures are pictured begin and end at the level of the transverse suture closest to s: on in this figure. A transverse cervicoisthmic suture also can be the cervix. Avoid damage to blood vessels and the ureters when i at placed, if needed, to control bleeding from the lower uterine placing the transverse sutures. Two longitudinal sutures and r segment. three transverse sutures are pictured in this figure. T us ll i 8 OBG Management | December 2012 | Vol. 24 No. 12 obgmanagement.com Editorial squeezes the uterus to aid compres- sion. Managing PPH following vaginal and cesarean delivery 8) Place a surgical knot while the assistant continues to compress the The sequential treatment of PPH can be conveniently divided into two algorithms: uterus. 1. PPH following vaginal delivery 9) Close the lower uterine segment 2. PPH at cesarean delivery. in the usual manner. B-Lynch1 ad- in both situations, administration of uterotonics; uterine massage; aggressive replacement of red blood cells and clotting factors (fresh frozen plasma, cryopre- vised that if there is excessive bleed- cipitate, riastap-lyophilized fibrinogen concentrate), and platelets and monitoring ing from a specific area of the uterus of coagulation effectiveness are critically important. Eliciting the aid of additional (possible placenta accreta) that a obstetricians, anesthesiologists, and nursing staff is also essential. figure-of-8 stitch should be placed through that area of the uterus prior Managing PPH following vaginal Managing PPH at cesarean delivery delivery to placing the compression suture. • Move the patient from labor room • Ensure no retained products to operating theatre and obtain of conception Choose suture material wisely appropriate surgical anesthesia In the original description of the • Thoroughly inspect pelvis for • Identify and repair cervical and unrecognized injuries B-Lynch suture, a chromic su- vaginal lacerations ture was used.1 In a later report, • Ligate or repair lacerations of veins a No. 1 poliglecaprone-25 suture • Explore the uterus by bimanual and arteries examination and/or ultrasound (Monocryl) was utilized.6 • Uterine compression suture, for I prefer a #1 chromic suture on • Suction and/or sharp curettage example B-Lynch suture with or to remove any retained products without intrauterine balloon placement a large curved needle (Ethicon GL30, of conception 65-mm tapered needle, 30” looped • Devascularize the uterus: with suture) because the uterine com- • Place an intrauterine balloon or pack uterine artery ligation, utero-ovarian the uterus with surgical packing artery ligation pression suture only needs to main- tain suture integrity for a few days to • Interventional radiology, uterine • uterine tourniquet artery embolization be effective. As the uterus involutes • Hysterectomy • Exploratory laparotomy to a nonpregnant size, delayed ab- • Pelvic packing sorption sutures may result in long “rabbit ear” loops separated from the uterus that theoretically could trap intra-abdominal tissue. It is Some experts recommend that, PPH. The uterine compression su- important to ensure that the suture for women considering a future ture represents a significant advance selected is sufficiently long to com- pregnancy, the uterine cavity be eval- in obstetric care. Every obstetrician plete the encirclement of the uterus uated, preferably with hysteroscopy.7,8 should be facile in placing at least and with sufficient residual length to Hysterosalpingogram, hys terosono- one type of compression suture. facilitate tying the knot. graphy, and MRI are alternative options for evaluating the uterus. Evaluate for postop complications Sutures are effective when used [email protected] Following recovery from a PPH When PPH is caused by uterine treated with a uterine compression atony, compression sutures have Dr. Barbieri reports no financial rela- suture, some women develop uter- been reported to effectively man- tionships relevant to this article. ine complications such as: age the hemorrhage in about 80% to References • hematometra 90% of cases if the suture is placed 1. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. • pyometra in an expedient manner.9–11 The in- The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative • Asherman’s syndrome troduction of uterine compression to hysterectomy? Five cases reported. Br J Obstet • localized areas of uterine necrosis sutures has helped to significantly Gynaecol. 1997;104(3):372–375. and full-thickness defects in the lower reduce the number of women who 2. Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management uterine segment or uterine fundus. undergo hysterectomy following a of postpartum hemorrhage. Obstet Gynecol. 10 OBG Management | December 2012 | Vol. 24 No. 12 obgmanagement.com 2002;99(3):502–506. 6. Price N, B-Lynch C. Technical description of the B- maran S. Systematic review of conservative man- 3. Pereira A, Nunes F, Pedroso S, Saraiva J, Retto H, Lynch brace suture for treatment of massive post- agement of postpartum hemorrhage: what to do Meirinho M. Compressive uterine sutures to treat partum hemorrhage and review of published cas- when medical treatment fails. Obstet Gynecol postpartum bleeding secondary to uterine atony. es. Int J Fertil Womens Med.
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