B-Lynch sutures for major primary postpartum haemorrhage at caesarean section.

This was a retrospective observational study of 11 consecutive patients of major primary postpartum haemorrhage (PPH) who had the B-Lynch suture at the time of caesarean section, performed between 1 March 2001 and 31 March 2004 at a teaching hospital in Scotland. Case-note review was performed in 123 patients, who had major primary PPH to identify patients who had B-Lynch sutures at the time of caesarean section. The patient's age, parity, gestation of pregnancy at which the B-Lynch suture was performed, the indication for caesarean section and the cause of primary major PPH were recorded. The operative details, intraoperative and immediate postoperative complications and the need for subsequent hysterectomy were noted. The patients were followed-up with clinic visits at 6 weeks and any further hospital referral for late postoperative complications and whether subsequent successful pregnancy was achieved, were documented. The incidence of major PPH in our centre was 0.5% of the total deliveries, of which 11 cases had the B-Lynch suture applied at the time of caesarean section. The patients were aged between 25 and 38 years old (mean 31 years). Parity ranged from 0 to 1 and the gestational age at which the procedure was performed ranged from 34 to 41 weeks (mean 38 weeks). Ten operations (91%) were performed by senior registrars supervised by the consultant on call and one (9%) case was performed by a consultant on call. All cases had the B-Lynch sutures performed for major primary PPH caused by uterine atony at the time of caesarean section. The weight of the babies delivered ranged between 2,110 - 4,820 g (mean 3,500 g). The total blood loss at surgery ranged from 2,000 - 10,000 ml (mean 3,500 ml). Only three patients (28%) required hysterectomy. All the patients made a good postoperative recovery. The hospital stay ranged from 4 - 24 days (mean 8 days). The patient who remained in hospital for 24 days did so because her baby was admitted into the neonatal unit. All the patients were reviewed 6 weeks postnatally. There was no significant morbidity. A subsequent successful pregnancy has been achieved in one patient.     

Intra-operative blood loss during elective lower segment caesarean section.

OBJECTIVE: To measure intra-operative blood loss at elective lower segment caesarean section and to compare estimated with measured blood loss. DESIGN: Prospective observational study. Blood loss was measured in patients who underwent lower segment caesarean section in the course of routine hospital activity. SETTING: Tsan Yuk Hospital (Hong Kong), which is affiliated to the University of Hong Kong, 1990-1991. SUBJECTS: Forty women (mean age 29 years) with singleton pregnancies (mean gestation 38 weeks) delivered by elective lower segment caesarean section under general anaesthesia (mean birthweight 3177 g). MAIN OUTCOME MEASURE: Intra-operative blood loss measured by the alkaline haematin method (intra-assay co-efficient of variation 2.2%). RESULTS: The mean measured blood loss was 487 ml (SE 40, range 164-1438). The mean estimated blood loss was 425 ml (SE 31) range 100-1300; mode 400). Observer error in estimating blood loss was higher if measured blood loss greater than 600 ml. One patient received a blood transfusion and another had a post-operative haemoglobin level less than 10.0 g/dl. CONCLUSION: Blood loss at elective lower segment caesarean section was usually less than 500 ml and was estimated with reasonable accuracy. However, there was a tendency to under-estimate blood loss when the measured loss exceeded 600 ml.     

Scar rupture in labour after previous lower uterine segment caesarean section: the role of uterine activity measurement

A series of 12 trials of scar associated with scar rupture is reviewed. Uterine activity patterns were assessable in 10 of them. Clinical features and characteristics of the intrauterine pressure waveform and uterine activity are discussed in relation to the integrity of the scar.     

Scar rupture in labour after previous lower uterine segment caesarean section: the role of uterine activity measurement

Summary. A series of 12 trials of scar associated with scar rupture is reviewed. Uterine activity patterns were assessable in 10 of them. Clinical features and characteristics of the intrauterine pressure waveform and uterine activity are discussed in relation to the integrity of the scar.     

Ergometrine given during caesarean section and incidence of delayed postpartum haemorrhage due to uterine atony.

Delayed postpartum haemorrhage due to uterine atony after caesarean section was occurring in women in our recovery area despite many of them already having an oxytocin infusion running to prevent such a problem. We therefore decided to compare the incidence of such problems for a 2-month period before and after altering our uterotonic policy: in addition to the routine bolus dose of 5 units of oxytocin after delivery of the baby, we added 500 microg of intramuscular ergometrine during abdominal closure. We noticed a reduced number of massive postpartum haemorrhages due to an atonic uterus in the recovery room but an increased incidence of nausea and vomiting. No prophylactic anti-emetic was given during this pilot study. This small study suggests that 50 women would need to be given ergometrine at caesarean section to prevent one delayed massive haemorrhage from uterine atony and four extra women would suffer with vomiting. We feel this is reasonable and now use a prophylactic anti-emetic as well as delaying the ergometrine until closure of the rectus sheath which reduces the incidence of nausea and vomiting.     

Radioisotope dilution technique for measurement of blood loss associated with lower segment caesarean section.

Using a 51Cr-labelled red cell dilution technique, the blood loss associated with elective lower segment Caesarean section was measured in 30 patients, half of whom had a previous history of Caesarean section. The blood loss (mean +/- SD) was 1290 +/- 240 ml for first Caesarean sections and 1012 +/- 380 ml for repeat operations.     

Abdomino-pelvic packing to control severe haemorrhage following caesarean hysterectomy.

Surgically uncontrollable peri-operative obstetric haemorrhage associated with coagulopathy, developed in five women who were managed by emergency caesarean hysterectomy. All women had a morbidly adherent anterior placenta praevia and a previous lower segment caesarean section scar. Conventional medical and surgical therapy to control bleeding from pelvic and abdominal raw surfaces were unsuccessful. Abdomino-pelvic packing was performed with 10-12 dry laparotomy pads applied firmly over bleeding sites. The abdomen was closed after observation of the cessation of bleeding for 5-10 minutes. Following correction of coagulation and haemodynamic disorders relaparotomy for pack removal was performed 34-48 hours later. One patient developed small bowel obstruction on the 5th post-operative day, however, there was no long term gynaecological morbidity in any of the cases. Abdomino-pelvic packing achieved complete haemostasis in all of the five women which we believe may have been impossible using alternative measures.     

Female genital tract morbidity and sexual function following vaginal delivery or lower segment caesarean section.

A total of 208 women were assessed 2 years' post-delivery to record the prevalence of subjective urinary and faecal incontinence, incontinence of flatus, dyspareunia, subjective depression and sexual satisfaction. This was correlated with mode of delivery. A sample population was selected from the Cardiff Birth Survey Database, in accordance with strict inclusion and exclusion criteria. Each woman was invited to complete and return a postal questionnaire addressing symptoms of pelvic floor dysfunction. There was a significant decrease in sexual satisfaction scores in women who underwent vaginal delivery in comparison with those who underwent elective caesarean section at 2 years follow-up. There was also a significant increase in the prevalence of urinary incontinence, incontinence of flatus, dyspareunia and subjective depression in women who underwent vaginal delivery.     

Ultrasonographic evaluation of lower uterine segment thickness in patients of previous cesarean section.

OBJECTIVE: To evaluate by ultrasonography, the lower uterine segment thickness of women with a previous cesarean delivery and determine a critical thickness above which safe vaginal delivery is predictable. METHODS: A prospective observational study of 71 antenatal women with previous cesarean delivery and 50 controls was carried out. Transabdominal and transvaginal ultrasonography were used in both groups to evaluate lower uterine segment thickness. The obstetric outcome in patients with successful vaginal birth and intraoperative findings in women undergoing cesarean delivery were correlated with lower segment thickness. RESULTS: The overall vaginal birth after cesarean section (VBAC) was 46.5% and VBAC success rate was 63.5%, the incidence of dehiscence was 2.82%, and there were no uterine ruptures. There was a 96% correlation between transabdominal ultrasonography with magnification and transvaginal ultrasonography. The critical cutoff value for safe lower segment thickness, derived from the receiver operator characteristic curve, was 2.5 mm. CONCLUSION: Ultrasonographic evaluation permits better assessment of the risk of scar complication intrapartum, and could allow for safer management of delivery.     

A randomised, controlled study of uterine exteriorisation and repair at caesarean section.

OBJECTIVE: To determine the surgical and anaesthetic benefits and problems associated with the practice of routine exteriorisation of the uterus to facilitate repair at caesarean section. DESIGN: A randomised controlled study of women undergoing caesarean section. After establishment of anaesthesia, women were randomised to either exteriorisation and uterine repair or suture of the uterus in the abdomen. SETTING: A maternity hospital in the United Kingdom. MAIN OUTCOME MEASURES: Peri-operative haemoglobin change, duration of operation, maternal morbidity and length of hospital stay. Intra-operative pain, nausea, vomiting, pulling or tugging sensations were secondary outcome measures. RESULTS: Three hundred and sixteen women were randomised, of whom 288 were subsequently analysed (139 women in whom the uterus was exteriorised and 149 where the uterus was not exteriorised). Exteriorisation of the uterus, an elective caesarean section and a spinal or general anaesthesia each had a statistically significant association with reduced blood loss (P < 0.05). There were no statistically significant differences between the two groups with regard to intra-operative complications or pain, nor were there any statistically significant difference in post-operative wound sepsis, pyrexia, deep vein thrombosis, blood transfusion or length of hospital stay. CONCLUSION: With effective anaesthesia, exteriorisation of the uterus for repair following caesarean delivery is not associated with significant problems and is associated with less blood loss.