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Uterine and Vaginal Tamponade
When the cause of a postpartum haemorrhage (PPH) is not immediately obvious and oxytocic agents have failed, examination under anaesthesia (EUA) is warranted. In the event of continued uterine bleeding after EUA, many clinicians used to resort to laparotomy and hysterectomy. In modern care, however, the availability of uterine tamponade as well as the means to diagnose and treat clotting abnormalities has made laparotomy for PPH rare.
Uterine Tamponade
Uterine tamponade is a relatively noninvasive procedure which is simple, does not require major surgery, can be done within minutes and will often immediately reduce or stop the bleeding. Although usually used in theatre following exploration of the genital tract for trauma and retained placental fragments, some use it in the delivery room as soon as uterotonics are found to be ineffective. If it stops the bleeding, this will be immediately apparent and the need for definitive surgery either averted or confirmed promptly. Thus, it may avoid the need for laparotomy and hysterectomy as well as reduce the need for blood transfusion with its inherent risks. It is ideal for postpartum haemorrhage due to nontraumatic causes and for those without any retained tissue in utero. It is important that conservative surgical procedures such as uterine tamponade or compression sutures are performed before coagulopathy sets in. Important adjuncts to effective tamponade are an infusion of oxytocin to maintain uterine tone, and clot stabilization with tranexamic acid 1−2 mg IV.
Rationale
A principle of first aid to stop bleeding is to apply pressure to the bleeding site sufficient to compress the blood vessels. This can be end-on or side-on compression and must be greater than the pressure of blood flow in that vessel. Once the applied pressure stops the bleeding, the blood can clot and form a permanent seal. Blood flows into the uterus with a mean arterial pressure of about 90 mmHg, although the spiral arteriolar arrangement in the uterus probably lowers the arterial pressure as the blood flows through the uterine muscle. After placental separation the venous sinuses and spiral arterioles are exposed, which results in bleeding from the placental bed if the uterus does not contract and retract efficiently enough to compress these vessels.
If uterine atony continues despite the appropriate use of oxytocic drugs, uterine compression is undertaken (usually bimanually) after excluding any obvious lower genital tract trauma. If this does not stop the bleeding, the uterus should be explored under anaesthesia to exclude retained products within the uterus and any uterine or lower genital tract trauma. If the bleeding is due to uterine atony, a ‘tamponade test’ is useful to decide whether uterine tamponade itself would be therapeutic or whether laparotomy is needed to arrest the bleeding. Traditionally, uterine tamponade was achieved by packing the uterus and vagina with cotton gauze. This has largely been superseded by the use of balloon tamponade.
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