Uterine Compression Sutures

Uterine compression sutures of an improvised type have been used for decades: for example, figure-of-eight sutures in the lower uterine segment in cases of placenta praevia. In recent years, more specific techniques for the application of compression sutures have been developed.

In most cases, haemostatic sutures are used at the time of caesarean section, although they are occasionally used when all other methods of haemostasis have failed following vaginal birth, and laparotomy is undertaken with a view to definitive arrest of haemorrhage by hysterectomy (see Chapter 34 , Fig 34.4 ). In such cases, major vessel ligation and/or uterine compression sutures may be used as a last-ditch attempt before resorting to hysterectomy. As with uterine tamponade, major vessel ligation and other rarely performed procedures, it is wise for each labour unit to have the equipment and instruments readily available in an identifiable pack so that they can be made rapidly available when needed. Diagrams of the various techniques of compression sutures can be added to the obstetric haemorrhage pack or posted on the theatre wall.

Strong, absorbable suture material is required for compression sutures, such as No. 1 polyglactin 910 (Vicryl), polyglycolic acid (Dexon) or poliglecaprone (Monocryl). No. 2 chromic catgut may also be used. Absorbable suture material is recommended so that no loops of suture are left in the abdomen to cause bowel obstruction once the uterus has retracted. For most compression sutures, a curved needle of at least 70–80 mm and sometimes larger is required. If not available, a straight needle of 8–10 cm long may be used. For the B-Lynch sutures, the suture should ideally be 90 cm long – if not, then two sutures may need to be tied together to get an adequate length. In many of the standard packaged suture materials, the needles are not of adequate dimension. It may therefore be advisable to have the correct suture material available in the haemorrhage equipment pack or labelled in theatre.

With all of the techniques for uterine compression sutures, it is important to assess the efficacy of the technique. To this end the patient should be placed in the Lloyd–Davies (frog-legged) position so that an assistant can remove any clots from the vagina. With both hands providing compression of the uterus, it can be seen whether or not this will stop the bleeding. If it does, the compression suture is applied and, upon its completion, a careful appraisal will confirm whether the bleeding has been controlled – the ‘test of tamponade’.

B-Lynch Suture

The first standardized technique of uterine compression sutures was described and named by Christopher B-Lynch in 1997. This type of suture is performed following low transverse caesarean section and is usually done for uterine atony unresponsive to oxytocic agents. The suture should be long (90 cm) and absorbable, and ideally attached to a large (≥70 mm), round-bodied, blunt, needle. With the uterus lifted out of the abdominal incision, the first suture is placed from outside in to the uterine cavity approximately 3 cm below the lateral margin of the lower transverse caesarean incision, guided through the uterine cavity and out 3 cm above the caesarean incision. The suture material is then looped over the fundus of the uterus down to the posterior wall of the uterus opposite the caesarean incision. The suture is carried through the muscular part of the posterior wall into the uterine cavity and out on the other side roughly opposite the lateral margins of the caesarean incision. This suture is then looped over the posterior wall of the uterus down the anterior wall and placed through the uterus 3 cm above the other lateral margin of the caesarean incision and out 3 cm below ( Fig. 37.1a ). Each of the suture insertion points is placed about 4 cm from the lateral border of the uterus. The two ends of the suture are then progressively tightened, with an assistant applying continuous anteroposterior compression to the uterus with both hands. The loops of the sutures over the fundus of the uterus are also placed approximately 4 cm from each lateral border of the uterus. It is very important that there be progressive compression and tightening of the suture, which may take 1–2 minutes to be completely effective. Once it is achieved, the two ends of the suture are tied across the midline below the transverse caesarean incision ( Fig. 37.1b ). At this point the assistant carefully checks the blood loss from the vagina to ensure that the suture has arrested the bleeding. If so, the low transverse incision is closed in the routine fashion, followed by closure of the abdomen. The placement of the suture is further illustrated in Figure 37.1c .