Description of Intervention
Before surgery, the Hb level was brought up to >100 g/L by blood transfusion. The possibility of intractable blood loss and hysterectomy has been discussed with the family and written consent was assigned. Combined lumbar anesthesia was applied in those without any risking factors according to preoperative sonography, and general anesthesia was used for the others.
We choose to open on the previous scar to avoid a cruciate incision except when the original transverse incision is very low. A incision sleeve is helpful for a fairly good exposure of the surgical field in both transverse and longitudinal incision. General anesthesia was initiated after all the elements were in position.
1: Open the utero-vesical serosa and try to separate the bladder from the lower uterine segment (video S1). There’s always engorged aberrant vessels under the utero-vesical fold, which should be opened elaborately. Pushing the bladder down enough to below the level of the uterine artery will help in later compression sutures. Sometimes it’s difficult for tense adhesion and bleeding, the bladder might be broken. Therefore this procedure had to be performed after delivery with sharp dissection.
2: Block the bleeding rightly after the baby is delivered and remove the placenta. Huge blood loss usually begins with the delivery, especially when the placenta was mainly located at the anterior wall. Try to avoid the placenta when cutting the uterus. If it’s not possible, cut the placenta with hand decisively to deliver the baby as soon as possible and leave it to the second assistant. Exteriorize the uterus from the pelvic cavity and grasp the lower uterine segment tightly to block bleeding with the operator’s left hand (The operator stands at the right side of the patient). Bleeding usually attenuate dramatically. Detach the placenta in bulk with right hand, and then clamp the lower uterine segment with two ovum forceps from each side (Figure 1). Bleeding will attenuate remarkably, clean the remaining placenta. (video S2)
3: Ligate the bilateral uterine artery and the lateral part of the lower uterine segment (video S2). With the uterus being distracted upward by the assistant, use the left hand to replace one of the ovum forceps, push the bladder down enough with the right hand, and do suture A (Figure 1, Figure 2) to ligate the uterine artery and compress the lateral lower uterine segment simultaneously. Do it for three times at 2 - 3 cm interval upward on each side.
4: Do sutures on the anterior lower uterine segment (suture B) (Figure 2) (video S2). With the index finger or the middle finger of the left hand as indicator, do sutures on the anterior lower uterine segment. By pushing the bladder down and outward enough, perform the suture on very low level without damaging the bladder or the ureter.
5: Do horizontal sutures on the posterior lower uterine segment (suture C) (Figure 3) (video S2). If bleeding continues from the lower part, do several horizontal sutures with large steps at 2 - 3cm interval upward with the index finger of the left hand as indicator.
6: Cut around the uterine incision if the uterine wall has been penetrated or very thin (Figure 2) (video S2). This will also decrease the volume of the uterus and therefore help in hemostasis. Furthermore, the healing of the incision would be better with thicker sides.
7: Usually another long step suture is needed on each end of the uterine incision (suture D) (Figure 2) (video S2). Additional local haemostatic sutures on the uterine wall may be needed. In very difficult cases, a long verticle suture running through the anterior and posterior lower segment on each side is necessary.
Complete hemostasis can be achieved in most situations with step 1-7.
8: Do suspending sutures on the uterine body (Figure 1, Figure 2). Bleeding from the upper part of the uterus may occur for uterine inertia and coagulopathy after huge blood loss. Suture E will work definitely. Compression on the uterus body by the assistant to tighten the suture is indispensable. Usually five stiches for term pregnancy uterus and three stiches for smaller uterus are needed. The longitudinal sutures will perfectly compress the upper part of the uterus and allow the drainage of occult intrauterine hemorrhage.The tiny space on the top of the uterus is used to prevent the incarceration of the bowl when the uterus shrinks later.
Then compression sutures has been performed in the entire uterus, and complete hemostasis can be achieved. Close and embed the uterine incision carefully. Do not stretch strongly if large area around the incision has been cut. Finally close the utero-vesical serosa after comprehensive hemostasis on the bladder.