Total no. of cases -11
Inclusion criteria- The study includes cases of major post
partum hemorrhage (PPH) following caesarean section, randomly selected,
where trickle from uterine cavity persisted despite uterine massage and
uterotonics (oxytocin infusion, erogmetrine, carboprost and
misoprostol). When bleeding persisted for more than 15-20 minutes
despite the conventional medical treatment, the case was considered for
exploration of uterine cavity to precisely locate the bleeding point in
the cavity, as described below.
Exclusion criteria- Patients with unstable vital signs or
diagnosed cases of placenta accreta, with or without invasion, were
excluded from the study. Cases of PPH following normal delivery and
traumatic PPH were not included in our study.
All cases were operated by the same surgeon (Prof. Sadhna Mathur), with
the assistance of other skilled obstetricians.
Patient particulars and a written consent were obtained from the
patient’s attendents prior to the intervention.
After delivery of the baby and placenta, routine oxytocin injection in
the dose of 5-10 IU intravenous directly and 20 IU in 500 ml Ringer
solution over 1 hour was started, and the uterus was exteriorized and
checked for bleeding from the uterine cavity if any. The margins of the
incision site were also examined for any significant bleeding, and if
present, was dealt with separately; either by suture or compression.
In cases of PPH, the uterine cavity was explored for any retained
placental pieces and if found were removed,. Exploration for any
possible trauma or laceration was done, ruling out traumatic PPH. For
cases of atonic PPH, after excluding contraindications, conventional
medical treatment was given, which included uterine massage and
injection methergin (0.2 mg intramuscular, up to 2 doses), injection
prostadin (250 mcg intramuscular, up to 3 doses) and misoprostol (1000
mcg per rectal).
Cases where trickle of blood continued despite giving conservative
medical treatment with apparantely contracted uterus for duration of
more than 15-20 minutes, were considered for precise localization of the
bleeding points, using the technique described below.
Sadhna’s Four Finger Technique:
Technique of localizing bleeding point and hemostasis- To
precisely locate the trickling point from the uterine cavity, the cavity
was arbitrarily divided into four quadrants and each quadrant was packed
with a small sponge separately. The inner surface of lower segment,
below the cesarean incision margin, was checked for any bleeding point
using a finger tip and a ‘figure of 8’ hemostatic suture was applied as
described below after reflecting the bladder, if necessary.
For localizing bleeding point inside the uterine cavity in upper
segment, the sponges were removed sequentially one after the other. As a
convention, we followed the sequence of removal of sponges from left
lower quadrant first, followed by left upper quadrant. The procedure was
repeated for the right side, removing sponge from the right lower
quadrant, before removing the sponge from right upper quadrant.
After removal of sponge in each quadrant, it was closely observed for
any bleeding from that specific quadrant and bleeding point was
localized using the four-finger technique as described. Filling of
cavity with blood on removing sponge from one quadrant, indicates that
the bleeder lies in that quadrant, which either could be on the anterior
wall, or the posterior wall of the uterus. To differentiate between the
two, we first cover the inner surface of anterior wall of uterus inside
the cavity with the palmer surface of four fingers of our right hand,
applying just enough pressure to prevent any bleeding from that surface.
The cavity is observed for any collection or trickling of blood, which
if present, indicates the source to be from the inner surface of
posterior wall of the uterus. The precise location of the bleeding
point, if present, is determined by using ‘four finger technique’ for
each surface separately.
In this technique, we cover the suspected bleeding surface with four
fingers of our right hand, and lift each finger one by one and observe
for any bleeding area in the horizontal plane under each finger,
starting from lateral to medial side. On localizing the bleeding point
horizontally and securing it beneath one of our fingers, we now proceed
to move the finger from above downwards, giving us the exact position of
the bleeding point in the vertical plane as well, under that finger.
For achieving haemostasis, we have used synthetic, absorbable Vicryl 1-0
(polyglactin 910) round body, ½ circle 4cm needle. Covering the bleeding
point, that has been localized, with tip of one of our fingers and
guiding the needle, a ‘figure of 8’ suture (Saravi’s
Haemostatic Suture) is applied over an approximately 1cm square area
around the bleeding point, entering through the serosal surface of the
uterus and taking near full myometrial thickness, but not entering the
uterine cavity. The suture is tied with optimum tension to achieve
haemostasis; neither too loose that fails to achieve the haemostasis,
nor too tight that cuts through the tissue.
For bleeding sinus localised on posterior wall, uterus was exteriorized
and anteverted well for easy placement of suture in the area overlying
the bleeding point posteriorly.