Indications for Bakri Balloon
See section on clinical decision-making.
Insertion of a Bakri Balloon for Uterine Tamponade
- Ensure adequate analgesia/anesthesia-transfer to OR
- Ensure uterus is empty (consider manual exploration or gentle curettage if retained POC is a possibility).
- Insert vaginal speculum (or use one hand in the vagina) and grasp the lip of the cervix with ring forceps
- Pass balloon into the uterus up to the fundus then inflate the balloon with 250-300ml of sterile saline while maintaining gentle traction on the cervix.
- Observe for bleeding via the drainage channel or around the Bakri and ensure that the balloon has not been pushed out of the cervix.
- If still bleeding more than normal postpartum, add more water gradually until bleeding is controlled or 500ml max is reached.
- Once bleeding is controlled continue to observe the cervix for 5-10 min. Insert Foley into bladder unless already done.
- Pack the vagina tightly with moist gauze to help keep the balloon in place and tamponade lower uterine segment.
- Monitor fundal height and/or use ultrasound to ensure that blood is not accumulating above the balloon.
The Bakri balloon is purpose-built for PPH and has the advantage of a drainage tube. The insertion is straightforward and success rate is high. The balloon is inflated with saline, usually 50ml at a time, while checking for ongoing bleeding. It is important to maintain some counter traction on the cervix so the balloon stays inside the uterus as it expands. If the balloon is expelled, no problem. Just deflate it and reinsert. After you are sure that the bleeding is controlled the vagina should be packed with moist gauze. Other devices described in the literature include an inflated condom tied to a Foley, a Rusch urological balloon and a blood pressure cuff inflated inside a surgical glove. Necessity is the mother of invention, particularly in the context of low resource settings. Uterine tamponade with these devices can be very effective, not just for uterine atony in the upper or lower uterine segment, but also in placenta accreta or coagulation disorders. If 500ml in the balloon does not control hemorrhage, laparotomy is the next logical step.
B-lynch compression sutures
Perhaps a better (and faster alternative) to balloon insufflation or uterine packing is the placement of a B-Lynch compression suture (or sutures) or Cho sutures. Whatever approach is taken, it is important to periodically check how much vaginal blood loss there is in order to monitor the outcome of your various interventions.
Indications for B-Lynch Compression Sutures
The B-Lynch suture is designed to compress the myometrium and address intractable uterine atony.
- Large bore IVs, Foley, blood pressure
- Crystalloid, colloid, blood
- Uterotonics (misoprostol, oxytocin, carboprost, ergometrine)
- Tranexamic acid
- Kerlix gauze, packing forceps
- Goodwin bundle (ring forceps, right angle retractors for the lateral vaginal walls, weighted speculum, chest needle drivers, long scissors)
- Intracavitary (Bakri) balloon
- Suture for B Lynch (eg. #2 Vicryl on a 70mm curved needle)
Be familiar with the equipment available at your site. Arrange for these essentials in anticipation of PPH and make sure your staff knows where they are kept.
The B-Lynch suture is designed to compress the myometrium and address intractable uterine atony. The technique compresses both the upper and lower uterine segments with full thickness bites using #2 polyglycolic suture on a 70mm curved needle. The surgical assistant squeezes the uterus to allow the suture to be tied without cutting into the uterus. If one compression suture is not sufficient, more can easily be added. The uterine incision is sutured closed after the compression sutures are in place.
B-lynch suture technique:
- Tamponade test:
- Compress uterus by standing on R side of patient and using L hand posterior to uterus(fingers towards cervix) and L hand compressing anterior wall of uterus.
- Compress for 3-5 minutes. Watch to see if bleeding is controlled with this method.
- If this tamponade test successfully slows bleeding, you can proceed to compression suture.
- The assistant will continue to compress the uterus throughout the procedure.
2) Mark the uterine landmarks:
A: 3 cm below uterine incision on R side of anterior uterus
B: 3 cm above uterine incision on R side of anterior uterus
C: On the posterior side of the uterus at the level of uterine incision. Located where the R uterosacral ligament inserts
D: On the posterior side of the uterus at the level of uterine incision. Located where the L uterosacral ligament inserts
E: 3 cm above uterine incision on L side of anterior uterus
F: 3 cm below uterine incision on L side of anterior uterus
3. Insert suture needle at point A and exit through point B.
4. Loop the suture around the fundus
5. Insert suture needle through the posterior wall at point C. Pull suture with adequate tension, while taking care to not tear the myometrium.
6. With the suture still in the uterine cavity, exit the posterior wall of the uterus through point D.
7. Loop the suture over the uterine fundus, while maintaining tension throughout.
8. Anchor the suture in the lower segment by inserting suture needle through point E and exiting out via point F.
9. Pull the two ends of the suture tight, while the assistant simultaneously squeezes the uterus.
10. Close the lower segment in the usual manner.
11. Place a surgical knot by tying together the leading and tail ends of the suture. Ensure that angles do not escape.
Hayman Suture/Modified BLynch suture technique:
Used in cases of PPH following Vaginal delivery, where there is no uterine incision. The principals here are the same; however, the technique differs slightly. If the Hayman suture is done following a caesarean section, the lower segment must be closed in the usual fashion beforehand.
- Tamponade test
- Assistant continues to compress uterus throughout the procedure.
- Gather supplies (see above)
- Insert suture needle through point A.
- Exit through posterior wall at point C.
- Pull leading end and tail end of suture tight to meet at the fundus. Ensure the assistant is adequately compressing the uterus.
- Tie the leading and tail end of suture together with 3-knot technique.
- On the left side, insert suture through anterior wall at point F.
- Exit the posterior wall at point D.
- Pull tail end and leading end of suture tight to meet at the fundus.
- Tie the leading and tail end to each other with 3-knot technique while the assistant continues to compress the uterus.
Video demonstrating B-Lynch suture
A multiple full-thickness square suture over the upper segment. They are applied selectively in areas of heavy bleeding. This requires a 10cm straight needle, as the technique approximates the anterior and posterior walls of the uterus. Multiple cho sutures can be inserted at selective sites of heavy bleeding in the upper segment.
- Insert suture needle through anterior uterine wall and exit at the same level through the posterior wall.
- From the exit point, move the needle 2-3 cm laterally. Pass the suture needle back through the posterior uterine wall, exiting through the anterior wall.
- Move the needle 2-3 cm upwards from the exit point. Insert it through the anterior wall and exit through the posterior wall.
- From the exit point, move 2-3 cm laterally (opposite direction of step 2). Insert the needle through the posterior wall and exit through the anterior wall.
- Tie the leading and tail end of the suture tightly, while taking care to not tear the myometrium.
- Repeat in other areas of heavy bleeding, as needed.