What surgical and mechanical interventions are used when uterotonics fail to control PPH?

1. Bimanual uterine compression and intrauterine balloon tamponade (e.g. Bakri balloon)
2. Brace (B-Lynch) compression sutures
3. Stepwise devascularisation - uterine artery then internal iliac artery ligation (or uterine artery embolisation)
4. Hysterectomy - the definitive, life-saving last resort

For trauma, identify and repair lacerations or rupture; for retained tissue, evacuate.

Clinical relevance. Knowing the surgical escalation (tamponade -> sutures -> ligation -> hysterectomy) is essential for life-threatening PPH.

More Detail

Surgical management of refractory PPH

When uterotonics and mechanical measures fail, escalating surgical interventions are used to save life.

Mechanical/tamponade

• Bimanual compression - compress the uterus between a vaginal and an abdominal hand while resuscitation and theatre are arranged.
• Intrauterine balloon tamponade (Bakri or condom catheter) - tamponades the cavity.

Compression and devascularisation

• Brace (B-Lynch) compression sutures - compress the uterus externally.
• Stepwise uterine devascularisation - uterine artery then internal iliac artery ligation, or uterine artery embolisation (interventional radiology) if available and stable.

Definitive

• Hysterectomy - the definitive, life-saving last resort when other measures fail (especially with accreta or rupture).

Cause-specific

For trauma, examine under anaesthesia and repair lacerations or uterine rupture; for retained tissue, evacuate; correct coagulopathy with blood products.