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In case of Atonic PPH, surgical management should be considered when the medical management fails.
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The management will be successful if it is completed within 30 minutes
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The surgical management of PPH depends upon the mode of delivery.
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In case of cesarean section ,we have to do compression test first
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If compression test is positive;compression sutures to be applied ,if negative ,stepwise devascularisation to be done
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If vaginal delivery, hayman modification to be considered
B-Lynch sutures
Principle
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Aims at continuous vertical compression on vascular system
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In case of placenta preavia a transverse lower segment compression suture is effective
Technique
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Rapidly absorbable suture on round body blunt needleis used
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Uterine cavity is explored and evacuated
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Allows free drainage of blood, debris and inflammatory material
Procedure:
First suture is placed 3 cm below and 3 cm lateral to the transverse hysterotomy incision on the right, passed through the uterine cavity to a point above the incision and about 4 cm from the lateral border of the uterus and 3 cm above the upper border, at which point it is passed through the anterior uterine wall.
The suture is then carried vertically over the fundus of the uterus, with the assistant maintaining compression of the uterus. The suture is then passed through the posterior uterine wall at the level of the hysterotomy incision and the uterosacral ligament.
The suture is carried horizontally to the corresponding position on the left side of the uterus and passed back through the posterior uterine wall on the left, over the fundus and down the side of the uterus anteriorly, again approximately 4 cm from the lateral side of the uterus.
The suture is then passed through the uterine wall into the cavity at a point symmetrical to that previously done on the opposite side.
The suture is passed through the wall below the transverse hysterotomyincision at a point corresponding to the initial entry point on the opposite side.

After closure of the hysterotomy incision, the 2 ends of the suture are tied.
The compression on the uterus is maintained throughout so that suture placement results in the greatest degree of compression possible.
Slippage of the uterine brace suture is best avoided by fixing the sutures at the uterine fundus
Mathewduncan folds are suggestive of a well contracted and retracted uterus
At this point check the blood loss from the vagina. If the blood loss has reduced the transverse incision is closed.
Modified B Lynch/Hayman’s sutures
Following vaginal delivery ,vertical parallel brace stitches are placed in the upper segment without incising LUS.The sutures are tied at the fundus. 2 to 5 such sutures may be placed depending on the width of the uterus. Lower stitch is taken at the level of the cervical canal,if there is bleeding from lower uterine segment .(taking care not toobliterate the cervix)Advantage of this technique is that it is lot easier and one polyglactin suture will be sufficient for each side while for B Lynch a longer material is needed.
Square compression sutures/Cho square stitches
Anterior &posterior walls of uterus are brought together by passing a needle from front to back moving laterally by 3 cm coming back through the uterine wall from back to front. The needle is passed 3 cm downwards from front to back & then laterally 3cm to a final pass from back to front. The suture is tightly tied. This may be repeated at a number of sites.
It can also be combined with other compression sutures like B lynch.

Precaution – The lower uterine segment should not be completely obliterated. There should be egress of blood &lochia
Gunasheela Global stitch
Serial encircling stitches taken on a superficial plane at a depth about 2-3mm in the myometrium, taken at an interval of 2 cm along the horizontal axis from fundus to 1cm from the lower uterine segment and tying in the midline anteriorly ( four parallel sutures may be required at an interval of 1 inch) + modified B Lynch vertical sutures (above the LUS near midline and taken through the myometrium - this will still allow a window for inspection to assess the success of the operation)
Success rate 75-80%
Step wise Devascularisation
Relations
The common iliac artery bifurcates at the level of lumbosacral junction
The important anatomical relations of the internal iliac (hypogastric) artery can be summarized as follows:
(1) Anterior medial – covered by peritoneum (the internal iliac artery is entirely retroperitoneal)
(2) Anterior – the ureter (retroperitoneal and attached to the peritoneum);
(3) Posterolateral – the external iliac vein and the obturator nerve;
(4) Posteromedial – the internal iliac vein;
(5) Lateral – the psoas major and minor muscles.
The internal iliac artery runs 3-4 cm & then divides into anterior & posterior divisions
Anterior division – 8 branches
Superior & inferior vesical
Uterine
Vaginal
Middle rectal

Obturator
Internal pudendal
Inferior gluteal
Posterior division – 3 branches
Ilio lumbar
Lateral sacral
Superior gluteal
The ureter on
Right side – crosses the common iliac artery
Left side – crosses the internal iliac artery
So ureter remains lateral to the internal iliac artery on the right side and medially on the left side.
3 collaterals
Lumbar artery anastamose with ilio lumbar artery
Middle sacral artery with lateral sacral artery
Superior rectal artery with the middle rectal artery
Unliateral ligation reduces pulse pressure by 75% on that side
Bilateral ligation by 85%

Thus by reducing pulse pressure it allows clotting to occur. However immediately after ligation collaterals open up reversing the flow preventing tissue necrosis.
Ovarian artery arises from the aorta passes in the infundibulo pelvic ligament superior to the ovary& ends by anastomosing with the ascending uterine artery.
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Unilateral uterine artery ligation
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Bilateral uterine artery ligation(at upper part of lower uterine segment)
 Low uterine artery ligation(after mobilisation of bladder)
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Unilateral ovarian vessel ligation
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Bilateral ovarian vessel ligation
Uterine artery ligation
Procedure :
The assistant should grasp and elevate the uterus and to the opposite side of the uterine artery in order to expose the artery to be ligated through the broad ligament. A large curved needle is passed through the myometrium from anterior to posterior 2cm medial to the lateral edge of the uterus.
The suture is brought back through an avascular area in the broad ligament & tied.
The level is 2-3 cm below a low transverse cesarean incision.
If bleeding continues then bilateral ligation is done.
Success rate – 80-95%
Low uterine artery/descending cervical artery ligation
After mobilizing the bladder ,ligate the artery at the level of internal os on both sides
Uterine branch ofOvarian Artery ligation
Suture is placed through the myometrium just below the utero – ovarian ligament near the cornua of the uterus including the ovarian artery.
Internal iliac artery ligation
This reduces the bleeding from lower uterine segment, cervix, broad ligament, vaginal, para vaginal areas

Approach:
Transabdominal
Extraperitoneal
Transabdominal approach
Uterus is elevated out of the abdominal incision & the fundus is tilted away.
The mid portion of the round ligament is clamped and divided.
Incision can be started in the peritoneum on the posterior surface of the round ligament, at the junction of the middle and medial thirds. The incision is extended proximally for about 10 cm.
Once the peritoneum is opened, loose areolar tissue is separated from it by blunt dissection in the direction of the vessels.
Ureter crosses the common iliac artery at the level of its bifurcation. It should be identified & retracted medially.
Ligate the internal iliac artery 3cm from the bifurcation, avoiding the posterior division.
Elevate the artery with a Babcoks& pass a double strand of absorbable suture behind the artery. The Michester clamp should be passed from lateral to medial. Artery is then doubly ligated.
Success rate – 40-90%
Extraperitoneal approach
The skin incision in the inguinal area parallels the course of the external oblique muscle. It runs
10–15 cm in length in a line 3–5 cm medial to the anterosuperior iliac spine. After the fat and subcutaneous tissues are dissected away, a muscle-splitting incision exposes the peritoneum.
This is gently reflected medially, together with the ureter. Ligation is performed as previously described. Closure is the same as for a herniorrhaphy and can be time-consuming if a bilateral approach is to be carried out.
If facilities are available pelvic vessel embolisation can be attempted
If bleeding is not controlled

Peripartum Hysterectomy if available Early recourse to hysterectomy is recommended especially where bleeding is associated with placenta accrete or uterine rupture
Subtotal hysterectomy is the operation of choice unless there is trauma to the cervix or lower segment.
The decision for hysterectomy should be made by an experienced clinician preferably after discussion with a second experienced clinician
Management of cervical tear:
Patient should be relaxed and co-operative with good light source
3 sponge holding forceps and 2 Sim,s speculum are needed to inspect cervix for tears
Walking around the cervix or leap frogging is done by holding the cervix with sponge holding forceps at 12’0 clock position and keeping that constant ,while the other 2 sponge holding forceps ate used to walk around the cervix
Inspect all around the cervix and identify area of bleeding
Use absorbable suture to suture the tear starting just above the apex of the tear(continuous without interlocking)
If apex cannot be visualized place the stitch as high as possible and the use it to apply gentle traction to bring the apex into view and suture in step ladder fashion .
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