Uterine Compression Sutures for Postpartum Hemorrhage

Obstetric and Maternal Outcomes After B-Lynch Compression Sutures: A Meta-Analysis

This review article aimed to determine the obstetric and maternal outcomes after B-Lynch compression sutures to control atonic postpartum hemorrhage (PPH). This meta-analysis was performed after registering the protocol in the PROSPERO database with the registration number CRD42022355358. Two independent reviewers systematically searched electronic databases and search engines (PubMed, Cochrane Library, and Google Scholar) to retrieve published articles from inception to July 2022. The obstetric and maternal outcomes after the B-Lynch compression suture were computed using the random-effects model in pooled proportion with a 95% confidence interval (CI). Meta-regression analysis and subgroup analysis were performed to explain any source of possible heterogeneity. Quality assessment of the included studies was done using Joanna Briggs Institute (JBI) tools which are critical appraisal tools for systematic reviews and meta-analyses. This meta-analysis included a total of 30 studies involving 1,270 subjects. The pooled proportion of B-Lynch suture alone was 91% (95% CI = 82-97%). The combined proportion of B-Lynch suture plus another compression suture was 1% (95% CI = 0-3%), and the pooled proportion of B-Lynch suture plus vessel ligation was 3% (95% CI = 1-6%). The pooled proportions of PPH controlled and hysterectomies were 94% (95% CI = 91-97%, I² = 65.3%) and 7% (95% CI = 4-10%, I² = 72.13%), respectively. Therefore, B-Lynch suture (either alone or in combination with other techniques) is a simple and effective measure to control atonic PPH.

Uterine preservation with Alcides-Pereira's compressive sutures for postpartum uterine atony

INTRODUCTION

Postpartum hemorrhage (PPH) is mostly caused by uterine atony and is the leading cause of maternal death. Hysterectomy may be necessary in severe cases, but uterine compressive sutures are an uterine-sparing alternative. In 2005, Alcides Pereira proposed a technique with serial superficial stiches around the uterus. To date, there were no further reports on its clinical use.

OBJECTIVE

To evaluate a tertiary center's experience with Alcides-Pereira's compressive uterine sutures for severe PPH due to uterine atony, reviewing its efficacy, morbidity, and impact on reproductive outcomes.

STUDY DESIGN

An 11-year retrospective cohort study of Alcides-Pereira's sutures for PPH at a single tertiary hospital. Demographic and obstetric data were collected. Details of subsequent pregnancies and fertility plans were collected through a telephonic interview. Comparison between women in which the sutures were effective and ineffective to prevent hysterectomy was made.

RESULTS

Alcides-Pereira's sutures were applied in 23 patients with PPH due to uterine atony. The technique was successful in controlling the hemorrhage and avoiding hysterectomy in 20 patients (87%). When successful, the sutures avoided the need for any blood therapy in 55% (RR 0.45, 95% CI 0.28-0.73) of patients, intensive care unit admission in 80% (RR 0.2, 95% CI 0.08-0.48) and significantly shortened the length of hospital stay. All patients with preserved uterus resumed their usual menstrual pattern. One had a subsequent term vaginal delivery; one had three first trimester miscarriages. All other patients did not try to conceive.

CONCLUSION

Alcides-Pereira's sutures are a feasible, uterine-sparing technique, providing an effective and safe option for PPH.

Subsequent pregnancy outcome after uterine compression suture placement for postpartum hemorrhage

OBJECTIVE

To evaluate the subsequent obstetrical outcome in women who received a uterine compression suture.

METHODS

This is a retrospective cohort study of women who received a uterine compression suture for postpartum hemorrhage (PPH) between January 2009 and December 2018 and had a subsequent pregnancy at a tertiary care hospital in India. Women who had PPH but did not receive uterine compression sutures and had a subsequent pregnancy were taken as controls.

RESULTS

Sixty-two women had a subsequent pregnancy after uterine compression suture and were included in this study. There were no significant differences in the subsequent pregnancy outcome between the study and control groups. However, women with a history of uterine compression suture were found to have a higher incidence of dense omental adhesions (15% versus 2.8%; P < 0.001), more intrapartum blood loss (740.5 ± 491.8 ml versus 638.8 ± 194 ml; P = 0.02), and were more likely to need repeat uterine compression suture (6.7% versus 0%; P = 0.004).

CONCLUSION

Women who received uterine compression sutures had similar obstetrical outcomes in their subsequent pregnancy compared with those who did not receive a suture for PPH management. However, they had a higher risk of dense omental adhesions, repeat uterine compression suture application, and intrapartum blood loss.

Uterine compression sutures with additional hemostatic procedures for the management of postpartum hemorrhage

AIM

The aim of the study was to evaluate the efficacies and possible short-term complications in women receiving uterine compression sutures only and those with additional hemostatic procedures for the management of postpartum hemorrhage.

METHODS

It was a retrospective study carried out from year 2009 to 2019 at a tertiary obstetric hospital and included 79 women who underwent uterine compression sutures (B-Lynch sutures, Hayman's sutures and Cho's sutures) for primary postpartum hemorrhage. Thirty-six of these women had additional hemostatic procedures (uterine artery ligation or embolization) performed for bleeding control.

RESULTS

Of the 43 women who were primarily treated with uterine compression sutures only, the success rate to preserve the uterus was 97.7% (42/43). In women with uterine compression sutures and additional hemostatic procedures performed, the success rate was 75% (27/36). Among these two groups of women without peripartum hysterectomy, there were no significant differences in the incidence of secondary postpartum hemorrhage (14.8% vs. 11.9%; P = 0.729), postoperative endometritis (14.8% vs. 14.3%; P > 0.99) and retained products of conception (3.7% vs. 9.5%; P = 0.641) during their 6-week postpartum checkup. Three women were diagnosed to have hematometra. No pyometra or uterine necrosis was noted.

CONCLUSION

Uterine compression sutures with additional hemostatic procedures are effective to control postpartum hemorrhage and prevent hysterectomy. The short-term complication rate is low. Long-term monitoring is needed to identify rare but potentially dangerous complications.

Ring compression suture for controlling post-partum hemorrhage during cesarean section

AIM

To avoid complications associated with uterine compression sutures, we devised a ring compression suture (RCS).

METHODS

The RCS was performed on 12 patients with post-partum hemorrhage (PPH) during cesarean section. The suture was inserted 0.5 cm below the attachment point of the uterosacral ligament into the uterine cavity and pushed downward through the cervical canal into the vagina. The other end of the stitch was threaded through the lower abdominal wall, from the inside of the abdomen cavity to the outside of the abdominal wall, emerging at the external surface of the lower abdomen 2 cm lateral to the ventral median line and 1 cm above the symphysis pubis. Then, the two ends of the suture (the end in the vagina had been pulled out in advance) were tied tightly on the pudendum. The same stitch was repeated on the contralateral side. After 48 h postoperatively, the suture was removed through the vagina under sterilization.

RESULTS

All 12 women with PPH who underwent RCS achieved hemostasis, and complications related to RCS were not seen. Two of them had successful pregnancies postoperatively. The remaining women had no desire for a further pregnancy.

CONCLUSION

The procedure can be used as an alternative to peripartum hysterectomy and also as a prophylactic application in PPH.

[Obstetric outcomes after uterine compression suture for treatment of postpartum hemorrhage: Long-term monitoring of 40 cases]

OBJECTIVE

Uterine atony is the first cause of postpartum hemorrhage. In caesarean section, different techniques of uterine compression suture exist when uterotonic drugs fail. Their effectiveness is shown but little data on their effects on subsequent pregnancies are available. The aim of this work is analyze of the obstetrical long-term consequences after uterine compression suture.

PATIENTS AND METHODS

This is a retrospective study of 40 cases of uterine compression suture performed in a level III maternity, between 2004 and 2010. The main objective is the evaluation of the obstetrical prognosis of subsequent pregnancies. The efficacy and safety of surgical techniques, according to their transfixing character or not, were analyzed.

RESULTS

Eleven pregnancies after uterine compression suture were reported among 14 women whishing another pregnancy. The median time to be pregnant was 27 months (6-78 months). Nine pregnancies were conducted at term. One case of intrauterine growth restriction and a moderate prematurity at 32 weeks were observed. There was no significant difference in efficacy and early surgical complications according to the surgical technique; however, both infectious and ischemic complications were observed after transfixing compression suture.

CONCLUSION

The obstetric prognosis after a uterine compression suture is kept. The transfixing techniques may cause more infectious and ischemic complications. An evaluation of surgical techniques depending on their transfixing, or not, character on a large cohort is necessary for the evaluation of the influence of the technique on fertility and postoperative complications.

Fertility and pregnancy outcomes following B-Lynch sutures for post-partum hemorrhage

AIM

The aim of this study was to investigate the long-term fertility prognosis after B-Lynch sutures for post-partum hemorrhage (PPH).

METHODS

A retrospective observational study was conducted on patients who underwent B-Lynch sutures in our hospital between 2005 and 2010. Patient data was collected from hospital records. Information regarding subsequent pregnancies and menstrual complications were obtained by posted questionnaires and telephone interviews with patients who avoided hysterectomy.

RESULTS

A total of 28 B-Lynch sutures were performed in 3976 deliveries, all in patients that underwent cesarean section. Twenty-two of the 26 patients who avoided hysterectomy answered our questionnaire or took part in an interview. All patients recovered regular menstruation with no severe complications. Of the 19 patients who wanted another child, 12 patients (63.2%) had 14 subsequent pregnancies in a mean follow-up period of 52.1 months. The results of pregnancies were nine uncomplicated term pregnancies, all delivered by elective cesarean section, two artificial abortions and three miscarriages. A significant difference was observed in the age of patients with subsequent pregnancies and those without pregnancies (30.8 vs 34.6 years, P = 0.04).

CONCLUSION

B-Lynch sutures for PPH do not appear to jeopardize fecundity. An older age was a risk factor for achieving subsequent pregnancies.

B-Lynch uterine compression sutures in the conservative surgical management of uterine atony

AIM

To evaluate the success rate and possible complications of the B-Lynch uterine compression sutures in women who suffered from postpartum uterine atony unresponsive to medical treatment.

MATERIALS AND METHODS

A total of 36 women who were managed with the B-Lynch suture, with or without additional surgical procedures following uterine atony unresponsive to medical treatment, were evaluated retrospectively.

RESULTS

Sixteen women were primarily managed with the B-Lynch compression sutures, and 11 women had the B-Lynch compression sutures following failure of achievement of hemostasis by ligation of uterine artery alone (n = 4), or uterine artery plus uterine branch of ovarian artery (n = 7). Eight women had bilateral internal iliac artery ligation (BIIAL) following failure of achievement of hemostasis by the B-Lynch compression sutures. Two women (5.5%) underwent post-cesarean hysterectomy. The overall success rate of B-Lynch was 75% (27/36), and the overall success rate of B-Lynch plus BIIAL was 94.4% (34/36). Three women were admitted to the intensive care unit. There was no death related to the hemorrhage in our series. No short-term complications such as uterine necrosis, hematometra, pyometra, or uterine erosion related to the uterine compression suture were observed.

CONCLUSION

Overall success rate of the B-Lynch sutures and B-Lynch sutures plus BIIAL was 75 and 94.4%, respectively. The B-Lynch technique does not necessarily require specific suture material. Uterine devascularization or BIIAL did not increase the risk of the possible short-term complications such as uterine necrosis. In case of failure of the B-Lynch uterine compression sutures, BIIAL may be beneficial to save the uterus.

B-lynch: a technique for uterine conservation or deformation? A case report with literature review

Postpartum haemorrhage is a leading cause of global maternal mortality and morbidity, accounting for 25-30% of all maternal deaths, and 75-90% of these casualties result from uterine atony. Uterine compressive sutures are a well established measure for control of haemorrhage following atonic postpartum haemorrhage, when medical and nonmedical interventions fail. Here, we are reporting a case of secondary infertility in a 24-year-old lady who had undergone an elective caesarean section for central placenta previa in her first pregnancy. She had massive postpartum haemorrhage, for which B-Lynch suture and vessel ligation were done. Subsequently, she failed to conceive for 4 years. This was because of severe pelvic adhesions and uterine deformation which were found intraoperatively, as a consequence of previous use of B-Lynch suture. As no definitive treatment could be offered to her, we suggested her to go for adoption.

Volume replacement following severe postpartum hemorrhage

Severe postpartum hemorrhage (PPH) can be defined as a blood loss of more than 1500 mL to 2500 mL. While rare, severe PPH is a significant contributor to maternal mortality and morbidity in the United States and throughout the world. Due to the maternal hematologic adaptation to pregnancy, the hypovolemia resulting from hemorrhage can be asymptomatic until a large amount of blood is lost. Rapid replacement of lost fluids can mitigate effects of severe hemorrhage. Current evidence on postpartum volume replacement suggests that crystalloid fluids should be used only until the amount of blood loss becomes severe. Once a woman displays signs of hypovolemia, blood products including packed red blood cells, fresh frozen plasma, platelets, and recombinant factor VIIa should be used for volume replacement. Overuse of crystalloid fluids increases the risk for acute coagulopathy and third spacing of fluids. A massive transfusion protocol is one mechanism to provide a rapid, consistent, and evidence-based team response to this life-threatening condition.

Complications and pregnancy outcome following uterine compression suture for postpartum haemorrhage: a single centre experience

In the treatment of postpartum haemorrhage from uterine atony, uterine compression sutures, such as the B-Lynch suture and its modifications have a role with the advantage of preservation of the uterus for fertility. There is however, a risk that apposition of the anterior and posterior walls of the uterus will impede drainage of lochia, resulting in undesirable complications. We undertook a five-year retrospective study of all women who underwent uterine compression sutures at the KK Women's and Children's Hospital, between 2008 and 2012. In total, 23 women had uterine compression sutures during the study period, of which, nineteen women managed to conserve their uterus. Our complication rate was 25%, which included persistent vaginal discharge, pyometra and endometritis. There were three conceptions, with two successful pregnancies. Our study shows uterine compression suture to be a safe and effective alternative to avoid hysterectomy with preservation of fertility at the time of major postpartum haemorrhage. The outcome of subsequent pregnancies is reassuring.

Fertility rate and subsequent pregnancy outcomes after conservative surgical techniques in postpartum hemorrhage: 15 years of literature

OBJECTIVE

To investigate the most appropriate surgical technique for optimizing hemostasis and preservation of subsequent fertility after postpartum hemorrhage (PPH).

DESIGN

Systematic review of the literature.

SETTING

Not applicable.

PATIENT(S)

None.

INTERVENTION(S)

Review of MEDLINE, EMBASE, ScienceDirect, and the Cochrane Library.

MAIN OUTCOME MEASURE(S)

Comparison of the effectiveness of conservative surgical techniques, separately or together, with respect to success rate (ability to stop bleeding and preserve the uterus), fertility rate (subsequent pregnancies or the return of regular menstrual cycles), complication rate of the procedure, and the outcomes of subsequent pregnancies in terms of type of delivery and eventual delivery complications.

RESULT(S)

Compressive sutures and vessel embolization may be considered life-saving procedures by achieving the best hemostatic efficacy. Data on restoration of menses and pregnancy rates after these procedures are limited by short-term follow-up and by the paucity of studies, especially for vascular ligation.

CONCLUSION(S)

Pelvic vessel embolization and compressive sutures are associated with high rates of restoration of regular menses and successive pregnancies, even if the former is burdened by an increased rate of placental disorders and fetal growth restriction and the latter by an increased risk of cesarean deliveries and PPH recurrence. Randomized trials would be desirable to define the best management of PPH.

Management of intractable postpartum haemorrhage in a tertiary center: A 5-year experience

BACKGROUND

The purpose of this study is to describe treatment alternatives to prevent postpartum hysterectomy after failure of conventional therapies. Prevention of hysterectomy was the main outcome studied.

MATERIALS AND METHODS

This is a retrospective study of 19 patients diagnosed to have intractable postpartum hemorrhage and not managed with medical treatment who were subsequently treated with operative interventions in our unit between January 2004 and January 2009. The cases were identified by review of medical records.

RESULTS

In the period under review, a total of 17,341 deliveries were conducted, out of which 19 women were managed for intractable PPH. The incidence of severe PPH unresponsive to standard medical treatment was 0.1%. The mean maternal age was 33.5±3.4 years (range 27-39 years). The mean gestational age was 38.3±1.3 weeks (range 37-41 weeks). Organ preserving surgery methods were utilized in all the patients with a success rate 78.9%. The mean duration of surgery was 95 minutes (range 50-130 minutes) and the mean hospital stay was for 5 days. The mean transfused blood volume was 2.4 units as packed red cells. Among these 19 cases, 4 cases were resorted to hysterectomy.

CONCLUSIONS

In the presence of uncontrolled hemorrhage, this simple procedure should be tried before other complex treatment alternatives are undertaken. Our case series suggests that the combination of uterine artery ligation with B-Lynch sutures might be the best surgical approach because it preserves future fertility better than other methods and avoids high operative risks and morbidity.

The combination of intrauterine balloon tamponade and the B-Lynch procedure for the treatment of severe postpartum hemorrhage

OBJECTIVE

To evaluate intrauterine balloon tamponade with or without B-Lynch sutures in avoiding postpartum hysterectomy in cases with severe postpartum hemorrhage.

STUDY DESIGN

Retrospective analysis using all women delivering between January 2005 and July 2010 in our center. Prevention of hysterectomy was the main outcome studied.

RESULTS

Twenty-four cases of severe postpartum hemorrhage occurred in which medical treatment alone failed. In 20 cases, the Bakri balloon was the first choice to stop hemorrhage. Sixty percent (n = 12) of these were successfully treated with the balloon alone, 30% (n = 6) with the balloon and the B-Lynch suture. Therefore, 90% (n = 18) were successfully treated with the balloon as part of the treatment. The balloon tamponade was not successful in 2 cases. Four cases were treated with emergency hysterectomy a priori.

CONCLUSION

The Bakri balloon with or without B-Lynch sutures in a stepwise approach is an effective option for the treatment of severe PPH.

Multiple square sutures for postpartum hemorrhage: results and hysteroscopic assessment

OBJECTIVE

The purpose of this study was to evaluate the efficiency and morbidity of multiple square sutures in severe postpartum hemorrhage.

STUDY DESIGN

A retrospective study encompassed 30 multiple square sutures that were performed for severe postpartum hemorrhage in 26,605 deliveries in a tertiary maternity center. The main outcome measures were the ability to stop hemorrhage and the assessment of the uterine cavity by hysteroscopy at 3 months.

RESULTS

Multiple square sutures stopped postpartum hemorrhage in 28 of 30 cases (93%). Twenty women underwent hysteroscopy after multiple square sutures. Eight women (40%) did not have intrauterine adhesions. Nine women (45%) had thin and localized intrauterine adhesions that were removed easily by the tip of the hysteroscope; 2 women had moderate intrauterine adhesions that were resected. One patient had endometritis followed by severe intrauterine adhesions.

CONCLUSION

Multiple square sutures are effective and safe for the control of severe postpartum hemorrhage and for uterine conservation in most cases. Although some patients had moderate or severe adhesions, a normal uterine cavity or minimal intrauterine adhesions that were removed easily were the most frequent findings at hysteroscopy. A prospective study may be helpful to compare the safety and efficiency of square and brace sutures.

Uterine compression sutures as an effective treatment for postpartum hemorrhage: case series

We evaluated the role of uterine compression sutures as a conservative treatment for postpartum hemorrhage (PPH) after failed medical treatment. We retrospectively reviewed the charts of all patients who delivered between 2003 and 2009 at a single tertiary care center and who underwent uterine compression sutures for PPH. Twelve women had uterine compression sutures for PPH. The mean age of the patients was 36.3 ± 5.2 years. The mean gestational age at delivery was 37.7 ± 2.0 weeks, and the average estimated blood loss was 2.1 ± 1.1 L. The mean procedure time to perform the uterine compression sutures was 9.3 ± 2.8 minutes. The success rate of compression sutures was 92% with only one failure resulting in a hysterectomy. Uterine compression sutures are an effective method for the treatment of PPH, thus avoiding hysterectomy and preserving potential fertility.

Efficacy of surgical techniques to control obstetric hemorrhage: analysis of 539 cases

OBJECTIVE

To analyze the efficacy of surgical techniques to stop excessive obstetric bleeding.

DESIGN

Retrospective follow up.

SETTING

Center for Medical Education and Clinical Research and a total of twelve hospitals in Buenos Aires.

POPULATION

Five hundred and thirty-nine consecutive patients were included: 361 had placenta accreta-percreta, 114 uterine atony, 19 cervical scar pregnancy, 21 placenta previa and 24 uterine-cervical-vaginal tears. Three hundred and forty-seven women had surgery, of whom 192 were emergencies.

METHODS

The surgical techniques included selective arterial ligation and compression procedures. The effectiveness of the techniques was assessed by cessation of bleeding according to source. Follow up included hysteroscopy of 100 patients and magnetic resonance imaging of 341 patients.

MAIN OUTCOME MEASURES

Strong association between topographical uterine irrigation areas and surgical hemostatic technique was established.

RESULTS

Hemorrhage stopped following arterial ligation or compression sutures in 499 women, but hysterectomy was needed in 40. In cervical, lower segment and upper vaginal bleeding, Cho's compression sutures proved to be an efficient and simple procedure. Most surgical hemostatic failures that led to hysterectomy occurred in women with severe hemodynamic deterioration and coagulopathy. Two women died due to multiorgan failure. After surgery, 116 successful pregnancies were reported.

CONCLUSIONS

Bilateral occlusions of the uterine artery or its branches were useful procedures to stop upper uterine bleeding. Square sutures were a simple and effective procedure to control lower genital tract bleeding.

B-Lynch suture technique to control postpartum hemorrhage in a patient with mullerian anomaly

Congenital anomalies of the uterus may cause gynecologic, obstetric and fertility problems. Obstetrical complications are reported to occur more commonly with mullerian duct anomalies, such as postpartum hemorrhage (PPH). Uterine compression sutures may be effective in controlling PPH in these conditions as an alternative to hysterectomy, especially if the patient has a desire to conceive. As the shape of the uterus is changed in congenital malformation, the usage of compression sutures such as B-Lynch can be more difficult. In this study we report a case of PPH accompanying a large septae, treated with B-Lynch suture. A 24 year old, multigravid and nulliparous patient (G:3) was admitted to our clinic with vaginal bleeding and abdominal pain at 31 weeks of gestation. Emergency cesarean section was performed for abruptio placenta and PPH occurred subsequently. A deep uterine septum was revealed during operation. Intermittent fundal massage and intravenous uterotonics were used to improve uterine tonicity without any improvement. After the B-Lynch suture was performed, the bleeding diminished dramatically. As the shape of the uterus is changed in congenital malformation, the application of secondary interventions in postpartum hemorrhage can be more difficult. There can be slippage or overlapping of the suture while using a B-Lynch suture. Because the uterine shape is not completely distorted, patients with septate uterus can be candidates for a B-Lynch suture. There is no such reported case from the literature regarding efficacy of B-Lynch suture in mullerian anomalies. his case illustrates the potential benefits of B-Lynch compression suture in an uterus with mullerian anomalies.

A new uterine compression suture for postpartum haemorrhage with atony

Postpartum haemorrhage (PPH) is a major cause of worldwide maternal mortality and is still associated with significant morbidity. After the B-Lynch suture was reported in 1997, several different uterine compression sutures were found to be successful in controlling PPH. In this paper, we describe another simple variation of the uterine compression suture technique, which was performed without an incision in the uterine wall, without entering the uterine cavity and without suturing the anterior and posterior walls of the uterus together, so minimising the trauma to the uterus. This new uterine compression suture is an effective and safe surgical treatment for PPH caused by atony. It has the potential to apply to intractable PPH after vaginal delivery.

Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage

OBJECTIVE

Describe a case of secondary infertility due to the development of severe Asherman Syndrome after the B-Lynch compression suture and uterine artery ligation, and to review the B-Lynch technique and documented complications.

DESIGN

Case report.

SETTING

Tertiary care hospital.

PATIENT(S)

A 29-year-old primigravida patient.

INTERVENTION(S)

B-Lynch suture and uterine artery ligation.

MAIN OUTCOME MEASURE(S)

Development of Asherman syndrome.

RESULT(S)

Development of secondary infertility due to Asherman syndrome after the B-Lynch suture.

CONCLUSION(S)

The B-Lynch suture is a highly successful conservative surgical technique used to treat this condition. There is little information regarding any potential for compromised future fertility, although there have been several reports of successful pregnancy after the use of the B-Lynch compression suture. In this report, we present a case of Asherman syndrome with complete obliteration of the uterine cavity after the B-Lynch suture.

Challenges of major obstetric haemorrhage

Every minute of every day, a woman dies in pregnancy or childbirth. The biggest killer is obstetric haemorrhage, the successful treatment of which is a challenge for both the developed and developing worlds. The presence of an attendant at every birth and access to emergency obstetric care are key to reducing maternal morbidity and mortality in the developing world while resource-rich countries have a rising caesarean section rate with its consequential effect on the incidence of abnormal placentation and its link with peripartum hysterectomy. Management of obstetric haemorrhage involves early recognition, assessment and resuscitation. Various methods are available to try to stop the bleeding - from pharmacological methods to aid uterine contraction (e.g., oxytocinon, ergometrine and prostaglandins) to surgical methods to stem the bleeding (e.g., balloon tamponade, compression sutures or arterial ligation). Interventional radiology can be used if placenta accreta is suspected. Cell salvage has been introduced into obstetrics relatively recently in an attempt to reduce allogeneic transfusion.