Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 233–249

Contents lists available at SciVerse ScienceDirect

Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Postpartum haemorhage associated with

caesarean section and caesarean hysterectomy
Sue Fawcus, MA (Oxon), MB BCh (London), FRCOG a,
Jagidesa Moodley, FCOG, FRCOG, Professor Emeritus b, *
a
Department of Obstetrics and Gynaecology, University of Cape Town, and Head, Obstetric Services,
Mowbray Maternity Hospital, Cape Town
b
Women’s Health and HIV Research Group, Nelson R Mandela School of Medicine,
University of KwaZulu-Natal, Private bag 7, Congella 4013, South Africa

Keywords:
Excessive haemorrhage associated with caesarean section, commonly
caesarean section defined as blood loss in excess of 1000 ml, is frequently under-
postpartum haemorrhage estimated, but is documented as occurring in more than 5–10% of
clinical and surgical management caesarean sections. Common causes are uterine atony, abnormal
placentation, uterine trauma and sepsis. It is a major cause of maternal
morbidity globally and of maternal mortality in low- and middle-
income countries; however, many reports do not disaggregate it
from postpartum haemorrhage in general. In this chapter, we outline
preventive measures, including uterotonic agents, and provide treat-
ment algorithms for managing excessive haemorrhage during and
after caesarean section. Several management options, including ute-
rotonic therapy, uterine compression sutures, balloon tamponade,
blood-vessel ligation and uterine artery embolisation are described;
each has a role for treating the different causes of caesarean section
bleeding in different contexts.
Caesarean hysterectomy is indicated when medical and conservative
surgical measures are unsuccessful, and as first-line surgery for
extensive uterine rupture and bleeding from morbidly adherent
placentae. It has an incidence ranging from 1–4 per 1000 caesarean
sections, significantly greater than that for vaginal delivery. Although
it is a life-saving procedure, it is associated with significant morbidity,
including massive blood transfusion and intensive care (10–48%),
urological injury (8%) and the need for relook laparotomy (8–18%).
Ó 2012 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel./Fax: þ27 031 2604241.

E-mail address: jmog@ukzn.ac.za (J. Moodley).

1521-6934/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bpobgyn.2012.08.018
234 S. Fawcus, J. Moodley / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 233–249

Introduction

Excessive haemorrhage during and after caesarean section is a serious adverse event, accounting
for major morbidity and associated with maternal mortality in well-resourced and poorly resourced
settings.
Caesarean hysterectomy is a major surgical procedure most commonly carried out as an emergency
life-saving procedure for intractable obstetric haemorrhage. Less commonly, it may be carried out as
a semi-elective procedure when operable cervical carcinoma is diagnosed during pregnancy.

Excessive haemorrhage associated with caesarean section

Postpartum haemorrhage (PPH) at caesarean section is commonly defined as blood loss of 1000 ml
or more.1,2 The Australian College of Obstetricians define PPH at caesarean section as blood loss greater
than 750 ml, and other definitions use 500 ml irrespective of mode of delivery.3
Blood loss greater than 1500 ml is described as severe PPH, with blood loss greater than 2500 ml
constituting massive blood loss.1 Some definitions of PPH at caesarean section include a change in
haematocrit of more than 10%, the need for blood transfusion, further surgical procedures, or both.
Definitions of PPH at caesarean section need to be standardised.4
Excessive blood loss can be intra-operative, but may also occur postoperatively through vaginal
bleeding or concealed intra-peritoneal bleeding. The latter problem is frequently unrecognised by
attending health workers.

Accuracy of blood loss estimation

Estimation of total blood loss during and after caesarean section is problematic owing to difficulties
in accurate collection. Blood may be collected in suction bottles where it is mixed with liquor, and
blood-loss estimation from soaked swabs and theatre linen is usually by visual inspection only. Blood
loss in the few hours after caesarean section is estimated by inspecting vaginal pads and bed linen.
Visual estimation of blood loss during and after caesarean section or vaginal delivery is notoriously
inaccurate, tending to overestimate at lower blood loss and underestimate at higher blood loss.
Fifty years ago, Pritchard et al.2 estimated average blood loss at caesarean section to be 930 ml using
a technique involving chromium labelled red blood cells. Such techniques are too complex to use in
clinical practice. Several studies prefer to use haematocrit changes, the need for blood transfusion, or
both, as more reliable indicators of excess bleeding.
Stafford et al.5 used a formula that calculates blood loss based on haematocrit changes before and
after caesarean section, maternal weight and height, and found that visual estimation significantly
underestimated blood loss compared with calculated blood loss, particularly for blood loss in excess of
1000 ml and 1500 ml.

Incidence of excessive blood loss associated with caesarean section

The incidence of excessive blood loss associated with caesarean section is context specific,
depending on the obstetric case mix at the particular level of care studied, and varies from 3–10% of
caesarean section deliveries. A study of 4836 caesarean sections by Magann et al.6 in Perth, Australia,
where blood loss was measured from collection drapes and weighing soaked swabs, showed the
postpartum haemorrhage (PPH) rate for caesarean section (blood loss > 1000 ml) to be 4.84% for
elective caesarean section and 6.75% for emergency caesarean section (P ¼ 0.007).6 The PPH rate for
blood loss greater than 1500 ml was 3.04% for emergency caesarean section. The same study is one of
the few to evaluate risk factors for PPH at caesarean section. It found that previous retained placenta,
blood disorders, antepartum transfusion, preterm birth and general anaesthesia were risk factors for
PPH after emergency caesarean section. Leiomyomata, placenta praevia, antepartum bleeding,
preterm birth and general anaesthesia were risk factors for PPH after elective caesarean section.
Combs et al.7 indirectly estimated blood loss using haematocrit changes, the need for blood trans-
fusion, or both, and gave a caesarean section PPH rate of 5.9%. The investigators showed that general
 S. Fawcus, J. Moodley / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 233–249 235

anaesthesia, pre-eclampsia, prolonged first and second stage of labour, chorioamnionitis, pre-
eclampsia and Hispanic ethnicity, all to be risk factors for PPH at caesarean section. Naef et al.8
described a caesarean section PPH rate of 7.9%, based on estimation of blood loss greater than
1500 ml, haematocrit changes, the need for blood transfusion, or all three. This study showed that
Native American ethnicity, prolonged active labour, and obesity were all risk factors. It would be useful
to evaluate risk factors in other settings, such as rural districts in Africa, or other poorly resourced
settings, where prolonged obstructed labour is more common and anaemia more prevalent.
Lower-segment caesarean section is associated with less blood loss than classical or upper segment
caesarean section.7
In clinical practice, knowledge of risk factors for caesarean section PPH enables adequate planning
for level of care, availability of blood products, and availability of skilled surgical assistance.

Causes of excessive blood loss associated with caesarean section

Excessive bleeding at caesarean section may be caused by uterine atony, trauma, placental site
bleeding, abruptio placenta, and adhesions. These are discussed below.

Uterine atony

Uterine atony is particularly common after prolonged labour and in the presence of cho-
rioamnionitis, but also occurs with caesarean section for multiple pregnancy, and polyhydramnios.

Trauma

Trauma refers to uterine tears and lacerations, including lateral tears into the uterine vessels in the
broad ligament and vertical tears down the lower segment. Trauma may be caused by a difficult
delivery of the baby; an impacted fetal head after prolonged second-stage of labour, or obstructed
labour being particularly high risk for excessive bleeding. In addition, caesarean section for transverse
lie and large baby may be associated with uterine tears and surgical extension of the incision into the
upper segment. Faulty surgical technique with the uterine incision being made too low on the lower
segment or too lateral on one side of the uterus may cause traumatic bleeding, as can too rapid
a delivery or excessive force used to deliver the fetal head.

Placental site bleeding

Placental side bleeding most commonly occurs with placenta praevia and morbidly adherent
placenta, but may also occur with an excessively large placental site (i.e. for multiple pregnancies and
diabetic mothers). With increasing rates of morbidly adherent placenta associated with higher
caesarean section rates, this cause is becoming more frequent.

Abruptio placentae

Caesarean section is recommended for abruptio placentae when the fetus is alive. If complicated by
a large retroplacental clot and couvelaire uterus, however, adequate uterine contraction does not occur,
resulting in severe haemorrhage.

Adhesions

Caesarean section carried out in the presence of extensive adhesions usually from a previous
caesarean section, requires sharp dissection and causes more intra-operative haemorrhage. The causes
of haemorrhage at caesarean section include all those from the commonly used ‘four Ts’ classification
(tissue, trauma, tone, thrombin) but, in addition, include aspects of surgical injury to the uterus or other
soft tissues.9
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Mortality and morbidity caused by excessive haemorrhage associated with caesarean section

Excessive haemorrhage is a major cause of severe acute maternal morbidity in well-resourced

settings. For example, in Scotland, which has an ongoing audit of severe acute maternal morbidity,
massive obstetric haemorrhage (>2500 ml) accounted for 50% of all severe morbidity between 2000
and 2002.10,11 The rate of massive obstetric haemorrhage was 3.7 per 1000 births, with 41% having had
an emergency caesarean section and 17.2% an elective caesarean section. This compares with a rate of
15% emergency caesarean section for all Scottish births. Data from some well-resourced settings indi-
cate that PPH-related morbidity is increasing, and this correlates with rising caesarean section rates.12
In poorly resourced countries, PPH is a major cause of maternal morbidity and is also the most
common cause of maternal death.13
Not many country reports disaggregate the proportion of haemorrhage deaths specifically related to
bleeding associated with caesarean section. It can be postulated, however, that, in poorly resourced
settings where cephalopelvic disproportion is prevalent, prolonged labour and sepsis would contribute
to bleeding associated with caesarean section. Shortage of surgical skills may mean that less experi-
enced personnel carry out caesarean sections, with minimal support.
In South Africa, which has an established national confidential enquiry into maternal deaths,
bleeding associated with caesarean section was the most common cause of maternal deaths from
obstetric haemorrhage between 2008 and 2010, accounting for 180 (26.2%) of the 688 maternal deaths
caused by obstetric haemorrhage.14 Related morbidities included obstructed labour, previous
caesarean section, abruptio placentae and placenta praevia. Most of these deaths were clearly avoid-
able. Lack of surgical skill to achieve haemostasis at the initial caesarean section, lack of skill to carry
out the additional surgical measures required to arrest haemorrhage, and poor post-caesarean section
monitoring were all avoidable factors.14,15 Such problems may occur in other poorly resourced coun-
tries where a serious lack of skills is evident, especially in more remote rural hospitals.
The most recent confidential enquiry into maternal deaths in the UK shows a sustained and marked
reduction of maternal mortality caused by obstetric haemorrhage.16

Prevention and early detection of excessive haemorrhage associated with caesarean section

The following steps should be taken to minimise haemorrhage associated with caesarean section
and to ensure early detection when it does occur.

Correct management of labour

Correct management of labour using the partogram is necessary so that prolonged labour is diag-
nosed timeously, the appropriate interventions made, and emergency caesarean section for this
indication is carried out before labour becomes obstructed.

Unnecessary surgery

Unnecessary caesarean section should be avoided.

Experience and training

A caesarean section, which is high risk for haemorrhage (i.e. major placenta praevia or suspected
placenta accreta) should be carried out at the appropriate level of care by the most experienced
surgeon. In many low-income countries, this may be difficult because of problems in making a diag-
nosis in advance, and junior doctors could be faced with this type of scenario on their own in a remote
rural hospital setting. Prior surgical training of this cadre of doctors, and the availability of a functional
telephonic link to a specialist in a referral hospital, would be helpful in this situation.
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Optimising haemoglobin

Haemoglobin optimisation before delivery by prevention, early detection and treatment of anaemia
can minimise haemorrhage associated with caesarean section.

Surgical techniques

Surgical techniques that have been shown, by available evidence, to reduce blood loss should be used.
The use of blunt dissection rather than sharp dissection for abdominal entry and controlled cord traction
rather than manual removal to deliver the placenta have both been shown to reduce blood loss at
caesarean section.17 As caesarean section is one of the most frequently performed surgical procedures
worldwide, there is a tendency among surgeons to ‘break the 10 minute’ barrier and compete to do the
shortest duration caesarean section. In such a situation, due care to ensure correct uterine closure,
particularly of the angles of the surgical incision, and careful checking for haemostasis, may be neglected.

Prophylactic uterotonics and medication at caesarean section

A uterotonic agent needs to be given after delivery of the baby to cause placental separation and
expulsion, and to ensure uterine contraction, as with active management of third stage of labour. This
has been shown to reduce the risk of PPH after vaginal delivery by 60%. The uterotonic regimen for
which there is most evidence of efficacy, with minimal side-effect profile, is 10 iu oxytocin intramus-
cularly.18–20 Debate has taken place between anaesthetists and obstetricians on the appropriate choice
of uterotonic agent at caesarean section, its dosage, and route of administration.21 The aim, however, is
to ensure optimal uterine contraction, and the anaesthetist is also concerned about possible intra-
operative side-effects. Hypotension has been shown to follow rapid intravenous boluses of oxytocin
in doses greater than 5 iu, and hypertension, vomiting, or both, may be a side-effect of ergometrine;
both of these agents are effective in preventing PPH. Shivering and pyrexia may follow misoprostol
administration, but this agent has been shown to be inferior to other agents in the prevention of PPH.
Current evidence recommends that the lowest intravenous bolus of oxytocin to achieve adequate
uterine contraction at caesarean section is 5 iu given over a few minutes; and it has the least side-effect
profile.22,23 An alternative suggested by some anaesthetic guidelines is to administer a 2.5 iu intrave-
nous bolus of oxytocin slowly, and concurrently administer a prophylactic oxytocin infusion of 10 iu in
1 L fluid.21 One randomised-controlled trial has been conducted on the use of carbetocin, a longer-acting
oxytocin, which has similar efficacy and reduces the need for the infusion. It is expensive, however, and
not readily available in most settings.24 In one prospective audit of introducing prophylactic intra-
muscular ergometrine at caesarean section in addition to intravenous oxytocin 5 iu, a reduction in
delayed PPH was reported, but an increase in side-effects of nausea and vomiting was found.25 There
seems to be no role for prophylactic use of prostaglandin preparations at caesarean section.26
Recently, attention has focused on the use of tranexamic acid (TXA) to reduce blood loss if given
prophylactically at caesarean section. This is not a uterotonic agent; TXA is an anti-fibrinolytic agent
better known to gynaecologists for oral use as treatment of menorrhagia, and to trauma surgeons
where it has been shown to reduce blood loss.27 Preliminary trials show that, given prophylactically at
caesarean section, TXA does reduce blood loss and the need for additional uterotonics.28–30 Concern
remains about the potential of TXA to promote venous thrombosis (VTE) in the context of a physio-
logical state when VTE risk is already increased. This has not been confirmed in any of the studies,
although most have not been powered for this outcome;

Vigilant post-caesarean section monitoring

Early detection of ongoing vaginal bleeding can be detected by deteriorating vital signs measured in
the recovery area. It is important that both anaesthetist and recovery nurse ensure that ongoing
bleeding is not occurring before transfer to a postnatal ward. Women at high risk should be monitored
in a high-care area. Frequent observations need to be continued in the postnatal ward, and action taken
on abnormal findings. This can be a problem in low-resource settings where staffing may be
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inadequate to monitor at the correct frequency, meaning that post-caesarean section bleeding is
detected when it as at an advanced stage and the woman already in hypovolaemic shock.14,15 In
addition, the attendant health workers need to have a high index of suspicion for ongoing intra-
peritoneal bleeding when vital signs are deteriorating in the absence of vaginal bleeding.
The colour coded Maternity Early Warning monitoring charts pioneered in the UK may be a useful
addition to monitoring by assisting the interpretation of abnormal measurements.31

Resuscitation for excessive haemorrhage at caesarean section

Resuscitation for excessive haemorrhage at caesarean section will be carried out by the anaesthe-
tist; good communication between anaesthetist and surgeon is essential to ensure that the former is
aware of ongoing excessive bleeding and the latter is informed about the haemodynamic status of the
patient.32 Most caesarean sections are carried out under spinal anaesthesia, but the anaesthetist will
need to convert to a general anaesthetic in the event of severe ongoing haemorrhage.
Blood loss of 1000 ml requires blood samples to be taken for haemoglobin, coagulations studies and
emergency cross-matching.
Fluid resuscitation is aimed at restoring intravascular volume and maintaining cardiac output. It requires
two large bore intravenous cannulae and initially involves the rapid infusion of two litres of crystalloid
solution. If bleeding is not controlled and the systolic blood pressure remains less than 100 mm Hg and the
pulse greater than 110 beats per minute, 500 ml of a colloid should be given and repeated if necessary. A
further litre of crystalloid can be given if no colloid is available. All fluids should be warmed.
Further resuscitation for ongoing hypovolaemia requires blood transfusion. This is preferably cross-
matched blood, but if no on-site blood bank is available, the ‘emergency blood’ stored in the maternity
area fridge can be used. Facilities carrying out caesarean section should have some form of blood
products available on site. In countries with limited resources, these are usually refrigerated O Negative
and O Positive units at district hospitals, with ‘blood banks’ at regional and tertiary hospitals.
Fresh frozen plasma is required after two units of red cell concentrate have been given, with
a formula of one fresh frozen plasma for one unit red cell concentrate. Platelets will be needed if the
haematology results show the count to be less than 50,000.
Failure to achieve a response to resuscitation implies continued bleeding, which must be identified
and treated by the surgeon while resuscitation continues.
Cell-salvage techniques are of potential value in situations in which urgent availability of blood is
limited, and in some women who are of the Jehovah’s Witness faith. This has been proven to be safe
and effective for ectopic pregnancy. At caesarean section, however, the blood suctioned from the
amniotic cavity is often mixed with amniotic fluid, and therefore could cause severe adverse reactions
if transfused back into the patient. Nevertheless, in some case studies, this has been carried out with
the use of special techniques to ‘clean’ the blood with success and minimal side-effects. Randomised-
controlled trials are indicated before this technique is accepted as routine practice.33

Management of excessive bleeding at caesarean section

It is useful to display in theatre algorithms for the management of PPH at caesarean section, as well
as to have diagrams of useful techniques that may be used, such as uterine compression sutures. The
algorithms presented in this chapter are currently being used in South Africa and have been published
in The monograph of the management of postpartum haemorrhage,34 a pocket manual on PPH for
healthcare workers based on current evidence-based guidelines and expert opinions.
The surgeon must diagnose the following: cause of the bleeding; uterine atony, tears and lacera-
tions; placental site bleeding, abruptio placentae or bleeding from adhesions; and whether there is
concurrent coagulopathy.
The surgeon must also monitor the response to the various measures used to arrest haemorrhage.
This may be by inspecting the bleeding areas visually or inspecting vaginal blood loss. The latter is
particularly important for monitoring ongoing bleeding from uterine atony or the placental bed after
uterine closure at caesarean section, and can be facilitated by having the patient in the Lloyd–Davies
position.
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The following treatment modalities can be used to arrest bleeding at caesarean section from the
different causes.

Atonic uterus

Medical treatment with stepwise use of uterotonic agents should be the first treatment option.
Oxytocin infusion 20 iu/L at 120–240 ml/h should be commenced. If the woman responds poorly and is
not cardiac or hypertensive, ergometrine 0.2 mgm intravenously can be given and repeated once.
Current research is evaluating the safety and efficacy of lower doses of ergometrine in women who are
hypertensive. The third-line uterotonic medication is a prostaglandin. This can be in the form of
sublingual misoprostol with doses of 400–600 mcg. The latter dose should not be exceeded. If the
woman is shocked or ventilated, the rectal route is recommended. If prostaglandin preparations, are
available, carboprost can be given 0.25 mgm intramuscularly or prostaglandin F2 alpha can be given by
intramyometrial injection. Care must be taken not to exceed the optimal dose, as bronchoconstriction
and severe hypertension are untoward side-effects. The 5 mgm vial should be diluted with sterile water
in a 20 ml syringe, and given as an intramyometrial injection of 2 ml, equivalent to 0.5 mg active
ingredient. This can be repeated until a maximum of 2 mgm (8 ml of solution) has been given.19,20
If medical treatment does not correct the uterine atony, surgical measures must be instituted and, if
a junior doctor is operating, senior assistance should be sought. The B lynch uterine compression suture
is the first surgical measure that should be carried out, and can be easily learned by all grades of doctor
or clinical officer who carry out caesarean sections. An absorbable suture should be used.35 The B Lynch
is carried out when the uterine cavity is open, but there are alternatives, such as the Hayman suture,
when the uterine incision has been closed.36
Successful outcome has been shown in case studies, defined as arresting the bleeding without the
need to proceed to hysterectomy, and minimal immediate postoperative morbidity have been iden-
tified.37–39 Long-term morbidity has been less well assessed; cases of successful pregnancies after
insertion have been reported.40 A few cases of uterine necrosis after insertion have also been re-
ported.41–43 No major long-term side-effects have been observed when compression sutures have been
combined with balloon tamponade; however, an increased risk of uterine ischaemia and necrosis has
been reported when compression sutures are combined with vessel ligation. It is recommended that
registers are kept of women in whom uterine compression sutures are placed to enable long-term
events to be ascertained.44

Trauma: lateral tears into broad ligament or tears into lower or upper segment of uterus

If the caesarean section incision has been inadvertently extended too far laterally or has torn
laterally into the broad ligament during delivery of the baby; arterial bleeding from vessels of the
uterine artery will occur. Haemostatic sutures placed in the broad ligament may control the bleeding
but, if poorly placed, can cause a broad ligament haematoma. It is preferable to do a uterine artery
ligation procedure such as the mass uterine artery ligation technique first described by O0 Leary45 and
developed into the stepwise uterine artery devascularisation approach suggested by Abdrabbo.46 The
suture should be placed at the level of the uterine incision; the medial placement will be in the lateral
border of the uterus, and the lateral placement will be in the avascular window of broad ligament
peritoneum between the uterine arteries medially and the infundibulo-pelvic ligament laterally. Some
practitioners, especially gynaecologists, prefer to open the broad ligament and identify the uterine
artery before ligating it.
Tears down the lower segment of uterus must be carefully identified and the apex of the tear
secured. It must be sutured with a continuous absorbable suture from the apex up to the uterine
incision. Then, the uterine incision must be closed. Lower-segment tears that are long and are directed
laterally will lie close to the ureteric path, and some case studies have shown the ureter having been
occluded by sutures placed for haemostasis. The path of the ureter at this level needs to be identified.
Tears or extension of the uterine incision into the upper uterine segment require closure as for
a classical caesarean section, and must be documented in the notes. The woman will need to be
managed as though she had a classical caesarean section in future pregnancies.
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The surgeon should always explore the posterior surface of the uterus before closing the abdomen
because posterior uterine rupture has been missed, especially after obstructed labour.

Bleeding from the placental bed

Bleeding from the placental bed is mostly associated with placenta praevia and a morbidly adherent
placenta in any part of the uterus. Uterotonic medical treatment should be commenced, but is
frequently insufficient to reduce this type of bleeding. It is best managed surgically by additional
haemostatic ‘figure of eight’ sutures. Excessive bleeding of the lower segment can be successfully
managed in many cases by balloon tamponade.47,48 A purpose-designed tamponade system, such as
the Cook-Bakri, or Rusch catheter, can be used or a ‘home made’ device using a condom or sterile glove
as the balloon attached to a Foley’s catheter34,49,50 This would be inserted with the balloon com-
pressing the lower segment and the catheter passing out through the cervix into the vagina. Antibiotic
cover is required. The balloon can be deflated and removed after 8–12 h. The ‘uterine sandwich’
technique describes a combination of surgical modalities, where a uterine compression suture is first
placed followed by insertion of a balloon tamponade sytem.51 This is particularly effective for placental
site bleeding but could also be used for intractable cases of uterine atony.
The use of medical treatment other than uterotonics requires more research. Infiltration of the
lower segment bleeding area with vasopressin has been described in individual cases, and the use of
tranexamic acid, which can be given as 1 gm intravenously for this problem, is being investigated.
If placenta accrete is present, uterine curettage with the largest uterine curette can be a useful way
of scraping off the adherent placenta. Placenta increta or percreta usually require direct recourse to
hysterectomy. With a placenta increta that fails to separate from the uterine wall after administration
of oxytocin and in the absence of any bleeding, it is best not to attempt placental removal at all, but
rather to leave it in situ and await spontaneous expulsion.
Technical details of procedures such as B Lynch uterine compression suture, balloon tamponade and
uterine artery ligation can be found in various texts; they should be displayed as posters in theatre and
taught to all practitioners who carry out caesarean sections.

Management of ongoing bleeding from all causes after above medical and surgical conservative measures
have been shown to be unsuccessful

Aortic compression
Aortic compression can be applied by an assistant as a temporising measure while help is called.

Recombinant factor V11

Recombinant factor V11 has been found to be effective in individual case reports, but is expensive
and has a strong association with thrombo-embolic complications; therefore, current evidence does
not strongly support its use.52–54

Uterine tourniquet
Some practitioners have described the use of a Foley’s catheter or feeding tube tied as a tourniquet
around the lower part of the uterus in a similar way to its use at myomectomy. This compresses the
uterine vessels and reduces blood loss while awaiting help or during transfer of a patient to a level of
care with more expertise. This technique has not been properly evaluated, but individual case reports
from South Africa have shown some women transferred from a district hospital after bleeding at
caesarean section with a uterine tourniquet in situ, who have had successful outcome. It is not known
as for how long such a tourniquet can be placed in situ without causing irreversible ischaemic changes
to the uterus.

Hysterectomy
In cases of irreparable uterine rupture or placenta increta or percreta, it is usually necessary to
proceed immediately to hysterectomy without attempting conservative measures. Hysterectomy will
also be necessary if all other modalities of treatment have been unsuccessful.
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Several research studies have shown less blood loss and better outcomes if there is a shorter delay in
carrying out the hysterectomy. This still remains a difficult area of clinical judgement, however, espe-
cially in the case of a young primipara. In many institutions, it is thought that two experienced obste-
tricians or doctors must make the decision, and the Head of the hospital be informed if prior consent has
not been obtained. The second section of this chapter provides more detail on caesarean hysterectomy.

Internal iliac artery ligation

Internal iliac artery ligation could be considered if fertility needs to be preserved and a hysterec-
tomy is indicated.55,56 The success rate, however, is only 50% and requires significant surgical expertise;
in well-resourced countries, it is mainly carried out by gynaecological oncologists. One study57 showed
higher success rates when this technique was used for controlling bleeding at caesarean section, rather
than for PPH after vaginal delivery. In addition to being carried out as a uterine preservation procedure,
it can also be carried out after hysterectomy if bleeding continues from pelvic vessels. It is probably
beyond the competence of generalist doctors carrying out caesarean sections in rural hospitals in less-
resourced settings where other procedures described above, intra-abdominal packing after hysterec-
tomy, or both, may be more feasible.

Uterine artery embolisation

Some institutions may have the radiological equipment and skills to carry out uterine artery
embolisation.58,59 This interventional radiological technique will be the procedure of choice if avail-
able, but requires a well-resuscitated patient. These facilities tend to be only available in tertiary
settings and seem to be used more frequently in some countries (e.g. the Netherlands) compared with
others. This procedure has been used with some success for bleeding after caesarean section, but
perhaps has a greater role when severe haemorrhage is predicted pre-operatively, such as for placenta
praevia increta or percreta where the facilities can be prepared in advance (Figs. 1 and 2).

Bleeding after caesarean section

Bleeding after caesarean section is a problem that should be minimised by the preventive measures
described previously in this chapter. Excessive bleeding per vaginam is more easily detected and most
commonly is caused by ongoing uterine atony, but also can be caused by placental site bleeding,
especially in placenta praevia and accreta. Occasionally, bleeding vessels in the angle of the uterine
incision, which were nor adequately ligated, point inwards to the uterine cavity and cause post-
operative vaginal bleeding.
Intra-abdominal bleeding is more difficult to detect because the bleeding is concealed. Deterio-
rating vital signs (e.g. tachycardia above 110 beats/min and blood pressure systolic less than 100 mms
Hg with pallor) are clues. The health worker should not diagnose hypotension as being a side-effect of
a spinal anaesthetic unless haemorrhage has been excluded. Intrabdominal bleeding is usually caused
by bleeding from the angle of the uterine incision, which may cause free blood in the peritoneal cavity
or a broad ligament haematoma.
Management is shown in the algorithm that follows. It involves volume resuscitation and blood
transfusion as appropriate. It is important to diagnose the cause of the bleeding. Uterine atony can
initially be treated medically. Placental site bleeding, if anticipated because it follows a placenta praevia
or placenta accreta, could be treated with balloon tamponade.
If a woman responds poorly to these measures, bleeding is massive, or both, a relook laparotomy
must be carried out without delay. Occasionally, bleeding may be unrelated to the uterus and arise from
perforating vessels under the rectus muscle, which were injured during abdominal entry; these should
be ligated. A Hayman uterine compression suture is indicated for uterine atony, which is not responsive
to medical therapy. The ‘uterine sandwich’ technique can be used in an attempt to conserve the uterus.
Haemostatic sutures can be placed for bleeding at the uterine angle together with a unilateral uterine
artery ligation, especially if the bleeding is thought to be from vessels in the broad ligament. If there is
vaginal bleeding in association with a well-contracted uterus, and no risk for placental site bleeding, it
is advisable to reopen the uterine incision and look for arterial bleeders at the angles, which can then
be ligated. If all these measure fail, it is necessary to proceed to hysterectomy.
242 S. Fawcus, J. Moodley / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 233–249

Prevention Management Diagnosis

2.5 iu oxytocin iv over 30 s Visual estimation
after delivery of baby, Blood loss in suction bottles
followed by >500ml
oxytocin infusion. Call for more
↓BP & ↑HR as detected by
senior help (if
Delivery placenta by anaesthetist
available or
cord traction.
telephonic advice).
Good surgical technique.

Resuscitation (anaesthetist)
Second intravenous infusion line. Arrest
20iu oxytocin in 1 litre as infusion. Haemorrhage*
Maintain blood pressure with fluids (surgeon)
and blood.
Convert to general anaesthesia.
Central line.

Atonic uterus Uterine tears Placental site bleeding

Oxytocin infusion. Lateral tears Mattress suture.
Ergometrine 0.2 mg iv Uterine artery ligation Compression sutures.
(not if hypertension or Inferior tears Stepwise uterine
cardiac) ; repeat x1 Secure apex & suture devascularisation.
Misoprostol 400 – 600 µgm (check ureters are lateral Balloon tamponade.
per rectum to tear) Subtotal abdominal
Prostaglandin F2 alpha 1 mg intra- Rupture* hysterectomy.
myometrial (repeat x 1). Repair or Subtotal abdominal
B-Lynch compression hysterectomy
suture.
Subtotal abdominal
hysterectomy.

Fig. 1. Bleeding at caesarean section. * Proceed immediately to subtotal abdominal hysterectomy if uterine rupture is irreparable or
placenta increta or perceta occur. STAH, subtotal abdominal hysterectomy.

Current evidence and research gaps

Limited, good-quality evidence is available to inform on the best practices for managing bleeding at
caesarean section. Much of what is presented here stems from ‘expert opinion’ and descriptive case
series. More robust research evidence involving randomised-controlled trials for the prevention and
medical prophylaxis of PPH at caesarean section is available. The problem of research on surgical
treatment of PPH at caesarean section is the ethical issues of informed consent for randomised-controlled
trials in shocked patients; however, this could be addressed with methodologies as outlined in the
CRASH trial.27 Randomised-controlled trials are currently in process on the efficacy and side-effect profile
of tranexamic acid used for the prevention, treatment, or both, of PPH at caesarean section.60
 S. Fawcus, J. Moodley / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 233–249 243

Prevention and early Management Diagnosis

detection Excessive vaginal bleeding.
Haemostasis at initial (revealed post partum
caesarean section. Resuscitate haemorrhage)
Regular post-operative Second intraveneous infusion A decrease in blood pressure, an
monitoring. line increase in heart rate, abdominal
Monitoring of at-risk
Oxytocin 20 iu in 1 litre infusion. distension, and pallor
women who bled
Maintain Blood pressure with (concealed bleeding).
intra-operatively in high-care
fluids and blood
area (if available).

Uterus atonic Uterus wall

Massage to remove clots. contracted
20 iu oxytocin in 1 L as infusion.
Ergometrine 0.2 mg iv (not if If ongoing Laparotomy
hypertension or cardiac) ; repeat x1
(Lloyd–Davies
Misoprostol 400 – 600 µgm per rectum. bleeding position)

Atonic uterus Bleeding from uterine incision Suspected placental site

bleeding*
↓

Compression Single bleeding Bleeding along

sutures vessel whole incision Balloon tamponade
↓ ↓ ↓ ↓
STAH Haemostatic Open uterine Stepwise uterine artery
sutures incision; explore devascularisation
↓ for bleeders and ↓
resuture
Stepwise uterine STAH
artery ↓
devascularisation Stepwise uterine
artery
↓ devascularisation
STAH
↓
STAH

Fig. 2. Bleeding after caesarean section. * Proceed immediately to subtotal abdominal hysterectomy if the woman is very unstable.
STAH, subtotal abdominal hysterectomy.

The so called ‘conservative’ surgical techniques, named as such because they obviate the need for
hysterectomy, have been introduced in the past 20 years. They include balloon tamponade, uterine
compression sutures, pelvic vessel ligation including uterine artery ligation and internal iliac artery
ligation, and interventional radiological embolisation. Success rates of 78–84% have been described
for balloon tamponade, 81–91.2% for uterine compression sutures, 42–84.6% for vessel ligations and
50–90% for radiological embolisation, in published case studies.11,44,61 Most of these studies do not
distinguish all PPH from those only associated with caesarean section. In clinical practice, balloon
tamponade is more frequently used for PPH after vaginal delivery and compression sutures for
244 S. Fawcus, J. Moodley / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 233–249

bleeding associated with caesarean section. Research studies comparing the different treatment
modalities, however, are difficult to design, implement and interpret. Also, different modalities of
management may be of more value for the different causes of bleeding at caesarean section, so are not
strictly comparable. Various case studies have shown that these treatment modalities reduce the need
for hysterectomy. The Scottish confidential audit of maternal morbidity for 2008 showed a significant
decrease in peripartum hysterectomy rate from 2003 to 2008, whereas, during the same time period,
increased use of conservative measures were reported, especially balloon tamponade and compression
sutures.62 In some of the case studies showing the ‘success’ of conservative surgical measures, it is
possible that there is lower threshold for doing them than there would be for hysterectomy. An audit by
the UK Obstetric Surveillance System (UKOSS) of contemporary practice for managing severe PPH,
showed that balloon tamponade was a primary procedure in most severe PPH cases followed by
compression sutures in 75%, pelvic vessel ligation in 36% and embolisation in 86% of cases, with 26%
requiring hysterectomy.63
Another study conducted identified five factors retrospectively in women with severe ongoing
haemorrhage who required advanced interventional procedures (e.g uterine artery embolisation,
intra-abdominal packing, arterial ligation or hysterectomy). These were abnormal placentation, heart
rate greater than 115 beats/min, prothrombin time less than 50%, fibrinogen less than 2 g/L, and
detectable troponin.64 A score was devised from these factors that correlated with the need for
advanced interventional procedures in a prospective cohort, thus validating the scoring system. The
investigators suggest such a score would prompt health workers to be more aggressive earlier in the
sequence of treatment, as many audits show that delays in instituting aggressive measures after failed
medical therapy are the most common modifiable factor. Some of these measures, however, require
accessible onsite laboratory facilities and these are beyond the scope of many hospitals in poorly
resourced settings where heart rate and abnormal placentation would be the only ones of these five
parameters that could be assessed.
More research in the form of prospective registers for long-term follow up of women with uterine
compression sutures and vessel ligations would be of value to review future fertility as well as side-effects.
More research is also needed into the efficacy of these interventions and hysterectomy rates in
developing countries, as most of the trials and case studies have been conducted in well-resourced
countries.

Level of care, health system and health worker training issues

Uterine compression sutures, balloon tamponade, and uterine artery ligations are all procedures
that need to be learned by any doctor trained to carry out caesarean section. These procedures can also
be carried out in a district hospital with emergency blood available. The skill to carry out subtotal
hysterectomy may not be available at this level, but should be available at all regional or tertiary
hospitals which, in the ideal situation, are the more appropriate level of care to manage women with
massive haemorrhage.
Algorithms, posters and booklets are useful, and require distribution to relevant health workers;
however, on their own, they are insufficient. It is important to emphasise the need for ‘hands on’ surgical
training for all doctors carrying out caesarean section, as well as an approach to, and demonstration of,
additional surgical skills to arrest excessive bleeding. The availability of experienced specialist assis-
tance for difficult cases preferably on site, or easily available telephonic advice in the case of a remote
rural hospital, is also important. Clinical outreach can help maintain skills and include surgical training.
Clinical managers of maternity services should monitor bleeding associated with caesarean section
as an indicator, ensure that guidelines are in place, that surgical training occurs, and that senior
assistance is available. In addition, constant availability of emergency blood must be ensured, and
adequate staffing and functional theatres are essential.

Caesarean hysterectomy

The first recorded caesarean hysterectomy in which both mother and infant survived was carried
out in 1876 by Porro in Italy, as a life-saving procedure for a woman with uncontrollable bleeding. As
 S. Fawcus, J. Moodley / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 233–249 245

the procedure became more commonly used for this type of scenario, a shift took place in the mid 20th
century for it to be carried out electively as a form of sterilisation in selected women requiring
caesarean section. The observed associated morbidity, however, halted this approach. Caesarean
hysterectomy is currently viewed as a life-saving measure to be used when no other procedure can
arrest the haemorrhage (e.g. extensive uterine rupture and bleeding placenta percreta), or after
conservative medical or surgical measures have failed to control bleeding from other causes.
A systematic review of obstetric hysterectomy shows that the incidence varies according to the
obstetric context from 0.2 per 1000 deliveries in Norway to 5 per 1000 in Eastern Turkey; and risk
factors include past or current caesarean section delivery, multiparity and abnormal placentation.65 A
study in Ireland showed the hysterectomy rate for vaginal delivery was 0.08 per 1000 vaginal deliv-
eries compared with to 1.6 per 1000 caesarean-section deliveries.66 This markedly increased risk of
hysterectomy after caesarean section compared with vaginal delivery is a consistent feature in other
studies.67–70 This difference, however, is more often explained by the condition that required the
caesarean section to be carried out rather than the operative procedure itself. Kacmar et al.71 partially
controlled for this by only including women for whom vaginal delivery was planned. The investigators
still found caesarean section was associated with an increased risk for caesarean hysterectomy. The
Obstetric Surveillance System in the UK conducted between 2005 and 2006 gives hysterectomy rates
of one in 30,000 vaginal deliveries, one in 1700 women with current first caesarean section, one in
1300 for women with one previous caesarean section, and one in 220 for women with two or more
previous caesarean section.72 Therefore, with rising rates of caesarean section worldwide, it may be
anticipated that caesarean hysterectomy rates will increase, and this could possibly offset the
contribution of conservative surgical measures for PPH in reducing the need for caesarean
hysterectomy.
Caesarean hysterectomy is more frequently carried out in women over 35 years and of higher parity,
but all case studies do show a small percentage carried out in young primipara.72
Indications in well-resourced countries tend to be mainly for abnomal placentation and intractable
uterine atony; however, in low- or middle-income countries, sequelae of obstructed labour such as
uterine rupture, atony and sepsis, may be major underlying factors for the ongoing haemorrhage
necessitating the hysterectomy.73 Less common causes are secondary PPH, fibroids and infection.
Elective procedures are uncommonly carried out, but are indicated when caesarean section is carried
out for carcinoma of the cervix. Hysterectomy is seen as a last resort and, although some practitioners
view it as a failure of management, it can undoubtedly be a life-saving procedure. It is a major
procedure and is commonly associated with massive blood transfusion and intensive care, and also can
be complicated by coagulopathy and urological injuries.
The challenges of caesarean section versus hysterectomy relate to the expertise required but also to
the decision making to do it. The possibility of hysterectomy should form part of preoperative coun-
selling of all women undergoing caesarean section, and, particularly, for conditions where the risk of
hysterectomy is higher. Preferably more than one obstetrician or senior doctor should make the
decision to do the hysterectomy.
Hysterectomy is often carried out too late after all conservative measures have been attempted but
failed, by which time the woman may be coagulopathic, thus adding to the morbidity of the procedure.
This is where clinical judgement is important. It is recommended to proceed straight to hysterectomy
in the presence of placenta percreta, or ruptured uterus which is irreparable, or when above
conservative measures are unsuccessful. Bleeding to caesarean section hysterectomy time interval is
longer in young primipara, presumably because of the surgeon persisting longer to conserve the
uterus.11
A subtotal abdominal hysterectomy (STAH) is usually sufficient to control the bleeding. If tears go
down into the cervix, a uterine rupture extends into the cervix or lower segment bleeding occurs
after major placenta praevia, the cervix will also need to be removed by total abdominal hysterec-
tomy. A STAH is a shorter procedure and tends to be associated with less blood transfusion and
urological injuries; however, these differences have not been found to be statistically
significant.65,67,74
The technique of STAH should be taught to all practitioners carrying out caesarean sections; in
Tanzania and Malawi, clinical officers have learned these procedures with good outcomes.75,76
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Problems at surgery relate to ongoing bleeding, coagulopathy, the possibility of bladder and ureteric
injury, complications of massive blood transfusion, such as transfusion related acute lung injury
and postoperative bleeding. Different case studies give morbidity rates ranging from 10–48%.65–69,74
Average blood transfusion per individual ranges from six to 12 units. Urological injuries occurred in 8%
(4% bladder and 4% ureter) in the Irish studies.66 This is similar to 7.5% of urological injuries observed in
the Nigerian study.73 Ongoing bleeding and the need for re-laparotomy is also a known consequence of
the procedure, being required in 8–18% of operations. The Nigerian study gave a high mortality rate of
12.5%, and the investigators suggested that mortality after caesarean hysterectomy would be greater in
situations where there are shortages of blood products and non-availability of intensive care facilities.
This would be the scenario in many rural hospitals in low-income countries. The Nigerian studies also
showed caesarean hysterectomy to be associated with a high perinatal mortality rate of 250 per 1000.73
This is a result of conditions such as uterine rupture and obstructed labour causing fetal demise in
addition to the massive bleeding. This is reflective of many low-income countries where prolonged
labour cannot be managed timeously, resulting in perinatal loss and the mother losing her chance of
future fertility.
If haemostasis is not satisfactory after STAH, a suction drain can be left in situ. If coagulopathy is
evident after STAH and total abdominal hysterectomy, then it is useful to carry out abdominal packing
to tamponade the abdominal cavity. At least five paediatric swabs followed by abdominal swabs can be
used. The woman will need to be kept ventilated and the packs removed after 48 h.
The woman should be observed in a high-care area where vital signs, including urine output, can be
monitored and blood products replaced as necessary.
The need for adequate psychological counselling to such women and their families after surgery
cannot be over emphasised. Follow up after discharge is required for clinical reasons, but also for
further counselling, especially if the baby died.

Conclusion

Excessive bleeding at caesarean section causes severe morbidity and mortality. Because caesarean
section rates are increasing worldwide and particularly in low and middle income countries,
preventative measures such as timeous operative delivery for prolonged labour, and careful surgical
techniques together with careful post-operative observations need to be emphasised.
Finally, bleeding during and after caesarean section not responding to conservative medical and/or
surgical measures, requires the consideration of caesarean hysterectomy to save the mother’s life.

Practice points

 Excessive bleeding at caesarean section causes severe maternal morbidity and mortality.
 Preventive measures, such as timeous caesarean section for prolonged labour, oxytocin and
careful surgical technique, can reduce bleeding at caesarean section.
 Vigilant postoperative monitoring can allow earlier detection and treatment.
 Algorithms are available to guide management for the various causes of bleeding during and
after caesarean section.
 Management requires team work between surgeon, anaesthetist and midwives.
 Surgeons who carry out caesarean section need to know the medical treatment of uterine
atony and be able to carry out additional surgical procedures for arresting haemorrhage and
preferably subtotal hysterectomy.
 Bleeding after caesarean section may be concealed (intra-abdominal) as well as revealed (per
vaginam).
 Bleeding after caesarean section not responding to medical or conservative measures
requires urgent re-laparotomy.
 S. Fawcus, J. Moodley / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 233–249 247

Research agenda

 Prospective recording in registers of women undergoing conservative surgical methods, such

as compression sutures and vessel ligations, so long-term complications and future fertility
can be evaluated.
 Morbidity surveillance for caesarean section in poorly resourced settings.
 Evaluation of techniques that can be carried out by non-gynaecological surgeons at district
hospitals to enable definitive treatment guidelines for this level of care to be promoted.
 Evaluation of a Foley catheter uterine tourniquet as a temporising method during transit or
awaiting senior help.
 Role of tranexamic acid in the prophylaxis and management of bleeding at caesarean section.

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