Expert Review
org
Uterine-sparing surgical procedures to control
postpartum hemorrhage
Hanane Bouchghoul, MD, PhD; Hugo Madar, MD; Benoit Resch, MD; Beth L. Pineles, MD, PhD; Aurélien Mattuizzi, MD;
Alizée Froeliger, MD; Loı̈c Sentilhes, MD, PhD
Introduction
Postpartum hemorrhage today accounts
for 27% of maternal deaths throughout
the world and is thus one of their leading
causes.1,2 At least 90% of maternal
deaths from postpartum hemorrhage are
avoidable because they often follow a
delay in diagnosis, a delay in manage-
ment, or insufficient treatment.2 A sur-
vey has shown that, depending on the
technique, 30% to 60% of attending
obstetrician-gynecologists report that
they have not mastered the surgical
techniques for managing severe hemor-
rhage (vessel ligation and/or uterine
compression sutures).3 This same survey
suggests that up to 18% of obstetricians
have not mastered any of these
methods.3 It is thus essential to dissem-
inate these treatments to manage severe
From the Department of Obstetrics and
Gynecology, Bordeaux University Hospital,
Bordeaux, France (Drs Bouchghoul, Madar,
Mattuizzi, Froeliger, and Sentilhes); Department
of Obstetrics and Gynecology, Rouen University
Hospital, Rouen, France (Dr Resch); Department
of Gynecologic Surgery, Clinique Mathilde,
Rouen, France (Dr Resch); and Department of
Obstetrics, Gynecology and Reproductive
Sciences, McGovern Medical School, The
University of Texas Health Science Center,
Houston, TX (Dr Pineles).
Received March 19, 2022; revised June 5, 2022;
accepted June 12, 2022.
L.S. has carried out consultancy work and been
a lecturer for Ferring Laboratories in the previous
3 years. The other authors report no conflict of
interest.
This research received no specific grant from
any funding agency in the public, commercial, or
not-for-profit sectors.
Corresponding author: Loïc Sentilhes, MD, PhD.
loicsentilhes@hotmail.com
0002-9378/$36.00
ª 2022 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2022.06.018
ajog.
Postpartum hemorrhage remains one of the principal causes of maternal mortality in the
United States and throughout the world. Its management, which must be multidisci-
plinary (obstetrics, midwifery, anesthesiology, interventional radiology, and nursing),
depends on the speed of both diagnosis and implementation of medical and surgical
treatment to control the hemorrhage.
The aim of this work is to describe the various techniques of vessel ligation and of uterine
compression for controlling and treating severe hemorrhage, and to present the ad-
vantages and disadvantages of each.
It is not difficult to perform vessel ligation of the uterine arteries: O’Leary’s bilateral
ligation of the uterine artery, Tsirulnikov’s triple ligation, and AbdRabbo’s stepwise
uterine devascularization (that is, stepwise triple ligation). These procedures are asso-
ciated with a high success rate (approximately 90%) and a low complication rate.
Bilateral ligation of the internal iliac (hypogastric) arteries is more difficult to perform and
potentially less effective (approximately 70% effectiveness) than the previously
mentioned procedures. Its complication rate is low, but the complications are most often
serious. There is no evidence that future fertility or subsequent obstetrical outcomes are
impaired by ligation of either the uterine or internal iliac arteries.
There are many techniques used for uterine compression sutures, and none has shown
clear superiority to another. Uterine compression suture has an effectiveness rate of
approximately 75% after failure of medical treatment and approximately 80% as a
second-line procedure after unsuccessful vessel ligation. The risk of synechiae after
uterine compression suture has not yet been adequately evaluated, but is probably
around 5%.
The risk of synechiae after uterine compression suture has not yet been adequately
evaluated, but probably ranges between 5% and 10%.
The methodologic quality of the studies assessing uterine-sparing surgical procedures
remains limited, with no comparative studies. Accordingly, no evidence suggests that any
one of these methods is better than any other. Accordingly, the choice of surgical
technique to control hemorrhage must be guided firstly by the operator’s experience.
If the hemorrhage continues after a first-line uterine-sparing surgical procedure and the
patient remains hemodynamically stable, a second-line procedure can be chosen.
Nonetheless, the application of these procedures must not delay the performance of a
peripartum hysterectomy in cases of hemodynamic instability.
Key words: fertility, internal iliac artery ligation, obstetrical prognosis, peripartum
hysterectomy, postpartum hemorrhage, uterine artery ligation, uterine compression
sutures (B-Lynch, Hayman, and Cho)
hemorrhage through as many pathways Vessel ligation
as possible.3 Uterine artery ligation
This study aimed to present the Bilateral uterine artery ligation.
uterine-sparing surgical procedures This technique was initially described by
currently available to treat postpartum Waters4 in 1952. He reported that this
hemorrhage refractory to medical treat- ligation enabled a 90% reduction of the
ment, and their advantages and disad- blood flow to the uterus (vs only 48%
vantages (Video 1). with ligation of the internal iliac
MONTH 2022 American Journal of Obstetrics & Gynecology 1
Expert Review ajog.org

mean success rate for uterine artery li-

FIGURE 1
gations was 93%. Therefore, the bilateral
Bilateral ligation of the uterine arteries ligation of uterine veins and arteries is a
simple, rapid technique that is easily
reproducible. It can always be per-
formed before a hysterectomy and
functions as the initial step to limit
blood loss before peripartum hysterec-
tomy. Thus, bilateral uterine artery
ligation does not delay the performance
of a peripartum hysterectomy.
The only complication reported after
bilateral ligation of the uterine arteries is
a retroperitoneal hematoma, reported in
A, Bilateral ligation of the uterine arteries (HL), then a second lower bilateral ligation 2 to 3 cm below
2 cases (1%) in O’Leary’s series.7 Only 15
the first (LL). B, Intraoperative view. Stepwise ligation of the uterine pedicle from the right side: uterus
pregnancies have been reported after
gently retracted superiorly and contralaterally by the assistant surgeon, the RL transected, and the
ligation of only the uterine arteries.7,9,10
bladder pushed away by the retractor. A PW is opened. Then, working from back to front, largely on
All proceeded with no complications
the myometrium, a HL is performed and then a LL of the uterine pedicle.
and led to term births of healthy
bl, bladder; HL, high ligation; LL, low ligation; o, ovary; PW, peritoneal window; RL, round ligament; ur, ureter; ut, uterus.
children.10
Bouchghoul. Uterine-sparing surgical procedures. Am J Obstet Gynecol 2022.
Tsirulnikov’s triple ligation.
This technique is a variant of bilateral
uterine artery ligation, known as ligation of
the uterine vessels, first described in
arteries).4 Performed transabdominally, Passing the suture from posterior to 1974.11 It systematically combines bilateral
it involves ligating the ascending anterior may decrease the risk of bowel ligation of both the round and the utero-
branches of the uterine arteries together injury.5 ovarian ligaments with bilateral uterine
with the deep venous plexus that ac- A second ligation called a low or artery ligation (Figure 2 and Video 2).
companies them. This ligation can be stepwise ligation can be performed 2 to During pregnancy, uteroplacental
performed in stages for each pedicle. The 3 cm below the preceding ligation to perfusion comes mostly from the uterine
technique begins by the exteriorization occlude the branches feeding the cervix arteries. Nonetheless, in 4% of cases, it is
of the uterus, pulling it gently upward (Figure 1). Because a single ligation instead the ovarian arteries that supply
and contralaterally to distance it from presents the risk of incomplete occlu- most of the placenta’s perfusion. Perfu-
the ipsilateral ureter; a self-retaining sion of the uterine artery (provided sion by the round ligament artery is
retractor is then placed. The ligation is below), we recommend performing the anecdotal.12 The ligation and transection
prepared by making an incision in the second one systematically.5 Later on in of the round ligament improves access to
vesicouterine peritoneum and dissecting the procedure, after the ligation, the the uterine pedicle without later func-
the bladder from the uterus 3 to 4 cm absence of a pulse in the uterine pedicle tional repercussions. Moreover, ligation
below the hysterotomy, if the delivery must be verified. It is important to insist of the round ligament arteries and the
was cesarean. The bladder is protected by on the need for sustained traction of the utero-ovarian ligaments may prevent the
the placement of a bladder blade. The uterus and the importance of fenestra- resumption of uterine perfusion by
round ligament can then be ligated and tion of the broad ligament to keep the various collateral networks (right/left
transected to separate the anterior and ureter out of the way. The depth into the transverse anastomoses between
posterior leaves of the broad ligament myometrium must be significant to branches of the uterine arteries; infra-
and facilitate safe access to the uterine avoid injuring the uterine vessels, which tubal and subovarian arcades formed by
pedicle. A finger is used to identify the could cause an arteriovenous fistula, but the anastomoses of the terminal
uterine artery and electrocautery used to penetrating the uterine cavity must be branches of the tubal and ovarian ar-
open the avascular zone of the anterior avoided.6 O’Leary7 reported his experi- teries; a branch of the round ligament
and then posterior leaf of the broad lig- ence ligating uterine arteries in a retro- born of the uterine artery anastomosed
ament 3 to 4 cm (more experienced spective study of 265 cases over a 30- to the round ligament artery).12 In the
surgeons can perform this procedure year period, with a success rate of article describing this technique, Tsir-
without sectioning the round ligament, 97%. In interpreting this exceptional ulnikov11 reported 24 cases, all because
but with a narrower window opening). rate, it must be noted that this series of uterine atony, treated by triple ligation
The ligation is performed with absorb- does not include any ligations for with a 100% success rate. A French study
able suture, through the myometrium, 2 placenta accreta spectrum.7 In the liter- retrospectively aimed at assessing the
to 3 cm below the incision (Figure 1). ature review by Doumouchtsis et al,8 the effectiveness of Tsirulnikov’s triple

2 American Journal of Obstetrics & Gynecology MONTH 2022

ajog.org
FIGURE 2
Tsirulnikov’s triple ligation11
Ligation of: (1) uterine arteries, (2) the round
ligament, and (3) the utero-ovarian ligaments.
bl, bladder; o, ovary; ur, ureter; ut, uterus.
Bouchghoul. Uterine-sparing surgical procedures. Am J
Obstet Gynecol 2022.
ligation. Among the 56 women who had
Tsirulnikov’s triple ligation as a first-line
treatment, 77% (43/56) subsequently
required a second uterine-sparing sur-
gical procedure.13 To explain the differ-
ence in success rate from that reported
by Tsirulnikov,11 O’Leary,7 and others,10
the authors suggested that some sec-
ondary procedures may have been
performed unnecessarily.13 They under-
lined that a second uterine-sparing sur-
gical procedure was less likely to be
performed over time, and considered
that this may reflect a learning period
necessary for the surgeons to feel confi-
dent with Tsirulnikov’s triple ligation.13
Stepwise uterine devascularization.
AbdRabbo et al described this technique
in 1994.14 The principle of this stepwise
ligation method is the progressive
devascularization of vessels supply
ing the uterus. Each step is performed
only if the preceding step did not stop
the hemorrhage within 10
minutes (Video 2). This technique
therefore comprises the following 5
successive steps: (1) unilateral ligation of
the ascending branch of a uterine artery,
as described above, (2) ligation of the
contralateral uterine artery, (3) lower
ligation of both uterine arteries and of
their cervicovaginal branches 2 cm
below the preceding upper ligations,
FIGURE 3
Stepwise uterine
devascularization14
AbdRabbo has proposed a stepwise uterine
devascularization in 5 steps, with each step
being performed only if the preceding step did
not stop the hemorrhage within 10 minutes:
unilateral and then bilateral ligation of the
uterine arteries (1þ2), stepwise low ligation of
both uterine arteries (3), unilateral and then
bilateral ligation of the suspensory ligaments of
the ovary (4þ5). We advised against steps 4
and 5 because of the risk of subsequent ovarian
failure.
bl, bladder; o, ovary; ur, ureter; ut, uterus.
Bouchghoul. Uterine-sparing surgical procedures. Am J
Obstet Gynecol 2022.
after dissection of the bladder from the
uterus, (4) unilateral ligation of an
ovarian pedicle, and (5) ligation of the
contralateral ovarian pedicle (Figure 3).
In the initial publications, the author
used the term “ovarian vessel ligation” to
describe steps 4 and 5.14 The term is
confusing because it could designate the
ligation of either the utero-ovarian liga-
ment (the stepwise ligation would thus
be a stepwise triple ligation with a double
ligation of each uterine artery) or of the
suspensory ligaments of the ovary. Given
that AbdRabbo used the term “ovarian
vessels” several times, it is probable that
he was referring to the latter.14
The advantage of this technique is its
explicit recommendation of a double
ligation of each uterine artery: the first 1
cm below the hysterotomy (after a ce-
sarean delivery) and the second 3 cm
below the first ligation. This reduces the
risk of an ineffective ligation that does
not or only partially blocks the uterine
MONTH 2022 American Journal of Obstetrics & Gynecology
Expert Review
artery and that the surgeon cannot di-
agnose even after verifying the absence of
a pulse at the uterine pedicle later during
the procedure.5 The persisting patency of
the uterine artery (assessed by arteriog-
raphy in cases of persistent hemorrhage
after uterine artery ligation5) can cause
the procedure to fail to stop the hemor-
rhage. Moreover, unlike ligation of the
uterine arteries at a single point, the
stepwise ligation devascularizes both the
lower uterine segment and the upper
cervix. It is thus appropriate for dealing
with disorders of the lower uterine
segment.
AbdRabbo reported a series of 103
women and a success rate of 100%.14
The bilateral double ligation of the
uterine arteries (steps 1e3) brought the
hemorrhage under control for 96 of
these 103 (93%) women: 65 of 66 (98%)
of those with uterine atony, 15 of 17
(88%) with placental abruption, all 5
(100%) with placenta previa, and both of
the women (100%) with placenta accreta
spectrum disorders.14 Steps 4 and 5 were
necessary only in all 4 (100%) women
with afibrinogenemia (n¼4) and 6 of 9
(67%) women with a Couvelaire
uterus.14
We evaluated AbdRabbo’s stepwise
uterine devascularization with a success
rate of 72% (16/58),10 less than that
reported by AbdRabbo14 and by au-
thors who performed bilateral double
ligation of the uterine arteries and no
other vessels.7,9,15 AbdRabbo also re-
ported the medium and long-term
maternal outcome for 45 of the 103
women with stepwise uterine devascu-
larization for postpartum hemor-
rhage,14 noting that they observed no
modification of the rhythm, volume, or
duration of their menstrual cycles.
Among the 15 women who stopped
contraception, 11 became pregnant af-
ter a mean time to conception of <1
year, and all gave birth at term to
healthy children.14 These pregnancies
were obtained both in women who had
undergone ligation of the ovarian
pedicle (n¼5) and those who had not
(n¼6). Nonetheless, AbdRabbo re-
ported no information about the 4
women who stopped contraception and
did not become pregnant.
3
Expert Review
We reported the follow-up of 32
women who underwent stepwise
devascularization that enabled them to
avoid a hysterectomy: 9 women had
only a double bilateral ligation of the
uterine arteries, 11 women a double
bilateral ligation of the uterine arteries
followed by bilateral ligation of the
utero-ovarian ligaments, and 12 women
a double bilateral ligation of the uterine
arteries followed by a bilateral ligation
of the suspensory ligaments of the
ovary.10 Only 4 reported modification
of their menstrual cycles: 3 had post-
partum amenorrhea, with 2 owing to
ovarian insufficiency and the third
owing to synechiae, whereas the fourth
had a necrotic and infected uterus
requiring a hysterectomy at 7 months
postpartum. All 4 had had a bilateral
ligation of the suspensory ligaments of
the ovary. Among the 16 women with
preserved fertility who stopped their
contraception, no secondary infertility
was observed.10 Twelve women had 16
pregnancies: 1 ectopic pregnancy, 2
elective abortions, and 13 term de-
liveries of 13 healthy children. These
pregnancies occurred both among
women who had undergone ligation of
the suspensory ligaments of the ovaries
(n¼5) and among those who had not
(n¼7). The postpartum hemorrhage
recurrence rate in this series was 31%,
similar to that observed after bilateral
ligation of the internal iliac arteries.10,16
In conclusion, the single or double
bilateral ligation of the uterine arteries,
whether or not followed by bilateral
ligation of the utero-ovarian ligaments,
does not seem to impair women’s fertility
or their subsequent obstetrical
outcome.10 This technique is simple,
rapid, and easily reproducible. It can al-
ways be performed before a hysterec-
tomy, especially because it constitutes the
first surgical steps of this more drastic
procedure. Conversely, double bilateral
ligation of the uterine arteries associated
with bilateral ligation of the suspensory
ligaments of the ovaries seems to impair
fertility (in 30% of our cases: 4/12) and
lead to ovarian insufficiency (2/12).
Ligation of these ligaments should
therefore not be performed.10
4 American Journal of Obstetrics & Gynecology MONTH 2022
Bilateral ligation of the internal iliac
(hypogastric) arteries (Video 3)
Bilateral ligation of the internal iliac ar-
teries in the management of postpartum
hemorrhage was first described in
189817 and was considered the reference
technique for many years (Video 3).
Performed transabdominally, this tech-
nique can be summarized by the
following steps. The uterus is exterior-
ized and pulled gently forward and
contralaterally, and then a retractor, self-
retaining or handheld, is placed. An
incision is made in the posterior peri-
toneum at the level of the common iliac
artery and extended 5 to 6 cm inferiorly.
At the level of the sacral promontory, the
iliac bifurcation can be palpated. On the
left, exposure of the iliac vessels is facil-
itated by mobilization of the sigmoid
colon and detachment of the colon,
peritoneum, and Toldt fascia. Dissection
of the peritoneum continues to the
bifurcation of the internal and external
iliac arteries. Because the ureter passes
directly under this bifurcation, it must
be identified and moved safely out of the
way. This avoids a ureteral injury and
exposes the surgical field. The internal
iliac artery is then dissected at a distance
from the surrounding structures. Liga-
tion of the internal iliac artery involves
its circumferential dissection to allow
the passage of a right-angle forceps for
suture ligation. A right-angle forceps is
introduced just under the artery,
perpendicular to the vessel, with a pas-
sage from the outside to the inside to
avoid damaging the underlying vein.
The ligation is performed 2 cm below
the iliac bifurcation to avoid ligating the
posterior branches feeding the gluteus. A
nonabsorbable suture is then inserted
into the open right-angle forceps and
passed around the artery. The absence of
a pulse in the uterine pedicle can be
verified after the ligation to confirm, in
case of doubt, that it was not the external
iliac artery that was ligated (Video 3).
This ligation must systematically be
performed bilaterally. That is, a uni-
lateral ligation can be a source of fail-
ure because of the existence of
numerous collateral networks between
the internal iliac artery and other
ajog.org
vessels supplying the uterus.18 The
effectiveness of internal iliac artery
ligation seems worse than initially
supposed.19 Doumouchtsis et al have
reviewed the literature about its effec-
tiveness,8 which varies among authors
from 39% to 100%, with a mean suc-
cess rate of 69% (136/197).8 Nonethe-
less, one study of 84 women reported a
success rate <60%, although all liga-
tions were performed by experienced
surgeons specialized in gynecologic
oncology.20
Ligation of the internal iliac arteries
seems to be interesting principally for
the management of obstetrical injuries
such as cervicovaginal injuries and
vaginal or pelvic thrombi and for
persistent bleeding after peripartum
hysterectomy.21 However, it is a diffi-
cult procedure, performed only rarely,
generally in major emergencies, and
involving a surgical field rarely
dissected by obstetrician-gynecologists
who do not practice oncologic sur-
gery. It can cause severe morbidity:
iliac vein injury, ligation of the ureter
or iliac artery, gluteal claudication, and
peripheral vein injuries.8 If performed
well, it may be difficult to perform a
secondary embolization should the
ligation fail.5,22 Sanders et al23 recently
described a simplified approach to oc-
clusion of the internal iliac artery,
limiting retroperitoneal dissection by
creating a space only on each side of
the artery, using a forceps placed lateral
and parallel to the artery. A clip applier
can be easily moved through the nar-
row space created on both sides of the
artery and can occlude the artery with
2 titanium vascular clips. This
approach is simpler and faster than the
technique initially described. The au-
thors have not reported any complica-
tion in their series of 32 cesarean
hysterectomies with clips placed by this
technique to occlude the internal iliac
arteries.23 Invasive placentation was the
indication for the cesarean hysterec-
tomies in this series.23
In any case, ligation of the internal
iliac arteries requires thorough knowl-
edge of the pelvic vascular anatomy and
adequate exposure.
ajog.org
What technique of vessel ligation
should you choose?
There are currently no studies, either
prospective or retrospective, that have
compared efficacy and morbidity be-
tween ligation of the uterine arteries and
ligation of the internal iliac arteries. The
urgent nature of postpartum hemor-
rhage makes the feasibility of controlled
trials, randomized or not, difficult. In the
absence of any type of controlled study,
no professional society has recom-
mended performing one of these first-
line treatments over another. The ques-
tion is still widely debated in the litera-
ture, and the place of these different
techniques continues to depend on the
culture of the country and even of each
center.24 Accordingly, the choice must be
guided firstly by the operator’s experi-
ence. Nonetheless, the ligation of uterine
arteries compared with that of the in-
ternal iliac arteries seems easier to learn
and perform and is associated with fewer
adverse events.3,25 A national survey us-
ing questionnaires completed anony-
mously by 286 attending obstetrician-
gynecologists in France showed that
33% of these specialists considered that
they had not mastered bilateral ligation
of the uterine arteries, whereas 40% had
not mastered Tsirulnikov’s triple liga-
tion, and 62% did not feel adequately
skilled in ligation of the internal iliac
arteries.3 The numbers were much
higher when the same questions were
asked to residents in obstetrics-
gynecology legally authorized to cover
call duties alone.25 Specifically, among
the residents, 74% (115/156) did not
consider that they had mastered
adequately or even at all the technique for
bilateral uterine artery ligation, whereas
85% (132/156) felt that way about Tsir-
ulnikov’s triple ligation, and 95% (148/
156) about internal iliac artery ligation.25
It is thus essential to disseminate these
surgical techniques for the management
of severe postpartum hemorrhage in as
many ways as possible.
Uterine compression sutures
These techniques of uterine compres-
sion have in common the performance
of a plication of the uterus by bringing its
anterior and posterior walls together to
exert pressure on it and prevent it from
filling up with blood.
Uterine compression suture: the
B-Lynch suture (Video 4)
In 1997, B-Lynch was the first author to
describe a technique of uterine
compression suture, which he used to
control postpartum hemorrhage in 5
women.26 This technique involves
creating a mediolateral suture as a brace
around the uterine body aimed at
bringing the anterior and posterior
uterine walls together to compress the
uterus (Figure 4 and Video 4). An open
uterine incision was necessary for the
initial version of this technique.26
Nonetheless, because hemorrhage
resistant to medical treatment (utero-
tonics) is almost always diagnosed after
the hysterotomy has been sutured, this
mediolateral brace suture can be per-
formed after the incision has been
closed. It is therefore unnecessary to
reopen the incision or—if delivery was
vaginal—make a new incision.27 B-
Lynch initially used No. 2 chromic
catgut suture, but most recently rec-
ommends using a No. 1 polyglecaprone
25 monofilament, mounted to a 70-
mm semicircular hand needle, which
has an absorption profile that decreases
with time: from 60% at 7 days to 20%
at 14 days, with resorption complete
between 90 and 120 days (code W3709,
information available at tcb@fsmail.
assets).28 This procedure can be per-
formed with a large round needle if a
hand needle is not available.
Although it has never been demon-
strated formally, B-Lynch considers
that this suture is likely to reduce the
risk of postpartum uterine necrosis,
pyometra, or synechiae compared with
polyglactin 910 suture.28 However, ac-
cording to B-Lynch, before any surgi-
cal procedure, bimanual compression
of the uterus acting on the hemorrhage
may predict the subsequent effective-
ness of this technique,26 although this
too has not been demonstrated. Since
then, numerous variants of uterine
compression sutures have been
described.
MONTH 2022 American Journal of Obstetrics & Gynecology
Expert Review
Uterine compression sutures: the Cho
procedure
The objective of this procedure is to
induce hemostasis by compression by
applying either multiple simple trans-
fixion sutures29,30 or multistitch square
sutures between the anterior and poste-
rior uterine walls (Figure 5).31 In 2000,
Cho et al31 were the first to describe a
multistitch suture technique in squares
that they termed “hemostatic multiple
square suturing.” This technique in-
volves identifying an area of heavy
bleeding and suturing the serosa of the
anterior wall to the serosa of the poste-
rior wall by stitches forming a square
(Figure 5). This square suture requires
the placement of 4 suture points by a
straight needle mounted with No. 0 pol-
yglactin 910 (Figure 5). The procedure is
repeated as many times as necessary.
The principal indication for uterine
compression suture techniques is uterine
atony. It seems especially useful for the
diffuse bleeding that occurs in the lower
uterine segment. Since its initial
description as a series of 23 cases, this
technique has, like the B-Lynch method,
spread widely throughout the world. It is
very probably the most frequently used
uterine compression suture technique
presently.
Uterine compression suture variants
Hayman et al modified B-Lynch’s initial
technique by substituting for the single
suture 2 independent mediolateral ver-
tical braces that can be positioned
without the need for a hysterotomy
incision (Supplemental Figure 1).32 Both
the B-Lynch et al,26 and Hayman et al32
techniques use transfixion stitches, that
is, they go all the way through the uterine
cavity. Pereira et al33 proposed another
uterine compression technique using 3
transverse (horizontal) sutures and then
2 longitudinal sutures applied with a No.
0 or 1 polyglactin 910 suture
(Supplemental Figure 2). The first
transverse suture passes through the
upper broad ligaments bilaterally, in the
avascular section (just below the uterine
horns); the next transverse suture is
lower, and the third in the lower
segment; they thus separate the uterus
5
Expert Review ajog.org

compression based on B-Lynch’s prin-

FIGURE 4
ciples (brace) and can be performed with
B-Lynch’s technique of uterine compression by plication26 the incision closed (Supplemental
Figure 4). Other variants have been
described.30,35 Huissoud et al35 reported
a technique of uterine compression
(named “total uterine ligation”) that
does not involve transfixion of the uterus
but is based solely on 4 transverse braces,
with no longitudinal brace. It can be
considered a variant of Pereira because
the brace compresses both the uterus
and its lower uterine segment but also
the vessels feeding the uterus (uterine
arteries, ovarian arteries, and round lig-
A, Diagram. The technique described here begins on the left side: aments). Compression suturing accord-
ing to Ouahba et al uses 4 simple stitches
- The needle crosses the anterior wall of the uterus approximately 3 cm under the still open, that completely transfix the anterior and
unsutured incision to 3 cm from the left lateral edge of the left uterus. posterior walls of the uterus
- It goes back through the anterior wall of the uterus and emerges 3 cm above the incision, still (Supplemental Figure 5).30
approximately 3 cm from the left lateral edge of the uterus. Steps (1) and (2) describe the first Regardless of the technique used
“passage” of the needle. (original or modified B-Lynch et al,26
- The suture travels up the anterior wall of the uterus, crosses the top of the fundus, and descends Hayman et al,32 or Pereira et al33), to
down the left posterolateral wall. obtain the best possible uterine
- The needle pierces the posterior wall and enters the uterine cavity at the same level of the compression (and therefore possibly the
preceding suture point (3 cm above the incision), that is, in the superior portion of the uterine best outcome), it is important for the
body-isthmus junction, always approximately 3 cm from the left lateral edge of the uterus. surgical assistant to perform bimanual
- The needle again pierces the posterior wall at the same horizontal level as the previous suture compression of the uterus to reduce its
point, but this time, at approximately 3 cm from the right lateral edge (the other side) of the uterus. volume before tightening its sutures (or
Steps (4) and (5) describe the second passage of the needle. braces).27,28
- The suture, now on the posterior wall of the uterus, moves up toward the uterine fundus along the
right lateral edge of the uterus, to descend down the right anterolateral wall. Effectiveness and complications of
- It returns back through the anterior wall of the uterus and emerges 3 cm above the incision, still uterine compression techniques
approximately 3 cm from the right lateral edge of the uterus. In the literature review by Dou-
- The needle again crosses the anterior wall of the uterus, this time approximately 3 cm above the mouchtsis et al,8 the overall effectiveness
(still unsutured) incision. Steps (7) and (8) describe the third passage of the needle. rate of these different techniques was
- The incision is then sutured according to the usual technique. 92% (99/108). Important reservations
- Both ends of the suture (straight needle, No. 0 polyglactin 910) are then put under tension, helped are nonetheless necessary because this
by the assistant’s manual compression, to be able to press one wall against the other. Both literature review compiled different
sutures are then tied at a lower level of the lower segment, under the now sutured incision. techniques that differ quite substantially
from one another (B-Lynch, Cho, and
B, Intraoperative view of myometrial brace compression by B-Lynch Pereira), with studies including small
Bouchghoul. Uterine-sparing surgical procedures. Am J Obstet Gynecol 2022. numbers of individuals, heterogeneous
series (variously associated with vessel
ligation), and especially very little detail
into transverse sections. Next, the 2 technique therefore uses no transfixion about the causes and severity of the
longitudinal sutures correspond to stitches through the uterus.33 hemorrhages requiring the procedure.36
Hayman’s 2 vertical mediolateral braces Another variant of the Hayman et al In particular, although some authors
(Supplemental Figure 2).33 These longi- compression suture does not double the have reported that the B-Lynch proced-
tudinal sutures compress the uterus 2 independent braces (Supplemental ure is effective for uterine ruptures37 or
longitudinally. At the level of the lower Figure 3) and thus reduces the number placenta accreta spectrum disorders,38,39
uterine segment, they are attached to the of the transfixion passages from 4 to 2, it seems that these techniques are used in
lowest transverse suture by a simple knot which could be an advantage. Finally, the the great majority of cases solely for
that is reinforced in the back and front uterine compression according to Bhal uterine atony resistant to medical
(frontally and posteriorly). Pereira’s et al34 presents the advantage of a uterine treatment.36

6 American Journal of Obstetrics & Gynecology MONTH 2022

ajog.org
FIGURE 5
Technique of hemostatic multiple
square suturing by Cho et al31
Suturing the serosa of the anterior wall to the
serosa of the posterior wall in square 4-stitch
sutures.
Making this multistitch square suture requires
the placement of 4 suture points by a straight
needle with No. 0 polyglactin 910:
- The first stitch (1) penetrates the anterior and
then the posterior wall of the uterus.
- The second stitch (2) retransfixes the poste-
rior wall to the anterior wall on the same
horizontal line 2 to 3 cm from the first suture
point to its left.
- The third (3) is performed by penetrating the
anterior then posterior walls of the uterus,
along the same vertical line 2 to 3 cm away
from and below the second suture point.
- The fourth stitch (4) penetrates first the
posterior and then the anterior wall on the
same horizontal line at 2 to 3 cm from the
third suture point, but toward the first point,
that is, to the right of the third suture point,
thus forming a square.
- Finally, both suture ends, from points 1 and 4
are tied together to make a square.
Bouchghoul. Uterine-sparing surgical procedures. Am J
Obstet Gynecol 2022.
The efficacy of uterine compression
has actually been known only since 2011
through a large prospective series of 211
uterine compressions performed in the
United Kingdom (UK Obstetric Sur-
veillance System [UKOSS] register)40
because previous studies were
small.26,31e33 In this study, the effec-
tiveness rate was 75% (95% confidence
interval [CI], 69e81), and the hysterec-
tomy rate did not differ by type of
uterine compression used (B-Lynch,
B-Lynch variant, compression sutures,
or multiple sutures).40
A French survey used an anonymous
questionnaire completed by 286
obstetrician-gynecologists who had
completed their residencies, and showed
that 37% of these specialists did not feel
that they had mastered the use of uterine
compression sutures; 47% felt that way
about peripartum hysterectomies.3 The
numbers were much higher when the
same question was asked to residents in
obstetrics-gynecology authorized to
cover call duties alone.25 Among them,
79% did not consider that they had
mastered uterine compression sutures
and 78% felt that way about peripartum
hysterectomy.25
In 2014, Doumouchtsis et al41 pub-
lished a systematic review of the litera-
ture including 125 women who had been
treated for postpartum hemorrhage by a
uterine compression technique. They
estimated that 91% of the women had
resumed normal menstrual cycles by 6
months after their uterine compression
procedure and that 75% of those who
wanted another pregnancy had had a live
birth (21/28 women).
The risk of synechiae after uterine
compression has not yet been adequately
evaluated, but I probably around
5%.36,41e44 If another pregnancy is
desired and if oligo-amenorrhea con-
tinues in the postpartum period, hys-
teroscopy is advised to assess for
synechiae.
Is it appropriate to perform a second-
line uterine-sparing surgical
procedure if the first one fails?
Few studies have assessed the effective-
ness of a second-line uterine-sparing
surgical procedure. One study evaluated
the effectiveness of B-Lynch sutures in 15
women with hemorrhage persisting
despite vessel ligation.27 It showed that
the B-Lynch sutures controlled the
hemorrhage, and thus immediate hys-
terectomy was avoided in 80% (12/15) of
the cases.27
MONTH 2022 American Journal of Obstetrics & Gynecology
Expert Review
A French study aimed at assessing the
effectiveness of uterine compression su-
ture after the failure of a Tsirulnikov
triple ligation. Second-line treatment by
uterine compression had a success rate of
88% (5/43).13 Another study assessed
the effectiveness of ligation of the inter-
nal iliac arteries, either alone or in
combination with other uterine-sparing
procedures. Of the 26 women with
hemorrhage owing to uterine atony,
31% (8/26) of women had ligation of the
internal iliac arteries after a first-line B-
Lynch uterine compression failed, and its
success rate was 87% (7/8).45
These studies suggest that it is
indeed appropriate to offer second-line
surgical treatment after vascular liga-
tion or uterine compression sutures fail
to stop the hemorrhage before per-
forming a peripartum hysterectomy
when the woman is hemodynamically
stable.13,27,45
In the prospective UK study of 211
women who had uterine compression
sutures to treat postpartum hemorrhage,
13% (28/211) had a second-line treat-
ment by vessel ligation or uterine artery
embolization.40 Although this study
does not assess the effectiveness of 2
successive uterine-sparing procedures, it
shows that this approach, although
infrequent, is not rare.
What procedure should be used as
the first-line treatment: uterine
compression suture or vessel
ligation?
No prospective or retrospective study has
compared effectiveness and morbidity
between uterine compression and vessel
ligation. In a prospective series, again
from the United Kingdom (UKOSS reg-
ister), including 199 uterine compression
procedures and 20 vessel ligations, the
hysterectomy rate was higher in the liga-
tion group (64%; 95% CI, 35e87 vs 25%;
95% CI, 19e33).40 The very low success
rate of vessel ligation found in this study is
striking. It is probably owing to the exis-
tence of bias in this uncontrolled pro-
spective study: the small number of vessel
ligations (n¼20) compared with the
number of uterine compressions
(n¼199) strongly suggests an indication
bias. This was confirmed on reading the
7
Expert Review
FIGURE 6
A proposed algorithm of surgical
technique to control postpartum
hemorrhage refractory to
medical treatment
The superscript letter a denotes this is only a
proposal. The choice, in particular for the first
uterine-sparing surgical procedure, between
uterine artery ligation and uterine compression
sutures depends mainly on the operator’s
preference. The superscript letter b denotes
uterine artery ligation or Tsirulnikov’s triple
ligation or stepwise uterine devascularization.
The superscript letter c denotes B-Lynch or Cho
suturing techniques.
Bouchghoul. Uterine-sparing surgical procedures. Am J
Obstet Gynecol 2022.
records; vessel ligation tended to be per-
formed in the most serious and most
complex clinical situations.40
In patients who are hemodynami-
cally unstable, peripartum hysterec-
tomy must be seriously considered.
However, this intervention is associ-
ated with considerable maternal
morbidity.46 For this reason, it is
appropriate to perform bilateral liga-
tion of the uterine arteries (the first
step of a peripartum hysterectomy) or
uterine compression (procedures that
are most often easy and fast) to avoid
the morbidity associated with peri-
partum hysterectomy and/or to reduce
the volume of blood loss.
It is appropriate to offer a patient who
is hemodynamically stable, young, pri-
miparous, and/or wants subsequent
pregnancies a first uterine-sparing sur-
gical procedure, and even a second and
possibly a third one before a peripartum
hysterectomy.
8 American Journal of Obstetrics & Gynecology MONTH 2022
The place of these different techniques
continues to depend on the culture of
each country and even each center.24
Accordingly, the choice of surgical
technique to control hemorrhage must
be guided firstly by the operator’s expe-
rience. Nonetheless, given that ligation
of the internal iliac arteries is probably
the technique most difficult to mas-
ter,3,25 especially for obstetrician-
gynecologists who do not practice sur-
gery regularly, and given that it is also
associated with rare but possibly severe
complications, we reserve this proced-
ure, if necessary, only for use after the
failure of a uterine ligation and/or uter-
ine compression (Figure 6).
The techniques for uterine artery
ligation and those for uterine compres-
sion have 3 important advantages: they
are easy to perform, easy to learn,3,25 and
associated with very low rates of imme-
diate morbidity.7e9,26,27,30,31,33,47 It has
been shown that as a first-line treatment,
obstetricians prefer vessel ligation
involving uterine arteries (51%) or
uterine compression sutures (36%) to
internal iliac artery ligation (12%).3 The
learning curves for the first 2 are signif-
icantly faster than that for the latter.3
Obstetricians considered that they had
mastered the techniques of uterine ar-
tery ligation or uterine compression after
4 or 5 procedures, whereas it took them 9
procedures to master internal iliac artery
ligation.3 Accordingly, uterine artery
ligation and/or uterine compression can
both be used as first- or second-line
treatments when bleeding persists,
depending on the procedure chosen
first.27 For example, uterine artery liga-
tion and then uterine compression su-
ture if the first fails, or uterine
compression suture and then uterine
artery ligation if the compression fails.
Nonetheless, between the techniques of
uterine artery ligation alone and those of
uterine compression, we (unlike some
other authors26,30,48) prefer uterine
ligation as a first-line treatment
(Figure 6). This choice is not based on a
belief that the effectiveness of vessel
ligation involving the uterine arteries
(approximately 90%) is significantly
greater than that of uterine compression
(approximately 75%) because the
ajog.org
possible biases mentioned above make
this a clearly invalid comparison.
Instead, the choice is essentially guided
by the existence, admittedly in the form
of case reports, of synechiae,27,42 pyo-
metra,49 and uterine necrosis,28,49 which
may impair fertility after uterine
compression, whereas these types of
complications have not been reported
after uterine artery ligation.
Conclusion
Postpartum hemorrhage remains one of
the principal causes of maternal mor-
tality in the United States and
throughout the world. Its management
must be multidisciplinary (anes-
thesiologists, obstetrician-gynecologists,
interventional radiologists, midwives,
and nurses). The keys to its manage-
ment lie in the speed of both diagnosis
and the implementation of medical and
surgical treatment for controlling the
hemorrhage, including uterine-sparing
surgical procedures when medical
treatment fails. The techniques of
uterine artery ligation and those of
uterine compression both present the
same advantages: they are easy to
perform, easy to learn, and associated
with very low rates of immediate
morbidity,3,25 whereas ligation of the
internal iliac arteries is harder to learn,
harder to perform, and associated with
a low rate of complications that can,
however, be severe.3,25 Vessel ligation
involving either or both of the uterine
and internal iliac arteries does not seem
to have any later effect on women’s
fertility or their obstetrical outcomes,
whereas complications impairing
fertility (such as uterine necrosis, pyo-
metra, and synechiae) have been
described after uterine compression.
The use of >1 uterine-sparing surgical
procedure is possible when the hemo-
dynamics remain stable. The choice
must be guided mainly by the opera-
tor’s experience, but the techniques
must all be regularly taught, given some
concerning surveys suggesting that up
to 18% of obstetricians have not
mastered any of the techniques.3
Moreover, 37% to 62% of attending
obstetricians do not feel that they have
mastered them sufficiently.
ajog.org
Nonetheless, it is important to recall
that the primary purpose of the treat-
ment of severe hemorrhage is to save the
patient’s life. If possible, this should be
done by the least invasive and least
morbid procedure, but this objective
must always remain in the foreground.
Accordingly, the performance of a
uterine-sparing surgical procedure must
in no case delay the performance of a
peripartum hysterectomy in women
with hemodynamic instability. -
ACKNOWLEDGMENTS
We thank Joann Cahn, for her help in editing this
manuscript. The authors thank the patients who
kindly gave written permission for their pictures
to be reported.
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ajog.org Expert Review

SUPPLEMENTAL FIGURE 1
Hayman’s uterine compression technique32

A, Two double independent mediolateral vertical braces on the right and left, which can be placed
after the hysterotomy incision has been closed.

- The needle (for example, a straight needle with No. 0 polyglactin 910 suture) crosses the anterior
and posterior walls of the uterus approximately 2 to 3 cm under the sutured hysterotomy incision,
at 3 to 4 cm from the left lateral edge.
- This first suture is “doubled,” that is, an adjacent second suture now also crosses the anterior and
posterior walls of the uterus, approximately 2 to 3 cm under the sutured hysterotomy incision, 3 to
4 cm from the left lateral edge.
- With a third suture, the needle crosses the anterior and posterior walls of the uterus approximately
2 to 3 cm under the sutured hysterotomy incision, at 3 to 4 cm from the right lateral edge.
- This third suture is also doubled; that is, an adjacent fourth suture now also crosses the anterior
and posterior walls of the uterus approximately 2 to 3 cm under the sutured hysterotomy incision,
3 to 4 cm from the right lateral edge.
- Both ends of the first suture are then pulled, aided by the assistant’s manual compression, so that
the anterior and posterior walls touch each other. Both sutures are then tied together at the level of
the uterine fundus.
- The same procedure is repeated for the 2 strands of the second, third, and fourth sutures.

B, Lateral view, visualization of 1 of the 4 sutures.

Bouchghoul. Uterine-sparing surgical procedures. Am J Obstet Gynecol 2022.

MONTH 2022 American Journal of Obstetrics & Gynecology 10.e1

Expert Review ajog.org

SUPPLEMENTAL FIGURE 2
Pereira’s uterine compression technique33

A, Anterior view. The superior transverse suture passes through the right and left broad ligaments of
the uterus high in the avascular area (just under the 2 uterine horns) and is tied at the anterior wall of
the uterus: (1) beginning of the superior transverse suture; (2) the superior transverse suture passes
through the left broad ligament of the uterus, high up in the avascular area; (3) end of the superior
transverse suture; and (4) the superior transverse suture is tied at the anterior wall of the uterus. B,
Posterior view. The 3 transverse sutures are in place and tied at the anterior wall of the uterus (1, 2,
3). On the posterior wall, a longitudinal suture (4) is tied to the transverse suture (5) situated at the
level of the lower segment. The suture is directed toward the uterine fundus; at the superior posterior
wall, it superficially transfixes the myometrium, with the aid of the needle, before reaching the uterine
fundus. Once at the fundus, the suture runs anteriorly along the anterior surface, which it also
transfixes superficially through the myometrium in its superior portion, then descends and is finally
tied on the anterior wall to the transverse suture located at the level of the lower uterine segment.
Bouchghoul. Uterine-sparing surgical procedures. Am J Obstet Gynecol 2022.

10.e2 American Journal of Obstetrics & Gynecology MONTH 2022

ajog.org Expert Review

SUPPLEMENTAL FIGURE 3 SUPPLEMENTAL FIGURE 4

Uterine compression by a Bhal’s uterine compression technique34
variation of the Hayman
technique

Two mediolateral independent vertical braces on

the right and left, not 2 on each side. They can
be placed after the hysterotomy incision has
been closed. There are then only 2 transfixing
sutures.
Bouchghoul. Uterine-sparing surgical procedures. Am J
Obstet Gynecol 2022.
A, This has the advantage of uterine compression based on B-Lynch’s principles (braces) and can be
performed with the incision closed. B, For each brace, the needle goes through only twice: the first
passage of the needle (1) goes through the anterior and posterior uterine walls, 3 cm beneath the
(closed) incision. The suture thus moves along the posterolateral wall of the uterus, toward the
uterine fundus, and then goes back down along the anterolateral wall of the uterus. The needle then
transfixes the anterior wall of the uterus, 3 cm above the (closed) incision to reemerge 2 cm below
the incision (exit point 3), or 1 cm above the first input point (A). The same procedure is performed for
the second, that is, left brace. C, The strands of the primary exit points (3 and 6) of the 2 braces are
then tied together (forming a first transverse suture at the lower segment, 3 cm under the incision);
the strands of the primary entrance points (1 and 4) of the 2 braces are then tied together (forming a
second transverse suture at the level of the lower segment, 4 cm under the incision).
Bouchghoul. Uterine-sparing surgical procedures. Am J Obstet Gynecol 2022.

MONTH 2022 American Journal of Obstetrics & Gynecology 10.e3

Expert Review ajog.org

SUPPLEMENTAL FIGURE 5
Ouahba’s uterine compression
sutures30

Technique based on 4 sutures: a suture in the

right uterine horn (1), mirrored by another suture
in the left uterine horn (2), a transverse suture in
the middle of the uterine body, and another
transverse suture at the level of the lower uterine
segment, below the sutured incision.
Bouchghoul. Uterine-sparing surgical procedures. Am J
Obstet Gynecol 2022.

10.e4 American Journal of Obstetrics & Gynecology MONTH 2022