SURGICAL MANAGEMENT OF POSTPARTUM HEMORRHAGE WITH

PARTICULAR REFERENCE TO LIGATION OF UTERINE ARTERIES

EDWARD G. WATERS, M.D., F.A.C.S., JERSEY CITY, N. J.
(From the Margaret Hague Maternity Hospital)

A Nsubjects,
APOLOGETIC foreword should introduce common
but in this instance I feel that postpartum
and often time-worn
hemorrhage and its
management require no such prefatory excuse. For this complication of preg-
nancy is at once the most common, most menacing, and most deadly, albeit most
preventable, of all the hemorrhagic threats to the parturient. Our experience
differs little in this respect from that of the other clinics. It is almost as common
as placenta previa, placental abruption, and rupture of the uterus combined.
Our definition of postpartum hemorrhage is blood loss in excess of 500 C.C. for
the first day after birth, The initial blood loss serves as an avenue for the advent,
of shock and puerperal infection which so often accompany it. While the
incidence of postpartum hemorrhage in our clinic is good by comparison, it
is poor by possibility, for I am sure it can be reduced here as elsewhere.
A few words on the causes of postpartum hemorrhage are in order since
treatment to a certain extent is conditioned by the causative pathology. First,
we have systemic diseases of hemorrhagic nature in which bleeding from the
birth tract is merely a manifestation of a general tendency. In recent years
we have had two fatal cases of thromhorvtoperlic purpura. which would fit into
such a group. Obviously, the obstetric hemorrhages encountered are related
but totally subject t,o the systemic disease.
The second group comprises those which are totally dependent upon the
pregnancy. From the obstetrician’s standpoint these could be subdivided into
those which are nonpreventable, due to circumstances beyond control of the
operator, and those which are preventable, in which failure to assess properly
a given situation and app1.v a.dequate means of therapy permits them to get out
of hand. The physician cannot control the development of hydramnios, multiple
pregnancy, baby’s weight, or size, and moldability of the fetal head. Neither
can he alter the inherent capacity of t,he vaginal tract to dilate adequately f,:)r
the passage of t,he given fetus. Succenturiate plarental lobes may be present
and not detectable. Lacerat,ions of the cervix and vagina of serious extent may
accompany otherwise perfectly normal vaginal delivery. Last month one of my
own patients, without disrupting the perineal skin, produced a perfect Schucharllt
incision which hemorrhaged profusely while caput was in sight. But in spite
of what has been said thus far, the vast majority of the causes of postpart,um
hemorrhage are preventable and are the direct responsibility of the obstetrician.
These involve most lacerat,ions, retention of secnndines and placenta. and atony
1143
 WATERS Am. J. Obst. & Gym.
November. 195 2

of the uterus. So well known is the role played in the production of this
condition by deep general anesthesia, long labor, exhaustion, forceps and breech
delivery, version and the like, that it scarcely needs more than recollecting.
In reviewing our deaths and near deaths from postpartum hemorrhage, a
fact that stands out stark and clear is the role played by uterine atony, which
to me is synonymous with mismanagement of the third stage of labor. Unless
the physician is aware of the patient’s blood status during her pregnancy and
at the approach of labor, he is in no position to estimate her capacity to stand
blood loss. The onset of shock after a prolonged loss of blood from vaginal or
perineal lacerations is as ominous as a sudden gush from a relaxed uterus. A
seemingly good physical status in the face of considerable blood loss is of small
comfort to the well-advised doctor, since he is aware that he has no means at
hand of assessing the patient’s capacity to withstand further blood loss nor her
proximity to the edge of “compensation plateau” from which she may plunge
into a state of shock which might well be irreversible. Unless we remain keenly
aware of this possibility, I can see a sharp rise in loss of patients from postpartum
hemorrhage because of the progressive scarcity of nursing personnel upon whom
we rely for postpartum care.
Mismanagement of the third stage of labor submerges all other causes of
postpartum bleeding. While previously mentioned noncontrollable obstetric
causes frequently engender hemorrhage, sensible manipulation or, more properly,
nonmanipulation of the uterus in these patients will aid the physiologic processes
which terminate postpartum bleeding. These uteri bleed because they fail to
contract, or the blood fails to clot, or there is a failure in the usual shutdown
of the arcuate and spiral arteries, failure of the usual involutional regression of
blood flow immediately post partum or because of ill-advised uterine manipula-
tion subsequent to the delivery of the placenta. The oxytocics are generally
employed with sense, the patient’s blood type is known and suitable blood is
readily available, but little training is given the individual delegated to watch
the uterus and the still anesthetized patient. Most commonly one sees the uterus
massaged, mauled, squeezed, and pushed down into the pelvis and toward the
perineum from which it is now normally retracting. The enlarged and firm
corpus, containing physiologic clots which are blocking the sinuses, is now
squeezed with vim and vigor and all eyes pop as the clots drop from the in-
troitus. After all, what other should one expect? The proper procedure is to
draw the uterus out of the pelvis, compress the lower segment against the
promontory of the sacrum, gently stimulate the fundus, and encourage the
formation of the intrauterine sinus-sealing clot formation. In the meantime,
Ergotrate or preferably intravenous Pitocin by drip will tend to maintain the
contraction already effected and rarely will there be need for gymnastics such
as bimanual compression with one fist in the vagina or uterus. For all practical
purposes, we never pack the vagina or uterus in these patients. Almost all of
the few we did pack died or continued to hemorrhage. A plug of gauze in the
uterus makes an ostrich out of the doctor who does not wish to see what he knows
is there. Just as there is an immediate increase in the blood flow to the uterus
at the time of conception and even before nidation, so with the delivery of the
Vdum 64 UTERINE ARTERY LIGATION FOR POSTPARTUM HEMORRHAGE 11.&j
Number 5

fetus and placenta there is an immediate lessening of the blood flow through the
uterine artery. If the blood clots in the sinuses are undisturbed, if some con-
traction and retraction of the uterus can be induced, the lost blood replaced and
the patient well oxygenated, there is need for little else. The salutary effect of
proper management of the third stage of labor on postpartum hemorrhage
incidence has been well shown by Dieckmann, who reduced his incidence from
1.36 to 0.35 per cent through proper control of the third stage of labor.
In considering surgical m,anagement of postpartum hemorrhage one should
refer first, of course, to the most obvious causes, which are lacerations of the
birth tract. There is no justifiable excuse for any patient bleeding herself ir.to
shock from lacerations of the cervix, vagina, or perineal body. The only
requisites aside from ordinary capability are good light, good anesthesia, good
a&stance, and, most importantly, good exposure. Every patient who continues
to bleed after the delivery of the placenta should have the uterus explored
manually. There is no other way to be sure that a succenturiate lobe is n.ot
present and it is the only way one can be reasonably sure that there is no lacera-
t,ion of the lower segment or high extension of a cervical laceration. The
placenta should be removed manually if it fails to deliver within twenty minutes
to a half hour. The old concern regarding manual removal is no longer
warranted. Under reasonably good aseptic measures and with the antibiotic
drugs which we now possess and which are always given, there should be no
mortality attendant upon this procedure. Prompt information is obtained as to
whether or not the placenta is retained, adherent, or whether or not one is deal-
ing with placenta accreta. In the last instance an entirely different method of
m.anagement may be indicated. However, we are no longer in a hurry to remove
the uterus for placenta accreta if there is no bleeding. The threat in bygone
days was infection but in the absence of gross hemorrhage we now believe this
is controllable, and judicious temporizing may save the uterus.
In the overwhelming percentage of cases, the measures already referred to
are sufficient. More blood is always given than the estimated loss, since t.he
estimate is always deficient. Oxytocies and, most valuably, int,ravenous Pitocin
solution and adequate oxygenation reinforcecl by constant and intelligent
observation carry these patients safely through the ordeal. Some pos8tp,artum
hemorrhages of very great severity will respond to such nonoperative treatment.
We recent,ly had a. patient, bleedin p supposedly from recurrent uterine atonp,
but actually from a retained succenturiate lobe, come close to death before the
uterus was emptied of the placental remnant. Tt was then held in the manner
previously described and sufficient supportive treatment was given to bring her
through, including 7,500 cc. of blood. There are a number of cases, however.
in which in spite of all that has been done the patient still continues to bleetl in
volumes equal to or exceeding that which can be replaced. UThat now can be
clone for these patients ? The usual procedure is to get the patient in as good
condition as possible, certainly out, of shock and well oxygenated to compensate
for some of the blood loss, explore the uterus, and then do a rapid hystere(~t,omy.
This has been assumed the only means available to thwart disaster and it is the
only one mentioned in almost all standard texts and writings. I do wit lwlicl~e
1146 WATERS Am. J. Obst. & Gym.
November, 1952

it ia necessary, with rare exceptions. Furthermore, the surgeon in so doing is

seriously disregarding the rights of the patient and offering little protection for
her life when he has achieved his end, if there is a safe alternative.
Many years ago I advocated bilateral uterine artery ligation in these gravely
imperiled women. The basis for the suggestion lay in an experience where the
condition upon opening of the abdomen became so desperate that death seemed
at hand. The large boggy uterus was ballooned with blood and clots, the pa-
tient pulseless, and forced respiration maintained with the anesthetic machine.
A quick ligation of the uterine arteries was done in the hope that sudden
deprivation of blood supply would induce uterine contraction incident to myo-
metrial hypoxia, as well as shut off more than 90 per cent of the blood flow
to the uterus. Within a few minutes fibrillary contractions were noted as
the uterus responded to stimulation and soon it became blanched and firm.
There was no further surgical treatment, but we continued with blood replace-
ment, oxygenation, and oxytocics. Prompt and amazing improvement ensued
with ultimate recovery. This experience has been successfully repeated in seven
patients under comparable conditions.
Let us briefly consider the varied course and functions of the uterine artery.
We know that the uterine artery originates from the anterior hypogastric, that
its course is on the lateral wall of the pelvis running medially and forward on
the upper surface of the endopelvic fascia and that it is attached by means
of its adventitia to and thereby strengthens somewhat the cardinal ligament.
We also know it arches over the ureter about 2 cm. from the uterus as the ureter
ducks beneath the cardinal ligament in its own fascial tunnel. We know that it
gives off a branch to the cervix, the latter anastomosing with the vaginal branches
at the lateral fornix of the vagina. In pregnancy, as the progressively enlarging
uterus demands more blood, the uterine artery elongates, hypertrophies, and
there is a hyperplastic overgrowth of the elastic laminas. It has fibrillary and
tenuous connections with the connective tissue at the base of the broad ligament,
which make it flexible and vary it somewhat from its normal position in the
nonpregnant pelvis. It anastomoses with the ovarian vessels at the upper inner
angle of the broad ligament, although its size at this site remains comparable
to that in the nonpregnant uterus. This is a matter of some importance, since
only uterine artery ligation is projected and not concurrent ovarian artery
ligation. The ovarian arteries do not change appreciably in pregnancy. Indeed,
there is no reason why they shou!d enlarge. The ovaries do not enlarge nor do
they markedly alter in function. Such changes as occur depend upon the early
growth of the corpus luteum and this imposes no great demand upon the blood
supply. The only alteration of any note is the increase in the venous plexus.
Here the ovarian veins apparently assist in carrying away some of the blood
from the generally markedly dilated and numerically increased uterine veins.
Likewise, the cervical branch of the uterine artery does not share the same
degree of growth. If it did there would be many more fatal hemorrhages from
cervical lacerations, since many of the latter are never detected until long post
partum. There is no cervical growth comparable to the uterine and since blood
supplied to a structure or organ is dependent upon the ‘need or demands, one
;~;;,r;~;4 UTERINE ARTERY LIGATION FOR POSTPARTUM HEMORRHAGE 1147

logically would not expect an excessive growth of the cervical artery. Over 90
per cent of the blood supply to the myometrium, therefore, is from the uterine
artery proper with an inconsequential flow from the ovarian and none of great
significance from the cervical. It follows that control of the arterial supply
through the main uterine artery should be sufficient to control blood loss from
the uterus and with interruption of the well-oxygenated blood flowing to the
myometrium there should come a marked anoxic spasm and muscular contrac-
tion. This fact is knowingly or unwittingly applied in the medical control of
postpart.um hemorrhage when the uterus is drawn upward and the lower seg-
ment compressed against the promontory. At the same time, the manner in
which the uterine artery in pregnancy reaches the uterus makes such medical
stricture of its blood flow effective, with diminution of mgometrial flow. There
is another anatomic fact concerning the uterine artery of practical interest and
that is the effect of labor upon its position. In the second stage of labor the
cervix descends and immediately post partum it approximates in position a
second-degree prolapse. In many primiparas and almost all multiparas the
cervix can be prolapsed easily through the introitus wit,h moderate fundal pres-
sure and the artery, now too long for the need, inadequately follows the descen-
SW. The position of the uterine artery is altered somewhat with the descent of
the head and the thinning out and effacement of the cervix since it is rather
loosely attached to the inner end and upper surface of the Mackenrodt ligament.
This obliquity of the uterine artery is an adaptive one and comparable in some
respects to the alteration seen concurrent with the growth of lateral cervical
fibroids.
These considerations lead to the conclusion that, wit,h normal blood-clotting
mechanism, control of the arterial flow to the uterus is the one important ana-
tomic factor required to control bleeding from the st.ructure. Hysterectomy of
course does that since it removes the uterus itself. Dependent upon the pa-
thology for which the operation is done, it may be argumentative whether or not
the uterus is primarily at fault. ITterine artery ligation will effect the same
end as hyst,erect.omy, if the bleeding is from so-called atony.
Many attempts have been made and recommendations offered for vaginal
attempt at cont,rol of the uterine artery flow, These are generally useless, bloody,
time consuming, and needlessly traumatizing. From the anatomic considerations
given, especially regarding the altered position of the artery as well as its well-
recognized enlargement and increasrd venous drainage, the vaginal approach is
ineffective and is condemned. Based upon false reasoning or more probably none
at all, vagin.al ligation of the cervical branches has been attempted fruitlessly
in many cases in our own clinic for uterine bleeding. It cannot be of anp con-
ceivable use, even if successful.
Abdominal uterine ligation, on the other hand, distinctly a surgical proce-
dure, is anatomically sound, physiologically rational, and surgically possible.
Of further significance is the fact that it may be used as an initial step to
determine whether blood loss will stop and the uterus contract, without corn-
promising the possibility of more extensive surgery. It is a st.ep which must
precede all extirpative methods. The artery is lig,ated. it, is not divided. When
 1148 WATERS Am.J.Obst.& Gynec.
November. 1952

the need for ligation arises following cesarean section, the vesicouterine peri-
toneal plies has already been separated, and the artery is readily found. Ex-
posure in other cases is assisted by similar transverse incision of the vesico-
uterine peritoneal fold. With the broad ligament grasped so that the thumb is
anterior and the fingers lift the base as they slip upward over the uterosacrals,
the surgeon can promptly identify the large tough artery. There is no other
vessel there except the thin-walled larger veins. After identification, it is sur-
rounded by ligature carrier or. blunt needle and strongly tied with No. 2
chromic catgut. The artery is not divided, and later re-establishes its flow.
Within five minutes the effect is noted, and has not failed when properly done.
Ligating the veins by error of course tends to increase congestion and bleeding.
This occurred in two cases in our clinic, where attempted ligation failed and
hysterectomy followed. Evidently the veins and not the arteries were ligated,
since the uterus was reported to become more dusky and during the subse-
quent hysterectomy the arteries had to be clamped and ligated. A preliminary
successful ligation would have obviated this step.

Summary
In our hands, ligation has not failed when attempted, and we have lost no
patients by re jetting hysterectomy. It is distinctly advisable to retain the
uterus if it is capable of functioning normally. Where extensive pathology and
the patient’s age render it useless, it is removed.
There are certain limitations to the procedure of ligation, some obvious
and some already noted: (1) When myometrial pathology prevents or inhibits
the contractions which the local anoxia induces. This is noted with cervical tu-
mors, fibroids, and excessive myometrial fractionation seen on very rare occa-
sions with placental abruptions. (2) When the veins are mistakenly ligated
instead of the arteries. One properly placed ligature is needed on each side,
not several blindly placed. (3) Wh en there are intraluminal lacerations in-
volving the cervix. (4) Wh en the uterus still contains placental tissue and
membranes, such as were found in many of our hysterectomy specimens. In
short, the uterine artery ligation will not surmount basic ignorance and care-
lessness. It is not offered to eliminate hysterectomy for certain uterine rup-
tures, atony with huge fibroids, completely obstructive lower segment fibroids,
nor as a panacea for bad obstetrics. It will overcome obdurate uterine atony
without sacrificing the uterus.
39 CLIFFORD AVIXUE