B-Lynch uterine compression suture for PPH

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• failure to control bleeding
• need for further surgery: vessel ligation or hysterectomy
• blood transfusion
• uterine ischaemia or necrosis (rare)
• adhesions inside the uterus (synechiae) (rare)
• infection
• bladder injury

Pre-operative details for this operation

1. Cause of PPHAtonyAtony with focal thin non-contracting areaPlacental bed bleeding (praevia)trauma and retained tissue excluded
2. SettingAt caesareanLaparotomy after vaginal birth
3. Measures already trieduterotonics (drug, dose, route, time), massage, bimanual compression, tranexamic acid, balloon
4. Estimated blood loss at decisionand pulse, BP
5. Decision by and timesenior informed / present
6. Consentfor compression suture and for hysterectomy if it fails; who gave it
7. Blood and productscross-matched units, massive transfusion protocol activated or not

Anaesthesia and position

1. AnaesthesiaSpinal (continued)Converted to generalGeneraltime of conversion
2. PositionSupine with left lateral tiltLithotomy
3. IV accesstwo large-bore lines

Operative findings

1. Uterine toneGlobally atonicFocal atonic / thinned area (site)
2. Uterine incisionintact / extended (where)
3. Placenta and cavitycomplete, cavity empty
4. Broad ligaments and adnexaNo haematomaHaematoma: side
5. Response to compression by handbleeding reduced or not when assistant compresses the uterus

Procedure (steps)

1. Uterus exteriorisedYesNo, in situ
2. Access to lower segmentThrough the caesarean incision (still open / reopened)Lower segment opened (after vaginal birth)bladder peritoneum separated from lower segment
3. Suture and needlematerial, size (e.g. No. 2 chromic catgut or other absorbable), large round-bodied needle
4. First anterior biteabout 3 cm below one lateral end of the incision, out 3 cm above the upper margin
5. Over the fundus to the backabout 4 cm from the lateral border
6. Posterior horizontal bitethrough the posterior lower segment at the level of the incision
7. Back over the fundus, second anterior bite on the other sidemirror of the first bite
8. Tied under compressionassistant compresses the uterus while the ends are tied
9. Hysterotomy closedlayers and suture
10. Additional measuresNoneUterine artery ligation (O'Leary)Balloon tamponade (sandwich)Proceeded to hysterectomy
11. Resultuterus contracted, bleeding from above and below controlled; time

Closure, drains and dressing

1. Peritoneal toilet and check of bladder, broad ligaments
2. DrainNonePelvic drain
3. Rectus sheathsuture and technique
4. SkinSubcuticularInterruptedStaples
5. Vaginal bleeding at endchecked from below
6. Urine in cathetercolour, volume

Specimens and implants

1. SpecimensNonePlacenta for HPE

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Shift to HDU / ICUas per stability
2. Vitals, uterine tone and vaginal bleedingevery 15 min for the first 2 hours, then half-hourly; hourly urine output
3. Uterotonic infusiondrug, dose, duration
4. InvestigationsHb, platelets, coagulation profile, fibrinogen after surgery and repeated
5. Blood productsfurther units and targets
6. Catheterkeep for urine output monitoring; time of removal
7. Thromboprophylaxismechanical at once; LMWH once bleeding has stopped and clotting is normal
8. Inform the senior on call ifbleeding restarts, uterus relaxes, pulse rises or BP falls
9. Counsellingexplain what was done; later pregnancy is usually not affected

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery