OT notes · Obstetrics

Uterine artery / internal iliac artery ligation

Usual anaesthesia
General anaesthesia; the existing spinal or epidural may be continued if the woman is stable and the procedure follows a caesarean
Position
Supine with left lateral tilt, or lithotomy (gives access to watch vaginal bleeding)
Setting
emergency

Operative note template for uterine artery and internal iliac artery ligation for postpartum haemorrhage, with a filled example for atonic PPH at emergency caesarean section.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

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 and need for hysterectomy
  • massive blood transfusion and ICU care
  • ureteric injury or kinking
  • injury to the internal or external iliac vein
  • accidental ligation of the external iliac artery
  • broad ligament or retroperitoneal haematoma
  • pelvic or buttock ischaemia (rare)
  • bladder injury

Pre-operative details for this operation

  1. Indication and cause of bleedingUterine atonyPlacenta praevia / accreta bedUterine ruptureExtension of uterine incision into broad ligamentBroad ligament / retroperitoneal haematomastate the cause as far as known
  2. SettingDuring caesarean sectionLaparotomy after vaginal deliveryRelaparotomy after caesarean
  3. Measures already tried, with timesuterine massage, uterotonics (drug, dose, route, time), tranexamic acid (dose, time), balloon tamponade, compression suture
  4. Blood loss so far and haemodynamic statusmeasured / estimated loss, pulse, BP, shock index
  5. Blood products and lab testsunits cross-matched and given, Hb, platelets, coagulation profile, fibrinogen if available
  6. Senior involvementname of consultant informed / present, time
  7. Consentinclude consent for hysterectomy if ligation fails; who signed if the patient could not

Anaesthesia and position

  1. AnaesthesiaGeneralSpinal continuedEpidural top-upConversion from spinal to generalif converted, time and reason
  2. PositionSupine with left lateral tiltLithotomy
  3. Access and monitoringtwo large-bore IV lines / central line, arterial line, Foley catheter

Operative findings

  1. Source of bleedingatonic uterus, placental bed, tear site and extent, haematoma site and size
  2. Uterine tone after uterotonics and massageContractedPartly contractedAtonic
  3. Haemoperitoneumvolume of blood and clots removed
  4. Uretersseen / palpated, peristalsing, intact
  5. Bladderintact / injured; urine colour
  6. Tubes and ovaries

Procedure (steps)

  1. IncisionExisting Pfannenstiel reopenedMidline verticalPfannenstielmidline if unstable or source unknown
  2. Temporary controlBimanual / manual uterine compressionAortic compressionTourniquet round the isthmusPelvic packingstart and release times for aortic compression or tourniquet
  3. Uterus exteriorised, bowel packed away, retractor placed
  4. Uterine artery ligation (O'Leary stitch)RightLeftBilaterallevel (just below the uterine incision / at the internal os), suture material and size, 2 to 3 cm of myometrium included, passed through avascular broad ligament lateral to the vessels, not dissected
  5. Second (lower) uterine artery ligatureDoneNot neededif placed, level below the first
  6. Ovarian / utero-ovarian anastomotic ligationRightLeftBilateralNot donesite (below the utero-ovarian ligament junction / cornual level), suture
  7. Compression suture addedB-LynchOtherNot donesuture used
  8. Retroperitoneum opened for internal iliac ligationside, peritoneum incised between round and infundibulopelvic ligaments / lateral to ovarian vessels
  9. Structures identified before tyingureter (retracted medially), common iliac bifurcation, external iliac artery, internal iliac artery, anterior and posterior divisions
  10. Internal iliac artery ligationRightLeftBilaterallevel (distal to the posterior division or near the origin), number of ties, suture, artery not divided
  11. Check after ligationexternal iliac pulsation present, no venous injury, ureter intact, bleeding status
  12. Uterus conserved or hysterectomyUterus conservedProceeded to hysterectomyif hysterectomy, time of decision and who decided
  13. Haemostasis and peritoneal toiletretroperitoneal spaces dry, any haemostatic agent or pack left (number)

Closure, drains and dressing

  1. RetroperitoneumLeft openClosed
  2. Uterine incision (if at caesarean)layers and suture
  3. Rectus sheathsuture material and technique
  4. SkinSubcuticularInterruptedStaples
  5. DrainNonePelvic drainSubrectustype and size
  6. Packs left in abdomenNoneYes: number, plan for removal
  7. Uterine tone, vaginal bleeding and urine at endurine colour, haematuria?

Specimens and implants

  1. SpecimenNoneUterus (if hysterectomy) sent for HPEPlacenta sent 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 toHDU / ICU / obstetric ward
  2. Vitals, uterine tone and vaginal bleedingevery 15 min for the first hour, then half-hourly till stable
  3. Urine outputhourly; watch for haematuria
  4. Uterotonic infusiondrug, dose, duration
  5. Blood productsunits still to be given, repeat Hb and coagulation profile timing
  6. Lower limb checkpulses, colour, warmth, power and sensation of both legs after internal iliac ligation
  7. Drain outputhourly for the first 6 h; inform if more than the set limit
  8. Thromboprophylaxisstart once bleeding and coagulation are controlled
  9. Debriefexplain events to the woman and family; plan for next pregnancy

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

Worked example

Fictional case: Mrs. S.M., 29 years, G2P1 at 38+4 weeks, emergency LSCS for non-progress of labour, with atonic PPH after delivery of the baby that did not respond to uterotonics and massage.

Case details

Date: 04/05/2026. Emergency LSCS followed by bilateral uterine artery ligation and bilateral internal iliac artery ligation. OT 1.

Baby delivered 22:14. PPH recognised 22:20. Uterine artery ligation 22:40. Internal iliac ligation completed 23:25. Closure completed 23:55.

Surgeon (LSCS and uterine artery ligation): Dr A. (3rd-year resident, OBGY). Internal iliac ligation: Dr C. (consultant), assisted by Dr A. Assistant: Dr B.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: atonic PPH at caesarean. Uterus remained flabby after delivery of placenta despite oxytocin 5 IU slow IV at 22:15, oxytocin infusion 20 IU in 1000 ml RL at 150 ml/h, uterine massage, and inj carboprost 0.25 mg IM at 22:22 and 22:37, and tranexamic acid 1 g IV over 10 min at 22:25.

Measured loss 1800 ml by 22:40. Pulse 124/min, BP 90/56 mmHg.

Blood group O positive. 4 units PRBC and 4 units FFP arranged. Massive transfusion protocol started 22:30. Consultant Dr C. informed at 22:21, in OT at 22:35.

Husband informed of PPH, possible ligation and possible hysterectomy. Consent signed by husband at 22:32 as patient under GA.

Anaesthesia and position

Spinal anaesthesia converted to GA at 22:28 for haemodynamic instability. Supine with left lateral tilt. Second 16G IV line and arterial line placed by anaesthetist. Foley catheter in situ.

Findings

Uterus atonic and boggy. No tear or extension of the uterine incision. Placental bed not bleeding more than the rest of the uterus.

About 300 ml blood and clots in the peritoneal cavity. Both tubes and ovaries normal. Bladder intact.

Procedure

Pfannenstiel incision extended laterally. Uterus exteriorised and bimanual compression given while resuscitation continued. Bowel packed away.

Bilateral uterine artery ligation (O'Leary): polyglactin 910 (Vicryl) No. 0 on a large round-body needle, passed through 2 to 3 cm of myometrium just below the uterine incision and back through an avascular area of the broad ligament lateral to the palpable uterine vessels, and tied. Vessels not dissected. Done on both sides.

Bleeding reduced but continued from the atonic uterus. Bilateral ligation of the utero-ovarian anastomosis at the cornual level with Vicryl No. 0.

Ongoing ooze. Decision for internal iliac artery ligation by Dr C. at 23:00.

Right side: peritoneum incised between the round ligament and the infundibulopelvic ligament. Ureter identified on the medial leaf and retracted medially. Common iliac bifurcation, external iliac artery and internal iliac artery identified. Anterior and posterior divisions seen.

Right internal iliac artery lifted with a Babcock clamp and a right-angle clamp passed beneath it with care to the vein. Two ties of Vicryl No. 0 placed on the anterior division, distal to the origin of the posterior division. Artery not divided.

Same steps on the left side, two ties of Vicryl No. 0.

After tying: external iliac pulsation felt on both sides. No venous injury. Both ureters seen peristalsing below the level of the ties.

Uterus firmer. Bleeding controlled at 23:25. Uterus conserved. Retroperitoneal spaces dry.

Closure

Retroperitoneum left open. Uterine incision already closed in two layers with continuous Vicryl No. 1. Rectus sheath closed with continuous Vicryl No. 1. Skin closed with staples. No drain. No packs left.

Uterus contracted at end. Minimal vaginal bleeding. Urine clear, 150 ml in bag.

End of procedure

Estimated blood loss 2600 ml (suction 1900 ml + weighed mops). Transfused 4 units PRBC and 4 units FFP in OT.

Mop, needle and instrument count correct, confirmed by scrub nurse.

Complication: atonic PPH as above. No ureteric, bladder or vessel injury.

Specimens: none.

Shifted to ICU on ventilator for elective extubation. Pulse 102/min, BP 108/68 mmHg at end.

Post-op orders

ICU care. Pulse, BP, SpO2, uterine tone and vaginal bleeding every 15 min for 2 hours, then every 30 min.

Hourly urine output. Inform if less than 30 ml/h or haematuria.

Oxytocin infusion to continue for 4 hours.

Hb, platelets, PT/INR and serum calcium 1 hour after arrival and at 6 hours.

Check both lower limb pulses, colour and movement every 2 hours for 24 hours.

Mechanical thromboprophylaxis now. Start LMWH only once bleeding has stopped and the clotting profile is normal.

Consultant to explain events to patient and husband after extubation.

Signature

Dr A., JR-3, OBGY. Reg. no. ________. 05/05/2026, 00:20. Countersigned Dr C.

Must document for this operation

  • Each step tried before surgery, with drug, dose and time. PPH audits and any later inquiry look at whether escalation was timely and in the right order.
  • Which vessels were tied, on which side, at what level and with which suture. The next surgeon and any interventional radiologist need to know which arteries are already occluded.
  • Level of the internal iliac tie relative to the posterior division. A tie above the posterior division explains buttock or limb ischaemic symptoms if they appear later.
  • That the ureter and external iliac artery were identified before and checked after the ligation. Ureteric and external iliac injury are the known complications and this is the evidence that they were looked for.
  • Start and stop times of aortic compression or an isthmic tourniquet. Prolonged occlusion can cause lower limb ischaemia and the ICU team must know the duration.
  • Blood loss, products given and the decision about hysterectomy with the name of the decision maker. Needed for maternal near-miss review and to explain why the uterus was or was not removed.
  • Any packs or haemostatic material left inside. They must be counted out at a planned relaparotomy.

Common mistakes in these notes

  • Writing 'B/L internal iliac ligated' without the level or the suture.
  • Not recording that the ureter was seen on each side.
  • Leaving out the uterotonic doses and times given before surgery.
  • Recording estimated blood loss as a single low guess when suction and mops were measured.
  • Not naming the senior who took the decision for ligation or hysterectomy.

Indian practice and paperwork

  • NQAS (National Quality Assurance Standards) OT checklist expects the operative note to show persons present, pre- and post-op diagnosis, procedure, duration, estimated blood loss, fluids given, specimens and complications. For PPH surgery the fluids and blood products given are part of this. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E8.4)

Sources

  • Apuzzio JJ, Vintzileos AM, Berghella V, Alvarez-Perez JR, eds. Operative Obstetrics. 4th ed. CRC Press; 2017, Ch 22, Postpartum hemorrhage (Brown HL, Edwards J, Small M): surgical treatment, uterine, hypogastric and ovarian artery ligation, pp. 280-288.
  • Handa VL, Van Le L, eds. Te Linde's Operative Gynecology. 13th ed. Wolters Kluwer; 2024, Ch 44, Surgery for obstetric hemorrhage (positioning, temporary measures, O'Leary stitch, hypogastric artery ligation); Ch 6 section on internal iliac and uterine artery ligation, e-book PDF pp. 377, 2304-2318.
  • Arulkumaran S, ed. Best Practice in Labour and Delivery. 3rd ed. Cambridge University Press, Ch 16, Postpartum haemorrhage: stepwise vessel ligation and internal iliac artery ligation, pp. 199-200.
  • Operative Obstetrics 4e, Ch 22, p. 280 (oxytocin 5-10 IU slow IV, infusion 10-40 IU in 1000 ml at 150 ml/h) and p. 282 (15-methyl PGF2 alpha 0.25 mg IM, repeat at 15-90 min, total not above 1-1.5 mg).
  • Operative Obstetrics 4e, Ch 30, Cesarean delivery, pp. 400-402 (uterine closure, fascial closure).
  • Arulkumaran, Best Practice in Labour and Delivery 3e, Ch 16, p. 198 (tranexamic acid 1 g IV over 10 minutes in PPH).

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

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