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Christopher B-Lynch


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Description Of Technique

The following steps are involved in the competent application of the B-Lynch suturing technique:

 

Parts (a) and (b) demonstrate the anterior and posterior views of the uterus showing the application of the B-Lynch Brace suture, Part(c) shows the anatomical appearance after competent application. (Illustrations by Mr Philip Wilson FMAA, AIMI, Based on the authors’ video record of the operation).

Five Cases Reported

We report the results of five cases of massive life threatening postpartum haemorrhage managed by the first author whilst on emergency duty as Consultant on call or called to such emergencies. Conventional ecbolics had proved ineffective. A thrombogenic (thromboxin soaked) uterine pack was considered unsuitable 4. Surgical procedures to reduce pelvic vascular pulse pressure by uterine, ovarian or internal iliac ligature or hysterectomy were considered in the main as viable options only if the B-Lynch suturing technique failed to achieve adequate control of haemorrhage. The tests of potential success was if haemostasis was achieved by BI-manual compression in the first place (table 1).

Table 1: Audit summary of five case histories of patients with severe life threatening postpartum heamorrhage treated by ecbolics and the brace suture application.
Age (years) 28 22 23 35 30
Parity n PP PP PP Twin PP (IVF) PP
Gestation (weeks) 39/40 43/40 37/40 38/40 40/40
Presenting Diagnosis Placental abruption
PPH
DIC
Prolonged labour persistent occipito position?
Cephalopelvic disproportion
Eclampsia in labour
PPH
DIC
Major Placenta Praevia Uterine atony
Mode of delivery,
infant characteristics & Apgar score
Spontaneous vertex;
Male (2800 g);
Apgar 4 at 1, 7 at 10
Emergency CS;
Male (4190 g);
Apgar 7 at 1, 10 at 10
Emergency CS;
1 Female (2735 g);
Apgar 3 at 1, 8 at 5
2 Female (2430 g);
Apgar 5 at 1, 8 at 5
Elective CS;
Female (3370 g);
Apgar 9 at 1, 10 at 10
Spontaneous vertex;
Male (3890 g);
Apgar 9 at 1, 10 at 10
Type of PPH Primary PPH Primary PPH Primary PPH Secondary PPH 9th day readmission Primary PPH
Treatment and volume transfused Ecbolics
20 units of blood
8 units fresh frozen plasma
BSA
Ecbolics
13 units of blood
5 units packed cells
BSA
Ecbolics
19 units of blood
5 units fresh frozen plasma
BSA
Ecbolics
15 units of blood
5 units fresh frozen plasma
BSA
Ecbolics
15 units of blood
7 units fresh frozen plasma
BSA
Intensive care admission 48 h;
full antibiotic cover
48 h;
full antibiotic cover
72 h;
full antibiotic cover
72 h;
full antibiotic cover
48 h;
full antibiotic cover
Outcome Good,
3 years later spontaneous vertex delivery; Female (3890 g);
no problems
Good,
Normal CT pelvimetry 2 years later,
elective CS at 39 weeks;
Female (3820 g).
no problems
Good,
No complications
Good,
No complications
Good,
No complications

 

PP – primiparous;
PPH – postpartum haemorrhage;
CS – caesarean section;
CT – computerised tomography;
DIC – disseminated intravascular coagulation;
BSA – brace suture application;
IVF – in vitro fertilisation;

Anterior View – Immediate Observations (Invivo) After Application Of The B-Lynch Surgical Technique

Posterior View – Immediate Observations (Invivo) After Application Of The B-Lynch Surgical Technique

Discussion

Of the three great messengers of death in maternity, haemorrhage might play the most important and dramatic role. Massive postpartum haemorrhage is an important cause of maternal mortality1,2,9. The number of direct maternal deaths from haemorrhage from 1988 to 1990 has more than doubled, compared with the period 1985 to 1987. Of the 277 deaths occurring during the period 1988 to 1990, during pregnancy or before 42 days postpartum, 22 were due to postpartum haemorrhage (PPH) 2 ,10. In the 1991—1993 report 15 deaths were recorded 9. In most cases of massive PPH, after ecbolics have been used and correctable causes excluded, hysterectomy or ligature of the internal iliac vessel is recommend and usually carried out 3 7.

There are a number of arguments against uterine tamponade in the management of postpartum haemorrhage 6.Hypogastric artery ligation (internal iliac division) does have a specific role in the management of obstetric haemorrhage, but it is not without substantial risk of failure 7. It is obviously not a definitive procedure regardless of causative factors and in patients who are not haemodynamically stable hysterectomy may be the procedure of choice.The B-Lynch suturing technique has been successfully used in all the described cases from 1989 to 1995 by the first author.

This procedure has been successful so far in all patients managed by this novel technique. The ‘brace’ or compression suturing effect allows conservation of the uterus and fertility as evidenced by subsequent deliveries described in Cases 1 and 2. Both had normal pregnancies. One had spontaneous vertex delivery. The other elected for lower segment caesarean section without trial of labour and the examination of the uterus after caesarean section showed no abnormal features. This B-Lynch suturing technique is simple and easy to apply than other surgical procedures recommended to reduce pelvic arterial pulse pressure. Among those described in the literature are ligature of the ovarian, uterine and internal iliac artery 3. These techniques are not easy to accomplish where control of such bleeding needs expeditious management. It is important to note that such suturing techniques may not achieve adequate control of bleeding particularly when there is coagulopathy and diffuse bleeding from an atonic uterus and delay in effecting surgical technique may further compromise the patient’s critical condition 3.

The B-Lynch suturing technique as demonstrated in these described cases has been effective in the control of massive postpartum haemorrhage. The test of potential efficacy is a simple bi-manual compression after exteriorising the uterus. The application of the suture itself is far less complicated than either internal iliac artery ligature or hysterectomy. The operating time is probably shorter.The illustrations (a), (b) and (c) in Fig. 1 demonstrate that the sutures are placed away from the uterine cornua without any major vessel or organ compromise. Figure 1c demonstrates the resultant compression effect. The bladder, ureter, major vessels and intestines were examined on each occasion. The immediate haemostatic result of this technique can be seen before closure of the abdomen if the patient is in the Lloyd Davies position. If this fails one can still resort to more invasive procedures but this has not been necessary in our series. The operation therefore should be considered a procedure of choice if ecbolics do not control PPH and certainly before any radical surgery is considered. A more user friendly prototype suture and needle with blunted tip exerting a less constricting effect but with effective haemostatic potential is being developed.

Conclusion

The invention of the B-Lynch brace suturing technique has proved invaluable in the control of massive postpartum haemorrhage as an alternative to hysterectomy. The five patients reported in this series evidence the effectiveness of this technique in such life threatening situations. The case summaries describe the critical conditions that prevailed and the gratifying outcome. The cost effectiveness of this procedure may encourage developing countries to consider its application where necessary both for prophylactic and therapeutic purposes

References

  1. Report on Confidential Enquiry into Maternal Deaths in England and Wales 1982—1984. London: HMSO, 1989.
  2. Report on Confidential Enquiry into Maternal Deaths in the United Kingdom 1988—1990. London: HMSO, 1994.
  3. Varner M. Obstetrics emergencies (postpartum haemorrhage ). Crit Care Clin 1991; 7: 883—897.
  4. Bobrowski RA, Jones JB. A thrombogenic uterine pack for postapartum haemorrhage. Obstet Gynecol 1995; 85: 836-837.
  5. Waters EG. Surgical management of postpartum haemorrhage with particular reference to ligation of uterine arteries. Am J Obstet Gynecol 1952; 64:1143—1148.
  6. Day LA, Mussey RD, DeVoe RW. The interuterine pack in the management of postpartum hemorrhage. Am J Obstet Gynecol 1948; 55: 231—243.
  7. Evans S, McShane P. The efficacy of internal iliac artery ligation in obstetric hemorrhage. Surg Gynecol Obstet 1985; 160:250—253.
  8. Clarke SL, Koonings P, Phelan JP. Placenta accreta and prior cesarean section. Obstet Gynecol 1985; 66:89—92.
  9. Report on Confidential Enquiry into Maternal Deaths in the United Kingdom 1991-1993. London: HMSO, 1996.
  10. Report on Confidential Enquiry into Maternal Deaths in the United Kingdom 1985—1987. London: HMSO, 1991.

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The B-Lynch Suture Technique

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