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Christopher B-Lynch


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Hysterectomy Should Be A Last Resort

Too many wombs are removed needlessly, a leading obstetrician says
Anjana Ahuja
The Times

It was 2am, and Professor Christopher Balogun-Lynch had been called to Milton Keynes General Hospital to deal with a mother bleeding uncontrollably after childbirth. The patient was unconscious, and unable to sign a consent form for hysterectomy.
While getting prepared for theatre, Professor Lynch, as he prefers to be known, recalled a dream that he’d had two months earlier. “In it a patient had haemorrhaged, and I was able to help her by using the braces I wear. The thought came to me as if from divine inspiration; I had compressed the uterus, and it worked in my dreams.”

It worked in real life too. And so, in 1989, Deborah Langford became the first recipient of the B-Lynch suture. According to its characterful inventor, who, with his three-piece suit and silk tie, looks like a gentleman surgeon of a bygone era, the suture trusses the womb in much the same way that a chef would truss a Christmas turkey. The technique, also called the brace suture, squeezes the womb in a “belt and braces” fashion to stem bleeding; many of the estimated 2,000 women who have undergone it have borne further children.

Many surgeons would have opted instead for an emergency hysterectomy. Far too many, in Lynch’s opinion. He believes that hundreds of women are having their wombs removed unnecessarily because of a lack of guidelines or protocol about how to deal with post-partum haemorrhage (PPH, bleeding after childbirth).

About 4 per cent of vaginal deliveries and about 7 per cent of Caesarean sections are associated with PPH — defined as the loss of at least 500ml of blood — although only a minority will warrant an emergency hysterectomy. Professor Lynch regards blood loss of more than 1,500ml as threatening.

But this emergency situation is much more likely to arise, he says, when there are delays in diagnosing PPH and managing it, such as organising blood transfusion quickly. Doctors also fail to recognise that some women, such as older mothers and those expecting twins or triplets, are at greater risk of PPH (because the womb is atonic, or slack, and struggles to contract).

Social trends — women delaying childbirth and the rise of multiple pregnancy associated with delayed childbirth and assisted reproduction — suggest that emergency hysterectomies will become more common. Not only does the procedure deny women the chance of future children, but when performed on an unconscious patient it also carries risks including urinary failure, leg paralysis and, in extreme cases, leg amputation.

Professor Lynch, a consultant obstetrician and gynaecological surgeon in Milton Keynes and at the Portland Hospital, London, says: “To perform a hysterectomy on a 19-year-old who has just had a baby is unacceptable. There are so many methods you can use to control bleeding that hysterectomy should be a last resort. I believe that it is not used as a last resort at the moment.”

Twenty years’ service as an expert witness in cases of medical litigation, he says, has turned up many cases where “the hysterectomy has been rushed as opposed to being considered. When you are a person on the spot, you will say, ‘This patient has lost a lot of blood. I have to do a hysterectomy.’ But the question should be asked, ‘What have you done in the period before the hysterectomy?’ That’s where the weakness in management lies.”

Now Professor Lynch, 59, together with some of the world’s leading experts on PPH, has devised just such a management protocol. It is contained within the first textbook dedicated to PPH, which claims the lives of an estimated 250,000 women each year. Most deaths occur in the developing world, which is why the textbook, of which Professor Lynch is editor-in-chief, was rejected by two publishers (doctors in poor countries tend not to buy expensive textbooks).

Sapiens Publishing came to the rescue, the Portland Hospital put £2,500 into the project and internationally renowned specialists queued to offer their expertise, at short notice, for no reward (royalties have been waived). The Princess Royal launched the textbook at a glittering London reception earlier this year.

Professor Lynch’s attitude is informed by his childhood in Sierra Leone; he came to Britain as a young boy, and followed his doctor parents into medicine, training first at Oxford University and then at Bart’s in London. He is aware that a hysterectomy can be a source of shame and distress in cultures that revere fertility. “Even if the mother survives, she’s lost her fertility. In some countries, the husbands take on new wives and the psychological damage to the woman is enormous.”

Before having my daughter in 2002, I never imagined that British women could bleed to death in childbirth. It was something utterly remote from my experience, something that happened in African villages or Victorian slums. Then the unthinkable happened. I had a PPH after a lengthy forceps delivery, losing 2,750ml of blood, and was confronted with a consent form for an emergency hysterectomy.

Nothing in your antenatal classes prepares you for the prospect of gaining a child and losing a womb simultaneously. Not when you’re 32, with a decade of breeding potential still ahead of you.

Fortunately, my obstetrician managed to stop the bleeding without taking that last drastic step. I left hospital four days later, emptied of haemoglobin but filled with gratitude and four pints of other people’s blood.

Patient gratitude, it turns out, is a real obstacle in trying to work out how many women have hysterectomies after a PPH. “Nobody keeps the data unless it goes into litigation or an inquiry,” Lynch notes. “Once the patient has a hysterectomy, they say, ‘Thank you very much, you saved my life’ and walk away, instead of saying, ‘Come on, you could have done better than that’. “The figures get swept under the carpet.

Mostly, you get reports when the patient dies and the family are astute enough either to take legal action or get publicity.”

A ten-year survey of a major London hospital revealed that of 31,079 deliveries, 15 were associated with emergency hysterectomies. That is about one in 2,000 births. Almost half were performed because the patient haemorrhaged as a result of placenta praevia (when the placenta lies low in the womb and covers some or all of the cervix, making vaginal delivery difficult or impossible).

The survey, published last year in the Archives of Gynaecology and Obstetrics, also found that older mothers, those with multiple pregnancies, and those having Caesareans, were at greater risk of losing their womb. He points out that the morbidity or illness brought about by emergency hysterectomies is considerable, and this troubles him more than the tiny number of deaths of British mothers due to PPH. Between 2000 and 2002, there were 106 maternal deaths overall, of which ten were due specifically to PPH (two mothers had no contact with doctors; two refused blood transfusions).

Because blood vessels and nerves attached to other areas of the body lie near the uterus, complications can include urinary failure and paralysis: “Doing it [a hysterectomy] when the patient is moribund can be a disaster. Those patients put their lives in your hands. No patient wants to end up with morbidity when they set out to have a child. But my question is, do you need the hysterectomy in the first place, and my answer to that is: not usually.”

The trick, he says, is to plan ahead and, above all, to avoid delay. Professor Lynch cites the failings at Northwick Park Hospital, the northwest London hospital where ten mothers died in three years. A report by the Healthcare Commission pointed to “serious system failures”. He says: “About 30-40 per cent of those deaths were from haemorrhage. Clear problems arose from delaying diagnosis, delaying treatment and delaying transfer of these women to appropriate units. Delay is a major problem in this country.”

Disturbingly, Professor Lynch predicts that not one obstetrician or gynaecologist in the country would disagree with him. He wants to see weekly “fire drills” carried out in every labour ward in the country, with every obstetrician carrying the seven-point action plan in their pocket (the hefty textbook comes with just such a leaflet). And, Professor Lynch says, if women continue to lose their wombs, or their lives, doctors deserve to get sued: “This is the one situation [PPH] that every obstetrician is terrified of facing. It is a nightmare. But there will be a lot of litigation because experts can say, ‘Here is a textbook on PPH, why on earth did you have to take this patient’s womb out?’ “It’s almost indefensible not to be able to follow the protocols in here. There are at least 1,800 successful cases of brace suture worldwide. That could have been 1,800 hysterectomies. How many would have died from the complications of surgery? Even if you save one life or one uterus, the effort is worth it.”

THE B-LYNCH SUTURE TECHNIQUE

‘MY HUSBAND WAS TOLD THAT I MIGHT NOT SURVIVE THE SURGERY’

Deborah Langford, the first person to have the B-Lynch suture, suffered a PPH after giving birth to her first child, Tom, now 17, in 1989. Deborah, an administrator, and her husband Alistair, a management consultant, also have a daughter, Grace, now 13, who was delivered normally. They live in Milton Keynes.

“It was a straightforward pregnancy and birth, as far as I was aware. The first I knew that there was a problem was when there was lots of consternation, my baby was whipped away and we set off for the operating theatre. Tom had blood in his lungs, and needed special care.

The haemorrhaging I was experiencing was so intense that we had to leave for theatre immediately. I was given a general anaesthetic. There wasn’t time to think about consent forms. I understand that I had 20 units of blood [Professor Lynch confirms that Deborah received 20 units of fresh blood and eight units of fresh frozen plasma]. It was luck, on my part, to be under Professor Lynch’s care. I was in intensive care for three days before moving to the maternity unit and being reunited with Tom.

It was all so unexpected, an enormous shock that you’re not prepared for. It isn’t something you cover in antenatal classes. You tend to focus on the risks for the baby; I didn’t ever consider that there might be risks for me. I think it was worse for Alistair because I wasn’t really aware of what was going on. He’d been told that I might not survive and it might be just him and the baby going home. And he doesn’t like blood at the best of times.

It was a close call and I am extremely fortunate to be alive. I was also grateful that I didn’t opt for a home birth. Some people get very strident about home births and I appreciate that some people prefer it, but you don’t know the risks. If it can happen to me, it can happen to anyone.”

The PPH textbook is available free, at www.sapienspublishing.com

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