Chez: Do you test for the potential efficacy of the B-Lynch suture before you perform the technique?
Lynch: Yes. First, I place the patient in the Lloyd Davies or lithotomy position. An assistant stands between the patient’s legs and intermittently swabs the vagina to determine the presence and extent of the bleeding. I then exteriorize the uterus and perform bimanual compression. To do this, the bladder peritoneum is reflected inferiorly to a level below the cervix. The whole uterus is compressed by placing one hand posteriorly with the ends of the fingers at the level of the cervix and the other hand anteriorly just below the bladder reflection. lf the bleeding stops on applying such compression, there is a good chance that application of the B-Lynch suture will be beneficial. It is not sufficient, however, to apply compression and assume that bleeding is controlled. There may be clots in the vagina impeding the escape of blood. That is why it is essential to use the Lloyd Davies position. With direct swabbing or visualization of the vagina, it is possible to assess objectively control of bleeding after compression has been performed.
Chez: Is the compression effective in the presence of a coagulopathy?
Lynch: Compression will control diffuse bleeding points when there is a coagulopathy If this is successful, then the application of the suture will be, as well. Obviously, however, application of the B-Lynch suture is not a substitute for treatment of the coagulopathy per se.
Chez: Given that the criteria for the B-Lynch suture are met, what are the next steps?
Lynch: The uterus remains exteriorized until application of the suture is complete The senior assistant takes over in performing compression and maintains it with two hands during the placement of the suture.
Chez:What type of needle and suture material do you use?
Lynch: I use a 70- to 80-mm round-bodied hand needle, with mounted number 2 plain or chromic catgut. I prefer a blunt needle so as to minimize needle-prick incidents.
Chez: Where do you place the first stitch relative to the low transverse cesarean section wound?
Lynch: With the bladder displaced inferiorly, the first stitch is placed 3 cm below the lower cesarean incision on the patient’s left side and threaded through the uterine cavity to emerge 3 cm above the upper incision margins, approximately 4 cm from the lateral border of the uterus (Figure 1).
Chez: What do you do next?
Lynch: I now carry the suture on the outside of the uterus over the top and to the posterior side.
Chez: Where is it located on the fundus?
Lynch: The suture should be more or less vertical and lying about 4 cm from the cornua (Figure 2). It does not tend to slip laterally toward the broad ligament because the uterus has been compressed and the suture milked through, ensuring that proper placement is achieved and maintained.
Chez: Is it difficult to identify the spot on the posterior uterus where the suture is going to be placed through the uterine wall, back to front?
Lynch: It actually is easy to locate the spot posteriorly because it is on the horizontal plane at the level of the uterine incision.
Chez: Do you attempt further compression at this point before passing the suture front to back through the posterior wall on the right side?
Lynch: The senior assistant compressing the uterus intermittently compresses the uterus as the suture is fed through to enable progressive, successive tension to be maintained as the suture compresses the uterus. It is essential that this be done because otherwise it would be difficult to pull the catgut through at the end to achieve maximum compression without breaking the catgut or traumatizing the uterus. The suture now lies horizontally on the inner aspect of the posterior uterine wall.
Chez: Again, bringing the suture over the top of the fundus, where do you place the suture on the anterior right side of the uterus?
Lynch: The suture is placed exactly the same way as it was on the left side. That is, 3 cm above the incision, 4 cm from the lateral side of the uterus through the top of the incision, into the uterine cavity, and then again back through 3 cm below the incision.
Chez: Now that you are ready to tie the two ends of the suture, what does the assistant do?
Lynch: The assistant maintains the compression as the catgut suture is milked through from its different portals to ensure uniform tension. The two ends of the suture are put under tension, and I place a double throw knot for security to prevent slipping.
Chez: Do you do this before or after closing the uterine incision?
Lynch: The tension on the two ends can be maintained while the lower segment incision is closed or the knot can be tied first, followed by closure of the lower segment If the latter option is chosen, it is essential that the corners of the C/S incision be identified and stay sutures placed before the knot is tied. This ensures that when the lower segment is closed, there is no escape of the angles of the incision. I have used both procedures and they work equally well.
Chez: In the latter instance, I assume the knot is low enough on the lower segment that there is room for closure of the C/S wound.
Lynch: That is correct. I must reemphasize the importance of identifying the corners of the uterine incision to make sure there are no bleeding points left unsecured.
Chez:When the uterus starts to respond and contract, does the suture become loose?
Lynch: We have not observed any slackening of the suture as the uterus starts to respond and contract. The atonic uterus will definitely take time to show this response. We have documented this observation in the series we reported and it has been our observation in the operating room as well1. The number 2 catgut is quite strong and it would be very difficult to slacken if placed properly. It is probable that the maximum effect is only about 24 to 48 hours. Considering that the uterus undergoes its maximum involuntary process in the first week after vaginal or C/S delivery, the suture probably will not have lost its tension but hemostatis will have been achieved. Because the suture is catgut, it will eventually weaken over time.
Chez: Do you now close the abdomen or do you delay doing so?
Lynch: There is no need for delay in closing the abdomen after the application of the suture, because the assistant standing between the patient’s legs has reswabbed the vagina and can confirm that the bleeding has been controlled.
Chez: How do you proceed in the patient who hemorrhages after a normal vaginal delivery and exploration of the vagina and cervix is negative for the source of the bleeding?
Lynch: If laparotomy is required for bleeding from the uterine cavity and there is no uterine incision, an incision must be made in order to explore the cavity to ascertain that the internal os can be dilated with a finger, and to ensure that correct application of the suture will give maximum compression effect.
I have also found that the B-Lynch suture is beneficial in cases of placenta accreta, percreta, and increta. In a patient with placenta previa, I first try a figure-of-eight or compression suture of the lower anterior or posterior segment, or both, to see if that will control bleeding. If it does not, I then place the B-Lynch suture for hemostasis. In both these instances, an incision in the uterus is required to place the B-Lynch suture.
Chez: Thank you.
Ronald A. Chez, MD, is professor of ob-gyn and professor of community and family health, University of South Florida, Tampa, FL.
Mr. Christopher B-Lynch is a consultant in obstetrics and gynaecological surgery, Milton Keynes General Hospital, Milton Keynes, U.K.
1. B-Lynch C, Coker A, Lawal All, et al. The B-Lynch surgical technique for the control of massive postpartum hemorrhage: An alternative to hysterectomy? Five cases reported. Br/U Obstet Gynaecol. 1997;104: 372-375.
Topics: The B-Lynch Suture Technique |
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