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Reconsideration of the uterine pack in postpartum hemorrhage
Reconsideration of the uterine pack in postpartum hemorrhage W.
M.
LESTER,
M.D.
R.
.4.
BARTHOLOMEW,
E.
D.
COLVIN,
W. J.
H. S.
W.
H.
Atlanta,
M.D.
GRIMES, FISH,
M.D
JR.,
M.D.
M.D.
GALLOWAY,
M.D.
Georgia
R E v I E w o F recent literature on postpartum hemorrhage reveals only occasional reference to uterine tamponade. Several authors have indicated belief that it is useless, archaic, or actually dangerous.G’ 7l lo Others however have strongly argued its va1ue.l”’ I61 ‘?I 2o That it is still employed in a large number of maternity centers was shown by Fisher.” In a group practice where uterine pack is employed rather often with seemingly
and
attributed to atony but a clotting defect was later diagnosed. The method of delivery is correlated with the indication for packing in Table II. The 2 cesarean sections listed under “atony” were done because of primary inertia. Possible etiologic factors occurring in the 113 cases of atony are outlined in Table III. There is much overlapping and some clinical guesswork in this listing. Particular attention is directed to the clinical impression that bleeding was originating principally from the flaccid lower segment in 41 cases. This was based on demonstration that the membranes had ruptured marginally, or that bleeding was coming from the lower segment in the presence of a firmly contracted uterIis or after the fundus had been packed. The results in these 163 cases have been analyzed in an effort to show whether suh-
methods
In a 10 year period, 1954 through 1963, uterine tamponade was employed 163 times in the immediate puerperium among 10,833 consecutive private patients delivered in the third trimester, an incidence of once in 66 deliveries. The indications for packing are shown in Table I. In 2 cases, hemorrhage was first From the Department Georgia Baptist Hospital.
Table
I. Indications
for pack
Uterine atony Placenta previa Hematoma (counter-pressure) Miscellaneous Adherent placental fragments Retained chorion ( 1) Partial laceration of lower Submucous fibroid (2)
of Obstetrics,
Presented at the Twenty-seventh Annual Meeting. of the South Atlantic A~ociatzon of Obstetricians and Gynecologists, Hot Springs, Virginia, Feb. 7-10, 1965.
Total
321
115 20 13 15 (9) segment
(3
j
__-.---
163
322
Lester
et al.
Table II. Type indication Type
delivery for pack
correlated
with
of delivery
Spontaneous
71 21 4 11 3 3 2
Low forceps Midforceps Forceps rotation Breech Version-extraction Cesarean section
Table III.
Possible cases of atony
3
6 3
12 1
4
1 1
1 16
etiologic
factors
Overdistention of uterus Large baby (31) Twins (9) Hydramnios (2) Manual removal of placenta Major operative delivery Primary uterine inertia Probable lower segment origin Ether anesthesia
in
42
14 6 3 41 95
sequent hemorrhage, shock, morbidity, or mortality indicated failure or danger of the pack. Eighty-two subsequent pregnancies occurring in 61 of these patients have been recorded. The outcome of these pregnancies has been reviewed to determine whether uterine tamponade had ill effect on future childbearing. Management
of the third
stage
Since the third stage of labor and the following hour include the crucial moments when hemorrhage is likely, it is well to recount our management of this period. Virtually all patients are under light general anesthesia (ether or cyclopropane), for delivery. Pitocin is given subcutaneously after the anterior shoulder comes beneath the symphysis and the delivery is conducted slowly. Unless abnormal bleeding occurs, the first few minutes are used caring for and examining the infant. By this time the placenta has usually separated. It is brought into the vagina by fundal pressure and the uterus is then elevated by suprapubic pressure as the placenta is lifted from the vagina. Intravenous Pitocin is given as the
placenta is delivered. Failure of separation within 15 minutes or significant bleedinK earlier than this is considered indication fol manual separation and removal of the placenta. In the last 5 years, the uterus has been explored manually after the third stage in nearly all cases. Careful examination of the placenta and membranes is an integral part of the properly managed third stage. Abnormal bleeding after the third stage is usually managed by fundal or bimanual massage and oxytocic drugs, and by intravenous infusion of a dilute Pitocin solution if bleeding is not quickly controlled. If atony is considered likely (as with prolonged labor or an overdistended uterus), the infusion is begun prior to delivery and Pitocin added to it during the third stage. If bleeding persists despite these measures, a uterovaginal pack is employed without hesitation; it is not withheld as a last resort. In cases of placenta previa, the uterus has been packed frequently as a prophylactic measure. Technique
of uterine
packing
Autoclaved units of gauze for packing are kept in glass jars in the delivery room, ready for use. The gauze is prepared by taking a 36 inch width of gauze? 20 feet long, folding it lengthwise four times, giving a 16 ply pack about 2 inches in width.* One unit is usually enough for a uterovaginal pack, though a second length can be tied to the first. We have found a dry gauze pack adequate and safe. Iodoform gauze has been recommended by some,“* Ic and Benaron and associates’ have found an oxidized cellulose gauze pack of value, with the added convenience that it does not have to be removed. Though manual packing has been recommended by Day, Mussey, and Devoe” and Reid,13 we agree with PosnerXF that instrumental packing is more efficient in placing the pack quickly and tightly, and have found the Holmes packer quite suitable (Fig. 1). After the entire birth canal is explored *Brunswick 8 inch width, pack.
Gauze. 4 ply,
available is well
from suited
Johnson and to preparation
Johnson. of
thr
Uterine
pack
in
postpartum
hemorrhage
323
packing is continued in a similar mannet to fill the vagina, and the lower end is lefr at the introitus for easy removal. In this manner adequate tamponade can be ~CCOIIIplished in three to four minutes. A retention catheter is left in the bladder. The patient is kept in bed until the pack is removed. Though the pack may develop a sour odor, antibiotics are not given urtless other factors indicate their use. The pack is removed, in bed, after 21 to 36 hours, An injection of meperidinc OI inhalation of trichloroethylene is sufficient to relieve the discomfort of removal. PitocTn is given as the pack is removed and the patient is watched for bleeding.
Fin. 1. Equipment
required
for packing
uterus.
and trauma ruled out, and with the uterus contracted as much as possible with intravenous Pitocin, the tube of the packer is guided with one hand to the upper extent of the uterine cavity and the end of the pack is introduced to the fundus with the spear. The rings at thr proximal end of the tubular casing are then held with the first and second fingers of one hand and the ring of the spear controlled with the thumb of the same hand, while the fundus is steadied with the other hand or by an assistant. Short quick strokcxs with the thumb are employed to apply the pack, while the end of the packer is gradually turned from side to side in order to fill the cavity evenly. Slight upward pressure is kept on the tube so that the placed pack slowly forces it downward. The force exerted is kept sufficient to place the pack tightly without distending the cavity to a size. ,greater than the contractility of the uterus is obtaining. When the muscular portion of the uterIIs is filled, particular attention is paid to the uncontracted lower segnltant. This requires wider circular motions of the tube and usually a greater amount of gauze than does the uterine cavity. The
Results Clomplete and immediate control of biccding was obtained by uterine tampona&: in all but 5 cases. Unfavorable results and (‘omplications are summarized in Table IV. Atony was thr causative factor in three of the casts in which the pack failed to cmtrol bleeding. In one, the pack \vas rrrnovcd and oxytocic drugs controlled the aiony. In another the pack was removed anti the uterus packed again with good results. In a third case, blood and Pitocin infusion vwrta given and the patient was taken to the* operatirl% table. Preparation was tnatl~. for hysterectomy but the hemorrhage gradually came under control with the pack still in place. Two patients bled through thrt pack protnptly; a clotting defect was diagnosed and fibrinogen stopped the excessive kolerding. One of these was associated with a stillborn erythroblastotic infant. The othc: \vas a result of amniotic fluid embolism which caused death in 5 hours. but not Iron: Iltr:rinc blood loss. Three patients had significant dt+iaycd blet>diny thrn~r~h the Ijack but thcw WYX
Table I\‘.
(:omplications
of packiny
Failure to control bleedinp Delayed hemorrhage Shock Pack caught 1,~ srrture icesarean) Morbidity
i 3 , 7 16
324
Lester
et al.
controlled with Pitocin infusion. Two other patients bled heavily at the time the pack was removed. Bleeding was controlled with oxytocic drugs in one case in which atony had been the reason for packing. In the other there had been extensive vaginal lacerations; on removal of the pack, brisk bleeding occurred from the repaired lacerations. Blood was given and another pack was employed. This controlled the bleeding and it did not recur when the second pack was removed 24 hours later. Shock was recorded in 34 cases. However, in only two did it recur or begin after packing and adequate blood replacement. In one patient it was possible to remove the portion of pack caught by cesarean repair suture after 4 days. This patient’s course was afebrile, but she had been protected with antibiotics. Of the patients exhibiting morbidity there was only one case of frank endometritis and there was no instance of thrombophlebitis or thromboembolism. Eleven of these 16 patients were given antibiotics. Another 11 patients were given antibiotics prophylactically. There were 2 deaths among the patients who were packed. One was the result of cerebral hemorrhage in a patient with hypertension 5 days after delivery. The other was a case of massive amniotic fluid embolism, with death resulting from respiratory faiIure and cerebeIlar hemorrhage. Blood loss had been adequately replaced and did not seem a major factor in her death. During this 10 year period there was one death due to ruptured uterus. This was the only case in which puerperal hysterectomy was required among these 10,833 patients. A pack had not been employed in this case. Whether there are any late sequelae to uterine packing should best be measured by the subsequent reproductive performance of women who have had a uterine pack. Of 150 women who might have become pregnant again, 61 were seen in 82 subsequent pregnancies. The results of these pregnancies are seen in Table V. Of 63 cases subsequently managed the
Table V. Subsequent
pregnancies
Term, healthy infant Premature, healthy infant Abortion Stillbirth Moved away Now pregnant
62 2 11 2 3 3
Total
82
third stage was uncomplicated in 51. There were 2 in which manual removal of the placenta was required and 10 in which postpartum hemorrhage occurred; in 5 of these the uterus was packed. Recurring abnormalities of the third stage have been noted previously by Dewhurst and Dutton4 and by Doran, O’Brien, and RandalL Comment The frequency with which uterine packing has been used in this series is due in part to its employment as a preventive measure or as early definitive treatment, and not as a desperate last resort. Though a number of uteri doubtless would have stopped bleeding without a pack, we believe there are others that would have continued to bleed to a life-threatening degree. Disrepute of tamponade has been based at times on review of cases of mortality from postpartum hemorrhage in which packing had been used. Such retrospective criticism could as well be applied to blood transfusion or any other measure used in fatal cases and is not justified. Uterine packing in unpracticed hands, with inadequate pack material and improper technique, without careful prior exploration, or done with the patient already in shock, may be worse than useless. In hospitals where packing is considered a definitive form of treatment in postpartum hemorrhage a very different evaluation is obtained. In 2 such instances, TayIor?O reports 65,000 deliveries and Pierce and Winkler15 report 38,000 deliveries with no hysterectomy for atony and no death due to hemorrhage from atony. The results in the present study along with such reports as these indicate that a judiciously employed and properly timed uterine pack is not
Uterine
dangerous or useless, but is an effective and valuable procedure in the management of postpartum hemorrhage. In centers where tamponade is not used, occasionally a young woman has her childbearing terminated by hysterectomy when other measures fail to check hemorrhage from atony.“, lg It is believed that such hysterectomies can usually he avoided, that blood loss can be appreciably reduced, and that the critical hours of the early puerperium can be faced with much more security when early uterine tamponade is employed for the atonic uterus. The use of general anesthesia for delivery, especially ether with its known propensity for relaxing the myometrium, has surely produced or aggravated atony in some cases, and thus is another factor in the high incidence of packing reported here. There was a reduction in our use of tamponade from one in 57 deliveries in the first 5 years of this study to 1332 in the second 5 years. This is attributed partly to a shift to cyclopropane instead of ether anesthesia in about half the cases in more recent years. Among objections to uterine packing have been that it distends the uterus preventing normal myometrial retraction and that it holds bleeding sinuses open. A properly applied pack should not distend the uterus to a size greater than its contractility at the time can obtain. Uterine atony is nearly always an intermittent condition; the uterus can be made to contract with oxytocic drugs and massage for brief intervals, but it cannot nkaintain the tone necessary to prevent bteeding. It should be packed while it is contracting, and oxytocic stimulation should be continued for at least one hour afterward. It ha.s been previously stressed by one of us (J. S. F.S j, that any open sinuses of the interior uterine wall are subjected to direct pressure by the pack, and this pressure is magnified by any contractile tendency of the myometrium. The response of the atonic uterus, as felt through the abdominal wall, pives the impression that it contracts much more adequately after packing. The ready control of brisk bleeding by the pack seems to confirm this impression.
pack
in postpartum
hemorrhage
325
The number of cases in which the lower uterine segment was thought, clinically, to be the source of bleeding amounted to 36 per cent of the cases of atony. The naturally atonic cuff of lower segment is certainly more likely to bleed should placental attachment, shallow lacerations or abrasions involve its surface. It is perhaps the source‘ of postpartum hemorrhage much more often than is usually recognized. The significance of lower segment bleeding has been discussed by Leff,‘? who has clearly described the rapid involution of the lower segment and its augmentation by the intermittent contractions produced by pituitary extract. The time involved in this retraction corrcsponds closely to the period of greatest clanger of postpartum hemorrhage. It is in thrse cases of lower segment bleeding, where oxytocic drugs can have no immediate c8ec.t in shutting off open sinuses, that a tight uterovaginal pack has its greatest potential v&c. For this reason we agree with Kimbrough and Jones’l that prophylactic packing is useful in placenta previa. Packing at the time of cesarean section is less satisfactory than packing per vaginam because counterpressure by the vaginal portion of the pack against the lower segment cannot be obtained, but we believe it is warranted svh~n the placental site is bleeding. The use of tamponade after removal CJf adherent placental fragments has been stressed in a previous study.‘” When focal areas of placenta accreta involve thr lower segment, as they did in three cases irf this series, packing is clearly indicated. A vaginal pack has often been s~ommended for counter-pressure after opening and packing a vaginal hematoma. It :s our belief that a uterovaginal pack is better in these cases than a vaginal pack alone since it exerts more pressure against the upper pelvic wall and averts the danper of concealed uterine bleeding. Summary One hundred and sixty-three cases are reviewed in which uterine tamponade was employed for postpartum bleedina; the inci-
dence of its use was once in 66 deliveries. The efficacy of uterine packing for atony depends upon its proper application and its employment early in the course of postpartum hemorrhage. Dry gauze packing placed with a mechanical packer from the uterine fundus to the introitus is recommended. No death from hemorrhage due to atony oc-
REFERENCES
12.
1. Benaron, H. B. W., Bradburn, G. B., Gossack, L., Tucker, B. E., and Roddick, J. W.: AM. J. OBST. & GYNEC. 71: 1220, 1956. 2. Cosgrove, R. A.: AM. J. OBST. & GYNEC. 62: 584, 1951. 3. Day, L. A., Mussey, R. D., and Devoe, R. W.: AM. J. OBST. & GYNEC. 55: 241, 1948. 4. Dewhurst, C. J,, and Dutton, W. A. W.: Lancet 2: 764, 1957. 5. Doran, J. R., O’Brien, S. A., Jr., and Randall, 1. H.: Obst. & Gvnec. 5: 186. 1955. 6. bouglass, L. H.:’ Bull. School Med. Univ. Maryland 40: 38, 1955. 7. Eastman, N. J., and Hellman, L.: Williams obstetrics. ed. 12, New York, 1961, AppletonCentury-Crofts, Inc., p. 1000. a. Fish, J. S.: Hemorrhage of late pregnancy, Sorinafield. Illinois. 1955. Charles C Thomas. Publiiher, ‘pp. 139:140. ’ 9. Fisher, J. J.: J. Florida M. A. 41: 634, 1955. 10. Hellman, L.: AM. .J. OBST. & GYNEC. 70: 215, 1955. 11. Kimbrough, R. A., and Jones, B. D.: AM. J. OBST. & GYNEC. 55: 496, 1948.
Discussion DR.
JOHN
D.
BUNCH,
JR.,*
Columbia,
South
Carolina. There are a number of arguments against uterine packing in the management of postpartum hemorrhage, some of which are as follows: ( 1) it is an unphysiologic process, as the procedure of choice is to empty the uterus to obtain maximum contractility; (2) there is too much danger of infection; (3) it will not always stop the bleeding; (4) you may pack a uterus that has been ruptured or the packing may actually produce a rupture; and (5) most important of all, the pack will very often mask the amount of continued bleeding, which can be massive in and around the pack, but largely concealed by the packing. If at the onset of excessive bleeding, not visible in origin, the vagina *By
invitation.
curred and hysterectomy was not required for atony in 10,833 consecutive cases. Ko serious complications followed packing and future childbearing did not seem to be affected. It is concluded that judicious use of the uterine pack is of continuing value in modern obstetrics.
13.
14. 15. 16. 17. 18.
19.
20.
Leff, M.: Ara. J. OBST. & GYNEC. 49: 734, 1945. Lester, W. M., Bartholomew, R. A., Colvin. E. D., Grimes, W. H., Jr., Fish, J. S., and Galloway, W. H.: AM. J. OBST. & GYNEC. 72: 1214, 1956. McCartney, C. P.: M. Clin. North America 38: 265, 1954. Pierce, J. R., and Winkler, E. G.: Minnesota Med. 39: 89, 1956. Posner, A. C.: Clin. Obst. & Gynec. 3: 76, 1960. Reid, D. E.: AM. J. OBST. & GYNEC. 73: 697, 1957. Reid, D. E.: Textbook of obstetrics, Philadelphia, 1962, W. B. Saunders Company, p. 589. Shulman, A., Ratzan, W. J., Grossbard, P., and Lawrence. A. C.: AM. J. OBST. & GYNEC. 71: 37, 1956.’ Taylor, E. S.: Clin. Obst. & Gynec. 3: 646, 1960. 272 Boulevard, N.E. Atlanta, Georgia 30312
are inspected and the uterus explored, and cervix the more common causes of bleeding will be eliminated. The elimination of deep anesthesia and narcosis and the use of oxytocics either intramuscular or intravenous together with bimanual stimulation of the uterus, will overcome most instances of bleeding due to uterine atony. Whole blood, if needed, should be used in sufficient quantity to replace the amount lost. If these measures fail, there should be no hesitation in ligating the hypogastric arteries or even doing a hysterectomy as a lifesaving procedure. Some authorities state that an atonic uterus cannot be packed effectively, and with this I agree. How you can determine whether an atonic uterus is underpacked or overpacked is beyond my comprehension. If a 4 x 4 sponge can hold 10 C.C. of blood and, if my mathematics
Uterine
is correct, the size pack used by Dr. Lester and associates which is 20 feet long, 2 inches in width, and 16 ply could absorb approximately 1,200 C.C. of blood before it would begin to be visil)le externally. It is interesting to me that in 5 patients in whom the pack failed to control the bleeding, the hleedinp was controlled in one after the pack was removed and oxytocic drugs used. In another, the pack was left in but blood and Pitocin infusion were given which apparently stopped the bleeding. In 2 of these patients a blood clotting defect was the cause of bleeding. In 5 patients with delayed bleeding, it is also of significance that in 3 it was controlled with Pitocin infusion and in one case bleeding was controlled with oxytocic drugs after the pack was removed. Thr other patient in this group of 5 had extensivc> vaginal lacerations as the cause of hleedinp. I believe a more concentrated effort of bimanual massagr of the uterus and intravenous infusion of Pitocin would eliminate the need for ut?rincs parking. DR. T. BERT E'I.ETC:HER, Tallahassee, Florida. This is a tinlrly sul1jrc.t since obstetrical hemorrhage still ranks among the first three causes of maternal deaths in this country. Qualified authoritit,s have, estimated that postpartum hemorrhage accounts for approximately 25 per cent of all deaths from ohstetriral hemorrhage. In thr majority of rqmrts, uterine atony has been the- principal cause of postpartum hemorrhage. It has hrrm my clinical impression that the most frrqucmt cat~scaof uterine atony is the use of any form of general anesthesia for delivery. I have reviewed all cases of postpartum hystc,ret.tomirs performed at Tallahassee Memorial Hospital during the past 12 years. During this pf+od, there wrrr 12,586 deliveries. There was a total of 7 postpartum hysterectomies. Two \\cr(~ performed for ruptured uteri in previous f’warean section scars, one case for transverse lie and fibroid utrrus, and 4 cases for uterine atoIly. Out of the 4 patients with uterine atony, one ~asr~ wap not packed; the other 3 were packed, and the pack failed to control the hemorrhagc. and the hysterectomies were performed. Dr. Lester bar rc~commended a dry gauze pad and rhr \IVC rlf ;I nlcchanical packer. I hn\.r n~vt’r knfr\rn [his luxury, and I prefer to 1~1c.k I lit% Iit(~riis n~an~~ally with the tw of :I ,qawr j~ttk wf.1 with saline or water. A clry paf’!i 1~rohl~ly works satisfactorily in a HoImf,s Ilackcr; but in manually parking a uterus, a wet l~k works much better. It has also been my
pack
in postpartum
hemorrhage
327
impression that the failure of a uterine path ~tr control hemorrhage has been due to its incorrect application in many cases. There is an art to th(s correct application of a pack, which has fin fully covered in this paper. If a correctly placc~i pack does not control the hemorrhage, thc~ other methods of control should be cmplo,rd, such as a hysterectomy. I am not in favo. iIf repacking the uterus in such cases. I would like to quote Dr. Duncan Reid who recently made this statement in the AX~EWC:.~X JOURNAL
OF OBSTETRICS
AND
GYNECOLOGY.
To
ignore the uterine pack means that in patients whom atony cannot be controlled hy uterine ( ornpression and after a limited trial with oxy:ocic therapy, must he subjected to immediate hysterectomy. Uterine packing may eliminat I’ the necessity of operation and give the obstetrician time to replace hlood loss and prepare th[, patient for hysterectomy if this becomes IWWS iry.” This seems to be good advice to mp. I would like to ask Dr. Lester two ql~t’st itrlis. First: What was the average amount of i&rod that was Riven this group of patients? Xest: Would you makr a further cornmcsnt OII vour policy of manually exploring the utr*rus aftt,r the third stage of labor? Are VW pleased XI ith the results and are you teaching this 10 your residents as a recommtxnded procedttrt,? II has always heen interesting to mc I(; IIO~P that \vhen M‘P arc‘ having our obstt‘tric.;tl stafF meetillg, we always find plently of ntrnl);~(~kin~ enthusiasts. On the other hand, when [hf. !,lr,od is rurtnitt,~ fast and furiously, it (XII tllak~~ pil<‘kers out of nonpackers in a hllrry! 1 believe thfsrr is a definite place for the uterine, pack in modern obstetrics 3% well as a pIact, for pucrp~~r;tl hysterectomy if the uterine park shollla / f:lil, which I a111 sure It dots m some cast*\! t:csrtainly, thp rcscults of this papet aIf c*xrellent and wrlll documented. In revitwirrq thf, literature. I have bern unable to find a:~y rrports hy the nonpacking advocatrs 1ha1 c1~1d begin to compare with this study. I hav.7 SWII several reports of hystrrectomies bring de,nr’ in womc‘n of low parity for postpartum hc~morrha,~c hy doctors \vho do not belirvct in packing thtk utC”rtlr.
328
Lester et al.
caused by a defect in the clotting mechanism of the blood. The hemorrhage from the placental site can be controlled by relatively slight pressure. The pressure is considerably less than that required to stop a similar amount of hemorrhage from most other organs. The placental site can be seen under direct vision at the time of a cesnrean section and the hemorrhage from it can be controlled by the operator in nearly every patient by a very mild, “finger tip” pressure. The uterine contractions against a properly placed pack can produce adequate pressure against the placental site to control the postpartum hemorrhage, It is necessary, however, for the uterus to be able to contract at least slightly against the pack after it has been inserted. Adequate contractions can be obtained if the uterus is able to offer some resistance to the packing at the time that it is being inserted. If the uterus is not capable of any recognizable contraction in response to intensive therapy with oxytocin and ergonovine, it will not contract adequately against a pack to control the hemorrhage. I have seen only 2 cases of this type of complete uterine atony in my 25 years of obstetrical experience. Both patients failed to have any uterine contraction after the administration of 2 C.C. of oxytocin and 1 C.C. of ergonovine given intravenously at the same time. These two patients are the only ones whom I have treated that have required a hysterectomy for the control of postpartum hemorrhage from uterine atony. In my own experience, I have found that I can pack the uterus more satisfactorily if I insert one hand into the uterus and then pack the cavity as firmly as possible against the counter pressure abdominally of my other hand. The packing should also include the vagina and it should be placed so firmly that an indwelling catheter is necessary for the bladder to empty. The packing of the uterus should be followed by the administration of an intravenous clysis containing oxytocin, given over a period of several hours postpartum. Ordinarily, I have removed the pack after 24 to 36 hours, with another clysis containing oxytocin being given at that time. It is well to remember that if an adequate uterine pack is not available, a very satisfactory substitute can be made of strips cut from towels or drapes by splicing them together. I wholeheartedly endorse the use of intra-
uterine packs to control the postpartum hcmorrhage from uterine atony. CAPTAIN JAMES P. SEMMENS, MC, USN, Oakland, California. I question the advisability or need of packing uteri for so many cases of placenta previa. In 1959, I reported 166 consecutive cases of placenta previa treated at the United States Naval Hospital, Portsmouth, Virginia, and currently I have compiled data on 350 more cases made available to me by obstetrical coding and data processing of the Bureau of Medicine and Surgery of the Navy. I plan to report these 500 cases of placenta previa as a follow-up of conservative management and its role in improved perinatal mortality, martemal morbidity, and marternal mortality in placenta previa. Dr. Lester reports 20 cases of placenta previa among 10,000 deliveries on the service in Atlanta that required uterine packing. If my mathematics are correct he is advocating that approximately I/r0 of one per cent of all deliveries be packed for bleeding from placenta previa. Since the general incidence of placenta previa is 0.5 to 1.0 per cent of the total number of deliveries it would appear to me that he is packing every fifth or tenth case. The point I wish to make is that in the entire series of 500 cases I plan to report there were only 2 cases requiring uterine packs and both cases were actually examples of placenta accreta. Therefore, I would pose a question as to whether or not uncontrolled blood loss or a routine policy was his indication for packing. I might mention that recently we have been able to eliminate the use of the uterine pack in several cases of excessive and uncontrollable bleeding which originated in the lower uterine segment, a condition commonly seen in placenta previa and abruptio placenta. We have found that injecting oxytocin in the musculature of the lower cervical segment via the vagina, using a No. 20 gauge spinal needle, has proved highly effective and in several cases has averted the need of a postdelivery hysterectomy for uncontrolled bleeding. DR. LESTER (Closing). Dr. Bunch has commented on the amount of blood a pack of this size could contain. I am sure that if we laid a loose pack here on the table it could be made to contain as much blood as he estimates. However, a pack within the tightly contracted uterus which packing produces actually contains very little blood. This is easily demonstrated on re-
Uterine
moval of an intrauterine pack which, though it is stained with blood, is usually almost dry. 1 would like to emphasize again that a pack does not lessen the need for oxytocic drugs. But when the source of bleeding is not controlled by them, especially when the source is in the noncontractile lower segment, this is when a pack is indicated. Contraction of the myomet&m is essential to the effectiveness of the park. In reply to Dr. Fletcher, I can state that among the cases of atony 54 patients were transfused with one to four pints of blood. Fifty-five per cent were not transfused because bleeding was controLled before blood loss was excessive. In reply to his second question, the residents on uur service are taught to explore the uterus
pack
in postpartum
hemorrhage
329
unless a contraindication exists; we believe the uterus can be adequately explored as a rule e\.en without anesthesia. There is a tendency in recent years to ccmsider that all that is old is outmoded and all that is new is better. There are many examples to show the fallacy of this. Despite reprated assignment to oblivion, uterine tamponade continues to rear its head here and there in the literature, and especially in the delivery room. We believe this is because it has real \,alur. Opinions to the contrary have frequently bpen based on misuse of the pack or misconception of its USC. We make a plea for its rccognitiolc as an important adjunct in the obstetrician’s armamentarium against his most subtle foe.
M.
LESTER,
M.D.
R.
.4.
BARTHOLOMEW,
E.
D.
COLVIN,
W. J.
H. S.
W.
H.
Atlanta,
M.D.
GRIMES, FISH,
M.D
JR.,
M.D.
M.D.
GALLOWAY,
M.D.
Georgia
R E v I E w o F recent literature on postpartum hemorrhage reveals only occasional reference to uterine tamponade. Several authors have indicated belief that it is useless, archaic, or actually dangerous.G’ 7l lo Others however have strongly argued its va1ue.l”’ I61 ‘?I 2o That it is still employed in a large number of maternity centers was shown by Fisher.” In a group practice where uterine pack is employed rather often with seemingly
and
attributed to atony but a clotting defect was later diagnosed. The method of delivery is correlated with the indication for packing in Table II. The 2 cesarean sections listed under “atony” were done because of primary inertia. Possible etiologic factors occurring in the 113 cases of atony are outlined in Table III. There is much overlapping and some clinical guesswork in this listing. Particular attention is directed to the clinical impression that bleeding was originating principally from the flaccid lower segment in 41 cases. This was based on demonstration that the membranes had ruptured marginally, or that bleeding was coming from the lower segment in the presence of a firmly contracted uterIis or after the fundus had been packed. The results in these 163 cases have been analyzed in an effort to show whether suh-
methods
In a 10 year period, 1954 through 1963, uterine tamponade was employed 163 times in the immediate puerperium among 10,833 consecutive private patients delivered in the third trimester, an incidence of once in 66 deliveries. The indications for packing are shown in Table I. In 2 cases, hemorrhage was first From the Department Georgia Baptist Hospital.
Table
I. Indications
for pack
Uterine atony Placenta previa Hematoma (counter-pressure) Miscellaneous Adherent placental fragments Retained chorion ( 1) Partial laceration of lower Submucous fibroid (2)
of Obstetrics,
Presented at the Twenty-seventh Annual Meeting. of the South Atlantic A~ociatzon of Obstetricians and Gynecologists, Hot Springs, Virginia, Feb. 7-10, 1965.
Total
321
115 20 13 15 (9) segment
(3
j
__-.---
163
322
Lester
et al.
Table II. Type indication Type
delivery for pack
correlated
with
of delivery
Spontaneous
71 21 4 11 3 3 2
Low forceps Midforceps Forceps rotation Breech Version-extraction Cesarean section
Table III.
Possible cases of atony
3
6 3
12 1
4
1 1
1 16
etiologic
factors
Overdistention of uterus Large baby (31) Twins (9) Hydramnios (2) Manual removal of placenta Major operative delivery Primary uterine inertia Probable lower segment origin Ether anesthesia
in
42
14 6 3 41 95
sequent hemorrhage, shock, morbidity, or mortality indicated failure or danger of the pack. Eighty-two subsequent pregnancies occurring in 61 of these patients have been recorded. The outcome of these pregnancies has been reviewed to determine whether uterine tamponade had ill effect on future childbearing. Management
of the third
stage
Since the third stage of labor and the following hour include the crucial moments when hemorrhage is likely, it is well to recount our management of this period. Virtually all patients are under light general anesthesia (ether or cyclopropane), for delivery. Pitocin is given subcutaneously after the anterior shoulder comes beneath the symphysis and the delivery is conducted slowly. Unless abnormal bleeding occurs, the first few minutes are used caring for and examining the infant. By this time the placenta has usually separated. It is brought into the vagina by fundal pressure and the uterus is then elevated by suprapubic pressure as the placenta is lifted from the vagina. Intravenous Pitocin is given as the
placenta is delivered. Failure of separation within 15 minutes or significant bleedinK earlier than this is considered indication fol manual separation and removal of the placenta. In the last 5 years, the uterus has been explored manually after the third stage in nearly all cases. Careful examination of the placenta and membranes is an integral part of the properly managed third stage. Abnormal bleeding after the third stage is usually managed by fundal or bimanual massage and oxytocic drugs, and by intravenous infusion of a dilute Pitocin solution if bleeding is not quickly controlled. If atony is considered likely (as with prolonged labor or an overdistended uterus), the infusion is begun prior to delivery and Pitocin added to it during the third stage. If bleeding persists despite these measures, a uterovaginal pack is employed without hesitation; it is not withheld as a last resort. In cases of placenta previa, the uterus has been packed frequently as a prophylactic measure. Technique
of uterine
packing
Autoclaved units of gauze for packing are kept in glass jars in the delivery room, ready for use. The gauze is prepared by taking a 36 inch width of gauze? 20 feet long, folding it lengthwise four times, giving a 16 ply pack about 2 inches in width.* One unit is usually enough for a uterovaginal pack, though a second length can be tied to the first. We have found a dry gauze pack adequate and safe. Iodoform gauze has been recommended by some,“* Ic and Benaron and associates’ have found an oxidized cellulose gauze pack of value, with the added convenience that it does not have to be removed. Though manual packing has been recommended by Day, Mussey, and Devoe” and Reid,13 we agree with PosnerXF that instrumental packing is more efficient in placing the pack quickly and tightly, and have found the Holmes packer quite suitable (Fig. 1). After the entire birth canal is explored *Brunswick 8 inch width, pack.
Gauze. 4 ply,
available is well
from suited
Johnson and to preparation
Johnson. of
thr
Uterine
pack
in
postpartum
hemorrhage
323
packing is continued in a similar mannet to fill the vagina, and the lower end is lefr at the introitus for easy removal. In this manner adequate tamponade can be ~CCOIIIplished in three to four minutes. A retention catheter is left in the bladder. The patient is kept in bed until the pack is removed. Though the pack may develop a sour odor, antibiotics are not given urtless other factors indicate their use. The pack is removed, in bed, after 21 to 36 hours, An injection of meperidinc OI inhalation of trichloroethylene is sufficient to relieve the discomfort of removal. PitocTn is given as the pack is removed and the patient is watched for bleeding.
Fin. 1. Equipment
required
for packing
uterus.
and trauma ruled out, and with the uterus contracted as much as possible with intravenous Pitocin, the tube of the packer is guided with one hand to the upper extent of the uterine cavity and the end of the pack is introduced to the fundus with the spear. The rings at thr proximal end of the tubular casing are then held with the first and second fingers of one hand and the ring of the spear controlled with the thumb of the same hand, while the fundus is steadied with the other hand or by an assistant. Short quick strokcxs with the thumb are employed to apply the pack, while the end of the packer is gradually turned from side to side in order to fill the cavity evenly. Slight upward pressure is kept on the tube so that the placed pack slowly forces it downward. The force exerted is kept sufficient to place the pack tightly without distending the cavity to a size. ,greater than the contractility of the uterus is obtaining. When the muscular portion of the uterIIs is filled, particular attention is paid to the uncontracted lower segnltant. This requires wider circular motions of the tube and usually a greater amount of gauze than does the uterine cavity. The
Results Clomplete and immediate control of biccding was obtained by uterine tampona&: in all but 5 cases. Unfavorable results and (‘omplications are summarized in Table IV. Atony was thr causative factor in three of the casts in which the pack failed to cmtrol bleeding. In one, the pack \vas rrrnovcd and oxytocic drugs controlled the aiony. In another the pack was removed anti the uterus packed again with good results. In a third case, blood and Pitocin infusion vwrta given and the patient was taken to the* operatirl% table. Preparation was tnatl~. for hysterectomy but the hemorrhage gradually came under control with the pack still in place. Two patients bled through thrt pack protnptly; a clotting defect was diagnosed and fibrinogen stopped the excessive kolerding. One of these was associated with a stillborn erythroblastotic infant. The othc: \vas a result of amniotic fluid embolism which caused death in 5 hours. but not Iron: Iltr:rinc blood loss. Three patients had significant dt+iaycd blet>diny thrn~r~h the Ijack but thcw WYX
Table I\‘.
(:omplications
of packiny
Failure to control bleedinp Delayed hemorrhage Shock Pack caught 1,~ srrture icesarean) Morbidity
i 3 , 7 16
324
Lester
et al.
controlled with Pitocin infusion. Two other patients bled heavily at the time the pack was removed. Bleeding was controlled with oxytocic drugs in one case in which atony had been the reason for packing. In the other there had been extensive vaginal lacerations; on removal of the pack, brisk bleeding occurred from the repaired lacerations. Blood was given and another pack was employed. This controlled the bleeding and it did not recur when the second pack was removed 24 hours later. Shock was recorded in 34 cases. However, in only two did it recur or begin after packing and adequate blood replacement. In one patient it was possible to remove the portion of pack caught by cesarean repair suture after 4 days. This patient’s course was afebrile, but she had been protected with antibiotics. Of the patients exhibiting morbidity there was only one case of frank endometritis and there was no instance of thrombophlebitis or thromboembolism. Eleven of these 16 patients were given antibiotics. Another 11 patients were given antibiotics prophylactically. There were 2 deaths among the patients who were packed. One was the result of cerebral hemorrhage in a patient with hypertension 5 days after delivery. The other was a case of massive amniotic fluid embolism, with death resulting from respiratory faiIure and cerebeIlar hemorrhage. Blood loss had been adequately replaced and did not seem a major factor in her death. During this 10 year period there was one death due to ruptured uterus. This was the only case in which puerperal hysterectomy was required among these 10,833 patients. A pack had not been employed in this case. Whether there are any late sequelae to uterine packing should best be measured by the subsequent reproductive performance of women who have had a uterine pack. Of 150 women who might have become pregnant again, 61 were seen in 82 subsequent pregnancies. The results of these pregnancies are seen in Table V. Of 63 cases subsequently managed the
Table V. Subsequent
pregnancies
Term, healthy infant Premature, healthy infant Abortion Stillbirth Moved away Now pregnant
62 2 11 2 3 3
Total
82
third stage was uncomplicated in 51. There were 2 in which manual removal of the placenta was required and 10 in which postpartum hemorrhage occurred; in 5 of these the uterus was packed. Recurring abnormalities of the third stage have been noted previously by Dewhurst and Dutton4 and by Doran, O’Brien, and RandalL Comment The frequency with which uterine packing has been used in this series is due in part to its employment as a preventive measure or as early definitive treatment, and not as a desperate last resort. Though a number of uteri doubtless would have stopped bleeding without a pack, we believe there are others that would have continued to bleed to a life-threatening degree. Disrepute of tamponade has been based at times on review of cases of mortality from postpartum hemorrhage in which packing had been used. Such retrospective criticism could as well be applied to blood transfusion or any other measure used in fatal cases and is not justified. Uterine packing in unpracticed hands, with inadequate pack material and improper technique, without careful prior exploration, or done with the patient already in shock, may be worse than useless. In hospitals where packing is considered a definitive form of treatment in postpartum hemorrhage a very different evaluation is obtained. In 2 such instances, TayIor?O reports 65,000 deliveries and Pierce and Winkler15 report 38,000 deliveries with no hysterectomy for atony and no death due to hemorrhage from atony. The results in the present study along with such reports as these indicate that a judiciously employed and properly timed uterine pack is not
Uterine
dangerous or useless, but is an effective and valuable procedure in the management of postpartum hemorrhage. In centers where tamponade is not used, occasionally a young woman has her childbearing terminated by hysterectomy when other measures fail to check hemorrhage from atony.“, lg It is believed that such hysterectomies can usually he avoided, that blood loss can be appreciably reduced, and that the critical hours of the early puerperium can be faced with much more security when early uterine tamponade is employed for the atonic uterus. The use of general anesthesia for delivery, especially ether with its known propensity for relaxing the myometrium, has surely produced or aggravated atony in some cases, and thus is another factor in the high incidence of packing reported here. There was a reduction in our use of tamponade from one in 57 deliveries in the first 5 years of this study to 1332 in the second 5 years. This is attributed partly to a shift to cyclopropane instead of ether anesthesia in about half the cases in more recent years. Among objections to uterine packing have been that it distends the uterus preventing normal myometrial retraction and that it holds bleeding sinuses open. A properly applied pack should not distend the uterus to a size greater than its contractility at the time can obtain. Uterine atony is nearly always an intermittent condition; the uterus can be made to contract with oxytocic drugs and massage for brief intervals, but it cannot nkaintain the tone necessary to prevent bteeding. It should be packed while it is contracting, and oxytocic stimulation should be continued for at least one hour afterward. It ha.s been previously stressed by one of us (J. S. F.S j, that any open sinuses of the interior uterine wall are subjected to direct pressure by the pack, and this pressure is magnified by any contractile tendency of the myometrium. The response of the atonic uterus, as felt through the abdominal wall, pives the impression that it contracts much more adequately after packing. The ready control of brisk bleeding by the pack seems to confirm this impression.
pack
in postpartum
hemorrhage
325
The number of cases in which the lower uterine segment was thought, clinically, to be the source of bleeding amounted to 36 per cent of the cases of atony. The naturally atonic cuff of lower segment is certainly more likely to bleed should placental attachment, shallow lacerations or abrasions involve its surface. It is perhaps the source‘ of postpartum hemorrhage much more often than is usually recognized. The significance of lower segment bleeding has been discussed by Leff,‘? who has clearly described the rapid involution of the lower segment and its augmentation by the intermittent contractions produced by pituitary extract. The time involved in this retraction corrcsponds closely to the period of greatest clanger of postpartum hemorrhage. It is in thrse cases of lower segment bleeding, where oxytocic drugs can have no immediate c8ec.t in shutting off open sinuses, that a tight uterovaginal pack has its greatest potential v&c. For this reason we agree with Kimbrough and Jones’l that prophylactic packing is useful in placenta previa. Packing at the time of cesarean section is less satisfactory than packing per vaginam because counterpressure by the vaginal portion of the pack against the lower segment cannot be obtained, but we believe it is warranted svh~n the placental site is bleeding. The use of tamponade after removal CJf adherent placental fragments has been stressed in a previous study.‘” When focal areas of placenta accreta involve thr lower segment, as they did in three cases irf this series, packing is clearly indicated. A vaginal pack has often been s~ommended for counter-pressure after opening and packing a vaginal hematoma. It :s our belief that a uterovaginal pack is better in these cases than a vaginal pack alone since it exerts more pressure against the upper pelvic wall and averts the danper of concealed uterine bleeding. Summary One hundred and sixty-three cases are reviewed in which uterine tamponade was employed for postpartum bleedina; the inci-
dence of its use was once in 66 deliveries. The efficacy of uterine packing for atony depends upon its proper application and its employment early in the course of postpartum hemorrhage. Dry gauze packing placed with a mechanical packer from the uterine fundus to the introitus is recommended. No death from hemorrhage due to atony oc-
REFERENCES
12.
1. Benaron, H. B. W., Bradburn, G. B., Gossack, L., Tucker, B. E., and Roddick, J. W.: AM. J. OBST. & GYNEC. 71: 1220, 1956. 2. Cosgrove, R. A.: AM. J. OBST. & GYNEC. 62: 584, 1951. 3. Day, L. A., Mussey, R. D., and Devoe, R. W.: AM. J. OBST. & GYNEC. 55: 241, 1948. 4. Dewhurst, C. J,, and Dutton, W. A. W.: Lancet 2: 764, 1957. 5. Doran, J. R., O’Brien, S. A., Jr., and Randall, 1. H.: Obst. & Gvnec. 5: 186. 1955. 6. bouglass, L. H.:’ Bull. School Med. Univ. Maryland 40: 38, 1955. 7. Eastman, N. J., and Hellman, L.: Williams obstetrics. ed. 12, New York, 1961, AppletonCentury-Crofts, Inc., p. 1000. a. Fish, J. S.: Hemorrhage of late pregnancy, Sorinafield. Illinois. 1955. Charles C Thomas. Publiiher, ‘pp. 139:140. ’ 9. Fisher, J. J.: J. Florida M. A. 41: 634, 1955. 10. Hellman, L.: AM. .J. OBST. & GYNEC. 70: 215, 1955. 11. Kimbrough, R. A., and Jones, B. D.: AM. J. OBST. & GYNEC. 55: 496, 1948.
Discussion DR.
JOHN
D.
BUNCH,
JR.,*
Columbia,
South
Carolina. There are a number of arguments against uterine packing in the management of postpartum hemorrhage, some of which are as follows: ( 1) it is an unphysiologic process, as the procedure of choice is to empty the uterus to obtain maximum contractility; (2) there is too much danger of infection; (3) it will not always stop the bleeding; (4) you may pack a uterus that has been ruptured or the packing may actually produce a rupture; and (5) most important of all, the pack will very often mask the amount of continued bleeding, which can be massive in and around the pack, but largely concealed by the packing. If at the onset of excessive bleeding, not visible in origin, the vagina *By
invitation.
curred and hysterectomy was not required for atony in 10,833 consecutive cases. Ko serious complications followed packing and future childbearing did not seem to be affected. It is concluded that judicious use of the uterine pack is of continuing value in modern obstetrics.
13.
14. 15. 16. 17. 18.
19.
20.
Leff, M.: Ara. J. OBST. & GYNEC. 49: 734, 1945. Lester, W. M., Bartholomew, R. A., Colvin. E. D., Grimes, W. H., Jr., Fish, J. S., and Galloway, W. H.: AM. J. OBST. & GYNEC. 72: 1214, 1956. McCartney, C. P.: M. Clin. North America 38: 265, 1954. Pierce, J. R., and Winkler, E. G.: Minnesota Med. 39: 89, 1956. Posner, A. C.: Clin. Obst. & Gynec. 3: 76, 1960. Reid, D. E.: AM. J. OBST. & GYNEC. 73: 697, 1957. Reid, D. E.: Textbook of obstetrics, Philadelphia, 1962, W. B. Saunders Company, p. 589. Shulman, A., Ratzan, W. J., Grossbard, P., and Lawrence. A. C.: AM. J. OBST. & GYNEC. 71: 37, 1956.’ Taylor, E. S.: Clin. Obst. & Gynec. 3: 646, 1960. 272 Boulevard, N.E. Atlanta, Georgia 30312
are inspected and the uterus explored, and cervix the more common causes of bleeding will be eliminated. The elimination of deep anesthesia and narcosis and the use of oxytocics either intramuscular or intravenous together with bimanual stimulation of the uterus, will overcome most instances of bleeding due to uterine atony. Whole blood, if needed, should be used in sufficient quantity to replace the amount lost. If these measures fail, there should be no hesitation in ligating the hypogastric arteries or even doing a hysterectomy as a lifesaving procedure. Some authorities state that an atonic uterus cannot be packed effectively, and with this I agree. How you can determine whether an atonic uterus is underpacked or overpacked is beyond my comprehension. If a 4 x 4 sponge can hold 10 C.C. of blood and, if my mathematics
Uterine
is correct, the size pack used by Dr. Lester and associates which is 20 feet long, 2 inches in width, and 16 ply could absorb approximately 1,200 C.C. of blood before it would begin to be visil)le externally. It is interesting to me that in 5 patients in whom the pack failed to control the bleeding, the hleedinp was controlled in one after the pack was removed and oxytocic drugs used. In another, the pack was left in but blood and Pitocin infusion were given which apparently stopped the bleeding. In 2 of these patients a blood clotting defect was the cause of bleeding. In 5 patients with delayed bleeding, it is also of significance that in 3 it was controlled with Pitocin infusion and in one case bleeding was controlled with oxytocic drugs after the pack was removed. Thr other patient in this group of 5 had extensivc> vaginal lacerations as the cause of hleedinp. I believe a more concentrated effort of bimanual massagr of the uterus and intravenous infusion of Pitocin would eliminate the need for ut?rincs parking. DR. T. BERT E'I.ETC:HER, Tallahassee, Florida. This is a tinlrly sul1jrc.t since obstetrical hemorrhage still ranks among the first three causes of maternal deaths in this country. Qualified authoritit,s have, estimated that postpartum hemorrhage accounts for approximately 25 per cent of all deaths from ohstetriral hemorrhage. In thr majority of rqmrts, uterine atony has been the- principal cause of postpartum hemorrhage. It has hrrm my clinical impression that the most frrqucmt cat~scaof uterine atony is the use of any form of general anesthesia for delivery. I have reviewed all cases of postpartum hystc,ret.tomirs performed at Tallahassee Memorial Hospital during the past 12 years. During this pf+od, there wrrr 12,586 deliveries. There was a total of 7 postpartum hysterectomies. Two \\cr(~ performed for ruptured uteri in previous f’warean section scars, one case for transverse lie and fibroid utrrus, and 4 cases for uterine atoIly. Out of the 4 patients with uterine atony, one ~asr~ wap not packed; the other 3 were packed, and the pack failed to control the hemorrhagc. and the hysterectomies were performed. Dr. Lester bar rc~commended a dry gauze pad and rhr \IVC rlf ;I nlcchanical packer. I hn\.r n~vt’r knfr\rn [his luxury, and I prefer to 1~1c.k I lit% Iit(~riis n~an~~ally with the tw of :I ,qawr j~ttk wf.1 with saline or water. A clry paf’!i 1~rohl~ly works satisfactorily in a HoImf,s Ilackcr; but in manually parking a uterus, a wet l~k works much better. It has also been my
pack
in postpartum
hemorrhage
327
impression that the failure of a uterine path ~tr control hemorrhage has been due to its incorrect application in many cases. There is an art to th(s correct application of a pack, which has fin fully covered in this paper. If a correctly placc~i pack does not control the hemorrhage, thc~ other methods of control should be cmplo,rd, such as a hysterectomy. I am not in favo. iIf repacking the uterus in such cases. I would like to quote Dr. Duncan Reid who recently made this statement in the AX~EWC:.~X JOURNAL
OF OBSTETRICS
AND
GYNECOLOGY.
To
ignore the uterine pack means that in patients whom atony cannot be controlled hy uterine ( ornpression and after a limited trial with oxy:ocic therapy, must he subjected to immediate hysterectomy. Uterine packing may eliminat I’ the necessity of operation and give the obstetrician time to replace hlood loss and prepare th[, patient for hysterectomy if this becomes IWWS iry.” This seems to be good advice to mp. I would like to ask Dr. Lester two ql~t’st itrlis. First: What was the average amount of i&rod that was Riven this group of patients? Xest: Would you makr a further cornmcsnt OII vour policy of manually exploring the utr*rus aftt,r the third stage of labor? Are VW pleased XI ith the results and are you teaching this 10 your residents as a recommtxnded procedttrt,? II has always heen interesting to mc I(; IIO~P that \vhen M‘P arc‘ having our obstt‘tric.;tl stafF meetillg, we always find plently of ntrnl);~(~kin~ enthusiasts. On the other hand, when [hf. !,lr,od is rurtnitt,~ fast and furiously, it (XII tllak~~ pil<‘kers out of nonpackers in a hllrry! 1 believe thfsrr is a definite place for the uterine, pack in modern obstetrics 3% well as a pIact, for pucrp~~r;tl hysterectomy if the uterine park shollla / f:lil, which I a111 sure It dots m some cast*\! t:csrtainly, thp rcscults of this papet aIf c*xrellent and wrlll documented. In revitwirrq thf, literature. I have bern unable to find a:~y rrports hy the nonpacking advocatrs 1ha1 c1~1d begin to compare with this study. I hav.7 SWII several reports of hystrrectomies bring de,nr’ in womc‘n of low parity for postpartum hc~morrha,~c hy doctors \vho do not belirvct in packing thtk utC”rtlr.
328
Lester et al.
caused by a defect in the clotting mechanism of the blood. The hemorrhage from the placental site can be controlled by relatively slight pressure. The pressure is considerably less than that required to stop a similar amount of hemorrhage from most other organs. The placental site can be seen under direct vision at the time of a cesnrean section and the hemorrhage from it can be controlled by the operator in nearly every patient by a very mild, “finger tip” pressure. The uterine contractions against a properly placed pack can produce adequate pressure against the placental site to control the postpartum hemorrhage, It is necessary, however, for the uterus to be able to contract at least slightly against the pack after it has been inserted. Adequate contractions can be obtained if the uterus is able to offer some resistance to the packing at the time that it is being inserted. If the uterus is not capable of any recognizable contraction in response to intensive therapy with oxytocin and ergonovine, it will not contract adequately against a pack to control the hemorrhage. I have seen only 2 cases of this type of complete uterine atony in my 25 years of obstetrical experience. Both patients failed to have any uterine contraction after the administration of 2 C.C. of oxytocin and 1 C.C. of ergonovine given intravenously at the same time. These two patients are the only ones whom I have treated that have required a hysterectomy for the control of postpartum hemorrhage from uterine atony. In my own experience, I have found that I can pack the uterus more satisfactorily if I insert one hand into the uterus and then pack the cavity as firmly as possible against the counter pressure abdominally of my other hand. The packing should also include the vagina and it should be placed so firmly that an indwelling catheter is necessary for the bladder to empty. The packing of the uterus should be followed by the administration of an intravenous clysis containing oxytocin, given over a period of several hours postpartum. Ordinarily, I have removed the pack after 24 to 36 hours, with another clysis containing oxytocin being given at that time. It is well to remember that if an adequate uterine pack is not available, a very satisfactory substitute can be made of strips cut from towels or drapes by splicing them together. I wholeheartedly endorse the use of intra-
uterine packs to control the postpartum hcmorrhage from uterine atony. CAPTAIN JAMES P. SEMMENS, MC, USN, Oakland, California. I question the advisability or need of packing uteri for so many cases of placenta previa. In 1959, I reported 166 consecutive cases of placenta previa treated at the United States Naval Hospital, Portsmouth, Virginia, and currently I have compiled data on 350 more cases made available to me by obstetrical coding and data processing of the Bureau of Medicine and Surgery of the Navy. I plan to report these 500 cases of placenta previa as a follow-up of conservative management and its role in improved perinatal mortality, martemal morbidity, and marternal mortality in placenta previa. Dr. Lester reports 20 cases of placenta previa among 10,000 deliveries on the service in Atlanta that required uterine packing. If my mathematics are correct he is advocating that approximately I/r0 of one per cent of all deliveries be packed for bleeding from placenta previa. Since the general incidence of placenta previa is 0.5 to 1.0 per cent of the total number of deliveries it would appear to me that he is packing every fifth or tenth case. The point I wish to make is that in the entire series of 500 cases I plan to report there were only 2 cases requiring uterine packs and both cases were actually examples of placenta accreta. Therefore, I would pose a question as to whether or not uncontrolled blood loss or a routine policy was his indication for packing. I might mention that recently we have been able to eliminate the use of the uterine pack in several cases of excessive and uncontrollable bleeding which originated in the lower uterine segment, a condition commonly seen in placenta previa and abruptio placenta. We have found that injecting oxytocin in the musculature of the lower cervical segment via the vagina, using a No. 20 gauge spinal needle, has proved highly effective and in several cases has averted the need of a postdelivery hysterectomy for uncontrolled bleeding. DR. LESTER (Closing). Dr. Bunch has commented on the amount of blood a pack of this size could contain. I am sure that if we laid a loose pack here on the table it could be made to contain as much blood as he estimates. However, a pack within the tightly contracted uterus which packing produces actually contains very little blood. This is easily demonstrated on re-
Uterine
moval of an intrauterine pack which, though it is stained with blood, is usually almost dry. 1 would like to emphasize again that a pack does not lessen the need for oxytocic drugs. But when the source of bleeding is not controlled by them, especially when the source is in the noncontractile lower segment, this is when a pack is indicated. Contraction of the myomet&m is essential to the effectiveness of the park. In reply to Dr. Fletcher, I can state that among the cases of atony 54 patients were transfused with one to four pints of blood. Fifty-five per cent were not transfused because bleeding was controLled before blood loss was excessive. In reply to his second question, the residents on uur service are taught to explore the uterus
pack
in postpartum
hemorrhage
329
unless a contraindication exists; we believe the uterus can be adequately explored as a rule e\.en without anesthesia. There is a tendency in recent years to ccmsider that all that is old is outmoded and all that is new is better. There are many examples to show the fallacy of this. Despite reprated assignment to oblivion, uterine tamponade continues to rear its head here and there in the literature, and especially in the delivery room. We believe this is because it has real \,alur. Opinions to the contrary have frequently bpen based on misuse of the pack or misconception of its USC. We make a plea for its rccognitiolc as an important adjunct in the obstetrician’s armamentarium against his most subtle foe.