Innovative Approach for Rapid Control of Postpartum Hemorrhage With Abdominal Pressure
Year: 2025
Type: article
Abstract: Introduction Postpartum hemorrhage (PPH) is a major threat to pregnant women worldwide and disproportionately affects developing countries or resource-limited areas. Every 4-5 minutes, a woman dies from PPH.1,2 For women who survived PPH, many of them suffered organ damage and physical or mental trauma either from a delay in controlling the hemorrhage or from the invasive procedures. Over the past few decades, many guidelines on the prevention and management of PPH have been issued by local, national, or international organizations, but implementation of any guideline is hampered by multidimensional barriers, and no substantial progress has been made in reducing PPH-related morbidity and mortality.3 The etiology of PHH is complex, and identifying the exact cause of PPH can be challenging because more than one cause is often present.4 Delay in controlling the PPH will lead to coagulopathy and myriad complications or even death.1,2 Oxytocin is an effective drug in preventing or treating PPH caused by uterine atony, which is universally supported by clinical trials and professional guidelines.1,2,5 However, there are many controversies surrounding other preventive strategies and management options. Bimanual uterine compression (BMC) has been used in clinical practice for many decades, but the study showed that a single provider was unable to fully compress the uterus and maintain compression for more than 150 seconds without fatiguing. For uterine compression to be effective, adequate pressure needs to be maintained for 5-10 minutes or much longer.6 The effectiveness of BMC was not well studied in a clinical trial or clearly demonstrated in clinical practice, which may lead to a provider’s reluctance to use it in the management of PPH.7 In the PPH care bundles proposed by the World Health Organization, BMC is not included in the first response bundle. Instead, it is included in the refractory PPH bundle to manage the bleeding that is resistant to first response measures.5 We designed a novel method of applying manual pressure on the uterus via the abdominal wall for rapid control of PPH from all sources (Fig. 1A & B). The goal of manual external uterine compression (MEUC) is to exert much higher pressure on the entire uterus for a prolonged period to completely stop PPH. This report is to summarize our initial experience of using MEUC in patients with PPH.Figure 1.: Manual external uterine compression. A Application of MEUC: The patient with postpartum hemorrhage is positioned supine or in lithotomy. The provider kneels at the bedside or stands on a step stool, placing one hand above the pubic symphysis and the other over the umbilicus, and applies vertical pressure to the entire uterus with elbows extended. B Mechanism of action: Manual pressure is transmitted through the abdominal wall, compressing the uterine fundus against the distal abdominal aorta and vertebrae, which may reduce pelvic blood flow. MEUC: Manual external uterine compression.Method The key steps in performing MEUC are: The patient with PPH is in a supine or lithotomy position. Insert a Foley catheter to empty the bladder. The provider stands on a step stool or kneels on the bedside. Push the uterus up through the abdominal wall and keep the uterine fundus at or above the umbilicus. Align the uterus along the midline. If the provider has difficulty in locating the uterus through the abdominal wall, insert a hand in the vagina and push the uterus up. With the elbows extended, the provider applies pressure vertically toward the spine using two open hands covering the entire uterus (from pubic symphysis to umbilicus). The weight of the provider’s upper body is used to apply the pressure to the uterine fundus, uterine body, and the lower uterine segment. Apply as much pressure as needed to stop the active bleeding from the vagina (Fig. 1). Maintain the pressure on the uterus for 5-10 minutes after vaginal bleeding stops. If vaginal bleeding recurs after discontinuing the pressure, resume the manual pressure to stop the bleeding. There is no upper time limit for performing MEUC. The total duration of MEUC should be individually determined by the provider before switching to other methods. While performing MEUC, we do not recommend performing other vaginal or abdominal procedures to interrupt MEUC, for example, performing vaginal examination to inspect vaginal or cervical lacerations. If there is bleeding from the episiotomy incision or perineal laceration, manual pressure can be applied by another provider to stop the bleeding from the wound. The efficacy of MEUC is judged based on the blood flow from the vaginal orifice; therefore, the vagina should not be tamponaded with gauze, hand, or instrument. Examine the vagina and cervix after PPH is stopped and repair the laceration as indicated. Do not suture the perineal laceration before PPH is under control. Clinical experience This study was conducted between June and July 2025 in the labor and delivery unit of Shijiazhuang Obstetrics and Gynecology Hospital in Hebei Province, China. The study was approved by the hospital’s ethics committee. Enrollment criteria for MEUC included blood loss ≥ 400 ml (alert level recommended in China) or rapid uterine bleeding after vaginal delivery. Patients with the following conditions were allowed to participate in the study: high body mass index, uterine fibroid, uterine malformation, abnormal placentation, fever or chorioamnionitis. Exclusion criteria included history of cesarean delivery, or myomectomy, current adnexal mass or cyst, uncontrolled hypertension, and any condition in which increased abdominal pressure is contraindicated. In our labor and delivery unit, epidural analgesia is the routine care provided to all laboring women. Blood loss was quantitatively measured by using calibrated drapes after delivery of the placenta and weighing all blood-soaked materials and clots. After delivery of the infant, oxytocin 10 units was given intravenously over 30 minutes to prevent PPH. After 30 minutes, the oxytocin infusion was changed to a maintenance rate and continued until the infusion of 30 units of oxytocin in 500 mL of normal saline was complete. For patients with diagnosed PPH, suspected PPH, or high-risk factors for PPH, it is our standard practice to give additional uterotonics besides oxytocin, which include ergometrine 0.2 mg given intramuscularly, carboprost 0.25 mg intramuscularly, carbetocin 0.1 mg intravenously, and carboprost suppository 1 mg. Tranexamic acid 1g given intravenously was also commonly used for PPH. However, which additional uterotonic to use is solely dependent on the provider. During the study period, MEUC was immediately applied when a patient had heavy vaginal bleeding after vaginal delivery and met the inclusion and exclusion criteria. We did not attempt to differentiate uterine atony, birth canal laceration, placental pathology, and coagulopathy before applying MEUC to the uterus, because it was difficult and inaccurate to determine the cause of bleeding in a life-threatening situation. The etiology of PPH was ascertained after the bleeding was under control. Success of MEUC was defined as complete resolution of PPH without a need to escalate the treatment, which includes intrauterine balloon tamponade, uterine curettage, uterine artery embolization, or laparotomy. MEUC was performed in ten patients with PPH (Supplementary Table 1, https://links.lww.com/MFM/A109). The etiology of PPH was related to uterine atony in seven patients, uterine inversion in one patient, retained placenta in one patient, and combined uterine atony and focal placenta accreta in one patient. Of the ten patients who received MEUC, nine patients stopped hemorrhage, and one patient with uterine atony did not stop bleeding completely and was treated with a Bakri balloon. The patient who failed MEUC was enrolled at the beginning of the study, and the provider felt more comfortable with the traditional method and discontinued MEUC prematurely, even though the vaginal bleeding diminished after applying pressure for six minutes. MEUC was used in one patient before placenta delivery due to brisk uterine bleeding after delivery of the infant. After the uterine bleeding was controlled with MEUC, the retained placenta was removed intact with vigorous massage of the uterus via the abdominal wall. Transfusion was needed in one patient with uterine inversion, who lost 1200 ml of blood due to the removal of the placenta from the inverted uterine fundus. After replacing the inverted uterus to its normal position, MEUC was immediately applied with minimal bleeding noted afterwards. One patient experienced heavy uterine bleeding after abortion at 30 weeks of gestation by intra-amniotic injection of ethacridine, and the bleeding was rapidly controlled by MEUC. The provider elected to discontinue MEUC after applying pressure for two minutes, and no further bleeding was noted. The time from initiation of MEUC to cessation of hemorrhage varied. The blood accumulated in the uterine cavity was squeezed out first. As the manual pressure increased, the active bleeding from the uterine cavity gradually stopped. Our protocol requires continuing MEUC for 5-10 minutes after cessation of active bleeding, but most providers did not wait that long and chose to stop MEUC early. If MEUC needs to be continued after applying pressure for ten minutes, we usually switch to a new provider to minimize fatigue. Only one patient with retained placenta needed to reapply manual pressure for five minutes after placental delivery for the purpose of preventing hemorrhage, and this patient had a total duration of 15 minutes of MEUC, which was the longest in this case series. All patients tolerated MEUC well, although nine out of ten patients received epidural analgesia during labor and delivery. No complications were found related to MEUC. Based on providers’ feedback, MEUC was easy to learn and perform. A provider could apply sufficient pressure using both hands and arms and the upper body to arrest uterine bleeding for ten minutes without difficulty. Discussion This case series demonstrated that MEUC can be readily performed in patients with PPH. MEUC, along with uterotonics and other standard management modalities, appeared to be effective in controlling PPH related to uterine atony and placental pathology. Compared to BMC, MEUC can deliver much higher pressure on the entire uterus for a long period. MEUC is also less invasive than BMC, because there is no need to insert a hand or fist into the vagina. Most importantly, by rapid control of uterine bleeding, MEUC allows the uterotonics to take effect without letting the PPH rapidly deteriorate to coagulopathy or jeopardize the functions of vital organs. The goal of MEUC is to stop uterine bleeding from all sources. Bleeding from vaginal laceration or episiotomy incision can be controlled with additional pressure. We do not recommend repairing vaginal or perineal lacerations while applying MEUC on the uterus. All the attention should be focused on stopping the uterine bleeding first. We speculate that MEUC stops PPH by the following mechanism: (1) blocks the blood flow to the uterus due to strong external pressure applied to the entire uterus; (2) promotes local hemostasis and thrombosis by reducing blood flow to the placental bed; (3) reduces the blood supply to entire pelvis due to compression of the distal abdominal aorta by the pressure transmitted through the uterine fundus (Fig. 1). However, MEUC is unlikely to block the arterial flow of abdominal aorta and cause ischemic injury. To completely block the distal abdominal aorta, a focal weight of 64 kg (140 lbs) is needed,7,8 which is beyond the reach of our female providers. In our study, monitoring the blood flow in the lower extremities with Doppler was not performed. Our study has many limitations. First, it is a case series from a single labor and delivery unit, and a successful result from such a small case series does not imply the effectiveness of MEUC by itself. To prove the effectiveness of MEUC, a randomized trial or large cohort study would be needed in the future. Second, our study used a lower threshold for diagnosing PPH that may affect the generalizability of the study results. Performing MEUC at a blood loss of 400 ml or less may exaggerate the success rate of MEUC. Third, the advantages of MEUC over BMC are speculative or theoretical, because we did not have a comparison group or use pressure measurement devices in the study. Fourth, multiple uterotonics were routinely used for patients with PPH or patients with high-risk factors for bleeding in our labor and delivery unit, which may complicate the interpretation of the study results. Fifth, patients appeared to tolerate MEUC well, but nine out of ten patients used epidural analgesia in our case series. The tolerance of the procedure needs to be further studied in patients without epidural analgesia. Finally, we cannot determine whether MEUC is a temporizing measure or a definitive treatment for PPH based on a small case series. Even with all the limitations of the study, MEUC offers a glimpse of hope to make a significant impact on PPH management. If proven effective in future studies, MEUC can be equally implemented in high and low-resource settings without any barriers.
Source: Maternal-Fetal Medicine
Authors: Thomas Qintian Zheng, Hui Du, Wenhui Song, Ying Feng, Xu Xie, Jingyi Zhao, Wenjing Guo
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4417114404