Key words
post partum haemorrhage - Atony - Compression
Schlüsselwörter
postpartale Blutung - Atonie - Kompression
Introduction
Every minute a woman dies during labour or delivery. The main cause of maternal mortality
is post partum haemorrhage (PPH) (24%) [1]. 99% of mortality occurs in developing nations and is due to the lack of proper
resources [2]. After vaginal delivery first line of therapy for hemorrhage is bimanual compression
of the uterus until stabilization is achieved. Often this cannot be maintained by
an individual for more than 150 s and a paired team may not last for more than 5 min
[3]. Uterine balloon tamponade has been found to be effective even in resource-poor
settings but its implementation and use in these settings is difficult [4]. Furthermore, intrauterine tamponade may stop acute haemorrhage but may interfere
with physiological contraction of the myometrium. In addition, uterine atony may develop
in combination with extensive lacerations of the vagina and surgical repair may be
very difficult. Suturing may result in extension of the lacerations with an increase
in bleeding. After unsuccessful attempts to control PPH by myometrium contractile
agents, fundal massage, ice packs and energy-sapping compression of the uterus 30
years ago we first used a combination of intrauterine and vaginal tamponade resulting
in insufficient haemostasis probably due to insufficient tightness of compression.
To increase compression we adopted the bandage described by Stöckel [5] packing the vagina with laparotomy pads. Later we developed the “sumo-compression”.
The term “Sumo-compression” was chosen, because most people are familiar with the
Japanese wrestlers and reminds them of the concept in extreme situations.
Method
We have applied “sumo-compression” after vaginal delivery in patients with severe
post partum haemorrhage, where the use of contractile drugs and surgical intervention
had been unsuccessful. After curettage of the uterus and revision of the cervix or
failure to stop bleeding by suturing traumatized vaginal tissue under general anaesthesia
and continuous infusion of contractile drugs the uterus is compressed from below by
tight packing of the vagina with 3–5 laparotomy pads ([Fig. 1]). A bandage is fixed like a very tight belt preventing the uterus from rising and
a roll of pads compresses the uterus from the fundus ([Fig. 2]). Counterpressure is achieved by a second bandage from the anterior to the posterior
part of the belt pressing the pads inside the vagina firmly against the uterus ([Fig. 2]). The hip areas are padded to reduce skin trauma.
Fig. 1 Schematical drawing of “sumo-compression” in PPH (carried out by Wolfgang Herzig
www.des-illu.de).
Fig. 2 Photograph of the applied “sumo-compression” in PPH.
Results
Since 1997 sumo compression has been used sporadically in the department of obstetrics
and gynaecology, Klinikum Fulda, Germany. Between December 2010 and October 2012 five
patients (24–34 years) gravida 1, parity 0 were treated. The gestational age at delivery
was 34+1 to 41+4 weeks of pregnancy. There were no signs of venous stasis in the legs.
Pedal pulses remained palpable indicating that the aorta is not significantly altered
by the sumo-compression. In all patients up to 9 (3–9) units of blood and 8 (0–8)
units of fresh frozen plasma had been transfused during the procedure and on the intensive
care unit. Once fibrinogen resp. tranexamic acid was given the patients were kept
in the intensive care unit for 1–2 days and general anaesthesia lasted 4–20 h. “Sumo-compression”
was removed before anaesthesia was stopped. Hospital stay was between 4–12 days. One
woman complained of a little hip pain lasting some days. Another woman showed a skin
abrasion in the same area.
Discussion
The “sumo-compression” technique is safe and easy to administer. Laparotomy pads and
elastic bandages are available even in resource-poor settings. Uterovaginal packing
is known since a long time (see method of Bumm cited in [5]) and has been successfully used in a great number of patients [6]. Differently from conventional balloon tamponage and intrauterine packing “sumo-compression”
does not interfere with normal contraction of the uterus during recovery and may avoid
further complications like secondary PPH or infection.
Profiting by the same general anaesthesia “Sumo-compression” should be utilized after
the use of contractile drugs, curettage and surgical intervention as described above
had been unsuccessful.
In extreme obstetrical situations such as PPH the name of an effective method should
be easy to remember and at the same time be illustrative such as “sumo-compression”
or “quilting sutures”. To stop PPH after caesarean delivery we use “quilting sutures”,
6–10 U-stitches from the fundus to the cervix. They are easy to perform and effective
in stopping haemorrhage by compressing the uterus [7]. In case of PPH after C-section “quilting sutures” in a second laparotomy may be
more effective than “sumo-compression”. With both methods in our department post partum
hysterectomy could nearly always be avoided. The ease of the method encourages the
obstetrician to act without loosing valuable time by hesitating to perform one of
the more complicated procedures. Hopefully the “sumo-compression” will help to reduce
maternal morbidity and mortality particularly in resource-poor settings.
Conclusion
“Sumo-compression” should be performed in case of PPH from atony or extensive trauma
of vaginal tissue if the use of contractile drugs, curettage and surgical intervention
had been unsuccessful. It is important not to delay in performing “sumo-compression”
in order to alter the clotting system as less as possible.
Details of Ethics Approval
Details of Ethics Approval
For this kind of study there was no need of an ethics approval.
