Abstract
BackgroundBimanual clot evacuation (BCE) is a simple clinical manoeuvre that may reduce need for surgical intervention in the management of severe postpartum haemorrhage (PPH). We sought to determine whether performing BCE in cases of severe PPH after vaginal birth reduces the need for surgical intervention.MethodsA retrospective chart review of women who delivered vaginally with a severe PPH between January 1, 2011 and December 31, 2014 in a single tertiary women’s hospital in Sydney, Australia was conducted. Severe PPH was classified as a blood loss ≥1000mls. The need for surgical management (including operating theatre uterine exploration or evacuation, intrauterine balloon tamponade, repair of significant trauma, uterine or internal iliac artery ligation, B-Lynch suture insertion or hysterectomy) was the primary outcome measure, as expressed by need for operating theatre utilisation.ResultsFrom a cohort of 438, 149 women (34.0%) had BCE, of whom 29 (19.5%) required surgical management compared to 103 of 289 women with no BCE (35.6%); an odds ratio (OR) of 0.38 for BCE (confidence interval 0.20–0.72; p = 0.003). Early BCE (< 1 h of delivery) was associated with a further reduction in surgery (OR 0.24; confidence interval 0.08–0.70; p = 0.009) compared to late BCE (> 1 h of delivery). There was no reduction in estimated blood loss (p = 0.86) or blood transfusion (p = 0.71) with BCE.ConclusionOur study suggests BCE reduces theatre utilisation in the context of severe PPH following vaginal delivery. Prospective trials are needed to determine whether BCE should be endorsed as a treatment modality for PPH post-vaginal delivery.
Highlights
Bimanual clot evacuation (BCE) is a simple clinical manoeuvre that may reduce need for surgical intervention in the management of severe postpartum haemorrhage (PPH)
The 2012 World Health Organisation (WHO) recommendations do mention the role of a similar procedure, bimanual uterine compression, as a temporizing measure for Postpartum haemorrhage (PPH) until further definitive management can be applied, this is a distinctly different procedure to BCE, where only physical pressure is applied for compression to aid haemostasis
Our findings suggest that, among women who experience severe PPH after vaginal delivery, BCE may be associated with a lower risk of operating theatre utilisation
Summary
Bimanual clot evacuation (BCE) is a simple clinical manoeuvre that may reduce need for surgical intervention in the management of severe postpartum haemorrhage (PPH). BCE involves ‘cupping’ the fundus of the uterus with one hand whilst performing a vaginal examination to digitally break down and expel any blood clots [9] This is hypothesised to enhance the effect of uterotonic agents on myometrial tissue by facilitating emptying of the uterine cavity. The 2012 World Health Organisation (WHO) recommendations do mention the role of a similar procedure, bimanual uterine compression, as a temporizing measure for PPH until further definitive management can be applied, this is a distinctly different procedure to BCE, where only physical pressure is applied for compression to aid haemostasis Whilst this has shown potential benefit there are only a limited number of randomised controlled trials, with both a Cochrane
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