Reply: Methods of holding the cervix and applying compression based on uterine bleeding: caudal or cephalad to the uterus?

Abstract

I thank Prof. Matsubara for his interest in my new procedure of uterine compression using an intrauterine balloon. Postpartum hemorrhage is a substantial burden for obstetricians and as a result many methods for achieving hemostasis have been developed to preserve the uterus. Although uterine artery embolization is very effective for postpartum hemorrhage, hospitals in some countries are unable to easily perform this procedure 1. Technical guidance is necessary to help less skilled obstetricians to more easily reduce postpartum hemorrhage. I have read the comments and description of Prof. Matsubara's new method called Matsubara–Yano (MY) suturing, using four sutures and also the modified MY suturing with three sutures in association with intrauterine balloon tamponade 2, 3. These are very similar to our technique with respect to compression of the caudal area, which is the bleeding site. Based on Prof. Matsubara's comments, we recommend differentiating between hemostatic methods based on the bleeding focus. I agree with the comment regarding the location of the main bleeding focus: caudal means the lower uterus or cervix, while cephalad means the uterine fundus or upper uterus. First, the uterine sandwich, such as a B-Lynch or Hayman suture, is effective for treating a cephalad bleeding focus in the uterus, such as in uterine atony 3. Second, uterine compression with an intrauterine balloon, i.e. our the uterine hollow obliteration (HYUNHO) method, modified MY suturing with three sutures associated with intrauterine balloon tamponade, or holding the cervix with a sponge forceps are effective for a caudal bleeding focus, i.e. in the lower uterus, such as in placenta previa. 2, 4. If obstetricians encounter postpartum hemorrhage, the main bleeding focus should be located and the most effective method for dealing with the specific cause of the emergency postpartum hemorrhage should be determined. Prof. Matsubara mentioned that holding the cervix is useful for preventing balloon prolapse and achieving hemostasis, and that holding the uterine cervix induces uterine contraction and reduces atonic bleeding 5. I agree that holding the cervix is effective for postpartum hemorrhage in the cervical area after cesarean section in patients with a total placenta previa. We also have experience with such cases. Holding the cervix with a sponge forceps reduces the bleeding from the implantation site of the placenta. However, complete cessation of the bleeding is not possible at the implantation site. Holding the cervix is an additional method with which to reduce bleeding during the use of other methods, such as cesarean hysterectomy or uterine artery embolization. Prof. Matsubara hypothesized that holding the cervix induces uterine contraction, citing this as evidence for supporting the utility of this procedure. However, objective proof is lacking and we do not agree that holding the cervix alone induces uterine contractions. The best method for reducing postpartum hemorrhage appears still to be compression. Many hemostatic methods are based on compression theory. Obstetricians should be reminded of the importance of compression and the need to be able to use methods targeted on the bleeding focus.