PDF Compression Sutures For Critical Hemorrhage During Cesarean Section A Guide by CG Animation Satoru Takeda Ebook Full Chapter

Compression Sutures for Critical
Hemorrhage During Cesarean Section

A Guide by CG Animation Satoru
Takeda
Visit to download the full and correct content document:
https://textbookfull.com/product/compression-sutures-for-critical-hemorrhage-during-c
esarean-section-a-guide-by-cg-animation-satoru-takeda/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...
Anesthesia for Cesarean Section 1st Edition Giorgio

Capogna (Eds.)
https://textbookfull.com/product/anesthesia-for-cesarean-
section-1st-edition-giorgio-capogna-eds/
Cesarean delivery: a comprehensive illustrated

practical guide 1st Edition Gian Carlo Di Renzo
https://textbookfull.com/product/cesarean-delivery-a-
comprehensive-illustrated-practical-guide-1st-edition-gian-carlo-
di-renzo/
Directing for Animation Everything You Didn t Learn in

Art School With Interviews by Legendary Animation
Directors 1st Edition Tony Bancroft
https://textbookfull.com/product/directing-for-animation-
everything-you-didn-t-learn-in-art-school-with-interviews-by-
legendary-animation-directors-1st-edition-tony-bancroft/
Understanding Compression Data Compression for Modern

Developers 1st Edition Colt Mcanlis
https://textbookfull.com/product/understanding-compression-data-
compression-for-modern-developers-1st-edition-colt-mcanlis/
Ward Based Critical Care A Guide for Health
Professionals Ann M Price
https://textbookfull.com/product/ward-based-critical-care-a-
guide-for-health-professionals-ann-m-price/
Non Obstetric Surgery During Pregnancy A Comprehensive

Guide Ceana H. Nezhat
https://textbookfull.com/product/non-obstetric-surgery-during-
pregnancy-a-comprehensive-guide-ceana-h-nezhat/
Timing for animation 3rd Edition Harold Whitaker
https://textbookfull.com/product/timing-for-animation-3rd-
edition-harold-whitaker/
Asthma Allergic and Immunologic Diseases During

Pregnancy A Guide to Management Jennifer A. Namazy
https://textbookfull.com/product/asthma-allergic-and-immunologic-
diseases-during-pregnancy-a-guide-to-management-jennifer-a-
namazy/
Clinical Sleep Medicine A Comprehensive Guide for

Mental Health and Other Medical Professionals 1st
Edition Emmanuel H. During
https://textbookfull.com/product/clinical-sleep-medicine-a-
comprehensive-guide-for-mental-health-and-other-medical-
professionals-1st-edition-emmanuel-h-during/
Compression Sutures
for Critical Hemorrhage
During Cesarean Section
A Guide by CG Animation
Satoru Takeda
Shintaro Makino
Editors
123
Compression Sutures for Critical
Hemorrhage During Cesarean Section
Satoru Takeda • Shintaro Makino
Editors
Compression Sutures for

Critical Hemorrhage
During Cesarean Section
A Guide by CG Animation
Editors
Satoru Takeda Shintaro Makino
Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology
Faculty of Medicine Faculty of Medicine
Juntendo University Juntendo University
Bunkyo-ku Bunkyo-ku
Tokyo Tokyo
Japan Japan
ISBN 978-981-32-9459-2 ISBN 978-981-32-9460-8 (eBook)

https://doi.org/10.1007/978-981-32-9460-8
© Springer Nature Singapore Pte Ltd. 2020

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721,
Singapore
Preface
Although the maternal mortality rate is on a decreasing trajectory in Japan, 28–54

deaths (2006–2016) are still reported annually. This number is equivalent to 2.8–5.0
deaths/100,000 live births. This mortality rate is lower than those in other developed
countries. However, it has stopped decreasing and has instead remained constant for
the past 10 years. A redoubled effort is therefore necessary to achieve further
improvement in perinatal outcomes. According to a review of successful cases in
which the pregnant woman was saved, 1 in approximately every 250 pregnant
women requires critical care at the time of delivery and is exposed to life-threatening
events. Among these, critical hemorrhage in obstetrics is the most common event,
and massive hemorrhage during Cesarean section accounts for 70% of those suffer-
ing such an event. Many of these urgent cases involve placenta previa accreta, hem-
orrhage from the placental separation site, concomitant disseminated intravascular
coagulation (DIC), etc. As the rate of Cesarean section has been rising in recent
years, it is extremely important to master techniques for controlling hemorrhage
during Cesarean section. Efforts must still be made to reduce maternal mortality.
Thus, practice guide for treating critical hemorrhage in obstetrics has been devel-
oped, and efforts have been made to reduce the mortality rate of pregnant women.
In this circumstance, arterial ligation and stepwise uterine devascularization
were conventionally performed as hemostatic techniques to control massive hemor-
rhage during Cesarean section without hysterectomy, thereby preserving the uterus.
However, depending on the sites of arterial ligation, the hemostatic effect was inad-
equate because of collateral circulation. Subsequently, insufficient blood flow and
ischemia in the preserved uterus caused complications, such as ovarian dysfunction
and endometrial growth impairment. Therefore, arterial ligation is no longer per-
formed. Because of the growing demands for optimal hemostatic techniques that
preserve the uterus and its function, various compression sutures, including the
B-Lynch suture which was first reported in 1997, are the current mainstream proce-
dures for achieving hemostasis and have replaced arterial ligation. These newer
hemostatic techniques are now widely used in clinical practice. Furthermore, there
are recent reports describing hemostasis as having been achieved by intrauterine
balloon tamponade alone or in combination with compression sutures.
Herein, compression sutures, which are surgical hemostatic techniques for criti-
cal hemorrhage during Cesarean section, are explained by using computer-generated
(CG) animation. The limitations and problems encountered are also noted. We hope
v
vi Preface
that the thoughts of obstetricians with extensive experience treating critical hemor-
rhage in obstetrics can be read between the lines and that this book will help our
readers to reduce maternal mortality, even if only modestly, in their future clinical
practice.
Tokyo, Japan Satoru Takeda

August 2018
Contents
1 History of Surgical Remedies for Obstetrical Uterine Hemorrhage�� 1

Satoru Takeda and Yasuhisa Terao
2 Uterine Compression Sutures for Atonic Bleeding �� 11
Shintaro Makino and Satoru Takeda
3 Double Vertical Compression Sutures�� 17
Shintaro Makino
4 Vertical Compression Sutures with Contrivances�� 19
Jun Takeda
5 Compression Sutures Removal �� 23
Jun Takeda
6 Critical Obstetrical Hemorrhage�� 27
Shigetaka Matsunaga and Satoru Takeda
vii
History of Surgical Remedies
for Obstetrical Uterine Hemorrhage 1
Satoru Takeda and Yasuhisa Terao
Abstract
Arterial ligation and stepwise uterine devascularization were formerly used as
hemostatic techniques to control massive hemorrhage during cesarean section
without hysterectomy and to preserve the uterus. However, depending on the
sites of arterial ligation, the hemostatic effect was often inadequate because of
collateral circulation. Subsequently, insufficient blood flow and ischemia in the
preserved uterus caused ovarian dysfunction and endometrial growth impair-
ment, (e.g., hypomenorrhea, oligomenorrhea, amenorrhea, and infertility).
Furthermore, it has been recognized that subsequent pregnancies can be compli-
cated by premature labor, spontaneous abortion, placenta accreta, etc. At present,
arterial ligation is not performed.
In place of this technique, various compression sutures, including the B-Lynch
suture which was first reported in 1997, are the current mainstream hemostatic
techniques for uterine hemorrhage during cesarean section and are widely used
in clinical practice. Moreover, Bakri et al. reported favorable hemostatic out-
comes when managing hemorrhage from placenta previa and placenta previa
accreta by balloon tamponade. This technique is used for hemostasis in uterine
hemorrhage not only during cesarean section but also after vaginal delivery. The
hemostatic techniques in use have recently undergone diversification, including
application of a combination of intrauterine compression hemostasis and balloon
tamponade and intraoperative arterial embolization, performed in a hybrid oper-
ating room.
S. Takeda (*) · Y. Terao

Department of Obstetrics and Gynecology, Faculty of Medicine,
Juntendo University, Bunkyo-ku, Tokyo, Japan
e-mail: stakeda@juntendo.ac.jp; yterao@juntendo.ac.jp
© Springer Nature Singapore Pte Ltd. 2020 1

S. Takeda, S. Makino (eds.), Compression Sutures for Critical Hemorrhage
During Cesarean Section, https://doi.org/10.1007/978-981-32-9460-8_1
2 S. Takeda and Y. Terao
Keywords
Critical uterine hemorrhage · Cesarean section · Compression sutures · Uterine
balloon tamponade · Interventional radiology · Arterial embolization · Arterial
balloon occlusion · Damage control
1.1 Introduction
In Japan, the main causes of maternal mortality include critical hemorrhage in

obstetrics, cerebrovascular disease, amniotic fluid embolism, cardiac and macrovas-
cular disease, pulmonary disease, and infection. Among various causes of intrapar-
tum critical hemorrhage, the most common is uterine hemorrhage associated with
a coagulation disorder, followed by uterine rupture, atonic hemorrhage, premature
separation, and uterine inversion. In the past, uterine hemorrhage was conservatively
treated by securing vascular access for fluid and blood product replacement, admin-
istration of uterotonics, and hemostatic techniques such as bimanual compression,
uterine tamponade achieved by packing with gauze, uterine balloon tamponade,
etc. And also special care and appropriate treatment for concomitant disseminated
intravascular coagulation should be needed in most cases with critical hemorrhage
[1–4]. When hemostasis was difficult to achieve despite these measures, laparotomy
was performed for arterial ligation and hysterectomy. However, arterial emboliza-
tion has been used in recent years [5], allowing hemostasis without administering
anesthesia or performing laparotomy, which further exacerbates the already poor
general conditions of women suffering massive hemorrhage.
On the other hand, hemostatic techniques combined with uterine preservation
that have been used during cesarean section in the past include arterial ligation
(e.g., ligation of the internal iliac artery, uterine artery, and ascending branch of the
uterine artery) and stepwise uterine devascularization, in which the feeding vessels
around the uterus are sequentially ligated. However, depending on the sites of arte-
rial ligation, the hemostatic effect is often inadequate because of collateral circula-
tion. Even if the uterus is preserved, insufficient blood flow and uterine ischemia
causes ovarian dysfunction and endometrial growth impairment, which can result
in hypomenorrhea, oligomenorrhea, amenorrhea, and infertility. It has also been
reported that subsequent pregnancies are complicated by premature labor, spontane-
ous abortion, placenta accreta, etc. Thus, novel hemostatic techniques that preserve
the uterus and its function are eagerly awaited.
1.2 hanges in Hemostatic Techniques for Uterine

C
Hemorrhage After Vaginal Delivery
Intrauterine gauze packing and uterine balloon tamponade have been performed
for postpartum uterine hemorrhage that is difficult to control [6]. However,
because these conservative treatment techniques have limits, surgical hemostasis
1 History of Surgical Remedies for Obstetrical Uterine Hemorrhage 3
by arterial ligation at laparotomy was long performed as a hemostatic technique

combined with uterine preservation. Although ligation of the internal iliac artery
was widely performed for more than 100 years, since the late 1800s, its hemosta-
sis success was limited to the range of 40–60.7%. This is mainly attributable to
blood flow in the uterus substantially increasing during pregnancy and the uterus
receiving blood flow from the external iliac, lumbar, median sacral, inferior mes-
enteric, and other arteries through abundant anastomoses at the periphery of the
internal iliac artery. Because of these anastomoses, ligation of the internal iliac
artery does not reduce the blood flow in the uterine artery. Thus, hemostasis can-
not be achieved. Particularly in cases with the placenta attached to the lower uter-
ine segment, such as placenta previa and placenta previa accreta, the blood flow
from the external iliac and other arteries further increases; consequently, ligation
of the internal iliac artery becomes even less effective. This situation prompted
arterial ligation in the vicinity around the uterus. Ligation of the uterine artery
was reported by Waters in 1952 [7], and ligation of the ascending branch of the
uterine artery was reported by O’Leary et al. in 1966 [8]. For uterine hemorrhage
resistant to ligation of the uterine artery, AbdRabbo described, in 1994, a stepwise
uterine devascularization process, in which the feeding vessels of the uterus were
sequentially ligated [9].
However, ligation of these arteries is performed via laparotomy and imposes a
high risk on women whose general condition is poor due to massive hemorrhage.
At present, because catheterization procedures, such as arterial embolization, have
been adopted, these surgical hemostatic techniques are very rarely performed.
1.3 Hemostatic Techniques During Cesarean Section
When hemostasis is performed for uterine hemorrhage during cesarean section, the
abdomen is already open. In this state, because hysterectomy can be performed in
the worst case situations, surgical hemostatic techniques are also easy to perform
[10]. However, because massive hemorrhage is expected in cases, such as placenta
previa accreta, placenta increta, and placenta percreta, hemostatic techniques have
been attempted and studied under various conditions, taking into account general
clinical states and factors (e.g., severity of hemorrhage, disease, and hemorrhagic
tendency) and the presence or absence of fertility in various cases.
1.3.1 Arterial Ligation
Arterial ligation, including ligation of the internal iliac artery, has a limited hemo-
static effect and is less effective in cases with abundant blood flow from the external
iliac artery, such as placenta previa accreta [11]. On the other hand, stepwise uterine
devascularization, in which the feeding vessels of the uterus are sequentially ligated,
has a relatively high hemostatic effect [9]. However, even if the uterus is preserved,
insufficient blood flow and uterine ischemia might cause ovarian dysfunction and
endometrial growth impairment, which results in hypomenorrhea, oligomenorrhea,

amenorrhea, and infertility. Thus, arterial ligation, which permanently interrupts
blood flow, can lead to multiple complications and is no longer widely performed.
1.3.2 Compression Suture
The compression suturing technique aiming to block blood flow by suturing a

bleeding site with absorbable suture was first reported by B-Lynch et al. in 1997
[12]. Because the B-Lynch suture procedure is complex, various modifications
were subsequently developed. Hwu et al. reported vertical compression sutures,
in which the anterior and posterior walls of the lower segment of the uterine body
are sutured to stop hemorrhage from the detachment site of placenta previa [13].
We also reported double vertical sutures, which are a simpler technique that can
be used even in cases with concomitant atonic hemorrhage [14–16]. When rapid
Vicryl sutures, which dissolve in a few days, are used, these techniques do not
cause postoperative complications, such as intrauterine adhesion formation. These
innovations have been widely adopted as simple techniques that can be expedi-
tiously performed by all obstetricians. Practicing obstetricians should acquire these
hemostatic techniques and apply them, whenever necessary, to achieve hemorrhage
during cesarean section.
In addition to compression suturing techniques, i.e., those designed to suture the
anterior and posterior uterine walls, other reported strategies include intermittent
circular sutures (a suturing technique aiming to stop hemorrhage from a wide area),
U-shaped suture, and enclosing sutures (a suturing technique aiming to enclose one
side of the uterine wall) [17].
1.3.3 Balloon Tamponade
For massive uterine hemorrhage after vaginal delivery, tamponade achieved by

packing with gauze and towels was long performed. However, packing of the uterine
cavity with gauze was difficult due to the lack of available space in the cavity, and
the effects of this technique were also limited. Thus, hemostatic techniques using
various balloons have been developed for uterine hemorrhage. For example, there
are compression techniques employing a Foley catheter, Sengstaken–Blakemore
tube, Rush balloon for the bladder, condom, Fujimetro, etc. [6].
The Bakri balloon was first used for hemorrhage during cesarean section in
women with low-lying placenta, placenta previa, or placenta previa accreta and
subsequently for massive hemorrhage after vaginal delivery [18]. In many coun-
tries worldwide, this balloon has been officially approved and is currently used
as a balloon for hemostasis of uterine hemorrhage [19, 20]. The hemostasis suc-
cess rate for balloons ranges from 77 to 88%, which is similar to that for arte-
rial ligation. Moreover, balloons enable monitoring of the volume of blood loss as
drainage and rapid determination of the hemostatic effect, in a tamponade test [21,
22]. If hemostasis cannot be achieved, the ballooning process can immediately be

switched to arterial embolization or surgical hemostasis. Thus, balloons are use-
ful. Approximately 60–250 mL of physiological saline is injected and retained for
24–48 h. The recent hemostasis success rates range from 86 to 91.5%, and our
performance has yielded a consistent rate of 88.6%. Regarding changes before and
after the introduction of balloon tamponade although the frequency of performing
surgical hemostasis or total hysterectomy did not change for hemorrhage during
cesarean section, the frequencies of surgical hemostasis and arterial embolization
both apparently decreased for hemorrhage after vaginal delivery. The usefulness of
balloon tamponade has been demonstrated [20]. At present, balloon tamponade is
also recommended as the first choice for hemostasis of uterine hemorrhage after
vaginal delivery, according to the guidelines of major societies worldwide, such
as the World Health Organization, the International Federation of Gynecology and
Obstetrics, the American College of Obstetricians and Gynecologists, the Royal
College of Obstetricians and Gynaecologists, and the Society of Obstetricians and
Gynaecologists of Canada. Balloon tamponade is effective for controlling a rela-
tively small volume of hemorrhage oozing from the placental separation site during
cesarean section in women with low-lying placenta or placenta previa who do not
have a coagulation disorder.
1.3.4 Interventional Radiology (IVR)
Advances in interventional radiology (IVR) have enabled various hemostatic tech-

niques, such as TAE and intra-arterial balloon occlusion to be introduced into
clinical practice. TAE is effective for conditions which are difficult to control by
surgical hemostasis, such as puerperal hemorrhage after vaginal delivery, vaginal
and retroperitoneal hematoma, placenta accreta, and retained placenta, and it is also
effective for repeated hemorrhage after total hysterectomy. While TAE is performed
with absorbable gelatin sponge and porous gelatin particles (Gelpart®), permanent
embolization materials, such as metal coils and N-butyl-2-cyanoacrylate (NBCA),
are also used. IVR guidelines for obstetrical hemorrhage were developed [5], and
the remarkable effectiveness of IVR has resulted in a substantial decrease in the fre-
quency of performing hysterectomy. On the other hand, IVR is also associated with
adverse effects, such as endometrial hypoplasia, Asherman syndrome, myometrial
necrosis, ovarian dysfunction, bladder necrosis, gluteal muscle necrosis, and pelvic
abscess [5]. Moreover, pregnancy after TAE is often reportedly associated with seri-
ous conditions, such as premature rupture of membranes, preterm delivery, cesarean
section, placenta accreta [23], uterine rupture [24, 25], and massive puerperal hem-
orrhage. Future accumulation of cases is warranted. Recently, arterial embolization
has been applied to massive hemorrhage due to placenta previa accreta during cesar-
ean section, performed in a hybrid operating room.
Arterial balloon occlusion, by which blood flow is temporarily interrupted, was
reported as an emergency hemostatic technique for trauma during the Korean War
[26]. Subsequently, this procedure was developed as a prophylactic hemostatic
technique to prevent massive hemorrhage by placement of an intra-arterial bal-

loon occlusion catheter before surgery. In the field of gynecology, this technique
has been used before cervical myomectomy and has been shown to be effective
for preventing massive hemorrhage and avoiding blood transfusion. In the field of
obstetrics, several reports have documented that an arterial balloon was preopera-
tively placed to prevent massive hemorrhage due to placenta previa accreta and
thereby prevented massive hemorrhage by blocking blood flow at the onset of hem-
orrhage. The reported sites for arterial balloon placement in women with placenta
previa accreta include the internal iliac artery [27], common iliac artery [28, 29],
and abdominal aorta [26].
1.3.5 Damage Control Surgery and Resuscitation
In emergency medicine, damage control surgery (DCS) is a strategy in which only

bleeding is controlled to achieve recovery from life-threatening systemic conditions
in patients with severe trauma accompanied by hemorrhagic shock, instead of per-
forming conventional surgical procedures [30–32]. The most prominent causes of
intraoperative and postoperative mortality in patients with severe trauma accompa-
nied by massive hemorrhage are metabolic acidosis, hypothermia, and coagulopa-
thy, in other words, “the trauma triad of death,” which are attributed to disruption of
physiological homeostasis [30–32]. In patients with disrupted homeostasis, while
hemostasis is difficult to achieve surgically, their conditions further deteriorate.
Even though correction of their conditions is attempted intraoperatively, recovery
is extremely difficult to achieve. In such cases, while invasiveness is minimized,
DCS is performed to achieve only immediate control of injury, and damage control
resuscitation (DCR) for improvement of general conditions. These strategies can be
applied to massive obstetric hemorrhage.
When sudden simultaneous onset of massive hemorrhage and coagulopathy,
such as disseminated intravascular coagulation (DIC), makes bleeding uncontrol-
lable during cesarean section, pressure hemostasis is applied by packing gauze or
towels on bleeding points or areas as DCS. Meanwhile, DCR is performed with
blood transfusion, replenishment of coagulation factors, etc. At facilities where
blood transfusion or replenishment of coagulation factors cannot be performed
immediately or where arterial embolization by interventional radiology (IVR) can-
not be performed, only DCS is performed. Then, the abdominal wall is closed with a
sterile seal without further treatment, and patients are transferred to a tertiary medi-
cal facility, where hemostasis and systemic control can be performed.
When massive hemorrhage occurs during surgery, the criteria for switching to
DCS include hypothermia at 35 °C or lower, arterial pH of 7.2 or lower, base excess
level of 15 mmol or lower, serum lactate level of 5 mmol or higher, and prolonga-
tion of prothrombin time or activated partial thromboplastin time by 50% or more.
DCS is also indicated in cases without resolution of obstetric DIC. Hypothermia
inhibits enzymatic activities in blood-clotting reactions and also reduces plate-
let function; consequently, coagulopathy is induced. A prolonged state of shock
causes anaerobic metabolism, which results in metabolic acidosis. When arterial

pH decreases to <7.2, catecholamine actions are reduced, and circulatory manage-
ment becomes difficult. For metabolic acidosis secondary to hemorrhagic shock,
administration of sodium bicarbonate is not recommended. It is important to restore
the circulating blood volume and to increase oxygen-carrying capacity by admin-
istering fluid and blood. When the fibrinogen level is 150 mg/dL or lower, the inci-
dence of non-surgical bleeding increases. Thus, an adequate amount of fresh frozen
plasma (FFP), fibrinogen preparations, and cryoprecipitate is administered from the
early stages to replenish coagulation factors [33–35]. Because bolus infusion of FFP
causes pulmonary edema and other conditions, caution should be exercised.
Complications associated with DCS include infection due to gauze left in place
for hemostasis, enhanced systemic inflammatory responses to the release of vari-
ous bioactive substances, fragility of the serous membrane of the bowel wall, and
abdominal compartment syndrome (ACS) due to elevated intraperitoneal pres-
sure by gauze and other materials. In ACS, portal blood cytokine levels are high,
and myeloperoxidase activity, which is an indicator of neutrophilic disorders of
the lung, is also elevated. Because even sterile packed gauze modifies neutrophil
activity, sivelestat sodium hydrate is used to prevent acute respiratory distress syn-
drome. Attention should be paid to pulmonary edema and hyperkalemia secondary
to massive blood transfusion. If needed, dobutamine, phosphodiesterase-III inhibi-
tors, carperitide, diuretics, and other drugs are administered, or hemodialysis is
performed.
Charoenkwan reported that pelvic floor hemorrhage after hysterectomy was
stopped with the Bakri postpartum balloon [36], a technique similar to the pack-
ing hemostatic technique. According to this technique, as described in a previ-
ous report, for pelvic floor hemorrhage after hysterectomy, the posterior fornix is
compressed and lifted toward the Douglas pouch. Using the level of the posterior
fornix as a mark, the Douglas pouch is transversely incised by 2.5 cm to gain
access. The shaft of the balloon is inserted through the incision and pulled out via
the vagina. Absorbable hemostatic materials are applied to bleeding sites, with
400–550 mL of physiological saline being injected into the balloon to compress
the pelvic floor. A 1-L bottle is tied to the shaft of the balloon for continuous
traction. After 24–30 h of continuous traction, the balloon is removed from the
vagina. In addition, Charoenkwan also reported a hemostatic technique using the
Bakri postpartum balloon for bleeding from the posterior uterine wall after cesar-
ean section [37].
When prolonged uterine hemorrhage is life-threatening in hemorrhagic shock
cases, an intra-aortic balloon occlusion catheter is inserted from the inguinal region
to occlude the aortic blood flow. Meanwhile, DCR is performed. After stabiliza-
tion of the patient’s general condition, hemostasis is attempted by IVR or other
techniques. The hybrid operating room, where IVR and surgery can be performed
simultaneously, is advantageous for performing laparotomy to achieve hemostasis
in women undergoing cesarean section for placenta previa, accreta, increta, or per-
creta, in whom massive hemorrhage is expected, and women with life-threatening
puerperal hemorrhage due to uterine rupture.
References
1. Matsunaga S, Seki H, Ono Y, Matsumura H, Murayama Y, Takai Y, Saito M, Takeda S, Maeda
H. A retrospective analysis of transfusion management for obstetric hemorrhage in a Japanese
obstetric center. ISRN Obstet Gynecol. 2012;2012. Article ID 854064, 8 pages. https://doi.
org/10.5402/2012/854064.
2. Makino S, Takeda S, Kobayashi T, Murakami M, Kubo T, Hata T, Masuzaki H. National sur-
vey of fibrinogen concentrate usage for post-partum hemorrhage in Japan: investigated by the
Perinatology Committee, Japan Society of Obstetrics and Gynecology. J Obstet Gynaecol Res.
2015;41(8):1155–60. https://doi.org/10.1111/jog.12708.
3. Matsunaga S, Takai Y, Nakamura E, Era S, Ono Y, Yamamoto K, Maeda H, Seki H. The clini-
cal efficacy of fibrinogen concentrate in massive obstetric haemorrhage with hypofibrinogen-
aemia. Sci Rep. 2017;7:46749.
4. Takeda S, Makino S, Takeda J, Kanayama N, Kubo T, Nakai A, Suzuki S, Seki H, Terui K,
Inaba S, Miyata S. Japanese clinical practice guide for critical obstetrical hemorrhage (2017
revision). J Obstet Gynaecol Res. 2017;43(10):1517–21.
5. Sone M, Nakajima Y, Woodhams R, Shioyama Y, Tsurusaki M, Hiraki T, Yoshimatsu M,
Hyodoh H, Kubo T, Takeda S, Minakami H. Interventional radiology for critical hemorrhage
in obstetrics: Japanese Society of Interventional Radiology (JSIR) procedural guidelines. Jpn
J Radiol. 2015;33(4):233–40. https://doi.org/10.1007/s11604-015-0399-0.IVR.
6. Georgiou C. A review of current practice in using balloon tamponade technology in the man-
agement of postpartum haemorrhage. Hypertens Res Pregnancy. 2014;2:1–10.
7. Waters EG. Surgical management of postpartum hemorrhage with particular reference to liga-
tion of uterine arteries. Am J Obstet Gynecol. 1952;64:1143–8.
8. O’Leary JL, O’Leary JA. Uterine artery ligation in the control of intractable postpartum hem-
orrhage. Am J Obstet Gynecol. 1966;94:920–4.
9. AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of
uncontrolled post-partum hemorrhage with preservation of the uterus. Am J Obstet Gynecol.
1994;171:694–700.
10. Makino S, Hirai C, Takeda J, Yorifuji T, Itakura A, Takeda S. Hemostatic technique during
cesarean section. Hypertens Res Pregnancy. 2016;4:6–10.
11. Iwata A, Murayama Y, Itakura A, Baba K, Seki H, Takeda S. Limitations of internal iliac artery
ligation for the reduction of intraoperative hemorrhage during cesarean hysterectomy in cases
of placenta previa accreta. J Obstet Gynaecol Res. 2010;36(2):254–9.
12. B-Lynch C, Coker A, Lawal AH, et al. The B-Lynch surgical technique for the control of mas-
sive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet
Gynaecol. 1997;104:372–5.
13. Hwu YM, Chen CP, Chen HS, et al. Parallel vertical compression sutures: a technique
to control bleeding from placenta praevia or accreta during caesarean section. BJOG.
2005;112:1420–3.
14. Makino S, Takeda S, Yorifuji T, et al. Double vertical compression sutures: a novel conser-
vative approach to managing post-partum haemorrhage due to placental praevia and atonic
bleeding. Aust N J Obstet gynaecol. 2012;52:290–2.
15. Tanaka T, Makino S, Yorifuji T, Saito T, Koshiishi T, Tanaka S, Ota A, Takeda S. Vertical
compression sutures for control of postpartum hemorrhage from a placenta previa in cesarean
section—to evaluate the usefulness of this technique. Hypertens Res Pregnancy. 2014;2:21–5.
16. Takeda J, Hiranuma K, Hirayama T, Makino S, Itakura A, Takeda S. The use of medial, wider
vertical compression sutures to reduce uterine blood flow for effaced uterine isthmus: a case
report. J Obstet Gynaecol. 2018;38(6):871–3. https://doi.org/10.1080/01443615.2017.1387522.
17. Takeda J, Makino S, Matsumura Y, Itakura A, Takeda S. Enclosing sutures technique for con-
trol of local bleeding in a case of placenta increta. J Obstet Gynaecol Res. 2018;44(8):1472–5.
https://doi.org/10.1111/jog.13670.
18. Bakri YN, Amri A, Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding. Int J Gynecol
Obstet. 2001;74:139.
19. Yorifuji T, Tanaka T, Makino S, Koshiishi T, Sugimura M, Takeda S. Balloon tamponade in

atonic bleeding induces uterine contraction: attempt to quantify uterine stiffness using acoustic
radiation force impulse elastography before and after balloon tamponade. Acta Obstet Gynecol
Scand. 2011;90(10):1171–2.
20. Takeda J, Makino S, Hirai C, Shimanuki Y, Inagaki T, Itakura A, Takeda S. Long-term uterine
balloon tamponade for treatment and obliteration of ruptured uterine pseudoaneurysm. Taiwan
J Obstet Gynecol. 2018;57:329–31.
21. Laas E, Bui C, Popowski T, et al. Trends in the rate of invasive procedures after the addition
of the intrauterine tamponade test to a protocol for management of severe postpartum hemor-
rhage. Am J Obstet Gynecol. 2012;207:281.e1–7.
22. Makino S, Takeda J, Hirai C, Itakura A, Takeda S. Uterine balloon tamponade as a test to assess
the further treatment. Acta Obstet Gynecol Scand. 2015;94(5):556. https://doi.org/10.1111/
aogs.12599.
23. Inoue S, Masuyama H, Hiramatsu Y, Multi-Institutional Study Group of Transarterial
Embolization for Massive Obstetric Haemorrhage in Chugoku & Shikoku Area Society of
Obstetrics and Gynecology. Efficacy of transarterial embolisation in the management of post-
partum haemorrhage and its impact on subsequent pregnancies. Aust N Z J Obstet Gynaecol.
2014;54(6):541–5.
24. Takeda J, Makino S, Ota A, Tawada T, Mitsuhashi N, Takeda S. Spontaneous uterine rupture
at 32 weeks of gestation after previous uterine artery embolization. J Obstet Gynaecol Res.
2013;40(1):243–6. https://doi.org/10.1111/jog.12122.
25. Sano Y, Takeda J, Kuroda K, Makino S, Itakura A, Takeda S. Embrittlement of uterus
after uterine artery embolization: a case of uterine perforation. Hypertens Res Pregnancy.
2016;4:42–4.
26. Hughes CW. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal
hemorrhage in man. Surgery. 1954;36:65.
27. Dubois J, Garel L, Grignon A, Lemay M, Leduc L. Placenta percreta: balloon occlusion and
embolization of the internal iliac arteries to reduce intraoperative blood losses. Am J Obstet
Gynecol. 1997;176:723–6.
28. Shih JC, Liu KL, Shyu MK. Temporary balloon occlusion of the common iliac artery: new
approach to bleeding control during cesarean hysterectomy for placenta percreta. Am J Obstet
Gynecol. 2005;193(5):1756–8.
29. Ono Y, Murayama Y, Era S, Matsunaga S, Nagai T, Osada H, Takai Y, Baba K, Takeda S, Seki
H. Study of the utility and problems of common iliac artery balloon occlusion for placenta
previa with accreta. J Obstet Gynaecol Res. 2018;44:456–62.
30. Wyrzykowski A. Trauma damage control. In: Mattox K, et al., editors. Trauma. 7th ed.
New York: McGraw-Hill; 2013. p. 725–46.
31. Moore EE, et al. Staged physiologic restoration and damage control surgery. World J Surg.
1998;22:1184–90.
32. Shapiro MB, et al. Damage control: collective review. J Trauma. 2000;49:969–78.
33. Takeda S, Takeda J, Makino S. A minimally invasive hemostatic strategy in obstetrics aiming
to preserve uterine function and enhance the safety of subsequent pregnancies. Hypertens Res
Pregnancy. 2019;7(1):9–15. https://doi.org/10.14390/jsshp.HRP2018-013.
34. Takeda J, Takeda S. Management of disseminated intravascular coagulation associated with
placental abruption and measures to improve outcomes. Obstet Gynecol Sci. 2019;62:299–
306. https://doi.org/10.5468/ogs.2019.62.5.299.
35. Takeda J, Makino S, Takeda S. Chapter. Hemostasis for massive hemorrhage during cesar-
ean section. In: Schmolzer G, editor. Cesarean delivery. London: IntechOpen. https://doi.
org/10.5772/intechopen.86394. Published: 3 Oct 2019.
36. Charoenkwan K. Effective use of the Bakri postpartum balloon for posthysterectomy pelvic
floor hemorrhage. Am J Obstet Gynecol. 2014;210(6):586.e1–3.
37. Charoenkwan K. Use of the Bakri postpartum balloon in a patient with intractable pelvic floor
hemorrhage: when other methods failed to stop postcesarean bleeding, physicians tried some-
thing new. Am J Obstet Gynecol. 2013;209(3):277.e1–5.
Uterine Compression Sutures for Atonic
Bleeding 2
Shintaro Makino and Satoru Takeda
Abstract
Uterine compression suture is a simple and effective hemostatic procedure that
requires no special skills. It can be performed in a primary medical institution
even in cases which need to be transferred. The implementation of TAE and arte-
rial ligation should be limited to cases with failure of local hemostatic proce-
dures (e.g., balloon tamponade and compression suture) in consideration of their
adverse effects. It is important that each institution has relevant protocols in
place. Keep in mind that DIC treatment is the top priority while performing dam-
age control, as described in Chapter 1.
Keywords
Atonic bleeding · Balloon tamponade · B-Lynch suture · Uterine compression
sutures · TAE
2.1 Introduction
Although there are various causes of bleeding during cesarean section, they are
roughly divided into two types, i.e., bleeding from the separated surface of the pla-
centa and atonic bleeding. The amount of bleeding depends on the time required for
identification of the cause of bleeding, treatment, and suturing of the myometrium.
Doctors should have full knowledge of hemostatic techniques and their procedures
in advance in order to take prompt action to prevent secondary atonic bleeding due
to massive bleeding.
S. Makino · S. Takeda (*)

e-mail: shintaro@juntendo.ac.jp; stakeda@juntendo.ac.jp

12 S. Makino and S. Takeda
2.1.1 imanual Compression, Drug Therapy, and the Search

B
for Causes of Bleeding
In the same manner as in vaginal delivery, bimanual compression and sufficient

uterotonic medication should first be performed for atonic bleeding during cesarean
section. If these treatments are effective, but postoperative rebleeding is predicted,
balloon tamponade should be performed postoperatively or after returning to the
ward to prevent rebleeding.
In patients who develop atonic bleeding after returning to the ward postopera-
tively, bimanual compression, uterotonic medication, balloon tamponade, etc. should
be performed according to the above protocol for bleeding during vaginal delivery.
If hemostasis is not achieved by these treatments, TAE should be performed.
2.1.2 Uterine Compression Suture
Although bleeding is controlled to some extent by bimanual compression during

laparotomy, uterine compression suture for the uterine body should be performed
when continuous compression of the uterine body is necessary. In our hospital, a
modified B-Lynch suture [1] is used. We use vertical compression sutures for bleed-
ing from the separated surface of placenta previa and have reported a new method
of vertical compression suture applicable to cases accompanied by atonic bleeding.
2.1.3 Arterial Ligation and Total Hysterectomy
If bleeding cannot be controlled by uterine compression suture, hemostasis should

be attempted by ligation of the bilateral ascending branches of the uterine artery,
ovarian arteries, and main trunk of the uterine artery in this order (stepwise uterine
devascularization). If bleeding is still difficult to control, total hysterectomy should
be performed.
2.2 Local Hemostasis or Blockage of Blood Flow
The prognosis of massive bleeding is dependent on how quickly the cause of bleed-
ing is identified, proper measures are implemented against it, and in cases of cesar-
ean section myometrial suture is completed. Because continuous bleeding may
cause secondary atonic bleeding, it is necessary to immediately choose the most
suitable method of hemostasis once massive bleeding takes place.
Hemostatic methods are roughly divided into local hemostasis and blockade of
blood flow or ligation of blood vessels by TAE, devascularization, etc. Regardless
of which type of hemostasis is chosen, it is important to make a choice based
on a good understanding of adverse effects and complications of the hemostatic
method. Local hemostatic measures include gauze compression, Z-suture, balloon
2 Uterine Compression Sutures for Atonic Bleeding 13
tamponade, the modified B-Lynch suture, and vertical compression suture. As com-
plications of these procedures, injuries to surrounding organs such as the bladder
and rectum may occur. On the other hand, arterial ligation and TAE, which block
blood flow into the uterus, may induce a wider variety of complications in com-
parison with local hemostasis [2]. Post-procedural complications include uterine
infection, myometrial necrosis, Asherman syndrome, menstrual abnormalities, such
as hypomenorrhea and oligomenorrhea, poor endometrial development, and infer-
tility. In addition, serious adverse effects, such as abortion, uterine rupture, placenta
accreta, and postpartum hemorrhage, may occur at the time of subsequent preg-
nancy. Therefore, blockade of blood flow and ligation should be implemented only
when compression suture, balloon tamponade, and other hemostatic measures have
failed to control bleeding.
2.3 Uterine Compression Suture
As mentioned above, uterine compression suture is performed when atonic

bleeding does not respond to medications or when continuous uterine body com-
pression is judged to be necessary although bimanual compression is effective
to some extent. Several hemostatic surgical techniques during cesarean section
have been reported previously (Table 2.1). Although there are many variation of
type of sutures, overall hemostatic rate is about 90%. We devised “double verti-
cal compression sutures” which is one of the relatively easy and effective ways
of achieving hemostasis during cesarean section for placenta previa and uterine
atony [8]. This technique was introduced in the Royal College of Obstetricians
and Gynaecologists Guideline [10]. And Tanaka et al. reported patients with ver-
tical compression sutures; the mean intraoperative blood loss was significantly
reduced in these patients, compared to those without compression sutures. Uterine
Table 2.1 Summary of compression sutures

Hemostatic
Authors Method Objective Cases rate (%)
J-C Shih, et al. [3] “Nausicaa” compression PAS, atonic 68 97.0
suture bleeding
Takahashi H, et al. [4] Matsubara–Yano suture PAS 50 92
Matsuzaki S, et al. [5] Modified Hayman suture Atonic 19 89.5
technique bleeding
Kaya B, et al. [6] B-Lynch plus bilateral Atonic 8 87.5
internal iliac artery ligation bleeding
(BIIAL)
Şahin H, et al. [7] Double B-Lynch suture PAS, atonic 14 100
bleeding
Makino S, et al. [8] Double vertical compression PAS 3 100
sutures
Tanaka T, et al. [9] Vertical compression sutures PAS 14 100
PAS placenta accreta spectrum
isthmus vertical compression sutures were effective for stopping bleeding from
the uterine isthmus and uterine body [9].
The major hemostatic mechanism of uterine compression suture was formerly
considered to be compression by suture. However, we previously assessed changes
in uterine artery flow before and after uterine compression suture by ultrasound
tomography and found that the blood flow rate decreased, and the resistance index
(RI) increased, after suturing. In general, 90% of the blood supply to the pregnant
uterus comes from the uterine artery. Therefore, it is presumed that uterine compres-
sion suturing exerts two actions, i.e., hemostasis by compression of the bleeding
surface and reduction of the uterine blood flow.
However, they are associated with the risk of uterine ischemia; thus, in a patient
who experiences excessive abdominal pain after receiving vertical compression
sutures, the need for uterine blood perfusion must be assessed. When uterine isch-
emia is found, removal of the compression sutures should be considered [11].
Based on these findings, uterine compression suturing is a hemostatic method
that should be mastered by doctors, particularly those working in institutions where
TAE is not immediately feasible.
2.4 For Success of Compression Suture
Although the above-mentioned compression suture can halt bleeding effectively, it

is important for the success of the procedure that blood coagulation function is nor-
mal. Bleeding during delivery is likely to be underestimated because of mixing with
amniotic fluid. Although obstetric massive bleeding is defined as 1 L or more in
cases of vaginal delivery and 2 L or more in cases of cesarean section, less bleeding
may actually cause abrupt changes in the maternal condition because of influences
of dehydration during delivery or complications of pregnancy such as preeclampsia.
Once DIC occurs, it induces secondary atonic bleeding, leading to a vicious cycle of
repeated massive bleeding. Therefore, when bleeding is massive, the cause should
be identified, and fluid therapy and blood transfusion should be initiated as needed,
with reference to the shock index (SI) while paying attention to not only the amount
of bleeding but also the patient’s general condition. In DIC cases, supplementation
of coagulation factors employing fresh frozen plasma (FFP) is most important. The
blood fibrinogen level should be restored to 150 mg/dL or higher as quickly as pos-
sible [12, 13].
A recent report showed that compression suture caused no significant difference
in the abortion rate or the incidence of preterm labor although the severity of pelvic
adhesion at the time of cesarean section after compression suturing was significantly
higher [14]. Therefore, further investigation is necessary concerning the influences
of compression suturing on the subsequent pregnancy. Another study showed that
among the patients who underwent elective cesarean, no differences were observed
between the UCS and non-UCS groups in the frequency of postoperative endo-
metritis (3/28 [10.7%] vs 6/54 [11.1%]; P = 0.957) or ileus (2/28 [7.1%] vs 3/54
[5.6%]; P = 0.776). After emergency cesarean, postoperative endometritis was
2 Uterine Compression Sutures for Atonic Bleeding 15
significantly more common in the UCS than in the non-UCS group (8/39 [20.5%]
vs 4/37 [10.8%]; P = 0.021), but the frequency of ileus did not differ (1/39 [2.6%]
vs 2/37 [5.4%]; P = 0.61) [15].
2.5 Conclusion
Unlike in cases of placenta previa or concomitant uterine myoma, in which massive

bleeding is predicted, intrapartum massive bleeding may occur suddenly and cause
rapid changes. Therefore, the prognosis of the patients varies widely, depending on
whether it is distinguished quickly from premature separation of normally implanted
placenta, soft birth canal laceration (vaginal wall or cervical laceration), retained
placenta or membranes, placenta accreta, vulvar or vaginal wall hematoma, uterine
inversion, uterine rupture, etc. and whether appropriate treatments for the condition
are performed. In addition, it is essential for the success of hemostasis that DIC
is treated promptly by initiating fluid therapy and blood transfusion while adding
blood tests and imaging tests according to the amount of bleeding and the general
condition of the patient. Balloon tamponade and the modified B-Lynch suture are
simple and effective hemostatic procedures that require no special skills. They can
be performed during transfer from a primary medical institution to a higher order
medical institution. The implementation of TAE and arterial ligation should be lim-
ited to cases with failure of local hemostatic procedures (e.g., balloon tamponade
and compression suture) in consideration of their adverse effects. It is important that
each institution has relevant protocols in place. Furthermore, doctors should obtain
training and familiarize themselves with how to deal with atonic bleeding once the
diagnosis has been made.
References
1. B-Lynch C, Cocker A, Lawal AH, et al. The B-Lynch surgical technique for the control of mas-
Gynecol. 1997;104:325–7.
2. Takeda S, Takeda J, Makino S. A minimally invasive hemostatic strategy in obstetrics aiming
to preserve uterine function and enhance the safety of subsequent pregnancies. Hypertens Res
Pregnancy. 2019;7(1):9–15. https://doi.org/10.14390/jsshp.HRP2018-013.
3. Shih JC, Liu KL, Kang J, Yang JH, Lin MW, Yu CU. ‘Nausicaa’ compression suture: a sim-
ple and effective alternative to hysterectomy in placenta accreta spectrum and other causes of
severe postpartum haemorrhage. BJOG. 2019;126:412–7.
4. Takahashi H, Baba Y, Usui R, Suzuki H, Horie K, Yano H, Ohkuchi A, Matsubara S. Matsubara-
Yano suture: a simple uterine compression suture for postpartum hemorrhage during cesarean
section. Arch Gynecol Obstet. 2019;299:113–21.
5. Matsuzaki S, Endo M, Tomimatsu T, Nakagawa S, Matsuzaki S, Miyake T, Takiuchi T, Kakigano
A, Mimura K, Ueda Y, Kimura T. New dedicated blunt straight needles and sutures for uterine
compression sutures: a retrospective study and literature review. BMC Surg. 2019;19:33.
6. Kaya B, Tuten A, Daglar K, Onkun M, Sucu S, Dogan A, Unal O, Guralp O. B-Lynch uterine
compression sutures in the conservative surgical management of uterine atony. Arch Gynecol
Obstet. 2015;291:1005–14.
7. Şahin H, Soylu Karapınar O, Şahin EA, Dolapçıoğlu K, Baloğlu A. The effectiveness of the
double B-lynch suture as a modification in the treatment of intractable postpartum haemor-
rhage. J Obstet Gynaecol. 2018;38:796–9.
8. Makino S, Tanaka T, Yorifuji T, Koshiishi T, Sugimura M, Takeda S. Double vertical com-
pression sutures: a novel conservative approach to managing post-partum hemorrhage due to
placenta previa and atonic bleeding. Aust N Z J Obstet Gynaecol. 2012;52:290–2.
9. Tanaka T, Makino S, Yorifuji T, Saito T, Koshiishi T, Takeda S. Vertical compression sutures
for control of postpartum hemorrhage from a placenta previa in cesarean section to evaluate
the usefulness of this technique. Hypertens Res Pregnancy. 2014;2:21–5.
10. Mavrides E, Allad S, Chandraharan E, Collins P, Green L, Hunt BJ, et al. Prevention and
management of postpartum haemorrhage: green-top guideline no. 52. Int J Obstet Gynaecol.
2017;124:106–49.
11. Takeda J, Kumakiri J, Makino S, Itakura A, Takeda S. Laparoscopic removal of uterine vertical
compression sutures. Gynecol Minim Invasive Ther. 2017;6:73–5.
12. Takeda J, Makino S, Takeda S. Hemostasis for massive hemorrhage during cesarean section.
In: Cesarean delivery. IntechOpen; 2019 (in press).
13. Takeda S, Makino S, Takeda J, Kanayama N, Kubo T, Nakai A, Suzuki S, Seki H, Terui K,
Inaba S, Miyata S. Japanese clinical practice guide for critical obstetrical hemorrhage (2017
revision). J Obstet Gynaecol Res. 2017;43:1517–21.
14. An GH, Ryu HM, Kim MY, et al. Outcomes of subsequent pregnancies after uterine compres-
sion sutures for postpartum hemorrhage. Obstet Gynecol. 2013;122:565–70.
15. Suzuki Y, Matsuzaki S, Mimura K, Kumasawa K, Tomimatsu T, Endo M, Kimura
T. Investigation of perioperative complications associated with use of uterine compression
sutures. Int J Gynaecol Obstet. 2017;139:28–33.
Double Vertical Compression Sutures
3
Shintaro Makino
Uterine compression suture is performed when uterine bleeding is not stopped by

using medications or uterine balloon tamponade and is revealed to be useful in
recent reports.
The B-Lynch suture [1] is a uterine compression suture technique first reported
in 1997 with the aim of achieving blockade of blood flow and compression hemo-
stasis in the bleeding surface using catgut thread. Because the original technique
uses one needle thread, it is difficult to achieve sufficient ligation. Therefore, a mod-
ified B-Lynch suture using two-needle threads is performed in a process similar to
modifications to the B-Lynch suture proposed by Hayman et al. [2].
3.1 Double Vertical Compression Sutures [3] (Video 3.1)
First, the bilateral cut ends of the uterine incision should be ligated, and bleeding
from the ascending branches of the uterine artery is to be stopped. Second, after
confirming that the bladder is sufficiently detached downwards, the needle thread
should pierce the uterus from the anterior wall to the posterior wall at a stroke below
the lateral side of the incision while paying attention to the rectum. On the contralat-
eral side, the needle thread is passed in the same manner, and ligation is performed
on the right and left sides of the uterine fundus while having an assistant compress
the uterus with both hands.
Electronic Supplementary Material The online version of this chapter (https://doi.org/10.1007/978-

981-32-9460-8_3) contains supplementary material, which is available to authorized users.
S. Makino (*)
e-mail: shintaro@juntendo.ac.jp

18 S. Makino
If blood is flowing outward from the separated surface of placenta previa, double
vertical compression suture combined with compression suture in the uterine cervix
should be performed to stop the bleeding. This method is also applicable to cases
of concomitant atonic bleeding after massive bleeding. We use 90 cm of Vicryl
Rapide® 1 (Ethicon, Tokyo), which dissolves in a few days, for uterine compres-
sion suture to prevent postoperative complications such as uterine cavity adhesion.
This allows reduction of the duration of uterine compression and decreases the risk
of menstrual disorder or implantation disorder resulting from deformation of the
uterus.
References
1. B-Lynch C, Cocker A, Lawal AH, et al. The B-Lynch surgical technique for the control of mas-
Gynecol. 1997;104:325–7.
2. Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of
postpartum hemorrhage. Obstet Gynecol. 2002;99:502–6.
pression sutures: a novel conservative approach to managing post-partum hemorrhage due to
placenta previa and atonic bleeding. Aust N Z J Obstet Gynaecol. 2012;52:290–2.
Vertical Compression Sutures
with Contrivances 4
Jun Takeda
Abstract
Postpartum hemorrhage is one of the leading causes of maternal morbidity and
mortality. Several hemostatic surgical techniques during cesarean section as
typified by B-Lynch sutures and Hyman sutures (see Chap. 2) have been reported
previously (B-Lynch et al., Br J Obstet Gynecol 104: 372–375, 1997; Hayman
et al., Obstet Gynecol 99: 502–506, 2002). Among them, vertical compression
sutures (Makino et al., Aust N Z J Obstet Gynecol 52: 290–292, 2012) are an
effective and easy way of achieving hemostasis during cesarean section and
now cited in BJOG Guidelines (Mavrides et al., BJOG 124: e106–e149, 2017).
However, in particular cases, it is difficult to achieve hemostasis only with the
compression sutures. In such cases, it needed contrivances to achieve hemosta-
sis and to act against complication as practical applications of compression
sutures. In this chapter, modifications of vertical compression sutures are
described.
Keywords
Complication · Compression sutures · Contrivance · Enclosing sutures · Medial
and wider compression sutures · Modification · Uterine balloon tamponade
4.1 Introduction
For the original method of the double vertical compression sutures, threads were
placed through the anterior wall and posterior wall of the uterus and compress the
uterine cavity by apposing the anterior and posterior walls [1]. It originally aims to
J. Takeda (*)
Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University,
Bunkyo-ku, Tokyo, Japan
e-mail: jtakeda@juntendo.ac.jp
20 J. Takeda
cease uterine bleeding during elective cesarean section for placenta previa. Some
contrivances aided compression sutures for the reliable hemostasis and minimal
invasive procedure.
Case 1: Uterine Compression Sutures with Balloon Tamponade [2]

A 28-year-old primipara underwent cesarean section due to dystocia of labor. Atonic
bleeding was started after the birth even with the usage of intravenous administra-
tions of uterotonic agents. As a mechanical hemostasis, uterine balloon tamponade
with metreurynter (Fujimetoro®: Fuji Latex, Co., Ltd. Tokyo) was attempted first;
however, it ends up with no effect. Thus, the uterine isthmus compression sutures
were performed. Because still a little bleeding continued, metreurynter was inserted
again at the middle of bilateral compression sutures, and hemostasis was accom-
plished. Metreurynter was deflated and removed a day after the surgery without
bleeding. She was able to discharge from the hospital 6 days after the surgery.
This case revealed that uterine isthmus compression sutures could have a poten-
tial to stop uterine corpus bleeding, possibly by ligating anastomosis of arcuate or
radial arteries between ascending and descending uterine arteries. In addition, com-
bination of uterine balloon tamponade and uterine compression sutures is effective.
Case 2: Medial and Wider Compression Sutures [3]

A 37-year-old nulliparous woman was diagnosed as having low-lying placenta.
After giving informed consent, she chose to undergo vaginal delivery. Labor was
induced by oxytocin for prolonged pregnancy; however, the fetal heart rate showed
a non-reassuring pattern, thus she underwent cesarean section. The cervix was
3 cm dilated and 50% effaced at that time. The operation went uneventful until
neonatal delivery and spontaneous placental separation. However, massive bleed-
ing was noted from the placental attachment area. Uterine isthmus balloon tam-
ponade using Fujimetoro® (Fuji Latex, Co., Ltd. Tokyo) was attempted but the
bleeding was continued. Thus, uterine isthmus vertical compression sutures were
performed using USP 1 VICRYL RAPID® with a 1/2 Circle 48 mm taper point
needle (Ethicon, Inc., Somerville, New Jersey), followed the original procedure
as Makino described previously [1]: 1.5 cm medially from the side of the uterine
isthmus and 3 cm caudally from the incised wound of the uterine for 3 cm long. As
the bleeding dissipated but remained, uterine isthmus vertical compression sutures
were attempted again but 1 cm medially and 2 cm longer to be 5 cm. The bleeding
became less apparent after the second uterine compression sutures. The balloon
was inserted again between the compression sutures and inflated with 80 mL of
sterile natural saline. With the compression sutures and balloon tamponade, the
remaining bleeding was stopped, and hemostasis was achieved. The balloon placed
for overnight and was deflated and removed the next day of cesarean section. She
was discharged from the hospital 5 days postoperatively without any signs of uter-
ine infection or necrosis.
This case indicated that in a case of dilated and effaced cervix especially in a case
of emergency cesarean delivery after trial labor, medial, and wider compression
sutures are needed to accomplish hemostasis.
4 Vertical Compression Sutures with Contrivances 21
Case 3: Enclosing Sutures Technique [4]

A 42-year-old nullipara with a history of four missed abortions treated with dilata-
tion and curettage, and hysteroscopic myomectomy was referred to our hospital in
40 weeks’ gestation. Cesarean delivery was chosen for clinical chorioamnionitis and
non-reassuring fetal status. Surgery was performed without incident until delivery of
the placenta. Placenta was unable to remove with a gentle pulling of umbilical cord,
and placenta accreta was diagnosed. Most of the placenta was removed manually, but
continuous bleeding from attachment site was observed. Firstly, uterine balloon tam-
ponade was attempted but failed. To reduce blood flow, four single knots using USP
1 VICRYL RAPID with a 1/2 Circle 48-mm taper point needle (Ethicon, Inc.) were
placed to enclose the bleeding site as the four single knots placed only at the poste-
rior wall of the uterus but not anterior wall to compress the uterine cavity. The gaps
were made on purpose to avoid excessive reduction of blood flow in the enclosed
area. The bleeding decreased and complete hemostasis was accomplished with uter-
ine balloon tamponade using a Bakri balloon (Cook). The balloon was deflated and
removed the day following cesarean section, with no evidence of continued bleeding.
Although placental retention was observed, no signs of uterine infection or necrosis
were found, and she was able to leave the hospital 5 days after surgery.
Enclosing sutures was attempted to this case to avoid compressing uterine cav-
ity with a risk of uterine synechiae. In addition, the gaps between the sutures were
aimed to avoid uterine necrosis.
4.2 Conclusion
There are two mechanisms of compression sutures to accomplish hemostasis, to

compress the bleeding site, and to reduce uterine blood flow. However, excessive
compression and reduction of blood flow may lead to complications like uterine
synechiae and uterine necrosis. To avoid those complications, extreme suturing
of uterine myometrium layer should be avoided and other contrivances including
combination with balloon tamponade or special suturing methods are better to be
chosen.
References
pression sutures: a novel conservative approach to managing postpartum hemorrhage due to
placenta previa and atonic bleeding. Aust N Z J Obstet Gynecol. 2012;52:290–2.
2. Takeda J, Tanaka K, Ohashi R. Uterine isthmus vertical compression suture for controlling
uterine corpus bleeding: a possible mechanism of decreasing uterine blood flow. Hypertens Res
Pregnancy. 2016;4:45.
3. Takeda J, Hiranuma K, Hirayama T, Makino S, Itakura A, Takeda S. The use of medial, wider
vertical compression sutures to reduce uterine blood flow for effaced uterine isthmus: a case
report. J Obstet Gynaecol. 2018;38:871–3.
4. Takeda J, Makino S, Matsumura Y, Itakura A, Takeda S. Enclosing sutures technique for con-
trol of local bleeding in a case of placenta increta. J Obstet Gynaecol Res. 2018;44:1472–5.
Compression Sutures Removal
5
Jun Takeda
Abstract
The mechanisms of achieving hemostasis with uterine compression sutures are
compressing the bleeding site and reduction of uterine blood flow. Thus, when
the excessive reduction of uterine blood flow happened, uterine ischemia or
necrosis may occur as the complications. In such a case, local pain which is dif-
ficult to control with general analgesics such as non-steroidal anti-inflammatory
drugs and acetaminophen may occur. As a countermeasure, removing uterine
compression sutures should be considered. Specialized suturing technique
assuming threads removal has been reported, but laparoscopic surgery should be
considered as it can accommodate any compression sutures and is less invasive
than abdominal surgery.
Keywords
Analgesic · Complication · Compression sutures · Laparoscopic surgery · Thread
removal · Uterine ischemia · Uterine necrosis
5.1 Introduction
Uterine compression sutures are now widely accepted for hemostasis during cesar-
ean section. Above all, B-Lynch suturing is one of the most well-known methods
for controlling postpartum hemorrhage [1]. Several different types of compression
sutures techniques have been developed since then (see Chap. 2). Although uterine
compression sutures did not appear to adversely affect the menstrual and fertility
J. Takeda (*)
Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University,
Bunkyo-ku, Tokyo, Japan
e-mail: jtakeda@juntendo.ac.jp

24 J. Takeda
outcomes in most women [2], still cases of uterine necrosis and synechiae have been
reported [3–7]. To avoid these complications, compression suture removal should
be considered.
Case: Laparoscopic Removal of Compression Sutures [8]

A 32-year-old woman underwent elective cesarean section for placenta previa.
During the cesarean section, vertical compression sutures using 0 Vicryl plus
(Ethicon, Somerville, NJ, USA) was performed because of uncontrollable hemor-
rhage with uterine balloon tamponade. Although hysterectomy was avoided, unbear-
able pelvic pain was noted despite regular use of non-steroidal anti-inflammatory
drugs. In addition, only a small amount of lochia without pooling in the uterus
was noted; therefore, uterine ischemia was conceivable. After the informed consent,
she decided to undergo laparoscopic removal of the compression sutures. Aiming
to detect the compression sutures thread into the deep aspect of pelvis with dis-
turbed view because of enlarged uterus after cesarean section, a flexible laparoscope
(EndoEye; Olympus, Tokyo, Japan) was used. After a 5 mm trocar was inserted into
her umbilicus for the optical device and a pneumoperitoneum was created, two 3.5-
mm thin trocars (Aesculap AdTec mini, B. Braun, Germany) were inserted into her
lower abdomen 3 cm inside of the bilateral anterior superior iliac spine. Although
the flexible laparoscope allowed the visualization of the uterine isthmus, the loca-
tions of the sutured points were obscure due to flaccid uterine isthmus. Thus, a
Kocher crump with folded gazes was inserted to vagina to elevate her uterus. In con-
sequence, the compression sutured thread was able to be detected removed using
forceps and scissors without the special technique to presuppose the suture removal.
After the compression suture removal, the patient was relieved from her pelvic
pain and the lochia discharge started which suggest that the compression sutures
were the causes of the pelvic pain due to uterine ischemia.
5.2 Conclusion
Removal of compression sutures contributes to avoid uterine necrosis. However,

as reoperation itself may lead to additional complications, patient selection has to
be carefully discussed. In addition, reoperation costs much more than the natural
course. Hence, only patients with extreme pelvic pain, which could not be con-
trolled with general analgesics suggesting of the existence of uterine ischemia or
necrosis, will be candidates for this operation. As the other methods, Aboulfalah
et al. and Zhang et al. reported removing the compression sutures abdominally [9,
10]. However, those methods need special techniques while attempting compres-
sion sutures for the first place. Thus, compared to those methods, laparoscopic
surgery has advantage that could accommodate any type of compression suture. In
a case of uterine ischemia or necrosis, although the risk of reoperation during the
early postpartum period still exists, compression suture thread removal should be
considered.
Another random document with
no related content on Scribd:
Launcelot.—Nay, indeed, if you had your eyes, you might fail of
the knowing me: it is a wise father that knows his own child. Well, old
man, I will tell you news of your son: give me your blessing. Truth will
come to light; murder cannot be hid long,—a man’s son may; but, in
the end, truth will out.
Gobbo.—Pray you, sir, stand up: I am sure you are not Launcelot,
my boy.
Launcelot.—Pray you, let’s have no more fooling about it, but give
me your blessing: I am Launcelot, your boy that was, your son that
is, your child that shall be.
Gobbo.—I cannot think you are my son.
Launcelot.—I know not what I shall think of that: but I am
Launcelot, the Jew’s man; and I am sure Margery your wife is my
mother.
Gobbo.—Her name is Margery, indeed: I’ll be sworn, if thou be
Launcelot, thou art mine own flesh and blood. Lord, worship’d might
he be! What a beard hast thou got! thou hast got more hair on thy
chin than Dobbin, my fill-horse, has on his tail.
Launcelot.—It should seem, then, that Dobbin’s tail grows
backward: I am sure he had more hair of his tail than I have on my
face, when I last saw him.
Gobbo.—Lord, how art thou chang’d! How dost thou and thy
master agree? I have brought him a present. How ’gree you now?
Launcelot.—Well, well; but, for mine own part, as I have set up my
rest to run away, so I will not rest till I have run some ground. My
master’s a very Jew: give him a present! give him a halter: I am
famish’d in his service; you may tell every finger I have with my ribs.
Father, I am glad you are come: give me your present to one Master
Bassanio, who, indeed, gives rare new liveries: if I serve not him, I
will run as far as God has any ground.—O rare fortune! here comes
the man:—to him, father, for I am a Jew, if I serve the Jew any
longer.
—Act II, Scene II, Lines 29-104.
HAMLET’S DECLARATION OF FRIENDSHIP
Hamlet. What ho! Horatio!
Horatio. Here, sweet lord, at your service.
Hamlet. Horatio, thou art e’en as just a man

As e’er my conversation coped withal.
Horatio. O, my dear lord,—
Hamlet. Nay, do not think I flatter;

For what advancement may I hope from thee
That no revenue hast, but thy good spirits,
To feed and clothe thee? Why should the poor be flatter’d?
No, let the candied tongue lick absurd pomp,
And crook the pregnant hinges of the knee
Where thrift may follow fawning. Dost thou hear?
Since my dear soul was mistress of her choice
And could of men distinguish, her election
Hath sealed thee for herself; for thou hast been
As one, in suffering all, that suffers nothing,
A man that fortune’s buffets and rewards
Hast ta’en with equal thanks: and blest are those
Whose blood and judgment are so well commingled
That they are not a pipe for Fortune’s finger
To sound what stop she pleases. Give me that man
That is not passion’s slave, and I will wear him
In my heart’s core, ay, in my heart of hearts,
As I do thee.
—From Act III, Scene 2.
OTHELLO’S APOLOGY
[The speech calls for great dignity, ease, and power, in both speech
and manner.]
Most potent, grave, and reverend signiors,
My very noble and approved good masters,
That I have ta’en away this old man’s daughter,
It is most true; true, I have married her:
The very head and front of my offending
Hath this extent, no more. Rude am I in my speech,
And little bless’d with the soft phrase of peace;
For since these arms of mine had seven years’ pith,
Till now some nine moons wasted, they have used
Their dearest action in the tented field,
And little of this great world can I speak,
More than pertains to feats of broil and battle,
And therefore little shall I grace my cause
In speaking for myself. Yet, by your gracious patience,
I will a round unvarnish’d tale deliver
Of my whole course of love; what drugs, what charms,
What conjuration, and what mighty magic,—
For such proceeding I am charg’d withal,—
I won his daughter.
...
Her father loved me; oft invited me;
Still question’d me the story of my life,
From year to year,—the battles, sieges, fortunes,
That I have pass’d.
I ran it through, even from my boyish days,
To the very moment that he bade me tell it:
Wherein I spake of most disastrous chances,
Of moving accidents by flood and field,
Of hair-breadth scapes i’ the imminent deadly breach,
Of being taken by the insolent foe
And sold to slavery, of my redemption thence
And portance in my travels’ history:
...
This to hear
Would Desdemona seriously incline:
But still the house-affairs would draw her thence;
Which ever as she could with haste despatch,
She’d come again, and with a greedy ear
Devour up my discourse: which I observing,
Took once a pliant hour, and found good means
To draw from her a prayer of earnest heart
That I would all my pilgrimage dilate,
Whereof by parcels she had something heard,
But not intentively: I did consent,
And often did beguile her of her tears,
When I did speak of some distressful stroke
That my youth suffer’d. My story being done,
She gave me for my pains a world of sighs:
She swore, in faith, ’twas strange, ’twas passing strange,
’Twas pitiful, ’twas wondrous pitiful:
She wish’d she had not heard it, yet she wish’d
That heaven had made her such a man: she thank’d me,
And bade me, if I had a friend that loved her,
I should but teach him how to tell my story,
And that would woo her. Upon this hint I spake:
She loved me for the dangers I had pass’d;
And I lov’d her that she did pity them.
This only is the witchcraft I have used.
THE SEVEN AGES

[This is a succession of purely imaginative ideas which the voice
should touch lightly. In this speech one meets always the question of
impersonation: shall the mewling infant, the whining schoolboy, the
sighing lover and the rest be imitated by the reader? It is in better
taste not to impersonate these seven characters beyond certain
almost imperceptible hints which the gayety of Jaques’s mind might
naturally throw off.]
All the world’s a stage,

And all the men and women merely players:
They have their exits and their entrances;
And one man in his time plays many parts,
His acts being seven ages. At first the infant,
Mewling and puking in the nurse’s arms:
And then the whining schoolboy, with his satchel
And shining morning face, creeping like snail
Unwillingly to school. And then the lover,
Sighing like furnace, with a woeful ballad
Made to his mistress’ eyebrow. Then a soldier,
Full of strange oaths and bearded like the pard,
Jealous in honor, sudden and quick in quarrel,
Seeking the bubble reputation
Even in the cannon’s mouth. And then the justice,
In fair round belly with good capon lined,
With eyes severe and beard of formal cut,
Full of wise saws and modern instances;
And so he plays his part. The sixth age shifts
Into the lean and slipper’d pantaloon,
With spectacles on nose and pouch on side;
His youthful hose, well saved, a world too wide
For his shrunk shank; and his big manly voice,
Turning again toward childish treble, pipes
And whistles in his sound. Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.
—“As You Like it,” Act II, Scene 7.
SOLITUDE PREFERRED TO COURT LIFE
Duke S. Now, my co-mates and brothers in exile,

Hath not old custom made this life more sweet
Than that of painted pomp? Are not these woods
More free from peril than the envious court?
Here feel we but the penalty of Adam.
The season’s difference, as the icy fang
And churlish chiding of the winter’s wind,
Which, when it bite and blows upon my body,
Even till I shrink with cold, I smile and say
’Tis no flattery; these are counselors
That feelingly persuade me what I am.
Sweet are the uses of adversity,
Which, like the toad, ugly and venomous,
Wears yet a precious jewel in his head;
And this our life, exempt from public haunt,
Finds tongues in trees, books in the running brooks,
Sermons in stones, and good in everything.
I would not change it.
Amiens. Happy is your grace,

That can translate the stubbornness of fortune
Into so quiet and so sweet a style.
...
Duke S. Come, shall we go and kill us venison?

And yet it irks me the poor dappled fools,
Being native burghers of this desert city,
Should in their own confines with forked heads
Have their round haunches gor’d.
—“As You Like It,” Act II.
THE POTION SCENE

Scene: Juliet’s Chamber
(Enter Juliet and Nurse, who bears wedding garments.)
Juliet (looking at garments).
Ay, those attires are best; but, gentle nurse,

I pray thee, leave me to myself to-night;
For I have need of many orisons
To move the heavens to smile upon my state,
Which, well thou knowest, is cross and full of sin.
(Enter Lady Capulet.)
Lady Capulet.
What are you busy, ho? need you my help?
Juliet.
No, madam; we have cull’d such necessaries

As are behoveful for our state to-morrow:
So please you, let me now be left alone,
And let the nurse this night sit up with you;
For, I am sure, you have your hands full all,
In this so sudden business.
Lady Capulet (crossing and kissing Juliet on the forehead).
Good night;
Get thee to bed and rest, for thou hast need.
(Exit Lady Capulet with nurse.)
Juliet (looking after them).
Farewell! God knows when we shall meet again.

I have a faint cold fear thrills through my veins,
That almost freezes up the heat of life:
I’ll call them back again to comfort me. (Runs to R.)
Nurse! What should she do there?
My dismal scene I needs must act alone.
Come, vial. (Takes vial from bosom.)
What if this mixture do not work at all?
Shall I be married then to-morrow morning?
No, no! (draws dagger) this shall forbid it.
(Lays dagger on table.)
Lie you there. (To vial.)

What if it be a poison, which the friar
Subtly hath ministered to have me dead,
Lest in this marriage he should be dishonored
Because he married me before to Romeo?
I fear it is; and yet, methinks, it should not,
For he hath still been tried a holy man.
(Puts vial in bosom.)
How if, when I am laid into the tomb,

I wake before the time that Romeo
Come to redeem me? there’s a fearful point!
Shall I not then be stifled in the vault,
To whose foul mouth no healthsome air breathes in,
And there die strangled ere my Romeo comes?
Or, if I live, is it not very like,
The horrible conceit of death and night,
Together with the terror of the place,—
As in a vault, an ancient receptacle,
Where, for these many hundred years, the bones
Of all my buried ancestors are packed;
Where bloody Tybalt, yet but green in earth,
Lies festering in his shroud; where as they say,
At some hours in the night spirits resort; ...
O, if I wake, shall I not be distraught,
Environed with all these hideous fears?
And madly play with my forefathers’ joints?
And pluck the mangled Tybalt from his shroud?
And, in this rage, with some great kinsman’s bone,
As with a club, dash out my desperate brains?
O, look! methinks I see my cousin’s ghost
Seeking out Romeo, ...
Stay, Tybalt, stay!—
Romeo, I come! (Drawing out vial—then cork.)
This do I drink to thee.
(Throws away vial. She is overcome and sinks to the floor.)
—From “Romeo and Juliet,” Act IV, Scene 3.

BANISHMENT SCENE
SCENE III, A ROOM IN THE PALACE
(Enter Celia and Rosalind.)
Cel. Why, cousin; why Rosalind;—Cupid have mercy;—Not a
word?
Ros. Not one to throw to a dog.
Cel. No, thy words are too precious to be cast away upon curs,
throw some of them at me; come, lame me with reasons.
Ros. Then there were two cousins laid up; when the one should be
lamed with reasons, and the other mad without any.
Cel. But is all this for your father?
Ros. No, some of it for my father’s child: O, how full of briars is this
working-day world!
Cel. They are but burrs, cousin, thrown upon thee in holiday
foolery; if we walk not in the trodden paths, our very coats will catch
them.
Ros. I could shake them off my coat; these burrs are in my heart.
Cel. Hem them away.
Ros. I would try; if I could cry hem, and have him.
Cel. Come, come, wrestle with thy affections.
Ros. O, they take the part of a better wrestler than myself.
Cel. Is it possible, on such a sudden, you should fall into so strong
a liking with old Sir Rowland’s youngest son?
Ros. The duke my father lov’d his father dearly.
Cel. Doth it therefore ensue, that you should love his son dearly?
By this kind of chase, I should hate him, for my father hated his
father dearly; yet I hate not Orlando.
Ros. No ’faith, hate him not, for my sake.
Cel. Why should I not? Doth he not deserve well?
Ros. Let me love him for that; and do you love him, because I do:
Look, here comes the duke.
Cel. With his eyes full of anger.
(Enter Duke Frederick, with Lords.)
Duke F. Mistress, despatch you with your safest haste, and get
you from our Court.
Ros. Me, uncle?
Duke F. You, cousin, within these ten days if thou be’st found so
near our public court as twenty miles, thou diest for it.
Ros. I do beseech your grace, let me the knowledge of my fault
bear with me: if with myself I hold intelligence, or have acquaintance
with mine own desires; if that I do not dream, or be not frantic (as I
do trust I am not), then, dear uncle, never so much as in a thought
unborn, did I offend your highness.
Duke F. Thus do all traitors, if their purgation did consist in words,
they are as innocent as grace itself: let it suffice thee, that I trust thee
not.
Ros. Yet your mistrust cannot make me a traitor: tell me, whereon
the likelihood depends.
Duke F. Thou art thy father’s daughter, there’s enough.
Ros. So was I, when your highness took his dukedom; so was I,
when your highness banish’d him: treason is not inherited, my lord:
or, if we did derive it from our friends, what’s that to me? my father
was no traitor: then, good my liege, mistake me not so much, to think
my poverty is treacherous.
Cel. Dear sovereign, hear me speak.
Duke F. Aye, Celia; we stay’d here for your sake. Else had she
with her father rang’d along.
Cel. I did not then entreat to have her stay, it was your pleasure,
and your own remorse; I was too young that time to value her, but
now I know her; if she be a traitor, so am I: we still have slept
together; rose at an instant, learn’d, play’d, eat together;
And wheresoe’er we went, like Juno’s swans,

Still we went coupled, and inseparable.
Duke F. She is too subtle for thee; and her smoothness,

Her very silence, and her patience,
Speak to the people and they pity her.
Thou art a fool: she robs thee of thy name;
And thou wilt show more bright, and seem more virtuous,
When she is gone: then open not thy lips;
Firm and irrevocable is my doom
Which I have pass’d upon her; she is banish’d.
Cel. Pronounce that sentence then on me, my liege;

I cannot live out of her company.
Duke F. You are a fool:—You, niece, provide yourself;

If you outstay the time, upon my honor,
And in the greatness of my word, you die.
(Exeunt Duke Frederick and Lords.)
Cel. O my poor Rosalind: whither wilt thou go?

Wilt thou change fathers? I will give thee mine.
I charge thee, be not thou more griev’d than I am.
Ros. I have more cause.
Cel. Thou hast not, cousin,

Pr’ythee, be cheerful: know’st thou not, the duke
Hath banish’d me his daughter?
Ros. That he hath not.
Cel. No? hath not? Rosalind lacks then the love

Which teaches thee that thou and I art one:
Shall we be sunder’d? shall we part, sweet girl?
No; let my father seek another heir.
Therefore devise with me, how we may fly,
Whither to go, and what to bear with us:
And do not seek to take your charge upon you,
To bear your griefs yourself, and leave me out;
For by this heaven, now at our sorrows pale,
Say what thou can’st, I’ll go along with thee.
Ros. Why, whither shall we go?
Cel. To seek my uncle.
Ros. Alas, what danger will it be to us,

Maids as we are, to travel so far?
Beauty provoketh thieves sooner than gold.
Cel. I’ll put myself in poor and mean attire,

And with a kind of umber smirch my face;
The like do you; so shall we pass along,
And never stir assailants.
Ros. Were it not better,

Because that I am more than common tall,
That I did suit me in all points like a man?
A boar-spear in my hand; and in my heart
Lie there what hidden woman’s fear there will,
We’ll have a swashing and a martial outside;
As many other mannish cowards have,
That do outface it with their semblances.
Cel. What shall I call thee when thou art a man?
Ros. I’ll have no other worse than Jove’s own page,

And therefore, look you, call me Ganymede.
But what will you be call’d?
Cel. Something that hath a reference to my state:

No longer Celia, but Aliena.
Ros. But, cousin, what if we assayed to steal

The clownish fool out of your father’s court?
Would he not be a comfort to our travel?
Cel. He’ll go along o’er the wide world with me;

Leave me alone to woo him: Let’s away
And get our jewels and our wealth together;
Devise the fittest time, and safest way
To hide us from pursuit that will be made
After my flight: Now go we in content,
To liberty, and not to banishment.
—From “As You Like It,” Act I.
CORYDON
By Thomas Bailey Aldrich
SCENE, A ROAD-SIDE IN ARCADY
Shepherd. Good sir, have you seen pass this way

A mischief straight from market-day?
You’d know her at a glance, I think;
Her eyes are blue, her lips are pink;
She has a way of looking back
Over her shoulder, and alack!
Who gets that look one time, good sir,
Has naught to do but follow.
Pilgrim. I have not seen this maid methinks,

Though she that passed had lips like pinks.
Shepherd. Or like two strawberries made one

By some sly trick of dew and sun.
Pilgrim. A poet.
Shepherd. Nay, a simple swain
That tends his flocks on yonder plain
Naught else I swear by book and bell.
But she that passed you marked her well
Was she not smooth as any be
That dwells here—in Arcady?
Pilgrim. Her skin was the satin bark of birches.
Shepherd. Light or dark?
Pilgrim. Quite dark.
Shepherd. Then ’twas not she.
Pilgrim. The peaches side

That next the sun is not so dyed
As was her cheek. Her hair hung down
Like summer twilight falling brown;
And when the breeze swept by, I wist
Her face was in a somber twist.
Shepherd. No that is not the maid I seek;

Her hair lies gold against her cheek,
Her yellow tresses take the morn,
Like silken tassels of the corn,
And yet brown-locks are far from bad.
Pilgrim. Now I bethink me this one had

A figure like the willow tree
Which, slight and supple, wondrously
Inclines to droop with pensive grace,
And still retain its proper place.
A foot so arched and very small
The marvel was she walked at all;
Her hand in sooth, I lack for words—
Her hand, five slender snow-white birds,
Her voice, tho’ she but said “God Speed”—
Was melody blown through a reed;
The girl Pan changed into a pipe
Had not a note so full and rife.
And then her eye—my lad, her eye!
Discreet, inviting, candid, shy,
An outward ice, an inward fire,
And lashes to the heart’s desire.
Soft fringes blacker than the sloe—
Shepherd. Good sir, which way did this one go?
Pilgrim. So he is off! The silly youth

Knoweth not love in sober sooth,
He loves—thus lads at first are blind—
No woman, only womankind.
I needs must laugh, for by the mass
No maid at all did this way pass.
PART FOUR
Oratoric Reading and the Art of Public Speech
Discussion of forceful speech in making history. Value of forceful
speech. Practice selections.
HAMLET’S INSTRUCTION TO THE PLAYERS

Speak the speech, I pray you, as I pronounced it to you,—
trippingly on the tongue; but if you mouth it, as many of our players
do, I had as lief the town-crier spake my lines. Nor do not saw the air
too much with your hand, thus, but use all gently; for in the very
torrent, tempest, and, as I may say, whirlwind of your passion, you
must acquire and beget a temperance, that may give it smoothness.
Oh! it offends me to the soul to hear a robustious periwig-pated
fellow tear a passion to tatters,—to very rags,—to split the ears of
the groundlings; who, for the most part, are capable of nothing but
inexplicable dumb show and noise. I would have such a fellow
whipped for o’erdoing Termagant; it out-herods Herod. Pray you
avoid it.
—Shakespeare.
CHAPTER XIII
ORATORIC READING AND THE ART OF PUBLIC SPEECH
Upon this important subject of public speaking, and the

interpretation of the addresses made by others, great men have thus
expressed themselves: Dr. Charles W. Eliot, formerly President of
Harvard University, says: “Have we not all seen, in recent years, that
leading men of business have a great need of a highly trained power
of clear and convincing expression? Business men seem to me to
need, in speech and writing, all the Roman terseness and the French
clearness. That one attainment is sufficient reward for the whole long
course of twelve years spent in liberal study.” Abraham Lincoln
likewise said: “Extemporaneous speaking should be practiced and
cultivated. It is the lawyer’s avenue to the public. However able and
faithful he may be in other respects, people are slow to bring him
business if he can not make a speech.”
Every thinker knows what a vital part eloquence plays in national
as well as individual welfare. If at first thought effective speaking
seems a simple thing and a superficial part of education, on mature
thought and consideration it will be found to be one of the most
complex, vital and difficult problems that education has to meet. And
yet, notwithstanding this complexity of the problem, the teacher is
cheered by the delightful assurance of giving the student a
consciousness of his latent talents and the ability to reveal and make
use of them for the proper influencing of his fellow men.
There is a belief fairly commonly held that only a limited few need
study the art of public speaking. Never was there a greater error or a
more fatal mistake—especially in a republic like ours, where every
man should be vitally interested in public affairs. No single citizen
can afford not to be able to stand before his fellows and clearly,
pleasingly and convincingly present his ideas upon any subject of
local, state, or national importance. It is no more an ornamental
accomplishment than is grammar, penmanship or simple arithmetic.
It should be as universal as “the three r’s.” The hints and selections
that follow are carefully chosen to incite every good citizen to the
acquirement of this useful and practical aid for his own benefit as
well as that of his fellows. All the lessons and analyses that have
gone before in these pages will materially aid in the elucidation of
these brief lessons.
The basis for development in Effective Speaking rests upon one’s
bodily, emotional and mental agencies of expression, and a
knowledge of their respective importance and efficient use. That
which counts most for development is conscientious practice; without
which, progress is impossible.
There are three definite means of communicating thought and
feeling to others: (a) Pantomime: face, hands, body; (b) Vocal: tone
sound; (c) Verbal: words, which are conventional symbols
manifesting mental and emotional states.
The problem, then, is to obtain a harmonious coördination of these
three languages. In other words, the content of the word when
spoken should be reflected in the tone and in the body. Thus speech
becomes effective merely because it receives its just and fair
consideration.
With this general understanding let us take up and master the
successive steps which ultimately lead to a realization of the desired
end.
The first important essential of effective speaking is the Spirit of
Directness. By this is meant natural, unaffected speech. Nothing can
be more important than that the person speaking use in public
address the ordinary elements of Conversation.
Hence, the first step is practice in natural speaking. Commit to
memory Hamlet’s Instructions to the Players given on a preceding
page. Do this not line by line, but the entire selection as a whole.
First: Read it through silently three times to familiarize yourself with
the subject-matter. Second: Read it aloud at least five times. Third:
Speak it conversationally at least five times from memory. In this
practice always be intensely conscious that you are addressing an
individual and not an audience.
Now take any of the prose or poetic selections from the earlier
pages of this book, memorize them, after studying them as the
instructions require, and speak them directly and naturally, in the
ordinary conversational style.
Sufficient practice in this is the necessary preparation for the next
step, viz., the acquiring of a natural elevated conversational style,
which is merely another name for the higher type of public speaking.
Commit all, or a part, of the following selections, keeping in mind
that in speaking them you are addressing a group of people.
THE GETTYSBURG ADDRESS

By Abraham Lincoln
Fourscore and seven years ago our fathers brought forth upon this
continent a new nation, conceived in liberty, and dedicated to the
proposition that all men are created equal. Now we are engaged in a
great Civil War, testing whether that nation, or any nation, so
conceived and so dedicated, can long endure. We are met on a
great battlefield of that war. We are met to dedicate a portion of it as
the final resting place of those who here gave their lives that that
nation might live.
It is altogether fitting and proper that we should do this. But in a
larger sense we cannot dedicate, we cannot consecrate, we cannot
hallow this ground. The brave men, living and dead, who struggled
here, have consecrated it far above our power to add or detract. The
world will little note, nor long remember, what we say here, but it can
never forget what they did here.
It is for us, the living, rather to be dedicated here to the unfinished
work they have thus far so nobly carried on. It is rather for us to be
here dedicated to the great task remaining before us, that from these
honored dead we take increased devotion to the cause for which
they gave their last full measure of devotion; that we here highly
resolve that these dead shall not have died in vain, that the Union
shall, under God, have a new birth of freedom, and that the
government of the people, by the people, and for the people, shall
not perish from the earth.
By this time you should have mastered Ordinary Conversational

Style; Elevated Conversational Style; and Abandon and Flexibility of
Speech. The next consideration is the importance of Clearness.
Clearness in speech means making prominent central words and
subordinating unimportant words, or phrases. In other words, the
logical sequence of thought must be clearly shown. This is brought
about by a variety of inflections, changes of pitch, pause, etc.
Clearness in speech is dependent upon clearness of Thinking.
It is important now to give full consideration to the subject of
Emphasis. There are more ways than one of emphasizing your
thought. The most common way is by merely increasing the stress of
voice upon a word. This, however, is the most undignified form of
emphasis. It is common to ranters and “soap-box” orators and is one
mark of an undisciplined and uncultured man. Remember that
loudness is a purely physical element, and does not manifest
thought. Such emphasis is an appeal to the brute instinct, and is only
expressive of the lower emotions. But Inflection, Changes of Pitch,
Pause, Movement and Tone-Color—as have been fully explained in
preceding pages—all appeal to the exalted nature of man.
In proportion to the nobleness of an emotion or thought, we find a
tendency to accentuate these above-named elements. Such
methods of emphasis are appropriate to the most disciplined and
cultured man. More than that, they are the surest evidence of a great
personality.
Commit, then make clear to the hearer, the vital thought in the
following:
He have arbitrary power! My lords, the East India Company

have not arbitrary power to give him; the King has no arbitrary
power to give him; your Lordships have not; nor the
Commons; nor the whole legislature. We have no arbitrary
power to give, because arbitrary power is a thing which

PDF Compression Sutures For Critical Hemorrhage During Cesarean Section A Guide by CG Animation Satoru Takeda Ebook Full Chapter

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

PDF Compression Sutures For Critical Hemorrhage During Cesarean Section A Guide by CG Animation Satoru Takeda Ebook Full Chapter

Uploaded by

Copyright:

Available Formats

Compression Sutures for Critical

Hemorrhage During Cesarean Section

Anesthesia for Cesarean Section 1st Edition Giorgio

Cesarean delivery: a comprehensive illustrated

Directing for Animation Everything You Didn t Learn in

Understanding Compression Data Compression for Modern

Non Obstetric Surgery During Pregnancy A Comprehensive

Timing for animation 3rd Edition Harold Whitaker

Asthma Allergic and Immunologic Diseases During

Clinical Sleep Medicine A Comprehensive Guide for

Compression Sutures for

ISBN 978-981-32-9459-2 ISBN 978-981-32-9460-8 (eBook)

© Springer Nature Singapore Pte Ltd. 2020

Although the maternal mortality rate is on a decreasing trajectory in Japan, 28–54

Tokyo, Japan Satoru Takeda

1 History of Surgical Remedies for Obstetrical Uterine Hemorrhage�������� 1

S. Takeda (*) · Y. Terao

© Springer Nature Singapore Pte Ltd. 2020 1

In Japan, the main causes of maternal mortality include critical hemorrhage in

1.2  hanges in Hemostatic Techniques for Uterine

by arterial ligation at laparotomy was long performed as a hemostatic technique

1.3 Hemostatic Techniques During Cesarean Section

1.3.1 Arterial Ligation

endometrial growth impairment, which results in hypomenorrhea, oligomenorrhea,

1.3.2 Compression Suture

The compression suturing technique aiming to block blood flow by suturing a

1.3.3 Balloon Tamponade

For massive uterine hemorrhage after vaginal delivery, tamponade achieved by

22]. If hemostasis cannot be achieved, the ballooning process can immediately be

1.3.4 Interventional Radiology (IVR)

Advances in interventional radiology (IVR) have enabled various hemostatic tech-

technique to prevent massive hemorrhage by placement of an intra-arterial bal-

1.3.5 Damage Control Surgery and Resuscitation

In emergency medicine, damage control surgery (DCS) is a strategy in which only

causes anaerobic metabolism, which results in metabolic acidosis. When arterial

19. Yorifuji T, Tanaka T, Makino S, Koshiishi T, Sugimura M, Takeda S. Balloon tamponade in

S. Makino · S. Takeda (*)

© Springer Nature Singapore Pte Ltd. 2020 11

2.1.1  imanual Compression, Drug Therapy, and the Search

In the same manner as in vaginal delivery, bimanual compression and sufficient

2.1.2 Uterine Compression Suture

Although bleeding is controlled to some extent by bimanual compression during

2.1.3 Arterial Ligation and Total Hysterectomy

If bleeding cannot be controlled by uterine compression suture, hemostasis should

2.2 Local Hemostasis or Blockage of Blood Flow

2.3 Uterine Compression Suture

As mentioned above, uterine compression suture is performed when atonic

Table 2.1 Summary of compression sutures

2.4 For Success of Compression Suture

Although the above-mentioned compression suture can halt bleeding effectively, it

Unlike in cases of placenta previa or concomitant uterine myoma, in which massive

Uterine compression suture is performed when uterine bleeding is not stopped by

3.1 Double Vertical Compression Sutures [3] (Video 3.1)

Electronic Supplementary Material The online version of this chapter (https://doi.org/10.1007/978-

© Springer Nature Singapore Pte Ltd. 2020 17

Case 1: Uterine Compression Sutures with Balloon Tamponade [2]

Case 2: Medial and Wider Compression Sutures [3]

Case 3: Enclosing Sutures Technique [4]

There are two mechanisms of compression sutures to accomplish hemostasis, to

© Springer Nature Singapore Pte Ltd. 2020 23

Case: Laparoscopic Removal of Compression Sutures [8]

Removal of compression sutures contributes to avoid uterine necrosis. However,

Hamlet. What ho! Horatio!

Tokyo, Japan Satoru Takeda

1 History of Surgical Remedies for Obstetrical Uterine Hemorrhage�� 1

1.2 hanges in Hemostatic Techniques for Uterine

1.3 Hemostatic Techniques During Cesarean Section

1.3.1 Arterial Ligation

1.3.2 Compression Suture

1.3.3 Balloon Tamponade

1.3.4 Interventional Radiology (IVR)

1.3.5 Damage Control Surgery and Resuscitation

2.1.1 imanual Compression, Drug Therapy, and the Search

2.1.2 Uterine Compression Suture

2.1.3 Arterial Ligation and Total Hysterectomy

2.2 Local Hemostasis or Blockage of Blood Flow

2.3 Uterine Compression Suture

2.4 For Success of Compression Suture

3.1 Double Vertical Compression Sutures [3] (Video 3.1)