INTRODUCTION — Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide [1,2]. The risk of maternal death due to hemorrhage is especially high in low-income countries .
Management of hemorrhage following delivery can be viewed as a multistage, sequential process that includes assessment and intervention, starting with less invasive interventions and then proceeding to more invasive interventions, as appropriate for the cause and severity of hemorrhage. One or more of the following procedures may be necessary to control hemorrhage: surgical repair of a deep laceration or tear in the uterus, uterine artery ligation or embolization, uterine compression sutures, tamponade with an intrauterine balloon and/or intrauterine/pelvic packing, and hysterectomy if more conservative measures are unsuccessful. While it is easier to review individual steps sequentially, in practice, brisk hemorrhage or patient instability may necessitate deploying such measures in parallel (simultaneously) to ensure hemostatic control.
This topic will discuss the use of intrauterine tamponade with an intrauterine balloon and/or pack in the management of PPH. Detailed information on causes of PPH, patient assessment and planning, and medical and surgical management can be found separately.
TYPES AND EFFICACY OF INTRAUTERINE TAMPONADE
Intrauterine balloon tamponade — Multiple types of balloon catheters have been used for intrauterine tamponade, ranging from devices specifically designed and marketed for intrauterine use (table 1) and those designed for other indications (table 2). The choice to use one balloon over another is largely driven by local availability, provider preference, and cost. Differences in the distensibility and maximum possible fill volume have been demonstrated in one in vitro trial ; however, rarely will such large volumes be required to achieve effective tamponade.
Devices designed specifically for intrauterine tamponade feature at least one balloon that remains collapsed until it is placed within the uterine cavity and a double lumen catheter to allow balloon filling through one portion of the catheter and drainage of blood from the uterus. Most balloons marketed specifically for intrauterine use come preassembled and offer an attachment that allows rapid filling using a bag of crystalloid rather than having to manually fill the balloon using a 60 mL syringe.
Each device is made from slightly different materials, has a unique size and volume, and has unique properties. In the setting of ongoing uterine bleeding, rapid deployment of balloon tamponade is often more important than the specific use of one brand over another when a choice is available.
Efficacy — In a meta-analysis including over 4700 patients with PPH (7 randomized or cluster randomized trials, 15 nonrandomized studies, 69 case series), the overall pooled uterine balloon tamponade success rate was 85.9 percent (95% CI 83.9-87.9), with the highest success in uterine atony (87.1 percent) and placenta previa (86.8 percent) and the lowest in placenta accreta spectrum (66.7 percent) and retained products of conception (76.8 percent) . Hemorrhage stopped more frequently when balloons were placed after vaginal delivery (87.0 percent) than when placed after cesarean delivery (81.7 percent).
In this analysis, success was defined as arrest of bleeding without maternal death or additional surgical or radiologic interventions after balloon placement. However, this is a narrow definition as the balloon can be useful as a temporizing measure to reduce blood flow to the uterus and thus provide time to initiate and continue other measures to stabilize the patient.
Intrauterine packing — Various types of packing can be used for intrauterine tamponade.
Plain gauze or laparotomy sponges — Traditionally, sterile gauze or laparotomy sponges have been used to pack the uterine cavity. Originally, these types of gauze packing were developed for the battlefield to allow quick temporization of traumatic bleeding and improve survival to surgery. The primary mechanism by which uterine packing works is similar to that of balloon tamponade: intraluminal pressure and a reduction in uterine artery perfusion pressure.
Despite studies from the early to mid-1900s describing success rates close to 100 percent, uterine packing fell out of favor without a clear reason other than a belief that the procedure was unphysiologic and therefore unacceptable ; however, there has been a resurgence in the use and acceptability of uterine packing for tamponade.
Hemostatic gauze — Specialized hemostatic or trauma gauze is preferable to plain gauze, especially in the setting of heavy bleeding or if there is concern for coagulopathy (table 3) [6-8]. Hemostatic gauze confers superior benefit due to the additional hemostatic mechanisms of the substances with which they are impregnated: kaolin-laden gauze activates the body's own coagulation cascade, and chitin-laden gauze forms a gel to which blood cells adhere outside the clotting cascade.
Contemporary small studies of the use of hemostatic gauze for tamponade report success rates of >90 percent [9-11].
Compressed mini-sponges — A novel packing device contains compressed mini-sponges encased in a mesh pouch; a long, tubular applicator facilitates placement . The mini-sponges rapidly absorb blood, expand and conform to the shape of the uterus, and exert intraluminal pressure for up to 24 hours.
In a prospective study including nine patients experiencing blood loss of >500 mL after vaginal delivery, all nine patients experienced cessation of bleeding within one minute of placement; no adverse events were noted related to the device, and no patients experienced a second bleeding episode . Further studies with larger numbers of participants are planned.
Vacuum-induced tamponade — A novel hemorrhage control device applies low-level intrauterine vacuum (70 to 90 mmHg) to rapidly evacuate blood and facilitate physiologic uterine contraction in patients with PPH due to atony that has not responded to uterotonic drugs and uterine massage (figure 1) [13-16]. When bleeding is controlled and the uterus feels firm and contracted, the vacuum is discontinued and the device removed 30 minutes later if the patient has remained stable.
In a prospective multicenter single-arm treatment study, the device controlled PPH in 100 of the 106 participants (94 percent), typically within two to five minutes of beginning the vacuum . There were no serious procedure-related adverse events. Forty participants received at least one unit of blood transfusion; five of the six cases in which the device was unsuccessful required additional treatment to control atony-related hemorrhage, and the remaining case was successfully treated for a previously unrecognized cervical laceration. Based on this study, the US Food and Drug Administration granted premarket approval for use in the United States in August 2020 . Given its rapid effect onset, this device is a promising new alternative to packing and balloon tamponade; ongoing data are needed to evaluate overall efficacy, effectiveness, and safety.
CHOICE OF TAMPONADE METHOD — Intrauterine balloon tamponade is the preferred method of tamponade in national guidelines for management of PPH and is widely used where available . However, few comparative studies have been performed and do not provide clear evidence of the superiority of one tamponade approach over another [6,11,19].
Advantages of balloon tamponade include:
●Relative ease of insertion
●Ability to use a single device and reduce the risk of retained foreign body
●The potential to monitor ongoing intrauterine bleeding in specially designed balloons
Compared with balloon tamponade, the advantages of gauze packing are that sterile gauze or other fabric packing is generally inexpensive and readily available, even in low-resource settings.
The potential disadvantages of packing include:
●A potentially longer time to fully insert gauze
●Absorption of blood into the fabric, thereby masking ongoing bleeding
●Risk of a retained foreign body
●Expertise required to place the pack so that it exerts sufficient pressure through the uterine cavity, which is essential for success
These risks can be mitigated by tying together separate sponges (to aid complete removal), documenting how many pieces of gauze are placed and ensuring the same number are retrieved, and by using radio-opaque materials in case evaluation for a suspected retained piece of gauze is required. In addition, monitoring fundal height for a rise despite packing bleeding can help detect occult blood loss absorbed by the gauze/fabric.
CANDIDATES — Patients with bleeding due to uterine atony not controlled by uterotonic drugs are candidates for tamponade. Tamponade is often attempted before resorting to more invasive or permanent surgical approaches.
Tamponade has also been used with variable success in patients with lower uterine segment bleeding following delivery complicated by placenta previa or a low-lying placenta. Infrequently, tamponade has been used alone or with other hemostatic measures for management of delayed (secondary) PPH or for focally invasive placenta, such as use of compression sutures. (See "Secondary (late) postpartum hemorrhage", section on 'Definition/diagnosis' and "Placenta accreta spectrum: Management".)
Contraindications — Contraindications include:
●Allergy to any component of the device or packing material.
●Clinical settings where tamponade is unlikely to be effective (eg, uterine abnormalities that prevent effective tamponade, suspected uterine rupture or other genital tract laceration).
As with any emergency, one must assess the risks and benefits of uterine tamponade and proceed accordingly. Tamponade should not be used when immediate hysterectomy is likely to be needed to save the patient's life or to replace evacuation of retained products of conception. The risk of infection in the setting of chorioamnionitis/endometritis also must be considered and appropriate antibiotic coverage provided. (See "Postpartum endometritis", section on 'Treatment'.)
MECHANISM OF ACTION — Tamponade (either by balloon or packing) applies inward to outward hydrostatic pressure against the uterine wall. Although the pressure may not be in excess of systemic arterial pressure, compression of proximal endometrial and myometrial blood vessels appears to reduce blood flow and facilitate clotting [20-22]. Mechanical stimulation of myometrial contraction may contribute to a reduction in blood flow . Specialized hemostatic gauze, such as those types impregnated with kaolin or chitosan, additionally act by activating coagulation locally.
PROCEDURE — Adequate lighting, appropriate patient positioning, an empty maternal bladder, and assistance from one or more people facilitate placement.
●Be prepared. Identify patients at high risk of PPH and have appropriate uterotonics, blood products, and tamponade equipment readily available. Because PPH can also occur in low-risk patients, the labor and delivery unit should have the necessary supplies and equipment easily accessible at all times.
●Perform tamponade before coagulopathy develops, as it is less likely to be successful once coagulopathy has occurred.
●Continue concurrent medical management of hemorrhage, including use of uterotonic drugs and, when appropriate, tranexamic acid. (See "Postpartum hemorrhage: Medical and minimally invasive management".)
●If bleeding continues despite intrauterine tamponade, initiate additional hemostatic procedures (eg, compression sutures, uterine artery ligation, hysterectomy). (See "Postpartum hemorrhage: Management approaches requiring laparotomy".)
Insertion of an intrauterine balloon
Equipment — The following equipment should be assembled:
●Balloon catheter of choice.
●Sterile fluid for irrigation (500 to 1000 mL of crystalloid to allow adequate fluid for instillation plus additional to spare if needed).
●At least two large Luer lock syringes (≥60 mL).
●Basin to facilitate quick syringe filling.
●500 to 1000 mL bag of crystalloid (sterile saline, water, or Lactated Ringer) for kits with a bag-spike adapter for rapid filling. Balloons should never be insufflated with air or carbon dioxide due to the risk of air embolism.
●Atraumatic forceps (eg, ring forceps).
●Portable ultrasound machine to look for retained products of conception (remove if present) and guide placement (performed by an assistant during transvaginal placement).
●Antiseptic solution (eg, povidone-iodine).
●Gauze or vaginal packing (if vaginal packing or balloon stabilization needed).
●Straight and/or indwelling bladder catheter.
●Urine collection bag with urometer (for monitoring and accurate measurement of ongoing bleeding through the efflux port).
Technique — Each balloon catheter is unique; therefore, insertion technique varies slightly depending on the device used. Provider preferences can also result in slight variations in technique.
●To place the balloon after a vaginal birth or after closure of the abdomen following cesarean delivery, place the patient in the lithotomy position in stirrups and insert the balloon transvaginally. Whenever possible, use ultrasound guidance during placement.
•Cleanse the cervix and vagina with antiseptic solution, such as povidone-iodine.
•Grasp the anterior cervical lip with ring forceps.
•Apply gentle traction so the cervical canal and uterine cavity are aligned.
•Use forceps (smooth long dressing, ring) to insert the balloon as high in the cavity as possible without using excessive force (which can lead to uterine perforation). The nondominant hand can be used to exert transabdominal pressure to maintain alignment of the cervical canal and uterine cavity.
The balloon can also be placed into the uterine cavity manually.
•If you encounter resistance before the entire balloon is above the internal cervical os, readjust the angle of insertion or abandon the procedure.
●To place the balloon at cesarean delivery before closure of the hysterotomy, bend the patient's legs at the knees with the hips externally rotated ("butterfly" position). Alternatively, to facilitate placement of the balloon and monitor for ongoing bleeding, the patient's legs can be supported in raised stirrups.
•Insert the balloon through the hysterotomy and into the uterine cavity.
•Pass the stem of the catheter through the cervix and into the vagina. Some catheters may permit removal of a stopcock to facilitate placement through the cervix; the stopcock must be reattached to the tubing prior to fluid instillation. Ask an assistant to pull the end of the catheter out through the introitus.
•Carefully close the uterine incision to avoid puncturing the balloon prior to fluid instillation. Uterine compression sutures can be used with balloon tamponade if the balloon alone does not control bleeding. (See 'Application of uterine compression sutures in addition to balloon tamponade' below.)
●To place the balloon after the hysterotomy is closed but the abdomen is still open following cesarean delivery, an assistant can insert the balloon transvaginally (as described above for vaginal delivery), and the surgeon can monitor insertion from above to ensure: 1) appropriate placement and 2) that the balloon fills appropriately and does not disrupt the hysterotomy repair. Any intra-abdominal bleeding following balloon inflation must also be addressed.
Uterine compression sutures can be used with balloon tamponade if the balloon alone does not control bleeding. Care must be taken to avoid puncturing the balloon during placement of compression sutures. (See 'Application of uterine compression sutures in addition to balloon tamponade' below.)
Filling the balloon
●Verify the position of the balloon with transabdominal ultrasound (or perform real-time, continuous ultrasound guidance if an assistant is available).
●Fill the balloon(s) with warm sterile fluid (warmth enhances the coagulation cascade) until slight resistance to further instillation is encountered and bleeding slows or stops.
●Ideally, one person holds the balloon in place (vaginally) while a second person instills fluid into the balloon to help prevent expulsion from the uterine cavity.
Perform a tamponade test. The tamponade test is positive if bleeding stops when the balloon is partially or completely filled and negative if bleeding fails to stop with maximum balloon filling. Cessation of bleeding from the lower segment often occurs between 250 and 300 mL of instillation, but more fluid (>500 mL) may be required to effectively stop bleeding in cases of uterine atony .
●Adding an additional 50 to 100 mL of fluid helps keep the balloon in place after bleeding stops. The maximum manufacturer-recommended fill volumes vary by type of balloon catheter (table 1 and table 2); actual filling capacities (as demonstrated by in vitro trials prior to balloon rupture) may be higher and are important to note if instillation of additional fluid is required to stop bleeding .
●If necessary, a vaginal pack may be placed to keep the balloon in position; if a double-balloon device is used, the vaginal balloon is filled to aid retention.
●Attach a collection bag, ideally with a flowmeter (such as for an indwelling urinary catheter), to the drainage port.
●Mark the level of the fundus to facilitate posttamponade monitoring. If the fundus rises (with or without visible bleeding from the drainage port), the patient should be evaluated for occult intrauterine bleeding.
Insertion of traditional or hemostatic packing
Equipment — The following equipment should be assembled:
●Atraumatic forceps (such as ring forceps)
●Long smooth forceps (without teeth)
●Straight and/or indwelling bladder catheter
●Antiseptic solution (such as povidone-iodine)
●Regardless of the route of delivery, gauze is usually placed vaginally. At cesarean delivery, it is placed after closure of the hysterotomy incision to prevent inadvertent suturing of the packing material to the uterine cavity.
●Long, single gauze ribbons are preferred to small pieces to limit the total number of fabric pieces placed. Occasionally, laparotomy sponges may be used. If more than one packing is required, we suggest tying them together and recording exactly how many gauze pieces are placed to ensure complete removal.
●The initial steps are similar to balloon placement, but instead of inserting a balloon, gauze is gently placed through the cervix to the fundus and layered within the uterine cavity either manually (requires a fully dilated cervix) or using packing forceps.
●The gauze can be packed all the way down the vagina, leaving a small "tail" of gauze to remain outside the introitus to allow visualization of any blood-tinged staining or ongoing bleeding and to facilitate removal. We secure this tail to the patient's thigh to facilitate identification and ensure that one does not inadvertently leave the intrauterine packing as a retained foreign body.
●Document in the medical record how many pieces of gauze were used so that it is clear (to a different provider who may remove the packing) how many pieces of gauze must be removed.
●Monitor placement with transabdominal ultrasound guidance, if available.
●Mark the level of the fundus to facilitate posttamponade monitoring. If the fundus rises (with or without visible bleeding from the drainage port), the patient should be evaluated for intrauterine bleeding.
Tamponade failure — Patients with persistent bleeding despite tamponade should proceed immediately to surgical hemostatic measures. (See "Postpartum hemorrhage: Management approaches requiring laparotomy".)
Arterial embolization by an interventional radiologist can be considered in patients who are hemodynamically stable and when personnel and facilities are readily available. (See "Postpartum hemorrhage: Medical and minimally invasive management".)
Application of uterine compression sutures in addition to balloon tamponade — External compression sutures can be considered if balloon tamponade alone fails (figure 2) [25-27]. Generally, the decision to use a combination of a tamponade balloon and compression sutures should be made quickly, prior to leaving the operating room rather than as serial measures over time, to avoid unnecessary delay that can lead to clinical deterioration and consumptive coagulopathy.
If the balloon is already in place, the balloon should be removed or deflated prior to placing the compression suture to avoid inadvertent puncture. The balloon can then be replaced and refilled with fluid, which should still be possible, provided that the compression sutures used were placed longitudinally (such as a B-Lynch or Hayman suture) and do not rely upon suturing the anterior and posterior uterine walls together (as with Cho or multiple box sutures). Stop the fluid instillation if blanching at the compression suture sites begins to occur as excessive reduction of myometrial blood flow could lead to uterine rupture or necrosis. (See "Postpartum hemorrhage: Management approaches requiring laparotomy", section on 'Uterine compression sutures'.)
Application of hemostatic gauze in addition to balloon tamponade — Hemostatic gauze packing can be used with intrauterine balloon tamponade in refractory cases . The gauze is first placed within the intrauterine cavity to promote a local hemostatic effect; then, the balloon is placed to provide direct intraluminal pressure. With this approach, removal of both the balloon and gauze is essential.
POSTPLACEMENT CARE AND MONITORING
Routine care — In addition to routine postpartum care:
●We suggest antibiotic prophylaxis with broad spectrum antibiotics while the balloon/pack is in place to reduce the risk of endometritis, although evidence of efficacy is low quality . We use cefazolin 2 g every six hours or gentamicin 1.5 mg/kg every eight hours plus either metronidazole 500 mg every eight hours or clindamycin 300 mg every six hours.
●We also administer a standard oxytocin infusion for 6 to 12 hours to prevent uterine atony. Additional uterotonics may be used as needed . (See "Postpartum hemorrhage: Medical and minimally invasive management", section on 'Administer additional uterotonic drugs and consider tamponade'.)
●Blood transfusion(s) and/or blood products should be administered, as needed, to correct prior deficits.
●In patients with a balloon tamponade, periodically flushing the drainage port (if present) with sterile saline may be required to prevent occlusion of the port by clots.
Monitoring — The patient should be closely monitored for signs and symptoms of ongoing blood loss, such as pallor, dizziness, hypotension, tachycardia, confusion, uterine enlargement, abdominal pain, abdominal distension, and oliguria. This is especially important when a gauze pack is used because a large amount of blood can collect behind the pack and conceal ongoing blood loss.
Obstetric providers should be prepared to intervene surgically if the patient's hemodynamic status worsens or does not immediately improve.
DURATION OF TAMPONADE AND DEVICE REMOVAL — Prior to removing the balloon or packing, we recommend ensuring that emergency surgical services and experienced staff members are readily available in the event that bleeding resumes.
●Duration of use – The optimal duration of balloon inflation has not yet been established. We recommend balloon removal at 2 to 12 hours if bleeding has abated. Manufacturers of devices specifically designed for intrauterine use recommend balloon removal within 24 hours [31,32]. In a retrospective cohort study of 274 patients who underwent balloon tamponade (excluding those with expulsion or need for other surgical intervention within the first 2 hours), 75 percent had tamponade for >12 hours and 25 percent had tamponade between 2 and 12 hours . Patients whose balloon remained in place for >12 hours had a higher rate of postpartum fever, but there were no other differences between groups (estimated mean blood loss, rate of transfusion of blood products, transfusion of ≥4 units of red blood cells, uterine artery embolization, hysterectomy, intensive care unit admission).
●Removal – Balloon catheters may be deflated and removed either all at once or slowly; there is no evidence to favor one approach over the other. If the balloon is deflated slowly, it can be quickly reinflated to temporize bleeding and allow preparation for surgical intervention; however, we recommend not reinflating a balloon if bleeding resumes after removal. We consider this as an indication for additional interventions. (See "Postpartum hemorrhage: Medical and minimally invasive management".)
For very rapid removal, the catheter tubing may be cut, which permits free and quick drainage of the fluid from the balloon. Once the balloon is completely emptied, it may be removed by pulling gently on the tubing.
●Duration of use – Similar to balloon tamponade, the optimal duration of intrauterine gauze packing has not been established. We remove gauze between 2 and 12 hours after insertion if bleeding has abated. However, if bleeding saturates completely through the gauze at any time, the gauze should be removed and additional surgical treatment rendered.
●Removal – Removal of the packing may be more easily performed in the operating room with anesthesia for patient comfort. Removal under anesthesia in the operating room is advised if the clinician suspects that bleeding will resume and require further interventions.
The patient is placed in lithotomy position or with the legs separated to allow access to the perineum and vagina. The tail of vaginal gauze packing, if present, may be moistened with sterile saline (10 to 20 mL) to facilitate removal. Gently, but quickly, pull the packing from the vagina and assess for bleeding.
COMPLICATIONS — Potential complications include uterine perforation, hysterotomy repair dehiscence during placement of a balloon or pack, and cervical trauma due to balloon inflation at an incorrect location [24,34]. Although rare cases of uterine rupture have been reported, it is likely that balloon tamponade was not the causal factor [35-37].
Infection has been reported, but causality is difficult to prove as these patients have had multiple risk factors for postpartum fever. In a review of balloon tamponade, the rate of complications attributed to the intervention was ≤6.5 percent and included fever or infection after placement, various types of lacerations, and one case of acute colonic pseudo-obstruction . A review of uterine packing found no cases of serious infection .
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Obstetric hemorrhage".)
SUMMARY AND RECOMMENDATIONS
●Intrauterine tamponade with a balloon or gauze pack is an effective method of controlling uterine bleeding unrelated to uterine rupture or other genital tract lacerations. We suggest placement of an intrauterine balloon rather than gauze packing when available (Grade 2C). Regardless of the approach, tamponade should be initiated before coagulopathy develops as it is less likely to be successful if clotting is impaired. (See 'Types and efficacy of intrauterine tamponade' above and 'Choice of tamponade method' above.)
●If bleeding does not stop, tamponade can still be an effective temporizing measure to reduce blood flow to the uterus and thus provide time to initiate and continue other measures to stabilize the patient. (See 'Efficacy' above.)
●The effectiveness of tamponade is assessed by the tamponade test, which rapidly identifies patients who will require a laparotomy. Patients with a negative test (ie, bleeding is not controlled) should proceed directly to laparotomy for use of other measures (eg, uterine compression suture, ligation of utero-ovarian arteries) and, possibly, hysterectomy, depending on the clinical assessment and condition of the patient. Arterial embolization by an interventional radiologist is an option for patients who are hemodynamically stable and when personnel and facilities are readily available. (See 'Procedure' above and 'Tamponade failure' above.)
●Prior to removing the balloon or packing, we ensure that emergency surgical services and experienced staff members are readily available in the event that bleeding resumes. Removal of a gauze pack may be more easily performed in the operating room with anesthesia for patient comfort. Removal under anesthesia in the operating room is advised if the clinician suspects that bleeding will resume and require further interventions. (See 'Duration of tamponade and device removal' above.)
●Prophylactic antibiotics are typically administered at the time of placement of intrauterine balloon or intrauterine gauze packing, and oxytocin infusion is administered for six to eight hours to maintain uterine tone. (See 'Postplacement care and monitoring' above.)
●The balloon or packing is removed between 2 and 12 hours after insertion if bleeding has abated. Retention of tamponade longer than 12 hours has been associated with an increased risk for endometritis. (See 'Duration of tamponade and device removal' above.)
ACKNOWLEDGMENTS — The editorial staff at UpToDate would like to acknowledge Younes Bakri, MD; Jorge Tolosa, MD, MSCE; and Sabaratnam Arulkumaran, PhD, DSc, FRCS, FRCOG, who contributed to earlier versions of this topic review.