Which uterine compression suture should I use for atonic postpartum haemorrhage? A comparison of B‐Lynch and Hayman compression sutures: technique, efficacy and complications

Articles in the Tips and Techniques section are personal views from experts in their field on how to carry out procedures in obstetrics and gynaecology. Atonic postpartum haemorrhage (PPH) remains a critical challenge in obstetrics. Despite significant progress in reducing obstetric haemorrhage-related mortality in the United Kingdom (UK), the 2020–2022 UK and Ireland Confidential Enquiry into Maternal Deaths and Morbidity reported 18 maternal deaths directly attributed to PPH. A recurring theme in these cases was that interventions often occurred ‘too little, too late’.1 While most PPH cases are effectively managed using a standardised pharmacological algorithm, surgical and radiological interventions become necessary when medical treatment fails.2 Surgical options include intrauterine balloon tamponade, compression sutures, selective devascularisation, and hysterectomy, as well as newer techniques such as vacuum-induced uterine tamponade.3 Interventional radiology techniques, if available locally, include uterine artery embolization and use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) balloons.2 Amongst these, insertion of uterine compression sutures stand out as a technically feasible approach to achieve haemostasis while preserving fertility, making it an essential skill for obstetricians.4 This is especially true because not all obstetric units have access to 24/7 interventional radiology services and the other specialised surgical devascularisation techniques are more difficult to master. Despite surgical management of PPH being a core competency within the Royal College of Obstetricians and Gynaecologists (RCOG) curriculum,5 opportunities for trainees to perform uterine compression sutures in clinical practice are limited due to the instability of haemorrhaging patients, which precludes inexperienced practitioners from gaining hands-on experience.4 In this Tips and Techniques article, the authors review two commonly used uterine compression sutures for rapid surgical management of atonic PPH and highlight practical and valuable insights for emergency scenarios. This is to facilitate resident doctors being able to learn and consider the application of uterine compression sutures when the need arises, considering the limitations of the training programme. In the authors' opinion, the B-Lynch and Hayman vertical compression sutures are probably the simplest techniques that apply sustained surgical uterine compression and form the basis of various modifications that follow these two eponymous sutures. Box 1 highlights the various types of compression sutures that have been described over the years.6 To date, no randomised controlled trials (RCTs) have compared the efficacy of the different compression sutures or whether the uterine compression suture is better than other procedures for achieving haemostasis.3 In the original published descriptions for B-Lynch (1997) and Hayman (2002) sutures respectively, success rates were reported as 100% (5/5 cases for B-Lynch, and 3/3 cases for Hayman).2 Based on a prospective study in the UK, the use of compression suture within 1 hour after delivery yielded a higher success rate of 84% while the overall success rate if the suture were to be applied at any time postpartum was 75%.7 A prolonged delay of 2–6 hours between delivery and uterine compression suture was independently associated with a fourfold increase in the odds of hysterectomy.7 For this reason, if the compression sutures are to be used, they should be performed as soon as possible, ideally within the first 60 minutes (‘golden hour’), before disseminated intravascular coagulation (DIC) becomes evident.7 The majority of PPH cases improve with conservative measures, but if these progressively fail in a stepwise manner, compression sutures may be considered before disseminated intravascular coagulation (DIC) becomes evident,7 especially when there is limited access to interventional radiology. During a caesarean section (CS), blood loss through the abdomen can be readily quantified using a Yankauer sucker or weighing of swabs, with the surgical team being regularly updated on the cumulative volume. However, concomitant vaginal bleeding during CS often remains concealed due to opaque surgical drapes and as the patient can compensate haemodynamically for an extended period, the surgeon may be misled into underestimating the true blood loss. In contrast, while blood loss is more apparent in vaginal deliveries, its estimation can be challenging without carefully suctioning all the blood which can collect in a puddle on the floor. Moreover, it becomes more difficult when blood is mixed with other bodily fluids such as amniotic fluid. Paradoxically, women undergoing vaginal delivery face a higher risk of hysterectomy when treated with uterine compression sutures.7 This is attributed to obstetricians' reluctance to perform a laparotomy for suture placement after significant bleeding in vaginal deliveries compared to CS. Delaying this intervention can lead to DIC and even death, whereas timely action significantly improves outcomes.7 Accurate measurement of postpartum haemorrhage (PPH) is critical for obstetricians to implement a stepwise approach in managing a deteriorating patient, particularly when early surgical intervention is necessary. This is especially relevant in vaginal deliveries, where additional time is required to prepare the patient for surgery. It is advisable for the clinician to perform a ‘compression test’ before determining the potential efficacy of the compression suture before placement. In theatre, the patient should be placed in the Lloyd Davies or lithotomy position. Once laparotomy is performed, an assistant should be standing between the patient's legs intermittently swabbing the vagina to determine the extent of bleeding.8 The uterus is exteriorized and compressed bimanually by placing one hand posterior with ends of fingers at the level of cervix and the other hand anteriorly over the fundus towards the bladder reflection—this has the effect of stimulating the interlinked lattice network of myometrial fibres for vascular compression as well as kinking the uterine vessels. By doing so, continuous vertical compression is placed on the vascular system. Moreover, an optimally placed ‘brace’ suture promotes anteflexion of the uterus and thereby causes slight kinking of the uterine vessels. During this manoeuvre, if the bleeding recedes and the uterus feels more contracted, it is likely that the use of a compression suture will be effective in controlling the atony. Professor B-Lynch first reported the successful use of the ‘Brace’ suture in five women in his seminal case series in the British Journal of Obstetrics and Gynaecology in 1997. As of 2006, the success rate of the B-Lynch suture was considered to be 99.5% with over 1800 cases being successfully performed worldwide.9 Box 2 is accompanied by a pictorial description of the B-Lynch suture technique (Figure 1). The Hayman suture technique was published in 2002 and was a more intuitive and technically simpler alternative to the B-Lynch suture. According to anecdote, it was conceived independently by Professors Arulkumaran and Steer when they needed to place a compression suture but could not recall the more complicated steps of the B-Lynch suture.10 The procedure was deemed to be quicker, easier to insert and did not necessitate a hysterotomy, with success rates of up to 93.75%.11 Box 3 is accompanied by a pictorial description of the Hayman suture technique (Figure 2). The assistant has the crucial role of maintaining compression of the exteriorised uterus with both hands while simultaneously anteverting the uterus so as to decrease bleeding by occluding the uterine artery. The optimal way for the assistant to hold the uterus is depicted in Figure 3. The assistant should be instructed to maintain compression on the uterus as the surgeon systematically takes up the tension of the suture at each point of entry and exit to ensure uniform pressure and tension. A Spencer-Wells tissue forceps can be used to grasp the knot after the first double throw (Figure 4a) in order to prevent knot slippage (Figure 4b). Professor B-Lynch originally used a 70 mm round-bodied hand needle on a No. 2 chromic catgut suture for his ‘Brace’ suture8 while Hayman and his colleagues described either polyglycolic acid (Dexon®, Covidien, Gosport, UK) or Vicryl® (Ethicon Ltd., Livingston, UK) (number 1 or 2 sutures) with a straight needle. The needle should have a shallow curve and be ideally at least 6 cm long so as to exceed the combined thickness of the anterior and posterior walls of the lower segment.12 The two senior authors routinely use a 90 mm blunt taper-point Monocryl 1 which they manually straighten slightly to generate a shallower curve which allows it to penetrate the anterior and posterior uterine walls without getting embedded in the myometrial thickness. The relatively more intuitive steps of the Hayman suture (Box 3) are easier to remember and to perform in an emergency, compared with the nine-step sequence of the B-Lynch suture (Box 2) which may be the reason why the latter had many variations described.6 Moreover, case series have reported a variable success rate of the B-Lynch or modified B-Lynch, and this is thought to stem from differences in the technique performed by the surgeon. If atonic PPH occurred in a mother who had a vaginal birth, the Hayman suture may be preferable as a hysterotomy is not required. This, however, assumes that the cavity is empty and risks sewing the anterior and posterior uterine walls together and inadvertently leading to retained blood clots. To mitigate this risk, it is recommended that residents perform a bedside ultrasound of the postnatal uterus to confirm an empty cavity. Regardless of which type, the insertion of a compression suture, often by the most experienced person present on the labour ward (i.e. the consultant or senior resident doctor), needs to be swift and confident.6 While the authors express a preference for the Hayman suture on the basis of its simplicity and speed of application, obstetricians should aim to become accustomed to at least one type of uterine compression suture to rapidly exert mechanical compression to an atonic uterus.6 On occasions such as placenta previa in conjunction with atony, the senior authors have had to employ the ‘Uterine Sandwich’ technique (Figure 5), which is a combination of vertical compression sutures and intrauterine balloon tamponade first described by Danso and Reginald13 and subsequently published as a case series by Yoong and colleagues.14 In this technique, the B-Lynch or Hayman suture is first applied and where a uterine incision is already present, the Bakri balloon is introduced abdominally via this incision and the caudal end then pulled through the cervix into the vagina by an assistant. If a hysterotomy incision was absent such as in the case of a vaginal birth, the Bakri balloon is inserted through the vaginal route. Placement of the compression sutures prior to the introduction of the balloon avoids the risk of puncturing the latter. The Bakri balloon is inflated to a median volume of 300 mL to exert counter pressure after the appropriate tension was applied by pulling taut the two lengths of the compression sutures. Insufflation of the balloon is discontinued when there is subjective visual evidence of blanching of the uterus.15 There is a theoretical risk of uterine ischaemia and further research is required to determine the optimal volume infused into the balloon. While the uterine sandwich technique has shown promise in managing PPH, there is limited formal evidence for its efficacy; hence, more large-scale comparative studies and randomised controlled trials are essential. While rare, complications have been reported following the B-Lynch suture, including partial ischaemic necrosis necessitating hysterectomy, pyometra, and erosion of the uterine wall with suture material protruding through the cervical os.16 Additionally, there are case reports of uterine rupture in subsequent pregnancies after B-Lynch suture placement16 although it is unclear whether these events are solely attributable to the technique or influenced by other confounding variables such as prolonged labour or infection. It is hypothesised that the ischaemic damage from uterine compression sutures occurs in the immediate postoperative period and is related to the degree of tension exerted on the myometrium. However, as the postpartum uterus rapidly involutes, the compressive effect of the suture typically diminishes within hours as it slips off the uterine fundus.16 The risk of ischaemia is theoretically increased with the ‘Uterine Sandwich’, where external compression is paired with internal tamponade. To mitigate this risk, it is recommended that balloon inflation volumes do not exceed 300 mL and that balloons are deflated within 12 hours.14 Nonetheless, cases of uterine necrosis have been reported with and without balloon tamponade.16 The Hayman suture is associated with a higher incidence of haematometra due to apposition of the anterior and posterior uterine walls, which may impede blood and lochia drainage. Compression sutures in general may also increase the risk of intrauterine synechiae (Asherman's syndrome) and subsequently infertility.9 Although appropriately inserted uterine compression sutures largely negate the need for a peripartum hysterectomy,7 it is crucial for the obstetric team to maintain team situational awareness during this critical time. The surgeon is likely to be task fixated and will lose track of cumulative blood loss and passage of time—it is therefore important for the team to maintain a ‘helicopter view’ (situational awareness).17 Multi-disciplinary team members should also start determining interventions based on the various thresholds of blood loss and consider other factors such as availability of blood products, attempted interventions, patient wishes and most of all, haemodynamic instability. In some cases, an emergency hysterectomy has to be considered. Timely escalation for senior consultant assistance should be done especially in the UK where consultants should be called when a PPH has reached a threshold of 1.5 L, unless the resident doctor has been found to be competent at management of this, in which case a threshold of 2 L can be used.18 A laparotomy set should be available on standby and effective communication within the multi-disciplinary team involving anaesthetists, haematologists and ancillary health workers is required to optimise patient outcomes. Lastly, the application of a compression suture is not a substitute for medical treatment of disseminated coagulopathy7—this correction should take place alongside the operative intervention! Not only is the use of low fidelity simulation feasible, reproducible and cost-effective, it encourages trainees to take an active role in decision-making and exposes them to the possibility of errors.19 A review of the literature revealed that various types of uterine models can be used: a knitted wool model, a folded towel model, women's pantyhose stockings filled with cotton wool and a hot water bottle.4 A typical hands-on training station on compression sutures used by the authors is shown in Figure 6 with two different models of uterus (knitted wool and pantyhose stuffed with cotton). When conservative measures fail in the event of atonic PPH, it is imperative for obstetricians to swiftly and effectively apply uterine compression sutures to control massive haemorrhage and prevent coagulopathy. This critical intervention often falls to the most experienced clinician on the labour ward (i.e. the consultant or senior resident doctor), who must execute the procedure with precision, speed and confidence. This article outlines two widely used vertical compression sutures for managing atonic PPH and provides practical insights from the authors' experiences (Box 4). It highlights key technical and non-technical skills essential for the timely and effective application of these sutures, offering actionable guidance for optimising outcomes in high-pressure scenarios. Finally, the ideas supported by this article should be complemented by direct hands-on training with clinicians experienced in the technique—the authors run regular hands-on compression suture stations at the RCOG Masterclass in the Management of MOH Study Days. Mr Wai Yoong received remuneration from Applied Medical Ltd for facilitating vNOTES courses. WY is also Deputy Editor-in-Chief of The Obstetrician & Gynaecologist; he was exlcuded from editorial discussions and had no involvement in the decision to publish. HS performed a literature search and co-wrote the article. AMM performed a literature search and peer-reviewed the manuscript. WL peer-reviewed the article. WY instigated and co-wrote the article. All authors approved the final version. The authors would like to thank Mr Dhanuson Dharmasena for providing Figure 6 in the manuscript. Ethics approval was not necessary for this article.