During management of a Grade III placenta previa cesarean section, the placenta is manually removed and there is persistent bleeding from the lower uterine segment. After bilateral uterine artery ligation fails to control hemorrhage, the surgical step that specifically addresses lower segment bleeding by reducing pulse pressure in the uterine circulation is:

• A B-Lynch compression suture to mechanically compress the uterine corpus
• B Bilateral internal iliac (hypogastric) artery ligation ✓
• C Hayman suture — vertical compression brace sutures at the lower segment
• D Cho square sutures through the lower segment anterior and posterior walls

Explanation

Bilateral internal iliac (hypogastric) artery ligation reduces pulse pressure in the uterine circulation by approximately 75%, converting pulsatile flow to near-venous flow, which allows clot formation. This is particularly effective for lower uterine segment bleeding after failed uterine artery ligation, as the internal iliac artery supplies the uterine vessels. The B-Lynch suture (A) is a corpus compression suture for atonic bleeding, not specifically lower segment. Hayman sutures (C) are brace sutures useful for atony but do not address vascular pressure reduction. Cho square sutures (D) are useful for lower segment bleeding by creating a sandwich compression but work differently from vascular ligation's pulse-pressure mechanism.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.