Massive APH is managed with emergency caesarean section. Intraoperatively, despite oxytocics and bilateral uterine artery ligation, torrential bleeding continues. The next surgical step before proceeding to hysterectomy is:

• A Internal iliac (hypogastric) artery ligation ✓
• B Ovarian artery ligation at the infundibulopelvic ligament
• C B-Lynch brachytherapy suture
• D B-Lynch compression suture

Explanation

After bilateral uterine artery ligation fails, the next surgical step in the stepwise approach to surgical haemostasis is bilateral internal iliac (hypogastric) artery ligation. This reduces pulse pressure in pelvic vessels by 85% and blood flow by 48%, converting pulsatile arterial flow to venous-pressure flow. B-Lynch sutures are uterine compression sutures useful for atony before proceeding to vessel ligation. Ovarian artery ligation is an additional step but internal iliac ligation is performed first as per standard protocols.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.