A woman delivers vaginally at term and has a PPH of 900 mL. Uterus is well contracted. Placenta is delivered complete. Perineal inspection shows a cervical laceration extending to the lower uterine segment. Despite primary repair the bleeding continues. What is the NEXT most appropriate step?

• A Bimanual uterine compression
• B Intrauterine Bakri balloon tamponade
• C Uterine artery embolisation
• D Internal iliac artery ligation ✓

Explanation

When PPH from a cervical laceration continues after repair and the uterus is well contracted, surgical haemostasis targeting the uterine blood supply is indicated. Internal iliac (hypogastric) artery ligation reduces pulse pressure to the uterus and is an appropriate next surgical step in an unstable patient at laparotomy. Bakri balloon is effective for uterine atony, not lacerations. Uterine artery embolisation requires a stable patient and interventional radiology. Bimanual compression addresses atony.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.