Packing cervix in the vaginal fornix significantly reduces postpartum hemorrhage bleeding

Pulling down the cervix and pack it in the vaginal fornix (PC-PVF) may be a safe and effective procedure to reduce blood loss among women who experience postpartum hemorrhage in the lower uterine segment (PPH-LUS) during a vaginal birth delivery, according to new data.¹

Findings from a pair of tertiary hospitals in China found that the addition of PC-PVF procedure to routine care of PPH in the lower uterine segment of women after vaginal deliveries resulted in a significantly reduced rate of blood loss versus lone standard treatment. The investigators also found that an earlier application of PC-PVF provided improved efficacy versus a later application.

Investigators from Shandong Provincial Hospital conducted a retrospective analysis of PC-PVF at 2 different timing intervals relative to routine treatment in cases of PPH-LUS observed between 2019 – 2022. PPH, among the leading causes of maternal death globally,² is conventionally defined as blood loss of >500 mL after vaginal delivery or >1000 mL after cesarean delivery within 24 hours.

PPH-LUS is specifically linked to uterine inertia, prolonged second stage of labor, vaginal birth after cesarean section, labor from assisted reproduction procedures and bleeding at the placenta attachment site. Despite it being a frequent, higher-risk outcome, there remains a lack of conventional, targeted treatment of PPH-LUS post-vaginal delivery outlined in international guideline recommendations.¹

“Innovations for the treatment of PPH-LUS are still greatly needed because, with currently available management strategies, there is still inconsistency in outcomes, increased risk of complications, and limited access in primary hospitals,” investigators wrote. “Therefore, there is an urgent need to develop a simple, safe, and effective hemostatic method for PPH-LUS.”

In the retrospective analysis, the team used a cohort of real-world patients who underwent vaginal delivery during the observed time period. The 124 patients who achieved hemostasis were divided into 3 arms: conventional treatment (n = 40); conventional treatment plus early PC-PVF intervention (n = 33); and conventional treatment plus late PC-PVF (n = 51). Investigators defined uterine massage, uterotonic administration and tranexamic acid administration as “conventional therapy” for PPH-LUS.

Investigators reported an efficacy rate of 44% (n = 40) among patients with PPH-Lus who received conventional treatment, whereas the efficacy rate of conventional treatment plus PC-PVF was 100% when excluding cases caused by laceration and those with incomplete rupture of the lower uterine segment. There were no significant differences in maternal age, gestational week, neonatal weight and Apgar score between the treatment arms.

Patients receiving conventional treatment plus early PC-PVF reported a mean total blood loss of 657.27 ± 131.61 mL—a significantly lower rate than those receiving conventional treatment (847.13 ± 250.37 mL) or conventional treatment plus late PC-PVF (1040.78 ± 242.70 mL; P <.01). Prior to tamponade, bleeding rates were faster among patients who received conventional treatment plus early PC-PVF than the other 2 arms (P < .01). Following tamponade, the bleeding rate of the former group was slower than the latter 2 (P <.05).

In reviewing the findings, the investigators stressed the “serious lack of early recognition and targeted hemostatic strategies” for lower uterine segment bleeding.

“Although there are many reported methods to treat postpartum hemorrhage, they all have some shortcomings,” they wrote. “The PC-PVF is simple to perform without special equipment, and only one operator is required. The lower uterine segment can be compressed directly and continuously in a few minutes. The convenience and effectiveness of this method make it a useful strategy for stopping bleeding when there is a lack of medical resources.”

The team concluded that their findings show PC-PVF is a suitable practice to treat PPH-LUS across hospitals at all levels due to its efficacy, simplistic technical requirements and easily accessible materials.

References

1. ^{Liu, X., Kang, Y., Cao, N., Sun, X., Gu, Y., Wang, X., & Wang, H. (2024). Early identification and conservative treatment of postpartum hemorrhage in the lower uterine segment after vaginal delivery. The Journal of Maternal-Fetal &amp; Neonatal Medicine, 37(1). https://doi.org/10.1080/14767058.2024.2386081}
2. ^{Krewson C. Early detection needed to reduce postpartum hemorrhage mortalities. Contemporary OB/GYN. Published October 9, 2023. Accessed August 16, 2024. https://www.contemporaryobgyn.net/view/early-detection-needed-to-reduce-postpartum-hemorrhage-mortalities}