doi:10.1111/jog.13676 J. Obstet. Gynaecol. Res.

2018

Ring compression suture for controlling post-partum

hemorrhage during cesarean section

Guang-Tai Li1*, Xiao-Fan Li2*, Yun-He Zhang1, Yue Si1,3, Guang-Rui Li4 and
Hong-Mei Xu3
1
Department of Obstetrics and Gynecology, China Meitan General Hospital, 2Department of Radiation Oncology, Peking
University School of Oncology, Peking University Cancer Hospital, 3Department of Obstetrics and Gynecology, Beijing Fengtai
Hospital, Affiliated Capital Medical University and 4China Academy of Chinese Medical Sciences, Wangjing Hospital, Beijing,
China

Abstract
Aim: To avoid complications associated with uterine compression sutures, we devised a ring compression
suture (RCS).
Methods: The RCS was performed on 12 patients with post-partum hemorrhage (PPH) during cesarean sec-
tion. The suture was inserted 0.5 cm below the attachment point of the uterosacral ligament into the uterine
cavity and pushed downward through the cervical canal into the vagina. The other end of the stitch was
threaded through the lower abdominal wall, from the inside of the abdomen cavity to the outside of the
abdominal wall, emerging at the external surface of the lower abdomen 2 cm lateral to the ventral median
line and 1 cm above the symphysis pubis. Then, the two ends of the suture (the end in the vagina had been
pulled out in advance) were tied tightly on the pudendum. The same stitch was repeated on the contralateral
side. After 48 h postoperatively, the suture was removed through the vagina under sterilization.
Results: All 12 women with PPH who underwent RCS achieved hemostasis, and complications related to
RCS were not seen. Two of them had successful pregnancies postoperatively. The remaining women had no
desire for a further pregnancy.
Conclusion: The procedure can be used as an alternative to peripartum hysterectomy and also as a prophy-
lactic application in PPH.
Key words: post-partum hemorrhage, prophylactic application, ring compression suture, uterine compres-
sion suture.

Introduction thread and persistent squeeze of UCS have been

Uterine compression sutures (UCS) are a recent inno-
vation used to address PPH. A variety of UCS,1–3
including our series of reports,4–9 have achieved good
hemostasis and preserved life and fertility. However,
postoperative complications related to the remnant
widely described in recent decades.1–3,10
In order to avoid possible adverse effects of our
suturing techniques described previously,4–9 we
devised a new ring compression suture (RCS), or
removable uterus-pubis binding suture (RUPBS),
whose threads, that might induce potential adverse

Received: August 29 2017.

Accepted: April 8 2018.
Correspondence: Dr Hong-Mei Xu, Department of Obstetrics and Gynecology, Beijing Fengtai Hospital, Affiliated Capital Medical
University, No. 1 Xi’an Jie, Fengtai District, Beijing 100071, China. Email: tigercatbee@163.com; Professor Guang-Rui Li, China
Academy of Chinese Medical Sciences, Wangjing Hospital, Huajiadi Jie, Chaoyang District, Beijing, 100102, China.
Email: wjyylgr@yeah.net
*Xiao-Fan Li and Guang-Tai Li contributed equally to this study and share first authorship.

© 2018 Japan Society of Obstetrics and Gynecology 1

G.-T. Li et al.

effects, are removed after 48 h postoperatively. The

procedure is highly effective and can be used as an
alternative to peripartum hysterectomy in every case
of uncontrollable PPH and also has potential for pro-
phylactic application in PPH.

Methods
A retrospective study was carried out on 12 women
who were diagnosed with PPH during cesarean
section (CS) from January 2013 to December 2016 at
China Meitan General Hospital. The application of
this suturing technique was approved by the Hospital
Ethics Committees on November 15, 2012, and the
approval number was MTK13017. The approval
numbers and dates of the Ethics Committees for six
previously published articles4–9 were MTK03006 on
November 14, 20024–6 and MTK05010 on November
18, 2004,7–9 respectively. Two informed consent forms,
for ordinary CS and for this procedure, were signed
by the women and/or their nearest relatives before
Figure 1 Sagittal section of ring compression suture.
the operation. The study protocol had been approved The arrows indicate the direction and line of the
by The Local Ethical Committees of China Meitan suture; the numbers represent the puncture point and
General Hospital and Beijing Fengtai Hospital. the pierce sequence.
Uniform protocol for the management of PPH was
in use in both hospitals. The uterus was exteriorized
and two 70-mm round needles with No. 1 absorbable
threads were used for suturing. The first puncture
point was selected at the dorsal uterine wall, which
was approximately 0.5 cm below the attachment
point of the right uterosacral ligament. The needle
was inserted vertically from the posterior wall into
the uterine cavity (Fig. 1,2). The left lateral suturing
was performed in entirely the same way as that of the
right. Two needles were cut off and the cephalic ends
of both threads were knotted together. The free length
of both threads, namely the stumps of the knot, were
about 30 cm in length. Then, the stumps were pushed
downward through the cervical canal into the vagina
(Fig. 1). Following closure of the hysterotomic inci-
sion, the caudal end of the right lateral stitch was
threaded with a 70-mm round needle and punctured
vertically into the right lower peritoneum and the
abdominal wall, from inside (the abdomen cavity) to
the outside of the abdominal wall, emerging at the
external surface of the lower abdomen 2 cm lateral to
Figure 2 Posterior view of ring compression suture.
the ventral median line and 1 cm above the symphy- The arrows indicate the direction and line of the
sis pubis (Fig.2,3). The same stitch was repeated on suture; the numbers represent the puncture point and
the left side. the pierce sequence.

2 © 2018 Japan Society of Obstetrics and Gynecology

 Ring compression suture to control PPH

The caudal ends and the cephalic ends, which had

been pulled out from the vagina, were tied tautly on
the pubis when the uterus was compressed against
the pubis by an assistant (Fig. 3), so the uterus was
bound beneath and behind the pubis. Because the
two threads encircling and binding uterus-pubis
formed a ring-shape after they were knotted, it was
also called a ‘ring compression suture’. To keep the
threads from nicking the skin and mucosa of the
pudendum, it is best to allow the threads to pass
through a latex pipe (F-28). After 48 h postopera-
tively, the suture was removed through the vagina
under sterilization.
A 6-week follow-up examination was conducted
and further follow-ups were carried out every
3 months for the first year, and then annually.
Patient’s medical records were reviewed to evaluate
the efficacy of the procedure. The women were
informed about PPH and advised to have close gyne-
cological follow-up examinations, including ultraso-
nography and a control hysteroscopy after 6 months.
Figure 3 Anterior view of ring compression suture
postoperatively. The arrows indicate the direction
Results and line of the suture; the numbers represent the
puncture point and the pierce sequence.
The 12 women who received RCS were followed up
for age, gravidity number, parturition, gestational 100% (12/12). Total operation time was between
age, mode of delivery, reason for cesarean birth, cause 61 and 98 min (78.33 10.98 min). Post-partum men-
of PPH, amount of blood loss and volume replace- strual flow and breastfeeding were normal. The time
ment, postoperative complications, hospital stay, periods for menstruation to resume were between
recovery of normal menstrual flow, imaging and 2 and 5 months (3.42 0.99 months).
endoscopy. The efficacy and the safety of the suturing No postoperative anatomical or physiological
technique were also assessed. abnormalities were seen in any of the 12 women in
The average follow-up time was 31.08  17.89 whom suturing was successful. There were no postop-
(mean  standard deviation) months. The age range erative symptoms, such as potential lower abdominal
of the women in the study was between 22 and complaints. Ultrasound confirmed that the endome-
36 years (30.25  3.55 years); eight of the women trium and ureter were normal, and hysteroscopy
were nulliparous and four multiparous. The average showed a normal uterine cavity in all the 12 women.
gestational age was 39 weeks and 2.58 days. Atonic Two of the 12 women had had successful pregnan-
bleeding possibly caused by macrosomia (n = 4), poly- cies after the operation. The remaining 12 women had
hydramnios (n = 3), prolonged labor (n = 3) and pla- no desire for a further pregnancy. The demographic
centa previa (n = 2). Neonatal weight was from 3460 data of the 12 women with uterine atony and PPH,
to 4580 g (4005.00  422.36 g). The amount of blood loss who underwent RCS during CS, are shown in
ranged from 1100 to 2200 mL (1383.33  294.91 mL), Table 1.
and the blood transfusion volume was between 200 and
1000 mL (366.67  238.68 mL).
All 12 cases had undergone conservative manage- Discussion
ment (uterotonic drugs, manual massage, gauze pack-
ing and so on) but the treatment had no effect before In the treatment of PPH, UCS such as the B-Lynch
the RCS was adopted. After suturing, there was obvi- suture and its modifications have an important role
ous reduction of bleeding in all cases, a success rate of with the advantage of preservation of the uterus for

© 2018 Japan Society of Obstetrics and Gynecology 3

4
Table 1 Demographic data of women with uterine atony (UA) and post-partum hemorrhage (PPH) who underwent ring compression suture during cesar-
ean section (CS)
G.-T. Li et al.

Case Age Gravidity Term Diagnosis at Neonatal Estimated Blood Operative Resumed Follow-up
no. (years) and (weeks of presentation weight blood transfusion time (min) menstruation /got (months)
parity gestation) (g) loss (mL) (unit) gestation (months)
1 31 G2P0 40 + 3 MS 4510 1200 2 units 64 3 53
PRBC
2 31 G2P0 38 + 6 PHA 3570 1300 2 units 65 5 51
PRBC;
200 mL
FFP
3 27 G2P0 40 + 1 MS 4580 1200 1 unit 61 2/35 49
PRBC
4 28 G2P0 39 + 2 MS 4520 1400 1 unit 84 3 47
PRBC;
200 mL
FFP
5 31 G3P1 38 + 1 PHA 3460 1100 1 unit 75 3/29 46
PRBC
6 33 G2P0 40 + 6 MS 4540 1400 2 units 83 4 35
PRBC;
200 mL
FFP
7 32 G3P0 39 + 2 PHA 3650 1200 1 unit 78 4 29
PRBC
8 30 G4P0 37 + 1 PP 3750 1500 2 units 89 3 19
PRBC;
200 mL
FFP
9 22 G1P0 41 + 2 PL 3980 1300 1 unit 77 2 16
PRBC
10 36 G4P1 37 + 3 PP 3650 2200 5 units 98 5 13
PRBC;
800 mL
FFP
11 33 G2P1 40 + 5 PL 3860 1600 3 units 87 3 10
PRBC;
200 mL
FFP
12 29 G3P1 38 + 6 PL 3990 1200 1 unit 79 4 5
PRBC
FFP: fresh-frozen plasma; MS, macrosomia; PHA: polyhydramnios; PL: prolonged labor; PP: placenta praevia; PRBC: packed red blood cells.

© 2018 Japan Society of Obstetrics and Gynecology


fertility. However, some complications related to it
have been reported, including uterine ischemia, ero-
sion, necrosis, infection, pyometra, synechiae, reinver-
sion, rupture, infertility and irregular menstruation
or menstruation-associated symptoms.1–3,10–16 The
causes of these adverse effects are principally the
suture depriving the site of blood supply, occluding
the uterine cavity and bringing about foreign body
reaction.
In order to reduce these adverse effects and to sim-
plify the operation of UCS, we have designed the
reflexed compression suture (ReCS),7 the simpler
compression suture (SCS)8 and the uterine folding
hemostasis (UFH).9 ReCS is more suitable for placen-
tal implantation in the uterine body than other UCS.
SCS decreases the number of microorganisms entering
into the uterine cavity so reducing the incidence of
uterine infection. UFH only stitches at the fundus of
the uterus and does not deprive the site of blood sup-
ply, nor does it occlude the uterine cavity. In addition,
we also devised the symbol ‘&’ suture (S&S),4 the fun-
nel compression suture (FCS)5 and the longitudinal
parallel compression suture (LPCS)6 to make up for
the disadvantages of some UCS that do not fully
cover the lower uterine segment (LUS) and occlude
the uterine cavity. S&S can simultaneously stop the
bleeding from the uterine body and LUS, and avoid
occlusion of the uterine cavity. FCS, which maintains
uterine cavity patency, can be used for severe bleed-
ing due to placenta accreta in LUS because it can
block blood flow from the origin of the uterine ves-
sels. LPCS does not need to reopen the cesarean inci-
sion when it is used to stop hemorrhage of LUS, nor
does it occlude the uterine cavity.
Although our techniques above partly solve some
problems that cause these complications, such as the
sutures depriving the site of blood supply and occlud-
ing the uterine cavity, there is still a negative factor
that has not been eliminated. That is, the remaining
threads bringing about foreign body reaction are still
not removed, and this is the main culprit in inducing
these adverse effects.10–16
Aiming to prevent these complications and to elimi-
nate the culprit, we devised a new removable UCS on
the basis of previous techniques, namely RCS, which
has more advantages and less disadvantages compared
with previous techniques (Table 2). The indications,
contraindications, advantages and disadvantages of
these seven methods are shown in Table 2.
RCS achieved an effective result in the 12 patients.
There were no morbidities or abnormalities in the
© 2018 Japan Society of Obstetrics and Gynecology
Ring compression suture to control PPH
women who underwent RCS. This good outcome is
because the suture can: (i) remove the threads to
reduce the incidence of complications and the psycho-
logical burden of patients; (ii) cover the total uterus
(including the upper and lower segment) and bind it
to the pubis to achieve complete compression hemo-
stasis; (iii) insert needles from the peritoneal cavity
into the uterus and the abdominal wall so as to avoid
contaminating abdominal cavity; (iv) only sew twice
at the posterior wall rather than repeatedly at both
walls of the uterus so as to minimize the trauma and
likelihood of infection of the uterus; (v) only squeeze
the posterior wall of the uterus to give the anterior
wall an indirect elastic compression rather than a
rigid cutting force of the threads, which inhibits the
induction of uterine ischemia and necrosis; (vi) keep
the uterine shape with anteversion and not force the
distortion of the uterus’ anatomical structure to con-
trol bleeding; (vii) easily be removed from the vagina
because the remaining threads within the abdominal
wall have retracted elastically into the abdominal cav-
ity after they are cut off, while the frictional resistance
within the thin muscle of the lower uterine segment is
negligible.
What needs to be emphasized is that our technique
makes the uncontrollable internal UCS threads fixed
on the uterus within the pelvic cavity change to an
adjustable external jerk line outside the abdominal
cavity, and the tension of the suture can be elevated
by placing a sterilized gauze pad under the threads
on the pubis when the bleeding is continuous or the
suture becomes loose due to uterus involution. In
addition, RCS is simple, safe, effective and practical
because it requires less experienced skill and its punc-
tures are directly into the posterior uterine walls and
the abdominal wall where there are no important
structures such as greater vessels or ureter in its sur-
roundings. This means the technique can be easily
mastered and performed by junior surgeons in an
emergency situation. Therefore, RCS should be incor-
porated into first-line surgical management of PPH.
Our team has devised seven sutures and RCS is the
first option at the present time, because we believe
that RCS is better than any of the methods that we
have previously reported.4–9 The only disadvantage
of this suture is that the distal side of the cervix, that
is, the outside area (the vaginal side) of the suture,
cannot be compressed, meaning bleeding from this
portion cannot be stopped, if it is present, but such an
occurrence is rare. Thus, we take RCS as the first
choice and are currently applying it for PPH. On
5
G.-T. Li et al.

Table 2 Comparison of advantages and disadvantages among seven compression suture techniques
References Suture Indications Contraindications Advantages Disadvantages
4
Symbol “&” suture Bleeding from Severe MAP such Simultaneously Need to penetrate
UC and LUS as PP stopping PPH into UC
from UC and LUS;
no need to open
UC for suturing
5
Funnel Bleeding from Bleeding from Blocking blood flow Need to separate
compression LUS due to CU from the origin of the bladder to
suture MAP the uterine vessels; the cervix to
ceasing severe expose the
bleeding due to whole LUS
PPA; keeping UC
patency
6
Longitudinal Bleeding from Bleeding from Suturing range Could not examine
parallel LUS due to CU or due to covers the full hemostatic effect
compression PA or CS severe PPP length of LUS; under direct
suture scar keeping UC vision because
patency; no need suturing is done
to open UC for after closed CS
suturing incision
7
Reflexed Bleeding from Bleeding from Particularly suitable Need to transfix
compression UC with LUC for PA in CU; no into UC;
suture MAP need to conduct a occasionally
hysterotomy for might cause
suturing uterine ischemia
and synechiae
like other UCS
8
Simpler Bleeding from Bleeding from No need to open UC Occasionally
compression UA or PA of LUS or PI and for suturing; might cause
suture CU PP in CU keeping UC uterine ischemia
patency and synechiae
like other UCS
9
Uterine folding Bleeding from Bleeding due to Not easy to cause Weaker strength
hemostasis UA of CU MAP or from uterine ischemia, of compression
LUS necrosis and hemostasis; only
synechiae; keeping applying in UA
UC patency of CU
Ring Bleeding from PPA next to the Removability of the Partial posterior
compression TU cervical canal suture; not easy to wall of the
suture cause uterine cervical canal
ischemia and cannot be
synechiae; covered and
synchronously compressed by
arresting PPH the suture
from UC and LUS;
no need to open
UC for suturing;
keeping UC
patency; may be as
a prophylactic
application in
potential PPH
CS: cesarean section; CU, corpus uteri; LUS, lower uterine segment; MAP, morbidly adherent placenta; PA, placenta accreta; PI, placenta
increta; PP, placenta percreta; PPA, placenta previa accreta; PPH, post-partum hemorrhage; PPP, pernicious placenta previa; TU, total
uterus; UA, uterine atony; UC, uterine cavity; UCS, uterine compression suture.

6 © 2018 Japan Society of Obstetrics and Gynecology


account of its simplicity, safety, efficacy and particu-
larly its removability, the procedure may also be pop-
ularized as a prophylactic application for women
with potential PPH.
The shortcomings of the present study include:
(i) the small sample size of our research is a limita-
tion; (ii) a long-term comparison with other UCS is
required; (iii) the suture should be further tested and
verified for its prophylactic application in PPH as
other authors have validated and analyzed the effi-
cacy of prophylactic B-Lynch sutures in high-risk
patients,17,18 which would be a chance to turn a cor-
ner on the therapeutic principles in PPH. We will fur-
ther explore the role of the suture in the prophylaxis
of PPH, hoping to find an effective suturing means to
prevent potential PPH. More than 100 patients will be
enrolled in our research in future to reevaluate the
efficacy and the incidence of side effects of RCS, as
well as to further compare the procedure with other
removable UCS and to obtain more precise data.
Disclosure
None declared.
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