Balloon tamponade for vaginal lacerations causing severe postpartum haemorrhage

A 17-year-old Sri Lankan woman in her first pregnancy presented at 39 weeks and 4 days gestation with a clear history of ruptured membranes, confirmed on speculum examination, and regular painful contractions. No major problems had been encountered during the antenatal period. Vaginal examination found the cervix to be long, closed and posterior. The patient was admitted to the antenatal ward upon this presentation in the early stages on labour. Later on the day of admission, the patient entered established labour and progressed quickly to deliver a female infant of 3220 g in good condition by normal vaginal delivery. The first stage of labour was recorded as having a duration of 2 hours and 25 minutes, while the second stage lasted 36 minutes and the third stage lasted 6 minutes with active management. Following delivery, it was reported that the perineum was intact and that the estimated blood loss was 200 ml. No comment was made regarding an examination of the placenta but the uterus was reported to be well contracted. Shortly after delivery, the patient was transferred to the postnatal ward. Approximately 5 hours after delivery, the patient was noted to be passing very heavy lochia with clots. The patient rapidly became tachycardic and hypotensive. Resuscitation was immediately commenced and the patient was transferred to the operating theatre for examination under anaesthesia. Upon examination, a large ruptured haematoma and several large lacerations were found to the left wall of the vagina. The uterus was found to be slightly relaxed and boggy but once the cavity had been emptied of clots and some placental tissue and the prostaglandin carboprost had been given the uterus remained well contracted. The cavity of the haematoma was evacuated and it was clear that virtually all of the bleeding was originating from the damaged vaginal tissues. Attempts were made to repair the lacerations but blood loss continued and it became apparent that the patient was developing disseminated intravascular coagulopathy. With the patient remaining under anaesthesia, the vagina was packed with a gauze roll, but unfortunately, this failed to arrest the bleeding. In view of the difficulties in obtaining haemostasis, balloon tamponade was performed with two separate Bakri tamponade balloons (Cook Ireland Ltd, Limerick, Ireland) placed in the vagina. The superior balloon was inflated with 400 ml of saline, while the inferior balloon was inflated with 350 ml. Two small sutures of Mersilk braided silk (Ethicon Endo-Surgery, Inc. Cincinnati, OH, USA) between the labia were required to hold the balloons in place and prevent them from being expelled. The use of the balloon catheter almost entirely stopped all bleeding. The patient was given intravenous antibiotics as prophylaxis. The estimated total blood loss was 3000 ml and the patient overall required 8 units of blood, the initial 2 of which were of O negative group due to the urgency of the situation, 6 units of fresh frozen plasma and 1 unit of platelets. The patient was transferred to the recovery area once she became stable and remained there until the balloon catheters were both deflated and removed after approximately 30 hours. Lochia remained minimal following the removal of the balloons and so the patient was able to be transferred to the postnatal ward. The patient made good further recovery and was able to be discharged home 5 days after her delivery. The patient was reviewed in the postnatal clinic approximately 6 weeks after discharge, when she reported that she had experienced no further bleeding and speculum and bimanual examination revealed a normal vagina with no scarring or adhesions.