What is the next step in managing postpartum hemorrhage (PPH) during a cesarean section (C-section) that has failed to respond to manual compression and oxytocin?

Next Step: Intrauterine Balloon Tamponade (Bakri Balloon)

After failed manual compression and oxytocin during cesarean section PPH, intrauterine balloon tamponade should be implemented immediately before proceeding to surgery or interventional radiology. 1, 2

Rationale for Balloon Tamponade as Next Step

• Intrauterine balloon tamponade has success rates of 79-90% when properly placed and should be the next intervention after first-line pharmacological management fails 2
• The American College of Obstetricians and Gynecologists explicitly recommends balloon tamponade before proceeding to surgery or interventional radiology 1
• This approach follows the established escalation hierarchy: uterotonics → balloon tamponade → invasive procedures 1, 2

Critical Additional Interventions to Implement Simultaneously

Tranexamic Acid Administration

• Administer intravenous tranexamic acid 1 g over 10 minutes immediately if not already given 1, 2, 3
• TXA must be given within 3 hours of birth—effectiveness decreases by approximately 10% for every 15-minute delay 1, 2, 3
• A second dose of 1 g can be given if bleeding continues after 30 minutes 1, 2
• TXA reduces bleeding-related mortality and should be part of the first-response bundle alongside uterotonics 3

Second-Line Uterotonics

• If oxytocin has failed, administer sulprostone within 30 minutes of PPH diagnosis (if available and not contraindicated) 4
• Alternatively, methylergonovine 0.2 mg IM can be used only if the patient is not hypertensive (>10% risk of severe hypertension and vasoconstriction in hypertensive patients) 1
• Methylergonovine should also be avoided in women with asthma due to bronchospasm risk 1

When Balloon Tamponade Fails

Arterial Embolization

• Embolization is particularly useful when no single bleeding source is identified at examination 3
• Requires hemodynamic stability for transfer to interventional radiology 1
• The American College of Radiology recommends embolization after conventional medical treatment and non-surgical interventions have been unsuccessful 3

Surgical Interventions

• Uterine compression sutures (B-Lynch or similar brace sutures) can be used if balloon tamponade fails 1
• Uterine artery ligation may be considered but has decreased efficacy due to collateral circulation 3
• Hysterectomy is reserved as the last resort when all other measures have failed 3

Essential Concurrent Resuscitation Measures

Massive Transfusion Protocol

• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 1, 2
• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio 1, 2
• Do not delay transfusion waiting for laboratory results in severe bleeding 1, 2
• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 1, 2

Temperature and Oxygenation

• Maintain normothermia by warming all infusion solutions and blood products and using active skin warming (clotting factors function poorly at lower temperatures) 1, 4
• Administer oxygen in severe PPH 1, 4

Antibiotic Coverage

• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 1

Common Pitfalls to Avoid

• Delaying balloon tamponade while attempting additional pharmacological measures—the guidelines are clear that balloon should be implemented before surgery or embolization 1, 2
• Failing to administer TXA or delaying beyond 3 hours (every 15-minute delay reduces effectiveness by 10%) 1, 2, 3
• Using methylergonovine in hypertensive or asthmatic patients 1
• Waiting for laboratory results before initiating transfusion in severe bleeding 1, 2
• Allowing hypothermia to develop, which impairs coagulation 1, 4

Answer to Multiple Choice Question

The correct answer is B. Bakri balloon (intrauterine balloon tamponade). This should be implemented before proceeding to B-Lynch sutures, artery embolization, or hysterectomy according to current guidelines. 1, 2