How do I perform intrauterine balloon tamponade for postpartum hemorrhage due to uterine atony after failure of uterotonics (oxytocin, methylergonovine, carboprost, misoprostol) and tranexamic acid in a hemodynamically unstable postpartum patient?

How to Perform Intrauterine Balloon Tamponade for Postpartum Hemorrhage

Intrauterine balloon tamponade should be implemented immediately after failure of uterotonics and tranexamic acid, before proceeding to interventional radiology or surgical interventions, as it achieves hemostasis in 90% of properly placed cases and 100% of uterine atony cases. 1, 2

Pre-Procedure Preparation

• Ensure large-bore IV access is established with ongoing aggressive crystalloid resuscitation 3
• Activate massive transfusion protocol if blood loss exceeds 1,500 mL, transfusing packed RBCs, FFP, and platelets in 1:1:1 ratio 4
• Administer second dose of tranexamic acid 1g IV if bleeding continues after 30 minutes or restarts within 24 hours of first dose 1, 4
• Continue uterine massage and bimanual compression during preparation 4
• Obtain informed consent if patient is stable enough; in emergencies, proceed under implied consent 2

Device Selection and Preparation

• Use commercially available intrauterine balloon catheters (Bakri balloon, BT-Cath, or similar devices) designed specifically for postpartum hemorrhage 5
• Prepare sterile water or normal saline for balloon inflation (typically 300-500 mL capacity) 2
• Have additional gauze available; consider wrapping balloon in gauze impregnated with tranexamic acid for refractory cases, as this combines mechanical compression with topical antifibrinolytic effect 6

Placement Technique

For Vaginal Delivery:

• Perform thorough pelvic examination to rule out cervical or vaginal lacerations as contributing factors 5
• Insert the deflated balloon catheter transcervically into the uterine cavity, advancing it to the fundus 2
• Inflate the balloon with sterile water incrementally (start with 250-300 mL, up to 500 mL) until vaginal bleeding stops 2
• Apply gentle traction on the catheter to ensure it is seated against the lower uterine segment 2
• Pack the vagina with gauze to prevent balloon expulsion through the cervix 2

For Cesarean Delivery:

• Place the deflated balloon directly into the uterine cavity through the hysterotomy before closure 5
• Inflate the balloon to 300-500 mL under direct visualization 2
• Close the hysterotomy around the catheter shaft 5
• Bring the catheter out through the cervix and vagina 2

Confirmation of Proper Placement

• Verify cessation of vaginal bleeding after inflation—this is the primary indicator of successful placement 2
• Monitor drainage through the catheter port; minimal or no drainage indicates effective tamponade 2
• Critical warning: Severe stabbing pain despite analgesia, refractory hemorrhage, or hemodynamic instability after placement may indicate iatrogenic uterine rupture and requires immediate removal and exploratory laparotomy 7

Post-Placement Management

• Maintain continuous hemodynamic monitoring for at least 24 hours due to significant fluid shifts 1, 4
• Continue oxytocin infusion (up to 80 IU for high-risk cases shows 47% reduction in hemorrhage compared to 10 IU) 1
• Keep balloon inflated for 12-24 hours if bleeding is controlled 2
• Monitor for complications: infection, uterine rupture, balloon migration 7
• Administer prophylactic antibiotics and re-dose if blood loss exceeded 1,500 mL 4

Balloon Removal

• Deflate and remove the balloon gradually after 12-24 hours if no bleeding recurs 2
• Remove vaginal packing simultaneously 2
• Monitor closely for 2-4 hours after removal for recurrent bleeding 2
• If bleeding recurs, reinflate the balloon or proceed to surgical intervention 2

When Balloon Tamponade Fails

• Success rate is 90% when properly placed overall, but only 80% for retained placenta and may fail in placenta percreta 2
• If bleeding continues despite proper placement, proceed immediately to: 5, 1
  • Bilateral uterine artery ligation
  • B-Lynch compression sutures
  • Interventional radiology for arterial embolization (requires hemodynamic stability for transfer)
  • Hysterectomy as last resort

Critical Pitfalls to Avoid

• Do not delay placement—balloon tamponade is a first-line conservative measure after uterotonic failure, not a last resort 1
• Technical failure occurs in approximately 13% of cases (3/23 in one series); ensure adequate training before attempting 2
• Do not ignore severe pain—this may indicate uterine rupture requiring immediate removal and laparotomy 7
• Maintain normothermia—warm all infusion solutions and blood products, as clotting factors function poorly at lower temperatures 4