Surgical Management of Obstetric Complications: Postpartum Haemorrhage and Uterine Rupture

Abstract

Background: Postpartum haemorrhage (PPH) remains the single largest direct cause of maternal death worldwide, accounting for approximately one quarter of all maternal mortality, with the greatest burden falling on low-resource settings. Uterine rupture is far less common but carries disproportionate maternal and perinatal consequences, complicating roughly 0.5 to 0.7 percent of trials of labour after one previous lower segment caesarean section and considerably more after a classical incision. Both conditions share a defining feature: outcome is determined less by the availability of any single technique than by the speed and coherence of the escalation pathway that leads to it. Objective: To compare the clinical, anatomical, and functional outcomes of contemporary surgical procedures for pelvic organ prolapse, assess postoperative complications and recurrence, evaluate patient satisfaction following different surgical approaches, and identify factors associated with favorable surgical outcomes. Methods: This prospective observational study was conducted among women undergoing surgical treatment for pelvic organ prolapse. Demographic characteristics, clinical presentation, prolapse stage, type of surgical procedure, operative findings, postoperative complications, anatomical outcomes, recurrence, and patient-reported outcomes were recorded. Patients were followed postoperatively to assess symptom improvement, functional recovery, recurrence, and satisfaction. Surgical outcomes were compared according to the type of prolapse and operative approach. Key Findings: Uterine atony accounts for 70 to 80 percent of primary PPH and responds to uterotonics in the majority of cases, but delay in recognising failure of medical therapy remains the commonest contributor to preventable death. Early tranexamic acid, given within three hours of birth, reduces death due to bleeding. Uterine balloon tamponade succeeds in approximately 85 percent of atonic haemorrhage and functions as both treatment and triage test. Compression sutures, stepwise uterine devascularisation, and internal iliac artery ligation preserve the uterus when applied early by an experienced operator, whereas the same techniques attempted late in an exsanguinating and coagulopathic patient increase mortality. In uterine rupture, fetal heart rate abnormality, most often prolonged bradycardia, is the earliest and most consistent sign, and immediate laparotomy takes precedence over further diagnostic confirmation. Repair is appropriate for clean transverse lower segment defects in a stable patient desiring future fertility; hysterectomy is indicated for extensive, stellate, or laterally extending tears, broad ligament involvement, or uncontrolled haemorrhage. Conclusion: Surgical success in obstetric haemorrhage depends on sequence rather than technique. A rehearsed, protocol-driven escalation from uterotonics through tamponade and conservative surgery to definitive hysterectomy, supported by early haemostatic resuscitation and timely senior involvement, saves more lives than any individual operation. The decision to abandon uterine conservation, taken early and without ambivalence, is frequently the most important judgement the obstetric surgeon makes.

Keywords: Postpartum Haemorrhage, Uterine Rupture, B-Lynch Suture, Uterine Balloon Tamponade, Internal Iliac Artery Ligation, Peripartum Hysterectomy, Placenta Accreta Spectrum, Tranexamic Acid, Maternal Mortality