5A Skills: Inserting and using intra-uterine balloon tamponade to treat postpartum haemorrhage

Contents

• Objectives
• Unique features of the Ellavi intra-uterine balloon
• Prerequisites for use
• Preparation prior to use
• Insertion into the uterus
• Intra-uterine pressure control
• Monitoring for bleeding
• Abdominal discomfort
• Removal

Objectives

When you have completed this skills chapter you should be able to:

• Explain the unique features of the Ellavi intrauterine balloon.
• Identify patients that meet the prerequisites for using intra-uterine balloon tamponade.
• Do the necessary preparations prior to inserting the intra-uterine balloon.
• Insert the intra-uterine balloon with the correct method.
• Use the correct intra-uterine pressure.
• Monitor for continued bleeding.
• Remove the device.

Unique features of the Ellavi intra-uterine balloon

The Ellavi intrauterine balloon is an open system that:

• Allows water to be expelled from the balloon back to the supply bag reducing the size of the balloon.
• Allows the physiological process of contraction and retraction of the myometrium.
• Allows pressure control that will prevent tissue necrosis if used together with brace sutures.

Note

The Ellavi intrauterine balloon is based on the same principles as the surgical glove balloon described in the 2010 NCCEMD Monograph of the management of postpartum haemorrhage.

Prerequisites for use

In the labour ward following:

• Implementing the emergency measures (Chapter 5, sections 11-28) for postpartum haemorrhage.
• Complete delivery of the placenta.
• Exclusion of perineal, vaginal and cervical tears.

In theatre:

• If the uterus remains atonic with continued bleeding following the manual removal of a retained placenta or evacuation of an incompletely delivered placenta.
• The partial removal of a morbidly adherent placenta.
• The insertion of compression sutures.

In a midwife obstetric unit:

• A placenta that was incompletely delivered.

Note

The Ellavi intrauterine balloon could be used to temporise blood loss prior to taking the patient to theatre for an evacuation.

If an Ellavi intrauterine balloon was used following the incomplete delivery of the placenta in a midwife obstetric unit this must be communicated with the referral hospital during the telephone call arranging the transfer and a highlighted note in the maternity case record. An evacuation of the uterus will be required.

Preparation prior to use

Use aseptic technique to:

• Remove the device from packaging.
• Close the T-valve.
• Fill the supply bag with 1000 ml clean water or saline.
• Screw the tubing cap to the supply bag.
• Alternatively, spike a vaculiter of saline or any other intravenuous fluid to the cap.
• Hang the supply bag on a drip stand at a height of 1.5 m above the patient.

Insertion into the uterus

Sterile gloves must be used for inserting the balloon into uterus:

• Insert a Sims speculum posterior in vagina.
• Grab the anterior cervical lip with two swab holders.
• Remove the Sims speculum.
• Place the balloon in the palm of your inserting hand.
• Hold the balloon with the thumb of the inserting hand.
• Insert the balloon as high as possible in the uterus while stabilising the uterus with the free hand on the swab holders.
• Place your finger tips of the hand in the uterus between the thick anterior and posterior layers of the upper segment.
• Hand the swab holder to an assistant to hold.
• Feed the balloon into the uterus on the tubing with your free hand.
• Withdraw your uterine hand, while holding the tubing with your free hand as high as possible below the hand that is withdrawn.
• Open the T-valve.
• The balloon fills within 45 seconds. While the balloon is filling 2 fingers are held below the cervix in the vagina to prevent the balloon from being expelled.
• Remove your fingers from the vagina and wait 2 minutes. Check whether the balloon remains above the cervix.
• Keep the T-valve open.

If a drip stand is available:

• Keep the T-valve open
• Every 30 minutes, the height of supply bag should be readjusted according to systolic blood pressure.

If a drip stand is not available:

• Close T-valve when balloon is full and place the supply bag on the bed.
• • The supply bag is full when the water or saline level in the supply bag stops deceasing.
• Every 30 minutes, lift the supply bag to the appropriate height and open the T-valve for 30 seconds. Close the T-valve again and place the supply bag on the bed. This is done in order to maintain appropriate pressure in the balloon.

Tape the tube distal to the T-valve to the patient’s upper leg with some leeway for movement.

Antibiotic prophylaxis

Prescribe a 5 day course of broad spectrum antibiotics using intravenous ampicillin and oral metronidazole or intravenous cefuroxime. The intravenous ampicillin and cefuroxime should be replaced by oral equivalents after 24 hours if the patient’s condition is stable.

Transfer

When the patient is transferred, close the T-valve for the duration of the journey.

Intra-uterine pressure control

Determine the blood pressure:

• The appropriate height for the supply bag is determined by the patient’s systolic blood pressure.
• Height markings for pressures of 80, 100, and 120 mm Hg are indicated on the tubing (see table).
• If the systolic blood pressure is below 80 mm Hg, use a height of 1.1 m.

Monitoring for bleeding

Closely observe the patient for bleeding and signs of shock. The blood pressure and pulse need to be measured every 15 minutes and continuously check the amount of vaginal bleeding.

• If bleeding is not considerably decreased within 15 minutes of insertion the tamponade test failed and surgical measures need to be considered. These could include:

  • Compression sutures. Remove the balloon prior to the insertion of compression sutures. The uterine balloon could again be inserted if haemostasis was not achieved with the compression sutures.
  • Systemic devascularisation.
  • A subtotal or total hysterectomy.

• After 8 hours of insertion, check for continued bleeding by lowering the supply bag with the T-valve open to the level of the patient while checking for bleeding. If bleeding recurs, hang the supply bag back at the appropriate height.

Abdominal discomfort

If abdominal discomfort is experienced following inflation of the uterine balloon, the height of the supply bag must be reduced by half and the uterus gently rubbed. Fluid will flow form the uterine balloon back in the supply bag. Once the abdominal discomfort has been relieved the supply bag must be replaced at the original height.

Removal

After 8 hours of insertion, check the blood pressure and pulse rate as well as general condition of the patient for clinical signs of shock:

• If the observations are normal, the general condition of the patient is good and only minimal vaginal bleeding is present (that did not increase subsequent to lowering of the bag), the bag can be removed.
• If removal is indicated, keep the T-valve open and place the supply bag on the bed.
• Allow 60 seconds for all fluid from the balloon to drain back into the supply bag.
• Carefully remove the balloon by pulling on the tubing.

Cautions and warnings

• Only appropriately trained personnel should use the Ellavi uterine balloon.
• The balloon can be kept in the uterus for a maximum of 24 hours.
• If bleeding has not considerably decreased within ONE hour of insertion, surgical intervention or rapid referral should be considered.

Video

Ellavi Uterine Balloon Tamponade

Video by the Department of Obstetrics and Gynaecology, Stellenbosch University made available under a Creative Commons Attribution-NonCommercial-NoDerivatives License