Postpartum hysterectomy can be subtotal unless the cervix and lower uterine segment are involved. Total hysterectomy may be necessary in the case of a tear of the lower segment that extends into the cervix or bleeding after placenta praevia.

• Review for indications.

• Review operative care principles and start an IV infusion.

• Give a single dose of prophylactic antibiotics:

- ampicillin 2 g IV;

- OR cefazolin 1 g IV.

• If there is uncontrollable haemorrhage following vaginal delivery, keep in mind that speed is essential. To open the abdomen:

- Make a midline vertical incision below the umbilicus to the pubic hair, through the skin and to the level of the fascia;

- Make a 2–3 cm vertical incision in the fascia;

- Hold the fascial edge with forceps and lengthen the incision up and down using scissors;

- Use fingers or scissors to separate the rectus muscles (abdominal wall muscles);

- Use fingers to make an opening in the peritoneum near the umbilicus. Use scissors to lengthen the incision up and down in order to see the entire uterus. Carefully, to prevent bladder injury, use scissors to separate layers and open the lower part of the peritoneum;

- Place a bladder retractor over the pubic bone and place self-retaining abdominal retractors. 

• If the delivery was by caesarean section, clamp the sites of bleeding along the uterine incision:

- In case of massive bleeding, have an assistant press fingers over the aorta in the lower abdomen. This will reduce intraperitoneal bleeding;

- Extend the skin incision, if needed.

SUBTOTAL (SUPRACERVICAL) HYSTERECTOMY

• Lift the uterus out of the abdomen and gently pull to maintain traction.

• Doubly clamp and cut the round ligaments with scissors (Fig P-54). Clamp and cut the pedicles, but ligate after the uterine arteries are secured to save time.

FIGURE P-54 Dividing the round ligaments 

• From the edge of the cut round ligament, open the anterior leaf of the broad ligament. Incise to:

- the point where the bladder peritoneum is reflected onto the lower uterine surface in the midline; or

- the incised peritoneum at a caesarean section.

• Use two fingers to push the posterior leaf of the broad ligament forward, just under the tube and ovary, near the uterine edge. Make a hole the size of a finger in the broad
ligament, using scissors. Doubly clamp and cut the tube, the ovarian ligament and the broad ligament through the hole in the broad ligament (Fig P-55). 

The ureters are close to the uterine vessels. The ureter must be identified and exposed to avoid injuring it during surgery or including it in a stitch. 

FIGURE P-55 Dividing the tube and ovarian ligaments 

• Divide the posterior leaf of the broad ligament downwards towards the uterosacral ligaments, using scissors.

• Grasp the edge of the bladder flap with forceps or a small clamp. Using fingers or scissors, dissect the bladder downwards off of the lower uterine segment. Direct the pressure downwards but inwards toward the cervix and the lower uterine segment.

• Locate the uterine artery and vein on each side of the uterus. Feel for the junction of the uterus and cervix.

• Doubly clamp across the uterine vessels at a 90̊ angle on each side of the cervix. Cut and doubly ligate with 0 chromic catgut (or polyglycolic) suture (Fig P-56).

FIGURE P-56 Dividing the uterine vessels 

• Observe carefully for any further bleeding. If the uterine arteries are ligated correctly, bleeding should stop and the uterus should look pale. 

• Return to the clamped pedicles of the round ligaments and tubo-ovarian ligaments and ligate them with 0 chromic catgut (or polyglycolic) suture.

• Amputate the uterus above the level where the uterine arteries are ligated, using scissors (Fig P-57).

FIGURE P-57 Line of amputation 

• Close the cervical stump with interrupted 2-0 or 3-0 chromic catgut (or polyglycolic) sutures.

• Carefully inspect the cervical stump, leaves of the broad ligament and other pelvic floor structures for any bleeding.

• If slight bleeding persists or a clotting disorder is suspected, place a drain through the abdominal wall. Do not place a drain through the cervical stump as this can cause postoperative infection.

• Ensure that there is no bleeding. Remove clots using a sponge.

• In all cases, check for injury to the bladder. If a bladder injury is identified, repair the injury.

• Close the fascia with continuous 0 chromic catgut (or polyglycolic) suture.

Note: There is no need to close the bladder peritoneum or the abdominal peritoneum.

• If there are signs of infection, pack the subcutaneous tissue with gauze and place loose 0 catgut (or polyglycolic) sutures. Close the skin with a delayed closure after the infection has cleared.

• If there are no signs of infection, close the skin with vertical mattress sutures of 3-0 nylon (or silk) and apply a sterile dressing.

TOTAL HYSTERECTOMY

The following additional steps are required for total hysterectomy: 

• Push the bladder down to free the top 2 cm of the vagina. 

• Open the posterior leaf of the broad ligament.

• Clamp, ligate and cut the uterosacral ligaments.

• Clamp, ligate and cut the cardinal ligaments, which contain the descending branches of the uterine vessels. This is the critical step in the operation:

- Grasp the ligament vertically with a large-toothed clamp (e.g. Kocher);

- Place the clamp 5 mm lateral to the cervix and cut the ligament close to the cervix, leaving a stump medial to the clamp for safety; 

- If the cervix is long, repeat the step two or three times as needed.

The upper 2 cm of the vagina should now be free of attachments. 

• Circumcise the vagina as near to the cervix as possible, clamping bleeding points as they appear.

• Place haemostatic angle sutures, which include round, cardinal and uterosacral ligaments.

• Place continuous sutures on the vaginal cuff to stop haemorrhage.

• Close the abdomen (as above) after placing a drain in the extraperitoneal space near the stump of the cervix.

POSTOPERATIVE CARE

• Review postoperative care principles.

• If there are signs of infection or the woman currently has fever, give a combination of antibiotics until she is fever-free for 48 hours:

- ampicillin 2 g IV every 6 hours; 

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours; 

- PLUS metronidazole 500 mg IV every 8 hours.

• Give appropriate analgesic drugs.

• If there are no signs of infection, remove the abdominal drain after 48 hours.

• Offer other health services, if possible.