Using the Uterine-Specific Bakri Balloon in the Management of Postpartum Hemorrhage: Case Series and Conceptual/Practical Guidelines

Various approaches have been advocated for the management of postpartum hemorrhage (PPH) due to uterine atony1,2. These range from massage of the uterine fundus, to the use of pharmacological agents, embolization procedures, compression sutures, vascular occlusion and ultimately hysterectomy3. Many of these approaches, however, require the availability of specialized equipment and/or personnel (embolization procedures), a degree of surgical dexterity (compression sutures/vascular occlusion by surgical ligation), or the presence of a hemodynamically stable patient (embolization procedures)4,5. In contrast, studies that use the recently introduced uterine balloon tamponade technology suggest that it is easily used, rapidly deployed, has minimal complications, may avoid a laparotomy and, in conjunction with the ‘tamponade test’, can serve as an orderly stepwise approach to the management of PPH6–8. Although the Bakri balloon (Cook Medical, Bloomington, IN, USA) has been specifically designed for use in the uterus, in 168 published cases where the balloon type is specified, 76% use other non-uterinespecific (NUS) balloons (Figure 1)7,9–11. These balloons may have been otherwise used in other cavities where bleeding is problematic (i.e. esophagus and bladder)12,13. Furthermore, studies of evaluations of effectiveness, prospective trials and feasibility studies of balloon tamponade in the management of PPH are not only based on NUS devices, but also these balloons require modification prior to usage (such as folding or removing a potentially perforating drainage tip), possess no drainage channel and may require prior sterilization6–8,14. Assuming genital tract trauma, retained products of conception and device damage prior to placement are excluded, one might expect 100% success if the balloons were effective regardless of how they were used in the management of an atonic uterus. However, data from confidential enquiries and from peripartum hysterectomies suggest that using balloon tamponade in the management of PPH is not always effective15,16. One of the reasons why this is the case may be the methodological variation used for uterine-specific and NUS balloons9. Despite methodological variation, the paucity of data in the literature and a reporting bias toward NUS devices, recent PPH management guidelines call for the use/availability of tamponade balloons in the management of PPH3,17 without any recommendation regarding which one(s) should be used and how they should be applied in the clinical situation. The primary aim of this chapter is to provide a conceptual and practical guide to the use of a uterinespecific tamponade balloon based on a personal case series that utilizes a consistent method of balloon placement and insufflation that relates to the clinical outcome of the so-called tamponade test.