Internal Manual Compression of the Aorta: A Lifesaving Technique for Controlling Pelvic Bleeding in Obstetrical Hemorrhage

Dr. Reena Sherene
Jul 12
3 min read

Obstetrical hemorrhage remains a leading cause of maternal morbidity and mortality worldwide. Rapid control of pelvic bleeding during such emergencies is critical to save lives. One effective, yet underutilized, technique is the internal manual compression of the aorta. This method provides temporary control of hemorrhage, buying valuable time for definitive surgical or medical interventions. This post offers a detailed explanation of the procedure, its effectiveness, and important considerations for practitioners in emergency obstetrical care.

Understanding the Role of Internal Manual Compression of the Aorta

Pelvic bleeding during obstetrical hemorrhage can be severe and life-threatening. The aorta supplies blood to the pelvic organs, and compressing it internally reduces blood flow to the pelvis, decreasing hemorrhage temporarily. This technique is especially useful when other methods such as uterine massage, uterotonics, or external compression fail to control bleeding.

Internal manual compression of the aorta is a rapid, hands-on method that can be performed during laparotomy. It is a bridge to more definitive treatments like arterial ligation, embolization, or hysterectomy. The technique requires skill, coordination, and clear communication among the surgical team.

Step-by-Step Procedure for Internal Manual Compression of the Aorta

Positioning the Assistant and Uterus

Assistant’s role: The assistant should be positioned opposite the surgeon, ready to manipulate the uterus as needed.
Uterus positioning: The uterus is gently elevated and displaced to the left or right to expose the aortic bifurcation and the abdominal aorta above it. This maneuver improves access and visibility.
Patient positioning: The patient is typically in a supine position with the abdomen fully exposed after laparotomy.

Surgeon’s Hand Placement and Technique

Locating the aorta: The surgeon identifies the abdominal aorta just above the bifurcation into the common iliac arteries, usually at the level of the fourth lumbar vertebra.
Hand placement: Using the dominant hand, the surgeon inserts fingers into the retroperitoneal space, carefully palpating and isolating the aorta.
Compression technique: The surgeon applies firm, steady pressure with the fingers and palm against the aorta, pressing it against the vertebral body to occlude blood flow.
Duration: Compression is maintained continuously until bleeding is controlled or further interventions are ready. Frequent reassessment is necessary to avoid ischemic complications.

Use of a Surgical Pad for Compression

Purpose: A surgical pad or sponge can be placed between the surgeon’s hand and the aorta to distribute pressure evenly and protect the vessel wall.
Placement: The pad is positioned directly over the aorta before manual compression begins.
Benefits: This reduces trauma to the vessel and surrounding tissues, minimizing the risk of injury during prolonged compression.

Effectiveness of Internal Manual Compression in Obstetrical Hemorrhage

Clinical experience and case reports demonstrate that internal manual compression of the aorta can significantly reduce pelvic bleeding in critical moments. It allows:

Rapid reduction of blood loss: By decreasing arterial inflow, bleeding slows immediately.
Improved surgical field visibility: Less bleeding facilitates identification of bleeding sources.
Time for definitive management: Surgeons gain time to perform arterial ligation, hysterectomy, or arrange interventional radiology procedures.
Potential to avoid hysterectomy: In some cases, temporary control allows uterine-sparing treatments.

While this technique does not replace definitive hemorrhage control, it is a valuable tool in the emergency surgeon’s arsenal.

Important Considerations and Potential Risks

Ischemia risk: Prolonged compression can cause ischemia to lower limbs and pelvic organs. Limit compression time and intermittently release pressure if possible.
Vessel injury: Excessive force or improper hand placement may damage the aorta or adjacent structures.
Requires surgical expertise: Only trained surgeons should perform this technique due to anatomical complexity.
Not a standalone solution: Internal manual compression is a temporary measure and must be followed by definitive hemorrhage control.
Patient monitoring: Continuous monitoring of vital signs and limb perfusion is essential during and after compression.

Practical Tips for Successful Application

Communicate clearly with the surgical team before and during the procedure.
Use gentle but firm pressure to avoid vessel trauma.
Prepare surgical pads in advance for quick placement.
Limit compression duration to under 20 minutes when possible.
Combine with other hemorrhage control methods for best outcomes.

Internal manual compression of the aorta is a critical lifesaving technique in obstetrical hemorrhage. It provides rapid, temporary control of severe pelvic bleeding, allowing time for definitive treatment. Mastery of this procedure enhances the surgeon’s ability to manage complex hemorrhagic emergencies effectively. Practitioners should familiarize themselves with the steps, benefits, and risks to improve maternal outcomes in critical situations.

REFERENCE:

AJOG Surgeon's Corner: Internal manual compression of the aorta—an effective way to temporarily control pelvic bleeding in obstetrical hemorrhage - Internal manual compression of the aorta:https://ow.ly/Vu4C50ZmFo1