Peripartum Hysterectomy 
Camille Robinson, Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Editor’s Note: Non-Obstetricians in resource-
limited settings should be prepared to do this 
operation with little warning- usually the first time 
you see a peripartum hysterectomy, you will be the 
one performing the surgery. If possible, scrub on 
elective hysterectomies with a specialist. As 
described here, the cervix is left in place (especially 
if done by an inexperienced surgeon), unlike elective 
hysterectomy.  
 
Introduction:  
Peripartum hysterectomy is a unique surgery 
that occurs when a hysterectomy is indicated after a 
birth has occurred, either via vaginal or Cesarean 
route. It is often called “Cesarean hysterectomy” if it 
occurs after a Cesarean birth. In some rare cases, the 
hysterectomy is planned. More often, it is a surgical 
emergency that becomes necessary after the delivery 
has occurred. While Cesarean deliveries are one of 
the most common major surgeries worldwide, it is 
estimated that less than 1% of all Cesarean deliveries 
end in hysterectomy.  
The most common planned indication for a 
Cesarean hysterectomy is placenta accreta spectrum. 
In this scenario, the placenta is abnormally attached 
to the uterus. Often the safest mode of action is to 
deliver the baby then remove the uterus and placenta 
together. The most common unplanned reason for a 
peripartum 
hysterectomy 
is 
uncontrolled 
hemorrhage, such as with refractory uterine atony, 
uterine rupture or an extension of the hysterotomy 
into uterine vessels.  
The most common indications for peripartum 
hysterectomy include: 
• Uncontrolled hemorrhage  
• Uterine rupture that cannot be repaired 
• Placenta accreta spectrum 
 
The steps of a peripartum hysterectomy are 
slightly different depending on the indication for the 
surgery. For example, how we approach the 
procedure for placenta accreta spectrum is different 
than for an unexpected hemorrhage. Here, we 
describe the steps for an unplanned peripartum 
supracervical 
hysterectomy, 
that 
would 
be 
performed because of postpartum hemorrhage due to 
atony, uterine rupture, or unexpected placenta 
accreta. Again, most peripartum hysterectomies 
should be supracervical, as this variant can be 
performed faster and with less risk of damaging the 
urinary tract. 
Any planned Cesarean hysterectomy (due 
to known placenta accreta spectrum) should 
ideally be transferred to a facility with 
Obstetricians or General Surgeons and blood 
transfusion capabilities in advance of the planned 
surgery. 
 
 
Anatomy for peripartum hysterectomy, viewed from cranial to 
the uterus, looking towards the pelvis. (Note that the photos in 
this chapter are viewed from caudal to the uterus looking 
cranially, in effect showing the “opposite side” from this view.) 
The uterus is lifted towards the left and the adnexa (ovary and 
fallopian tube) have been lifted upwards. The dotted line 
represents the level of the cervix, which is palpable as a 
thickening below the body of the uterus. The ureters are 
vulnerable to injury if any sutures are placed below the level of 
the cervix, within the Red circle. Structures: 1.) Body of the 
uterus 2.) Right Fallopian tube 3.) Ovary 4.) Round ligament 5.) 
Ovarian vessels running in the infundibulo-pelvic ligament- this 
is the blood supply to the ovary. 6.) Uterine vessels 7.) Rectum 
8.) Sacrouterine ligament 9.) Avascular area of Broad ligament. 
Source: 
Primary 
Surgery 
Volume 
1, 
https://global-
help.org/products/primary-surgery/ 
Peripartum Hysterectomy 
Camille Robinson, Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Steps: 
If Cesarean is the mode of delivery, for more detail 
on the steps for a Cesarean birth including 
variations on delivery technique please see 
Cesarean birth. We also describe here various 
techniques to treat hemorrhage and potentially 
avoid removal of the uterus.  
 
1. After the birth of the baby, via vaginal route or 
Cesarean, if significant bleeding occurs that 
cannot be stopped with uterine massage and use 
of uterotonics, and is deemed to be due to uterine 
atony, all uterotonics available at the facility 
should be exhausted as a first line measure.  This 
includes oxytocin (Pitocin), methylergonovine 
(Methergine), 
carboprost 
tromethamine 
(Hemabate), 
and 
misoprostol 
(Cytotec). 
Tranexamic Acid is a fibrinolytic which can be 
used to supplement the use of uterotonics and 
reduce total blood loss. Also assure that that 
retained products of conception are not 
contributing to the bleeding- all products of 
conception, such as fragments of the placenta, 
must be evacuated. 
2. At this stage, it is important to notify anesthesia 
of blood loss and consider administration of 
blood products. In addition, adequate IV access 
should be re-assessed at this point. If available, a 
second surgeon should be called to help.  
3. If atony is not resolved with medical treatment, 
an intrauterine balloon catheter can be placed. If 
successful, placement of a balloon for treatment 
of uterine atony can negate the need for surgical 
treatment including a peripartum hysterectomy 
and salvage the patient’s uterus. Commonly used 
compression balloons are the treatment of uterine 
atony are Bakari balloons or multiple Foley 
balloons inflated to their maximum capacity. If 
intrauterine balloon catheters are utilized, it is 
important to also place a Foley catheter in the 
bladder to drain urine as the urethra will often be 
obstructed by the compression balloon. 
4. If it is determined that hemostasis cannot be 
achieved 
with 
conservative 
management 
(medications 
and/or 
balloon 
tamponade), 
proceed with surgical management.   
5. If surgical management is chosen after a vaginal 
delivery, the following steps should be taken to 
prepare (these would already have been taken if 
the delivery is a Cesarean): 
• Administer prophylactic antibiotics. Ideal 
preoperative antibiotics are a first-generation 
cephalosporin (e.g. cefazolin 1g IV for 
patients 80 kg, 2-3g IV for patients > 80 kg) 
administered in the hour prior to surgery.  
• Place a urinary catheter.  
• Consider thromboembolism prophylaxis. If 
available, pneumatic compression devices 
should be placed. 
• Prepare and drape the abdomen and pelvis. 
Abdomen should be prepared with surgical 
solution typically used in the facility. Vaginal 
preparation should be performed as well to 
help reduce the risk of postoperative 
infection. This should ideally be performed 
with 4% chlorhexidine gluconate vaginal 
scrub but povidone-iodine is an acceptable, 
slightly less effective alternative. 
• Place the patient in supine position; her legs 
may have been in stirrups previously. This 
improves your surgical access and decreases 
the risk of deep venous thrombosis. 
• Perform a laparotomy; if the delivery was a 
vaginal delivery, performing a midline 
vertical incision is the best choice to provide 
excellent exposure for the treatment of 
hemorrhage.  If Cesarean was performed, the 
incision from the Cesarean delivery can be 
utilized. 
6. If significant blood loss has already occurred, 
the surgeon may choose to move directly to a 
peripartum hysterectomy to avoid ongoing 
bleeding and delay in treatment.  If a 
hysterectomy is chosen as the next step, please 
move to Step 8. 
7. If the cause of the ongoing bleeding is uterine 
atony and there is adequate time to attempt other 
surgical measures prior to a hysterectomy, 
placement of a B-lynch compression suture can 
be attempted to treat the atony and avoid a 
Peripartum Hysterectomy 
Camille Robinson, Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
peripartum hysterectomy.  This is placed using 
the following steps after a laparotomy: 
 
The B-Lynch compression suture is placed as above, using one 
continuous slowly absorbable suture. If there is a hysterotomy, 
as from previous Cesarean birth, the suture closes it. If there 
was no hysterotomy, the suture is placed as shown in the place 
where the hysterotomy would have been. Uterus with completed 
and tied compression suture is shown on the Right. Source: 
Garofalo M and Posner GD, DOI 10.7759/cureus.2725 
 
 
A large needle should be used with delayed 
absorbable suture: 
• The suture is first placed across the hysterotomy 
(or where a hysterotomy would be if a vaginal 
delivery was performed) overlapping 
the 
hysterotomy by 3cm above and below it, as 
shown above. 
• The suture is then looped around the uterine 
fundus and placed in a lateral fashion on the 
contralateral (cranial) side of the uterus at the 
same level as the hysterotomy, through the entire 
thickness of the posterior uterine myometrium. 
• After exiting, the suture is looped back around 
the fundus and pulled very tightly on the uterus.  
If an assistant is available, they should “roll” the 
uterine fundus which is often floppy and atonic 
to a tightly rolled position while the surgeon pulls 
the compression suture tightly to provide 
compression.  
• Finally the suture is placed across the 
hysterotomy, about 3 cm above and below, and 
the two ends of the suture tied together.  
 
If the above measures have not resolved bleeding, 
proceed with a peripartum hysterectomy with the 
following steps: 
 
8. Assess exposure with the current abdominal 
incision.  Often the initial incision made for the 
Cesarean is sufficient, but if it is not, do not waste 
time attempting this lifesaving surgery through 
an inadequate incision. If the transversely-
oriented incision does not give sufficient 
exposure, make another incision vertically in the 
midline, meeting the previous incision in the 
shape of an inverted “T”. 
9. Pack away the bowel with moist laparotomy 
sponges. The uterus should then be placed on 
cephalad traction in order to obtain adequate 
exposure either with manual traction, or with 
strong clamps on the utero-ovarian ligaments 
bilaterally. 
 
The uterus is exteriorized and the hysterotomy quickly 
closed if a Cesarean was the mode of delivery.  
 
10. The round ligament should be doubly clamped 
lateral to the uterus. Each pedicle should be 
ligated with a slowly absorbable suture (such as 
Vicryl). It is then transected to provide access to 
the anterior leaf of the broad ligament. The broad 
ligament is caudal to the utero-ovarian ligaments, 
and will be visible as you pull cranially on the the 
Utero-Ovarian ligaments (or the clamps you 
applied to them in Step 9). There is an avascular 
plane beneath the round ligament that is quite 
Peripartum Hysterectomy 
Camille Robinson, Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
distinct from the broad ligament itself, which 
runs beneath the Fallopian tube.  
 
The left round ligament is isolated and suture ligated after 
creating a window in an avascular space beneath it 
 
11. Create a “window” lateral to the uterus and 
beneath the utero-ovarian ligament and fallopian 
tube in an avascular space. The window can be 
made sharply by cutting with mayo scissors or 
bluntly after confirming the area is avascular. 
The window should be large enough to then place 
two strong clamps as shown below. This area is 
quite vascular during pregnancy so take care to 
find an avascular space for the window.  
 
The left utero-ovarian ligament and fallopian tube are 
isolated and beneath them a finger is placed in the 
avascular plane to make the window lateral to the uterus.  
 
 
As shown in this hysterectomy model, the left utero-ovarian 
ligament and fallopian tube are doubly clamped at the site 
of the window and cut.  
 
12. The surgeon should then cut between the clamps 
and leave the clamp on the uterus in place for the 
remainder of the surgery.  The distal clamp 
holding 
fallopian 
tube 
and 
utero-ovarian 
ligament should be doubly suture ligated with 
delayed absorbable suture. Again, the medial 
clamp stays to be removed later with the entire 
specimen.  
Peripartum Hysterectomy 
Camille Robinson, Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The incised left utero-ovarian ligament and fallopian tube. The 
clamp in the Black circle should be left in place for the rest of 
the operation. The tissue inside the clamp in the Red circle 
should be suture ligated, preserving the blood supply of the 
ovary (also within the Red circle), which comes in lateral to this 
area through the infundibulopelvic ligament. The clamp shown 
by the Black arrow, can still be used for traction throughout the 
case. 
 
13. The anterior leaf of the broad ligament should 
then be incised to reflect the bladder off of the 
lower uterine segment. This can be achieved by 
gently placing the distal portion of the ligated 
round ligament on traction laterally and 
dissecting the anterior broad ligament bilaterally, 
meeting in the center of the uterus to develop the 
plane between the uterus and the bladder. This is 
very important in order to avoid ureteral injury 
and properly ligate the uterine vessels.  Once the 
plane has been developed from both sides, the 
bladder should be dissected inferiorly. This can 
be done either bluntly or with Metzenbaum 
scissors, to the level of the internal cervical os in 
the same avascular plane. 
 
 
Use a clamp to elevate the anterior leaf of the left broad 
ligament and incise it with diathermy or with scissors if 
diathermy is not available. A similar incision from the right side 
will meet this one at the midline.   
 
 
Once the plane has been developed from both sides, the bladder 
is dissected inferiorly below the level of the interior cervical os 
using diathermy or sharp dissection. 
Peripartum Hysterectomy 
Camille Robinson, Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
14. The posterior leaf of the broad ligament should 
be undermined to ensure it is away from any 
blood vessels, then incised caudad towards the 
uterosacral ligaments.  This helps to further 
protect the ureters from injury when ligating the 
uterine vessels. 
15. The bladder flap should be rechecked prior to 
ligating the uterine vessels to ensure that it has 
been dissected at least below the level of the 
internal cervical os. Dissection of the bladder 
flap can be done using smooth forceps and 
Metzenbaum scissors. 
16. Prepare to ligate the uterine vessels by placing 
the uterus on traction opposite the side of planned 
ligation. The arterial pulsation should be palpated 
and identified then doubly clamped, adjacent to 
the uterus and above the level of the bladder flap- 
ideally at the level of the upper cervix. Take care 
not to place clamps deeper than the level of the 
cervix to avoid injuring the ureter. Use two 
clamps and apply them to form a “v” and touch 
at their tips to avoid vessels coming lose. The 
clamp that is cephalad helps with bleeding and 
will remain with the specimen.  It is very 
important not to remove the cephalad clamp; 
removal will result in significant “back bleeding.”  
17. Mayo scissors are used to cut in between the two 
clamps, ideally leaving a small pedicle on each 
side.  The uterine vessels are very large during 
pregnancy and the utmost care needs to be 
take in their ligation.  The cephalad (superficial) 
clamp again remains with the specimen and 
should not be removed or significant bleeding 
will occur.  The pedicle in the caudal (deep) 
clamp is suture-ligated with 0-Vicryl suture by 
placing a suture at the very tip of the clamp to 
ensure the entire pedicle is ligated.  If needed, a 
second suture can be placed.  
  
 
 
Two clamps placed across the uterine artery forming a “V” and 
cut in-between with Mayo scissors. The top picture shows a 
simulation model, and bottom picture shows the same step of 
uterine artery transection. Note that the tips of the clamps close 
on the adjacent broad ligament, not the uterus itself. The clamp 
within the Black circle should not be removed. The tissue within 
the clamp below that one should be carefully suture-ligated, 
passing the needle just next to the tip of the clamp and not going 
deeper than the level of the cervix to avoid injury to the ureter.  
 
18. Once these steps have been performed on one 
side, they should all be repeated on the opposite 
side of the uterus.  
Peripartum Hysterectomy 
Camille Robinson, Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
19. After bilateral uterine arteries are ligated, two 
sturdy curved clamps should be placed across the 
uterine body/upper cervix at the same level of the 
uterine artery ligation and using heavy scissors, 
or diathermy, the uterus amputated at (not below!) 
the level of the uterine artery ligation.   
 
 
  
The above two figures show two curved clamps placed across 
the uterus, superior to the cervix, after division of the uterine 
arteries bilaterally. 
 
The clamps remain in place after the uterus has been incised 
and removed.  
 
20. The upper cervix can then be closed by placing a 
transfixion suture as each clamp is removed. 
Interrupted figure-eight sutures can then be 
placed in an anterior to posterior fashion to 
approximate the middle portion of the remaining 
tissue.  Alternatively, the length of the opening 
can be closed in a running locked fashion below 
the clamp with 0-Vicryl. During closure, take 
care not to suture more laterally than the uterine 
artery ligation, as this can cause bleeding and/or 
injury to the ureters.  
 
This figure shows a completely closed uterus after removal of 
the clamp. The sutures are typically left long until the entire cuff 
is closed to assist with retraction.  
 
21. A systematic survey should be performed to 
assess for ongoing bleeding. Irrigate the pelvis 
with warm normal saline solution, as underwater 
bleeding is more visible to the surgeon.  
Peripartum Hysterectomy 
Camille Robinson, Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
22. Once it has been ensured that there is no ongoing 
bleeding, the abdomen can be closed in a 
standard fashion. 
 
Pitfalls 
• Ovarian ischemia: As Cesarean hysterectomy is 
typically being done emergently, if care is not 
taken to identify the utero-ovarian ligament 
properly, it is possible to mistakenly ligate the 
infundibulopelvic ligment, lateral to the ovary. 
This will lead to loss of the ovaries and 
subsequent premature menopause.  Thus, it is 
very important to identify the utero-ovarian 
ligament correctly during steps 11 and 12.  
• The most common complications of Cesarean 
hysterectomy are significant blood loss and 
urinary tract damage. These complications are 
higher when the procedure is being performed 
emergently. The procedure is associated with 
substantial bleeding, especially when the 
indication 
for 
surgery 
is 
uncontrolled 
hemorrhage. The physiology of pregnancy 
makes the vessels that supply the uterus larger 
and more tortuous. Edema makes it more 
difficult to identify tissue planes. Hematomas, 
uterine rupture, and long labor can cause 
distortion of anatomy which make a cesarean 
hysterectomy more difficult and risky.  
• In cases of hemorrhage with high volume blood 
loss, pay close attention to vital signs and urine 
output to ensure adequate resuscitation with IV 
fluids and blood products. Coagulopathies may 
present prior to the procedure or as the surgery 
progresses.  
• Urinary Tract Damage: The most common 
location of bladder injury is the dome, especially 
if the patient has had a previous Cesarean birth. 
Urinary tract damage is identified by cystoscopy 
or by retrograde instillation of fluid through a 
foley catheter into the bladder, either sterile milk 
or methylene blue. Methylene blue or sodium 
fluorescein, each as a single 50mg dose, can be 
given IV as well. Injury to the uterters is a risk 
during peripartum hysterectomy as well, an if 
there is concern for this, cystoscopy should be 
performed looking for bilateral efflux from both 
ureters. Briefly, close a bladder injury in 2-3 
layers using running technique and a 3-0 
absorbable or delayed absorbable suture such as 
Vicryl. First, the mucosa is closed followed by 
the muscularis and serosal layers. If an injury to 
the urinary tract is identified, a Foley catheter 
should remain in place posteroperatively for 14 
days to allow for continuous urine drainage and 
allow for adequate healing and prevent fistula 
formation. If you are able to perform a cystogram, 
using this study to confirm no leakage allows you 
to remove the catheter sooner, sometimes as early 
as 7 days. See also the chapter Approach to 
Ureteral Injuries.  
• As stated previously, the cervix is typically left 
in place during a Cesarean hysterectomy. The 
cause of bleeding is typically addressed by 
removing the uterine body.  Removal of the 
cervix is associated with significantly higher 
rates of injury to the urinary tract and should only 
be attempted if there is significant ongoing 
bleeding after removal of the uterine body, as in 
a deep cervical tear extending into the uterus 
itself. If you must remove the cervix, identify the 
ureters 
through 
visualization 
in 
the 
retroperitoneum.  Try to avoid dissection into the 
retroperitoneum as this can lead to significant 
bleeding, particularly in a patient who may be 
coagulopathic.  Tissue lateral to the cervix should 
be suture ligated immediately lateral to the cervix 
as the ureters can lie very close to the cervix after 
labor, leading to high risk of damage. Clamps 
should then be placed directly under the cervix. 
Then, the vaginal vault is suture ligated after 
removal of the cervix as described above.  
 
The authors gratefully acknowledge Dr. Chelsea 
Fechter for creating the models used in the 
illustrations for this chapter.  
 
Camille Robinson, MD  
Lindsey E. Zamora, MD, MPH 
Vanderbilt University Medical Center 
Tennessee, USA 
 
July 2023 
