Surgery Observation Experience

1. Which surgical procedure did your patient experience? Hysterectomy 2. Describe how this surgery might impact the patient’s life. 3. Give examples of how this patient received patient-centered care during your OR observation. -According to QSEN the definition of patient centered care is recognizing the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values and needs. qsen.org – 4. Describe the various roles the nurse takes in the peri-operative area (pre-op through PACU) 5. Describe your overall view of the surgical experience for the patient and the nurses. 1. Summarize this article in 3-4 sentences J Perinat Neonat Nurs Vol. 24, No. 3, pp. 207–214 Copyright ⃝c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Exploring the Role of Uterine Artery Embolization in the Management of Postpartum Hemorrhage Linda A. Hunter, EdD, CNM Postpartum hemorrhage is a potentially life-threatening obstetric emergency that requires prompt nursing and medical interventions. In the majority of cases, initial strategies such as fundal massage and uterotonic medications will effectively stop excessive bleeding. Unfortunately, the incidence and severity of postpartum hemorrhage are on the rise and peripartum hysterectomy remains a life-saving intervention in cases of intractable bleeding. As an emerging alternative to hysterectomy, uterine artery embolization (UAE) has demonstrated success rates of more than 90% in controlling postpartum hemorrhage unresponsive to other therapies. Research to date has shown UAE to be a safe, minimally invasive procedure with few reported complications and minimal effects on future fertility. For patients who are hemodynamically stable with access to an interventional radiology suite, UAE is an important consideration in the treatment of severe postpartum bleeding. This article explores the role of UAE as a part of this management algorithm. The technical aspects of this procedure, reported complications, and effects on future fertility are described. The prophylactic use of intra-arterial balloon catheters in the management of abnormal placentation is also discussed. Key words: abnormal placentation, peripartum hysterectomy, postpartum hemorrhage, uterine artery embolization As one of the most commonly encountered obstet- ric emergencies, postpartum hemorrhage is the leading cause of maternal death worldwide.1 Although the overall maternal mortality in higher-resource coun- tries such as the United States accounts for only 1% of these deaths, some researchers have begun to ob- Author Affiliations: Warren Alpert Medical School of Brown University, Department of Obstetrics & Gynecology, Nurse-Midwifery Section, Women & Infants Hospital, Providence, Rhode Island. There are no disclaimers, acknowledgments, or financial disclo- sures. Corresponding Author: Linda A. Hunter, EdD, CNM, Department of Obstetrics & Gynecology, Nurse Midwifery Section, Women & Infants Hospital, 101 Dudley St, Providence, RI 02905 (lhunter@ wihri.org). Submitted for publication: February 23, 2010 Accepted for publication: May 19, 2010 serve increasing morbidity trends as a result of severe 2–4 postdelivery hemorrhage. Commonly referred to as “near-miss” events, adverse outcomes such as multiple blood transfusions, obstetric intensive care unit admis- sions, and hypovolemic shock have increased in re- cent years.2–4 Much speculation exists as to the causes of rising postpartum hemorrhage incidence and sever- ity, especially in developed countries that have im- mediate access to skilled nurses, experienced obstet- ric providers, and advanced surgical interventions.2–4 Fortunately, in the majority of cases, first-line man- agement strategies such as fundal massage and utero- tonic medications effectively stop excessive postpar- tum bleeding.5–7 There are less-common situations, however, when even the most advanced methods fail and hysterectomy becomes the a priori life-saving intervention.8–10 Although utilized only as a last resort, hysterectomy unfortunately results in a permanent end of future childbearing opportunities. 207 Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 208 Journal of Perinatal & Neonatal Nursing/July–September 2010 One emerging alternative to hysterectomy that holds considerable promise in controlling intractable postpartum bleeding is selective uterine artery em- bolization (UAE).11–13 First described in 1979,14 UAE is a safe, minimally invasive procedure that has con- sistently demonstrated success rates of more than 90% in achieving hemostasis when other methods have failed.5 Research has also reported minimal effects on future pregnancies and fertility.15–17 In addition, intra-arterial balloon (IAB) catheters can be inserted prophylactically to control anticipated bleeding during scheduled cesarean deliveries that are complicated by a known placenta accreta or other abnormal placentation.12,18 This article explores the role of UAE and IAB catheters in the management of obstetric hemorrhage. A brief overview of postpar- tum hemorrhage and the initial nursing and medical stabilization measures are reviewed. The history and literature supporting UAE, as well as its technical aspects, complications, and future fertility issues, are presented. The controversial use of IAB catheters in cases of abnormal placentation is also discussed. DEFINITIONS AND INITIAL MANAGEMENT OF POSTPARTUM HEMORRHAGE Primary postpartum hemorrhage is most commonly defined as an estimated blood loss within the first 24 hours of more than 500 mL after vaginal delivery or 1000 mL after cesarean section.13,19,20 Some sources also consider a total drop in hematocrit of 10% as a reliable indicator of excessive bleeding.7,12,19 A ma- jor obstetric hemorrhage is defined as a blood loss of more than 2500 mL or bleeding that has required more than 5 units of transfused blood.13 Estimates of postpartum blood loss have been found to be no- toriously inaccurate and consequently require a low threshold for prompt aggressive response if excessive bleeding is encountered.2,6 Although specific risk fac- tors have been identified, postpartum hemorrhage is often unanticipated and occurs in approximately 5% of all deliveries.5,9,19,20 Uterine atony, retained placental fragments, and vaginal/perineal lacerations collectively account for 95% of major postpartum hemorrhage with uterine atony alone responsible for more than half of the reported cases.20,21 Less-common causes include coagulation disorders, vascular defects, uterine inver- sion or rupture, and abnormal placentation.12,21 When excessive bleeding is encountered by ei- ther nursing staff or the delivery provider, initial management steps are aimed at improving uterine tone with immediate fundal massage, intravenous f luid resuscitation, and administration of uterotonic medications.smash7,12 If these methods fail to control bleeding, additional resources are mobilized and more aggressive interventions such as bimanual compres- sion, internal uterine packing, and/or balloon tam- ponade techniques are employed.7,13 Other potential causes of bleeding must be thoroughly explored and laboratory tests such as a complete blood count, type and crossmatch, and coagulations studies obtained im- mediately. Transfusion of blood products should be in- stituted without hesitation once estimates of bleeding reach 1500 mL.13 Appropriate uterotonic medications can also be readministered as needed up to the max- imum allowable dosages.7 An overview of commonly used uterotonic medications can be found in Table 1. Nursing staff should anticipate and prepare the woman for transfer to the operating room for surgi- cal intervention if tamponade techniques fail to achieve hemostasis. The blood bank should be notified that ad- ditional transfusions may be required and the woman’s condition closely monitored for signs of hypovolemic shock. Once in the operating room, surgical interven- tions commence with an exploratory laparotomy to gain access to the uterus and provide adequate ex- posure to the surrounding structures.9,13,19 Various surgical techniques such as hypogastric or uterine artery ligation and stepwise pelvic devascularization have long been used to control intractable postpar- tum hemorrhage.9,10 More recently B-Lynch compres- sion sutures of the uterus have shown consistently higher success rates of more than 90% in achieving hemostasis.5 First described in 1997, this fairly straight- forward procedure involves manually compressing the uterus, often by simply rolling it onto itself, and en- circling it externally with firmly secured dissolvable sutures.22 Although current evidence has not demon- strated a clear advantage of B-Lynch compression su- tures over artery ligation or pelvic devascularization in controlling severe hemorrhage, this procedure is rela- tively easy to perform and can rapidly provide hemosta- sis in cases of uterine atony.5 Clearly, in all cases of unexpected hemorrhage, these initial steps must be performed without delay. Peripar- tum hysterectomy remains the last-resort life-saving measure and carries with it a mortality rate of 1% to 6%.9,10 Moreover, high-volume transfusions are often required and there are significant postsurgery morbid- ity risks such as renal failure, hepatic failure, respira- tory distress syndrome, coagulopathies, septicemia, tissue hypoxia, and pituitary necrosis (Sheehan syndrome).8,9,13,23,24 Although overall peripartum hysterectomy rates have not increased significantly in the past 10 years, several researchers have found rising Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Exploring the Role of Uterine Artery Embolization 209 Table 1. Uterotonic medications commonly used in postpartum hemorrhagea Medication Oxytocin (Pitocin) Methylergonovine (Methergine) Misoprostil (Cytotec) Prostaglandin F2 (Hemabate) Dose/route IV: 10–40 units per liter of lactated ringers or normal saline IM: 10 units 0.2 mg IM 800–1000 ̄g rectally 250 ̄g IM or intramyometrial Frequency If there is initial rapid infusion, then titrate rate as needed continuously IV to a maximum dose of 40 units May repeat every 2–4 h to a maximum of 5 doses One-time dose May repeat every 15–90 min to a maximum dose of 2 mg (8 doses) Comments Do not give diluted via IV route Initial 10 units IM dose can be given if patient does not have an IV Contraindicated if patient is hypertensive Do not give IV Diarrhea is a common adverse effect Contraindicated in patients with asthma May also be injected directly into the uterus Abbreviations: IM, intramuscular; IV, intravenous. aAdapted from Rajan and Wing,7 Winograd,13 and ACOG Practice Bulletin.19 cesarean section rates and abnormal placentation to be risk factors for severe postpartum hemorrhage.8,23–26 More important, placenta accreta is emerging as a more common cause of peripartum hysterectomy and combined with uterine atony accounted for 72% of cases in one recent multicenter study.26 These trends are concerning and lend further sup- port to improving availability and access to all uterine conserving therapies such as UAE. In addition, obstet- ric units should have major hemorrhage protocols that clearly outline the appropriate nursing and medical interventions in response to severe postdelivery bleeding.2,6,9,10,12,20 These protocols and periodic practice drills facilitate early notification of potential resources to enhance the team approach that is nec- essary to properly manage this emergency. Perinatal nurses play a particularly critical role in these scenarios as they are often the first to identify heavy bleeding, mobilize necessary resources, and initiate first-line therapies. When bleeding is unresponsive to these interventions, nurses also provide ongoing bedside monitoring and are instrumental in anticipating and coordinating interdisciplinary care when transfer to another location is required. An overview of the postpartum hemorrhage-management steps can be found in Table 2. UTERINE ARTERY EMBOLIZATION IN THE TREATMENT OF POSTPARTUM HEMORRHAGE Brown and colleagues14 first described the successful use of UAE to control intractable postpartum bleeding after both hypogastric artery ligation and hysterectomy failed to achieve hemostasis. Uterine artery emboliza- tion was later reported to resolve excessive bleeding in 2 cases of postpartum hemorrhage caused by uter- ine atony.27 Although hysterectomy was not prevented in any of these landmark cases, there has been a myr- iad of subsequent research supporting the efficacy of UAE in the control of severe postpartum bleeding be- fore surgical interventions.5,11,28–30 Although no ran- domized controlled trials have been conducted so far to compare postpartum hemorrhage management strate- gies, these studies and case reports continue to pro- vide helpful evidence that UAE holds an invaluable place in the management algorithm for postdelivery bleeding. Despite these reassurances, obstetric clinicians who wish to proceed with UAE face several challenges. Ar- terial embolization procedures are performed by spe- cially trained interventional radiologists in a properly equipped radiology suite. The immediate availability of these resources may be limited in rural areas or smaller community hospitals and may require perinatal nurses and obstetric providers to consider this intervention early in the treatment plan.28 In many cases, the in- terventional radiology team will be able to assume the care of the woman during the procedure. Perinatal nurses should be prepared, however, to accompany the woman to the interventional radiology suite and pro- vide ongoing support and monitoring during the pro- cedure if needed or required by hospital protocols. Second, active bleeding should be under reasonable control and any abnormalities in vital signs should be corrected with fluid resuscitation and transfusion of Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 210 Journal of Perinatal & Neonatal Nursing/July–September 2010 Table 2. Steps in postpartum-hemorrhage managementa After vaginal delivery Assess uterine tone and massage the fundus Administer uterotonic medications as indicated (see Table 1) Inspect the perineum and vagina for lacerations and/or enlarging hematomas Inspect the placenta for any evidence of retained fragments or accessory lobes Ensure that the bladder is empty Perform bimanual uterine compression Call for additional help and ensure that there is adequate analgesia/anesthesia Manually explore uterus for retained products or clotsb Draw complete blood count, coagulation studies, and type and crossmatch for possible blood transfusion Start second IV line and closely monitor vital signs Proceed with internal uterine tamponade techniques (insert a Bakri balloon or uterine packing with gauze)c Administer blood products and oxygen if blood loss of more than 1500 mL appears Proceed with uterine artery embolization if hemodynamically stable and interventional radiology services are available If unstable, transfer to the operating room for exploratory laparotomy (see below) Consider other causes (rupture of pseudoaneurysm, vascular abnormalities, coagulopathies) If initial treatments fail or bleeding occurs during cesarean section Apply uterine B-Lynch compression sutures Perform uterine artery embolization if hemodynamically stable and interventional radiology services are available If bleeding persists proceed with devascularization of the uterusd Ligate hypogastric or internal iliac arteries Perform hysterectomy as last resort if bleeding continues Anticipate transfer to intensive care unit or acute monitoring service From Porreco and Stettler,9 Winograd,13 and ACOG Practice Bulletin.19 bCurettage with a banjo curette or ring forceps can be used to remove retained products if manual attempts fail. cOne or more Foley balloon catheters or a Sengstaken-Blakemore tube can also be used. dDevascularization includes ligation of the uterine and/or ovarian arteries. blood products. Preprocedure blood work includes a complete blood count, renal function tests, electrolyte tests, and coagulation studies.12 Documentation of any allergies to contrast dye should be noted. Informed con- sent must also be obtained and the discussion with the woman and her family of the risks, benefits, and potential complications of UAE appropriately docu- mented. Some radiologists recommend that a single in- travenous dose of a broad-spectrum antibiotic be ad- ministered prior to the procedure to reduce the risk of infection.12,31 Arterial embolization can be performed under conscious sedation, local, epidural, or spinal anesthesia.30 Intravenous narcotics can also be used for management of pain and anxiety.12,30 In the radiology suite, the interventional radiologist obtains arterial access via the femoral artery, and a pressurized intravenous solution of heparinized nor- mal saline is begun. Under direct fluoroscopy guid- ance, an angiographic catheter is advanced past the aortic bifurcation and contrast dye is injected into the internal iliac arteries for an initial diagnostic pelvic arteriogram.12 The origin of the uterine arteries is iden- tified and any areas of extravasation suggesting active bleeding are noted. Contrast extravasation is not al- ways present, however, especially in cases of uterine atony and does not negate the potential success of UAE to achieve hemostasis.12,29,30 The catheterization procedure then continues to selectively access the uter- ine arteries and the surrounding collateral vessels if necessary. The hemodynamic stability of the woman dictates the extent subselective catheterization of the collateral circulation occurs and, depending on the clinical situation, more rapid catheterization and em- bolization of the main vessels may be required.12 Once the targeted areas are identified, small pieces of absorbable gelatin-sponge “pledgets” are mixed with contrast material and slowly injected under direct flu- oroscopy until arterial stasis is observed.12 This em- bolization technique is especially useful in cases of uterine atony or acute active bleeding and rapidly pro- vides a safe, temporary vascular occlusion that typically lasts 30 to 45 days.12,29 Although the majority of re- ported cases identified the uterine arteries as the pri- mary source of bleeding, there is an extensive collateral blood supply to the uterus during pregnancy.12,29,32 Consequently, bilateral UAE is generally recommended to avoid any future bleeding from secondary recanaliza- tion of collateral branches.11,12,28,30 Moreover, in cases where postpartum bleed- ing is caused by surgical laceration, ruptured Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. pseudoaneurysm, or arteriovenous fistulas; platinum coils, vascular plugs, and polymerizing agents (glue) are more effective than temporary embolic agents.11,12 These rare occurrences usually result in massive bleed- ing that is unresponsive to the usual interventions and often requires a more complex approach utilizing a combination of embolizing techniques.12 Ultimately, the interventional radiologist will base these proce- dural decisions on the angiographic findings and the women’s overall hemodynamic status. RISKS AND COMPLICATIONS OF UTERINE ARTERY EMBOLIZATION Complications from UAE are infrequent, occurring in approximately 5% to 7% of cases.29,30 Postprocedure fever, pain at the injection site, and transient numb- ness of the buttocks, feet, or thighs are the most com- monly reported adverse effects and generally resolve spontaneously with supportive treatments.11,29,30 Fail- ure to control hemorrhage is another potential com- plication that could lead to repeated embolization attempts, further increasing the risks for vessel perfora- tion, arterial hematoma, and pelvic infection.11,30,32 Co- agulopathies often develop as a result of hemorrhage and generally begin to resolve once the bleeding is un- der control.28 Although the presence of an underlying coagulopathy is not considered as a contraindication, persistent bleeding postembolization could indicate a more serious concern that requires ongoing investiga- tion and monitoring.11,30 Migration of embolus material into the general circu- lation is another extremely rare complication that can lead to ischemic injury of the lower extremities, uterus, or bladder.11,29,32 It has been suggested that the use of permanent occlusion devices increases this risk; how- ever, isolated cases of uterine necrosis have also been reported after the use of absorbable materials.32,33 Con- sequently, extreme care must be taken to ensure that the gelatin pieces are not larger than 1 to 2 mm and that the smallest feeder arteries are embolized first.11,12,30 Furthermore, careful observation for any retrograde particle migration during injection of the emboliz- ing agents is paramount to ensure a complication-free outcome.11,32 Women who have experienced a postpartum hem- orrhage necessitating advanced interventions such as UAE require ongoing skilled nursing care to monitor for these complications and any continued bleeding. Depending on the woman’s hemodynamic status, post- procedure care is often continued in the labor and de- livery unit, especially in tertiary centers. In some cases, however, more acute monitoring may be necessary and transfer to the intensive care unit is required. Re- gardless of these immediate logistics, perinatal nurses remain a vital component of the woman’s ongoing re- covery process, especially in promoting the return to normal postpartum family-centered care. It is impor- tant to remember that this woman recently gave birth and, depending on the condition of the newborn, will likely want updates and contact as soon as possible. PRESERVING FUTURE FERTILITY One of the main advantages of UAE in the treatment of postpartum hemorrhage is its potential to avoid hys- terectomy and preserve a woman’s future childbear- ing options. Since the first successful pregnancy fol- lowing uterine artery embolization was confirmed in 1997,34 there have been several studies that have mon- itored the future fertility in women who were treated with UAE for postdelivery bleeding. A systematic re- view of this literature reported a subsequent preg- nancy and live birth rate of 71% in 154 women who underwent successful artery embolization for postpar- tum hemorrhage.16 In addition, other authors have re- ported a return of normal menses in the majority of patients treated with UAE.15,17,35 These findings are consistent with data on successful fertility after elec- tive uterine fibroid embolization, further validating that UAE for postpartum hemorrhage is a viable treatment option for women wishing to preserve their fertility.11 Some concerns remain, however, as to the long-term effect of UAE on the uterine and ovarian blood supply as well as the surmised radiation exposure to the ovaries from the use of fluoroscopy during the procedure.11 These concerns are speculative and have not been sub- stantiated in the current literature to date. There have been other reported complications, however, that do raise some key questions. In their extensive review of the existing studies on UAE and future fertility, De- lotte et al16 found an overall postpartum hemorrhage recurrence rate of 19% and 2 cases of unexplained in- trauterine fetal growth restriction. In another recent study, postpartum hemorrhage recurrence was found in 15% of cases, all of which were caused by abnormal placentation.17 Delotte et al16 also found a surprisingly high elective pregnancy-termination rate of 11%, lead- ing them to consider the overall psychological trauma women might face after surviving a near-miss postpar- tum hemorrhage event. Certainly the evidence to date has demonstrated the safety of UAE in the management of severe postdelivery bleeding and there have been several reported cases of Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Exploring the Role of Uterine Artery Embolization 211 212 Journal of Perinatal & Neonatal Nursing/July–September 2010 successful pregnancies following this procedure over the last several years. Given the relatively small number of cases, definitive long-term effects on fertility are still uncertain, making it difficult for researchers to ascer- tain any absolute conclusions.11,16 Large-scale prospec- tive studies will undoubtedly assist clinicians in both the management of post-UAE pregnancies and the pro- vision of invaluable data on the impact UAE procedures will have on future fertility.11 In the meantime, it is recommended that post-UAE pregnancies be carefully monitored, ideally at a tertiary center that has access to the resources needed to manage a recurrent post- partum hemorrhage.16 Serial prenatal ultrasounds will be especially helpful in identifying any fetal-growth re- striction as well as discerning placental location and any areas of abnormal attachment.16,17 Lastly, nursing and medical staff should be especially vigilant for signs of postpartum depression or posttraumatic stress be- haviors in women or their family members follow- ing any major postpartum hemorrhage. Women who have survived a near-miss event may need consider- able emotional support, not only in the immediate post- partum period but also when future pregnancies are contemplated.16 ABNORMAL PLACENTATION AND PROPHYLACTIC INTRA-ARTERIAL BALLOON CATHETERS Abnormal placentation occurs when the chorionic villi of the placenta extend into the myometrium and be- come adherent to the uterine wall. Commonly referred to as a placenta accreta, this abnormal attachment can penetrate deeper into the uterine muscle (placenta increta). In the most severe cases, the placental villi extend completely through the uterus and sometimes invade the surrounding organs (placenta percreta). Al- though the exact etiology is unknown, the incidence of placenta accreta and its variants increases dramati- cally with each subsequent cesarean section. This oc- currence can be especially high when accompanied by a placenta that has implanted low in the uterus and occludes the inner cervical opening (placenta previa).25,36 It is further postulated that rising cesarean delivery rates have led to a 10-fold increase in the inci- dence of abnormal placentation with occurrence rates now reported at 1 in 2500 deliveries.18 This may seem a fairly rare event; however, placenta accreta is fast be- coming the most common cause of major postpartum bleeding and peripartum hysterectomy.8,25,26 Most importantly, any degree of abnormal placenta- tion carries with it the potential for massive hemor- rhage when attempts are made to deliver the placenta in the usual fashion.25 Consequently, planned cesarean hysterectomy has been the preferred delivery strategy, especially if a placenta percreta is present.25 Moreover, some authors recommend screening for abnormal pla- centation with ultrasound or magnetic resonance imag- ing for all pregnant women diagnosed with placenta previa, particularly those with a history of previous ce- sarean section.18,25 Regardless of the level of placental invasion, once the diagnosis is confirmed, preoperative planning with a multidisciplinary team is crucial. This plan includes determining the timing and location of the delivery; mobilizing adequate nursing, medical, and surgical resources; ensuring the availability of adequate blood products; and establishing a clear management strategy for control of massive hemorrhage.11,18,25 Despite the success of UAE in the treatment of unex- pected postpartum hemorrhage, the preventive role of interventional radiology procedures in cases of abnor- mal placentation has been controversial. Some sources have advocated prophylactic insertion of IAB catheters into the internal iliac arteries preoperatively in case massive hemorrhage occurs during surgery.12,18,37 In- termittently inflating the balloon catheters as the need arises will temporarily occlude arterial blood flow to the uterus and potentially minimize bleeding, improve visualization, and facilitate access for rapid emboliza- tion postoperatively.11,12,25 One noteworthy review, however, observed no differences in blood loss or sur- gical outcomes with IAB catheters in place.38 In addi- tion, these authors reported that 16% of the cases they reviewed had serious complications directly related to the intravascular catheters.38 They also point out that the data available to support the efficacy of prophylac- tic IAB catheters is inconsistent and based primarily on small retrospective studies and case reports.38 With no clear advantage and the potential for com- plications, the question remains as to the feasibility of IAB catheters in the management of cases complicated with abnormal placentation. In spite of these concerns, other authors have asserted that abnormal placenta- tion carries such a significant risk for massive hemor- rhage that optimal preoperative management includes utilizing all available resources to avoid catastrophic outcomes.18,25 Accordingly, 1 recent study reported sig- nificant reductions in blood loss when a coordinated, staged embolization hysterectomy was performed for known cases of placenta accreta.39 This novel proce- dure combined prophylactic IAB catheterization, clas- sical cesarean delivery, and uterine and placental vascu- lar embolization before hysterectomy.39 Although the results from this small cohort study are promising, fur- ther research is still needed to more closely examine Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. the best management approaches in these challeng- ing clinical situations. For now, the rising incidence of abnormal placental attachment remains a valid con- cern that should prompt screening of pregnant women deemed to be at higher risk. In formulating a delivery management plan when this diagnosis is confirmed, some consideration should be given to interventional radiology if these services are readily available. SUMMARY AND RECOMMENDATIONS Postpartum hemorrhage is a serious complication of pregnancy that is often unanticipated. Even with prompt aggressive management, postdelivery bleeding can quickly evolve to a life-threatening event. Peri- natal nurses are often the first to observe significant postpartum bleeding and their prompt initial response and continued assessments are pivotal in the anticipa- tion and coordination of necessary interventions. This multidisciplinary team support is critical as obstetric caregivers need a full armamentarium of medical and surgical strategies to manage intractable bleeding. In situations where stabilization can occur and an inter- ventional radiology suite is nearby, UAE is an impor- tant consideration before proceeding with peripartum hysterectomy. Furthermore, research to date has con- sistently demonstrated that UAE is a safe, minimally in- vasive procedure with a reported success rate of more than 90% in the treatment of postpartum hemorrhage. In addition, this procedure may preserve a woman’s fu- ture fertility, giving it a clear advantage over peripartum hysterectomy. REFERENCES 1. World Health Organization. Maternal Mortality Fact Sheet 2008. who.int pregnancy safer mortality/en/index.html. Ac- cessed January 21, 2010. 2. Knight M, Callaghan WM, Berg C, et al. Trends in post- partum hemorrhage in high resource countries: a review and recommendations from the International Postpar- tum Hemorrhage Collaborative Group. Obstet Gynecol Surv. 2010;65(4):211–212. 3. KuklinaEV,MeikleSF,JamiesonDJ,etal.Severeobstetric morbidity in the United States: 1998–2005. Obstet Gy- necol. 2009;113:293–299. 4. Goffman D, Madden RC, Harrison EA, Merkatz IR, Cha- zotte C. Predictors of maternal mortality and near-miss maternal morbidity. J Perinatol. 2007;27:597–601. 5. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of post- partum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv. 2007;62:540–547. 6. Lombard H, Pattinson RC. Common errors and reme- Immediate availability and transfer logistics to an in- terventional radiology suite remain a challenge, espe- cially for community hospitals located in more rural areas. The potential catastrophic outcome of a mas- sive hemorrhage event begs a crucial question: Should interventional radiology services be compulsory in all hospitals that provide maternity care? Given the rising cesarean section rates and the escalating likelihood of abnormal placentation, the availability of prophylactic IAB catheterization may further justify the inclusion of these procedures in all postpartum-hemorrhage treat- ment algorithms. At the very least, all obstetric units should have a major hemorrhage protocol in place and perform periodic practice drills that incorporate when and how to mobilize resources such as interven- tional radiology. Perinatal nurses play a central role in these algorithms and are invaluable in coordinating the team approach necessary to manage this potentially life-threatening situation. An interdisciplinary quality review of all near-miss events should be conducted with an emphasis placed on continued education and training. Nonbiased re- porting of cases in which either UAE or IAB catheters were used will add to the growing body of literature. Careful follow-up of these women and their families may further clarify any association to postpartum de- pression or posttraumatic stress disorder as a result of surviving a life-threatening hemorrhage. Lastly, future research should also focus on randomized prospective studies that help define the evolving role of interven- tional radiology procedures in the management of post- partum hemorrhage. dies in managing postpartum hemorrhage. Best Pract Res Clin Obstet Gynaecol. 2009;23:317–326. 7. Rajan PV, Wing DA. Postpartum hemorrhage: evidence- based medical interventions for prevention and treat- ment. Clin Obstet Gynecol. 2010;53:165–181. 8. Glaze S, Ekwalanga P, Roberts G, et al. Peripartum hys- terectomy. Obstet Gynecol. 2008;111:732–738. 9. PorrecoRP,StettlerRW.Surgicalremediesforpostpartum hemorrhage. Clin Obstet Gynecol. 2010;53:182–195. 10. Shah M, Wright JD. Surgical intervention in the man- agement of postpartum hemorrhage. Semin Perinatol. 2009;33:109–115. 11. 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