Manual external uterine compression for postpartum hemorrhage after vaginal delivery: a prospective cohort study

Postpartum hemorrhage remains a leading cause of maternal mortality, particularly in low-resource settings where experienced birth attendants are scarce. Uterine massage and bimanual uterine compression have been incorporated into care bundles for many decades, yet their efficacy lacks robust supporting evidence. Bimanual uterine compression is invasive and painful for women without neuraxial analgesia.

This study aimed to assess whether manual external uterine compression could effectively control postpartum hemorrhage from uterine atony and placental pathologies after vaginal delivery.

In this single-center, prospective cohort study of postpartum hemorrhage following vaginal delivery, we assessed the feasibility and efficacy of manual external uterine compression, a technique using the provider's upper body weight to apply pressure to the entire uterus. Once bleeding ceased, compression was maintained for 5 to 10 minutes. The primary outcome was success rate, defined as complete resolution of uterine hemorrhage using abdominal pressure and uterotonics without requiring escalating interventions. Key secondary outcomes included compression duration, use of intrauterine balloon tamponade, blood transfusion, blood loss, hematocrit/hemoglobin change, and acceptability to providers and patients. Outcomes from the early study phase were compared with those from the later phase.

Manual external uterine compression was performed in 100 women with postpartum hemorrhage over a 10-month period, achieving an overall success rate of 94% (94/100). In the early phase, the success rate was 87.8% (43/49), as 6 women used intrauterine balloon tamponade following compression. In the later phase, no balloon tamponade was used after application of MEUC. Total compression duration ranged from 2 to 50 minutes (median: 10 minutes). All women tolerated the procedure well. Eight women (8%) received blood transfusions, and none required surgery. One woman experienced delayed uterine bleeding at 145 minutes postpartum.

Manual external uterine compression may offer a less-invasive alternative to bimanual uterine compression for managing postpartum hemorrhage after vaginal delivery.