Uterine atony accounted for 70 ~ 80% of etiology in postpartum hemorrhage, and the incidence of uterine atony was continuously increasing [12–13]. In 2019, the rate of postpartum hemorrhage in West China Second Hospital of Sichuan University was about 6.0%, and uterine atony was the leading cause. Currently, active management of the third stage of labor was recommended as a prevention to reduce postpartum hemorrhage such as oxytocin administration, uterine massage and umbilical cord traction [14–16]. Except for Oxytocin, almost 3 ~ 25% of cases in PPH required another uterotonic including ergonovine, carbetocin, 15-methyl prostaglandin F2-a or misoprostol [17]. But some problems could not be overlooked, gestational hypertension, preeclampsia, heart disease, glaucoma, asthma and drug hypersensitivity were uterotonic contraindications, and drug life-time limits its repeated usage in a short time, uterotonics also brought side effect like nausea, vomiting, diarrhea, headache and increased blood pressure [8], a systematic review in 2015 even found no satisfactory evidence could suggest what kind of uterotonic was the most effective for uterine atony [18]. Two previous studies mentioned so-called clamp for fixing intrauterine balloon, or recommending Bilateral Cervix Apex Clamping (BCAC) procedure as a noninvasive therapy for severe postpartum hemorrhage [11, 19], both operations were completely different from bilateral-contralateral cervix clamp we proposed. The present study found this new technique could effectively reduce blood loss at third stage of labor or after vaginal/caesarean birth, and it was much safer than uterotonics. However, the bilateral-contralateral cervix clamp could not be recommended during caesarean section, because it was not a more rapid, immediate choice in comparison with surgical measures.
Maternal deaths caused by postpartum hemorrhage still varied in regions with different medical levels, compared with 31% of maternal deaths in Asia, 21% in Latin America, 34% in Africa were caused by postpartum hemorrhage, however, only 13% in developed countries such as the United States and 18% in France [20–21]. If uterotonics failed, intrauterine Bakri balloon and invasive management such as uterine artery intervention or laparotomy may be recommended as second-line therapy to treat refractory hemorrhage [22–23]. It was reported that 86% of women who had balloon tamponade did not require further procedures, and the success rate of UAE was greater than 80%, but UAE required rapid access to computed tomography and interventional radiologist, not available to all hospitals [24–25]. Lack of uterotonics, Bakri balloon and UAE, maternal women in low income areas would be in high risk of hysterectomy and death. As for bilateral-contralateral cervix clamp, only two sponge forceps required for hospitals, also no extra charge for patients, and trained obstetrician/midwife could accomplish in 5 minutes, so this new technique could be another uterus-preserving management at basic-level hospital. Because no extra nursing or hospital stay required, there was also no increased burden for patient.
Even the present study was a retrospective cohort study, several ways increased its strengths. First of all, both inclusion and exclusion criteria were strictly made, three experienced midwives or obstetricians together improve accuracy of blood loss, and quantitative analysis helped directly confirm its efficacy. Then comparison of side effect, complications and cost indirectly explained its advantage. The limitations of this study included a small sample size, lacking randomization and long-term follow up. Most of all, present study couldn’t prove it work in severe PPH (≥ 1000 ml), or reducing incidence of intrauterine Bakri balloon, UAE or laparotomy. The future study will make perspective randomized controlled trial (RCT) and increase samples.