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Potential sites for manual aortic compression at laparotomy for control of postpartum hemorrhage.
If there is an imminent threat of exsanguination (ie, within a few minutes), the surgeon should compress the aorta against the vertebrae a few centimeters superior to the sacral promontory; the bifurcation into the common iliac arteries is just distal to this point. Alternatively, the aorta can be compressed just below the renal arteries, which will minimize collateral flow to the uterus from the ovarian and inferior mesenteric arteries. Compression at either site will slow the volume of bleeding and will afford a better opportunity for finding and controlling the source of hemorrhage. Compression just above the bifurcation may be easier to accomplish, but is less effective than below the renal arteries because of the extensive collateral blood supply to the uterus.
An intraaortic balloon catheter is another option. The balloon is positioned below the renal arteries and above the ovarian and inferior mesenteric arteries and then inflated, which should lead to a substantial reduction in uterine blood flow. The balloon must be deflated intermittently to prevent ischemic limb and colon complications.