Bakri Balloon Placement Technique

Updated: Jul 05, 2016
  • Author: Gabor C Mezei, MD, PhD; Chief Editor: Carl V Smith, MD  more...
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Technique

Approach Considerations

After vaginal delivery

For transvaginal placement following vaginal delivery, the following steps should be considered:

  • Before insertion the balloon, ensure that the bladder is empty by placing a Foley catheter.

  • Inspection of the uterine cavity should be made to ascertain that the uterine cavity is clear of placental fragments.

  • The cervix and vagina should be cleansed with an antiseptic solution, such as povidone iodine.

  • Grasp the cervix with ring forceps. Insert the balloon into the cavity of the uterus under ultrasound guidance, making sure that the entire portion of the balloon passes the cervical canal above the internal cervical os. This can be also achieved by manual insertion of the catheter similar to insertion of an intrauterine pressure catheter.

  • Once the correct placement is confirmed, inflate the balloon with sterile saline using the enclosed syringe. The recommended maximum capacity of the balloon is 500 mL.

  • In order to maximize the effect of tamponade most notable to the lower uterine segment, apply gentle traction to the shaft of the balloon. This can be achieved and maintained by securing the balloon shaft to the patient leg or attaching to a weight, not to exceed 500 grams.

  • Connect the drainage port to a fluid collecting bag to monitor hemostasis.

  • Monitor patient continuously for signs of increased bleeding and uterine cramping.

After cesarean section

At laparotomy following a cesarean section, the following specific steps should be considered:

  • Insert the end of the catheter through the open uterine incision to the cervix and then into the vagina.

  • Close the uterine incision while taking special care not to damage the balloon by the suturing needle.

  • Insufflate the balloon under direct visualization.

This may potentially result in balloon failure secondary to incidental puncture of the balloon by the needle. An alternative approach is to close the uterus first and then insert the balloon from the vagina and inflate it while the surgeon watches from above.

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The Tamponade Test

The effectiveness of the intrauterine balloon catheter can be assessed by the “tamponade test” first described by Condous and colleagues. [20] This test is considered positive when control is achieved following inflation of the balloon. [21] Patients with a negative test (ie, persistent bleeding despite the balloon placement) should proceed to more invasive therapeutic approaches such as laparotomy or embolization depending on personnel and facilities.

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Use of Vaginal Pack

The early publications involving the Bakri balloon suggested the use of a vaginal pack to maintain the balloon in the vagina and to provide additional compression of the lower uterine segment. However, no clear evidence suggests the beneficial effect of this additional approach. If a vaginal pack is to be used, then a positive tamponade test needs to be demonstrated prior to placement of the vaginal pack. Otherwise, a danger exists that the pack will obscure any continuing bleeding leading to a delayed diagnosis of ineffective tamponade.

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Use of Antibiotics and Uterotonic Agents

Most experts suggest the use of antibiotics to reduce the risk of iatrogenic infection caused by contamination of the uterine environment by the balloon. However, the effectiveness of antibiotics in this setting has not been studied. Prophylactic (single-dose) administration or for the duration of balloon usage (up to 24 hours) is recommended.

The use of oxytocin or other uterotonics (eg, methylergonovine, prostaglandins) are generally recommended to prevent atony. But again, no clear evidence for this approach exists either

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Combination with Other Techniques

External compression plus internal tamponade (uterine sandwich)

Intrauterine balloon catheters can be used in combination with other surgical interventions to potentially increase effectiveness.

One study evaluating the effectiveness of placing an intrauterine Bakri balloon in conjunction with the B-Lynch uterine compression suture in successfully treating uterine atony. [22] Five cases of cesarean deliveries with persistent bleeding from uterine atony refractory to medical treatment and B-Lynch suture underwent Bakri balloon placement with median volume of 100 mL of fluid inflation. The numbers of cases are very small, but the result is promising.

Uterine vessel ligation plus internal tamponade

Hypogastric artery ligation, O’Leary uterine artery ligation, or bilateral looped uterine vessel sutures (B-LUVS) can be also used in conjunction with intrauterine Bakri balloon placement. No scientific data are available at this moment regarding these techniques, but an evaluation of this combinational technique regarding efficacy and safety is ongoing. [9]

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