Revised Submission Of Manuscript For Publication After Corrections Biology Essay

We, herewith, are subjecting a revised manuscript titled ‘Efficacy of Hayman Suture Technique in the Management of Atonic Post-Partum Hemorrhage ‘ for publication in your honored diary under ‘original article ‘ . The itemized response to reviewer ‘s remarks has besides been attached herewith.

On behalf of all the writers I, Dr. Anamika Majumdar, will be the corresponding author.We assure that the contents of the manuscript have non been already published and the paper is non being submitted elsewhere.

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There is no possible struggle of involvement and anterior publications.All writers have contributed significantly in each phase of conceive and planning of the work ; every bit good as, composing, reappraisal and alteration of the paper. I, Dr. Anamika Majumdar, the first writer of the survey, am herewith accepting the duty for guaranting that the version of the paper submitted has blessing of all the joint authors. The hereafter corrected cogent evidence will besides hold blessing of all writers.

Thanking you,Yours unfeignedly,Dr. Anamika Majumdar,Assistant Professor, Department of Obstetrics and Gynecology,Surat Municipal Institute of Medical Education and Research ( SMIMER ) , SuratItemized response to reviewer ‘s remarksRemark 1: Why the survey was carried out is non good justified in the debutResponse 1: Purpose of survey has been detailed in the last parity of debutRemark 2: How the patients were followed up is non given although decisions include long term efficaciousnessResponse 2: Follow-up tabular array is includedRemark 3: Decisions are non justified by the consequence eg: easy and quickly appliedA A A A A A A A A A A A A A A A A A A A A birthrate continuing etc. but writers have concluded as suchResponse 3: The above said reasoning sentence have been removedRemark 4: Results subdivision include some methodological statements and has to be re arranged.Response 4: The method portion in consequence subdivision is removedRemark 5: Retrospective survey of this nature is limited by inability to varify the blood loss pre and station process which has to be acknowledged by the writers in decisionResponse 5: The restriction included in decisionTitle page

Title of manuscript:

Efficacy of Hayman Suture Technique in the Management of Atonic Post-Partum Hemorrhage

Writers in order with association:

Anamika Majumdar1, Kallol Mallick2, Bipin Vasava2, Kanan T. Desai3, Malati Dalal41 MD, Assistant Professor, Department of Obstetrics and Gynecology, Surat Municipal Institute of Medical Education and Research ( SMIMER ) , Surat2 MD, Assistant Professor, Department of Community Medicine, Surat Municipal Institute of Medical Education and Research ( SMIMER ) , Surat.3 MBBS, Postgraduate occupant, Department of Community Medicine, Surat Municipal Institute of Medical Education and Research ( SMIMER ) , Surat.4 MD, Professor & A ; Head, Department of Obstetrics and Gynecology, Surat Municipal Institute of Medical Education and Research ( SMIMER ) , Surat

Institute of survey:

Surat Municipal Institute of Medical Education and Research ( SMIMER ) , Surat.

Fiscal support:


Matching writer:

Dr. Anamika Majumdar,Assistant professor, Dept of Obstetrics and Gynecology,Surat Municipal Institute of Medical Education and Research ( SMIMER ) ,Opp. Bombay market, Umarwada,Surat-395010Contact no. : 09426772605E-mail reference: anamikakallol @ yahoo.


Runing rubric:

Haymen Suture in Post Partum HemorrhageAbstraction



To analyze the effectivity of Hayman sutura technique to command postnatal bleeding. Method:Hayman sutura was applied in 43 instances. A No-1 Vicryl sutura was used on a unit of ammunition organic structure or a consecutive acerate leaf.

In 36 instances ( 83.72 % ) Hayman sutura was the lone intercession. In 4 instances ( 9.30 % ) uterine vass and ovarian vass were besides ligated along with Hayman sutura. In 3 instances ( 7 % ) , along with Hayman sutura, Gunasheila ‘s circumferential suturas were taken. Consequences:None of the 43 patients needed hysterectomy.


Hayman sutura technique is an easy and quickly applied, effectual, simple, safe, life economy and birthrate continuing method to command atonic postpartum bleeding.



Atonic Post Partum Hemorrhage, Hayman Suture, B-Lynch Suture.Text


It has been estimated that universe broad over 125000 adult females dice of postpartum bleeding ( PPH ) each year1. PPH complicates about 3.7 % of vaginal and 6.4 % of cesarean delivery2. In India 25.6 % of maternal deceases are due to hemorrhage3.

Uterine atonicity histories for 75 % -90 % of primary PPH. The traditional direction of this status begins with conservative methods such as two-handed compaction, medical therapy with uterotonic agents, uterine temponade with balloons and on occasion arterial embolisation4, the failure of which frequently mandates surgical intercession. Surgical steps such as ligation of the major pelvic vass demand a seldom used accomplishment possessed by few registrars. In the event of intractable bleeding, despite the above steps, hysterectomy is normally the concluding resort.In 1997, Christopher B- Lynch devised an advanced technique to handle uterine atonicity, where a uninterrupted sutura was used to enfold and automatically compact the womb in an effort to avoid hystrectomy4.

Hayman sutura, the alteration of B- Lynch sutura, offers the possible advantage that it can be applied faster and easier, avoiding the public presentation of a lower section hysterectomy when PPH follows a vaginal delivery5.The purpose of our survey is to reexamine the instances in which Atonic PPH was non controlled with the available drugs ( uterotonics ) , where birthrate continuing Haymans suturas were applied over extremely adept obstetric hysterectomy in our establishment and their clinical results.

Materials and methods

A retrospective survey of all adult females who delivered between April, 2007 and March, 2010 was collected from our departmental database. Primary PPH is defined as a blood loss of more than 500 milliliter at or with in 24 hours of bringing. There were a sum of 18,750 bringings during this period, with primary PPH happening in 938 of these instances. The Hayman sutura process was performed in 43 instances merely after uterine atonicity did non react to steps such as uterine massage, two-handed compaction and the usage of uterotonics, i.e. Oxytocin, Ergometrine, PG-F2I± , Misoprostol.

Out of these 43 instances, 38 instances delivered in our institute and 5 instances were referred from other infirmary. The demand for hysterectomy was avoided in all the instances. Uterine and ovarian vas ligation was done in 4 instances and Gunashila ‘s cosmopolitan circumferential suturas were taken in 3 instances in add-on to Hayman sutura. The process was done with Vicryl No-1 ( Polyglactin ) in all the instances.The process for Hayman sutura technique was as follows:The patient was given appropriate anaesthesia and catheterized.

The venters was opened by an appropriate sized scratch or if the patient had a cesarean subdivision, the same scratch.On come ining the venters the womb was exteriorized and rechecked to place any hemorrhage point. If hemorrhage was diffuse as in uterine atonicity, coagulopathy, or profuse placental bed shed blooding where no obvious hemorrhage point is observed, so two-handed compaction was foremost applied to measure the possible opportunities of success of the Hayman suturing technique.

The vagina was swabbed to corroborate equal control of the hemorrhage.If the vaginal hemorrhage was controlled, a consecutive acerate leaf or a curving acerate leaf is used to fascinate the womb from forepart to endorse, merely above the contemplation of the vesica and is so tied at the fundus of the womb. This can be done as one sutura on each side of the womb or more than one sutura if uterus is peculiarly broad6.


Age distribution of adult females is shown in figure 1, bulk of the patients were in the age group of 20-25yrs.

Gestational hebdomads of adult females in table 1, most of the gestation were term gestation. Mode of bringing of adult females is as in figure 2, out of 43 patients 34 delivered by LSCS. Type of intercession is as given in table 2. In 36 patients, hayman suturas entirely were taken. In remainder of the 7 patients extra methods like ligating uterine Artery and ovarian Artery ( in 4 patients ) and Gunasheilla ‘s cosmopolitan suturas were taken ( in 3 patients ) . Numbers of primary instances is given in figure 3, 9 patients were referred from outside.

Follow up of the patients was as per tabular array 3, out of the 43 patients, 14 became pregnant of which 5 delivered later.Figure 4 shows the exposure of Hayman sutura taken in a instance of atonic PPH.All the instances had grounds of uterine atonicity which responded ill to conventional uterotonics. Bleeding was controlled in all the instances with Hayman sutures therefore debaring hysterectomy. Besides, the full patient ‘s had an uneventful post-operative recovery except in one referred instance, in whom hemorrhage was controlled with Hayman suturas but subsequently she developed blood poisoning plus Acute Respiratory Distress Syndrome ( ARDS ) and died on 21st postnatal twenty-four hours.


Christopher B-Lynch ‘s original instance series of five patients underwent the B-Lynch ‘s process for monolithic PPH as conventional uterotonic agents proved ineffective4. In 2002, Hayman placed two perpendicular suturas on each side of the fundus of the womb in three patients with PPH without executing a hysterotomy7. The process was successful in continuing the womb and hence birthrate. Although uterine atonicity is frequently the indicant for the usage of the compaction sutures, it has been shown in many instance studies that the sutura is besides utile in commanding hemorrhage in instances of placenta previa and placenta accrete.

7Assorted sutura stuffs have been tried, including Vicryl ( polyglactin910 ) , Dexon ( polyglycolic acid ) , PDS ( polydioxanone ) , prolene ( monofilament polypropene ) and nylon. It is believed that the ideal sutura should be strong, monofilament ( to minimise possible injury to the crumbly tissue of the atonic womb ) , rapidly absorbed, and mounted on a big curved or on a consecutive acerate leaf. Ideally the sutura needs to keep the tensile strength for 48-72 hours. In our series of 43 instances, Vicryl was used in all, although this was non recommended for the grounds stated supra, there were no subsequent long term complications encountered in these patients.There have been isolated studies of inauspicious effects after B-Lynch application.

In 2004, Grotegut et al reported one instance of eroding of a B-Lynch sutura through the uterine wall, in a 19 twelvemonth old primigravida8. Partial ischaemic mortification of the uterus happening 24 hours after the process has besides been reported in a 26 twelvemonth old gravida I, who underwent an exigency cesarean subdivision for foetal hurt followed by B-Lynch sutura 9.The consequence of the eroding on future birthrate and labour remains unknown.

Despite this, many patients on long term follow up have demonstrated recommencement of normal catamenial periods and normal generative health10.Long term complications such as, formation of intestine adhesion have besides been reported 7.Comparing B-Lynch sutura with Hayman sutura, B-Lynch is clip devouring and there is shed blooding from uterus due to multiple bites. Uterine gap is avoided with Hayman sutura.

Cervical stricture, haematometra, partial mortification and shedding of uterine wall have been documented by assorted sawboness as a complication of original B-Lynch sutura technique. Since modified B-Lynch brace suturas is a newer technique, and most of the surveies are based on instance studies and are without proper controlled surveies, more controlled surveies are required before it is accepted as a standard method 6.In our series, none of the patients had any known inauspicious result boulder clay day of the month. Our series of 43 patients illustrate the utility of the Hayman process in the direction of intractable PPH, therefore avoiding hysterectomy. To day of the month, we have no farther information of continued birthrate in patients whose womb was preserved. There is no randomised controlled informations comparing Hayman process to other methods of hemostasis for PPH, and it is improbable that such informations would of all time be forthcoming, given that PPH is frequently unforeseen and occurs under urgent or life baleful state of affairss, thereby rendering randomisation and the procedure of commanding for variables highly is hard, if non impossible to implement and ethically questionable 10.

Decision: Our initial series of instances of atonic PPH treated with Hayman process shows that it is an effectual method of commanding PPH. The Hayman sutura has the advantage of being applied easy and quickly. It should be attempted every bit early as possible in order to maximise its success and contraceptive application should be considered in patients at high hazard. Application of a Hayman suturas should be taught to all trainees and registrars in OBs. Its comparative simpleness and easiness of application, its life salvaging possible, comparative safety, and above all, its capacity for continuing the womb, makes it the recommended process of pick if conservative steps do non command PPH, and should be attempted before any extremist surgery is considered.

It does non necessitate any excess accomplishment and even a resident physician or a junior physician can execute it.Restriction of survey:Retrospective survey of this nature is unable to verify the blood loss pre and station process.Mentions


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