INTRODUCTIONGlobally uterine atony is one of the commonest form of PPH and results in significant maternal mortality and morbidity.As one of the quick, effective and safe interventions for control of PPH, uterine compression sutures(UCS) were introduced by Christopher B Lynch. Since then many modifications of UCS has been practised. 1-3Combination technique of external compression incorporating the UCS and internal uterine tamponade (uterine sandwich) using a Bakri balloon has been employed which applies forces to both the external as well as the internal surfaces of the myometrium. 4 Since in low resource settings Bakri balloon is not available, we have used Foley's catheter (which is universally available), as a means of internal uterine tamponade. 5Since PPH results in significant maternal morbidity and mortality and at times in face of PPH refractory to ABSTRACT Background: Uterine atony is the most common cause (75%-90%) of primary postpartum hemorrhage (PPH) and Christopher B Lynch was the first to highlight the use of Uterine Compression Sutures (UCS) for the management of atonic PPH. In combination therapy, the (UCS) is combined with intrauterine balloon tamponade, known as (uterine sandwich), for combined external as well as internal compression for more effective hemostatic control of uterine bleeding. Methods: The uterine sandwich technique was used in a total of twelve patients managed in a tertiary care service hospital during caesarean deliveries. In four cases of uterine atony, the sandwich technique was used, for patients unresponsive to the conservative management. In eight patients the sandwich technique was used as a prophylactic measure, where according to the clinical profile of the patient there was high risk of PPH and where either blood was not available or availability was limited. Results: In the four cases of uterine atony, the uterine sandwich technique was used therapeutically. All the patients were multigravidae. The period of gestation ranged from 34 weeks to 37 weeks. Average operating time was 50-60 mts, average estimated blood loss was 1600 ml, average distension of Foleys catheter was 90 ml and average duration of the intrauterine Foleys catheter balloon being in situ was 12 hrs. In eight patients, the sandwich technique was used as a prophylactic measure, for varied indications. In all the cases there was successful outcome. Post-operative outcome was uneventful in all the cases. Conclusions: The uterine sandwich technique can be used either prophylactically or therapeutically for control of PPH. It is simple, safe, easy, effective and is easier to perform than internal iliac artery ligation and should be considered prior to proceeding for hysterectomy in a hemodynamically stable patient, in whom uterine conservation or fertility preservation is essential.

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Background: Generally misopristol alone is used in cases of early fetal demise successfully. However to further enhance the success rate a combination of mifepristone along with misopristol can be used. This results in avoiding anesthesia, surgery and operating theater resources, thus being economically viable and results in an overall greater patient satisfaction levels also. Globally, there is a general trend to grant patient greater autonomy in their treatment plan, minimize intervention levels, shorter hospital stay and quicker return to normal schedule and enhanced patient satisfaction levels.Methods: 100 patients with early fetal demise, who reported to a tertiary care service hospital were prospectively evaluated. An oral dose of mifepristone 200 mg stat and 48 hours later misoprostol 800 μg was inserted vaginally. Three hours following the first dose, two further doses of 400 μg misoprostol, was administered vaginally at 3 hours intervals. Repeat medical regime was offered with misoprostol patients who failed to pass products of conception. Success was defined as complete uterine evacuation within 3 days, without the need for surgical evacuation.Results: The overall success rate of medical management was 84%. Mifepristone alone induced natural expulsion of products of conception in (40%) patients complained of heavy bleeding within 48 hours of mifepristone administration alone and in 29 (29%) patients complete miscarriage was confirmed on ultrasound scan. Of the 68 women who were symptomatic at presentation the medical regime failed in 28 (41%), compared with five (16%) failures of the 32 who were asymptomatic. Of the 25 women who had surgical evacuation, eight required an emergency curettage for bleeding.Conclusions: Combination of oral mifepristone along with vaginal misopristol is a simple, safe and effective means of treating early fetal demise, and is an effective alternative method to expectant and surgical options.