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Refractory postpartum hemorrhage (PPH) affects 10–20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.

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The objective of this video is to highlight the evolution of sterilization techniques from historic open procedures to modern minimally invasive techniques. DESCRIPTION: The following is a collection of videos highlighting the different techniques for sterilization. Each video segment highlights the important steps to safely and effectively carry out each procedure. The historical open techniques are demonstrated on a simulation model. The more modern minimally invasive techniques are shown during laparoscopic surgery. The techniques to be covered are the following: Irving, Uchida, Parkland, fimbriectomy, laparoscopic Pomeroy, Filshie Clip, Fallope ring, and laparoscopic salpingectomy. CONCLUSION: Sterilization is the most common form of contraception used throughout the world. It is important for surgeons to understand all the different techniques available to perform a safe and effective sterilization procedure. This video provides a comprehensive summary of the majority of techniques available, both past and present.