Uterine Balloon Tamponade
Learning Resource Package
Jhpiego is an international, nonprofit health organization affiliated with Johns Hopkins University.
For more than 40 years, Jhpiego has empowered frontline health workers by designing and
implementing effective, low-cost, hands-on solutions to strengthen the delivery of health care
services for women and their families. By putting evidence-based health innovations into everyday
practice, Jhpiego works to break down barriers to high-quality health care for the world’s most
vulnerable populations.
Published by:
Jhpiego
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1615 Thames Street
Baltimore, Maryland 21231-3492, USA
www.jhpiego.org
© Jhpiego Corporation, 2016. All rights reserved.
Contributors
Blami Dao
Kusum Thapa
Lauren Arrington
Patricia Gomez
Willy Shasha
Sheena Currie
John Varallo
Susheela Engelbrecht
Erica Chin
Uterine Balloon Tamponade Learning Resource Package
iii
Table of Contents
How to Use This Learning Resource Package
1
PowerPoint Presentation on Uterine Balloon Tamponade
7
Job Aid for UBT
40
Checklist for UBT Demonstration
41
Documentation Checklist
43
Knowledge Assessment
44
Knowledge Assessment Answers
48
Case Study 1: Management of PPH without UBT
54
Case Study 1: Answers
55
Case Study 2: Management of PPH with UBT
56
Case Study 2: Answers
57
References
59
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Uterine Balloon Tamponade Learning Resource Package
How to Use This Learning Resource Package
This learning resource package (LRP) was designed to provide a set of learning tools that can be used
for training health care providers on the use of the uterine balloon tamponade (UBT) for
management of postpartum hemorrhage (PPH). It can be used as a stand-alone training activity or
integrated with a larger training program on PPH and obstetric emergencies. However the materials
are used, the recommended learning approaches, described below, should guide any utilization of
these resources.
Uterine Balloon Tamponade: A Valuable Tool
PPH is an obstetrical emergency and a leading cause of maternal morbidity requiring prompt
response. When a woman suffers PPH, the UBT can be inserted into her uterus and then inflated
with fluid. Once inflated to the size of the uterus, the balloon puts pressure on the uterine wall.
When the pressure exerted by the UBT exceeds capillary blood vessel pressure, bleeding often stops
because blood flow is reduced and clotting is facilitated.
The World Health Organization (WHO) recommends the use of UBT as a second-line treatment
for PPH due to uterine atony when bimanual compression and uterotonic drugs fail. UBT success
rates are as high as 97%, obviating the need for surgical intervention. However, if bleeding persists
after correct insertion of the UBT, definitive treatment, which may include surgical intervention,
must be initiated. Even if UBT “fails,” it may reduce bleeding and provide time to prepare for other
interventions or transportation to a point of care where surgical management is available.
Multiple types of UBT devices are available for uterine tamponade, many of which are quite
expensive. Low-cost UBT devices can be created with materials that are usually already available in
health centers, even in low-resource settings. The materials needed to assemble and insert a low-cost
UBT device are: a condom, Foley catheter, suture string, IV infusion bag with saline, IV giving set,
Sims speculum, and two ring forceps. UBT devices assembled with these resources are as effective as
more expensive devices.
The UBT can be readily implemented by providers with minimal training to limit ongoing uterine
blood loss; therefore, all maternal health care providers should know how to use this lifesaving
device.
Contents of This LRP
UBT PowerPoint presentation: This presentation contains the knowledge component of the
training. After the presentation, the facilitator should demonstrate the step-by-step, hands-on process
of assembling, inserting, and removing a UBT. Then, learners should be divided into small groups
and provided with ample time for hands-on practice by each learner using the UBT checklist as a
guide. This presentation can be accessed online or through a USB disk or flash drive.
Uterine Balloon Tamponade Learning Resource Package
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UBT job aid poster: This poster describes the steps for assembly, insertion, monitoring, and
removal of the UBT; in addition, it provides information on how to decide if the UBT has “failed”
and additional interventions are required. It should be displayed prominently in the training room
and referred to during the training activity. At the end of the training activity, the poster should
remain in the health center.
UBT video: This animated video takes learners through the process of assembling and inserting the
UBT. The video should be shown during the training and shared with providers post-training via
digital platforms whenever possible.
LRP booklet: The booklet is designed as the main resource for both facilitators and learners. Unlike
many LRPs, there is only one booklet for both facilitators and learners. This was done intentionally
to simplify access to training resources and facilitate continued transfer of learning between
colleagues at the facility level. This booklet contains a paper form of all LRP resources, including
references to the video on use of the UBT.
The following items are contained within the LRP booklet:
2

Case studies/Role plays: Case studies are designed to assess and facilitate clinical decisionmaking skills. They can be read or demonstrated through clinical simulation. If the case
studies are demonstrated through simulation, learners should be selected to play the roles of
client and provider and the facilitator should serve as a narrator.

Case study/Role play 1: This case study is designed to assess clinical decision-making
around current management of PPH and should be carried out before learning about UBT.
The case study is designed to spark a discussion about how learners manage PPH without
UBT.

Case study/Role play 2: This case study is designed to simulate use of the UBT in a clinical
situation. It should be conducted after demonstration of correct use of the UBT.

PowerPoint slide thumbnails: Copies of the PowerPoint slides are available in the LRP
booklet. Learners can use the slide thumbnails to follow along and take notes during the
presentation, or the slide thumbnails can take the place of a projected presentation when a
projector is not available.

Knowledge assessment questions and answers: These questions are designed to assess
retention and comprehension of information presented during the PowerPoint presentation
and simulated practice. This assessment should be given at the start of the workshop to assess
the knowledge that participants already have and then given again at the end of the
workshop to assess improvement in knowledge. Knowledge assessment questions should be
answered individually and reviewed/discussed as a group at the end of the workshop.

Checklist for demonstration of UBT: This checklist should be used to practice the skills
needed to use UBT effectively during and after the initial training. This checklist can also
serve as source of guidance during clinical practice.
Uterine Balloon Tamponade Learning Resource Package

Documentation checklist: This checklist is designed to remind health care providers of the
essential information that should be documented in the client’s record whenever UBT is
used. Such documentation facilitates effective communication between health care providers
and allows for monitoring and improvement of device use.

UBT job aid: A smaller version of the UBT poster is available for each learner in the LRP
booklet.
Learning Objectives for This LRP
By the end of this training, learners will be able to:
Describe indications and contraindications for uterine balloon tamponade.
Assemble a condom catheter for uterine tamponade.
Describe the steps for insertion of the uterine balloon tamponade.
Demonstrate insertion of the uterine balloon tamponade on an anatomic model.
Describe peri-procedure monitoring and care for uterine balloon tamponade clients.
Describe the steps for deflation and removal of the uterine balloon tamponade.
Demonstrate deflation and removal of the uterine balloon tamponade on an anatomic model.
Describe potential complications and how to respond.
Describe signs that the UBT has “failed” and immediate surgical intervention is most likely
necessary.
Who Should Be Trained to Use UBT?
UBT should always be used in accordance with national guidelines. UBT should be used only at
points of care and by health care providers, such as midwives and doctors, authorized by the
Ministry of Health. Other members of the health care team should also be educated on where to
find the necessary materials for UBT, and how to assemble the condom catheter for uterine
tamponade.
Learning Approach
This LRP is designed to support competency-based learning for health care providers.
Competency-based learning promotes approaches that ensure learners acquire the essential
knowledge and skills needed to achieve the course learning objectives and supports the learner until
she/he can competently demonstrate the skill to standards defined for the course. The learning
process continues beyond the close of the initial training until each learner can demonstrate
proficiency in the skill. This LRP provides a resource to support competency-based learning during
both the initial training activity and in continued practice.
Uterine Balloon Tamponade Learning Resource Package
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Whole-site, facility-based training is recommended to ensure that the entire health care team is
involved and the materials needed for UBT are available. If UBT training is conducted as a
stand-alone activity, the facilitator can conduct training sessions in small groups when the unit is not
busy. If this LRP is integrated with a larger training activity, for example, PPH management or basic
emergency obstetric care, whole-site training may not be possible. In either case, facility-based
clinical mentors should be selected to lead simulation-based practice at the facility during clinical
drills and provide guidance and support for newly trained providers using UBT with a client until
they are comfortable and confident providing the intervention.
During simulated practice, the ideal facilitator to learner ratio is 1:4.
Facilitator Selection and Preparation for Training
Facilitators should be health care providers who have been trained in UBT and are comfortable and
confident using it in the clinical setting. In preparation for training, the facilitator should review all
training materials and be familiar with research on UBT. Facilitators should also have training skills
and be familiar with adult learner and competency-based learning principles. Links to references on
UBT training are provided in the Additional Resources section below.
When planning a training activity, the facilitator should be familiar with what resources are available
at the facility where learners practice and understand local practice guidelines that impact utilization
of the UBT. To support transfer of learning to the workplace, the facilitator should ensure
availability of the required medicines and supplies for UBT use.
Supplies needed for training
4

LRP booklets for facilitator and all learners

Equipment to project PowerPoint presentation and video (computer, projector, screen);
otherwise, use printed slides found in booklet

Job aid poster

PowerPoint presentation

Animation video

Markers

Flip chart

UBT materials (one set for every two participants): condoms, Foley catheter, suture string,
IV infusion bag with saline, IV giving set, Sims speculum, and two ring forceps

Examination gloves for all participants

Elbow-length gloves for all participants
Uterine Balloon Tamponade Learning Resource Package

Samples of uterotonic drugs and antibiotics

Sample client record from the learners’ facilities to practice documentation

Simulators – MamaU and/or empty 8-ounce water bottles
Example of a Course Schedule
This sample course includes all activities that are recommended for UBT training. As needed, these
activities can be broken up into more than one session.
Schedule:

Introduction (10 minutes)

Pre-knowledge assessment (10 minutes)

Case study/Role play 1—What is your current practice? (20 minutes)

PowerPoint presentation with UBT (30–45 minutes)

Presentation

Discussion questions:
−
What will you need to do this intervention at your facility?
−
Where in the client record will you document the UBT procedure?
−
How will you practice this skill to achieve and maintain competency?

Video animation (5 minutes)

Demonstration by the facilitator

BREAK (15 minutes)

Simulated practice: (60 minutes)

Each learner performs the procedure while receiving guidance and feedback from the
facilitator.

Next, in pairs of two, one learner uses the checklist to provide guidance and feedback to
another learner as she/he performs the procedure. Then learners switch roles.

Case study/Role play 2—What would you do now? (15 minutes)

Knowledge assessment (15 minutes)

Answer review and discussion (10 minutes)

Next steps discussion – How can you practice and use this skill? Develop a learning plan. (15
minutes)
Achieving Competency
This LRP is designed to be part of an ongoing process of learning and practice. Completing one
UBT course does not make a provider competent in the provision of UBT. The definition of
Uterine Balloon Tamponade Learning Resource Package
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competency for UBT should be discussed among the team leading the training, facility
administrators, and members of the Ministry of Health. Before attempting UBT in a clinical setting,
learners must demonstrate competency in simulation. This can be defined as scoring at least 90% on
a skills assessment in a simulated setting and at least 85% on the knowledge assessment. Learners
who then qualify to use UBT with supervision in the clinical setting should be assessed and receive a
skill assessment score of at least 90% before practicing independently.
Skill assessments for UBT can be conducted using the “Checklist: Uterine Balloon Tamponade.”
This checklist contains 24 items. Four points can be given for performing each item correctly
(4x24=96) and up to an additional four points can be given for overall performance.
Additional Resources
Effective In-Service Training Techniques, Frequency, Settings and Media: Evidence from an
Integrative Review of the Literature
http://reprolineplus.org/system/files/resources/FINAL_IST_Technical%20report.pdf
Effective Teaching Skills: A Blended Learning Approach – Facilitator’s Guide
http://reprolineplus.org/system/files/resources/ets_facilitator_guide_formatted.pdf
Effective Teaching: A Guide for Educating Healthcare Providers – Reference Manual
http://reprolineplus.org/system/files/resources/EffectiveTeaching_full.pdf
Tindell K, Garfinkel R, Abu-Haydar E, Ahn R, Burke TF, Conn K, Eckardt M. 2013. Uterine
balloon tamponade for the treatment of postpartum haemorrhage in resource-poor settings: a
systematic review. BJOG. 120: 5–14. http://onlinelibrary.wiley.com/doi/10.1111/j.14710528.2012.03454.x/epdf
World Health Organization. 2012. WHO Recommendations for the Prevention and Treatment of
Postpartum Haemorrhage. Geneva, Switzerland: WHO.
http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf
Additional Support
Please feel free to contact the MNH unit at Jhpiego with any questions, comments, or concerns
regarding this LRP.
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Uterine Balloon Tamponade Learning Resource Package
Uterine Balloon Tamponade
A Workshop for Frontline Health
Workers
Uterine Balloon Tamponade Learning Resource Package
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Learning Objectives
1. Describe indications and contraindications for
uterine balloon tamponade.
2. Assemble a uterine balloon tamponade kit.
3. Describe the steps of the uterine balloon
tamponade technique.
4. Perform uterine balloon tamponade procedure
on an anatomic model.
5. Explain how to monitor uterine balloon
tamponade clients.
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Uterine Balloon Tamponade Learning Resource Package
Postpartum Hemorrhage (PPH)
All women who give birth risk developing PPH!
 Blood loss > 500 cc within 24 hours after
childbirth
 #1 cause of maternal death in developing
countries (Africa and Asia: 30%, WHO 2012)
 Mostly preventable
 Uterine atony is the leading cause
 Death can occur within 2 hours if emergency
treatment is not provided!
Uterine Balloon Tamponade Learning Resource Package
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General Management of PPH
1.
2.
3.
4.
5.
Call for help!
Massage the uterus.
Secure an IV line.
Make sure the bladder is empty.
Administer a uterotonic: oxytocin, misoprostol,
syntometrine, or ergometrine.
6. Identify the cause (4Ts: thrombin, tissue, tone,
trauma).
10
Uterine Balloon Tamponade Learning Resource Package
Management of PPH Caused by Atony
PREVENTION: AMTSL*
UTERINE MASSAGE/MORE OXYTOCICS
Establish Cause
TEARS
RETAINED PLACENTA
ATONY 75%
COAGULOPATHY
BIMANUAL COMPRESSION
UTERINE BALLOON TAMPONADE +/- NASG*
SURGERY
COMPRESSION SUTURING; B-LYNCH PROCEDURE
LIGATION OF UTERINE AND OVARIAN ARTERIES
HYSTERECTOMY
* AMTSL = active management of third stage of labor; NASG = Non-pneumatic anti-shock garment
Uterine Balloon Tamponade Learning Resource Package
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When will you use UBT in your facility?
Uterine balloon tamponade (UBT) is
one step in a comprehensive PPH
management plan
Always follow national guidelines and
integrate UBT into care when
appropriate
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Uterine Balloon Tamponade Learning Resource Package
Evolution of Uterine Tamponade
1983
Goldrath
used a Foley
catheter to
stop uterine
bleeding
1992
Bakri used
balloon
tamponade for
PPH
Uterine Balloon Tamponade Learning Resource Package
2001
First study
published
on Bakri balloon
2003
Akhter used
condom for
uterine
tamponade
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Mechanism of Action
1. Increased intrauterine pressure, which
becomes superior to capillary blood vessels
pressure
2. Compression of the bleeding site by the inflated
condom
3. Contractions induced by the presence of the
condom inside the uterus (due to the release of
prostaglandins?)
Source: Keski-Nisula L, Heiskanen P, Heinonen S. 2011. Extra-membraneous pregnancy, prolonged ruptured
membranes and circumvallate placenta. Acta Obstetrica et Gynecologica Scandinavica. 90:1170‒1171.
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Uterine Balloon Tamponade Learning Resource Package
Indications
 Postpartum hemorrhage due to atony, when
uterine massage, uterotonics, and bimanual
compression have failed to stop the bleeding
 When temporary control of PPH is needed
before referring the client to a higher level of
care
Uterine Balloon Tamponade Learning Resource Package
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Contraindications
 Arterial bleeding requiring surgical exploration or
angiographic embolization
 Cases requiring hysterectomy
 Untreated uterine anomaly, cervical or uterine cancer
 Uterine infections
 Disseminated intravascular coagulation
 A surgical site that would prohibit the device from
effectively controlling bleeding
 Lack of trained provider
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Uterine Balloon Tamponade Learning Resource Package
Uterine Tamponade Kits
High-cost kits
 Readily available
 Different types of balloon
 Single use
Uterine Balloon Tamponade Learning Resource Package
Low-cost kits
 Based on the use of a
condom
 Components available in
most health facilities
 Must be assembled
17
High-Cost Balloon Tamponade Devices
Sengstaken–Blakemore
$220 for two devices
Bakri
$250 per device
BT-CATH
$200 per device
Rusch hydrostatic
$77 per device
(quoted £50)
Source: Georgiou C. 2009. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG. 116:748–757.
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Uterine Balloon Tamponade Learning Resource Package
Low-Cost Balloon Tamponade Devices
Akhter’s CT unit ≤ $5
Uterine Balloon Tamponade Learning Resource Package
Massachusetts General
Hospital (MGH) CT unit < $5
19
Balloon Tamponade Kit
made with supplies that are already available in most health centers
IV set
Sims
Speculum
Ring
forceps
Condom
Infusion
bag with
saline
Foley
catheter
Suture
string
20
Uterine Balloon Tamponade Learning Resource Package
Do you have what you need to use UBT in
your facility?
 Do you have all the materials required for the
kit?
 Trained providers?
 Staff who know how to assist?
 System for documentation?
 What happens when supplies run out?
Uterine Balloon Tamponade Learning Resource Package
21
Step 1: Preparation
 Call for help!
 Obtain a UBT kit or assemble elements of the kit.
 Explain to the woman what her condition is and
what you are going to do.
 Administer prophylactic antibiotics: 2 g ampicillin
or 2 g cephalosporin IV.
 Make sure the bladder is empty.
 Make sure the source of bleeding is atony and not
lacerations or retained placenta.
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Uterine Balloon Tamponade Learning Resource Package
Assemble Uterine Balloon Tamponade
 Place the condom over the Foley catheter, leaving a small portion of
the condom beyond the tip of the catheter.
 With sterile suture or string, tie the lower end of the condom snugly
on the Foley catheter.
 Tie should be tight but should not strangulate the catheter and
prevent inflow of water.
Uterine Balloon Tamponade Learning Resource Package
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Step 2: Transvaginal Placement
(after Vaginal Delivery)
 Determine that the uterus is clear of any retained
placental fragments, arterial bleeding, or lacerations.
 Assemble the balloon tamponade.
 Expose the cervical opening with a Sims speculum and
clamp the anterior portion of the cervix with a sponge or
ring forceps.
 Insert the condom attached to the catheter under direct
visual control, and with the aid of forceps, make certain
that the entire condom is inserted past the cervical canal
and internal os.
24
Uterine Balloon Tamponade Learning Resource Package
Step 2: Transvaginal Placement (cont.)
Uterine Balloon Tamponade Learning Resource Package
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Step 3: Inflation
 Inflate UBT by connecting open/outlet end of catheter to
giving set connected to infusion bag.
 Inflate condom with water or saline to about 300–500 mL.
 Clamp catheter when desired volume is achieved and
bleeding is controlled.
 If bleeding is not controlled within
15 minutes of initial inflation of UBT, abandon procedure
and seek surgical intervention immediately.
26
Uterine Balloon Tamponade Learning Resource Package
Step 3: Inflation (cont.)
 Maintain in situ for 12–24 hours if
bleeding is controlled and client is
stable.
 Continue to monitor client closely;
resuscitate and/or treat shock
necessary.
 Place a pen mark on the abdomen
at the level of the uterine fundus.
Monitor for rise in fundus (sign of
concealed bleeding).
 Continue uterotonic infusion for
6–8 hours.
Uterine Balloon Tamponade Learning Resource Package
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Step 3: Inflation (cont.)
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Uterine Balloon Tamponade Learning Resource Package
Placement during Cesarean Delivery:
Transabdominal Placement
 Determine that the uterus is clear of any retained
placental fragments, arterial bleeding, or
lacerations.
 Determine uterine volume by intraoperative
direct examination.
 From above (via access of the cesarean
incision), put the condom partly in the uterine
cavity.
Uterine Balloon Tamponade Learning Resource Package
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Placement during Cesarean Delivery:
Transabdominal Placement (cont.)
 Have an assistant pull the Foley catheter through
the cervix and the vaginal canal and make sure the
condom is entirely in the uterine cavity.
 Close the incision per normal procedure, taking care
to avoid puncturing the condom while suturing.
 Inflate the condom by connecting open/outlet end of
catheter to giving set connected to infusion bag with
saline.
30
Uterine Balloon Tamponade Learning Resource Package
Step 4: Deflation
 When client is stable (after 12–24 hours), slowly deflate
condom by letting out 200 mL of saline every hour.
 Re-inflate to previous level if bleeding reoccurs while
deflating. (Persistent or recurrent bleeding is an
indication to proceed with another treatment option.)
Re-inflate as a temporary measure and reconsider
surgical intervention.
 UBT may be kept in place for up to 24 hours.
Uterine Balloon Tamponade Learning Resource Package
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Step 4: Deflation (cont.)
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Uterine Balloon Tamponade Learning Resource Package
Client Monitoring
 Monitor closely for the next 6 hours.
 The following information should be recorded every
15 minutes for the first 2 hours, then every 30 minutes for the next
2 hours, and then every hour for the next 2 hours:





Blood pressure
Pulse
Urine output
Pallor and active bleeding
Uterine tone
 The device should not be left indwelling for more than 24 hours.
Uterine Balloon Tamponade Learning Resource Package
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Document
Each time a uterine balloon tamponade is placed,
document the following in the client’s record:
 Outcome of placement
 Blood loss before and after UBT placement
 Volume of liquid used to fill the condom
 Time from insertion to cessation of bleeding
 Deflation start time and time of complete removal
 Type of provider placing it—nurse, midwife, or
doctor
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Uterine Balloon Tamponade Learning Resource Package
Practice This Skill and Prepare for
Emergencies
 On-the-job practice:
 Assembly of UBT and insertion using anatomic
models
 Review of staff roles during emergencies
 Prepare facility:
 Assemble kits and store them for easy access during
emergencies
 Have a plan to identify when supplies are low and
ensure that new supplies are acquired
Uterine Balloon Tamponade Learning Resource Package
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Effectiveness of Uterine Balloon Tamponade
 Success rate can reach
97%.
 UBT when successful leads
to a significant reduction in
need for surgery.
 Based on the success rate,
the World Health
Organization is
recommending UBT as a
second line of treatment in
cases where uterotonics
and bimanual compression
fail.
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Uterine Balloon Tamponade Learning Resource Package
Comprehensive PPH Reduction Approach
PROMOTION OF COMPREHENSIVE PACKAGE OF INTERVENTIONS TO
PREVENT AND MANAGE PPH
Education: Birth Planning/Complication Readiness; Promotion of ANC;
Encouragement of Facility Birth with Skilled Birth Attendant
Facility Birth:
• Correct management of
labor and birth, including
partograph
• Routine administration of
uterotonic immediately
after birth (oxytocin
preferred; if not,
misoprostol)
• Uterotonic availability and
quality
• Postpartum vigilance for
PPH
• Proper management of PPH
Uterine Balloon Tamponade Learning Resource Package
Transport:
• Initial dose of
uterotonic
• Use of UBT
• Use of nonpneumatic anti-shock
garment
Home Birth:
• Education about PPH
detection
• Education about use of
misoprostol
• Advance distribution of
misoprostol for selfadministration after birth
• Education about what to do
for continued bleeding
37
In Summary
 UBT treats PPH due to uterine atony when
uterotonics and bimanual compression fail to
stop bleeding.
 It reduces the need for surgical intervention and
blood transfusion and can be used during
transfer.
 UBT should be part of the PPH emergency kit:
sterile gloves, IV infusion bag with saline, IV
giving set, 2 ring forceps, scissors, condom,
Sims speculum, Foley catheter, and suture.
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Uterine Balloon Tamponade Learning Resource Package
In Summary (cont.)
 Before insertion of UBT, make sure the uterus is
clear of any retained placenta or fragments and
no lacerations are present.
 If bleeding is not controlled within 15 minutes of
UBT insertion, seek surgical care immediately.
 Do not use UBT when there is arterial bleeding,
cervical or uterine cancer, danger of uterine
rupture, infections, uterine anomalies, or
disseminated intravascular coagulation.
Uterine Balloon Tamponade Learning Resource Package
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Uterine Balloon Tamponade Learning Resource Package
Checklist: Uterine Balloon Tamponade
(To be used by the Facilitator at the end of the module and for continued practice by the Learner
at the facility)
*Some tasks can be done by a trained assistant. These tasks include gathering equipment, putting
together the condom tamponade, and connecting the outlet of the Foley catheter to the IV set. Make
sure to practice all steps so that you can perform them independently.
Place a “√” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or
N/O if not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step or task not performed by learner during evaluation by facilitator/teacher
Learner:
Date Observed:
Step/Task
Cases
Preparation
Gather the necessary equipment. All instruments and materials should
be sterile or high-level disinfected. Connect infusion bag that will be
used to inflate the condom to the IV catheter.
Tell the woman (and her support person) what is going to be done,
listen to her, and respond attentively to her questions and concerns.
Provide continual emotional support and reassurance, as feasible.
Ensure that her bladder is empty. Catheterize the bladder if necessary.
Give prophylactic antibiotics: 2 grams of ampicillin or 2 grams of
cephalosporin IV.
Put on personal protective barriers.
Skill/Activity Performed Satisfactorily
Insertion and Inflation of the Condom
Wash hands and forearms thoroughly and put on high-level disinfected
or sterile surgical gloves (use elbow-length gloves, if available).
Place condom over the Foley catheter leaving a small portion of the
condom beyond the tip of the catheter.
Using sterile suture or string, tie lower end of condom snugly on the Foley
catheter. Tie should be tight enough to prevent leakage of saline solution
but should not strangulate catheter and prevent inflow of water.
Place a Sims speculum along the posterior vaginal wall. Clamp the
anterior portion of the cervix with the sponge or ring forceps. Using
aseptic technique, place the condom end high into uterine cavity, past
the cervical canal and internal os with aid of forceps.
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Step/Task
Cases
Connect the outlet of the Foley catheter to IV set, which has been
connected to the infusion bag. Inflate condom with saline to about
300–500 mL.
Skill/Activity Performed Satisfactorily
Continued Monitoring and Treatment
If bleeding is not controlled within 15 minutes of initial insertion of
condom tamponade, abandon procedure and seek surgical
intervention immediately. UBT should remain in place until surgical
intervention is available.
Continue uteronic infusion: 20 IU oxytocin in 1,000 mL saline solution, 60
drops/minute for 6–8 hours to prevent uterine atony.
Continue to monitor client closely every 15 minutes for the first 2 hours
(vital signs, urine output, uterine tone, vaginal bleeding). Resuscitate
and/or treat shock necessary. Hours 3–4, monitor every 30 minutes.
Hours 5–6, monitor every hour.
Place a pen mark on the abdomen at the level of the uterine fundus.
Any increase in uterine size above this mark. Along with changes in
pulse, blood pressure, respiratory rate, and urine output despite no overt
vaginal bleeding, suggests that blood is accumulating within the uterine
cavity above the balloon.
Maintain in situ for 12–24 hours if bleeding controlled and client is stable.
Mobilize transport to higher-level facility if surgical management is not
available at that site.
Skill/Activity Performed Satisfactorily
Post-Procedure Tasks
Remove the personal protective equipment and the gloves and discard
the gloves in a leakproof container or plastic bag.
Wash hands and forearms thoroughly.
Skill/Activity Performed Satisfactorily
Deflation
When no further bleeding has occurred and the client has been stable
for at least 12 hours, slowly deflate condom by letting out 200 mL of
saline every hour.
Re-inflate to previous level if bleeding reoccurs while deflating. Consider
surgical intervention.
Skill/Activity Performed Satisfactorily
Documentation
Document blood loss before and after uterine balloon tamponade
placement.
Document time of condom tamponade insertion and amount of fluid
inserted into the balloon.
Document deflation start time and time of complete removal of uterine
balloon tamponade.
Skill/Activity Performed Satisfactorily
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Documentation Checklist
Step/Task
Cases
Make sure to include in the medical record
Cadre of health care provider placing balloon
Prophylactic antibiotics given and dose
Estimated blood loss before condom tamponade (mL)
Volume of saline solution used to inflate the condom (mL)
Time from insertion and inflation of UBT to cessation of bleeding (minutes)
Whether or not client was referred to a higher-level facility after cessation of
bleeding
Name of facility to which client was transported
Length of time tamponade was in place (hours)
Whether or not there was reoccurrence of hemorrhage after deflation
Skill/Activity Performed Satisfactorily
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Uterine Balloon Tamponade Workshop Knowledge
Assessment
Instructions: Circle the letter of the single best answer to each question.
PPH
Which statement about postpartum hemorrhage (PPH) is correct?
a. PPH is the leading cause of maternal death in Africa and Asia
b. Atony is the most frequent cause of PPH
c. In case of PPH, if appropriate management is not undertaken, the mother may die within
2 hours
d. All of the above
Indications and contraindications
Uterine balloon tamponade (UBT):
a. Is indicated for uterine atony as the first-line of treatment for PPH
b. Can be used to buy time while referring the patient for advanced care
c. Should be done prior to bimanual compression as a treatment for PPH
d. Is indicated for PPH caused by cervical or vaginal lacerations and heavy bleeding caused by
disseminated intravascular coagulation
Contraindications for UBT include all the following except:
a. Lack of a trained provider
b. Disseminated intravascular coagulation
c. Cases requiring surgery
d. Uterine atony after failure of uterine massage, bimanual compression, and administration of
uterotonics
UBT devices
There are two types of UBT devices:
a. High-cost and low-cost devices
b. Homemade and single-use devices
c. Single-use and multiple-use devices
d. Multiple-use and self-administered devices
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All of the following are true about low-cost UBT devices except:
a. They can be assembled in most health centers in low-resource settings
b. They need a high degree of expertise to be assembled
c. They can be assembled by most health care workers
d. They can be assembled with a condom, Foley catheter, suture string, IV set, and saline
infusion bag
Low-cost UBT devices:
a. Are not as effective as the other devices
b. Are as effective as high-cost devices
c. Can be used multiple times after sterilization
d. All of the above
Preparation
The preparation for placement of the UBT includes:
a. Ensuring that the mother’s bladder is full so that the balloon tamponade works effectively
b. Discouraging the mother from asking questions to facilitate efficient placement of the device
c. Administering broad-spectrum antibiotics before the procedure and ensuring that the
mother’s bladder is empty
d. Ensuring that the source of bleeding is vaginal or cervical lacerations
Insertion
When inserting the UBT:
a. Visualize the cervix with a Sims speculum and ensure that the condom is inserted deeply into
the uterus with the aid of forceps
b. Place the Sims speculum along the anterior vaginal wall
c. For quick placement, insert the UBT manually as the cervix is wide open immediately after
delivery
d. Inflate the condom prior to insertion
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Inflation
All of the following are true about inflation of the condom except:
a. The recommended amount of saline solution is 300–500 mL
b. Inflation is best achieved by using a 60-mL syringe
c. An infusion bag connected to a giving set is the best way to fill the condom
d. The catheter should be clamped when desired volume is achieved and bleeding is controlled
Deflation
When bleeding is controlled by the UBT, it will be left in place for several hours. Which
statement about deflation is correct?
a. Deflate the UBT after the client has been stable for 6 hours by letting out 200 mL of saline
every 30 minutes
b. Deflate the UBT after the client has been stable for at least 12 hours by letting out 200 mL
of saline every hour
c. Deflate the UBT as soon as bleeding is stable by letting out 100 mL of saline every hour
d. Deflate the UBT after the client has been stable for at least 12 hours by slowly letting out all
of the saline over 10 minutes
Monitoring the patient
Which statement about monitoring the client is correct?
a. A client with a UBT should be monitored every 15 minutes for the first 2 hours
b. Monitoring includes vital signs, vaginal bleeding, and uterus tone
c. Failure of the procedure is indicated by continuation of the bleeding 15 minutes after the
UBT is in place
d. All of the above
Effectiveness
UBT success:
a. Is based on stopping the bleeding 5–15 minutes after the inflation of the condom
b. Is about 50–60% effective when a proper technique is used
c. Is most likely when UBT is used as the first-line treatment for PPH
d. Is based on the expulsion of retained products of placenta 5–15 minutes after the inflation of
the condom
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Referral
A mother who has benefited from UBT:
a. Should be referred if bleeding has not stopped within 15 minutes
b. Should be referred if bleeding has stopped and she is in a primary health center
c. Should be given a completed referral form whenever referred to a higher-level facility
d. All of the above
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Uterine Balloon Tamponade Workshop Knowledge
Assessment
Instructions: Circle the letter of the single best answer to each question.
PPH
Which statement about postpartum hemorrhage (PPH) is correct?
a. PPH is the leading cause of maternal death in Africa and Asia
b. Atony is the most frequent cause of PPH
c. In case of PPH, if appropriate management is not undertaken, the mother may die within
2 hours
d. All of the above
Answer: D
PPH is the most common direct cause of maternal death worldwide (WHO 2012). Failure of the uterus to
adequately contract after childbirth (uterine atony) and thus prevent bleeding is the leading cause of
PPH. PPH should initially be addressed with fundal massage and administration of uterotonics (Georgiou
2009). PPH is treatable but requires rapid recognition and care to prevent life-threatening
consequences. If untreated, PPH can cause death within 2 hours (Walvekar et al. 2012).
Indications and contraindications
Uterine balloon tamponade (UBT):
a. Is indicated for uterine atony as the first-line of treatment for PPH
b. Can be used to buy time while referring the patient for advanced care
c. Should be done prior to bimanual compression as a treatment for PPH
d. Is indicated for PPH caused by cervical or vaginal lacerations and heavy bleeding caused by
disseminated intravascular coagulation
Answer: B
Uterine balloon tamponade (UBT) is not a first-line treatment for PPH. UBT is one intervention in a
comprehensive management plan for PPH. Prevention of PPH with active management of the third stage
of labor (AMTSL) by a skilled birth attendant and birth preparedness and complication readiness
counseling are the standard of care for all women. If PPH is caused by uterine atony, and uterine
massage, bimanual compression, and uterotonics fail to resolve it, UBT should be considered as an
intervention that can reduce bleeding and may allow time to transport the client to a higher level of
care. (Gurung et al. 2014; WHO 2012). Disseminated intravascular coagulation is a contraindication to
UBT use because it is not an appropriate treatment for that condition. The first-line management for
vaginal and cervical lacerations is repair of the lacerations to control bleeding.
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Contraindications for UBT include all the following except:
a. Lack of a trained provider
b. Disseminated intravascular coagulation
c. Cases requiring surgery
d. Uterine atony after failure of uterine massage, bimanual compression, and administration of
uterotonics
Answer: D
Contraindications for UBT include disseminated intravascular coagulation, arterial bleeding requiring
surgical exploration or angiographic embolization, cases requiring hysterectomy, untreated uterine
anomaly, a surgical site that would prohibit the device from effectively controlling bleeding, and lack of
a trained provider. Uterine atony after failure of uterine massage, bimanual compression, and
administration of uterotonics is an indication for UBT (Gurung et al. 2014).
UBT devices
There are two types of UBT devices:
a. High-cost and low-cost devices
b. Homemade and single-use devices
c. Single-use and multiple-use devices
d. Multiple-use and self-administered devices
Answer: A
There are many different types of UBT devices. These include the Bakri balloon, Foley catheter,
Sengstaken-Blakemore tube, Rusch balloon, and condom catheter. All devices are for single use and
vary in cost from less than $5 for a condom catheter to $250 for a Bakri balloon (Georgiou 2009).
All of the following are true about low-cost UBT devices except:
a. They can be assembled in most health centers in low-resource settings
b. They need a high degree of expertise to be assembled
c. They can be assembled by most health care workers
d. They can be assembled with a condom, Foley catheter, suture string, IV set, and saline
infusion bag
Answer: B
Low-cost UBT devices can be assembled by health care workers in most health centers in low-resource
settings. The required equipment is usually already available in the health center and consists of a
condom, Foley catheter, suture string, IV set, and IV infusion bag. To place the device, a Sims speculum
and two ring forceps are also needed. With training, health care workers can assemble the device
(Gurung et al. 2013; Tindell et al. 2013).
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Low-cost UBT devices:
a. Are not as effective as the other devices
b. Are as effective as high-cost devices
c. Can be used multiple times after sterilization
d. All of the above
Answer: B
Low-cost UBT devices have been found to be as effective as high-cost devices. Research indicates that
the low-cost UBT is a good alternative to standard balloon tamponade in low-income countries. A
systematic review of numerous studies of UBT found that it successfully treated 186 out of 193 cases in
which it was used. UBTs are single-use items that should be discarded after use (Georgiou 2009; Tindell
et al. 2013).
Preparation
The preparation for placement of the UBT includes:
a. Ensuring that the mother’s bladder is full so that the balloon tamponade works effectively
b. Discouraging the mother from asking questions to facilitate efficient placement of the device
c. Administering broad-spectrum antibiotics before the procedure and ensuring that the
mother’s bladder is empty
d. Ensuring that the source of bleeding is vaginal or cervical lacerations
Answer: C
In preparation for placement of the UBT, you want to make sure that the source of bleeding is atony and
not lacerations or retained placenta. The woman’s bladder should be empty. Catheterize if necessary
and administer prophylactic antibiotics: ampicillin 2 gm IV or cephalosporin 2 gm IV. Other key steps in
preparation for inserting a UBT are to explain the procedure to the woman and her support person, ask
her if she has any questions or concerns, listen and respond attentively, and provide continual
emotional support and reassurance.
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Insertion
When inserting the UBT:
a. Visualize the cervix with a Sims speculum and ensure that the condom is inserted deeply into
the uterus with the aid of forceps
b. Place the Sims speculum along the anterior vaginal wall
c. For quick placement, insert the UBT manually as the cervix is wide open immediately after
delivery
d. Inflate the condom prior to insertion
Answer: A
When inserting the UBT, it is important to use a technique that facilitates adequate visualization of the
cervix such that the UBT is placed correctly and the risk of infection is minimized. Therefore, the cervix is
initially visualized with a Sims speculum. The anterior portion of the cervix is then clamped with a sponge
or ring forceps. Holding the cervix in place, push the condom catheter high into the uterine cavity, past
the cervical canal and internal os, with the aid of forceps to maintain aseptic technique (Rathore et al.
2012).
Inflation
All of the following are true about inflation of the condom except:
a. The recommended amount of saline solution is 300–500 mL
b. Inflation is best achieved by using a 60-mL syringe
c. An infusion bag connected to a giving set is the best way to fill the condom
d. The catheter should be clamped when desired volume is achieved and bleeding is controlled
Answer: B
After placement, the UBT should be filled with 300–500 mL of saline solution. To do this, the outlet of the
Foley catheter should be connected to an IV set and infusion bag. Once the UBT is in place, the saline
should flow into the condom through the Foley catheter. An IV infusion bag is preferred over a 60-mL
syringe because it allows for a faster infusion of saline and can facilitate prompt management of the
PPH. If bleeding is not controlled within 15 minutes of initial inflation of UBT, abandon the procedure and
seek surgical intervention immediately (Akhter et al. 2003; Thapa et al. 2010).
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Deflation
When bleeding is controlled by the UBT, it will be left in place for several hours. Which
statement about deflation is correct?
a. Deflate the UBT after the client has been stable for 6 hours by letting out 200 mL of saline
every 30 minutes
b. Deflate the UBT after the client has been stable for at least 12 hours by letting out 200 mL
of saline every hour
c. Deflate the UBT as soon as bleeding is stable by letting out 100 mL of saline every hour
d. Deflate the UBT after the client has been stable for at least 12 hours by slowly letting out all
of the saline over 10 minutes
Answer: B
The UBT should be left in place for at least 12 hours if bleeding is controlled and the client is stable. If
surgical management is not available at your facility, transport should be arranged to a higher-level
facility for all clients requiring UBT placement. While the UBT is in place, the client should continue to
receive uterotonic infusions of 20 IU oxytocin in 1,000 mL saline solution at 60 drops/minute for the next
6–8 hours. Continue to monitor the client closely for the next 6 hours: every 15 minutes for the first 2
hours, then every 30 minutes for the 3rd and 4th hours, and then hourly for the 5th and 6th hours. Check
vital signs, urine output, uterine tone, and vaginal bleeding during each assessment. After the client has
been stable for at least 12 hours, deflate the condom by letting out 200 mL of saline every hour. If
bleeding restarts during deflation, re-inflate to the previous level.
Monitoring the patient
Which statement about monitoring the client is correct?
a. A client with a UBT should be monitored every 15 minutes for the first 2 hours
b. Monitoring includes vital signs, vaginal bleeding, and uterus tone
c. Failure of the procedure is indicated by continuation of the bleeding 15 minutes after the
UBT is in place
d. All of the above
Answer: D
While the UBT is in place, continue to monitor the client closely: every 15 minutes for the first 2 hours,
checking vital signs, urine output, uterine tone, and vaginal bleeding. After the initial 2 hours, vital signs,
urine output, uterine tone, and vaginal bleeding should be evaluated every hour. If bleeding is not
controlled within 15 minutes of initial insertion of the UBT, abandon the procedure and seek surgical
intervention immediately. Keep the UBT in place until you are able to intervene surgically.
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Effectiveness
UBT success:
a. Is based on stopping the bleeding 5–15 minutes after the inflation of the condom
b. Is about 50–60% effective when a proper technique is used
c. Is most likely when UBT is used as the first-line treatment for PPH
d. Is based on the expulsion of retained products of placenta 5–15 minutes after the inflation of
the condom
Answer: A
UBT placement is considered successful when bleeding stops within 5–15 minutes of inflation of the
condom. UBT success rates range from 80–90% when UBT is used with proper technique. UBT is
considered a second-line treatment for PPH. The first step in PPH caused by uterine atony is medical
treatment with uterotonics, uterine massage, and bimanual compression. If UBT fails to stop the
bleeding, surgical management should be the next step. UBT is a treatment for uterine atony; it will not
lead to expulsion of retained products of placenta.
Referral
A mother who has benefited from UBT:
a. Should be referred if bleeding has not stopped within 15 minutes
b. Should be referred if bleeding has stopped and she is in a primary health center
c. Should be given a completed referral form whenever referred to a higher-level facility
d. All of the above
Answer: D
Referral to a higher-level facility is always indicated if the client is in a primary health center. If bleeding
does not stop within 15 minutes, the referral process must be expedited immediately. Whenever referral
occurs, a referral form should be completed—with details about amount of blood loss, medication and
treatments given, and a timeline for birth, delivery of placenta, initiation of heavy bleeding, and steps
taken to manage the hemorrhage.
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Case Study/Role Play 1: Management of PPH without
UPT
You are a health care provider in the labor ward of a health center that is located 20 kilometers away
from the district hospital. Ama arrives at your ward in active labor at 1:00 a.m. She is accompanied by
her husband. This is her fourth child. You encourage Ama to move freely during labor. At 1:30 a.m.,
Ama has the urge to push, and when you assess her, you find that she is completely dilated and the
fetal heart rate is 136 beats/minute. She chooses to squat during second stage and at 1:45 a.m. she gives
birth to a live baby girl who cries spontaneously. You assist Ama to the cot and place the newborn on
her chest with a cloth wrapped around both of them. Her husband smiles and kisses the baby.
What do you do next?
After performing AMTSL, you check the placenta and find that it is complete, you palpate the
uterus and find it is well-contracted, and you do not see any perineal or vaginal tears. When you
check Ama 15 minutes later, you notice a large gush of blood with clots followed by steady,
moderate to heavy bleeding. Her uterus is soft and she denies any pain. Heavy bleeding continues
after clots are removed.
What do you do next?
You diagnose her with PPH due to uterine atony. Despite your efforts, her uterus remains atonic
and the bleeding continues. Her placenta is intact and she doesn’t have any lacerations.
What are your options? (UBT is not available at your facility.)
What is the likely outcome?
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Anwers to Case Study/Role Play 1: Management of
PPH without UPT
You are a health care provider in the labor ward of a health center that is located 20 kilometers away
from the district hospital. Ama arrives at your ward in active labor at 1:00 a.m. She is accompanied by
her husband. This is her fourth child. You encourage Ama to move freely during labor. At 1:30 a.m.,
Ama has the urge to push, and when you assess her, you find that she is completely dilated and the
fetal heart rate is 136 beats/minute. She chooses to squat during second stage and at 1:45 a.m. she gives
birth to a live baby girl who cries spontaneously. You assist Ama to the cot and place the newborn on
her chest with a cloth wrapped around both of them. Her husband smiles and kisses the baby.
What do you do next?
Active management of third stage of labor (AMTSL): 1) within 1 minute of delivery of the baby, palpate
the abdomen to rule out the presence of an additional baby(s); 2) administer a uterotonic medication
within 1 minute after the birth of the baby (oxytocin 10 IU IM is the uterotonic drug of choice); 3)
perform controlled cord traction; and 4) verify uterine tone and, if the uterus is not well-contracted,
perform uterine massage.
After performing AMTSL, you check the placenta and find that it is complete, you palpate the
uterus and find it is well-contracted, and you do not see any perineal or vaginal tears. When you
check Ama 15 minutes later, you notice a large gush of blood with clots followed by steady,
moderate to heavy bleeding. Her uterus is soft and she denies any pain. Heavy bleeding continues
after clots are removed.
What do you do next?
Conduct a rapid assessment, treat shock if detected, check uterine tone and massage if not wellcontracted/soft, give oxytocin 10 IU IM (or another uterotonic drug) or IV if an IV is in place, start an IV
infusion if not in place and infuse isotonic crystalloids, check the bladder and help the woman empty if
distended (catheterize only if she can’t pass urine), recheck the placenta, recheck for lacerations, decide on
diagnosis, and manage per diagnosis.
You diagnose her with PPH due to uterine atony. Despite your efforts, her uterus remains atonic
and the bleeding continues. Her placenta is intact and she doesn’t have any lacerations.
What are your options? (UBT is not available at your facility.)
Additional uterotonic drugs or different route (IV vs. IM), bimanual uterine compression, aortic
compression, non-pneumatic anti-shock garment (NASG)
Transfer to higher level of care.
What is the likely outcome?
Surgical intervention/death
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Case Study/Role Play 2—Management of PPH with
UBT
You are a health care provider at the local health center. It is 7:00 a.m. and you have just arrived at
work. You assume care of Thokozani, who delivered a healthy baby boy at 5:00 a.m. This is her first
child and he is breastfeeding well. She had a second-degree perineal laceration that was repaired and
her bleeding has been stable. Her placenta delivered spontaneously with AMTSL and was intact. She
is accompanied by her sister and you are waiting for her husband to arrive to do postpartum family
planning counseling before discharging her home. Her vital signs are stable. You are also caring for a
woman who is in active labor. Suddenly her sister runs over to you and says, “Thokozani is bleeding
too much and she feels faint!”
What do you do?
Thokozani’s uterus is soft and you find that the cloth on her bed is soaked with blood. You massage
her fundus and two baseball-size clots come out, followed by more blood. When you rechecked the
placenta, you find it was complete. The laceration is well-repaired and there does not appear to be
bleeding from the laceration; her bladder is not distended. You administer misoprostol 800 mcg
sublingually. She appears faint and her blood pressure is 90/50 and her pulse is 120. You attempt
bimanual compression. The uterotonics and bimanual compression have not stopped the bleeding
and her uterus is still not firm. You call for help.
What do you do?
Under what circumstances would you not place a UBT?
UBT is in place and has been inflated with 500 mL of saline. How long should it take for bleeding
to stop? What should you do if bleeding doesn’t stop in that time frame?
Bleeding stops in 10 minutes. How should you continue to monitor Thokozani? How long should
the UBT stay in place?
Twelve hours pass and no bleeding is noted. What is your next step?
As you start deflate the condom, bleeding resumes. What do you do?
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Answers to Case Study/Role Play 2—Management of
PPH with UBT
You are a health care provider at the local health center. It is 7:00 a.m. and you have just arrived at
work. You assume care of Thokozani, who delivered a healthy baby boy at 5:00 a.m. This is her first
child and he is breastfeeding well. She had a second-degree perineal laceration that was repaired and
her bleeding has been stable. Her placenta delivered spontaneously with AMTSL and was intact. She
is accompanied by her sister and you are waiting for her husband to arrive to do postpartum family
planning counseling before discharging her home. Her vital signs are stable. You are also caring for a
woman who is in active labor. Suddenly her sister runs over to you and says, “Thokozani is bleeding
too much and she feels faint!”
What do you do?
Conduct a rapid assessment, treat shock if detected, check uterine tone and massage if not wellcontracted/soft, give oxytocin 10 IU IM (or another uterotonic drug) or IV if an IV is in place, start an IV
infusion if not in place and infuse isotonic crystalloids, check the bladder and help the woman empty if
distended (catheterize only if she can’t urinate), recheck the placenta, recheck for lacerations, decide on
diagnosis, and manage per diagnosis.
Thokozani’s uterus is soft and you find that the cloth on her bed is soaked with blood. You massage
her fundus and two baseball-size clots come out, followed by more blood. When you rechecked the
placenta, you find it was complete. The laceration is well-repaired and there does not appear to be
bleeding from the laceration; her bladder is not distended. You administer misoprostol 800 mcg
sublingually. She appears faint and her blood pressure is 90/50 and her pulse is 120. You attempt
bimanual compression. The uterotonics and bimanual compression have not stopped the bleeding
and her uterus is still not firm. You call for help.
What do you do?
Place a UBT (learners should go through the steps of performing UBT according to the checklist) and
monitor continuously.
Under what circumstances would you not place a UBT?
In postpartum patients allergic to any component of the device, and in clinical situations where tamponade
is unlikely to be effective (e.g., bleeding from pelvic vessels or cervical or vaginal trauma; uterine
abnormalities that prevent effective balloon tamponade; suspected uterine rupture; cervical cancer; and
purulent infection of the vagina, cervix, or uterus).
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UBT is in place and has been inflated with 500 mL of saline. How long should it take for bleeding
to stop? What should you do if bleeding doesn’t stop in that time frame?
If bleeding does not stop within 15 minutes, proceed to surgical intervention Keep the UBT in place until
surgical intervention is possible.
Bleeding stops in 10 minutes. How should you continue to monitor Thokozani? How long should
the UBT stay in place?
Answers should follow guidance in the checklist.
Continue to monitor the client closely every 15 minutes for the first 2 hours (vital signs, urine output,
uterine tone, vaginal bleeding). Resuscitate and/or treat shock necessary. Hours 3–4, monitor every
30 minutes. Hours 5–6, monitor every hour.
Place a pen mark on the abdomen at the level of the uterine fundus. Along with changes in pulse, blood
pressure, respiratory rate, and urine output despite no overt vaginal bleeding, any increase in uterine size
above this mark suggests that blood is accumulating within the uterine cavity above the balloon.
Maintain in situ for 12–24 hours if bleeding is controlled and client is stable. Mobilize transport to a
higher-level facility if surgical management is not available at that site.
Continue uteronic infusion: 20 IU oxytocin in 1,000 mL saline solution, 60 drops/minute for 6–8 hours
to prevent uterine atony.
Twelve hours pass and no bleeding is noted. What is your next step?
When no further bleeding has occurred and the client has been stable for at least 12 hours, slowly deflate
the condom by letting out 200 mL of saline every hour.
As you start deflate the condom, bleeding resumes. What do you do?
Re-inflate the UBT and transfer the woman to higher level of care.
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References
Akhter S, Begum MR, Kabir Z, Rashid M, Laila TR, Zabeen F. 2003. Use of a condom to control
massive postpartum haemorrhage. MedGen-Med. 5:38.
Bakri YN. 1992. Uterine tamponade drain for hemorrhage secondary to placenta previa-accreta.
IJGO. 37(4):302–303.
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Uterine Balloon Tamponade Learning Resource Package