The second operative procedure

More often than not atonic postpartum hemorrhage tends to stop when the measures described above are applied, although, when this is not possible, the obstetrician needs to consider selective vascular embolization or abdominal surgery in the form of internal iliac artery ligation or abdominal hysterectomy. Maternal age, parity, and number of surviving children all influence the choice to some extent, although the more severe the situation, the more rapidly one has to resort to hysterectomy. If the expertise to perform selective pelvic arterial embolization is available, this may be preferable to internal iliac artery ligation, but such a radiological approach demands both correction of coagulation and a reasonable degree of clinical stability as it may take up to 2 h to be accomplished successfully. For this reason, laparotomy with a view to hysterectomy and/or ligation of the internal iliac arteries is still the usual approach.

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