15/02/2026
AJOG Expert Review in Cesarean: Management of immediate and delayed postpartum hemorrhage with cesarean delivery - Stepwise uterine devascularization and Tsirulnikov's triple ligation
Stepwise uterine devascularization involves 5 steps, each performed only if the previous step fails to stop the hemorrhage within 10 minutes: unilateral and then bilateral ligation of the uterine arteries (1+2), stepwise low ligation of both uterine arteries (3), unilateral and then bilateral ligation of the suspensory ligaments of the ovaries (4+5). We prefer for Tsirulnikov's triple ligation (∗) of the uterine arteries, the round ligament, and the utero-ovarian ligaments because ligation of the suspensory ligaments of the ovaries appears to impair fertility and because in infrequent cases, it is the ovarian arteries and to a lesser extent the round ligament artery that supply most of the placental perfusion, although most often uteroplacental perfusion comes primarily from the uterine arteries. https://ow.ly/RqiB50YfJRm