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Well, of course there's times that we can be silly, kind of have a good time like on the show. And then we all know this, guys, there are times of hyper acuity where the stress level goes up immediately. I mean, I've been there, guys have been out for 25 years. I've seen some stuff. I mean I've practiced nationally and internationally. Man, when things go south, I mean, nothing can can heighten your cortisol level like a problem in the or. Now, specifically with regards to C section, which we're going to talk about here, we're going to get into previa related bleeding. Now, about three weeks ago, we had a scheduled patient. She was on the books first thing in the morning. It was done late preterm. Everybody knew this. It wasn't a surprise. We knew she was a complete previa. She was typed and crossed. Anesthesia was ready to go. She had two large bore IVs. Everybody was ready. And of course section came out just fine. But as we removed the placenta from that lower uterine segment, you know, the blood started wheeling up in that lower uterine segment. And my well meaning, less experienced intern said what you would expect to say. Oh my gosh, there's just so much blood. Hey, there's so much blood. We gotta do something. Yes, we are gonna do something. First, everybody has to be calm. Number one, calm. Because you gotta center yourself. And we addressed this quickly so we made sure that there was no sub occult accreta or per creta. And there wasn't said, hey, we're going to do something here called the concentric purse string suture, which I applied. We actually did two layers, one at the bottom, then one at the top, making sure to not completely occlude the lower uterine segment or the internal cervical loss. So I did and we did not. My finger still went all the way down and I said, okay, we're going to do one and it greatly reduces bleeding. We did a second concentric internal purse string suture and the bleeding was done. Okay. Took about less than 10 minutes to do. We whip stitched this, but you would have thought that I had pulled out a rabbit out of my proverbial magical scrub hat because the intern and the resident were like, what the hell was that? Hot. What? There's an internal purse string suture. Yeah. And we're going to talk about this. So the fact that they hadn't heard of this, and I get this, I mean, it's not like we're going to do this on every section, because it doesn't. You don't need to do this in every section. This is specifically. Guys, I'm going to be very clear. And this is not for acne. Acne is the body that is bleeding. This is the lower uterine segment. Remember that the pathophysiology of previa bleeding at a section is that that anterior lower uterine segment, it's typically the anterior because the posterior wall is thicker. But that anterior lower uterine wall is very thin. And as the placental bed invades into that area, once that placenta is removed, it leaves those venous sinuses open. So B. Lynch is not going to work for something like this. Haman sutures aren't going to work. Piera isn't going to work for this. And even an o' Leary stitch, that's not going to work because that typically hits the anterior branch of the uterines, that leaves the lower uterine area still exposed. So I thought, look, this happened three weeks ago. And, you know, and it worked. And I didn't make that up. Guys, we're going to cover the data here. But the fact that they didn't know about this really got me thinking. Just recently, guys, we did an episode on do it Yourself tools for uterine Atne. Now, that's different. That's for acne. And we talked about the Focus technique where you do a Foley for uterine cavity suction. And there's ways to do this to get on top of the issue. Right. My point is, when we did that episode, somebody listened to that episode in the morning. In the afternoon, they had a case of intractable bleeding, unresponsive to medications. They were about to hyster. And because he listened to that episode, they dropped a Foley in there. They couldn't put anything else in there. Dropped a Foley in there, and it stopped the bleeding connected to wall suction. So I've honestly been inspired and I feel compelled to kind of get these things out there because intraoperative bleeding or postpartum hemorrhage is terrible. So I wanted to Just briefly talk about three lower uterine suture techniques that are in print. Guys. Two of these actually were from January 2026. They've been around for a while, but somebody, you know, officially put them in print. Two of these were January 2026. One of them is the Nausicaa technique. Nausicaa, like in the Odyssey. Okay, Nausicaa. Not Nautica, but Nausicaa. Okay, that. That's the specific way to close uterine segment, the low uterine segment, basically like a compression. That's simple to do. Now, to be very clear, the authors that. And this was out of the a. Now, this Nausicaa suture, this. They use this for nacreta. Okay, this was grade three accreta. And there's a little video that they have in the surgeon's corner. Amazing. Now, remember, I gotta say right here, just to be clear, the standard of care right now for a bleeding accreta is hysterectomy. However, if she's otherwise stable, which is kind of an oxymoron with a placenta accreta, but there are some where the bleeding is kind of controlled, you could perhaps try to do this to try to salvage the uterus. But I want to be very clear, the standard of care for a placenta accreta that is bleeding is a hysterectomy. Houston, just down the road from us, is doing. They're part of a registry where they leave the placenta in and try to do methotrexate. That's. That's got its own set of issues. But right now, the most standard at a placenta placenta accreta center is to remove the uterus. However, maybe if the bleeding is not so bad, then it depends on what kind of grade of the accreta.
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I'm not advocating for it, but these authors did it in small number of pages patients. This is called the nausicaa suture. From AJOG January 2026. Very easy to do. My point is, while I don't advocate using this for nacreta, I totally advocate using this for bleeding previa after you take out the placenta. This is easy, guys. This is. Look, I'm gonna tell you. Let me just read you through the punch real quick. The Nausicaa is nothing more than basically lower uterine segment big interrupted sutures going transversely in a stacked fashion. So. So you kind of compress all that tissue between the enter and the exit point of your suture. I'm going to read you directly their description, but it's nothing more than a big interrupted and then stacking, you know, one or two on top of that to try to compress that lower uterine segment that is a Nausicaa. Then there's another publication that came out January 2026 that also is very easy. This is specifically for previa. Okay? For placenta previa. The title is A modified uterus preserving treatment 4 placenta previa by reconstruction of the Lower Uterine Segment. Well, it's not really that much of a reconstruction. We're not cutting things out. We're not putting graft in there. But it's called the wave technique, guys. Super easy. It's an inundating, basically running transverse suture of the lower uterine segment. Start on one side, go in from out to in, and then up and down, almost like in a baseball kind of stitch, like a wave, indulating wave pattern, and then just tie the ends. That is the wave pattern from January 2026. Then we're going to talk about what I did, which actually goes back to 2022. This was published out of Saudi Arabia, where they did the concentric purse string suture. That's an internal. So hysterotomy is still open. You're seeing the, well, you know, spring up in the lower uterine segment. And then you basically do like an internal cerclage of the lower uterine segment going all the way around to the posterior uterine compartment. And this is through and through, right? So you go all the way through, kind of like a cerclage, and then just cinch that down, making sure. Let me say it right away. Making sure that you don't occlude the internal cervical os or the cervix. All right, so we have two transverse sutures. One is an indulating wave, one is a simple kind of a interrupted. It's called the Nausicaa. But it's done at least, you know, two to three to Kind of stack them one on top of the other and then a concentric purse string. Remember, this is not for atne at knees, for the body. You got to hit the body with either a utertonic agent or something like a B. Lynch. But the lower uterine segment doesn't get included into that. This is in general under the hysterotomy. So I'm giving you three suture techniques, guys. Easy to use and the references are in our show notes. Nausicaa, the concentric purse string, and then the wave compression suture. Keep these in mind next time you have a scheduled preview. Even though it's not a placenta accreta, these can bleed. Fear the previa. Fear the previa. Really fear the accreta. That thing is horrific. However, you should not ignore the risk of previa. Previa has a risk of bleeding, so be on high alert. Two large IVs have blood on standby. Tell anesthesia, tell the patient there's a risk of hysterectomy. Although these novel lower uterine segment techniques that are super easy to do can help control the bleeding, I've got personal experience with two of these. One is a concentric purse string suture that I did recently and I have done my own version of the Nausicaa, which are the basically the large interrupted sutures across the bleeding bed in the lower uterine segment, enter out in at one end of the lower urine segment and then go into out on the other and just compress all that tissue and do that in a stacked format. And I do at least two of those preferentially. Three. One, two, three. Like little staircases. And it works. Of course. You gotta make sure that the bladder is away from your side. I don't make a bladder flap. Just make sure the bladder is away, which it typically is. So two transverse options. One is a wave, one is a straight interrupted, and then the circumferential purse string suture. This is for lower uterine segment bleeding, for previa related bleeding to try to save her uterus. We'll be right back. Podcast Family. I'm happy to share information from one of our corporate sponsors, Perspective Medical. 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So much blood. Yeah, it's scary when there's too much blood. You just want to do something, and that's right. We should be quick to act. Don't dilly dally, but also have control. It's controlled chaos. Controlled chaos. By itself, uncontrolled is very dangerous. Right? So get a grip and then focus. So the first thing I want to talk about very quickly is this circumferential purse string suture thing, just as it sounds. Okay. So this is the placenta has already been removed. Remember, you do have to check, make sure that there's no leftover chunk of placenta down there, that it's not an increta or an accreta or something else. You just gotta make sure per creta is you're pretty much going to see, but make sure that's not a morbidly adherent on the PAS spectrum. So an accreta or an increta. So you can do that just by feeling, make sure there's no placental chunks down there and make sure that the lower uterine segment is intact. What these authors then did is pass the suture from the external to the intra part of the uterine segment as a stay suture, and then ran the suture, as you would think, like a cerclage, around the lower uterine segment, including the posterior part of the uterus, for control. So you pass one suture, you tie both of the loose ends together, and you leave that in, making sure, of course, that there's still room for blood and material to pass because you don't want to occlude the internal cervical os. Okay, so this works. Now, these authors do have a little schematic, you know, kind of show the uterus, a little bladder and the cervical opening, and it is a circumferential suture all the way around. Again, remember this circumferential suture they used for previa There's a separate one for a creda because you got to be more focal in your, in your stitches there to make sure that you close any large open vascular pores that may be affected by the accreta. But in this transverse purse string suture for previa, this seems to, you know, again, it's a small end. I have done it, but it does seem to reduce some of the bleeding. You just have to make sure, of course, that this doesn't take the place of utertonics. You still got to give meds. You got to do what you got to do. I've also injected just on top of the, the bleeding area, make sure it's not into, directly into a vascular space. You know, I've injected 10 units of, of pitresin or pitocin directly into there to try to contract the uterus. That also helps as well. But this is basically a internal lower uterine segment cerclage, making sure that you don't close off the entire cervix. Okay. So as they state in their narrative, they use figure of eight sutures to take care of any big bleeding sites and then basically did a purse string suture circumferentially around the lower uterine segment and then tied it to together. Now this again does pass through the uterine serosa all the way through. You just got to make sure, of course, that the bladder, I have to say it, that the bladder is away and in this case, it did control the bleeding. This is not, you know, guys, these are kind of rescue techniques. It's not like ACOG says this, these are things that surgeons have reported and that, you know, I have found that have worked, knowing, of course, that more data is needed. But this is the concentric pursing structure. There's a nice picture of what that looks like. It's in their figure 3 as I'm looking at it right now in this draft. This is from Saudi Arabia. I've been in Saudi. I was there for, oh my gosh, 15 years ago. I was faculty for a week in Riyadh. I've seen, in Jeddah, I've seen these things work. But back then I was like, this is kind of weird. I don't know if I'm ever going to do that. And then lo and behold, 2022, I see this in print, by the way. These are different authors and who I had worked with. So I'm just throwing this out very quickly just to prepare you. Maybe this is a good journal club. Include these three techniques, these three different articles as as you gotta do something, and it's better than running just straight to a hist where you sacrifice her fertility. Okay, I'm not saying that a hist is wrong. I'm saying try to fight for it, especially if she wants more children, for God's sakes. The Nausicaa suture technique was done in the Gray Journal in January of 2026. It sounds so fancy, the Nausicaa. I didn't know what that was, and I didn't know this was in the Odyssey. Apparently it's named after some character in the Odyssey, because the way that it looks in this kind of compressed stepwise, you know, three little interrupted sutures. It looks kind of like a clamshell, whatever. So if you're familiar with the Odyssey, knock yourself out. Apparently it is a something in that Greek epic, the Odyssey. It's a character. The Nausicaa, short of it, is nothing more than big, interrupted sutures from outside to the internal portion of the uterine cavity and then back out the other end without going to the posterior wall. Okay, you don't want to. You don't want to close. You don't want to put the lower uterine segment together and bridge it together. Even with a concentric person suture, the center is still open. Okay, so this doesn't go from the anterior all the way to the posterior. This is just from the anterior lower uterine segment. And I've. And I've done this. I take two rings, and I grab the lower uterine segment that's bleeding, and I pull it away from the posterior wall. And then still looking at it. Okay, the hysterotomy is still open. Then I take a suture, pass it through one end of the lateral border of the bleeding base, and then go in from the inside to the out, like just a big interrupted. But you want to start low, make sure the bladder is away. Start low and just in the anterior low urine segment. You don't want to get the ureter. Guys, this is not far out, like, by the uterine arteries. This is in the lower uterine segment, you know, median plane. You do one stitch, and then you do one or two above that. So you have this little stacking. And what you have done then is compressed the lateral parts, the thicker part of the malmitrum, back together. And if you're thinking, what about all that tissue in the middle? Hey, the uterus is very forgiving. It's very vascular, like the vagina. It will heal. Okay. So what you end up with is this kind of Lobster tail looking, if you will see the little, the little scales are the successive bites of the low uterine segment as you step ladder that up, typically up to of course, the hysterotomy. Okay, this is just for the lower uterine segment. This is going to do nothing for at me because ATNE typically has to do with bleeding from up on top. All right, now to be very clear, these authors actually say that this procedure should not be done for uterine atony. They did it and they had, they had two patients, two patients, two cases where Nausicaa was used in addition with other methods to try to control uterine atne and it was way too constrictive and they had, they had a little bit of ischemia down there. So this is only to focus the control in the lower uterine segment. If you got uterine at knee, don't do this, do a B. Lynch, do a Heyman, do a Piera, do a B. Lynch, whatever, do a balloon, do the focus technique. But this is just to control bleeding from a previa. Obviously this would work, you would think for an accreta, although, you know, this is very, very small numbers here. The, these authors that published this in January 2026 did do that exactly for a PAS from Placenta Creta spectrum. And I don't feel comfortable with it, but if she's hemodynamically more stable and you can buy some time, why not? Just gotta make sure you don't leave a placenta fragment in there that can go bad or necrose later. So I would do this for a previa. They did do this for placenta accreta spectrum. I think that's a little risky, but as a way to try to control the bleeding, these authors in their very small numbers, it worked. I mean, basically just compressed all those bleeding vessels once they dug out all the attached placenta fragments. Not standard. My point is if you're in a rural place and you already in above your head and you're like, oh my gosh, I didn't realize what's going on here. I thought it was just a previa in an attempt to try to buy you time and decrease bleeding. Once you remove the chunks, as these authors did, the Nausicaa N A U S I C A a Nausicaa procedure is nothing more than basically big interrupted sutures in the low uterine segment to compress all that there may buy you some time. Now, to be very clear, this is not smfm, this is not acog, this is not the Royal College These are independent group of authors that say, hey, this bought us some time and it worked. Okay, so Nausicaa, just to know what's out there, so that we talked about the concentric purse string. This is Nausicaa, basically big interrupted sutures. And then lastly, just to talk about the wave suture, this was published out of the journal Medicine also January 2026, and the title is Wave compression suture. A Modified Uterus preserving Treatment for placenta Previa by reconstruction of the lower uterine segment. Same deal, guys. Just like the Nausicaa, in the lower uterine segment, once you make sure that there's no chunks that are still in there, instead of just doing one right to left or vice versa, you know, interrupted suture, they basically did this as throwing like a baseball stitch, if you will, from the outside to the inside, from the lower uterine segment serosa to the inner basalis layer in an undulating suture. In and out, in and out, in and out. So up on top, then come down to the bottom. Up on top, down to the bottom. So it almost looks like a baseball stitch, if you will. Kind of like how we used to close myomectomies back in the day for seroso closure. Right? Baseball stitch. That's basically what it is. Going from one end of the incision up to the other in an up and down into naming wave. All you're doing once you tie the two ends together is you're compressing all that. So you put the suture through and then you pull on the suture so that it accordions in in the middle, right? So start on the right, you know, kind of go up and down, up and down in a wave like pattern. Then pull out on the left side of the lower uterine segment, medial still, guys, to the uterine arteries and the branches. We're not trying to get into the vessels here. This is just in the tissue. And then pull on both ends so it kind of squishes in the middle and then tie that. Does that make sense in a wave like form? That's all it is. A more fancy Nausicaa. So I've covered three things. Concentric purse string, this wave like form for a previa and then the Nausicaa, which was actually used ballsy in a placenta accreta spectrum review. I'm gonna put these three references in our show notes. I just wanted to prepare you guys. Honestly, totally inspired by the fact that somebody listened to the episode on DIY PPH tools. They did it that afternoon. Evening Guys. And they prevented a hysterectomy. I mean, you talk about divine inspiration and timing. Wow. I mean, I'm telling you guys, I'm not metaphysical. I'm not kind of, you know, out there. But yeah, I think some everything happens for a reason. So this can save somebody's uterus and or life from bleeding. Please listen to this. There are novel techniques just in the lower uterine segment that don't constrict the anterior to the posterior wall. Because this is lower uterine segment, you need that to drain. Even a concentric suture leaves the middle open and you can either drop in a Foley to make sure that it stays open. I just put my finger in to make sure that it's not occluded. There's been different techniques of how you guarantee that it's not closed in that, in that concentric purse string. They dropped a Foley balloon to make sure that it stayed down there. That's fine. Plus you can connect it to wall suction, like with focus. My point is you don't want to compress the anterior of the posterior wall like with a Hayman or a choice suture in the lower uterine segment, because you need that to drain. Okay. So the concentric circle leaves it open. The nausicaa just focuses on the anterior wall, and even the indulating wave is just the anterior wall segment. These seem to have a benefit. I've got experience with two, and I'm just saying it's not going to be the end all, be all. These aren't going to win any Nobel peace prizes because it just needs more data. But this is something that you can consider as a way to buy time. Okay, so, podcast family, I think I've done what I wanted to do. Just a quick review on three potential life saving strategies here for the low uterine segment. Because the uterusual compression stuff won't work. It will not work. That's on top. Meanwhile, the lower uterine segment is bleeding. These are also big causes of concealed vaginal bleeding. And you're like, holy crap, I thought we were done. And then took off the drape that you can't see through and she's, you know, got blood in between her legs, which is why again, it'll plug. Now for one of our corporate sponsors and friend that has a see through drape, especially in previa, this is very helpful. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community, Michael. Now I'm all worked up, brother. Come on, let's take it home.