Definition
Bakri balloon insertion is a procedure used for temporary control or reduction of postpartum hemorrhage when conservative management of uterine bleeding is warranted, after bleeding from genital tract lacerations and retained products of conception has been excluded.
Description of the Bakri balloon
The device consists of a 24-French, 54 cm long silicone catheter that contains a large central lumen and a balloon around it at the proximal end below the tip.
The collapsed balloon is inserted into the uterus. When filled with the fluid, the balloon adapts to the configuration of the uterine cavity to tamponade endometrial bleeding. The central lumen of the catheter allows drainage and aids to monitor ongoing bleeding above the level of the balloon.
Mechanism of action of the ballon in the control of bleeding
The balloon is believed to act by exerting inward to outward pressure against uterine wall resulting in a reduction in persistent capillary and venous bleeding from the endometrium and the myometrium.
Indications for Balloon Use
- For temporary control or reduction of PPH when conservative management bleeding is warranted.
- Failure to cause sustained control of hemorrhage after vaginal delivery, secondary to uterine atony.
- As a temporary measure to decrease hemorrhage while waiting and preparing for other definitive treatment such as often abdominal uterine surgery or uterine artery embolization.
Contraindications
- Cervical cancer.
- Congenital uterine anomaly.
- Uterine cavity distorting pathology (leiomyomas).
- Suspected uterine rupture.
- Purulent infection of vagina, cervix or uterus.
- Allergy to silicone material.
Articles
A tray containing:
- Sponge holding forceps to hold the uterus.
- Bowl with gauze pieces and cotton swabs.
- Sim’s double bladed vaginal speculum to visualize the cervix.
- Bakri balloon.
- Betadine solution to clean the perineum.
- 30 ml syringe with needle to infuse fluid after the Bakri balloon insertion.
- Normal saline to inflate the balloon after insertion.
- Foley’s catheter to catheterize the bladder.
- Urobag to collect the fluid from the Bakri balloon.
- Lubricant jelly to lubricate the Foley’s catheter.
- Mask, gown, cap and plastic apron.
- Sterile gloves.
Procedure
| Nursing Action | Rationale | |
| 1. | Preparation of patient Explain to the patient and family about the PPH which is a medical emergency. Obtain informed consent if patient is alert and if not possible quick verbal consent. | Patient and family understand the emergency situation and the need for intervention without any delay. |
| 2. | Assess the patient’s vital signs, blood loss and causes that need to be excluded such as lacerations, retained fragments of products of conception. | Monitors continuously for signs of shock. |
| 3. | Evaluate pulmonary function, hematocrit level, urine output, uterine tone and general condition. | Monitors continuously for signs of shock. |
| Inserting the balloon transvaginal placement following vaginal delivery | ||
| 4. | Assist the patient to assume a lithotomy position. | Helps to perform the procedure steps under clear view. |
| 5. | Drape the perineum and clean with antiseptic solution. | Avoids chances of getting infection. |
| 6. | Insert the Foley’s catheter and drain the bladder. | Prevents injury to bladder. |
| 7. | Cleanse the vagina and cervix with povidone iodine. | Maintains asepsis. |
| 8. | Inspect the uterine cavity. | Ascertains that uterine cavity is clear. |
| 9. | Grasp the cervix with sponge holding forceps. | Visualizes the internal os. |
| 10. | Insert the deflated Bakri balloon to the uterine cavity under ultrasound guidance, making sure that the entire portion of the balloon passes the cervical canal above the internal os. | Balloon placed in the uterine cavity ready for inflation. |
| 11. | Once correct placement is confirmed, inflate the balloon with sterile saline. Recommended maximum capacity 500 ml. A vaginal pack may be placed in some cases. | Fully inflated balloon holds a maximum of 500 ml to exert pressure on the uterine wall. |
| 12. | After inflating apply gentle traction to the shaft of the balloon and secure the balloon shaft to the patient’s leg or attach to a weight not exceeding 500 g. | This step maximizes the effect of tamponade to the lower uterine segment. |
| Transabdominal placement: Post-caesarean delivery | Insertion of the balloon is performed through the abdominal incision. | |
| 13. | Insert the end of the catheter through the open uterine incision to the cervix and then into the vagina. | The balloon remains intact to serve the purpose. |
| 14. | Close the uterine incision taking special care not to damage the balloon by the suture needle. An alternative approach is to close the uterus first and then to insert the balloon from the vagina and inflate it while the surgeon watches from above. |
Precautions
- Never inflate the balloon with ait, carbon dioxide or any other gas which may cause complications.
- Do not fill the balloon with more than 500 ml. Over inflation may result in the balloon getting displaced into the vagina.
- Place (insert) and leave a Foley’s catheter in the bladder to collect urine and monitor urine output.
- Always confirm proper placement of the balloon using an ultrasound, after the balloon is inflated to the predetermined volume.
Post-procedural care
- Connect the drainage port of the balloon to a collection bag to monitor hemostasis.
- Monitor the patient for signs of increased bleeding and uterine cramping.
- The device should not be left indwelling for more than 24 hours.
- Closely monitor the woman’s bleeding, her fundal height and vital signs.
- After 6 hours and up to 24 hours, if the woman is stable with no vaginal bleeding and her fundal height is at the same level-start to slowly remove the fluid from the balloon.
- Use of antibiotics is recommended to reduce the risk of iatrogenic infection.
- Use of oxytocin or other uterotonic such as methylergometrine and prostaglandins are generally recommended.
Removing the balloon
- The timing of balloon removal should be determined by the clinician upon evaluation of the client, based on the status of control of bleeding and the patient’s condition (maximum indwelling time is 24 hours).
- Release the tension on the shaft and remove any vaginal packing if present.
- Aspirate balloon contents until the balloon is completely empty.
- Gently retract the balloon and discard it.
- Monitor the patient for signs of bleeding.
Advantages
- The shape of the balloon device naturally conforms to the uterine cavity so that effective tamponade is obtained.
- The risk of uterine perforation may be very low.
Complications
Complications related to intrauterine balloon placement are very rare but potentially include perforation of the uterus and cervical trauma due to inflation at an incorrect location.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Annamma Jacob, Manual of Midwifery and Gynaecological Nursing, 4th Edition, 2023, Jaypee Publishers, ISBN: 978-9356961593
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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