Uterine Incision Extensions

Uterine incision extensions
Module by: Tina Gao.

Risk factors

  • Arrest of the first or second stage
  • Fetal malposition (e.g. OP, asynclitic)
  • Macrosomia
  • Failed forceps or vacuum delivery
  • Chorioamnionitis
  • Abnormal fetal heart rate
  • Prematurity
  • Factors cluster into the following categories of risk factors for lateral extension of a transverse uterine incision:
    • Difficulty of extraction
    • Urgency of delivery
    • Poorly developed lower segment

Prevention

  • In cases predisposed to an “inadequate” lower segment, the best prevention is to avoid making a transverse lower segment incision. It is much safer to make a lower segment, vertical incision that can be extended into the upper segment if necessary.
  • In the case of second stage arrest cesarean sections, consider moving your incision site 2 fingerbreadths cephalad.
  • To expand an incision, do so bluntly in a cephalocaudal direction, or extend in the midline making an inverted T incision.
  • With a narrower lower segment, use bandage scissors.

Classification

Classification by location:

  • Myometrium 
  • Broad ligament (containing uterine vessels)
  • Cervix/Vagina

Consequences

Extension of lateral uterine incisions increases maternal morbidity via:

  • Higher risk of intraoperative hemorrhage (>1.2 L)
  • Decline in post-operative hemoglobin level
  • Intra-operative evaluation for urinary tract injuries
  • Longer operative time

Setup to Manage Uterine Incision Extension

Exposure

  • Exteriorize the uterus
  • Visualize angles of incision extensions and retracted vessels
    • Inform anesthesiologist
    • Keep wet sponge on fundus

Additional tools

  • Surgical assist
  • Retractors
  • Green-armytage forceps
  • Sponges
  • 0-vicryl
  • Consider vicryl on an “SH” needle for suturing in broad ligament or through myometrium

Uterine Artery Injury

Presentation

  • Retroperitoneal hematoma during cesarean section.

Management

  • O-Leary Stitch
    • Pass a suture at the level of the incision, through the lateral aspect of the lower uterine segment into the myometrium
    • Pass the suture back through the avascular broad ligament lateral to the uterine vessels

Postoperative Care

  • If intraoperative blood loss was significant:
    • Trend hemoglobin
    • If suspecting a GI/urinary injury, start antibiotics (Ancef/Flagyl)
  • If extension injured the ureter or bladder, see module 4.4.
    • Leave foley in situ
    • Consider cystoscopy or CT IVP

Uterine incision extensions into the upper segment are contraindications to TOLAC. They also predispose the patient to abnormal placentation in future pregnancies.

References

  1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS. Williams Obstetrics. 24th ed.; 2010.
  2. Field A, Halood R. complications of caesarean section. The Obstetrician & Gynaecologist. 2016; 18:265-72
  3. Belfort MA. Postpartum hemorrhage: Management approaches requiring laparotomy. Uptodate, Nov 14, 2019
  4. O’Leary JL, O’Leary JA. Uterine artery ligation in the control of intractable postpartum hemorrhage. Am J Obstet Gynecol 1966; 94:920.
  5. O’Leary JA. Uterine artery ligation in the control of postcesarean hemorrhage. J Reprod Med 1995; 40:189.
  6. Goldfarb I, Henry D, Dumont O, Barth W. Inadvertent hysterotomy extension at cesarean delivery and risk of uterine rupture in the next pregnancy. American Journal of Obstetrics & Gynecology 2011 (poster)
  7. Giugale L, Sakamoto S, Yabes J, Dunn S, Krans E. Unintended hysterotomy extension during caesarean delivery: risk factors and maternal morbidity, March 2018, Journal of Obstetrics and Gynaecology 38(8):1-6 
  8. Urinary tract injury in gynecologic surgery: Identification and management. UpToDate.

Updated on November 3, 2021

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