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
- Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS. Williams Obstetrics. 24th ed.; 2010.
- Field A, Halood R. complications of caesarean section. The Obstetrician & Gynaecologist. 2016; 18:265-72
- Belfort MA. Postpartum hemorrhage: Management approaches requiring laparotomy. Uptodate, Nov 14, 2019
- O’Leary JL, O’Leary JA. Uterine artery ligation in the control of intractable postpartum hemorrhage. Am J Obstet Gynecol 1966; 94:920.
- O’Leary JA. Uterine artery ligation in the control of postcesarean hemorrhage. J Reprod Med 1995; 40:189.
- 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)
- 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
- Urinary tract injury in gynecologic surgery: Identification and management. UpToDate.