Difficulties with Caesarean section

Many difficulties attend Caesarean section, and many disasters can follow it, so the list below is long. Torrential bleeding when you cut through a placenta praevia can kill a mother. Disasters with the urinary tract are usually the result of very poor technique. Fortunately, most of the others are rare. Some of these many difficulties are only seen in the developing world, where inexpert operators find themselves working under difficult circumstances.

DIFFICULTIES [s8]WITH CAESAREAN SECTION For difficulties with infection, see section 6.8.

DIFFICULTIES [s7]WITH THE INCISION If a patient has had a PREVIOUS CAESAREAN SECTION, dense adhesions may have formed between her uterus and her abdominal wall. They would have been much less likely to have formed, if her omentum had been placed between her uterus and her abdominal wall, at the last operation. Excise the scar in her abdominal wall with an elliptical incision. If the sides of this might be difficult to join up accurately, make some scratch marks across it and align them later.

Open her parietal peritoneum as far as you can. Lift it between haemostats to stretch the adhesions, and divide them with the points of scissors directed at her uterus. If you find a plane of loose connective tissue, free it with a finger or swab. Cut fibrous bands. If dissecting the adhesions is very difficult (unusual), give up and make an upper segment incision.

CAUTION ! (1) Stay close to her uterus to avoid her bladder. (2) Open her uterus between stay sutures (see the story of Wambue in Section 18.9).

If she has had a PREVIOUS CLASSICAL CAESAREAN SECTION, you would probably be wiser to do a lower segment operation this time.

If after a previous operation, HER BLADDER HAS STUCK TO HER LOWER SEGMENT, so that you cannot mobilize it with a finger or swab, incise the peritoneum on her uterus about 2 cm above her bladder. Lift the lower edge in forceps to stretch the adhesions between her bladder and her uterus. Cut them close to her uterus, keeping the points of the scissors directed at it. If this is difficult, give up and make an incision about 3 cm above where her bladder and her uterus have stuck together.

If the baby's HEAD IS STUCK TIGHTLY UNDER AN OLD SCAR IN HER UTERUS, an incision just above it will probably tear as you deliver him. Instead, make a wide V-shaped transverse incision with the point of the ''V' lying across the middle of the scar. This will divide it and reduce the tension. If her uterus does tear, it will do so near the midline, where you can more easily see and repair it.

If the INCISION IN HER UTERUS TEARS as you remove his head, there will probably be a vertical tear in the corner which will run down behind her bladder, often with heavy bleeding. If you are alone with the scrub nurse, ask for an extra assistant.

Identify the edges of the incision and the tear. Mobilize her bladder further downwards if necessary.

If you cannot define the extent of the tear, carefully open her broad ligament by cutting her round ligament. This will let you feel her ureter, so that you can avoid it before you apply any clamps. Now apply Green Armytage forceps to the edges of the tear, and draw its angle into view. Apply direct pressure with a dry pack, find the bleeding vessels, and tie them. Use interrupted sutures in the area of the tear. They will be easier to unpick if you catch her bladder or her ureter by mistake.

CAUTION ! After repairing a tear, check that her ureter has not been caught in a stitch by mistake.

If these measures fail, the only way to control bleeding may be to tie her both uterine arteries (See ''Stop Press') or her internal iliac artery on that side (3.5). If you are not able to repair her uterus, do a subtotal hysterectomy (very rarely needed, 20.12).

DIFFICULTIES [s7]WITH PARTICULAR PRESENTATIONS If her labour is OBSTRUCTED WITH A CEPHALIC PRESENTATION, enter her abdomen just below her umbilicus so as to avoid her bladder. If catheterization before the operation was impossible, empty her bladder now with a needle and syringe. Much of the swelling will be oedema, which will not go away. Mobilize her bladder free from her lower segment as usual.

If an assistant is to push the baby's head up from below through her vagina, let him do so now before you open her uterus. If he waits until after you have opened it, the baby's shoulder may prolapse into the incision and make delivery more difficult.

Make a transverse incision in the lower segment. Choose its level carefully. If it is too high, delivery will be difficult; if it is too low, you may enter her vagina.

If delivering his head is difficult, don't panic. Everyone finds this a problem, especially when the uterus is tight around him. Take time to push back its wall from around his head, by inserting 2 fingers all round. You will then be able to apply forceps. If you still have difficulty, enlarge the wound upwards and laterally at its ends.

CAUTION ! (1) Don't lever his head out with your whole hand, because this can cause vertical downward tears in the lower segment. (2) If her liquor was purulent or infected, clean her abdomen carefully, and wash out her pelvis with warm saline.

If his BREECH is presenting, delivery may be be more difficult than with a cephalic one. Feel for a leg, or better, both legs, and deliver him breech-first as if you were delivering his head. Then deliver his head slowly, or you may damage it. If, by mistake, you take hold of an arm, replace it. Then feel for a leg; recognize it by feeling for his heel. If an arm comes out and will not go back, you are in trouble (unusual). You may have to make an inverted ''T' incision to get him out. When necessary, deliver his arms by a modified Lovset manoeuvre, and his head by a modified Mauriceau[nd]Smellie[nd]Veit manoeuvre (19.8).

If there is a TRANSVERSE LIE, the choice of incision is important. See also 18.9.

If she is in early labour, and her lower segment is poorly developed, with most of the baby in the upper segment, make a transverse incision in the upper segment and deliver him by breech extraction (19.8).

If she is in early labour, her lower segment is well developed, and her membranes are still intact, make a transverse incision in her lower segment, and deliver him by breech extraction.

If labour is obstructed, and most of him is in the overdistended lower segment, simple delivery through a transverse incision in the lower segment will cause large tears. So:

If he is alive make a vertical incision in the lower segment, and extend the incision into the upper one until it is big enough to deliver him.

If he is dead, make a transverse incision in the lower segment, decapitate or eviscerate him, and deliver him in any convenient way. If his hand is outside her vulva, separate his arm at the shoulder joint before Caesarean section starts.

CAUTION ! (1) Don't try to deliver him intact, because this will tear her lower segment severely. (2) Don't make a classical or inverted ''T' incision for a dead baby.

DIFFICULTIES [s7]WITH THE PLACENTA If you anticipate PLACENTA PRAEVIA, expect difficulty, and get help if you can. You can usually use the ordinary transverse lower segment incision. This is contraindicated if: (1) She has a poorly developed lower segment, which would not allow a transverse incision of adequate length. (2) She has a very vascular lower segment with large veins on it. (3) The presenting part is high, and he is lying transversely, indicating that the placenta praevia is probably central. If so, mobilize her uterovesical fold, as for a lower segment operation. Make a low vertical midline (de Lee) incision. Deliver him as for a low classical section. If there is severe bleeding, quickly feel for a foot. His half breech will plug the bleeding area, and you will have the situation under control. Some surgeons make a vertical or transverse incision in the upper segment.

If you find PLACENTA IN THE INCISION: (1) Peel it away from her uterine wall and enter her uterus from above it. (2) If the edge of the placenta is too far away to allow this, cut through it quickly, and deliver him without delay through the hole that you have just made. If you meet his cord, clamp it before you deliver him, but don't waste time looking for it: you can clamp it immediately afterwards. Remember that a baby can easily bleed from an injured placenta. His mother can also bleed, so if you see a large bleeding vessel in the placental bed (unusual), control it with a figure of eight suture.

If she BLEEDS POSTOPERATIVELY (not uncommon with placenta praevia), she is probably bleeding from her lower segment at the site of the attachment of the placenta. Give her oxytocin, and if necessary transfuse her. In desperation, pack her uterus (19.11a).

DIFFICULTIES [s7]WITH BLEEDING See also under ''Difficulties with the incision' and ''Difficulties with placenta praevia' above.

If you have a LOT OF TROUBLE WITH BLEEDING during the operation, it is often helpful to bring the uterus out of the abdomen. You can then reach behind it with your hand and place the sutures at the angle of the incision. It is usually safe to put sutures beyond the end of the incision provided you suture only into the substance of the uterus. See ''Stop Press'.

If she has SEVERE VAGINAL BLEEDING 8 to 14 days after delivery (secondary postpartum haemorrhage), the operation site is infected (common after an obstructed labour with sloughing of the tissues). Under perioperative antibiotic cover (2.9) take her to the theatre, and examine her under an anaesthetic. Put a gloved finger into her uterus through her external os and feel: (1) for a piece of retained placenta, and (2) for the inner wall of her uterine scar. If this feels weak, or has broken down, reopen her abdominal incision. You may find a soft necrotic bleeding uterus, with blood and spreading infection in her peritoneal cavity. What was the scar may now be an infected hole in her uterus. Under such circumstances she should have a total or subtotal hysterectomy (20.12). If you don't attempt one, she will die. Expect to find that her parametrium is acutely infected and swollen, so that it feels like cheese.

Alternatively, and less satisfactorily, remove what slough you can and carefully pack the wound. You will probably be unable to find any obviously bleeding vessels. If this fails, you will have to try to remove her uterus or to tie her internal iliac vessels (3.5). Even so, you may fail to save her.

DIFFICULTIES [s7]WITH THE URINARY TRACT See also 18.18 and 18.19D If you OPENED HER BLADDER, identify the hole carefully, hold its edges with Allis forceps, mobilize the surrounding tissues if necessary, and bring its edges together with continuous inverting sutures of fine chromic catgut. Try not to penetrate its mucosa. Drain her bladder continuously with an indwelling catheter for 10 days. On the 10th day spigot it 2- hourly. If she is satisfactory (no leaks, no abdominal discomfort, and a good flow when you release the spigot), remove the catheter on the the 11th day.

If you have INJURED HER URETER at operation, first check that her other ureter is intact. Either, repair it if you can. Or, insert a T[nd]shaped drain into her ureter, bring it out to the surface, and close her abdomen. Later, refer her for expert help. Don't try to do a ureterostomy.

If she has ANURIA: (1) This may be the result of severe hypotension, while she was in obstructed labour (not uncommon). Hydrate her well and give her frusemide 40 mg, intravenously. See Section 53.3. (2) You may have tied both her ureters (fortunately, rare). Refer her. If this is delayed do a temporary nephrostomy on both sides (23.13).

If she complains of a severe dull PAIN IN ONE LOIN postoperatively, you may have tied one of her ureters. Do an IVP to look for a hydronephrosis or a ''nonfunctioning kidney' (actually a poorly functioning one, because insufficient dye is excreted to show the calyces). If you think you have tied a ureter, refer her. If referral is delayed, do a temporary nephrostomy (23.13). Sometimes, when you tie a ureter, neither she nor you are aware of it: her kidney merely stops working.

If URINE DISCHARGES FROM HER VAGINA 2 to 5 days postoperatively, check that: (1) Her bladder is not distended (overflow incontinence). This can happen if it has been bruised. (2) She has not got bladder/urethral incompetence. If you see her urethra leaking, ask her to cough. If urine spurts out, this is what she has. If it is disabling, refer her for a sling operation. (3) She may have a fistula. Treat her with salt perineal baths (Sitz baths). Examine her at 10 days, if necessary under anaesthesia (EUA), when examination will be easier. She may have one of three fistulae:

(A) If urine is COMING FROM HER ANTERIOR VAGINAL WALL: (1) She has a VVF due to pressure from the fetal head during a long and difficult labour. Refer her to have it repaired at 6 weeks, or repair it yourself (see Section 18.18). Or, (2) urine may be leaking from her ureter. To confirm this put cotton wool swabs in her vagina, and instil methylene blue through a catheter into her bladder. If the swabs are stained blue, she has a vesicovaginal fistula. If they are wet, but not blue, she has a ureteric leak (ureterovaginal fistula). The classical test is to insert 3 swabs. If only the lower swab is stained blue, she has stress incontinence. If the middle and upper ones are blue she has a VVF. If the upper one is wet but not blue, she has a ureteric fistula.

CAUTION ! Don't instil gentian violet into the bladder: it causes a chemical cystitis and a contracted bladder.

(B) If she has a URETEROVAGINAL FISTULA (uncommon), it was probably caused by damage to her ureter at Caesarean section by: (1) clamping it in error, not recognizing this, and leaving the clamp on for more than a few minutes, or (b) by including the ureter in a suture closing the uterine wound. An IVP will tell you which side it is on. The kidney on the affected side will show some degree of hydronephrosis. She may or may not have pain in her loin.

A ureterovaginal fistula is more hopeful and less urgent than (a) tied ureter(s), because it means that her kidney(s) will not stop functioning. You will be able to refer her for elective repair. Her ureter may need reimplanting into her bladder, or repair end to end. If she is to retain good kidney function, refer her without delay.

(C) If URINE IS COMING THROUGH HER CERVIX (a vesico- uterine fistula), it is the result of cutting her bladder, not immediately recognizing and repairing it, and finally stitching up her uterus so that her bladder communicates with her uterine cavity. Refer her.

If you cannot refer her, wait for 4 to 6 weeks. Open her bladder as for cystotomy for stone (23.15), and repair her uterus and bladder in separate well-defined layers. Drain her bladder as for a VVF; a Foley catheter is an acceptable alternative to the ''button' method (18-23).

OTHER DIFFICULTIES [s7]WITH CAESAREAN SECTION If she has a CONTRACTION RING (Bandl's ring), in her lower segment, or between the lower and the upper segment, deal with it like this: If her baby is entirely above the ring, make a transverse incision entirely above it. If it is round his neck, make a vertical incision across it.

If she has FIBROIDS, leave them unless they are pedunculated and removal is very easy. Otherwise, leave them: they may settle and atrophy. Removing a fibroid, at delivery, from within the wall of the uterus causes severe bleeding.

If she has OVARIAN CYSTS OR TUMOURS, remove them if they are [mt]5 cm. Ovarian cystectomy is possible, but removing the ovary and tube will be quicker and safer. Smaller functional luteal cysts will have usually disappeared spontaneously by the end of pregnancy. See also 20.7.

If she has ADHESIONS, you will have to separate them sufficiently to get good access to her uterus. Don't try to remove them from around her tubes and ovaries; they will ooze and form again.

If you have sewn up her uterus WITHOUT REMOVING HER PLACENTA, it will probably be delivered vaginally in a few hours. The danger is that it might be retained and become infected. Even so, it is probably wise not to reopen her uterus and remove her placenta operatively. If necessary, remove it manually through her vagina.