Unintended hysterotomy extension during caesarean delivery: risk factors and maternal morbidity

Abstract

We conducted an observational retrospective cohort study to evaluate the risk factors and the maternal morbidity associated with unintended extensions of the hysterotomy during caesarean delivery. We evaluated 2707 women who underwent low-transverse caesarean deliveries in 2011 at an academic, tertiary-care hospital. Hysterotomy extensions were identified through operative reports. Of the 2707 caesarean deliveries, 392 (14.5%) had an unintended hysterotomy extension. On the multivariable regression modelling, neonatal weight (OR 1.42; 95%CI 1.17-1.73), the arrest of labour [first-stage arrest (2.42; 1.73-3.38); second-stage arrest (5.54; 3.88-7.90)] and a non-reassuring foetal status (1.65; 1.20-2.25) were significantly associated with hysterotomy extensions. Hysterotomy extensions were significantly associated with an increased morbidity including an estimated blood loss >1200 millilitres (2.06; 1.41-3.02), a decline in postoperative haemoglobin ≥3.7 g/dL (2.07; 1.35-3.17), an evaluation for lower urinary tract injury (5.58; 3.17-9.81), and a longer operative time (8.11; 6.33-9.88). Based on these results, we conclude that unintended hysterotomy extensions significantly increase the maternal morbidity of caesarean deliveries. Impact statement What is already known on this subject? Maternal morbidity associated with caesarean delivery (CD) is significantly greater than that in vaginal delivery. Unintended extensions of the hysterotomy occur in approximately 4-8% of CDs and are more common after a prolonged second stage of labour. The morbidity associated with hysterotomy extensions has been incompletely evaluated. What do the results of this study add? We demonstrate a rate of hysterotomy extension in a general obstetric population of approximately 15%, which is higher than previously reported estimates, and represents a potential doubling of the rate of the unintended hysterotomy extensions in recent years. The most significant risk factor for a hysterotomy extension was a second-stage labour arrest with a fourfold increase in the frequency of extensions. A hysterotomy extension is a significant independent risk factor for an intraoperative haemorrhage, a drop in postoperative haemoglobin, an intraoperative evaluation for lower urinary tract injury, and longer CD operative times. What are the implications of these findings for clinical practice and/or further research? A second-stage arrest is a strong independent risk factor for a hysterotomy extension. Recent re-evaluations of the labour curve that extend the second stage of labour will likely increase the frequency of CDs performed after a prolonged second stage. In these scenarios, obstetricians should be prepared for an unintended hysterotomy extension and for the possibility of a longer procedure with the increased risks of blood loss and the need for evaluation of the lower urinary tract.

The impact of prolonged second stage in twins on perinatal outcomes

“…In that sense, a delayed CD for an obstructed, prolonged labor may be associated with devastating maternal-fetal sequelae. 28,29 Indirect data from singleton pregnancies suggest that the risks of chorioamnionitis and admission to NICU rise with prolonged labor. 3,20,30 As several risk factors for chorioamnionitis have been reported, and are often interdependent, 31,32 we were not able to provide a solid answer to whether a higher rate of chorioamnionitis in our study was secondary to the prolonged second stage itself or to some other underlying risk factors (e.g.…”

Quantifying Maternal Blood Loss from the Hysterotomy at Cesarean Delivery

“…This study was limited in that it included only patients undergoing scheduled cesarean deliveries, and cannot be extrapolated to labored cesareans, which are more likely to be complicated by hysterotomy extensions. In prior studies, hysterotomy extensions are associated with increased blood loss, longer operating time, and evaluations for lower urinary tract injury [7]. A strength of this study was our method of blood collection from the hysterotomy site.…”

Reverse Breech Extraction at Cesarean Section in Second Stage of Labor

“…Furthermore, difficulties during child delivery might cause damage of urinary bladder and neonatal birth injuries. [6,7,9,12,13]. Several approaches have been proposed to solve such problems: 1.…”

“…The frequency of such surgeries is approximately 1.5% of all C-sections and approximately 25% of urgent C-sections [6,7]. The traditional approach to delivery out fetal head deeply inserted into pelvis and tightly attached to pelvic wall with over-stretched lower segment can lead to significant complications [8,9]. Of note, carrying out the C-section at full cervical dilatation requires a higher transversal hysterotomy, which usually takes place at the level of the fetal shoulders.…”