Abstract
Key Pointers
Key Facts
Maternal Implications These include prolonged operating time, conversion of a regional anaesthetic to a general anaesthetic, need for additional procedures and blood transfusion, delay in bonding with the newborn, longer hospital stay, pain, prolonged urinary catheterisation, stoma and sepsis due to unrecognised bowel injury that in rare cases leads to death.
Fetal Implications Fetal injuries including skull fracture; delay in delivering the fetus, leading to hypoxia and brain injury; neonatal seizures and long-term outcomes including cerebral palsy; very rarely death during the procedure or early neonatal death.
Medico-legal Implications Clinical negligence claims due to failure to recognise unintended intraoperative complications and inappropriate management of those complications.
Key Pointers
Unexpected Bleeding
Bleeding during a caesarean section occurs mostly due to uterine atony. The other reasons include uterine angle extension, broad ligament tears, injury to vesical venus plexus, abnormal placentation and unexpected coagulopathy. Injury to the inferior epigastric artery due to stretching of the rectus abdominis muscle during entry and injury to omental vessels during division of omental adhesions can also cause bleeding.
Injury to Visceral Organs
Bowel Injury
Previous abdominal surgery, adhesions secondary to inflammatory bowel disease, endometriosis and cleaning the paracolic area without direct vision are common causes of bowel injury.
Management of Bleeding
Remember 4 T’s (tone, tissue, thrombin and trauma)
For atony, alert the anaesthetist.
Commence uterotonics (IV oxytocin at 10 IU/hour and IM prostaglandin F2α (Hemabate) 250 mcg every 15 minutes or rectal misoprostol).
Check the uterine cavity for retained products and commence direct uterine massage.
Algorithms such as HAEMOSTASIS may aid management. If bleeding continues, consider informing an experienced obstetrician and attempt uterine compression to sutures such as B-lynch and vertical/horizontal compression sutures.
Commence Massive Obstetric Haemorrhage protocol if bleeding exceeds 2 L or earlier if continued bleeding is anticipated.
Systematic pelvic devascularisation (bilateral uterine artery ligation and ligation of both tubal and uterine branches – quadruple ligation).
Uterine tamponade using hydrostatic balloon or packing the uterine cavity with ribbon gauze if appropriate.
Further measures include internal iliac artery ligation, interventional radiology for pelvic arterial embolisation and hysterectomy as a last resort.
Extension of Lower Segment Uterine Incision
Follow the incision to visualise the apex of the tear extension.
Exteriorise the uterus if necessary to allow direct vision.
Exclude extension into the broad ligament with or without the involvement of the ureters/bladder (call for senior help).
Avoid blind sutures.
Secure the extension with hemostatic sutures under direct view with the use of suction.
Injury to Inferior Epigastric Vessels
The inferior epigastric artery arises from the external iliac artery above the inguinal ligament and ascends along the medial margin of the abdominal inguinal ring to pierce the transversalis fascia. It then ascends between the rectus abdominis muscle and its sheath and lies on the posterior surface of this muscle close to its lateral border.
Sharp dissection to get into the abdominal cavity or cutting the rectus muscle can injure the inferior epigastric vessels.
Knowledge of anatomy helps to avoid injury to this vessel and hence reduces the risk of intra-abdominal bleeding or formation of hematoma.
These vessels can retract easily, posing a challenge to recognition of the injury and repair.
If damage is identified, deep haemostatic sutures should be applied.
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