What are the possible interoperative complications of cesarean delivery (C-section)?

Updated: Dec 14, 2018
  • Author: Hedwige Saint Louis, MD, MPH, FACOG; Chief Editor: Christine Isaacs, MD  more...
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Uterine lacerations, especially of the lower uterine segment, are more common with a transverse uterine incision. These lacerations can extend laterally or inferiorly. They are easily repaired. Take care to identify the uterine vessels when repairing lateral extensions, and think about the ureters when repairing inferior extensions. If the laceration extends into the broad ligament, strongly consider opening the broad ligament medial to the ovaries and identifying the course of the ureters.

Bladder injury is an infrequent complication; it is more common with transverse abdominal incisions and in repeat cesarean deliveries. The bladder most commonly is injured during entry into the peritoneal cavity or when the bladder is separated from the lower uterine segment. Bladder injury has been reported to occur in more than 10% of uterine ruptures and in approximately 4% of cesarean hysterectomies.

If a possibility exists that a cesarean hysterectomy may be performed, mobilize the bladder inferiorly as well as possible when dissecting it free of the lower uterine segment. If the dome of the bladder is lacerated, it can be repaired simply with a 2-layer closure of 2-0 or 3-0 chromic sutures, with the Foley catheter left in place for a few extra days. If the bladder is injured in the region of the trigone, consider ureteral catheterization with possible assistance from a urologist or gynecologic surgeon.

Injury to the ureter occurs in up to 0.1% of all cesarean deliveries and up to 0.5% of cesarean hysterectomies. It is most likely to occur in the repair of extensive lacerations of the uterus. Ureteral injury, most commonly occlusion or transection, is usually not recognized during the time of the operation.

Bowel injuries occur in less than 0.1% of all cesarean deliveries. The most common risk factor for bowel injury at the time of cesarean delivery is adhesions from prior cesarean deliveries or prior bowel surgery.

If the bowel is adherent to the lower portion of the uterus, dissect it sharply. Injuries to the serosa can be repaired with interrupted silk sutures. If the injury is into the lumen, perform a 2-layer closure. The mucosa can be closed with interrupted 3-0 absorbable sutures placed in a transverse fashion for a longitudinal injury. For multiple injuries and injury to the large intestine, consider intraoperative consultation with a general surgeon or gynecologic oncologist.

Uterine atony is another intraoperative complication that can be encountered in a patient with a multiple gestation, polyhydramnios, or a failed attempt at a vaginal delivery in which the patient was on oxytocin augmentation for a prolonged period. When the uterus is closed, attention must be paid to its overall tone. [110]

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