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Chapter 12

The Difficult Caesarean Section

Elmarie Basson

The incidence of caesarean section is roughly 15-25% of all deliveries in developed countries, and
is regarded as a safe route of delivery, with an associated maternal mortality of less than
1 in 10 000.

The safety of the lower uterine segment technique has increased due to the development and
administration of safe regional (and general) anaesthesia, the availability of blood products,
the appropriate use of the correct suture material, better surgical techniques, the availability of
antibiotics and post operative thromboprophylaxis.

Unfortunately, there are still situations where the caesarean section is a surgical challenge,
with risk of fetal and/or maternal morbidity (see Table 1).

Prior to skin disinfection and operative field draping, always catheterize the patient and
ascertain the fetal presenting part. Breech presentation and transverse lie present specific
problems glance at the ultrasound report to ensure the placenta is not praevia, which may
account for these situations.


The fibroid uterus
Fibroids are well known for being very vascular, even more so when encountered at caesarean
section. Consensus supports the fact that myomectomies must never be carried out at
Table 1 The difficult caesarean section
Maternal factors:
1. Fibroid uterus
2. Previous surgery with extensive adhesions
3. Poor haemostasis
4. Absence of a lower uterine segment
5. Placenta praevia
Fetal factors:
1. Breech presentation
2. Twin pregnancy
3. Transverse lie

caesarean section. Unfortunately, if the fibroid is situated near the lower segment at the
uterine incision line, it becomes a potential life-threatening problem.

Always aim to do a transverse lower uterine segment incision (Figure 1), but if the fibroid is
over the intended incision line, then rather opt for a vertical lower uterine incision (Figure 2), or
a classical caesarean section incision (Figure 3).

Figure 1 Transverse lower uterine segment incision

Figure 2 Vertical lower uterine segment incision (Delee incision)

Figure 3 Classical caesarean section incision


Care must be taken to avoid the actual fibroid, as incisions in the vicinity of a fibroid can lead to
haemorrhage. If a vertical lower uterine segment incision is planned, there needs to be more
extensive dissection of the bladder in order to keep the vertical incision within the lower
segment. If the incision extends downwards, it may tear through the cervix to the vagina and
possibly the bladder. The advantage of this incision is a lower risk of lateral extension into the
uterine vessels.

The classical caesarean section has a limited place in modern obstetrics, and is only performed
if there is no lower segment of the uterus, or with a difficult transverse lie. However, if a large
fibroid obscures the whole lower segment, this may be your only option.

After delivery of the baby and placenta, the uterus is closed in two to three layers: usually with
a classical caesarean section the muscle is relatively thick, and therefore needs to be sutured in
multiple layers. The serosa is then closed with a suture material that would not cause adhesion
formation, for example monocryl (if available).
Carefully monitor this patient for blood loss, as a fibroid can interfere with myometrial
contraction. Give the patient one Misoprostil per os (200g) during the procedure, and
instruct the anaesthetist to give 5-10 IU Syntocinon as a stat dose, and a further 10-20 IU
Syntocinon in the drip as a continuous infusion. Post operatively administer 400g Misoprostil
per rectum. The Misoprostil can be used for a further 1-2 days depending on the vaginal blood
Previous Caesarean Section / Surgery with Extensive Pelvic Adhesions
This procedure is often fraught with unexpected difficulties. The rule is to expect the worst
and to approach the surgery with great caution.

After the skin and the fascia have been opened, gently approach the sheath. Be very careful
with the sheath, because bladder, bowel or even the uterus might be adherent. Sometimes the
sheath might be fibrous and unyielding, but with the cautery on cutting (at 40 watts) one
can easily get through it.
If omentum is adherent to the sheath and peritoneum, clamp the adhesion, cut and tie it off
with vicryl (or similar)
If the bladder is adherent to the sheath and peritoneal surface, try to open the peritoneal
cavity by cutting cephalad, and adequate exposure is safely achieved.
In the unlikely event of bowel adhesions, gently try to separate the bowel from the adherent
tissue by using a Russian forceps and fine dissecting scissors.
The most important aspect of adhesions is to try to restore normal anatomy as far as possible.
One often has thick fibrous bands extending from the uterus to the rectus muscle. Those are
also tied and cut through, in order to secure easy access to the lower uterine segment.
Dont hesitate to call in the help of other specialists, like a surgeon, vascular surgeon or even a
urologist. In the event of poor exposure and access to the lower uterine segment, it may
sometimes be necessary to incise the belly of the rectus muscle laterally; this is safe and easy,
and affords excellent exposure. Repair the muscle with interrupted vicryl sutures, after delivery
of the baby.


Absence of a Lower Segment
This is usually encountered at the delivery of a premature infant (<30weeks, gestation), at
placenta praevia or at breech presentation.

The safest entry would be to employ a classical caesarean section, as this allows adequate
The most common problem with a classical caesarean is securing adequate haemostasis, and
care should be taken to ensure that the muscle of the uterus is closed properly (usually 2-3
layers of suturing is required). Most importantly, one needs to prevent the formation of
adhesions, and thus the serosal layer should be closed with a PDS or monocryl suture (if

Placenta praevia
This is probably one of the most difficult caesarean sections as the risk of haemorrhage is high.
The prudent doctor will have access to O neg blood, which may be life saving in the event of
catastrophic bleeding.

If the patient has an anterior placenta praevia, try to enter the uterus above the placenta, via
the lower segment. If this is not possible, make a lower segment uterine incision and with
blunt dissection (using your fingers), go through the placenta until you reach the baby. This is
extremely nerve-wrecking as it can bleed substantially. A better bet would be to do a
classical uterine incision, to avoid damage to the placenta.
Dont be afraid to extend the uterine incision into a J or a T incision (see picture). There is no
time to waste in a situation like this, so get to the baby as quickly as possible, and clamp the
umbilical cord immediately.

J incision T incision

If the placenta praevia is posterior, delivery of the baby can usually be done via the lower
uterine segment.
The other problem with a placenta praevia is that the lower segment doesnt contract very
well, and the patient is at risk of post partum haemorrhage.

If haemostasis is suboptimal, try deep figure-of-8 stitches into the placental bed in order to tie
off the bleeders. Dont forget the simultaneous use of Pitocin (Oxytocin) and Misoprostil, as
previously described.
Another option is to inject diluted Prostaglandin f2x directly into the muscle of the uterus.


Caesarean Section in the case of Breech Presentation
It is always wise to ensure the breech presentation is not caused by a placenta praevia:
reference to an ultrasound report should clear this.

The breech delivery needs more space and better lower uterine segment exposure. Dont
believe that breech deliveries at caesarean section are necessarily easy because the head
cannot get stuck. There is much more to delivery of a breech baby than merely delivery of the
aftercoming head. If necessary, increase exposure of the lower uterine segment by incision of
the rectus abdominus muscle as previously described.

Open the uterus, and draw the incision laterally by digital traction. Introduce the right hand and
feel for the feet: grasp the feet and firmly draw these downwards. Perform a gentle breech
extraction, similar in technique to a conventional vaginal breech delivery. Always keep the
babys back upwards. Close in the conventional way.

Caesarean Section in the case of a Twin Pregnancy
Dont assume that twins are small little babies and hence the space and exposure to the lower
uterine segment needs to be limited. Give twins the same respect as a singleton pregnancy,
and this prudence will be rewarded. If ever the operator finds space and exposure limited,
extend the skin incision within reason and if muscle relaxation is insufficient, resort to
cutting the rectus muscles. The idea of a caesarean section is to deliver a baby gently and
swiftly and if access to the infant is limited, then the delivery will be neither gentle nor swift.
Bear in mind that after a twin delivery, women are prone to a PPH, so it is prudent to
administer 1 or 2 misoprostil tablets, orally or rectally, to contract the uterus and prevent blood

Caesarean Section in the case of a Transverse Lie
When a transverse lie is encountered, it is possible to deliver via a transverse skin incision.

If the obstetrician is inexperienced, it is prudent to consider delivery through a midline sub-
umbilical skin incision. Good free access to the lower uterine segment is important: if this is
limited and more space is thought necessary, cut the rectus muscle with scissors from the
medial margin laterally, as this increases exposure markedly.

Once in the abdomen, review the fetal lie by gentle uterine palpation and manipulation. If the
uterus is relaxed, with plenty of liquor, it may be feasible to coax a head or a breech into a
longitudinal position. Beware of large caliber vessels coursing over the lower segment these
may indicate a placenta praevia and should be tied off with 2/0 vicryl, 441 or monocryl 3463 3/0

sutures. Incise and displace the uterine peritoneum with Russian forceps and Mayo scissors.
Have forceps or a vacuum extractor ready to deliver the fetal head.
Commence wall suction, to keep the operative field clear of fluids, and gently incise the lower
uterine segment. Open the final few millimetres with mayo scissors or digitally; and manually
feel for the fetal presenting part. If a head is felt, call for fundal pressure and deliver either with
Wrigleys forceps or by vacuum extraction.

If you feel feet, seize these and perform gentle breech extraction, keeping the fetal back
uppermost. If a cord, hand or shoulder emerges, pop these back and feel for the feet. If you
feel only the fetal back, then remove your hand, straighten the baby into a longitudinal lie, re-
introduce your hand, and deliver the baby. If you open the lower uterine segment and find a
placenta praevia, proceed as under placenta praevia. Close in the usual manner. If the rectus
abdominus muscle was cut, close the muscle with a haemostatic repair using a few figure-of-8
sutures. Left overs from the uterine closure are excellent for this purpose.