Clinical Tips of Cesarean Section in Case of Breech, Transverse Presentation, and Incarcerated Uterus

Abstract

The presentation, position, and attitude of the fetus should be confirmed by transabdominal ultrasonography on admission and at departure from the ward for cesarean section. It is important to have images of the course of the surgery and delivery of the fetus by confirming the fetal position, location of the placenta and umbilical cord, and volume of amniotic fluid. The operation should be performed by imaging the descent, presentation, position, and attitude of the fetus through external examination according to Leopold's maneuver before laparotomy. Such imaging facilitates learning of the cesarean section techniques and obstetric management in the long run. AbstractCesarean section in breech or transverse presentation involves more complicated procedures than cesarean section in cephalic presentation because the former requires additional manipulations for guiding the presenting part of the fetus, liberation of the arms, and the after-coming head delivery; therefore, those cesarean sections are likely to be more invasive. Making a rather wide uterine incision to prevent uterine injury during delivery of the fetus facilitates smooth delivery of the fetus. Furthermore, in cases of breech or transverse presentation, it is important to initially identify the presenting part of the fetus and guide it to the incision opening in the lower uterine segment, because delivering the presenting part of the fetus first is a basic rule of delivery of the fetus. Smooth delivery of the fetus by means of breech extraction can prevent excessive stress or injury to the fetus. Therefore, it is important to acquire the knowledge and skills necessary to perform these techniques, including the internal version. Smooth delivery of the fetus is also less invasive for the mother because an extension of the uterine excision or injury to arteries and veins in the uterus and parametrium can be avoided. Incarcerated uterus occurring in cases of pregnancy with intrapelvic adhesion, endometriosis, cervical myoma, or extended cervix may result in excessive uterine and cervical injury when a transverse incision of the lower uterine segment is performed without caution. These conditions may result in difficulty in fetal delivery. Therefore, it is important to identify risks in advance and to choose the incision line with great care. Countermeasures for difficult delivery of the fetus need to be mastered by all practitioners of obstetrics. If the transverse incision fails to reach the uterine cavity, an inverted T-shaped or J-shaped incision should be made. Risks of complications such as injury to the cervical canal, the vagina, the bladder or ureter, and massive hemorrhage must be kept in mind.

Importance of the early diagnosis of incarcerated gravid uterus: Case report and systematic review

“…However, for patients in whom the diagnosis is delayed beyond week 20, a very high percentage do not receive any type of treatment, potentially leading to the need to end the pregnancy by cesarean section. 15 In some cases, diagnosis is made during the cesarean section, which is associated with, as previously reported in the literature, an increase in maternal-perinatal complications. 7 Globally, this pathology is associated with worse pregnancy outcomes and with higher frequencies of abortion, PROM, and preterm delivery.…”

“…Our analysis indicates that the early diagnosis of this pathology is associated with higher rates of resolution and with less invasive techniques for treatment. However, for patients in whom the diagnosis is delayed beyond week 20, a very high percentage do not receive any type of treatment, potentially leading to the need to end the pregnancy by cesarean section 15 . In some cases, diagnosis is made during the cesarean section, which is associated with, as previously reported in the literature, an increase in maternal‐perinatal complications 7 …”

Anterior uterine incarceration complicated by placenta previa and placenta accreta spectrum disorder: a case report

“…Compared to ultrasound, MRI provides more comprehensive anatomical insights into the pelvis, and has a higher tissue resolution and a wider field of vision. It can not only display the relative positions of the uterus, placenta, and cervix, but can also display the structure of the surrounding pelvic organs, such as the bladder, vagina, and rectum ( 11 , 12 ).…”

Are Deliveries by Inverted T-Incision on the Rise Due to Fibroids?: A Case Report

“…To prevent injuries of enormous stress to the fetus, breech delivery was most suitable. Studies have also suggested, that in cases where an inverted T-incision is not applicable, a vertical incision or a J- shaped incision are other options to consider [ 6 - 7 ]. Inverted T-incisions incidence has increased from 0.2% to 0.9%, with a remaining high risk to maternal health [ 8 ].…”