Time to Reevaluate Cesarean Section Techniques
Thursday, May 10, 2007
Kenneth F. Trofatter, Jr., MD, PhD
To be fair, the technique was based in good surgical principles designed to minimize risks for bleeding and infection at a time when these were major concerns, prior to both blood transfusion and antibiotics. Indeed, the procedure most commonly used today (the low-transverse cesarean section – referring to a cross-wise incision in the uterus, regardless of the skin incision) has not changed much since it was first described by Kerr in 1926. Over the years, we developed specific guidelines for the type of skin incision (transverse, lower abdominal vs. vertical) that was made under specific circumstances; we usually ‘developed the bladder flap’ (incised the thin layer of peritoneum over the lower uterine segment and pushed the bladder down before incising the uterus) except in dire emergencies; we knew the type of uterine incision that was preferred (transverse or vertical) under specific circumstances; we reached into the uterus to remove the placenta after the baby was delivered and then wiped the uterine cavity clean; we closed the uterine incision in two layers; and, then reapproximated ‘like-to-like’ (closed the bladder flap, closed the peritoneum, closed the fascia, closed the subcutaneous layer of fat, and then closed the skin) to complete the operation. And, despite all those steps, most of us could perform the procedure in a woman having her first one in less than 30 minutes ‘skin-to-skin’.
About 15 years ago, a paper was authored by Dr. John Hauth that suggested closing the uterus in a single layer was just as good as closing in two, thereby reducing operative time and the ‘perinatal morbidity’ associated with prolonged procedures, mainly, blood loss, infection, and risk for deep venous thrombosis and pulmonary embolism. In other words, there did not appear to be any short-term risks to this approach and there might even be some benefits. Around the same time, other papers challenged the necessity of closing the peritoneum (the thin layer of ‘skin’ that lines the inner abdomen and covers the internal organs (i.e., the ‘bladder flap’ over the uterine incision as well as the peritoneum of the abdominal wall). Without critically evaluating the individual risks and benefits of omitting these steps, many practitioners jumped on the bandwagon of the ‘simplified cesarean section’ and began closing the uterus in one big layer, leaving the raw surfaces of the ‘bladder flap’ and uterine incision exposed, and stopped closing the peritoneum lining the inner abdominal wall. Although I was rather skeptical at the time that this was really the right thing to do (raw surfaces tend to increase the risk for adhesions (scar) formation), especially because we had no long term follow-up on these women with regard to subsequent deliveries, our residents loved it because there were fewer steps (although they never seemed to do the operation any faster than us old fogies did in our heyday when ALL the steps were performed), so we just sort of went along for the ride.
Well, in recent years, as the cesarean delivery rate has skyrocketed, vaginal births after cesarean section have diminished (significantly), and we are performing more and more repeat cesarean procedures (and threepeats, and fourpeats, and fivepeats,….). We are also encountering more and more complications secondary to the previous procedures (occult and overt uterine ruptures, dense adhesions, placenta previas, placenta accretas, cesarean hysterectomies…). It is becoming clear that revisiting what, why, and how we are doing cesareans, and systematically ascertaining the best approach to the entire operation is necessary. It is also likely that the approach I was taught, based on what was considered to be ‘good surgical technique’ (but no data) and passed on by tradition, and the current ‘minimalist’ procedure, also based on a limited amount of data compared to the total number of procedures done, are at opposite extremes and the ‘truth’ probably lies somewhere in between.
As Dr. Lee-Parritz pointed out, if we look at the information already available from various sources both in OB and other surgical specialties, we are well on our way to defining a better approach to cesarean section. Without going into details of the hows and whys, herein, her analysis of the literature supports the fact that we should continue to use prophylactic antibiotics perioperatively (probably best given prior to the skin incision); we can probably perform most cesareans through a transverse abdominal incision; we probably do not routinely need to develop extensively the bladder flap; the uterine incision can safely be widened by blunt dissection; the placenta should be removed by traction rather than by ‘manual extraction’ (to minimize blood loss and infectious morbidity); the uterus should probably be closed in two layers (at least for all women planning another pregnancy, although how that is best accomplished and even what suture should be used is yet to be decided; if no ‘bladder flap’ is developed, we probably do not need to close either the visceral or parietal peritoneum; we should reapproximate the subcutaneous tissues, especially in obese patients; and, we can close the skin anyway we want to, although most patients would prefer not to see sutures or have staples that need to be removed at a later time and, actually, seem to have less postoperative pain when the skin is closed in a running subcuticular (under the skin) stitch.
If these steps were routinely employed, we should be able to minimize short-term risks of infection, bleeding, length of procedure, and perioperative pain and perhaps put a dent in the long-term complications of uterine scar dehiscence and pelvic adhesions that increase the morbidity of a subsequent pregnancy for both mother and baby. Who knows, an improved technique might also reduce the subsequent risk of placenta accreta and cesarean hysterectomy (allowing women to have more and more cesarean sections!). Unanswered questions could be readily addressed by a few well-organized multicenter research studies (in view of the huge total number of cases being performed each year, both first time and repeat procedures). We should be able to decide upon the best technique for closure of the uterus, the best suture to use under specific circumstances, and the best approach to employ with regard to closure of all the other body layers we went through to get the baby delivered.
Labels: cesarean section, delivery
99 Comments:
At Fri Jun 22, 04:03:00 AM 2007,
Anonymous said…
Hi my name is katie i had two c/sections and they were the worst thing that ever happend me i have a number of proploms sense my last one e.g i have not had a period for two years and my bump never went down, so there for i think that sections should not be done onless its in a life or death situation.is ther any one who suffered the same or similer complaints as me?
At Wed Jun 27, 06:04:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Hi Katie,
Although most cesarean sections are not accompanied by major complications, short- or long-term, they are still MAJOR operations. And, the more c/sections you have, the greater the risk of complications related to scar tissue (adhesions), damage to adjacent organs, placenta previa and accreta, and uterine rupture. I doubt the cesareans themselves are related at all to your lack of periods. For some reason you ar probably not ovulating. Are you breast-feeding still or do you still have milk in your breasts? Even if you are, most women will have a return of ovulation and their periods by this time. Are you feeling like you're having a period each month but just not bleeding? Sometimes you are actually cycling, but scar tissue has closed up the cervix and the blood is just not coming out of the uterus. That is a rare problem after cesarean section, but since you asked, I bring the possibility up! Did you have complications of the procedure itself such as low blood pressure, heavy blood loss, or high fever afterwards? These events can be associated with damage to your hypothalamic-pituitary axis that can affect your hormone production throughout your body. I strongly suggest you go to a doctor and voice your concerns because the problem could be more serious than a "bump" and not having periods. Thanks for reading and I hope this helps!
At Tue Jul 03, 07:14:00 PM 2007,
Anonymous said…
Hi,
my daughter had a c-section 12 days ago due to failure to progress. all went well and a healthy 8.8 pound boy was the result. approx. five days after delivery my daughter started running a high fever and had drainage from the incision site. The physican instructed us to take her to the er immediately when we contacted them she was admitted and in the er her incision opened up completely to the facia. they did a culture and admitted her to the hospital that was five days ago today she went to surgery and had the wound debrided and an I &D performed and is continuing to have the wound packed with wet to dry dressings bid. my concern is that with this infection which I truly believe is nosocomial has caused an increased hardship as her husband cannot work as he must care for the newborn and a 4 year old daughter as well as my daughter will have to be out of work longer than anticipated. this by the way cultured out to be staph. my daughter also may have to return to the or in two days for additional debridement. does she have any recourse on the hospital for loss of income for her family due to this infection? I or we do not want to file malpractice. just looking for a way to help them regain income for excess loss due to this nosocomial infection
At Tue Jul 03, 09:06:00 PM 2007,
Anonymous said…
I just had a 2nd cesarean after attempting a VBAC. It seems that during my first cesarean in 2003, my bladder was attached to my uterus. The younger dr. who started the 2nd cesarean was unfamiliar with this technique and ended up calling a 2nd Dr. in to complete the surgery. Was attaching the bladder to the uterus a common practice in the past? If so why? My labor was very prolonged and when they opened me up there were significant adhesions on the lower segment of my uterus. Is this a common reason for a failed VBAC? Thanks, Maria
At Thu Jul 05, 05:28:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous July 3 0714: I'm sorry your daughter had problems, but unfortunately, infection is one of the recognized complications of cesarean section, especially after a long labor for a big baby. If she is a smoker, or overweight, or had diabetes during the pregnancy, any of these might have put her at even greater risk. This is the time to turn to friends and family or a local church to help with the care of the children. It is not the hospital's responsibility in any way. I also don't necessarily agree that this has to be a nosocomial infection. Staph colonizes normal, otherwise healthy people, but it is becoming a bigger problem, because even 'community acquired' Staph may be methicillin resistant (MRSA). Indeed, we had a woman die from this 1 day following a cesarean section and it was something she brought with her as pneumonia when she came to the hospital. I wrote a post on this subject many months ago. Rather than the 'wet-to-dry dressings' if your daughter qualifies for a Wound Vac, her doctors should look into that for her. It works much better. Good luck and I'm sorry for your trouble. Thanks for reading!
At Thu Jul 05, 05:39:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Maria July 3: I am not exactly sure what they found but are adhesions are a growing problem in OB because of the high rate of cesarean sections and REPEAT cesarean sections (and things are NOT going to get any better with time). It is doubtful the adhesions caused you to fail the trial of VBAC. The bladder does sit right on top of the cervix, and many doctors still push it down lower when they do a c/section to avoid bladder injury when tehy make and repair the uterine incision(although this may not be necessary, if you see in my post on this subject). Anyway, when I trained, the routine was to sew the bladder back up where it started. We have learned in recent years that that probably is not necessary either, but some doctors continue to do this. I will say this, we seemed to have FEWER adhesions when we reapproximated the bladder over the uterine incision line, probably because it made a very smooth surface and covered up the sutures in the uterine incision that might stimulate adhesion formation. Thanks for reading and for your question. Enjoy your baby and forget about the operation!
At Fri Jul 13, 07:05:00 AM 2007,
elaine said…
Was it common not to reapproximate the subcutaneous layer for a time? Because I know an awful lot of cesarean moms end up with a shelf of fat that overhangs their scar. It looks like the fat was pushed out of the way and then not properly pulled back down. If this is a preventable disfigurement then it is truly sad that this was not being done as routine for some time.
At Fri Jul 13, 03:59:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Hi Elaine: Actually, when I trained (too many years ago) we were taught to reapproximate EVERY layer. It has only been in recent years that less and less of that gets done. Some women have the 'disfigurement' because of where the incision was made at the time of delivery; some have just gained weight in all the wrong places; some just do not heal well. Currently we do recommend to our residents a subcutaneous closure for any woman with more than 3 cm of fat, but other places have different routines. Thanks for reading and for your question. I bet a lot of women would like to know the answer to what you asked!
At Thu Jul 26, 02:30:00 PM 2007,
Adeola said…
Hi,
I'm deola. I've had two c-sections. The second was just about 25days ago. i actually attembted a VBAC but eventually had a section again. Today, i noticed a string showing from my incision. I tried to pull it and could pull it a little after which it stopped moving. I'm afraid to pull hard and am scared and wondering why it's there. My doctor didn't tell me there would be any strings, it actually like a tiny rope afterwards. is it normal?
At Fri Jul 27, 05:02:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Hi Adeola: If the "string" is thick, is is probably the suture that was used to close the tough fibrous tissue called the fascia that sits between the fat (under your skin) and the muscle (under the fascia). The fascia is the stuff that holds us together (muscle and fat are rather useless in that regard). Most doctors use a delayed absorbable suture, such as vicryl or PDS) to close the fascia and it can take 60 days or longer to be completely dissolve. If the "string" was very fine, it might have been the suture that was used to close either the fat or the skin. Regardless, if you are 25 days out from your c/section, you are probably healed well enough that you don't need it anyway, so don't fret. You can pull it up with tweasers and cut it off right at the skin, or if you are worried, go see your doctor. Thanks for reading.
At Sun Aug 05, 11:33:00 AM 2007,
yvlyons said…
Hi my name is Yvette. I turned 36 in 2007. I have had 6 pregnancies and 3 births. Three miscarriages between children were early. A blighted ovum. Two DNC's. I did not have any medical complications during my pregnancies. I did have an umbilical hernia after my first pregnancy that was never repaired. I am questioning whether it is safe for me to have a 3rd c-section. I have had one vaginal delivery in 2000 no spinal or epidural. It was a great experience. I had a successful c-section in 2003 due to the baby being breech the week of my delivery date. I had a 2nd repeat c-section in 2005 because my doctor was not in favor of a VBAC. My bladder was nicked during the c-section. Leaving me with a catheter for 2 weeks and no further complications. I was told that I had a lot of scar tissue. The urologist said that my bladder and uterus are now joined, they have become one now. He advised me to mention that should I need surgery in the future. I am wondering if the urologist most likely joined my uterus and bladder after he repaired the nick or if they were joined with scar tissue. Both my OB and the urologist have given me the green light to have another baby. I still question how that can be safe where my bladder is attached to my uterus. Isn't it dangerous for the bladder to be stretched with the uterus as it grows larger and how can they avoid it during the 3rd c-section? My Ob said that they would make a lower vertical incision to avoid the bladder. My concern is that the bladder may have healed up higher or other organs are in this area? Is there any type of test that they can do before a c-section to find a safe place for an incision? My past incisions were lower horizontal (transverse?)I have three healthy boys and I am afraid to put myself through any unnecessary risks when life is good right now. We would just love to add to out happy home if it is safe as the doctors suggested. Maybe it is just my perception of things which is not a realistic concern. Thank you for your time. Any input would give me some peace of mind.
Thank you.
At Tue Aug 07, 06:44:00 PM 2007,
Anonymous said…
Hi, My name is Zara.
I had a c-section in 1996 at the age of 29 after 4 normal pregnancies and 4 normal births. I opted to have a tubal ligation done at the same time.
For the last 5 years I've been having hot flashes and other menopausal related symptoms. Is it possible that the combination of a c-section and a tubal ligation has some how damaged my ovaries thus leading me into early menopause?? Is this reversible? If so, what is the operation called and where can I get it? I'd like to have one more child. Please advise. Thank you.
At Sun Aug 12, 06:17:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Hi Yvette: The bladder sits right on top of the cervix and under completely normal circumstances stretches some as the uterus grows, so I don't think I would worry so much about that. We are seeing more and more women like you who have developed severe scar tissue following cesarean sections. Personally, I think some of that is related to the attempts to 'simplify' the procedure by not closing all the layers as we did many years ago. But, others seem to think otherwise. Since we are now doing three times as many c/sections as we did when I trained, it may also be due in part to the large number of repeat cesareans we do every day. You are at greater risk for damage to bowel and bladder if they are causght up in your adhesions, but if your doctors have given you the 'green light' I would trust their judgment. We can usually tell what's bladder and what isn't! I am probably a little more worried about the integrity of your uterine scar. I would not recommend a trial of lablr in your case because if that turned into an emergency cesarean for fetal induications or uterine rupture, it might not be possible to get the baby out quickly enough if the adhesions are dense. Where they make the next uterine incision will depend on what they find when they get inside of you the next time. There is no reliable 'test' that can be done beforehand. I must caution you though, because of your multiple uterine scars, you are at increased risk for a condition called placenta accreta where the placenta eats into and sometimes through the wall of the uterus and even into the bladder. That is something we can often detect before the operation, so ask your doctor to explain that to you before you make a final decision about having another baby. Good luck with things and thanks for reading! Dr T
At Sun Aug 12, 06:25:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Hi Zara: If you are truly experiencing 'menopausal' symptoms, you may be undergoing premature ovarian failure. Is there any family history of early menopause? Anyway, I doubt either the c/sections or the tubal ligation could have caused that. We are frequently told that some women start experiencing irregular periods after tubal ligation (and I don't think anyone has ever sorted out whether that is simply due to normal aging or some poorly undertsood disruption of 'communication' between the uterus and the ovaries), but I have never heard of the procedure causing ovarian failure (unless of course the blood supply to the ovaries was completely disrupted which is very hard to do). Regardless, if you are going through menopause, there is not anything we can do to reverse that process. If you are interested in trying to get pregnant again, I would suggest you find a good specialist in Reproductive Endocrinology and Infertility (REI) to discuss your options ASAP. They can also evaluate you for premature ovarian failure.
At Wed Aug 15, 08:07:00 AM 2007,
Tiffany said…
MY name is Tiffany, I have had 4-c section bikini cut, do to repeat and large babies 8-9lbs , I want another baby, How many c-sections are safe to have with a uterine scar dehiscence with 2 of my last c-sections?
At Fri Aug 17, 04:01:00 AM 2007,
Anonymous said…
Thank you Doctor your answer has cleared up all my misunderstandings, doubts and concerns. I believe my mother had the same symptoms around my age so it must be premature menopause. I'll get on to a fertility doctor right away... Thanks again. Kindest regards, Zara.
At Fri Aug 17, 05:26:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Zara: Thanks for letting me know. I really appreciate the follow-up. Let me know what you find out! Best wishes... Dr T
At Fri Aug 17, 06:06:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Tiffany Aug 15: You are well beyond "safe" if your uterine scars were not to be attenuated at your last two c/sections! You are just plain lucky, but be careful, sometimes folks run out of luck. You are at increased risk for complete rupture of the uterus (even in the absence of labor), placenta accreta (increta or percreta), and loss of your uterus (and possibly your life and your baby's) with any subsequent pregnancy. You are alos at increased risk for damage to other organs (particularly bladder and bowel) because of adhesions from all of your operations. Do what you will, but be careful! Best of luck if you decide to try again! Dr T
At Sat Sep 15, 09:06:00 AM 2007,
Melissa Naasko said…
Dr. Trofatter:
I recently suffered a 70% placental abruption and was rushed to the closest hospital for surgery. The baby and I are fine despite a 2.8 liter estimated blood loss. I had seven quick, easy vaginal deliveries and un-complicated pregnancies prior to this one, which was complicated by severe polihydrominios. I had a two layer closure and the fascia was sutured closed as well. My doctor prior to my surgery was a family pracitioner and I do not have a relationship with or even know the surgeon who operated on me because of the situation. I am planning on seeing an OB/GYN to discuss my surgery and its implications in any future pregnancies. Still, I would also like to ask your opinion on the likelihood of another abruption given my limited explanation here?
Thank you,
Melissa
At Mon Sep 17, 10:02:00 AM 2007,
Anonymous said…
I had two c-sections, I got infections after both. After the second section, I had to have 2 wound debridement surgeries and many courses of IV antibiotics. Two years later I was getting cellulitis of the pelvic area where my scar was. I found a wonderful doctor who discovered my adhesions (uterus adhesed to abdominal wall). I was in terrible pain. I had a hysterectomy at 30 years old. Go to www.adhesionscenter.com for some great information. Thank you for getting info out there about the risk factors of c-sections!
At Mon Sep 17, 08:27:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Sept 17: Thank you for sharing your experience. Believe me, you are not alone in terms of what you have been through. There is not a day that goes by that we don't have a problem with a patient undergoing a repeat cesarean delivery! I am doing more hysterectomies now than I have done in the past 25 years since going into Maternal-Fetal Medicine. Thanks for reading! Dr T
At Tue Sep 18, 11:09:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Melissa Sept 15: There are many different reasons for placental abruption and your recurrence risk to some degree, depends on why you had this one. I will answer briefly here, but probably will devote an entire post or two to the subject in the future.
From what you have told me, your primary risk factors are your age and, probably more importantly, your high parity (lots of babies). In the absence of any other risk factors, and having had a severe placental abruption, your recurrece risk is in the range of 10-15%. And, if it happens again, the risk goes up to 25-50%.
Part of the problem arises because there are only so many 'implantation sites' inside the uterus. As your parity goes up, there is an increasing likelihood of implantation at a less than favorbale site and the poor placentation that results can lead to placenta previas (over the cervix), placental abruptions (premature separation of the placenta before the birth of the baby), and placenta accreta (in which the placenta 'eats' its way into the wall of the uterus itself rather than just the inner uterine lining, or endometrium).
These conditions increase your risk for poor fetal growth, fetal demise in utero, hypertensive disorders of pregnancy, and bleeding complications. Now that you have had a cesarean delivery, the risks are increased further for all of these problems, especially if the placenta implants beneath the uterine incision scar. If that should happen, the chance for needing a hysterectomy with another pregnancy at the time of delivery also goes up dramatically. Best wishes and thank you for reading and for the great questions! Dr T
At Tue Sep 18, 08:59:00 PM 2007,
Melissa Naasko said…
Thank you, Dr. Trofatter, for answering my question. I truly appreciate your perspective and I will keep a look out for your further posts on this same subject. We will certainly consider seriously the risks of any future pregnancy, especially given my age. The concern here is not that I am older, but rather that I have potentially many years left of fertility as I am only 31. Thanks again
At Fri Sep 21, 09:46:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
You're welcome Melissa and thanks again for reading!
Dr T
At Thu Oct 25, 10:31:00 AM 2007,
Anonymous said…
Hi. My name is Shannon. 12 years ago I had a c-section (vertical incision) at 32 weeks after a diagnosis of HELLPs. With my platelet count so low, c-section was not originally even considered, but after 36 hours of induced labor and failure to dilate, the cord became wrapped around my daughter's neck and c-section became our only option. During the procedure the surgeon nicked my intestines. Along the way, the order for antibiotics was lost and, because of the delay, I developed peritonitis. My uterus scarred to my intestines and was surgically separated; some sort of "mesh" was inserted to keep them from scarring together again. The drainage tube they put in during that surgery broke during removal and had to be surgically removed. All in all, I had 3 more surgeries (there was also a major debridement) in the month after my c section. I was discharged with the wound left open to heal "inside out" to avoid trapping any infection. I have a huge, puckered, distorted scar. 6 years ago I had another c-section, bikini transverse cut, not trial of labor at 33 weeks (my water broke early...go figure). I had no complications but was readmitted 3 weeks later for an abcess along the recent incision.
Over the years, 2 different knots of stitches from the original surgery have become abcessed and been removed in outpatient procedures.
My questions are
1)what sort of "mesh" would have been implanted?
2)if I was to need abdominal surgery, decide to have another baby (unlikely at age 38) or decide to have a WLS procedure like the LapBand, what sort of risk could the adhesions pose?
3)if I had some sort of scar revision, would I risk just developing more adhesions?
4)am I likely to be at greater risk for gynecological issues that may lead to hysterectomy down teh road?
Thanks for your article...very interesting reading1
At Fri Oct 26, 05:32:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Oct 25: Whew, you certainly prove the point that things in OB seem to go very well or VERY badly! I really cannot answer your questions very well without more information. Revision of the abdominal scar alone (by a good surgeon or plastic surgeon) should not be an unusually risky procedure (but neither are most c/sections) because that usually can be done without entering the abdominal cavity. Any intraabdominal procedure will likely be complicated by adhesions that WILL place you at greater risk for bowel/bladder injury. But, again, in experienced hands, those risks can be minimized. With regard to need for future hysterectomy, that depends on you and your family history. If you are overweight, ovulate irregularly, have fibroids, a history of abnormal Pap smears, or a family history of uterine or ovarian cancer, your risks are greater. My suggestion is that you sit down with a good surgeon, tell him/her what you are thinking about, let them get your records and review your case, and then come up with a game plan for the future. They may have some other ideas about what you should do before considering ANY additional elective operative procedures. By the way, since pregnancy keeps trying to kill you, that is one thing you might want to avoid so that you can be around to have fun with your grandchildren! Thanks for reading! Dr T
At Tue Nov 13, 02:21:00 PM 2007,
Anonymous said…
Hi,my name is Shira and on Aug 15th I went into My second C-section. This was schedualed, and all went well and had a healthy baby boy. That all changed the day after when I had my catherather taken out. I went to the shower and about 2 min into the shower I was over come by a great deal of pain! I couldn't stand up straight, hard to breath and a great amount of preasure in my stomach area. All the ob nurses and my doctor and surgeon said that I was experiencing slow moving bowels and extreme gas presure. They just said it would take time. They said this was a common side effect to surgery. 5 days later I was sent home telling me it would just take time. 2 days later I went to the emergency room, still feeling great presure my stomach was actually bigger than when I was pregnant! At the emergency room they said i was going into Kidney failure and needed to be transfered to a bigger hospital, so at 11:30 at night I had to leave my newborn and off to a bigger hospital and at 3:30 in the morning had to do dialisis, and many tests. The next morning they needed a urine sample and had to put a catherater in and after 45 mins of draining they got almost 3 gallons of urine out of my abdominal cavity. COme to find out they nicked my bladder and I was filling up with urine. I was in shock, honestly my family thought I was dying. This was very scary for both my husband and myself. Not to mention some valuable time lost with my newborn.
At Wed Nov 14, 06:24:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Shira Nov 13: Thanks for sharing your story. Unrecognized (at the time of surgery) bladder injuries are becoming a more frequent cause of pregnancy complications related to repeat cesareans. I am sorry you had to go through all that, but I am also very glad they figured out what was going on in time! Other folks aren't so lucky. Thanks for reading! Dr T
At Tue Nov 27, 10:46:00 PM 2007,
Anonymous said…
My name is Michelle I am pregnant with my 9th child. My first delivery was a failed vaginal labor in NJ ( no one in the room at all with us) and pressured to have an epidural where I felt nothing. I had 5 VBACS in a row until in Georgia ( much better than NJ) until #7 which was a shoulder presentation where my water broke at 7cms usually they must brake my water several times so this was way different. They ended up doing an emergency CSection because her arm was mostly down the birth canal by the time I was checked about an hour after my water broke. With my 8th the "experts" kept telling me the baby was big and and had to have another Csection. My midwife supported a VBAC. At 38 weeks and being 3cm dilated for 3 weeks I was pressured into another CSECTION. The baby was 8 pounds 2 oz. It turned out that I had lots of adhesions including a twisted bowel and one ovary behind my back along with the bladder and uterus being adhesed. It was my understanding at the time that all the scar tissue was removed and the bladder and uterus separated. BUt maybe not. I plan to have more children after this baby and don't want to take the risks of another CSection. I felt good after recovering from the last one.
What are my chances of having a successful VBAC if my uterus and bladder are attached and there are more adhesions?
I've been taking Glyconutrients since my surgery and also rubbing them into area of the inscision. They help the body heal and are found in mothers breast milk . They are known as well to stimulate the production of massive amounts of adult stem cells in your bone marrow, so I am not worried about the intergrity of my uterus. I had a level 2 ultrasound and they said the placenta looked great and it was positioned well.
Hope you can comment.
At Thu Nov 29, 11:21:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Nov 27: I cannot imagine any adhesions such as you describe preventing you from delivering vaginally. As you are well aware, your greatest risk is the integrity of the previous scar. You are probably as good a candidate as any for a VBAC after multiple c/sections, but that should definitely be done at an institution that has 24 hour in-house anesthesia coverage, a blood bank, and with an obstetrician who is willing to give you a chance once you have acknowledged the risks and formally documented that with her/him in an informed consent process. Unfortunately, there are many hospitals that cannot, and many physiciaans who will not, give you that chance under the circumstances, so you may have to do some serious looking. Good luck and thanks for reading! Dr T
At Thu Nov 29, 08:55:00 PM 2007,
Anonymous said…
hi I had a c-section almost 3.5 years ago followed by a VBAC exactly 19 months later.One end of my scar is clearly adhered to the layer underneath...it is dented in and puckered and cannot freely move like the other side...It is visible under a bathing suit adn is somewhat painful.Any hope of improving its appearance or decreasing discomfort so long after the fact?
At Sun Dec 02, 09:02:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Nov 29: Any good surgeon or plastic surgeon can probably fix this for you as a simple 'outpatient procedure.' You could also have that taken care of at the time of another c/section, although, since you have had a successful VBAC, I certainly would not recommend having a c/section for that reason alone! Best wishes and thanks for reading! Dr T
At Thu Dec 27, 08:10:00 AM 2007,
Dawn G said…
Dear Doctor,
I had a c-section 3 years ago after I could not push my son out (8lbs 11oz). I am hoping to get pregnant again but I would like to know if I am just putting myself at too much of a risk. I had a 4in.by 6in. cellutis that ruptured on its own after being ignored for 6months. My incesion was infected in the begining also and was relanced and packed daily.
On the operating table the notified me that I am missing an ovary and the falobian tube is just a stub....They also couldn't find one of my kidneys.
Am I more prone to get a sever infection again? Should I be concerned about loosing my kidney?
I have talked to 2 different doctors and recieved 2 different opinions. I am really torn. Thank you for any words of wisdom.
At Thu Jan 17, 11:20:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Dawn G Dec 27: Women who have congenital abnormalities of their genital tracts are at higher risk for other abnormalities, most frequently of the urinary tract, so I am not entirely surprised by the fact you only have one kidney. With regard to your other questions, any pregnancy puts a woman at risk, but quite frankly, it sounds like you did just fine until the delivery and then you had a series of post-operative complications. Yes, women who have had infectious complications are at gretaer risk for a repeat performance, but your doctors should be able to take some steps around the time of surgery to reduce those risks substantially. Because you only have one kidney, you need to watch out for serious urinary tract infections during pregnancy, but as long as that kidney is working well, it has already gotten you through one good pregnancy and there is no reason to suspect it wouldnt again. So, unless there is something you are not telling me about yourself, I don't see why you shouldn't go for another baby unless you just don't want to! Good luck to you and thanks for writing. Dr T
At Thu Jan 24, 02:39:00 PM 2008,
Erin_Owens said…
Hi Dr. I'm pregnant with my third child, and I've had two unplanned c-sections after trials of labor that failed to progress. During my last section, I was on the table for a little under three hours and the OB said that I had some serious adhesions between my uterus and abdominal wall. While he was still operating on me, I asked him if it looked like I could have another child, and he said yes. Well, three years later, I'm pregnant again, and I have a new OB, and she seems very concerned about the adhesions I had last time. I told her that the other OB had spent a LOT of time removing the old adhesions, and asked if that would maybe make the situation easier this time around, and she said not really. She mentioned possibly having to open me horizontally at first to see if the adhesions are severe, and if they are, opening me vertically as well, leaving me with a T scar on my abdomen. My question is, do you think I'm going to have as much of a problem this time around, even after all the work my old OB put in to remove the adhesions and clean me up? I'm going in for the next section on Feb. 1st, and I'm really starting to get worried. I can't have anything happen to me. I have two children at home and one on the way. I guess I'm just wondering how bad it could be. Thanks for reading my question.
At Fri Jan 25, 11:32:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Erin: There really is no way to know until they open you up. Some people tend to form adhesions more readily than others and they recur and others will benefit from all the effort your previous doctor put into your surgery. I would say this, just because adhesions are there does not mean they need to be removed this time around. If they can get the baby out, it doesn't matter how many adhesions are present and, in fact, unless there appears to be some risk for compromising your bowel or interfering with the repair of the uterus, personally, I would just leave them alone. If your doctor appears very concerned about the surgery, she/he might want to have someone more experienced in the wings to help out if there is trouble. We will frequently consult with our GYN Oncologists under these circumstances, even before the surgery, since those folks are generally very experienced in handling difficult pelvic operations and the complications that can arise. Good luck and keep your chin up. All of your babies are STILL going to have a Mom! Let me know how things turn out. Dr T
At Wed Jan 30, 12:29:00 PM 2008,
Anonymous said…
Dr. Trofatter,
What are the ramifications, if any, of having a tubal liation at the time of a repeat C-Section?
JCR,JR.
At Sat Feb 02, 05:06:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To JCR Jan 30: It is a very simple procedure to perform at the time of cesarean, adding about 3-4 minutes (or less) to the operative time. The failure rate should be about 1 in 1000 (although some folks will quote rates as high as 1in 200). It should not add significantly to the postoperative pain or the recovery time from cesarean section. Some women will begin having irregular menstrual cysvles following ti=ubal ligation, but it is hard to determine if this is related to simply aging or to the tubal ligation itself. Hope this helps! Dr T
At Thu Feb 07, 07:01:00 PM 2008,
marie said…
Hello Dr.Trofatter, I too have concerns of adhesions. I am 49 and wanting to stay as healthy as possible. I formed an 8" keloid scare from an abdomanal operation at 8 yrs old. At 26 an emergency c-section for a sick baby with bikini cut. VBAC at 28..no problems. At 30 a vaginal delivery with a uterus that ripped top to bottom and side to side. Everyones o.k. Tubes tied at 33 with an overnight because of a poked uterus. Now my uterus is attached 6" to outside. I've been shown how to do deep palpatation to break up adhesions...because they never stop growing...yikes! Among other things..why does my heart feel weird when I to keigel exercises? Thanks for your attention given. Marie
At Wed Feb 13, 11:28:00 AM 2008,
Mim said…
Hi, I am 34. I have had two children, an 11yr old and 7yr old. My first was a failed vaginal delivery and had to have a c-section. My last son, I tried to go vaginal again and ruptured my uterus and caused damage to my bladder (extremely infected and raw) . It was attached to my uterus and I had very dense scar tissue. I have now been diagnosed with Interstitial Cystitis. During the whole ordeal I lost a lot of blood and had to have a transfusion. We would love to have another child but my doctor advises the risks to my bladder and another possible rupture are too high. She said the uterus wall is also extremely thin only 2mm. Please could you give me your opinion regarding these and other possible risks, so hopefully I can make an informed decision.Thank you
At Thu Feb 14, 06:38:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Marie Feb 7: Your heart may "feel weird" when you do Kegel exercises because you are probably holding your breath while trying to exhale while your mouth is closed. That is called a 'Valsalva maneuver'. This is the same technique you might use to 'clear your ears' when flying, however, it can have effects on your heart as well and, indeed, is used to diagnose and treat certain heart conditions. When you 'Valsalva', the first thing that happens is that the pressure in the chest increases, forcing blood from the lungs into the left heart. This usually causes an increase in blood pressure at first. After 5-10 seconds however, if you keep holding your breath, the pressure in the chest will slow blood return to the heart which will then reduce cardiac output and the blood pressure will fall. When the blood pressure falls, your autonomic reflexes try to fix things by constricting your blood vessels and increasing the heart rate, but since blood not enough blood is returning to the heart, cardiac output will remain low and you might start to feel lightheaded and dizzy and sense the heart 'palpitations'. Usually these are not a serious problem unless you have some underlying heart disease. I guess I would coaution you that if you feel really "weird" or experience any chest pain while doing your exercises, hold off on the Kegel's and have a doctor evaluate your heart! Thanks for reading. Dr T
At Fri Feb 15, 10:14:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Mim Feb 13. I am afraid your doctor is probably correct. There is high risk of another uterine rupture as well as further damage to your bladder and urinary tract. There is also no certainty thatthe 'adhesions' will make anotther operation any easier. In fact, if you rupture the uterus next time, the outcome might not be so good for either you or the baby. Let me make a suggestion. If you have your heart set on another baby that is entirely your own, consider talking with a reproductive endocrinologist about having IVF and hiring a 'surrogate' to carry the baby for you! Good luck and thanks for writing. Dr T
At Tue Feb 26, 06:19:00 AM 2008,
Erin said…
Dear Doctor-
I posted about a month back. My name is Erin and I was very concerned about going in for my third section as I had some problems with adhesions during my second section. Anyway, I just wanted to post back to let you know that all went well. They did end up having to cut my uterus vertically as I had major adhesions to the bladder and abdominal wall. Jack (the cutest baby) and I are doing very well. My only issue now is that my husband and I always wanted 4 kids, and I'm unsure how wise it would be to try again in the future. At any rate, I just wanted to let you know that I really appreciated you taking the time to answer my question, and you put me more at ease going into the surgery. Thanks again!!!!
At Wed Feb 27, 07:37:00 AM 2008,
Mim said…
Hi, Dr. This is Mim again (From Feb 13). Thank you for your advice and suggestion, but unfortunately because of religious beliefs I cannot go the surrogate route. I just read the post by Erin who said she had a vertical incision and all went well. I know my situation is different, but do you think it's possible to have a successful delivery if I was to have a vertical incision? Also why are vertical incisions not a common practice anymore?
Thank you.
At Wed Feb 27, 05:14:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Erin Feb 26: Congratulations on the good outcome! I am sure your doctor informed you, though, that a vertical incision in the uterus has a gretaer risk for rupture even before the onset of labor. keep that in mind when you go for the fourth baby! Thanks for letting us know about your baby! Dr T
At Wed Feb 27, 05:17:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Mim: The type of incision for another pregnancy will not affect your chance for complications with that pregnancy, but a vertical incision increase your risk for uterine rupture even more with the pregnancy after that! That's why we don't do vertical incisions unless we are in a situation where we have to. Take care and thanks again for writing, Mim. Dr T
At Thu Feb 28, 03:16:00 PM 2008,
Anonymous said…
Hi, I'm hoping you might be able to help me - I had a C section delivery including stitching the abdominal muscles together due to diastasis 10 months ago and still have constant pain. It hurts to wear clothes or anything touching my abdomen from about an inch below my bellybutton down to the bikini scar and all along the scar. My family physician originally thought it was neuropathy and sent me for nerve blocks at the hospital pain clinic which have slightly reduced the pain level but no large effect. I also have bladder pain and recurrent infections despite every attempt to reduce the possibility of infection or irritation of my bladder. I'm concerned that my bladder may have been nicked. So far, I've had ultrasounds that have shown no abdominal issues like fluid accumulation or obvious signs of infection. Now my family doctor has referred me for laparoscopy - but I am concerned since she has also suggested that I might be having some sort of general inflammatory reaction as part of the healing process from the C section or possibly an allergic reaction to the suture material used (and the last thing I want is to generate more wounds or introduce more suture material and make things worse!). I'm not sure what to do and am also very hopeful that I could have another child in future. I would be so grateful for any advice you could provide, it has been a difficult 10 months. Thank you so much, Allison
At Tue Mar 04, 06:26:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Allison Feb 28: You most likely have 'adhesions' (scar tissue) that formed beneath your incision, perhaps where the abdominal muscles were reapproximated. These might involve the omentum, the bowel, or the uterus itself. At times the bladder can also be involved. I suggest going ahead with the laparoscopy. That should be the easiest way to establish the diagnosis and, perhaps, treat the problem. Let us know how things turn out. Best of luck. Dr T
At Thu Mar 13, 01:35:00 PM 2008,
John said…
HI my name is Gloria, I just recently had a vertical / classical c-section at 28.3 weeks lost our twins. This was Our first pregnancy. How soon is it safe to get pregnant again? What are the chances of my Uterus rupturing?
At Wed Mar 19, 06:07:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Gloria Mar 13: Classical c/sections (vertical scars in the fundus of the uterus) are notorious for not healing well despite great care that is usually taken to close the uterine incision in several layers. When the uterus contracts following delivery, that portion of the uterus tends to pull apart, putting the suture line under considerable tension and resulting in a poorly healed scar. Although statistics vary, about 12% of women will rupture their uterus if they labor with a subsequent pregnancy and about one-third will do so even prior to the onset of labor. Our usual recommendation is to perform an amniocentesis at 36-37 weeks in a subsequent pregnancy to assess fetal lung maturity and deliver prior to term. I cannot tell you how long you should wait before trying again to conceive, but would strongly recommend at least 6 months, if not a year, to give the scar as long as possible to mature before putting a lot of tension on it with another pregnancy. Scar tissue does not stretch the same way healthy uterine tissue does as the uterus expands to accomodate the baby. Thanks for writing and nest wishes! Dr T
At Mon Mar 24, 03:24:00 PM 2008,
lou said…
hi,i have had 3 c-sections.1 emergency due to fetal distress and 2 planned.recovery got better with each one.about 2 years ago i went to see my ob.gyn as i want another child.she said she saw no reason why i shouldnt because at the 3rd i had minimal scarring and minimal blood loss.i still havnt tried though as im scared due to the old rule 3 should be the maximum.what is your opinion on this.thanks lou
At Tue Mar 25, 05:16:00 AM 2008,
Anonymous said…
hi,im lou.i have had 3 previous c-sections.1st emergency due to fetal disstress and the second 2 were planned.the first 2 children have an age gap of 16months and my last was 5 years after.i went to see my ob/gyn about having another child 2 years ago,she said she said to go ahead as my last section there was minimal scarring and minimal blood loss.but i have still not tried as im worried because the rule no more than 3 has stuck in my head.what is your opinion on this
At Wed Mar 26, 07:41:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Lou: There really is no maximum, especially, if you have healed well, although the risk does increase with each for complications. Your doctor is in the best position to counsel you in that regard because she has seen what you have to work with! I would follow her advic under the circumstances. Dr T
At Thu Mar 27, 02:04:00 AM 2008,
Anonymous said…
my main worry is my uterus completly popping open and me bleeding to death before i can get to hospital.do you normally have warning signs that this is going to happen before you rupture.lou
At Thu Mar 27, 06:32:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Lou: I understand your concerns! Sometimes you do have warning signs and sometimes you do not! The best thing you have going for you is that you have healed well in the past and probably will again with the recent c/section. By the way, sometimes we can see a 'uterine defect' at the site of the previous scar by ultrasound later in pregnancy. If you get pregnant again, that is something for your doctor to consider. Dr T
At Sun Mar 30, 11:45:00 AM 2008,
Anonymous said…
hi,lou again.what is the actual percentage of people who rupture on 4th pregnancy after 3 c-sections.and is that explosive rupture or where the scar comes apart a little and noticed at delivery.also does some of the percentage include people that have been warned to have no more due to extensive scarring or previous rupture
At Sun Mar 30, 02:10:00 PM 2008,
Anonymous said…
hi my name is brandi and i am 23yrs old and i am having my 5th c-section and i am really scared but my doctor is telling me that everything is going to be alright.What do u think DR.t
At Wed Apr 02, 07:10:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Lou and Brandi: All I can tell both of you is that the risks increase with each cesarean delivery. Uterine rupture is NOT the primary risk! The more common risks are for abnormalities of placentation, such as placenta previa and placenta accreta, more intraabdominal adhesions, longer operative times, and increased risk for hemorrhage, damage to bladder and bowel, and for hysterectomy. Your own risk depends on how well you were repaired, how well you heal, how soon after your c/sections you got pregnant again, and if you had any complications of your procedures such as excessive bleeding or infection as well as your body habitus an associated medical conditions. You must trust your doctors and take your chances. The most common signs/symptoms associated with uterine are decreased fetal movement or an abnormal fetal heart rate tracing, abdominal pain and bleeding - BUT, 'silent' separation of the uterine scar can occur throughout pregnancy with absolutely no symptoms prior to the acute complete separation of the previous scar. Best of luck to both of you. Dr T
At Fri Apr 04, 08:19:00 AM 2008,
Anonymous said…
Dr. Trofatter,
I had an emergency c-section at full term three months ago due to fetal distress during an induced labor. Very sadly, our baby passed away. My doctor gave me the ok to try again four - six months after the c-section (which we are now coming up on), but I've since read anything from three months through eighteen months suggested as waiting times. I have had a transverse cut and seemed to have healed very well physically (no complications post-section). What is your opinion on the risks of conceiving again three - six months post c-section, and how significantly are those risks lessened by waiting longer?
At Fri Apr 04, 04:33:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 4: I am sorry for your loss. I usually ask women to wait at least 4-6 months after a cesarean delivery, especially if the cesarean was at term. This gives the uterine scar chance to heal more thoroughly and the inner lining of the uterus (endometrium)to become restored as much as possible at the site of the uterine scar. If you have healed well, hopefully, that will minimize your risk for uterine rupture and for a condition called 'placenta accreta' where the placenta grows into the muscle of the uterus that normally underlies the endometrium. Other advantages are that time gives your body a chance to recover, both physically and psychologically. Pregnancies within a year of a previous delivery are at increased risk for complications. You should use this time to replenish your iron, vitamin, and calcium stores. Also, did your doctors ever determine why your baby had problems and are there some conditions for which you might need to be evaluated before you conceive again? We wish you the best and thanks for writing. Dr T
At Sun Apr 13, 06:36:00 PM 2008,
Anonymous said…
Hi Dr T. my name is brandi and i am on my 5th c-section.i have had a ultrasound to see if my placeta was growing into my utersia and its not i did have complacations with the other 4 c-sections so do you think this one will go good to.
At Tue Apr 15, 06:54:00 PM 2008,