Inadvertent Laparoelytrotomy During the Second-Stage Cesarean Section: Relooking the Lost Art and Proposing Surgical Management and Prevention Strategies

Introduction Laparoelytrotomy, or anterior vaginotomy, describes a transverse vaginal incision. It has been described since the 19th century1–3 as a method of delivering the fetus during a second stage cesarean section (CS).4,5 More recently, reports have been published on inadvertent laparoelytrotomy during emergency CS at full cervical dilatation, due to the anatomical changes that occur with prolonged duration of obstructed labor. There has been an increasing incidence CS performed at full dilatation, 6,7 likely due to increasing rates of failed operative delivery and reduced attempts at instrumental delivery. The difficulties of second-stage CS arise from the impaction of the fetal head in the maternal pelvis. With increased duration of the second stage of labor, fetal head impaction and stretching of the lower uterine section distort the normal anatomical landmarks that differentiate the vagina, cervix, and uterine body.8 De Lee9 described retraction of the cervical lip with cephalad advancement of the vagina, such that in obstructed labor, the cervix may retract to a point where most of the fetus lies within the vagina.1 Hence, a standard incision on what appears to be the lower uterine segment may risk incising into the bladder, vagina (i.e., inadvertent elytrotomy) or cervix. The possible levels of uterine incision during a CS in the second stage of labor are shown in Figure 1.Figure 1: Possible levels of uterine incision during second stage of labor. A Uterine incision at the original attachment of the uterovesical fold after retracting down the bladder. B At this level, inadvertent incision may involve the fully dilated and retracted cervix, vagina, or both. C Level of vaginal incision below the cervix after bladder has been retracted (laparoelytrotomy).Prolonged second stage of labor, emergency setting,10 and multiparity5 are described risk factors for elytrotomy. Complications encompass hemorrhage from uterine artery injury, bladder and ureteric injury and fistula, infection,11 laceration of adjacent ligaments, difficult approximation of the vaginal incision,12 uterine and cervical trauma, and fetal trauma.5 We present our repair technique during a case of inadvertent elytrotomy during an emergency second-stage CS. We also propose strategies for prevention, including our innovative classification of levels of the impacted fetal head and methods for disimpaction at each level. Our experience Our case was a middle-aged primigravida in her 40s who was admitted for term labor and progressed from a cervical dilatation of 2.5 cm to os full within 11.5 hours. However, she remained at full cervical dilatation for 3 hours before eventual delivery because of a combination of poor maternal efforts at pushing and a likely element of cephalopelvic disproportion. In view of nonreassuring fetal heart rate abnormalities, decision was made to expedite delivery. After an uneventful fetal delivery, it was noted that the intended uterine incision was in fact at the level of the vagina below the fully dilated cervix. An associated full-thickness bladder injury was noted. The bladder was repaired by urologists and an indwelling catheter was left in situ for 14 days postoperatively. The vaginal incision was repaired in layers as described in the following discussion. Postoperatively, the patient developed ileus, which resolved with nasogastric tube decompression and bowel rest. She was discharged well on the eighth day postoperatively. After 14 days of bladder drainage, a check cystogram performed confirmed intact bladder integrity, and the urinary catheter was removed. Repair procedure Goodlin et al.1,11 described the anterior vaginotomy procedure. Prerequisites are a fully dilated and retracted cervix such that the upper 4 cm of the anterior vagina is exposed. The fetal vertex should be well into the vagina. The uterovesical fold should be brought downward further than in a traditional CS, and the anterior vagina identified by a ballooned, shiny appearance. A transverse incision into the anterior vagina is made. He described repair of the vaginal incision using a single layer of interrupted figure-of-eight chromic sutures.1 Double-layer running lock closure after antibiotic irrigation of the vagina has also been described.11 Many authors have described common principles of repair—prompt recognition, meticulous hemostasis, and careful inspection for bladder injury, followed by anatomical closure of the vaginal defect.10,12,13 Our proposed repair technique is as follows: 1. Identify the anatomy (Figure 2). (1). Identify the posterior fornix of the vagina, the cervix, and lateral vaginal angles. (2). Identify the uterine artery and its descending (vaginal) branch, as well as the ureter. (3). From the lateral vaginal angles on both sides, trace the anterior vaginal wall laterally to medially. (4). Use nontraumatic forceps (Green Armytage or Babcock) to raise up the lower rim of the anterior vaginal wall (or anchor the rim with 2–0 Polyglactin sutures [Ethicon Coated Polyglactin 910 suture] held by artery forceps to raise up the vaginal wall). 2. Anchor the lateral angles of the vagina to the lateral angles of the cervix. 3. Inspect for vertical tears in the lower rim of the anterior vagina that may extend downward toward the bladder. 4. If vertical tears are present, suture/repair them first. Caution at this point not to damage the bladder neck—an indwelling urinary catheter is helpful to identify the bladder. (1). The safest way to stitch the vagina without injuring the bladder is running the suture inside the vagina. (2) The apex of the vaginal tear can be approached vaginally—suture vaginally from the apex of the tear to close the vertical tear and then bring the suture up through the abdominal incision to complete the repair of the vertical tear abdominally 5. After repairing vertical tears, approximate the lower rim of the vagina to the remnant upper rim of the vagina and anterior cervix to create the neo-anterior vaginal fornix. 6. Anchor the vagina to the cervix and lower segment of the uterus to support the cervix to the vagina. The suture should run through a good amount of the cervical tissue and not just vaginal wall, which is thin and may tear. Figure 2: Laparoelytrotomy and vaginal wall identification. A Cervical rim. B Lateral vaginal angle. C Lower rim of anterior vaginal wall tear.Prevention steps that could avoid a vaginal incision We advocate two prevention strategies. 1. Incise the uterus at the attachment of the uterovesical fold to the uterus, rather below this margin. This is almost always a consistent attachment to the uterus rather than to the vagina. (1) Because of the stretching of the lower uterine segment in the second stage with resultant advancement of the vagina, the uterine incision should be made higher to avoid inadvertent incision into the cervix or vagina.8 (2) Rashid5 proposed keeping the uterine incision within 2 to 3 cm from uterovesical fold. Avoid excessively retracting down the uterovesical fold. (1) The uterovesical fold and bladder can be retracted downward easily during the second stage when the impacted fetal head provides a firm base. (2) Excessively retracting the bladder downwards will increase exposure of the anterior vagina and increase the risk of incising lower than expected, as it becomes difficult to differentiate the lower uterine segment from the vagina (Figure 1—levels b and c are difficult to differentiate). (3) Keeping a vaginal pack at the vaginal fornix that can be easily identified as the level of the vagina may also help to avoid vaginotomy. However, even if an incision on the lower uterine segment is correctly made, incorrect method of disimpacting the fetal head during delivery may lead to extension of tears in the lower uterine segment, as well as cervical or vaginal tears. The resultant tear is more complex as the vagina, cervix, and uterus all require repair. This contrasts to when a direct elytrotomy is made, which requires only vaginal repair. We feel that recognition of the potential levels of fetal head impaction and methods to disimpact the head at different levels can help prevent inadvertent elytrotomy. Impacted fetal head classification The fetal head can be impacted at three different levels during the cardinal movements of labor as the fetal head passes through the maternal pelvis. At each potential level of impaction, the method of disimpaction has to be modified (Figure 3).Figure 3: Coronal view of level of impacted fetal head demonstrating the available spaces within the pelvis to insert the hand for disimpaction of the fetal head in different positions. OT: Occipito-transverse position; ROA: Right occipito-anterior position; ROP: Right occipito-posterior position. 1. Level 1 impacted fetal head: at the pelvic brim The fetal head in the antero-posterior diameter impacts with the transverse diameter of the inlet of pelvis. Method of disimpaction: At this level, there is more room at the anterior aspect of the pelvis; hence, after disimpaction of the fetal shoulders, the hand should be inserted anteriorly into the pelvis to disimpact the fetal head. 2. Level 2 impacted fetal head: between the pelvic brim and the ischial spines, in the midcavity of the pelvis The fetal head undergoes internal rotation from right or left occipito-transverse position to the right or left occipito-anterior (OA) or occipito-posterior (OP) position. During this internal rotation process in the midcavity, the fetal head can get impacted in the right, left, or direct OA or OP position. Method of disimpaction: The hand of the surgeon should be inserted either laterally (if direct OA/OP) or anteriorly (if right or left OA/OP) depending on the position of the fetal head. 3. Level 3 impacted fetal head: at the outlet of the pelvis below the ischial spines The fetal head is in the OA or OP position. Method of disimpaction: At this point, the hand should be inserted laterally into the pelvis to disengage the fetal head, as more space is found laterally. The push and pull method should be used—with an assistant flexing and “pushing” up the fetal head from the vagina, while the surgeon “pulls” and delivers the fetal head abdominally (Figure 4).Figure 4: Disimpacting the head using the pushing and pulling method.Laparoelytrotomy may be an alternative for the delivery of the deeply impacted fetal head, as disimpaction methods such as pushing the head up vaginally can cause fetal trauma.8 Another benefit is the maintenance of uterine integrity—patients can thus have a safe trial of vaginal birth in subsequent pregnancies without the increased risk of uterine scar rupture.1 Without a uterine scar, there is potentially reduced risk of morbidity associated with myometrial scar niche defects14 including placenta accreta spectrum and irregular bleeding. Cases of well-managed laparoelytrotomy reported have had good prognosis,12 and fetal and future obstetric outcomes were not affected.10 Whether in the future the benefit to subsequent pregnancies becomes the basis for deliberate laparoelytrotomy in CS at full cervical dilatation remains uncertain. Conclusions Understanding the labor mechanism and delivering the impacted fetal head is important to avoid unintentional laparoelytrotomy and avoid its associated complications. If a laparoelytrotomy occurs, a clear understanding of the anatomy is required before attempting repair.