**3.1 C-section after obstructed labor**

In some cases, a C-section after obstructed labor can cause high morbidity or mortality for the woman, so in case of fetal death and if a vaginal destructive procedure is possible, this may be the most advisable course of action. If the fetus is in a cephalic presentation, the skull can be shattered to remove the brain material, allowing the skull to collapse and stillbirth to happen. Although morally disturbing, in most cases, a vaginal delivery is preferable to a C-section. These women are particularly at risk of uterine atony and post-partum hemorrhage, so delivery should only be started in contexts where resuscitation is present; these women often have a history of recent or past infection and an increased risk of placental abruption: it is essential to start an antibiotic treatment and/or antithrombotic prophylaxis [41]. After childbirth and for several days of the puerperium, it is mandatory to perform a careful evaluation of the vagina and cervix to promptly diagnose vaginal, cervical, and bladder necrosis. All women who have had a long period of obstructed labor may need a bladder catheter for 5–7 days, and any fistula formation should be promptly diagnosed [41]. In those cases where there is a live fetus (or, in special circumstances, stillbirth) and an informed decision has been made to perform a C-section, there are some technical issues that deserve to be considered:


The resulting damage can cause permanent damage to the urinary tract. The best way to avoid this situation is to initially disengage the fetal head vaginally, with a slight upward pressure, before starting the actual cesarean section. Disengagement

may take a few minutes and is usually associated with a loud sucking sound and upward movement of the fetal head returning to the maternal pelvis. Overall, it is advisable to operate with the patient in a low lithotomy position to allow vaginal access during surgery; in addition, a midline incision should be made with extensive exposure of the lower uterine segment. The hysterotomy, after careful identification of the bladder, should be performed higher on the uterus than in an unobstructed labor; a narrow U-shaped incision, directed upward away from the uterine arteries, remains the preferable cutting mode. Before the extraction of the fetal head, an assistant can gently lift the head into the pelvis, to minimize trauma on the lower uterine segment and on the bladder. Uterine atony and postpartum hemorrhage may develop after the extraction, so it is necessary to administer oxytocin and start a uterine massage with manual compression of the myometrium. At the slightest sign of uterine atony and persistent hemorrhage, balloon tamponade (Bakri), compression sutures, and concomitant use of other uterotonic drugs should be resorted to immediately. In most low-resource settings, early recognition of bleeding and the aggressive use of methods to reduce blood loss are mandatory. In this setting, a fully dilated C-section can be performed even after a long labor, and such delays can cause further complications, including a longer hospital stay, increased risk of hemorrhage, the extension of the surgical incision with laceration of the vagina or uterine arteries, the development of lesions to the genitourinary and/or gastrointestinal tract, and the onset of postoperative fever [24]. In the case of extremely prolonged and hindered labor, necrosis of the cervix may develop with separation of the uterus and vagina, and it is almost always accompanied by the presence of a stillbirth, infection or sepsis, and extensive destruction of the bladder, usually at the level of the trine. At the same time, the risk of other complications, such as acute respiratory distress syndrome and pulmonary compromise, increases; it is advisable to transfer the patient to a reference center to avoid such occurrences. Hysterectomy may be the best option due to the likely presence of micro-abscesses in the damaged myometrial tissue, with such significant lesions and the high risk of uterine necrosis. Particular attention should be paid to the ureters to ensure their patency and integrity; in the event that the ureters were detached and no urological expertise is available, catheterization with ureteral stents and urine drainage in a sterile bag are used, while the patient is transported to a special department and undergoes definitive repair. It has recently been suggested that healthcare professionals should be trained to perform the symphysiotomy in all settings [42]. Symphysiotomy is an old operation in which the fibers of the pubic symphysis are partially divided to allow the separation of the symphysis and therefore the enlargement of the pelvic dimensions, in order to facilitate vaginal birth in the presence of cephalopelvic disproportion; this surgery can be performed under local anesthesia and does not require an operating room or advanced surgical skills [42, 43]. A recent review concluded that symphysiotomy can be a life-saving procedure in certain circumstances and that appropriate guidelines should be drawn up for the indications of this procedure [43].

#### **3.2 C-section in obese women**

Overweight and obesity (BMI 30–45) are more common than underweight in young women residing in both urban and rural areas of many countries with adequate economic resources. In the teaching hospital of the University of Nigeria, Enugu, from May 2008 to December 2010, there was an incidence of 12.4% of pathological maternal obesity [44]. Complication rates in obese women are similar in different

parts of the world and include intra-partum and postoperative complications such as wound infection and endometritis, wound opening, hematoma, or seroma.

### **3.3 Myomectomy during C-section**

Since access to blood products is insufficient in countries with limited resources and myomectomy is associated with an increase in blood loss, there is little experience in performing these two interventions in these settings. A study conducted in Accra, Ghana, comparing cesarean sections with and without myomectomy [45] enrolled 24 women, of whom 12 were with leiomyomas and 12 without. In women undergoing myomectomy within the cesarean section, the surgery duration was 11.25 minutes longer than that performed on women with a regular uterus; however, this difference was not statistically significant. There was comparable blood loss in the two groups, with an estimated mean of 392 mL in patients undergoing myomectomy versus 388 mL in patients in whom the procedure was not performed. In a systematic review of nine studies in women who underwent myomectomy during a cesarean section, there was a greater than 0.30 g/dL drop in hemoglobin in the myomectomy and cesarean group compared to the control group, but the difference was not found to be significant [46]. These data suggest that a cesarean section and myomectomy may be a reasonable option for those women (e.g., with anterior leiomyoma) who are potentially at risk for postoperative bleeding.
