**2.13 Retroperitoneal hemorrhage during a cesarean section**

The most common cause of retroperitoneal hemorrhage at the time of a C-section is the extension of a hysterotomy in the broad ligament with injury to the uterine artery. This lesion may be unrecognized for some time, and often, it is discovered once the blood loss is significant and may have caused the formation of hematomas. In most cases, unless there is an immediate need to drain the blood collection into the retroperitoneum, the safest and most effective way to control bleeding may be the embolization of the uterine arteries or other supply arteries. Attempting to locate the bleeding vessel within an established retroperitoneal hematoma is difficult; if possible and only if the patient is hemodynamically stable, selective embolization may be an option. If embolization is ineffective or impractical and in the presence of continuous life-threatening bleeding, it may become impossible to avoid surgery. In this case, regardless of the initial incision, it is preferable to make a midline

abdominal incision, to allow access to the upper retroperitoneum; it is necessary to include in the team a vascular surgeon who can resort to methods such as aortic compression, aortic cross-locking, and the positioning of intraortic balloon devices [32, 33]. It is preferable to enter the retroperitoneum at the top and where there is no hematoma in order to correctly identify the vascular structures and the possible source of the bleeding. In an unstable patient with coagulopathy, compression of the pelvic structures to temporarily reduce blood loss may provide time for life-saving resuscitation. The placement of a pelvic pressure gauze pack [35] or a balloon device to compress the pelvic lateral walls [36] may allow additional time for the aforementioned resuscitation efforts. The combination of pelvic pressure and embolization can allow definitive control of the bleeding.

### **3. C-section in low-resource countries**

Most of the complications seen in well-resourced obstetric settings also occur in limited-resource settings, often with a higher incidence. Fetal heart rate monitoring during labor is relatively rare in contexts with limited resources, as it is infrequent to perform a C-section due to impaired fetal conditions; most urgent or emergent cesarean sections are performed for obstructed labor, antepartum hemorrhage, and uterine rupture. Prolonged labor is followed by dehydration, anemia, infection, and sepsis. The uterus is often edematous and ischemic, with areas of bleeding in the myometrium, and in many of these cases, fetal death has already occurred. Stabilization of the maternal condition prior to surgery is crucial in patients with precarious balance. An urgent C-section performed to attempt to rescue a compromised fetus must be carefully weighed against the risk of losing the mother during or after surgery due to inadequate resuscitation capacity in the face of sepsis or hypovolemic or hemorrhagic shock. In many cases, the mother dies from hypovolemic shock after a technically successful cesarean section with average blood loss simply because she cannot tolerate such loss. Such a situation may exist in women with severe chronic anemia due to malaria or other causes (e.g., malnutrition, hookworm, or other helminth infestation) where there has been time for the mother to compensate for a chronically low hemoglobin level (such as 4 or 5 mg/dl), but she is unable to sustain an average blood loss of 500 cc as the heart rate and output are already at the limits of their capacity. In these cases, blood pressure drops with slight changes in stroke volume, and there is no compensatory response. Performing spinal or general anesthesia on a woman in septic shock will often represent insurmountable stress. The clinician should understand that maternal outcome is primary and that some decisions that are absolutely not contemplated in high-resource settings must necessarily be implemented in such scenarios. The obstetric surgery algorithm includes acts that are different from those used in a well-resourced environment, such as assessing whether the mother can reasonably survive the anesthesia, stress, and blood loss of a normal C-section compared to her state of health. It may be reasonable to proceed with the surgery if the setting has all the characteristics to safely perform the surgery such as a skilled anesthetist and medical team and required equipment and blood products. If, on the other hand, she is in a facility without access to emergency resuscitation and blood transfusion, the wisest action could be to delay any surgery until the maternal condition improves or to transport the patient to a more equipped facility; such a decision could inevitably involve the loss of the fetus. In the case of fetal death and obstructed labor, performing a destructive fetal procedure to allow vaginal delivery and avoid major

### *Complex Cesarean Section DOI: http://dx.doi.org/10.5772/intechopen.109165*

abdominal surgery may be an acceptable option in expert hands [37, 38]. Although the application of these procedures is a rare event and training in such practices is almost nonexistent in well-resourced environments, it would be advisable to carry out specific training considering multiple circumstances. Considering the low resources, abdominal surgery can be avoided in women with fetal death and placental abruption, and vaginal delivery can be performed safely without serious complications or loss of maternal life [39, 40]. In many resource-limited settings, the rate of uterine rupture is estimated to be much higher than in high-resource settings, possibly due to traditional practices that encourage the use of herbs and drugs to accelerate labor. Many of the decision-making problems mentioned above are not the ones that most physicians trained in high-resource settings usually face, so it would be necessary to be trained in high-level institutions before being employed in low-resource settings. This preparation may include participation in conferences, counseling by a mental health professional, simulated scenarios, and interviews with people with experience in this area. The staff should be closely monitored for signs of stress; demoralization; feelings of hopelessness, anger, and frustration with the local system; and PTSD (post-traumatic stress disorder), which can occur at any time during their stay.
