**2.4 Uterine leiomyomas**

The incidence of uterine leiomyomas in pregnancy ranges from 0.1 to 3.9% [15, 16]. Uterine leiomyomas can cause various complications during pregnancy, including recurrent miscarriage, preterm birth, premature birth, premature rupture of membranes (PROM), and malpresentation. Furthermore, large uterine myomas are at risk of degeneration during pregnancy, leading to inflammation and pain accompanying the degenerative process. Furthermore, women with uterine leiomyomas were more likely to experience complications of labor and delivery, such as dysfunctional or prolonged labor, breech presentation, and cesarean delivery (OR, 1.90; 95% CI, 1.65–2.18); women with leiomyomas were more likely to require a cesarean section than women whose uterus was of regular morphology (OR, 7.59; 95% CI, 5.47–10.53). Even with medical indications for a cesarean section, women with uterine leiomyomas were much more likely to require a cesarean section (OR, 5.26; 95% CI, 3.98–6.95). A systematic review examining the influence of uterine leiomyomas on the whole course of pregnancy showed that the difficulties of a cesarean section depend on the number and location of the fibroids [16]. In a study based on hospital records among women who gave birth between 1987 and 1993 in Washington (USA), the prevalence of diagnosed uterine leiomyoma was 0.37% [15]. The study showed that women with uterine leiomyomas were more likely to have pregnancy complications, including first-trimester bleeding, placental abruption, and PROM (OR, 1.87; 95% CI, 1.59–2.20). Several factors must be taken into consideration when determining the best way to deliver: women with single pregnancy and a single large fibroid should undergo a primary cesarean section if the fetal head is unable to pass the myoma and engage in the pelvis. If the uterine myoma involves a significant portion of the lower uterine segment, thus making a low transverse incision difficult or impossible to access through the uterus, the only viable and safe option may be a classic incision. The safety of myomectomy at the time of a cesarean section has long been debated due to the possibility of uncontrollable bleeding following the removal of uterine myomas in the presence of increased vascularity during pregnancy [17]. A retrospective case–control study of 120 women with uterine leiomyomas present during delivery included 40 women who underwent myomectomy at the time of a cesarean section and 80 controls without myomectomy [16]. The authors defined an excessive intraoperative blood loss as both a drop in hematocrit of 10 points or more

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

from the preoperative value and the need for a transfusion. The surgical technique was described as follows: "A linear incision was made on the myoma and electrocautery was used to remove the myomas with minimal blood loss. The closure of the myometrium was made in one or two layers using absorbable broken sutures (1/0 vicryl caliber). The serosa is sutured using a continuous absorbable suture (2/0 or 3/0 vicryl caliber)." Women who had undergone myomectomy at the time of cesarean section had statistically larger uterine leiomyomas compared to those who did not have a myomectomy (8.1 ± 4.7 cm vs. 5.7 ± 2.7 cm, *P* < 0.05). There was no statistically significant difference in the rate of bleeding (12.5% vs. 11.3%) or postoperative fever (defined as temperature ≥ 38.0° C; 7.5% vs. 10%), while myomectomy involved longer operations (53.3 ± 18.6 minutes vs. 44, 4 ± 6.7 minutes, *P* < 0.05) and a longer length of hospitalization (3.3 ± 0.8 gi hours vs. 2.7 ± 0.6 days, *P* < 0.05). A large university hospital in China has adopted the policy of routine myomectomy at the time of a cesarean section for women with uterine leiomyomas; a retrospective study was subsequently performed to evaluate the safety and efficacy of the procedure [18]. A total of 1967 pregnant women also had uterine fibroids, 1438 of whom underwent a cesarean section (73.1%): 1242 (86.4%) were simultaneously subjected to myomectomy, 51 (5.3%) to hysterectomy, and 145 (10.1%) underwent only a cesarean section. The surgical technique has been described extensively, and electrocautery has not been used. Excessive bleeding was defined as a 10% decrease in hematocrit or the need for intraoperative transfusion. Women who had a cesarean section associated with hysterectomy had leiomyomas of a larger mean diameter (8.1 ± 3.9 cm) than women who underwent myomectomy at the time of a cesarean section (7.3 ± 4.6 cm) and women undergoing a cesarean section without myomectomy (3.6 ± 2.1 cm). There were no significant differences between the three groups in terms of length of hospitalization. The mean length of hospitalization, even routine, among patients with a cesarean section without myomas was quite long (4.9 ± 1.9 days). There were also no significant differences between the groups in the frequency of bleeding or the incidence of post-operative fever (defined as temperature ≥ 38.0°C). The duration of surgery was longer in women undergoing myomectomy at the time of a cesarean section (83.6 ± 10.8 minutes) compared to a cesarean section in women without uterine leiomyomas (40.2 ± 8.9 minutes) and a cesarean section in women with uterine leiomyomas (41.9 ± 9.1 minutes). Cumulative data suggest that, in appropriately selected pregnant women, myomectomy can be performed safely at the time of a cesarean section without concern for uncontrolled bleeding or post-operative fever. However, the optimal technique to use in the context of a cesarean section remains unclear, as several techniques are described, including the use of tourniquets and electrocautery. Patients should be informed of the longer operating time and length of hospital stay when a myomectomy is performed.

### **2.5 Pelvic adhesive disease**

The formation of an adhesion is a complex process that results from the imbalance between the deposition of fibrin and its disintegration during the healing process. Most of the adhesions rise during the first postoperative week. While opening the abdomen, the obstetrician could sometimes be faced with severe pelvic adhesions, which can be the result of previous cesarean sections, pelvic inflammatory disease, or bowel, bladder, and gynecological surgeries. Unless there is an immediate danger to the fetal condition, it would be better to restore the anatomy before performing the cesarean section even if there could be a greater risk of sectioning

the underlying bowel or bladder. When faced with impenetrable adhesions, it is advisable to make a higher incision in order to expose non-scarred tissue; once the abdomen has been entered and the distinct structures recognized, an orderly approach can be undertaken. The option of an inverted T incision, a J incision, or even a separate supraumbilical incision should be taken under consideration. If adhesions make the lower uterine segment completely inaccessible, a fundus or even a posterior uterine incision may be required to deliver the newborn. The presence of adhesions during the cesarean section increases with each subsequent operation and affects both the time of delivery of the newborn and the overall surgical operating time. A recent study showed that in the presence of adhesions, the delivery time was increased by 18.2, 20.3, and 27.5 minutes, respectively, from the second to the fourth delivery [19]. When the abdomen is full of severe, extensive, and dense adhesions, delivery times increase by 8.4, 12.6, and 21.5 minutes from the second to the fourth cesarean section compared to the first cesarean section. The proportional decrease in the pH values of the umbilical cord and in Apgar scores was reported in newborns delivered after a woman already underwent multiple cesarean sections. This study was limited by its retrospective nature and reliance on the interpretation of surgical reports, but the presence and severity of adhesion suggest a potential impact on fetal well-being as a consequence of cesarean sections. These results are consistent with another retrospective review showing that delivery times are significantly increased by 3–5 minutes as the number of cesarean sections increases [20]. The surgical technique focused on the prevention of postoperative adhesions has been studied with variable results, including the closure or non-closure of the rectus muscles and the peritoneum. The presence of intraperitoneal and bladder adhesions has been related to the creation of a bladder flap at the time of hysterotomy; in conclusion, the creation of a bladder flap causes inflammation and fibrotic reaction, that leads to the activation of reactive processes and the release of regenerative mesothelial agent with a subsequent subomesothelial hyperplasia and fibrosis [21]. The same authors, as well as others, have suggested that the closure of the visceral peritoneum during a cesarean section can produce an inflammatory reaction and adhesions [22, 23]. Therefore, scientific evidence seems to support the non-creation of a bladder flap and the non-closure of the visceral peritoneum at the time of hysterectomy and uterine closure. A recent study has suggested that the presence of severe striae gravidarum may indicate the presence of underlying intraperitoneal adhesions in women who have had a previous cesarean section [24]. The authors used the Davey striae gravidarum score to quantify the severity of the striae and found that 50% of women with severe striae and a previous cesarean section had intraperitoneal adhesions versus 9% of women without striae. Similarly, the relationship between keloid presence and adhesion formation among women of different races was examined [20]: while adhesion formation appears to be comparable, women with cesarean scar keloids have more adhesions between the uterus and the anterior abdominal wall.

#### **2.6 Abnormal fetal station/fetus not engaged**

Understanding the fetal station, presentation, and position of the head prior to entry into the abdomen or uterus saves valuable minutes at delivery by enabling a strategic approach to surgery. Advantages include proper planning of the incision and correct positioning of the hand, which allow for the best grasp and flexion of the fetal head in the case of cephalic birth (or of the feet in the case of breech birth) and to

ensure that any additional maneuvers, such as forceps or suction cups, are available in the room for quick use.

#### **2.7 Fetal head not engaged**

When an uncommitted or "floating" fetal head is encountered, it can be difficult to guide the head to a transverse uterine incision, in particular when the fetal head deflects. In this case, the use of a suction cup or forceps can be particularly useful in extracting the fetus. However, it is not always possible to know when the forceps or the suction cup will be needed, and if these instruments are not part of the normal cesarean section set, it is advisable to have them available in the operating room to avoid a delayed extraction caused by the recovery of these instruments. To apply a suction cup at the time of a cesarean section, the same general principles should be followed as for operative vaginal delivery. Almost all types of forceps can be used at the time of a cesarean section; however, long handles and standard handles can create problems in its use, and it is therefore advisable to use forceps with short handles and handles during a cesarean delivery. The technique for applying these tools is different from the one used in the vagina. First, the fetal head must be palpated to determine presentation; once the presentation is confirmed, the posterior blade should be guided under the fetal head and held in place by the assistant. Only at this time can the anterior blade be positioned: depending on the maternal anatomy and the type of forceps available, the anterior blade can be placed directly on the fetal head, or it may be necessary to position it posteriorly and guide it into position before locking the handles. It is important to lock the handles before exerting any traction on the blades. Finally, the surgical assistant should provide pressure on the fundus of the uterus while gentle upward traction of the forceps is exerted, guiding the fetus out of the hysterotomy; conversely, pulling down and toward the mother's feet can cause an extension of the hysterotomy.

#### **2.8 Transverse posterior spine situation**

Delivery of a fetus in a transverse posterior position is technically challenging and often requires a classic incision. When transverse uterine incisions are attempted for this presentation, it is often necessary to use a J incision or a T incision on the uterus to extract the infant. Extension of the uterine incision is associated with increased blood loss, broad ligament hematoma, and uterine artery tear [25]; thus, the preoperative execution of an ultrasound for the evaluation of the fetus, when the presentation is uncertain, can be the key to a safe birth.
