- Email: [email protected]
Accidental fetal lacerations during cesarean delivery: Experience in an Italian level III university hospital
American Journal of Obstetrics and Gynecology (2004) 191, 1673e7
www.ajog.org
Accidental fetal lacerations during cesarean delivery: Experience in an Italian level III university hospital Salvatore Dessole, MD,a,* Erich Cosmi, MD,a Antonio Balata, MD,b Luisa Uras, MD,a Donatella Caserta, MD,a Giampiero Capobianco, MD,a Guido Ambrosini, MDa Departments of Obstetrics and Gynecologya and Neonatology,b University of Sassari, Sassari, Italy Received for publication December 29, 2003; revised February 18, 2004; accepted March 11, 2004
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– KEY WORDS Accidental fetal lacerations Cesarean delivery Fetus
Objective: The purpose of this study was to investigate the incidence, type, location, and risk factors of accidental fetal lacerations during cesarean delivery. Study design: Total deliveries, cesarean deliveries, and neonatal records for documented accidental fetal lacerations were reviewed retrospectively in our level III university hospital. The gestational age, the presenting part of the fetus, the cesarean delivery indication, the type of incision, and the surgeon who performed the procedure were recorded. Cesarean deliveries were divided into scheduled, unscheduled, and emergency procedures. Fetal lacerations were divided into mild, moderate, and severe. Neonatal follow-up examinations regarding laceration sequelae were available for 6 months. Results: Of 14926 deliveries, 3108 women were delivered by cesarean birth (20.82%). Neonatal records documented 97 accidental fetal lacerations. Of these accidental lacerations, 94 were mild; 2 were moderate, and 1 was severe. The overall rate of accidental fetal laceration per cesarean delivery was 3.12%; the accidental laceration rate in the cohort of fetuses was 2.46%. The crude odds ratios were 0.34 for scheduled procedures, 0.57 for unscheduled procedures, and 1.7 for emergency procedures. The risk for fetal accidental lacerations was higher in fetuses who underwent emergency cesarean birth and lower for unscheduled and scheduled cesarean births (P ! .001). Conclusion: Fetal accidental laceration may occur during cesarean delivery; the incidence is significantly higher during emergency cesarean delivery compared with elective procedures. The patient should be counseled about the occurrence of fetal laceration during cesarean delivery to avoid litigation. Ó 2004 Elsevier Inc. All rights reserved.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
* Reprint requests: Salvatore Dessole, MD, Obstetrics and Gynecology, University of Sassari, 07100 Viale San Pietro 12, Sassari, Italy. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2004.03.030
Cesarean delivery is performed for several indications, both maternal and fetal, to decrease maternal and fetal morbidity and mortality rates. Complications that are related to cesarean delivery are increased risk of infections, transfusion, and prolonged hospitalization. Moreover, accidental fetal lacerations occur in 1% to 2% of cesarean delivery procedures.1-3 The
1674
Dessole et al
Table I Incidence of fetal laceration during cesarean delivery per indication Laceration per indication (%)
Indication
N
Fetal lacerations (n)
Emergency cesarean delivery Fetal distress during labor and PROM Fetal distress during labor PROM without labor Dynamic dystocia Fetal chronic hypoxia (pregnancy-induced hypertension, intrauterine growth restriction, gestational diabetes mellitus) Scheduled cesarean delivery Repeat, macrosomia, placenta previa Multiple gestation Fetal anomalous presentation Unscheduled cesarean delivery Repeat, macrosomia, placenta previa Multiple gestation Fetal anomalous presentation TOTAL
1421
76
5.3
115
25
21.7
594
29
4.9
89 318 305
7 7 8
7.9 2.2 2.6
1242
13
1.0
398
5
1.25
634 210
0 8
0 3.8
445
8
1.8
222
6
2.7
189 34
0 2
0 5.9
3108
97
3.12
frequency of the latter condition appears to be related to several factors such as the surgeon’s experience; the most common situation is a well-thinned-out lower uterine segment in a patient with ruptured membranes, in this case the uterus at the incision may be only 2 to 3 mm thick.3 Usually these lacerations are of cosmetic importance for the newborn infant, yet a small number of papers have reported fetal injury during cesarean delivery that cause newborn infant handicap or death.3,4 The aim of the study was that to investigate the incidence of laceration, the type of accidental fetal lacerations during cesarean delivery that were performed in our level III University Hospital, and the risk factors that may contribute in determining the lacerations.
In the group that had cesarean delivery, the following data were assessed: gestational age, presenting part of the fetus at the moment of cesarean delivery, cesarean delivery indication, the type of uterine incision, and the surgeon who performed the procedure (either an attending physician or a resident). Cesarean deliveries were divided into 3 groups: scheduled, unscheduled, and emergency. Both scheduled and unscheduled cesarean deliveries were defined as elective cesarean deliveries; the former were performed in a scheduled time and day; the latter were performed in a different planned day and time because of circumstances that required the procedure to be done (such as the onset of uterine contractions in a repeat cesarean delivery). The emergency cesarean delivery was defined as a procedure to be done within 20 minutes because of fetal distress. Neonatal data were available from the Neonatal Department of our University Hospital, and neonatal birth weight and Apgar score at 5 minutes were assessed in all the newborn infants who were delivered by cesarean. Neonatal data were reviewed for the presence of accidental fetal lacerations; on its occurrence, the type and location of laceration were recorded. Fetal lacerations were divided into 3 groups: (1) mild (those lacerations for which the extension was limited at the level of skin); (2) moderate (those lacerations that involved the skin and muscle), and (3) severe (those lacerations that involved skin, muscle, bone, and other structures, such as nerves). Neonatal follow-up concerning laceration sequelae was available for a time period of 6 months. At the end of the study, we calculated the incidence of fetal accidental lacerations compared with total cesarean deliveries and compared with the number of infants who were considered as a cohort of infants delivered by cesarean delivery. Moreover, we calculated the crude odds ratios for the 3 categories of cesarean deliveries to evaluate the grater risk among the aforementioned procedure in determining fetal accidental lacerations. For differences in the rates among the 3 groups, the c2 test was used. A probability value of !.05 was considered statistically significant. Multiple logistic regression analysis has been used to control for confounders such as gestational age, presenting part of the fetus, cesarean delivery performed by residents, or attending physicians.
Results Material and methods All deliveries and the cesarean delivery rate in our level III University Hospital were reviewed retrospectively from January 1995 to December 2002.
From January 1995 to December 2002, a total of 14926 deliveries occurred in our University Hospital. Of these, 11, 818 births (79.17%) were vaginal delivery, and 3108 births were by cesarean delivery (20.82%). From
1675
Dessole et al Table II
Fetal lacerations according to fetal presentation, location, and type
Fetal presentation
Laceration location
Mild lacerations (n)
Moderate lacerations (n)
Severe lacerations (n)
Cephalic
Scalp Frontal region Occipital region Parietal region Face Ear Maxilla Supracillary crest Orbital region Neck
63 (64.9%) 15 34 14 21 (21.6%) 9 7 5 d d 8 (8.2%) 8 d 2 (2.06%) 1 1
2 (2.0%) d d d 0 d d d 1 1 0 d d 0 d d
d 0 d d 0 d d d d d 1 (1.03%) d 1 0 d d
Breech Buttock Thigh Transverse Shoulder Forearm
January 1995 to December 2002, there was a statistically significant increase (P ! .001) in cesarean delivery rate per year performed in our University Hospital (16.8% in 1995; 40.2% in 2001, and 39.5% in 2002). Neonatal records of the 3108 cesarean deliveries were available from the Neonatal Unit of our University Hospital, and a total of 97 accidental fetal lacerations that occurred during cesarean delivery were recorded. The mean gestational age at the time of cesarean delivery was 38.67 weeks of gestation (range, 29-42 weeks of gestation). The type of uterine incision that was performed was a transverse low uterine incision in 3085 cesarean deliveries and a T-inverted incision in 23 cases. In the group with fetal accidental lacerations, a low transverse uterine incision has been performed in all women but in one in which case the latter was extended in an inverted T incision. Mean neonatal birth weight was 3033.75 g (range, 825-4350 g), and neonatal Apgar score at 5 minutes was R7 in 94 cases and !7 in 3 cases. Table I gives the cesarean delivery indications, the number of fetal lacerations, and the percentage of fetal lacerations per indication. Table II gives the type and location of accidental fetal lacerations according to fetal presentation. Of 97 lacerations, 94 lacerations were mild; 2 lacerations were moderate, and 1 laceration was severe. All mild lacerations involved the skin at the level of the presenting part of the fetus. These lacerations were treated with the use of sterile strip and resolved by first intention; no functional sequelae occurred, but a slight permanent scar persisted at 6 months of neonatal follow-up. Among these lacerations, 63 lacerations occurred at the level of the fetal scalp (15 lacerations involved the frontal region; 34 lacerations involved the occipital region; 14 lacerations involved the parietal re-
gion); 21 occurred at the level of the face (9 lacerations involved the ear; 7 lacerations involved the maxillar region; 5 lacerations involved the supracillary crest); 8 lacerations occurred at the level of the buttock, 1 laceration occurred at the level of the shoulder, and 1 laceration occurred at the level of the forearm. A moderate 2-cm long laceration occurred in 1 fetus, which involved the upper orbital region that included the skin and the muscle; plastic surgery was required to solve the esthetic damage that was created. At 6 months, the neonate showed the presence of a visible permanent scarring. A moderate 4-cm long laceration occurred in 1 fetus that involved the neck, the semispinalis capitis muscle, and the splenius capitis muscle. Plastic surgery was required, and a large permanent scar persisted in the neonate. In 1 fetus, a severe laceration occurred that involved the superior external region of the upper part of the thigh with a superficial extension of 5 cm that included, respectively, the skin, the tensor fascia lata muscle, the sartorius muscle, and the lateral femoral cutaneous nerve of the thigh. The newborn infant recovered after plastic surgery, but a large and permanent scar persisted. All moderate and severe lacerations occurred during emergency cesarean delivery. There were no lacerations among twins in multiple pregnancies. The fetal lacerations rate did not display a statistical difference from year to year in the study period (P = .9). The overall rate of accidental fetal laceration per cesarean delivery was 3.12%; the rate of accidental fetal laceration in the cohort of fetuses in the study group was 2.46%. The crude odds ratios for the 3 categories of cesarean deliveries were 0.34 for scheduled cesarean delivery, 0.57
1676 for unscheduled cesarean delivery, and 1.7 for emergency cesarean delivery. The reference group in the calculation of the crude odds ratios has been the overall accidental fetal lacerations (97 cases) in our study population divided per the total number of cesarean deliveries that were performed (3108 deliveries). We calculated the c2 test among the 3 categories, and there was a statistically significant difference between the rates among the 3 groups (P ! .001); thus, the risk for fetal accidental lacerations was higher in fetuses who underwent emergency cesarean delivery and was lower for the unscheduled and scheduled cesarean delivery group. Moreover, in the group of emergency cesarean delivery, fetal distress during labor with premature rupture of membranes (PROM) and secondly PROM without labor constituted a risk factor for fetal accidental lacerations (P ! .05). Fetal accidental lacerations were significantly higher after 33 weeks of gestation to term. Cephalic presentation of the fetus determined a significantly higher risk for the occurrence of fetal accidental lacerations. Low uterine transverse incision was correlated with a greater risk for fetal accidental lacerations. Fetal accidental laceration did not show a statistical difference when either a resident or an attending physician performed the procedure.
Comment In this study of 3108 cesarean deliveries, the fetal laceration rate was 3.12%. Although the decision to perform cesarean delivery may not be altered by the possible occurrence of accidental fetal laceration, women should be informed about the aforementioned complications, because of litigation problems.5 The present retrospective study has been performed to investigate fetal accidental injuries that may occur during cesarean delivery. Smith et al2 reported an incidence of fetal accidental injuries of 1.9% of a total of 896 cesarean deliveries that were performed; Wiener and Westwood6 described an occurrence of 1.5% of 876 cesarean deliveries that were performed; the latter investigators did not find a correlation between fetal lacerations and cesarean delivery indications. In the present study, total accidental fetal lacerations were 97 of a total of 3108 cesarean deliveries that were performed; thus, the incidence of laceration per cesarean delivery was 3.12%, although the incidence of lacerations per fetus was 2.46%. The difference between the present study and the aforementioned investigations may be related to a larger sample group that was considered and to meticulous neonatal records in the description of the type and location of fetal lacerations. There is a correlation between fetal accidental lacerations and cesarean delivery indications because the for-
Dessole et al mer were more common during emergency cesarean delivery compared with unscheduled and scheduled procedures. Moreover, in the group of emergency cesarean delivery, fetal distress during labor with PROM and PROM without labor constituted a risk factor for fetal accidental lacerations, probably being related to the critical short time period that is available to perform the cesarean delivery to avoid the risk of fetal morbidity and death. In addition, an incision at the level of the low uterine segment in these circumstances usually is rapid, and the surgeon may play little attention to potential fetal lacerations that may be created during the opening of the uterus with a scalpel. Furthermore, an incision at the level of the low uterine segment, which may be only 2 to 3 mm thick, and the absence of amniotic fluid because of PROM may constitute a further predisposing factor in the determination of fetal lacerations. In the present study, all fetal lacerations occurred during low uterine transverse incision, except 1 case with inverted T incision. Nowadays, in our hospital, low transverse uterine incision is performed commonly; in the case of a difficult extraction of the fetus that may be related to prematurity, the incision usually is converted to an inverted T incision. As regards classic vertical uterine incision, it has not been performed since 1995. Several methods may be used during cesarean delivery to minimize the risk of fetal accidental laceration occurrence.6 Meticulous suctioning of the uterine incision, scoring the uterus along the entire length of the incision with the scalpel and bluntly entering the uterine cavity with a finger into the central portion of the incision may avoid the occurrence of accidental fetal injuries. In addition, during the opening of the uterus the surgeon may use a Kelly clamp to expand the uterotomy. Moreover, the uterine incision may be elevated from the presenting part of the fetus with an Allis clamp or ring forceps. As regards laceration sequelae, mild lacerations resolved spontaneously, with no need for plastic surgery, because they were superficial and involved only the skin. Most of them were of cosmetic significance and did not create functional sequelae, and after local wound care, which consisted of sterile strip application, a slight permanent scar persisted. In our series, only 2 moderate fetal lacerations and 1 severe laceration occurred, all of which required plastic surgery to resolve the esthetic damage that was created. In 2 fetuses with moderate lacerations and in 1 fetus with severe lacerations, in which suture placement was required, a notable permanent scarring was recorded at 6 months of neonatal follow-up. Although in the present study accidental fetal lacerations constituted only cosmetic problems, it is to be borne in mind that severe complication (such as newborn infant handicap or death) may occur.3,4
1677
Dessole et al In conclusion, accidental fetal laceration may occur during cesarean delivery procedures; the incidence is notably higher during emergency cesarean deliveries compared with elective procedures, because fetal lacerations are more common during fetal distress that is associated with PROM and PROM without labor. The surgeon may reduce the risk of fetal lacerations by using particular precautions that were described earlier throughout the procedure performance. The patient should be counseled about the possible occurrence of fetal laceration during cesarean delivery to avoid litigation problems.
References 1. Gerber AH. Accidental incision of the fetus during cesarean delivery. Int J Obstet Gynecol 1974;12:46-8. 2. Smith JF, Hernandez C, Wax JR. Fetal laceration injury at cesarean delivery. Obstet Gynecol 1997;90:344-6. 3. Bowes WA. Clinical aspects of normal and abnormal labour. In: Creasy RK, Resnik R, editors. Maternal-fetal medicine. 4th ed. Philadelphia: WB Saunders; 1999. p. 541-68. 4. Durham JH, Sekula-Perlman A, Callery RT. Iatrogenic brain injury during emergency cesarean section. Acta Obstet Gynecol Scand 1998;77:238-9. 5. Scialli AR. Cesarean section. Lawyers Med J 1981;9:111-8. 6. Weiner JJ, Westwood J. Fetal lacerations at cesarean section. J Obstet Gynecol 2002;22:23-4.
www.ajog.org
Accidental fetal lacerations during cesarean delivery: Experience in an Italian level III university hospital Salvatore Dessole, MD,a,* Erich Cosmi, MD,a Antonio Balata, MD,b Luisa Uras, MD,a Donatella Caserta, MD,a Giampiero Capobianco, MD,a Guido Ambrosini, MDa Departments of Obstetrics and Gynecologya and Neonatology,b University of Sassari, Sassari, Italy Received for publication December 29, 2003; revised February 18, 2004; accepted March 11, 2004
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– KEY WORDS Accidental fetal lacerations Cesarean delivery Fetus
Objective: The purpose of this study was to investigate the incidence, type, location, and risk factors of accidental fetal lacerations during cesarean delivery. Study design: Total deliveries, cesarean deliveries, and neonatal records for documented accidental fetal lacerations were reviewed retrospectively in our level III university hospital. The gestational age, the presenting part of the fetus, the cesarean delivery indication, the type of incision, and the surgeon who performed the procedure were recorded. Cesarean deliveries were divided into scheduled, unscheduled, and emergency procedures. Fetal lacerations were divided into mild, moderate, and severe. Neonatal follow-up examinations regarding laceration sequelae were available for 6 months. Results: Of 14926 deliveries, 3108 women were delivered by cesarean birth (20.82%). Neonatal records documented 97 accidental fetal lacerations. Of these accidental lacerations, 94 were mild; 2 were moderate, and 1 was severe. The overall rate of accidental fetal laceration per cesarean delivery was 3.12%; the accidental laceration rate in the cohort of fetuses was 2.46%. The crude odds ratios were 0.34 for scheduled procedures, 0.57 for unscheduled procedures, and 1.7 for emergency procedures. The risk for fetal accidental lacerations was higher in fetuses who underwent emergency cesarean birth and lower for unscheduled and scheduled cesarean births (P ! .001). Conclusion: Fetal accidental laceration may occur during cesarean delivery; the incidence is significantly higher during emergency cesarean delivery compared with elective procedures. The patient should be counseled about the occurrence of fetal laceration during cesarean delivery to avoid litigation. Ó 2004 Elsevier Inc. All rights reserved.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
* Reprint requests: Salvatore Dessole, MD, Obstetrics and Gynecology, University of Sassari, 07100 Viale San Pietro 12, Sassari, Italy. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2004.03.030
Cesarean delivery is performed for several indications, both maternal and fetal, to decrease maternal and fetal morbidity and mortality rates. Complications that are related to cesarean delivery are increased risk of infections, transfusion, and prolonged hospitalization. Moreover, accidental fetal lacerations occur in 1% to 2% of cesarean delivery procedures.1-3 The
1674
Dessole et al
Table I Incidence of fetal laceration during cesarean delivery per indication Laceration per indication (%)
Indication
N
Fetal lacerations (n)
Emergency cesarean delivery Fetal distress during labor and PROM Fetal distress during labor PROM without labor Dynamic dystocia Fetal chronic hypoxia (pregnancy-induced hypertension, intrauterine growth restriction, gestational diabetes mellitus) Scheduled cesarean delivery Repeat, macrosomia, placenta previa Multiple gestation Fetal anomalous presentation Unscheduled cesarean delivery Repeat, macrosomia, placenta previa Multiple gestation Fetal anomalous presentation TOTAL
1421
76
5.3
115
25
21.7
594
29
4.9
89 318 305
7 7 8
7.9 2.2 2.6
1242
13
1.0
398
5
1.25
634 210
0 8
0 3.8
445
8
1.8
222
6
2.7
189 34
0 2
0 5.9
3108
97
3.12
frequency of the latter condition appears to be related to several factors such as the surgeon’s experience; the most common situation is a well-thinned-out lower uterine segment in a patient with ruptured membranes, in this case the uterus at the incision may be only 2 to 3 mm thick.3 Usually these lacerations are of cosmetic importance for the newborn infant, yet a small number of papers have reported fetal injury during cesarean delivery that cause newborn infant handicap or death.3,4 The aim of the study was that to investigate the incidence of laceration, the type of accidental fetal lacerations during cesarean delivery that were performed in our level III University Hospital, and the risk factors that may contribute in determining the lacerations.
In the group that had cesarean delivery, the following data were assessed: gestational age, presenting part of the fetus at the moment of cesarean delivery, cesarean delivery indication, the type of uterine incision, and the surgeon who performed the procedure (either an attending physician or a resident). Cesarean deliveries were divided into 3 groups: scheduled, unscheduled, and emergency. Both scheduled and unscheduled cesarean deliveries were defined as elective cesarean deliveries; the former were performed in a scheduled time and day; the latter were performed in a different planned day and time because of circumstances that required the procedure to be done (such as the onset of uterine contractions in a repeat cesarean delivery). The emergency cesarean delivery was defined as a procedure to be done within 20 minutes because of fetal distress. Neonatal data were available from the Neonatal Department of our University Hospital, and neonatal birth weight and Apgar score at 5 minutes were assessed in all the newborn infants who were delivered by cesarean. Neonatal data were reviewed for the presence of accidental fetal lacerations; on its occurrence, the type and location of laceration were recorded. Fetal lacerations were divided into 3 groups: (1) mild (those lacerations for which the extension was limited at the level of skin); (2) moderate (those lacerations that involved the skin and muscle), and (3) severe (those lacerations that involved skin, muscle, bone, and other structures, such as nerves). Neonatal follow-up concerning laceration sequelae was available for a time period of 6 months. At the end of the study, we calculated the incidence of fetal accidental lacerations compared with total cesarean deliveries and compared with the number of infants who were considered as a cohort of infants delivered by cesarean delivery. Moreover, we calculated the crude odds ratios for the 3 categories of cesarean deliveries to evaluate the grater risk among the aforementioned procedure in determining fetal accidental lacerations. For differences in the rates among the 3 groups, the c2 test was used. A probability value of !.05 was considered statistically significant. Multiple logistic regression analysis has been used to control for confounders such as gestational age, presenting part of the fetus, cesarean delivery performed by residents, or attending physicians.
Results Material and methods All deliveries and the cesarean delivery rate in our level III University Hospital were reviewed retrospectively from January 1995 to December 2002.
From January 1995 to December 2002, a total of 14926 deliveries occurred in our University Hospital. Of these, 11, 818 births (79.17%) were vaginal delivery, and 3108 births were by cesarean delivery (20.82%). From
1675
Dessole et al Table II
Fetal lacerations according to fetal presentation, location, and type
Fetal presentation
Laceration location
Mild lacerations (n)
Moderate lacerations (n)
Severe lacerations (n)
Cephalic
Scalp Frontal region Occipital region Parietal region Face Ear Maxilla Supracillary crest Orbital region Neck
63 (64.9%) 15 34 14 21 (21.6%) 9 7 5 d d 8 (8.2%) 8 d 2 (2.06%) 1 1
2 (2.0%) d d d 0 d d d 1 1 0 d d 0 d d
d 0 d d 0 d d d d d 1 (1.03%) d 1 0 d d
Breech Buttock Thigh Transverse Shoulder Forearm
January 1995 to December 2002, there was a statistically significant increase (P ! .001) in cesarean delivery rate per year performed in our University Hospital (16.8% in 1995; 40.2% in 2001, and 39.5% in 2002). Neonatal records of the 3108 cesarean deliveries were available from the Neonatal Unit of our University Hospital, and a total of 97 accidental fetal lacerations that occurred during cesarean delivery were recorded. The mean gestational age at the time of cesarean delivery was 38.67 weeks of gestation (range, 29-42 weeks of gestation). The type of uterine incision that was performed was a transverse low uterine incision in 3085 cesarean deliveries and a T-inverted incision in 23 cases. In the group with fetal accidental lacerations, a low transverse uterine incision has been performed in all women but in one in which case the latter was extended in an inverted T incision. Mean neonatal birth weight was 3033.75 g (range, 825-4350 g), and neonatal Apgar score at 5 minutes was R7 in 94 cases and !7 in 3 cases. Table I gives the cesarean delivery indications, the number of fetal lacerations, and the percentage of fetal lacerations per indication. Table II gives the type and location of accidental fetal lacerations according to fetal presentation. Of 97 lacerations, 94 lacerations were mild; 2 lacerations were moderate, and 1 laceration was severe. All mild lacerations involved the skin at the level of the presenting part of the fetus. These lacerations were treated with the use of sterile strip and resolved by first intention; no functional sequelae occurred, but a slight permanent scar persisted at 6 months of neonatal follow-up. Among these lacerations, 63 lacerations occurred at the level of the fetal scalp (15 lacerations involved the frontal region; 34 lacerations involved the occipital region; 14 lacerations involved the parietal re-
gion); 21 occurred at the level of the face (9 lacerations involved the ear; 7 lacerations involved the maxillar region; 5 lacerations involved the supracillary crest); 8 lacerations occurred at the level of the buttock, 1 laceration occurred at the level of the shoulder, and 1 laceration occurred at the level of the forearm. A moderate 2-cm long laceration occurred in 1 fetus, which involved the upper orbital region that included the skin and the muscle; plastic surgery was required to solve the esthetic damage that was created. At 6 months, the neonate showed the presence of a visible permanent scarring. A moderate 4-cm long laceration occurred in 1 fetus that involved the neck, the semispinalis capitis muscle, and the splenius capitis muscle. Plastic surgery was required, and a large permanent scar persisted in the neonate. In 1 fetus, a severe laceration occurred that involved the superior external region of the upper part of the thigh with a superficial extension of 5 cm that included, respectively, the skin, the tensor fascia lata muscle, the sartorius muscle, and the lateral femoral cutaneous nerve of the thigh. The newborn infant recovered after plastic surgery, but a large and permanent scar persisted. All moderate and severe lacerations occurred during emergency cesarean delivery. There were no lacerations among twins in multiple pregnancies. The fetal lacerations rate did not display a statistical difference from year to year in the study period (P = .9). The overall rate of accidental fetal laceration per cesarean delivery was 3.12%; the rate of accidental fetal laceration in the cohort of fetuses in the study group was 2.46%. The crude odds ratios for the 3 categories of cesarean deliveries were 0.34 for scheduled cesarean delivery, 0.57
1676 for unscheduled cesarean delivery, and 1.7 for emergency cesarean delivery. The reference group in the calculation of the crude odds ratios has been the overall accidental fetal lacerations (97 cases) in our study population divided per the total number of cesarean deliveries that were performed (3108 deliveries). We calculated the c2 test among the 3 categories, and there was a statistically significant difference between the rates among the 3 groups (P ! .001); thus, the risk for fetal accidental lacerations was higher in fetuses who underwent emergency cesarean delivery and was lower for the unscheduled and scheduled cesarean delivery group. Moreover, in the group of emergency cesarean delivery, fetal distress during labor with premature rupture of membranes (PROM) and secondly PROM without labor constituted a risk factor for fetal accidental lacerations (P ! .05). Fetal accidental lacerations were significantly higher after 33 weeks of gestation to term. Cephalic presentation of the fetus determined a significantly higher risk for the occurrence of fetal accidental lacerations. Low uterine transverse incision was correlated with a greater risk for fetal accidental lacerations. Fetal accidental laceration did not show a statistical difference when either a resident or an attending physician performed the procedure.
Comment In this study of 3108 cesarean deliveries, the fetal laceration rate was 3.12%. Although the decision to perform cesarean delivery may not be altered by the possible occurrence of accidental fetal laceration, women should be informed about the aforementioned complications, because of litigation problems.5 The present retrospective study has been performed to investigate fetal accidental injuries that may occur during cesarean delivery. Smith et al2 reported an incidence of fetal accidental injuries of 1.9% of a total of 896 cesarean deliveries that were performed; Wiener and Westwood6 described an occurrence of 1.5% of 876 cesarean deliveries that were performed; the latter investigators did not find a correlation between fetal lacerations and cesarean delivery indications. In the present study, total accidental fetal lacerations were 97 of a total of 3108 cesarean deliveries that were performed; thus, the incidence of laceration per cesarean delivery was 3.12%, although the incidence of lacerations per fetus was 2.46%. The difference between the present study and the aforementioned investigations may be related to a larger sample group that was considered and to meticulous neonatal records in the description of the type and location of fetal lacerations. There is a correlation between fetal accidental lacerations and cesarean delivery indications because the for-
Dessole et al mer were more common during emergency cesarean delivery compared with unscheduled and scheduled procedures. Moreover, in the group of emergency cesarean delivery, fetal distress during labor with PROM and PROM without labor constituted a risk factor for fetal accidental lacerations, probably being related to the critical short time period that is available to perform the cesarean delivery to avoid the risk of fetal morbidity and death. In addition, an incision at the level of the low uterine segment in these circumstances usually is rapid, and the surgeon may play little attention to potential fetal lacerations that may be created during the opening of the uterus with a scalpel. Furthermore, an incision at the level of the low uterine segment, which may be only 2 to 3 mm thick, and the absence of amniotic fluid because of PROM may constitute a further predisposing factor in the determination of fetal lacerations. In the present study, all fetal lacerations occurred during low uterine transverse incision, except 1 case with inverted T incision. Nowadays, in our hospital, low transverse uterine incision is performed commonly; in the case of a difficult extraction of the fetus that may be related to prematurity, the incision usually is converted to an inverted T incision. As regards classic vertical uterine incision, it has not been performed since 1995. Several methods may be used during cesarean delivery to minimize the risk of fetal accidental laceration occurrence.6 Meticulous suctioning of the uterine incision, scoring the uterus along the entire length of the incision with the scalpel and bluntly entering the uterine cavity with a finger into the central portion of the incision may avoid the occurrence of accidental fetal injuries. In addition, during the opening of the uterus the surgeon may use a Kelly clamp to expand the uterotomy. Moreover, the uterine incision may be elevated from the presenting part of the fetus with an Allis clamp or ring forceps. As regards laceration sequelae, mild lacerations resolved spontaneously, with no need for plastic surgery, because they were superficial and involved only the skin. Most of them were of cosmetic significance and did not create functional sequelae, and after local wound care, which consisted of sterile strip application, a slight permanent scar persisted. In our series, only 2 moderate fetal lacerations and 1 severe laceration occurred, all of which required plastic surgery to resolve the esthetic damage that was created. In 2 fetuses with moderate lacerations and in 1 fetus with severe lacerations, in which suture placement was required, a notable permanent scarring was recorded at 6 months of neonatal follow-up. Although in the present study accidental fetal lacerations constituted only cosmetic problems, it is to be borne in mind that severe complication (such as newborn infant handicap or death) may occur.3,4
1677
Dessole et al In conclusion, accidental fetal laceration may occur during cesarean delivery procedures; the incidence is notably higher during emergency cesarean deliveries compared with elective procedures, because fetal lacerations are more common during fetal distress that is associated with PROM and PROM without labor. The surgeon may reduce the risk of fetal lacerations by using particular precautions that were described earlier throughout the procedure performance. The patient should be counseled about the possible occurrence of fetal laceration during cesarean delivery to avoid litigation problems.
References 1. Gerber AH. Accidental incision of the fetus during cesarean delivery. Int J Obstet Gynecol 1974;12:46-8. 2. Smith JF, Hernandez C, Wax JR. Fetal laceration injury at cesarean delivery. Obstet Gynecol 1997;90:344-6. 3. Bowes WA. Clinical aspects of normal and abnormal labour. In: Creasy RK, Resnik R, editors. Maternal-fetal medicine. 4th ed. Philadelphia: WB Saunders; 1999. p. 541-68. 4. Durham JH, Sekula-Perlman A, Callery RT. Iatrogenic brain injury during emergency cesarean section. Acta Obstet Gynecol Scand 1998;77:238-9. 5. Scialli AR. Cesarean section. Lawyers Med J 1981;9:111-8. 6. Weiner JJ, Westwood J. Fetal lacerations at cesarean section. J Obstet Gynecol 2002;22:23-4.