Fetal Laceration Injury at Cesarean Delivery

Fetal Laceration Injury at Cesarean Delivery JAMES F. SMITH, MD, CESAR HERNANDEZ, MD, AND JOSEPH R. WAX, MD Objective: To investigate the incidence of fetal laceration injury in cesarean delivery. Methods: A retrospective review was conducted using a computer-based data coding system. All neonatal records were reviewed for infants delivered by cesarean during a 2-year period. Maternal records were reviewed in those cases of documented fetal laceration injury. The Fisher exact test was used when indicated. Results: There were 904 cesarean deliveries performed during the study period; of these, 896 neonatal records (98.4%) were available for review. Seventeen laceration injuries were recorded (1.9%). The incidence of laceration appeared higher when the indication for cesarean was nonvertex (6.0% versus 1.4%, P 5 .02). One of 17 (5.9%) maternal records indicated the presence of the laceration of the fetus. Conclusion: Fetal laceration injury at cesarean delivery is not rare, especially when it is performed for nonvertex presentation. The minority of obstetric records show documentation of such lacerations, suggesting that this complication often may not be recognized by obstetricians. (Obstet Gynecol 1997;90:344 – 6. © 1997 by The American College of Obstetricians and Gynecologists.)

The rate of cesarean delivery has increased in the last 25 years. Well-known complications associated with cesarean delivery include an increased risk of infectious morbidity, transfusion, and prolonged hospitalization. Many textbooks describing the technique of cesarean delivery address the issue of potential laceration injury of the fetus and describe measures to avoid these complications, but the incidence is rarely reported.1–3 A description of several types of laceration injuries has been reported.4 This included six cases, and an association was reported with rupture of membranes and level of experience of the operator. The incidence of laceration injury was not documented. The present study was initiated to investigate the incidence of fetal laceration injury at cesarean delivery. From the Departments of Obstetrics and Gynecology, St. Joseph Hospital, Denver, Colorado; Rochester General Hospital, Rochester, New York; and the Naval Medical Center, Portsmouth, Virginia. The opinions expressed herein are those of the authors and not necessarily those of the United States Navy or the United States Government.

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Materials and Methods We conducted a retrospective review of all neonatal records of infants delivered by cesarean between 01 January 1990 and 31 December 1991. The patient population consisted of active-duty personnel and eligible family members in a large military teaching hospital. All cesareans were performed by resident physicians under staff supervision. The review used a hospital computer-based data coding system to identify all neonatal records of infants born by cesarean. Neonatal records were reviewed in their entirety for documentation of laceration injuries, admission and discharge notes by pediatricians, nursing notes by neonatal nursing staff, and discharge summaries. When a neonatal record indicated that a laceration injury was present, the maternal record was reviewed. The obstetric delivery note, subsequent daily progress notes, and discharge summaries were reviewed for documentation of lacerations. Information was obtained regarding the injury and delivery, including indication for cesarean, type of incision, location of injury, and presentation. For comparisons, the Fisher exact test was used.

Results During the time period of the study, 4953 deliveries occurred. Of these, 911 (18.4%) were by cesarean. Of the 911 deliveries by cesarean, 896 neonatal records were available for review (98.4%). Indications for the 896 cesareans in which neonatal records were available are listed in Table 1. Uterine incision type included 14 low transverse incisions, two low vertical incisions, and one classical incision. Location of laceration injury and presentation are shown in Table 2. Of the neonatal charts, 17 indicated the presence of a laceration injury (1.9%). The most common sites for description of the laceration injury were in the newborn nursing notes (17 of 17) and newborn discharge summaries (17 of 17) prepared by the pediatricians. Only ten of these 17 records demonstrated documentation of laceration injury by pediatricians at delivery, and in

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Table 1. Fetal Laceration Injury During Cesarean Delivery by Indication % Lacerations (number of Laceration lacerations per group Total (N 5 896) (%) (N 5 17) indications) P* Failure to progress Fetal intolerance of labor Repeat elective Nonvertex presentation Breech Transverse Macrosomia Twin gestation Placenta previa Other Total

450 (50) 156 (17)

8 2

1.8 (8/450) 1.3 (2/156)

.64 .82

101 (11)

1

1.0 (1/101) 6.0 (6/100)

.82 .02

95 (11) 5 (1) 38 (4) 14 (2) 8 (1) 29 (3) 896 (100)

5 1 0 0 0 0 17

0 0 0 0 1.9 (17/896)

* P values by Fisher exact test.

only one case (5.9%) was documentation made in the operative report for the cesarean by the obstetricians managing the delivery. Of the 896 cesareans done in which neonatal records were available, 100 were done for nonvertex presentation (breech and transverse). Six of these 100 (6.0%) sustained laceration injury compared with 11 of 796 (1.4%) cesarean deliveries done for other indications (P 5 .02). Treatment recorded in neonatal records included observation, local wound care, application of skin closure tape, and suture placement. The records did not indicate that the neonatal hospitalization was extended as a result of the laceration injury, and no

Table 2. Presentation and Location of Fetal Laceration Injury Presentation

Location

Vertex Vertex Vertex Vertex Vertex Vertex Vertex Vertex Vertex Vertex Vertex Breech Breech Breech Breech Breech Transverse

Left cheek Left cheek Left forehead Left jaw Forehead Forehead Occiput Left eyelid Left periauricular area Right shoulder Left shoulder Right buttock Right ankle Left leg Lower back Lower back Left shoulder blade

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long-term follow-up was made regarding the incidence of permanent scarring.

Discussion This retrospective review was done primarily for descriptive purposes to investigate the incidence of fetal laceration injury at cesarean delivery. This complication draws attention from patients and physicians alike because it is iatrogenic in nature and often occurs during a procedure intended to minimize fetal trauma. Although the decision for cesarean may not be altered by the risk of fetal laceration, many parents may wish to know of this potential complication. The risk of laceration injury may be viewed differently if the indication for the cesarean is to avoid birth trauma associated with breech delivery compared with an indication of elective, repeat cesarean following a single, low transverse incision for a nonrecurring indication. Although power for comparison of subgroups by indication is low, we found a significant correlation between fetal laceration injury and nonvertex presentation. Explanation for this may include lack of recognition of fetal tissue once the uterine incision has transected the uterine wall completely. Lacerations occurring in such fetuses were in the lower part of the body. Hair may be an identifying mark of fetal tissue when the vertex is presenting in cesareans and may result in better identification of fetal tissue. The incidence of fetal laceration was derived from neonatal records, and the retrospective nature of such a review limits the interpretation. The lacerations were assumed to have been made at the time of cesarean delivery from the descriptions or notations suggesting this etiology. It is interesting to note that the obstetric records with delivery notes identified only 5.9% of the lacerations that were described in the discharge summaries of the neonates and that the pediatricians in attendance for each delivery identified only 70%. Most likely, the obstetricians did not notice the lacerations at the time of delivery. Although lack of documentation of laceration injury in the maternal record may not correlate with obstetrician recognition of this complication, documentation of such a discussion with the mother, if it occurred, would have been prudent if the complication had been recognized. Likewise, although pediatricians were present for each delivery, full documentation of laceration injury may not have occurred at the time of the examination done at delivery. As a result, some may have been missed altogether, resulting in underestimation. In addition, a stable neonate often is wrapped in blankets, and thus, observation of lacerations would have been limited. Conversely, although the presence of lacerations are difficult to dispute retro-

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spectively, it is possible that some were caused not by scalpel injury but by other trauma that may have occurred during or shortly after delivery. In any event, this record review indicates that fetal laceration injury associated with cesarean delivery is not a rare event. Because there is marked discordance in documentation of such findings in obstetric records versus neonatal records, such a complication may be often not recognized by obstetricians. An incidence of fetal laceration injury of 1.9% would suggest routine disclosure of such complications when obtaining informed consent from patients about to undergo a cesarean delivery. In particular, disclosure of the risk of fetal laceration is important when a cesarean is being planned and nonvertex presentation is present. Methods to reduce the incidence of fetal laceration injury have been described previously.3,4 General surgical methods to reduce the risk of fetal laceration injury have included meticulous suctioning at the time of uterine entry3 and removal of retractors of the abdominal wall, if used, before delivery of the fetus to minimize trauma risk and to create more room for the delivery.4 Methods of uterine entry advocated to reduce fetal trauma have included scoring the uterus along the entire length of the proposed uterine incision with the scalpel and bluntly entering the uterine cavity by inserting a finger into the central portion of the uterine incision. The uterine incision is then extended in both lateral directions by retraction with index fingers.4 Another method of uterine entry includes grasping the lateral edges of the uterine incision with ring forceps or Allis clamps, elevating the uterine incision away from the fetal presenting part, and completing uterine entry

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with the aid of bandage scissors.4 Possibly the most important factors in preventing fetal laceration injury, as succinctly stated by Gerber,4 “must be based upon an increased awareness and candid admission of the inherence of such a risk to the fetus at every cesarean section delivery.”

References 1. Phelan JP, Clark SL. Cesarean delivery—The transperitoneal approach. In: Phelan JP, Clark SL, eds. Cesarean delivery. 2nd edition. New York: Elsevier, 1988:210 – 8. 2. Clark SL. Cesarean section. In: Hankins GDV, Clark SL, Cunningham FG, Gilstrap LC, eds. Operative obstetrics. Norwalk: Appleton and Lange, 1995:301–32. 3. Abuhamad A, O’Sullivan MJ. Operative technique for cesarean section. In: Plauche WC, Morrison JC, O’Sullivan MJ, eds. Surgical obstetrics. Philadelphia: W.B. Saunders, 1992:417–29. 4. Gerber AH. Accidental incision of the fetus during cesarean section delivery. Int J Gynecol Obstet 1974;12:46 – 8.

Address reprint requests to:

James F. Smith, MD Mountain States Maternal Fetal Medicine 2005 Franklin Street, Suite 750 Denver, CO 80205

Received December 23, 1996. Received in revised form May 2, 1997. Accepted May 8, 1997.

Copyright © 1997 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.

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