This case involves a patient who presented in labor at full term during a first pregnancy. After the patient experienced second-stage arrest, a C-section was performed. During the procedure, there was an extension of the uterine incision, which was repaired intraoperatively.
Despite repair of the incision extension, the patient continued to experience significant bleeding. A laparotomy was performed, but persistent bleeding from the left uterine artery could not be clearly visualized or controlled. General Surgery was consulted and was able to suture ligate areas of venous bleeding, which improved hemostasis. Due to the severity of the hemorrhage, the patient required extensive blood product transfusion, abdominal packing, and transfer to a tertiary care center for further resuscitation and surgical management.
Upon arrival at the tertiary care center, the patient was emergently taken to the operating room for exploratory laparotomy. Active bleeding was identified from a branch of the left uterine artery near its origin from the internal iliac artery. Sutures were placed, and the bleeding was controlled. Ultimately, the patient required a hysterectomy.
From a legal perspective, this case may turn on whether the uterine incision extension and resulting hemorrhage were timely recognized, managed, and escalated appropriately. The key issues may include surgical technique during the C-section, efforts to identify and control the bleeding source, timing of specialist involvement, transfusion and transfer decisions, and whether earlier intervention could have prevented the need for hysterectomy.
Questions to the OBGYN expert and their responses
What are the most pertinent intraoperative measures that should be taken to avoid damage to the left uterine artery during a C-section?
Proper placement of incision, exposure, adequate hemostasis, elevation of fetal head from below and careful handing of tissues can help decrease risk of injury to uterine arteries.
About the expert
This expert has over 25 years of experience in the field of obstetrics and gynecology. He earned both his BS in biology and MD from the University of Iowa. He then completed his residency in obstetrics and gynecology at the University of Illinois St. Francis Hospital. Today, this expert is board certified in obstetrics and gynecology and stays active in his field as a member of multiple professional organizations, including the American College of Obstetrics and Gynecology and the Iowa Medical Society. He previously served as a physician and partner at Ottumwa Obstetrics and Gynecology, P.C. as well as the chair of obstetrics and gynecology at MMC Cedar Rapids. Currently, he serves as an associate professor at a medical university, an adjunct clinical assistant professor at a different medical school, and a partner at a private practice, all located in Iowa.
E-324492
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Questions to the OBGYN expert and their responses
How does the timeliness of diagnosis and intervention typically affect patient outcomes in cases of uterine rupture?
Urgent management of uterine rupture is mandatory, as outcomes are almost certainly related to timely diagnosis and treatment. The combination of pain and hemoperitoneum should also have alterted clinicians to the high probability of rupture.
About the expert
This expert is certified in obstetrics and gynecology by the Royal College of Physicians and Surgeons of Canada. He earned his BS in biological science from the University of Guelph and his MD from the University of Western Ontario. He completed his formal medical training with a residency in obstetrics and gynecology from McMaster University and a fellowship in contraception advice, research, and education at Queen's University. This expert has authored a book on contraception and family planning and has published over ten peer-reviewed journal articles. He formerly served as an assistant professor of obstetrics and gynecology and the director of continuing education at McMaster University.
E-303457
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Questions to the OBGYN expert and their responses
What actions and precautions should be taken when the uterine artery is injured during a c-section, and there is significant bleeding?
Rapid recognition of the uterine artery injury, control of bleeding including uterine artery ligation, blood product replacement and cardiorespiratory support of patient throughout surgical management. Many institutions would activate a massive obstetric hemorrhage protocol in this circumstance.
About the expert
This obstetrics and gynecology expert has experience managing elective repeat cesarean sections and complications involving obstetric hemorrhage. In their practice, they perform approximately 2–5 elective repeat cesarean deliveries per month and can address the recognition and management of uterine artery injury, including hemorrhage control, uterine artery ligation, blood product replacement, cardiorespiratory support, and activation of massive obstetric hemorrhage protocols. They have reviewed several obstetric hemorrhage cases, including one involving maternal death secondary to cardiac arrest and massive hemorrhage.
E-092125
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