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INTRODUCTION

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Cesarean delivery is currently the most frequently performed major surgical procedure for women in the United States. More than 1 million procedures are completed each year (MacDorman, 2008). Associated mortality rates are low with this operation, but it has higher maternal morbidity rates during both initial and subsequent pregnancies. In many instances, associated risks for urinary tract and bowel injury are identified preoperatively, and preemptive steps are taken. However, in other cases, undiagnosed adhesive disease, hysterotomy laceration, or unplanned hysterectomy can increase adjacent organ trauma. Thus, all obstetricians ideally are able to recognize these injuries. Simple repairs can be completed in most cases by a generalist. However, more extensive damage often requires consultation with surgeons skilled in these more difficult repairs. Importantly, differentiation between the two is essential to maximize patient outcome.

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INCIDENCE

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Injury to the urinary tract during cesarean delivery is infrequent. Rates range from 0.08 to 0.94 percent for bladder injury and from 0.027 to 0.09 percent for ureteral injury (Eisenkop, 1982; Rajasekar, 1997; Tarney, 2013). Virtually all bowel injuries associated with childbirth are to the anal sphincter and lower rectum during vaginal deliveries. These injuries and their repair are described and illustrated in Chapter 20 (p. 325). Bowel injuries during cesarean delivery are rare, and estimated rates range between 0.04 and 0.08 percent (Davis, 1999).

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From 1996 to 2009, the cesarean delivery rate increased from 20.7 percent to 32.9 percent of all births (Osterman, 2014). As described in Chapter 25 (p. 404), these numbers reflect several modifiable factors. Among these are higher labor induction rates, lower operative vaginal delivery rates, emergence of cesarean delivery on maternal request, and a decline in rates of vaginal birth after cesarean (VBAC). In fact, 90.8 percent of women with low-risk pregnancies currently undergo repeat cesarean delivery (Office of Disease Prevention and Health Promotion, 2014). Logically, these trends correspond with an increase in the frequency of urinary tract and bowel injuries (American College of Obstetricians and Gynecologists, 2015; Osterman, 2014).

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RISK FACTORS

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Several specific patient or pregnancy characteristics raise the risk for gastrointestinal or urinary tract injury and are listed in Table 28-1. In general, these attributes can be divided into those that are identifiable preoperatively and those that are found intraoperatively. The most consistently reported risk factors for injury include prior cesarean delivery, prior pelvic surgery, pelvic adhesions, emergent delivery, cesarean hysterectomy, and cesarean delivery during labor (Davis, 1999; Eisenkop, 1982; Phipps, 2005; Tarney, 2013). Extension of the uterine incision, either by direct trauma or with attempts to control bleeding, can be associated with adjacent ureteral injury. Also, uterine artery ligation used to control postpartum hemorrhage places the ipsilateral ureter at risk. Prior myomectomy, multiple cesarean deliveries, or pelvic surgery that is associated with bowel adhesions to uterus, anterior abdominal wall, or other pelvic structures increases the potential for intestinal injury (Davis, 1999; Eisenkop, 1982). ...

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