Gupta AS

Pregnancy is not a disease. It is a physiological process, a period of anticipation, joy and expectation. However, sometimes in a moment a normal pregnancy becomes abnormal, or high risk and the outcome sometimes for the mother or the child or both becomes tragic. Usually it is expected that a low risk pregnancy would end in a normal delivery with a good maternal, and fetal outcome. Unnecessary or unwarranted operative delivery can be one of the causes of changing a normal pregnancy to an abnormal one.
The commonest operative delivery performed in women is cesarean section. Globally the incidence of cesarean sections is increasing in developed as well as the developing countries. The ideal rate as stated by WHO and the international societies should be between 10-15 %. However in reality they are hovering around 35-40 % and in certain setups may even be as high as 70%.  Many of these cesarean births are not warranted. Clinicians should not aim to attain the ideal or targeted rate but should evaluate need based or evidence based need for cesarean deliveries.
Cesarean section is associated with various immediate or late complications. Hemorrhage primary, reactionary or secondary, hollow viscus injuries to the urinary and the gastrointestinal tract, sepsis and need of re-laparotomy are the commonest complications encountered after cesarean section.
Intraoperative hemorrhage can occur due to various reasons like, uterine atony, tears, extensions of incisions, injuries to cervix or even the vagina in second stage sections with deeply engaged head where the incision may be placed near the cervico vaginal junction in thinned out tissues, bladder trauma or bleeding following adhesiolysis, coagulation disorders and disorders of placentation. Cause should be treated.
Postoperative or postpartum sepsis usually caused by cesarean section. Surgical site infections, endometritis are the commonest sites for infection and incidence of infection is higher in emergency cesarean sections. Evidence shows that antibiotic prophylaxis prior to skin incision, good hemostasis and sound surgical technique can reduce postoperative wound sepsis.
Hollow viscus injuries are serious complications of cesarean section and are best avoided or diagnosed during and repaired intraoperatively. Incidence of bladder injuries is about 0.1-0.13%. As the incidence of cesarean section is rising so also the incidence of repeat cesarean sections is increasing. Careful separation of the bladder from the lower uterine segment is warranted to prevent direct or ischemic bladder injuries. Incidence of major degrees of placenta previa alone or with focal or complete morbid adherence of placenta increases the risks of bladder injuries and also ureteric injuries significantly. Intraoperative diagnosis and confirmation sometimes by retrograde cystodistention with methylene blue and meticulous double layer closure with a delayed absorbable suture and continuous bladder decompression for 14 days along with urinary antiseptics results in good healing of the bladder injury. Disruption of the repair or non detection of the injury can present with oliguria, anuria, urinary incontinence, vesico-vaginal fistula, urinary ascites, deranged renal function or intra-abdominal bleed. Urologist consultation, imaging studies and re-exploration with repair and prolonged catheterization, breakdown of the repair and increased morbidity is the unfortunate outcome of this complication.
Ureteric injuries are rarer than vesical injuries and they are more likely to be missed intraoperatively and present at various times and have various presentations in the postoperative period. Ureter can get transected, ligated, kinked at the level of the uterine incision, at its insertion in the bladder during obstetric total hysterectomy in cases of morbidly adherent placenta or atonic PPH with placenta previa, or injured while repairing a bladder injury.
Bowel injuries is not a serious risk as the gravid uterus shields the intestines behind itself. A bowel loop trapped in adhesions due to previous surgeries may be injured while separating adhesions or while entering the peritoneal cavity. Bowel trauma should be diagnosed during surgery and repaired by surgeons promptly either by closing the injury or by resection and an ostomy. However, many of these injuries remain undetected during the intraoperative phase and presents with fecal peritonitis.
Obstetricians should be alert to prevent a low risk pregnancy or delivery accelerating into the high risk group and developing serious morbidity, or even mortality due to complications many of them being inadvertently iatrogenic.
The much awaited May issue of our journal is here for our most valued readers and it has besides a bouquet of cases one case of postpartum bladder injury which makes for interesting reading.