Download PDF
Am J Perinatol 2025; 42(05): 572-579
DOI: 10.1055/a-2408-7813
Original Article

Unintended Upper Uterine Wall Extensions at the Time of Cesarean Delivery: Risk Factors and Associated Adverse Maternal and Neonatal Outcomes

Tzuria Peled   #
1   Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
,
Noa Saar   #
2   Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
,
Giulia M. Muraca
3   Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
4   Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
5   Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
,
Hen Y. Sela 
1   Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
,
Sorina Grisaru-Granovsky
1   Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
,
Misgav Rottenstreich 
1   Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
3   Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
6   Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel
› Author Affiliations Funding G.M.M. is funded by a Hamilton Academy of Health Sciences Organization Innovation Grant (grant no.: HAH-23-016).
› Further Information
Also available at
    Permissions and Reprints

Abstract

Objective

This study aims to estimate the frequency of unintended upper uterine wall extensions during cesarean delivery (CD) and identify associated risk factors and adverse outcomes.

Study Design

A multicenter retrospective cohort study was conducted, including patients who underwent CD between 2005 and 2021. Demographic factors, obstetric history, CD indications, delivery and surgical characteristics, adverse maternal and neonatal outcomes were compared between those with unintended upper uterine wall extensions during CD and those without extensions. Crude and adjusted estimates (odds ratios [ORs] and 95% confidence intervals [CIs]) were used.

Results

Among 30,517 patients meeting inclusion criteria, 117 (0.4%) had an unintended upper uterine wall extension. In univariate analysis, upper uterine wall extensions were associated with higher rates of intrapartum CD, second-stage CD, unplanned or emergency CD, CD following failed vacuum delivery or trial of labor after CD, chorioamnionitis, prolonged labor, increased vaginal exams, lower fetal head station, and higher birth weight. During surgery, higher rates of general anesthesia, significant intraperitoneal adhesion, fetal malpresentation, and fetal extraction by the leg were observed. Multivariable analysis identified fetal extraction not by head (adjusted OR [aOR]: 9.17, 95% CI: 5.35–15.73), vertex fetal presentation (aOR: 3.65, 95% CI: 1.81–7.35), second-stage CD (aOR: 3.07, 95% CI: 1.24–7.59), and trial of labor after cesarean (aOR: 2.04, 95% CI: 1.08–3.84) as significant risk factors for unintended upper uterine wall extensions. Additionally, upper uterine wall extensions were associated with higher rates of maternal and neonatal complications, including longer operating times, excessive bleeding, postpartum hemorrhage, intraperitoneal drainage, blood product transfusion, puerperal fever, paralytic ileus, Apgar score < 7 at 1 and 5 minutes, and fetal intracranial hemorrhage.

Conclusion

Our study identifies risk factors for unintended upper uterine wall extensions during CD. While these extensions are infrequent, their occurrence is associated with increased maternal and neonatal morbidity.

Key Points

  • Unintended upper uterine wall extensions occur in 0.4% of cesarean deliveries.

  • Significant risk factors include fetal extraction not by head and second-stage CD.

  • Extensions are associated with increased maternal complications like excessive bleeding and prolonged surgery.

  • Neonatal complications include lower Apgar scores and intracranial hemorrhage.

  • Awareness of these risks is critical for improving cesarean delivery outcomes.

Keywords

cesarean delivery - uterine incision extension - risk factors - T and J uterine extensions - adverse outcomes - fetal extraction - maternal complications - neonatal morbidity

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required. This article does not contain any studies with animals performed by any of the authors. The Shaare Zedek Medical Center institutional review board approved the study (approval no.: 0001-23-SZMC), with full waiver of informed consent due to the retrospective, observational design of the study.


Authors' Contributions

T.P. designed, planned, and conducted the study, and wrote the manuscript; N.S. designed, planned, and conducted the study and wrote the manuscript, G.M.M. designed, planned, and conducted the study and wrote the manuscript, H.Y.S. conducted the study, S.G.G. analyzed the data and edited the manuscript, and M.R. designed, planned, and conducted the study.


Note

Participation of N.S. in this study was performed in fulfillment of the research requirements of the Faculty of Medicine, The Hebrew University of Jerusalem, toward her MD degree.


# Both authors have equally contributed.




Publication History

Received: 29 May 2024

Accepted: 02 September 2024

Accepted Manuscript online:
03 September 2024

Article published online:
27 September 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Chien P. Global rising rates of caesarean sections. BJOG 2021; 128: 781-782
    CrossrefPubMedSearch in Google Scholar
  • 2 Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PLoS One 2016; 11 (02) e0148343
    CrossrefPubMedSearch in Google Scholar
  • 3 Betran AP, Ye J, Moller A-B, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health 2021; 6 (06) e005671
    CrossrefPubMedSearch in Google Scholar
  • 4 Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: systematic review and meta-analysis. PLoS Med 2018; 15 (01) e1002494
    CrossrefPubMedSearch in Google Scholar
  • 5 Antoine C, Young BK. Cesarean section one hundred years 1920-2020: the good, the bad and the ugly. J Perinat Med 2020; 49 (01) 5-16
    CrossrefPubMedSearch in Google Scholar
  • 6 Karavani G, Chill HH, Reuveni-Salzman A. et al. Risk factors for uterine incision extension during cesarean delivery. J Matern Fetal Neonatal Med 2022; 35 (11) 2156-2161
    CrossrefPubMedSearch in Google Scholar
  • 7 Lurie S, Raz N, Boaz M, Sadan O, Golan A. Comparison of maternal outcomes from primary cesarean section during the second compared with first stage of labor by indication for the operation. Eur J Obstet Gynecol Reprod Biol 2014; 182: 43-47
    CrossrefPubMedSearch in Google Scholar
  • 8 Patel SS, Koelper NC, Srinivas SK, Sammel MD, Levine LD. Adverse maternal outcomes associated with uterine extensions at the time of cesarean delivery. Am J Perinatol 2019; 36 (08) 785-789
    Thieme ConnectPubMedSearch in Google Scholar
  • 9 de la Torre L, González-Quintero VH, Mayor-Lynn K. et al. Significance of accidental extensions in the lower uterine segment during cesarean delivery. Am J Obstet Gynecol 2006; 194 (05) e4-e6
    CrossrefPubMedSearch in Google Scholar
  • 10 Cromi A, Ghezzi F, Di Naro E, Siesto G, Loverro G, Bolis P. Blunt expansion of the low transverse uterine incision at cesarean delivery: a randomized comparison of 2 techniques. Am J Obstet Gynecol 2008; 199 (03) 292.e1-292.e6
    CrossrefPubMedSearch in Google Scholar
  • 11 Boyle JG, Gabbe SG. T and J vertical extensions in low transverse cesarean births. Obstet Gynecol 1996; 87 (02) 238-243
    CrossrefPubMedSearch in Google Scholar
  • 12 Bligard KH, Durst JK, Stout MJ. et al. Risk factors and maternal morbidity associated with unintentional hysterotomy extension at the time of cesarean delivery. Am J Perinatol 2019; 36 (10) 1054-1059
    Thieme ConnectPubMedSearch in Google Scholar
  • 13 Isquick S, Henry D, Nakagawa S. et al. The association between nitroglycerin use and adverse outcomes in women undergoing cesarean delivery in the second stage of labor. J Matern Fetal Neonatal Med 2017; 30 (11) 1297-1301
    CrossrefPubMedSearch in Google Scholar
  • 14 Giugale LE, Sakamoto S, Yabes J, Dunn SL, Krans EE. Unintended hysterotomy extension during caesarean delivery: risk factors and maternal morbidity. J Obstet Gynaecol 2018; 38 (08) 1048-1053
    CrossrefPubMedSearch in Google Scholar
  • 15 Wilkie G, Shipp TD, Little SE, Fadayomi A, Carusi DA. Hysterotomy extension at cesarean delivery and future uterine rupture. Obstet Gynecol 2021; 137 (02) 271-272
    CrossrefPubMedSearch in Google Scholar
  • 16 Sabol B, Denman MA, Guise J-M. Vaginal birth after cesarean: an effective method to reduce cesarean. Clin Obstet Gynecol 2015; 58 (02) 309-319
    CrossrefPubMedSearch in Google Scholar
  • 17 Baskett TF. Preparedness for emergency “crash” caesarean section. J Obstet Gynaecol Can 2015; 37 (12) 1116-1117
    CrossrefPubMedSearch in Google Scholar
  • 18 Wilkof-Segev R, Naeh A, Barda S, Hallak M, Gabbay-Benziv R. Unintended uterine extension at the time of cesarean delivery - risk factors and associated adverse maternal and neonatal outcomes. J Matern Fetal Neonatal Med 2023; 36 (01) 2204997
    CrossrefPubMedSearch in Google Scholar
  • 19 Sung JF, Daniels KI, Brodzinsky L, El-Sayed YY, Caughey AB, Lyell DJ. Cesarean delivery outcomes after a prolonged second stage of labor. Am J Obstet Gynecol 2007; 197 (03) 306.e1-306.e5
    CrossrefPubMedSearch in Google Scholar
  • 20 Bergholt T, Stenderup JK, Vedsted-Jakobsen A, Helm P, Lenstrup C. Intraoperative surgical complication during cesarean section: an observational study of the incidence and risk factors. Acta Obstet Gynecol Scand 2003; 82 (03) 251-256
    CrossrefPubMedSearch in Google Scholar
  • 21 Ezra O, Lahav-Ezra H, Meyer R. et al. Cephalic extraction versus breech extraction in second-stage caesarean section: a retrospective study. BJOG 2020; 127 (12) 1568-1574
    CrossrefPubMedSearch in Google Scholar
  • 22 Nooh AM, Abdeldayem HM, Ben-Affan O. Reverse breech extraction versus the standard approach of pushing the impacted fetal head up through the vagina in caesarean section for obstructed labour: a randomised controlled trial. J Obstet Gynaecol 2017; 37 (04) 459-463
    CrossrefPubMedSearch in Google Scholar
  • 23 Krispin E, Fischer O, Kneller M. et al. Fetal extraction maneuvers during cesarean delivery in the second stage of labor. J Matern Fetal Neonatal Med 2022; 35 (11) 2070-2076
    CrossrefPubMedSearch in Google Scholar
  • 24 Asıcıoglu O, Gungorduk K, Asıcıoglu BB, Yıldırım G, Gungorduk OC, Ark C. Unintended extension of the lower segment uterine incision at cesarean delivery: a randomized comparison of sharp versus blunt techniques. Am J Perinatol 2014; 31 (10) 837-844
    PubMedSearch in Google Scholar