CHAPTER 26

Clinical Challenges at
Caesarean Section: Uterine
Rotation, Transverse Lie and
Caesarean at Full Dilatation
S. Paterson-­Brown

INTRODUCTION a)

Caesarean section (CS) is a common operation of which

the majority are straightforward. This risks a relaxed atti-
tude to the procedure, and its occasional complexities can Body
catch out the unwary. This chapter highlights important
anatomical and surgical principles relevant to all CS but Isthmus
of particular importance in three challenging situations:
an exaggerated or malrotated uterus, a transverse fetal lie, Cervix
and in the second stage of labour. Many surgical difficulties
can be avoided with forethought, and even if unavoidable, b)
anticipating in advance enables mental rehearsal of strate-
gies/techniques to overcome as well as early recognition of
the problems when they are encountered.
Peritoneum
Peritoneum

Bladder
CRUCIAL POINTS OF UTERINE ANATOMY
AT CS
Development of the Lower Segment
In the nonpregnant state the uterus comprises body, isth-
mus and cervix. The serosal peritoneum over the body of c)
the uterus is inseparable from the myometrium, whereas
inferiorly the isthmus has a loose covering of peritoneum
(the uterovesical fold) and the cervix lies directly behind
the bladder (Fig. 26.1). From the second trimester of preg-
nancy onwards the isthmus elongates and dilates to become
the lower uterine segment and with advancing gestation the
superior part of the cervix follows the same pattern. In nor-
mal circumstances the fully formed lower segment consti- Level of
tutes 70% isthmus and 30% cervix. Thus the point at which peritoneal
the free peritoneum fixes to the uterine serosa marks the reflection
upper limit of the lower segment of the uterus (Fig. 26.1).
The lower segment is therefore poorly developed at FIG. 26.1 n Components of the uterus (a), their relationship
extremely preterm gestations, but can also be deficient with the peritoneal reflections (b) and their development dur-
when the fetal lie is transverse, with major placenta prae- ing pregnancy (c). Note the upper limit of the lower segment is
identified by the point at which the loose uterovesical peritoneal
via and with isthmic fibroids. fold attaches to the myometrium. Above this level the serosa is
inseparable from the myometrium.
Rotation of the Uterus Figure 26.2 shows a case where the uterus had rotated 180
The distended sigmoid colon in pregnancy (exacerbated by degrees: in this extreme case there was no lower segment as
the smooth muscle relaxing effect of progestogen) causes the axis of rotation maintained the narrow isthmic and cervi-
dextrorotation of the uterus, which can become exaggerated. cal pedicle inhibiting normal lower segment development.

173
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en diciembre 19, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
174 PART II Labour and Delivery

D E

F
FIG. 26.2 n A uterus which rotated 180 degrees. In this case, it was not possible to correct the rotation before delivery and there was
no identifiable lower segment, so a midline uterine incision was placed in the posterior aspect of the upper segment.

Fibroids can also have a huge impact on the posi-
tion of the uterus as it grows: it is always worth check-
ing an ultrasound scan performed very early in pregnancy
to review the fibroid locations before the progres-
sive uterine rotation due to pregnancy (and fibroid)
enlargement. Late scans can be falsely reassuring that
the fibroid lies laterally when it had arisen from the
anterior isthmic wall: on entry, after correction of
the rotation, it may inhibit access, and the opportu-
nity to plan an appropriate incision might have been
missed.
Changes in Labour
The myometrial fibres of the upper segment contract
and shorten, pushing down on the fetus while pull-
ing up on and stretching the lower segment. So, over
time, the retraction of the upper segment causes it to
shorten and get thicker while the lower segment gets
thinner and ballooned. In normal circumstances this
is accompanied by descent and then delivery of the
fetus, but in advanced labour and especially when per-
forming a CS at full dilatation the lower segment can
be very ballooned out, extending high up towards the
level of the umbilicus (Fig. 26.3). This is most obvious
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en diciembre 19, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
in obstructed labour where a Bandl’s ring develops
(Figs. 26.3 and 26.4).
SURGICAL PRECISION AT CS
Checking and Correcting for Rotation
Safe precise technique at CS should be routine: checking
symmetry of the broad ligaments/round ligaments prior
to incising the uterus allows for correction of any rota-
tion before incising the uterus. Failing to do this risks
an asymmetrical incision, increasing the likelihood of a
troublesome angle extension.
Identifying the Landmarks for the Junction
Between Lower and Upper Segments of the
Uterus
Appreciating that the loose peritoneum becomes fixed at
the upper margin of the lower uterine segment:
• Enables full assessment of whether there is an ad-
equate lower segment available through which to
allow access and delivery at very early gestations or
when the fetus lies transversely.

a)
b)
FIG. 26.3 n (a) In normal labour the upper segment contracts
and retracts and the lower segment is pulled over the descend-
ing presenting part of the fetus to effect cervical dilatation and
delivery. (b) In obstructed labour the presenting part does not
descend and the lower segment (which is still pulled up by the
retracting upper segment) becomes increasingly elongated and
ballooned out.
$FWLYH
VHJPHQW
3DWKRORJLFDO
3K\VLRORJLFDO UHWUDFWLRQULQJ
UHWUDFWLRQULQJ %DQGO
3DVVLYH 2EOLWHUDWHG
VHJPHQW LQWHUQDORV
([WHUQDO
RV
FIG. 26.4 n Bandls ring. The constricting Bandls ring is situated
at the junction of upper and lower uterine segments.
• A
 ssists in positioning the uterine incision relatively
high in the lower segment, thereby avoiding incis-
ing too inferiorly when it is ballooned out in ad-
vanced or obstructed labour.
Delivering the Head
The fetal head delivers through the CS incision from a
transverse position, which is achieved through a com-
bined process of flexing and rotating the head before
laterally flexing it into the wound. Knowing where the
fetal spine is before attempting manipulations allows for
rotation in the correct direction, especially important at
CS in second stage.
UTERINE ROTATION
Once recognized, correcting uterine rotation is usually
easily achieved by the assistant exerting pressure exter-
nally. When extreme, the operator can insert their hand
into the abdomen, pass it around the uterus and gently
correct the rotation, which can then be maintained by the
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en diciembre 19, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
26 Clinical Challenges at Caesarean Section 175
assistant with external pressure. Very occasionally this is
not possible, as in the illustrated case (Fig. 26.2) where
the rotation of 180 degrees was irreducible. The fetus was
lying transversely and the twist in the uterus had inhib-
ited any development of the lower segment, so a longitu-
dinal incision was placed in the midline of the posterior
aspect of the uterus and the baby delivered uneventfully.
The incision was closed as for a classical incision and then
the uterine rotation was corrected before other pathology
and trauma were excluded as a potential cause or conse-
quence of the extreme rotation, respectively.
CS FOR TRANSVERSE LIE
Before embarking on a CS for transverse lie, the key
questions to address are:
• What is the likely cause? (Extreme prematurity,
placenta praevia, pelvic mass, fetal anomalies, or
uterine anomalies – be especially suspicious if it is a
nulliparous woman.)
• Is there likely to be a lower segment?
• Are the membranes intact?
Transverse Lies Where a Developed Lower
Segment Is Likely
$FWLYH This includes a multiparous patient with a patulous abdomi-
VHJPHQW nal wall, polyhydramnios or a twin pregnancy. Careful entry
through a transverse uterine incision leaving the membranes
intact facilitates the fetal manipulations of either external
3DVVLYH cephalic or internal podalic version. When internal podalic
VHJPHQW version is used (as with vaginal delivery of the second twin),
the aim is to grasp the fetal foot/feet (recognized by the
heel) and bring them down into the wound while keeping
the fetal back anterior. Grasping the posterior foot when the
fetus lies back down is best (anterior foot best when the fetal
back is up) but it is not always clear which foot has been
grasped, so while applying traction, rotate the fetus to bring
the back anterior before completing the delivery. The mem-
branes will break during this procedure (but should be kept
intact as long as possible) and expediting delivery is aided by
the assistant applying gentle fundal pressure.
Complex Transverse Lies: a Deficient Lower
Segment or Membranes Already Ruptured
After opening the uterovesical fold of peritoneum and
reflecting its inferior aspect, a midline longitudinal uter-
ine incision affords good access to deliver the transverse
lie fetus. As with any CS it is important to know placental
location and a pre-­operative bedside scan can help: access
through an anterior placenta may be unavoidable, but
knowing where the cord insertion is and avoiding it is vital.
Prompt rather than delayed cord clamping is needed in all
cases where the placenta has been disrupted during delivery.
CAESAREAN SECTION AT FULL
DILATATION
By definition these procedures are performed in advanced
labour, and usually after an unsuccessful attempt at vagi-
nal delivery.
176 PART II Labour and Delivery
The incidence of these procedures has risen in
recent years due to a combination of factors1 which
include:
• Loss of clinical experience due to reduced hours
and run-­ through training (clinical experience on
entering consultant posts in surgical specialties fol-
lowing the European Working Time Directive has
been estimated to be 30% of the older style train-
ing).2
• A preference for ventouse delivery, resulting in
○ reduction in use and loss of skills in rotational
forceps
○ more failures in achieving vaginal delivery.
• The increasing failures with vacuum deliveries,
which have in turn led to a tendency to take women
to theatre for a ‘trial’ where dense anaesthesia com-
promises pushing, exacerbating the likelihood of
failure.
• An unwillingness to embark on rotational vaginal
deliveries for fear of litigation.
Exploring the incidence of CS at full dilatation is
difficult. Many units cannot identify their rates and
variable denominator figures are used, for exam-
ple unsuccessful instrumentation rates ignore those
women who were operated on at full dilatation without
an attempt at vaginal delivery. The most meaningful
denominator which identifies the obstetrician’s skills,
experience, judgement and decision-­ making within
this arena is the total number of women who reach full
dilatation and do not deliver spontaneously (i.e. have
an operative delivery of any sort), as illustrated in the
analysis by Louden et al.1 This can be further analyzed
within the Robson Ten Group Classification System, as
decisions may be further influenced by parity or, par-
ticularly, previous CS.
PATHOPHYSIOLOGY
CS at full dilatation is needed because attempting an
instrumental birth is either deemed unsafe, or has been
unsuccessful. Both judgement and technical skills are heav-
ily influenced by clinical experience,3 but the tendency for
an inexperienced clinician to prefer abdominal delivery can
be very misplaced. CS at full dilatation when vaginal deliv-
ery would have been achieved safely where the fetal head is
low can be fraught with difficulties. Conversely, some CS
will be a last resort after the attempt at instrumental deliv-
ery has been unsuccessful and traction applied will have
further compounded any impaction. In these situations,
the head is usually in a mal-­rotated position and/or has a
deflexed attitude, further complicating the delivery
CLINICAL HISTORY
Clinical assessment following unsuccessful spontane-
ously delivery should include a review of the history,
the pattern of labour, the progress on the partogram,
fetal growth and the condition of the mother and
baby.
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en diciembre 19, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
CLINICAL EXAMINATION
Abdominal palpation should assess uterine contractions,
whether there is a suggestion of obstructed labour (a
ballooned-­out lower segment), the amount of fetal head
palpable and on which side of the mother the fetal back
is lying.
Pelvic examination should then include fetal presen-
tation, position, attitude, moulding and station, as well
as pelvic assessment, with particular care being taken to
assess the outlet (subpubic arch ischial spines and the coc-
cyx). An outlet obstruction results in a failure to deliver
at the very last stage of vaginal delivery, leaving the fetal
head very deeply engaged and impacted.
Having decided to abandon vaginal delivery and when
the uterine contraction has stopped, the fetal head can
be very gently disimpacted, flexed and rotated towards
the occipitotransverse position, to anticipate abdominal
delivery. Also inform the anaesthetist to prepare them for
the possibility of tocolysis being needed (see later). There
is now a ‘fetal pillow’ which can be inserted prior to CS
to help in this situation, but the author has not used this
and robust evidence of its efficacy is awaited.
PROCEEDING TO CS
Once the abdomen has been opened, the uterus is imme-
diately visible and attention should focus on recognizing
and correcting any uterine rotation before assessing the
lower segment (likely to be well developed, oedematous
and stretched). The point where the peritoneum cannot
be reflected marks the superior limit of the lower seg-
ment and the uterine incision should be placed a couple
of fingers’ breadth below this, avoiding the risk of incis-
ing (inadvertent laparoeltrotomy4) or extending into the
vagina.5
Entry to the uterus should be extremely careful to
avoid fetal injury (more likely due to the thin lower seg-
ment and absence of liquor) and then the hand should
be inserted gently into the pelvis. The uterus will be
contracting in response to the surgical handling at this
point and the tight squeeze felt should not trigger panic;
rather, the operator should maintain a sense of calm, stop
all movements and wait (remembering there is no rush –
the fetus is still being perfused and oxygenated). When
the uterus relaxes (which it will if movement stops), the
hand can then be gently pushed further into the pelvis,
below the fetal head. A contraction is likely to start again,
so again the operator should wait without moving, until it
eases, and then proceed to try to correct the position and
attitude to achieve a flexed head in the transverse posi-
tion, proceeding to deliver the head by lateral flexion. In
all cases it is important to avoid pressure on the fetal head
during uterine contractions as it is unlikely to be effec-
tive, and more likely to cause trauma.
Difficulty With the Head
Disimpacting and delivering the deep transverse arrested
fetal head does not usually cause problems in the same
 26
way as the deeply engaged occipitoposterior head, as the
former just needs flexion prior to delivery, while the lat-
ter requires flexion with rotation (flexion without rota-
tion will not work and rotation will not occur without
flexion). Identify which side the fetal back is on, then flex
and rotate accordingly, i.e. the occiput needs to finish on
the same side as the fetal spine—although this sounds
obvious a fetus with an left occipitoposterior head posi-
tion can have its back lying to the right hand side of the
mother’s spine and needs to be rotated to right occipi-
totransverse position. There are lots of anecdotes about
what can help with this manoeuvre, with some people
favouring left/right or dominant/nondominant hand,
but the secret is to remember which way the head needs
to end up. The author personally tends to use the right
hand for all these manoeuvres, but takes time and atten-
tion to check which way the rotation should go before
attempting it.
DIFFICULTIES ENCOUNTERED/SPECIAL
CIRCUMSTANCES
The Head Will Not Disimpact
The key here is to establish if this is because the uterus
is contracting (stopping moving and await relaxation
should help) or not. If further relaxation of the uterus is
needed, ask the anaesthetist (ideally forewarned prior to
the procedure) to relax the uterus (intravenous terbuta-
line 250 μg or Glyceryl trinitrate [GTN] 250 μg works
well). Relaxation takes a minute or so, during which any
movements should be avoided (remember the fetus is
still being oxygenated—there is no need to panic). There
seems to be a fairly popular belief that it is good to get
someone to push up from below, but this is illogical and
potentially dangerous—pushing on a fetal head when it is
impacted in the pelvis, and being resisted by uterine tone,
can damage it. Better to try to push up from within the
uterus on the shoulder but only with the uterus relaxed
(otherwise it will not work!).
The Head Still Will Not Disempact
If the above fails then the choices are between extend-
ing the uterine incision upwards to allow for more space,
and/or delivering by the breech: the two techniques for
breech delivery include the Patwardan manoeuvre and
reverse breech extraction. The Patwardan method is used
when the back is anterior (occipitoanterior positions) and
involves delivering the shoulders prior to the breech;
reverse breech is used when the back is posterior (occipi-
toposterior positions) or transverse, and involves grasp-
ing the feet first.
There are variable reports supporting these tech-
niques but the most recent Cochrane review com-
paring pushing or pulling techniques concludes that
there is currently insufficient information available
from randomized trials to recommend one over the
other, and further randomized controlled trials are
needed.6
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en diciembre 19, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
Clinical Challenges at Caesarean Section 177
COMPLICATIONS
Maternal and neonatal complications are higher after CS
in second stage, compared with CS in the first stage of
labour, with increased admissions to intensive care, and
increased morbidity and mortality.7
The main maternal complications from CS at full
dilatation include maternal trauma and haemorrhage.
The uterine incision is more likely to extend because the
effects of advanced labour result in an oedematous swol-
len distended lower segment which is more vulnerable to
tearing (especially if there is difficulty manipulating the
fetal head or the uterine rotation was not corrected). This
results in postpartum haemorrhage, which is often exac-
erbated by uterine atony as a consequence of a long, dif-
ficult labour. Other complications to the mother include
other genital tract trauma, either caused directly from the
manipulations, or during surgical attempts at repairing
damage, especially when the vagina or broad ligament
have been inadvertently opened.
The main neonatal complications from delivery by CS
at full dilatation relate to trauma from a difficult delivery,
but many of these babies have been subjected to an unsuc-
cessful instrumental delivery prior to the CS.8 It is best to
act on a case-­by-­case basis to achieve a safe delivery either
vaginally or abdominally depending on the clinical find-
ings, rather than thinking CS at full dilatation is an easy
or a safer option than proceeding with an instrumental
vaginal delivery, if the latter is appropriate.
CONCLUSIONS
Embarking on a CS in any complex clinical situation
should be performed by an experienced obstetrician who
has anticipated the potential problems and pays careful
attention to detail. Remembering basic anatomical and
physiological principles goes a long way to avoiding trou-
ble, and precise techniques, gentle manipulations and
good communications within the team help in maintain-
ing calm, careful deliberate and skilled care.
AUDIT
CS at full dilatation as a proportion of all women
requiring an assisted delivery at full dilatation.
Grade of operator in theatre for trials of operative
delivery, and for CS at full dilatation.
Number of cases of angle extensions and Massive
Obstetric Haemorrhage in CS at full dilatation.
REFERENCES
1. Loudon JAZ, Groom KM, Hinkson L, et al. Changing trends
in operative delivery performed at full dilatation over a 10 years
period. J Obstet Gynaecol. 2010;30(4):370–375.
2. Barber P. The colleges, Calman, and the new deal. Lancet.
1997;350:974.
3. Oláh KS. Reversal of the decision for caesarean section in the
second stage of labour on the basis of consultant vaginal assess-
ment. J Obstet Gynaecol. 2009;25(2):115–116. https://doi.org/10.
1080/01443610500040547.
178 PART II Labour and Delivery

4. P  eleg D, Perlitz Y, Pansky S, et al. Accidental delivery through a
vaginal incision (laparoelytrotomy) during caesarean second in the
second stage of labour. Br J Obstet Gynaecol. 2001;108(6):659–660.
5. Porter S, Paterson-­Brown S. Avoiding inadvertent laparoelytrot-
omy. Br J Obstet Gynaecol. 2003;110:91–92.
6. Waterfall H, Grivell RM, Dodd JM. Techniques for assisting difficult
caesarean section. Cochrane Database Syst Rev. 2016;31(1):CD004944.
Available at: www.cochrane.org/CD004944/PREG_techniques-
­assisting-­difficult-­caesarean-­section.
7. Pergialiotis V, Dimitrios G, Vlachos, et al. First versus second
stage C/S maternal and neonatal morbidity: a systematic review
and meta-­analysis. 175:15–24.
8. Vousden N, Cargill Z, Briley A, et al. Caesarean section at full dila-
tation: incidence, impact and current management. Obstet Gynaecol.
2014;16:199–205. https://doi.org/10.1111/tog.12112.

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en diciembre 19, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.