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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
› Institutsangaben
Funding G.M.M. is funded by a Hamilton Academy of Health Sciences Organization Innovation Grant (grant no.: HAH-23-016).
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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.




Publikationsverlauf

Eingereicht: 29. Mai 2024

Angenommen: 02. September 2024

Accepted Manuscript online:
03. September 2024

Artikel online veröffentlicht:
27. September 2024

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