A Rare Case of Transvesical Cesarean Section.

Cesarean section, also commonly known as C-section, is a surgical procedure in which incision is made through a mother's abdomen and uterus to deliver one or more babies. According to urgency, they are classified either as elective or emergency. According to technique, they have been classified as classical, lower uterine segment and cesarean hysterectomy. Intentional transvesical cesarean though not a routinely practiced technique is used for delivery in women born with imperforate anus, ectopic intravaginal urethra, vaginal and urethral strictures, and bladder adherent completely over the uterus. Since such cases are very rare, we are reporting one such case of transvesical cesarean section.

Introduction

A cesarean section is often performed when a vaginal delivery would put the baby's or mother's life or health at risk.[1]

History of cesarean section in India dates back to 320 BC when Chanakya, the great Indian emperor, Chandragupta's teacher, and advisor, cut open the belly of the queen and took out the baby, thus saving his life, when queen died accidently after consuming poison.[23] Initially, cesarean section resulted in death of the mother. The first well-recorded incident of a woman surviving cesarean section was in 1580 in Switzerland.[4]

The first modern cesarean section was performed by German gynecologist Ferdinand Adolf Kehrer in 1881.[5] The international health-care community has considered the rate of 10% and 15% to be ideal for cesarean sections.[6] Today's typical method for the cesarean section is Pfannenstiel incision named after Hermann Johannes Pfannenstiel.[7] Cesarean sections have been classified in various ways by different perspectives.

Case Report

A 40-year-old woman came to Dayanand Medical College and Hospital on November 16, 2015. She was primigravida, underwent in vitro fertilization (IVF), and conceived triplet pregnancy with a period of gestation of 29 + 5 weeks and presented to us at urinary tract infection and urinary retention. She was managed conservatively with antibiotics. Daily fetal heart rate monitoring was done for the patient. Emergency cesarean was done on November 19, 2015, due to fetal distress in one of the three fetuses. Intraoperatively, bladder was badly adherent and stretched over the uterus till the fundus as there was a history of myomectomy 4 years back. Anterior and posterior cystostomy was done taking care not to injure the trigonal area. An incision was made on the anterior wall of the uterus, and transvesical delivery of three fetuses was done. The first fetus weighing 1020 g was delivered as breech. The second fetus weighing 1080 g and the third fetus weighing 950 g were delivered as vertex. Placenta was delivered completely. Urologist was called for opinion [Figure 1]. The uterus was closed in single layer. Bilateral ureters were cannulated with number six feeding tubes. Posterior wall of bladder was sutured with Vicryl 2-0 in single-layer continuous manner. Infant feeding tubes were removed and suprapubic catheter was put. Thereafter, anterior wall of the bladder was stitched with Vicryl 2-0 in single-layer continuous manner. The abdomen was closed after securing hemostasis and packs counted. Postoperatively, the patient was given cefuroxime and amikacin. One hundred milliliter per hour normal saline was used for bladder irrigation which was continued for 3 days. Catheter was kept for 14 days and the patient was kept in the hospital for 7 days. Postoperative period was uneventful. Skin sutures and catheter removed after 14 days. Two of the neonates were discharged after 15 days, and the third neonate was discharged after 45 days of stay in the neonatal unit. The patient was followed up weekly for 6 weeks and had no complications.

Figure 1

Peroperative picture showing the anterior and posterior walls of the bladder in front of the uterus

Discussion

Cesarean sections have been classified in various ways by different perspectives. According to urgency, they are classified either as elective or emergency.[8] According to technique, they have been classified as classical, lower uterine segment and cesarean hysterectomy.[910] Intentional transvesical cesarean though not a routinely practiced technique is used for delivery in women born with imperforate anus, ectopic intravaginal urethra, vaginal and urethral strictures, and bladder adherent completely over the uterus. We encountered a very rare situation during an emergency cesarean in a 40-year-old primigravida at 29 weeks 5 days gestation with triplets (IVF-conceived, with history of myomectomy) for fetal distress wherein the urinary bladder was badly adherent and stretched over the uterus till the fundus, and the babies were delivered through transvesical approach. The case was managed successfully with the help of urologist. Teamwork and multidisciplinary approach helped us in achieving successful maternal and fetal outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.