Advertisement

Fetal laceration injury during cesarean section and its long-term sequelae: a case report

      This case report illustrates the cosmetic outcome of a scalpel-related laceration injury sustained to a newborn infant that occurred during the course of an elective cesarean section for breech presentation. This buttock laceration was noted to be 2 cm in length at the time of birth. Twelve years later, the same scar had migrated in a cephalad direction and had increased to 10 cm in length.

      Key words

      Case Report

      An injury to buttock was sustained by a newborn infant at cesarean section while the surgeon was incising the uterine lower segment (Figure 1). The indication for cesarean section was breech presentation. The laceration was measured and found to be 1.5-2.0 cm at the time of birth and located at the mid area of the buttock region. It was treated with the application of adhesive skin closure strips to the wound. Twelve years later, the same scar is still very much visible and has migrated in a cephalad direction with a significant increase in size (10 cm in length) as well as a more irregular appearance (Figure 2). The current scar may be associated with a negative impact on the psychologic well-being of this 12-year-old girl because of its size and appearance.
      Figure thumbnail gr1
      FIGURE 1Laceration during cesarean section
      The fetal laceration after cesarean section is shown being treated by application of steristrip adhesive dressing.
      Gajjar. Fetal laceration injury during cesarean section. Am J Obstet Gynecol 2009.
      Figure thumbnail gr2
      FIGURE 2Same scar at 12 years of age
      The scarring from fetal laceration 12 years later is shown and appears wider, longer (approximately 10 cm), more irregular, and has migrated in a cephalad direction.
      Gajjar. Fetal laceration injury during cesarean section. Am J Obstet Gynecol 2009.

      Comment

      The incidence of fetal laceration varies from 0.7-1.9% according to reports found in the literature.
      • Smith J.F.
      • Hernandez C.
      • Wax J.R.
      Fetal laceration injury at caesarean delivery.
      • Wiener J.J.
      • Westwood J.
      Fetal lacerations at caesarean section.
      • Alexander J.M.
      • Leveno K.J.
      • Hauth J.
      • et al.
      Fetal injury associated with cesarean delivery.
      Risk factors include emergency cesarean section for fetal distress and second-stage cesarean deliveries and ruptured membranes and an inexperienced surgeon.
      • Alexander J.M.
      • Leveno K.J.
      • Hauth J.
      • et al.
      Fetal injury associated with cesarean delivery.
      • Gerber A.H.
      Accidental incision of the fetus during cesarean section delivery.
      • Haas D.M.
      • Ayres A.W.
      Laceration injury at cesarean section.
      • Puza S.
      • Roth N.
      • Macones G.A.
      • Mennuti M.T.
      • Morgan M.A.
      Does cesarean section decrease the incidence of major birth trauma?.
      In these situations, the speed of surgery required to deliver the infant safely is a contributory factor with incision-to-delivery times of less than 3 minutes being most associated with fetal laceration. Furthermore, fetal skin injury is more likely when a “J” or inverted “T” incision is made into the uterus compared with transverse or vertical incisions. According to 1 study, the incidence of fetal laceration was found to be higher (approximately 6%) in the nonvertex presentation group.
      • Smith J.F.
      • Hernandez C.
      • Wax J.R.
      Fetal laceration injury at caesarean delivery.
      Approximately, 70% of lacerations occurred on the face, head, and ear, 20% of lacerations occurred below the waist (buttocks, leg, and ankle), and 10% were on the back.

      Fetal lacerations associated with cesarean section. PA-PSRS Patient Safety Advisory, vol. 1, no.4. Harrisburg, PA: Pennsylvania Safety Authority; 2004.

      Fetal lacerations have been classified as follows
      • Dessole S.
      • Cosmi E.
      • Balata A.
      • et al.
      Accidental fetal lacerations during cesarean delivery: experience in an Italian level III university hospital.
      :
      • 1
        Mild: those lacerations that affected skin only.
      • 2
        Moderate: those lacerations that involved the skin and muscle.
      • 3
        Severe: those lacerations that involved skin, muscle, bone, and other structures such as nerves.

      Management

      Mild lacerations resolve spontaneously, with no need for plastic surgery because they are superficial and involve the skin only. Minor lacerations can be managed by the application of adhesive plaster or topical tissue adhesives such as 2-octylcyanoacrylate.
      • Saraf S.
      Facial laceration at caesarean section: experience with tissue adhesive.
      Accurate assessment of the wound, especially with regard to wound tension and careful application of the adhesive to ensure sufficient wound eversion, is mandatory to maximise a satisfactory outcome. Moderate and severe lacerations need immediate cosmetic surgical advice for consideration of primary repair of deep structures and skin approximation.

      Prevention

      General surgical methods to reduce the risk of fetal laceration injury have included meticulous suctioning at the site of uterine entry while the incision is being performed
      • Abuhamad A.
      • O'Sullivan M.J.
      Operative technique for cesarean section.
      as well as removal of intraabdominal retractors, if used, before delivery to minimize fetal injury risks and to create more room for the delivery. In addition, the uterine incision should be swept by the finger with each pass of the scalpel to minimize inadvertent deep laceration. Methods of uterine entry used to reduce fetal trauma have included scoring the uterus along the entire length of the proposed uterine incision with a scalpel and then bluntly entering the uterine cavity by inserting a finger (or Spencer-Wells forceps) into the central portion of the uterine incision. The uterine incision is then extended in both lateral directions by retraction with index fingers only and not with the use of a scalpel. Another method of uterine entry includes grasping the lateral edges of the uterine incision with ring forceps or Allis clamps, elevating the uterine incision away from the fetal presenting part, and completing uterine entry with the aid of bandage scissors.
      • Gerber A.H.
      Accidental incision of the fetus during cesarean section delivery.
      In situations in which the membranes are intact, this should allow the operator to incise the uterus carefully and keep the membranes intact to allow them to buffer the scalpel from the underlying fetal parts.
      Most fetal injury cases are not published, making risk reporting and patient counselling more problematic. Most obstetric units would report this event as a risk management issue and investigate it accordingly. There is a need for further studies to assess the long-term cosmetic implications of fetal laceration sustained at cesarean delivery. Because of international rates of cesarean section being consistently upward, the number of fetal skin lacerations observed is likely to increase with time. Currently, no data are available to help the obstetrician counsel parents about the long-term outlook for these injuries. Nevertheless, this case report demonstrates that skin lacerations can elongate over time and move “relatively” as the child grows and develops over subsequent years. Furthermore, although the incision was initially a straight cut, over time and with the child's growth, the scar is now an erratic line caused by differential skin stretching. This information is useful to help parents appreciate the natural history of surgical skin wounds sustained at birth and future appearance.

      References

        • Smith J.F.
        • Hernandez C.
        • Wax J.R.
        Fetal laceration injury at caesarean delivery.
        Obstet Gynecol. 1997; 90: 344-346
        • Wiener J.J.
        • Westwood J.
        Fetal lacerations at caesarean section.
        J Obstet Gynaecol. 2002; 22: 23-24
        • Alexander J.M.
        • Leveno K.J.
        • Hauth J.
        • et al.
        Fetal injury associated with cesarean delivery.
        Obstet Gynecol. 2006; 108: 885-890
        • Gerber A.H.
        Accidental incision of the fetus during cesarean section delivery.
        Int J Gynaecol Obstet. 1974; 12: 46-48
        • Haas D.M.
        • Ayres A.W.
        Laceration injury at cesarean section.
        J Matern Fetal Neonatal Med. 2002; 11: 196-198
        • Puza S.
        • Roth N.
        • Macones G.A.
        • Mennuti M.T.
        • Morgan M.A.
        Does cesarean section decrease the incidence of major birth trauma?.
        J Perinatol. 1998; 18: 9-12
      1. Fetal lacerations associated with cesarean section. PA-PSRS Patient Safety Advisory, vol. 1, no.4. Harrisburg, PA: Pennsylvania Safety Authority; 2004.

        • Dessole S.
        • Cosmi E.
        • Balata A.
        • et al.
        Accidental fetal lacerations during cesarean delivery: experience in an Italian level III university hospital.
        Am J Obstet Gynecol. 2004; 191: 1673-1677
        • Saraf S.
        Facial laceration at caesarean section: experience with tissue adhesive.
        Eplasty. 2009; 9: e3
        • Abuhamad A.
        • O'Sullivan M.J.
        Operative technique for cesarean section.
        in: Plauche W.C. Morrison J.C. O'Sullivan M.J. Surgical obstetrics. WB Saunders, Philadelphia1992: 417-429