What is hysterectomy during C-section?
Hysterectomy (surgical removal of the uterus) may be performed during Cesarean delivery and is referred to as a Cesarean hysterectomy. It involves the removal of the uterus at the time of Cesarean delivery. The uterus undergoes several anatomical changes during pregnancy, hence making a Cesarean hysterectomy a challenging procedure for the surgeon. Following a hysterectomy, a woman is no longer fertile and hence would never be able to get pregnant again, which is why a Cesarean hysterectomy is usually only performed when there are no other treatment options or other treatment options fail. In most cases, it’s unplanned and usually performed to save the mother’s life.
Understanding the anatomy and physiology: The uterus consists of three layers, namely, the endometrium (inner lining), myometrium (middle muscular layer, and serosa (thin layer covering the uterus). Normally, the placenta is attached to the uterus through which the exchange of nutrients takes place between the mother and fetus during pregnancy. After the fetus is delivered, the placenta separates from the uterus. The uterus contracts (mainly the muscular layer) and shrinks in size. The contraction of the muscular layer of the uterus causes contraction of the uterine muscles, causing cessation of bleeding after delivery of the baby.
When is a Cesarean hysterectomy done?
A hysterectomy following cesarean delivery is usually only performed when there are no other treatment options or other conservative treatment options fail. In most cases, it’s unplanned and usually performed as an emergency surgery to save the mother’s life. A Cesarean hysterectomy is usually indicated in the following conditions
- Abnormal placentation: This is the most common indication for performing a Cesarean hysterectomy. In this condition, the placenta fails to separate from the underlying uterine tissue. There are different types of abnormal degrees of abnormal placentation noted: placenta accreta (the placenta is adhered to the myometrium), placenta increta (there is invasion of the placenta through the myometrium) and placenta percreta (invasion completely through the myometrium and into the serosa, sometimes even into the bladder). Risk factors for abnormal placentation include previous uterine surgeries and previous Cesarean delivery. Abnormal placentation may be detected prior to delivery based on ultrasonography or magnetic resonance imaging (MRI) or may be suspected based on a history of risk factors but can also be unexpected at the time of delivery.
- Postpartum hemorrhage: Postpartum hemorrhage or bleeding usually occurs when the muscular layer of the uterus fails to contract. This failure of the uterus to contract is also called uterine atony. Several medications and less invasive procedures such as balloon tamponade, uterine artery or iliac artery ligation (tying of the blood vessels) on both sides or compression sutures may be attempted by the surgeon to control bleeding before proceeding with a hysterectomy. A hysterectomy for postpartum bleeding is usually performed only when all other measures to control bleeding have failed. If there is significant blood loss after delivery, the mother could develop a condition called disseminated intravascular coagulation (DIC), which is a widespread life-threatening bleeding condition that can make controlling the bleeding even more difficult. DIC usually requires multiple transfusions with multiple blood products. This could be fatal.
- Tumors of the uterus or cervix: A Cesarean hysterectomy may be performed in women who are diagnosed with tumors in the uterus or cervix, cancerous or large non-cancerous tumors, after getting pregnant. A hysterectomy can help limit the spread of cancer. This is preferable in women who do not want to bear a child in the future. Other treatments such as radiotherapy and chemotherapy may be required along with surgery as well.
When is a Cesarean hysterectomy not done?
The main contraindication to a Cesarean hysterectomy is the refusal of the procedure by women, but this is generally rare because in most cases, they are performed for life-saving reasons.
How is a Cesarean hysterectomy performed?
The patient is administered spinal anesthesia (waist down anesthesia). Cesarean delivery is performed as usual by making an incision in the lower abdomen. Once the baby is delivered, the surgeon proceeds with the hysterectomy, if indicated. The uterus is detached from the upper portion of the vagina, fallopian tubes, ovaries, surrounding blood vessels and connective tissues that support it and removed through the vaginal opening. The cervix may be removed as well.
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