ADHESIONS FOLLOWING CAESAREAN SECTIONS
“Dust”
“Wueh! Hizi previous scars zitatuonyesha mambo!” says Ndicho, the theatre nurse at Kigumo, after we finished operating on a mother who had a previous cesarean section.
“Leo tumeona dust” I replied
WHO Safety Check List
The WHO surgical safety review guideline dictates that the surgeon introduce himself to the theatre team and client and state what surgery is to be done and the estimated time of surgery and expected complications. Repeat caesarean sections for mothers who have had previous surgeries may take a longer time and are more challenging if adhesions are encountered.
Previous CS location
“Mama, hiyo CS ingine ulifanyiwa wapi?” we jokingly ask mothers on the theatre table awaiting spinal anaesthesia. This is to prepare for possible adhesions.
Adhesions, Definition, Cause, Consequences and Prevention
Adhesions are bands of scar tissue that form between tissues and organs after surgery.
When doing a cesarean section these bands can be encountered anywhere from the skin to the abdominal cavity. One may find the rectus muscle adherent to the sheath, the uterus adherent to the anterior abdominal wall, the omentum attached to the previous caesarean section scar, the bowel adherent to the uterus or the bladder adherent to the uterus.
Causes
After a cesarean section adhesions may occur mainly due:
– Peritoneal trauma
– Ischemia of tissue
– Inflammatory response from foreign material in the peritoneal cavity
– Posp-operative sepisis
– Delayed fibrinolysis when healing is prolonged or complicated
Prevention
While adhesions cannot be eliminated entirely, several strategies reduce risk including gentle surgical technique, meticulous hemostasis, infection prevention, avoidance of unnecessary peritoneal closure, Minimizing foreign body reaction and selective use of adhesion barriers.
Long term complications
We also encounter the longer term complications of post caesarean section adhesions that include:
– Infertility and Subfertility
– Chronic Pelvic Pain
– Bowel Complication like small bowel obstruction
– Surgical Complications in Repeat Cesareans
– Increased risk of Bladder injury, Ureteral or bowel injury
– Increased operating time
– Increased blood loss
– Increased risk of Abnormal Placentation. Multiple cesarean scars and adhesions predispose to placenta previa and placenta accreta spectrum in future pregnancies.
Changing times & GyneCaesareanologist
As the number of caesarean sections increase, it is important for the doctors performing them to ensure the highest quality of care for the mothers even in future. As a medical intern and officer twenty five years ago I did cesarean section in 15 – 30 minutes. With time, and in line with gentle surgical technique, my 15-minute CS era is over. I predict that in future cesarean sections of mothers with previous cesarean and myomectomy scars will be operated on by gynaecologists specialized in cesarean section – GyneCaesereanologist (Tongue-In-Cheek)
Dr Simon Kigondu is a gynaecologist at Excella Healthcare and a GyneCaesereanologist
simonkigondu@gmail.com