///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Association of operator experience and unintended uterine extension with hemorrhage at cesarean delivery.

Abstract Number: F3C-426
Abstract Type: Original Research

Eli Zarkhin MD1 ; Eli Zarkhin MD2; Ghislaine C Echevarria MD MS3; Christina Dgheim DO4; Jerome Lax MD5; Gilbert J Grant MD6

Introduction: Cesarean delivery is the most commonly performed intra-abdominal surgery worldwide [1]. The rate of cesarean delivery the United States is approximately 32% [2]. Cesarean delivery is associated with a greater complication rate than vaginal delivery, including endometritis, wound infection, thromboembolic disorders and increased risk of readmission [3]. Hemorrhage is one of the most common complications of cesarean delivery [4]. Uterine extensions during low transverse cesarean delivery are associated with increased blood loss and higher rates of maternal blood transfusions [3,5]. This study was designed to retrospectively determine if the experience level of the operator was associated with risk of uterine extension and large blood loss during low transverse cesarean delivery.

Methods: We reviewed the electronic medical records of all cesarean deliveries performed at our institution from January 1 to December 31, 2018. Records with a quantified blood loss (QBL) of at least 1,000 mL were identified. Data was extracted from each record included demographics, obstetrical information, the presence of extension(s) of the hysterotomy incision, and name of the primary operator. The experience of the operator was determined as defined by years since completion of residency.

Results: A QBL of at least 1,000 mL was identified in 391 cesarean deliveries. Extension(s) of the hysterotomy incision was noted as the primary cause of hemorrhage in 18 deliveries (4.6%). In 14 of the 18 cesareans with extension(s) (77.8%), the primary operator had completed residency within the past 5 years (p = 0.014; Fisher’s exact test).

Discussion: Uterine extensions are a common complication of low transverse cesarean delivery, and may increase maternal morbidity [3]. If the US cesarean delivery rate remains in excess of 30%, uterine extensions are destined to continue to contribute to postpartum hemorrhage. Our findings suggest that the incidence of uterine extensions may be modified by experience. Perhaps a focus on training to avoid uterine extensions can improve the performance of relatively inexperienced operators.


1- Asıcıoglu O, et al. Unintended extension of the lower segment uterine incision at cesarean delivery: a randomized comparison of sharp versus blunt techniques. Am J Perinatol 2014;31(10): 837–844.

2- Martin JA, et al. National Center for Health Statistics: Births – Methods of Delivery. 2016;67(1). Available at: https://www.cdc.gov/nchs/fastats/ delivery.htm.

3- Patel SS, et al. Am J Perinatol. 2019 Jan 15. doi: 10.1055/s-0038-1676827.

4- Sekhavat L, et al. Effect of expansion technique of uterine incision on maternal blood loss in cesarean section. Arch Gynecol Obstet 2010;282: 475-479.

5- De la Torre L, et al. Significance of accidental extensions in the lower uterine segment during cesarean delivery. Am J Obstet Gynecol 2006;194(05):e4–e6.

SOAP 2019