Caesarean Hysterectomy

Sometimes when a woman is bleeding excessively after delivery the only way to control the bleeding is to remove the whole uterus. This is pretty much a last-resort option when other techniques to stop the bleeding have proved inadequate. In England caesarean hysterectomy is pretty unusual – in six years of training I had personally only ever been involved with one – but here they are much more common. I get a lot more referrals from other units, and certain management options (e.g. interventional radiology) are not available here. Also significantly, a lot of our women are anaemic, and it’s much more difficult to get blood for transfusion.

From November to January we had 8, and those weren’t particularly unusual months.

· 5 placenta praevias with associated accreta (where the placenta is at the bottom of the uterus and cannot be separated from the uterine muscle) - (4 following previous caesarean sections)
· 1 uterus with massive fibroids
· 1 uterus that refused to contract
· 1 ruptured uterus

Many of these babies are premature at delivery, and 2 of the 8 died not long after birth. I am always very grateful for our excellent neonatal unit as without our it at least 4 others would have died as well.

This little one started off on 'bubble CPAP' to support her breathing.

A few days later she was breathing well on her own, and has since gone home with her mother.

Frankly, these are not operations that I enjoy (at least, not until they are over). They occur in dangerous situations where a woman’s life is at risk, frequently in the middle of the night with theatre staff who are not used to gynaecological procedures. They require great speed and usually you are operating in a bloodbath. Knowing when to proceed to hysterectomy is not always easy – you don’t want to rush to a procedure that will prevent a woman from ever having more children in the future, but you know that if you delay too long, she will have used up all her clotting factors and be much more likely to die.

Last Friday was one of my more interesting caesarean hysterectomies. This woman had been actually come to casualty because her husband was ill, and then she started to bleed. When I scanned her and saw the praevia I knew that with her history of 2 previous caesareans she was highly likely to have an accreta. What I didn't expect, as I was opening the abdomen was to find that the placenta had eroded all the way through the uterus and was stuck to the anterior abdominal wall and the bladder.

The mother is doing very well post-operatively, but her baby is struggling a bit, still requiring CPAP.