Bladder Rupture Following Both Successful and Failed Trial of Labor After Cesarean [02L

Abstract

INTRODUCTION: The incidence of bladder injury during cesarean section is estimated to be 0.08 to 0.94%. In patients with previous cesarean delivery, rate of bladder injury after successful VBAC is 0.2% while unsuccessful TOLAC confers 1.1% risk. The average length of bladder injury is 4.2 cm. METHODS: Case presentation. RESULTS: The first patient is a 26 year-old gravida 3 para 2 presenting at 39w3d in spontaneous labor with history of 31 week emergent cesarean for breech presentation at complete dilation. Labor augmented with oxytocin and patient progressed to complete. Successful vacuum-assisted delivery performed for fetal bradycardia. Approximately 90 minutes after delivery, patient was noted to have copious amounts of fluid from the vagina upon retrograde bladder fill. Exploratory laparotomy demonstrated posterior bladder rupture from dome to neck and anterior cervicovaginal rupture causing cervical avulsion. The second patient is a 34 year-old gravida 2 para 1 presenting at 38w6d in spontaneous labor with history of cesarean for failed vacuum delivery. Patient progressed to complete by own mechanism but opted for cesarean after 1 hour of pushing. After an atraumatic delivery of infant, entirety of Foley catheter was noted within surgical field. Large cystotomy present from posterior aspect of dome distally through trigone and bladder neck concurrent with uterine rupture demonstrating vaginal extension. CONCLUSION: Successful VBAC does not preclude urologic injury. TOLAC counseling should be individualized based upon prior operative reports, with high indices of suspicion when hysterotomy may have been performed lower than anticipated. With early recognition of injury, favorable prognosis can be achieved.