INTRODUCTION: Cesarean section is a live saving procedure but when performed without appropriate indications can add risk to both mother and baby. As per WHO report, at population level, Cesarean section rates higher than 10% are not associated with reductions in maternal and new-born mortality rates. In India as per District level household survey 3 (DLHS) Cesarean section rate is 28.1% in private sector and 12% in public sector health care facilities. The close embryonic development and anatomical proximity of the urinary bladder and genital organs, are responsible for the urinary tract to injury during surgical procedures in the female pelvis. During LSCS bladder injury is demonstrated by the presence of gas filling up the Foley bag or visibly bloody urine in the Foley bag. Veress needle injuries and other small injuries to the bladder can be successfully managed conservatively by catheter drainage for seven to 14 days followed by cystography while large bladder injuries, such as from 5 or 10 mm trocar or surgical dissection usually require suturing the injuries closed. Risk factors for bladder injury during LSCS include previous operations, expodure to radiation, malignancy, chronic infection, and inflammation.
MATERIAL AND METHODS: In suspected cases of bladder injuries cystogram X-ray of the bladder after injection of contrast medium is performed. For extraperitoneal injuries (grade 2) without complicating factors, treatment is a insertion of Foley catheter for 7 - 14 days. grade 3 to grade 5 injuries generally require operative repair. Closed suction drains should be left in place after repairs. Suprapubic tube placement is not necessary in most cases. For injuries to the ventral bladder, dome, or posterior bladder, the mucosa is closed in a running fashion using 3-0 vicryl followed by a seromuscular running suture of 2-0 vicryl. The bladder is irrigated to ensure a watertight closure. A third layer in a Lembert fashion can be used in cases at high risk for fistula formation or when a leak is identified. In the laparoscopic setting, a one-layer closure is performed using 2-0 vicryl to close all layers of the bladder. An additional layer can then be added using a 2- 0 vicryl in a Lembert fashion for more extensive injuries.
RESULTS: There were 986 LSCS done in the department of Obstetrics and gynaecology in the given study period. Of which 14 were diagnosed with the bladder injuries during. Among all patients who suffered from bladder injury, 3 cases were primigravida and 11 were multigravida type. Out of 14injuries, 10 injuries were repaired in 2 layers by vicryl 2.0 without insertion of SPC (suprapubic cystectomy) whereas 4 injuries were repaired by primary repair with vicryl 2.0 with insertion of SPC. In post-operative period patients were monitored for vitals, urine output and stitch sites of wounds. No complications were found in 13 patients post operatively and Foleys catheter and SPC catheter were removed after 12 days of operation in those patients.
CONCLUSION: 1.4% of the bladder injuries were observed. Early detection and prompt management of bladder injury can decrease the morbidity and mortality in LSCS cases
The Incidence, Management, and Outcome of Penetrating Bladder Injuries in Civilians Resultant from Armed Conflict in Baghdad 2005-2006
