T AND J VERTICAL EXTENSIONS IN LOW TRANSVERSE CESAREAN BIRTHS

Objective: To determine the frequency of T and J extensions in low tra nsverse cesarean births at a regional perinatal center, identify the i ndications for these incisions, and evaluate the associated complicati ons. Methods: We reviewed the medical records of 56 patients delivered between January 1988 and November 1994 by low transverse cesarean bir th requiring vertical extension of the incision into the upper uterine segment. Cases of extension were compared with controls matched for g estational age, presentation, and indication for cesarean delivery. Da ta collected included demographic information, indications for extensi on, extension type, estimated blood loss, intraoperative complications , and length of hospital stay. Paired Student t test and McNemar test were used for statistical analysis. Results: Vertical extensions were performed in 1.3% (95% confidence interval 0.42-2.26%) of low transver se incisions over a 7-year period. The most common indications were ma lpresentation (n = 31), poorly developed lower uterine segment (n = 12 ), and fetal head deeply arrested in the midpelvis (n = 6). Estimated blood loss was greater for patients requiring an extension (990 +/- 31 0 mL) compared with controls (790 +/- 150 mL), as were differences in preoperative versus postoperative hemoglobin and hematocrit (P < .05). Surgical complications were observed in 28 of 56 (50%) subjects with a uterine extension, including excessive blood loss (n = 20), broad li gament hematomas or extensions (n = 4), cervical lacerations (n = 4), and uterine artery lacerations (n = 4). Patients with vertical extensi ons also had longer hospital stays (4.6 +/- 1.6 versus 3.8 +/- 1.1 day s) (P < .05). Conclusions: Low transverse uterine incisions may be ina dequate for the safe delivery of a fetus in cases of malpresentation, preterm birth, and poor development of the lower uterine segment. Used to complete these difficult deliveries, T and J extensions are often associated with intraoperative complications and prolonged hospital st ays compared with controls.