An inadvertent laparoelytrotomy usually happens during a caesarean section in patients with advanced cervical dilatation where the head of the baby is deeply engaged. This is because the cervix is now well above the head of the baby and an incision can be easily made in the anterior vaginal wall. However, this poses little danger to the mother or baby and, indeed, a laparoelytrotomy can be an alternate and appropriate surgical technique for the delivery of a baby in these patients. It is performed electively by displacing the bladder caudally, exposing 3.8–4 cm of the anterior vaginal wall and making a longitudinal incision in the vaginal wall. The incision is longitudinal to avoid injury to the ureters (). The wall of the vagina is easily recognised given its ballooned out and shiny appearance. This is not a commonly performed procedure but, in fact, compared to more commonly used techniques to deliver a deeply engaged head in the second stage of labour, a laparoelytrotomy seems to have much fewer complications. For example, the conventional technique of pushing the head up vaginally to assist with delivery can cause direct fetal trauma and also increases the likelihood of the lower uterine segment incision being extended, which can result in major obstetric haemorrhage and injury to the lower urinary tract.4 5 6
The breach extraction technique, where the delivery is facilitated through a more superior vertical incision in the uterus, can also pose significant risk to the mother and fetus. It is of note that subsequent deliveries in patients who have undergone a laparoelytrotomy should be vaginally as there has been no incision made in their uteruses.
Schematic diagram of an elective laparoelytrotomy incision (figure courtesy of D. Middleton. Medical Illustration Department, James Paget Hospital)
However, in a non-labouring patient, such as in this case, an inadvertent laparoelytrotomy can have serious maternal and fetal consequences and must be avoided. The aetiology for the inadvertent vaginal incision is this case was probably multifactorial. The patient was multiparous and had a moderate degree of laxity of her utero-vaginal compartment in turn due to lax utero-sacral ligaments. Multiparity, even in a non-pregnant patient, causes the vagina to move superiorly from its normal position. In pregnancy it rises further up due to the ascending gravid uterus. In this case, the surgeon was not aware that the incision was in the vaginal wall and persistent attempts to deliver the baby along with the use of forceps eventually did dilate the cervix and allowed the delivery of the baby albeit with difficulty. Although no harm came to the mother or baby in this case, there is always a potential risk, during an inadvertent laparoelytrotomy in a non-labouring patient, of causing extensive uterine and cervical tears and trauma to the baby. It can be avoided, first by anticipating such a problem in a multiparous woman and second, during surgery, by keeping the margins of the uterine incision within 2–3 cm of the utero-vesical folds.
- A laparoelytrotomy is the delivery of a baby through a vaginal incision.
- It is usually inadvertent but can also be an alternate and appropriate surgical technique in patients in advanced stages of labour where the head of the baby is deeply engaged.
- It can be dangerous if it occurs in a non-labouring patient.