A woman with two previous lower segment cesarean sections is scheduled for her third cesarean. Intraoperatively, the bladder is found densely adherent to the lower uterine segment. Which step should precede uterine incision?

• A Careful bladder dissection and reflection downward before making the uterine incision ✓
• B Fundal uterine incision to avoid the bladder
• C Cystoscopy to identify ureteric orifices before proceeding
• D Proceed directly with transverse uterine incision and repair bladder injury if it occurs

Explanation

With repeat cesarean sections, bladder adhesions to the lower uterine segment are common due to prior scarring. Before making the uterine incision, careful sharp dissection and downward mobilisation of the bladder is essential to prevent inadvertent cystotomy. This allows the lower uterine segment to be clearly visualised and the incision placed safely. A fundal (classical) incision should be avoided unless absolutely necessary due to higher maternal morbidity and risk of uterine rupture in future pregnancies. Prophylactic cystoscopy is not routinely required but is reserved for complex cases with suspected ureteric injury.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.