During a repeat cesarean section, dense adhesions obscure the lower segment. While extending the uterine incision laterally with scissors, the surgeon notes sudden brisk bleeding and a glistening structure visible in the wound that bulges with each inspiration. Which structure has most likely been injured?

• A Uterine vessels at the lateral angle
• B Right ureter at the level of the uterine artery
• C Urinary bladder dome ✓
• D Rectus muscle belly

Explanation

Extension of a lower segment incision tears downward or laterally toward the bladder, which is dissected off the lower segment as the vesicouterine (bladder) flap. Injury to the bladder dome is the most common urinary tract injury at cesarean, and a glistening mucosal surface that moves with respiration is characteristic. The ureter runs far posterolateral at the level of the uterine vessels and is injured more often during hysterectomy or control of broad ligament bleeding, not by simple incision extension. Lateral angle bleeding comes from uterine vessels, not a glistening inspiratory structure.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.