During a C-section, “bladder attached to uterus” refers to adhesions, which are bands of scar tissue. These adhesions can form after previous abdominal surgeries, including a prior C-section. These adhesions can alter the normal anatomical relationship between the bladder and the uterus.
Understanding Bladder-Uterine Adhesions
Adhesions are fibrous bands of scar tissue that cause organs or tissues to stick together. After a C-section or other uterine surgeries, the body’s healing process can lead to these adhesions. The peritoneum, a membrane lining the abdominal cavity, can be disrupted during surgery. As it heals, adjacent surfaces may adhere to each other or to the peritoneum.
Normally, the bladder sits in the pelvis, just behind the pubic bone and in front of the uterus. The uterus is a pear-shaped, muscular organ located between the bladder and the rectum. A peritoneal recess, the vesicouterine pouch, exists between the bladder’s posterior surface and the uterus’s anterior surface. Adhesions can obliterate this pouch, causing the bladder to become abnormally attached to the uterine wall, especially at a previous uterine incision site. These adhesions are often asymptomatic, meaning they do not cause noticeable symptoms in daily life.
Risks During Cesarean Delivery
The primary concern when bladder-uterine adhesions are present during a C-section is the potential for bladder injury. During a C-section, the surgeon needs to separate the bladder from the lower uterine segment to create space for the uterine incision and safely deliver the baby. When adhesions are present, the bladder may not be easily separated from the uterus due to the dense scar tissue, which distorts the normal anatomy. This increased difficulty in dissection raises the risk of inadvertently cutting or tearing the bladder.
The incidence of bladder injury during a repeat C-section is estimated to be between 0.22% and 0.44%. This risk increases with each subsequent C-section, with a reported incidence of adhesion development after a primary C-section ranging from 46% to 65%. Adhesions can also contribute to other intraoperative complications, such as increased surgical time and greater blood loss, as the surgeon must carefully navigate and dissect through the adhered tissues.
Surgical Management of Adhesions
Surgeons identify and manage bladder-uterine adhesions during a C-section through careful dissection. The process typically involves creating a “bladder flap,” where the connective tissue above the bladder is cut, and the bladder is then gently pushed down and away from the area where the uterine incision will be made. When adhesions are present, this separation can be more challenging, requiring meticulous technique.
Surgeons may employ sharp dissection, using surgical instruments to carefully cut through the fibrous bands of scar tissue. The goal is to safely release the bladder from the uterus without causing injury. The skill and experience of the surgeon are important in navigating these situations, especially with dense adhesions or multiple prior C-sections. If a bladder injury does occur, it is typically recognized and repaired immediately during the same surgery. Post-operative care may involve temporary catheterization to allow the bladder to heal, with the duration depending on the extent of any repair.
Future Pregnancy Considerations
A history of bladder-uterine adhesions can influence considerations for future pregnancies and delivery plans. The likelihood of adhesions recurring or becoming more severe generally increases with each subsequent C-section.
The presence of adhesions can impact options such as Vaginal Birth After Cesarean (VBAC). While VBAC may still be considered, the adhesions could potentially increase the risk of uterine rupture, especially if the scar tissue is extensive or affects the integrity of the uterine wall. For future deliveries, a repeat C-section might be recommended, and in such cases, the surgical team will be prepared to manage the adhesions. Each individual’s situation is unique and requires a thorough consultation with a healthcare provider to discuss the specific risks and benefits of various delivery options.