Cesarean Section for Large Fundal Posterior Wall Uterine Myoma (10x6 cm)
Vaginal delivery should be attempted as the primary mode of delivery for this patient, with cesarean section reserved strictly for obstetric indications, not based on myoma presence or size alone. 1, 2
Primary Delivery Recommendation
The presence of a large fundal posterior wall myoma, even measuring 10x6 cm, is not an indication for cesarean section. 1 The American College of Cardiology explicitly states that cesarean section should be reserved for obstetric indications only, as it carries significantly higher maternal morbidity without providing additional benefits in most myoma cases. 1
Vaginal delivery remains preferred because cesarean section increases maternal risks including postpartum infections (5-7 times higher), endometritis, wound complications, and chronic wound pain (15.4% at 3-6 months). 2
Critical Assessment Factors
The location and characteristics of this specific myoma require careful evaluation:
Fundal posterior wall location is favorable - this myoma is unlikely to obstruct the birth canal, which is the primary anatomical concern that would necessitate cesarean section. 3, 4
Size alone (10x6 cm) does not mandate cesarean section, though myomas >200 cm³ are associated with increased risk of complications including abruptio placentae and pelvic pain. 5 This myoma's volume (approximately 314 cm³) warrants close monitoring but not prophylactic cesarean section.
Assess placental location relative to the myoma - retroplacental myomas and those in direct contact with the placenta have higher complication rates including abruptio placentae. 5, 4 Serial ultrasound evaluation should document whether the placenta overlies or is adjacent to this posterior myoma.
Specific Indications That Would Change Management to Cesarean Section
Cesarean section becomes indicated only if:
- The myoma obstructs the birth canal (unlikely with fundal posterior location). 3
- Fetal malpresentation occurs (breech, transverse lie) - myomas increase this risk, particularly large and multiple myomas. 6, 4
- Standard obstetric indications arise (placenta previa, fetal distress, failed labor progression, etc.). 1, 2
- The myoma is cervical in location (not applicable here). 3
Required Monitoring Protocol
Serial ultrasound examinations throughout pregnancy to monitor fetal growth, presentation, myoma size changes, and placental location relative to the myoma. 5, 4
Heightened surveillance in second and third trimesters when hemodynamic load is highest. 1
Assessment for complications including threatened preterm delivery, abruptio placentae (especially if placenta contacts myoma), and pelvic pain. 5
Labor Management Approach
Trial of labor is appropriate unless birth canal obstruction or other obstetric contraindications develop. 3, 4
Prepare for potential cesarean section if labor fails to progress or fetal malpresentation is confirmed at term. 6, 4
If cesarean section becomes necessary, the fundal posterior location may complicate surgical approach - a vertical corporeal incision may be required if the myoma prevents safe access to the lower uterine segment. 7
Critical Pitfall to Avoid
Do not perform prophylactic cesarean section based solely on myoma size or presence - this increases maternal morbidity (infection risk, future pregnancy complications including placenta accreta, uterine rupture risk) without proven benefit. 1, 2 Approximately 70-90% of pregnant women with myomas do not develop major complications. 3