Intraoperative surgical complication during cesarean section : an observational study of the incidence and risk factors

부산백병원 산부인과조인호

Acta Obstet Gynecol Scand 2003 : 82: 251-256

Introduction Kerr introduced (1926)

The retrovesical, transverse, lower segment Ut. incision -> to reduce the incidence of Ut. rupture in subsequent pregnancies.

Today, it most commonly used. Cesarean section -> m/c gynecologic-obstetric

operation But, intraoperative surgical complications have been

presented. The incidence of morbidity related to cesarean

section in Copenhagen County.

Materials and methods The Univ. hosp in Gentofte, Herlev, Glostrup

기간 : August 1st 1995 - July 30th 1996 대상 : 7782 women c/sec rate: 929 (11.9%) Emergency c/sec rate : 636(68.5%) c/sec 방법 : Modified Pfannenstiel abdominal and

lower seg. transv. Ut. Incision 연구 방법 : Medical records and parthograms

were reviewed.

Results Incidence of intraoperatve surgical complications

Type of complication Total Emergency Elective

Cervical laceration 3.6%(33) 4.6%(29) 1.4%(4)

Corporal laceratoin 0.3%(3) 0.3%(2) 0.3%(1)

Vaginal laceration 1.2%(11) 1.7%(11) 0.0%(0)

Bladder laceration 0.5%(5) 0.8%(5) 0.0%(0)

Bowel laceration 0.0%(0) 0.0%(0) 0.0%(0)

Lacerations in total 5.2%(48) 6.8%(43) 1.7%(5)

Blood transfusion 1.0%(9) 1.1%(7) 0.7%(2)

EBL ≥ 1000ml 9.2%(77) 9.0%(57) 6.8%(20)

Uterine rupture 0.3%(3) 0.5%(3) 0.0%(0)

Hysterectomy 0.2%(2) 0.2%(1) 0.3%(1)

Total 12.1%(112) 14.5%(92) 6.8%(20)

Results Demographic and obstetric charcteristics of the study

population

Variable NumberAge (mean) 30.3 years

Parity (mean) 0.7

Pre-pregnancy body mass index (mean)

23.3kg/height2

Previous cesarean section 25.7%

Gestational age (mean) 38.7weeks

Birth weight (mean) 3.315kg

ResultsTable III. Risk of intraoperative laceration of the cervix, vagina and bladder during cesarean section (I)

Variables n (%) Crude OR Adjusted OR

Educational level of surgeon

not under specialist education

97 (10.5) 1.0 1.0

under specialist education 434 (46.8) 1.2 1.2 specialist 397 (42.7) 0.9 1.2Previous cesarean section no 689 (74.2) 1.0 1.0 yes 239(25.8) 1.3 2.1

Emergency cesarean section

no 293 (31.5) 1.0 1.0 yes 635 (68.5) 4.2 2.3Maternal age(10 years) 928 (100) 1.8 2.1

Station of the presenting part

above ischial spines 820 (88 4) 1.0 1.0 ischial spines or below 108 (11.6) 4.3 5.9

ResultsTable III. Risk of intraoperative laceration of the cervix, vagina and bladder during cesarean section (II)

Variables n (%) Crude OR

Adjusted OR

Fetal distress as indication no 687 (74.0) 1.0 1.0 Yes 241 (26.0) 2.3 3.7Dystocia as indication no 623 (67.1) 1.0 1.0 yes 305 (32.9) 2.6 2.3Birth weight (g) <3000g 249 (26.8) 1.0 1.0 3000-3999 507 (54.7) 0.9 2.4 ≥4000 172 (18.5) 2.1 5.3Interaction between birth weight ≥4000 g and station at ischial spines or below no 895 (96.4) 1.0 1.0 yes 33 (3.6) 1.9 0.2

ResultsTable IV. Risk of intraoperative blood loss ≥1000 ml

during the cesarean section (I)

Variable n (%) Crude

OR Adjusted

OR Educational level of surgeon not under specialist education 96 (10.4) 1.0 1.0 under specialist education 432 (46.8) 1.1 1.3 specialist 395 (42.8) 1.1 1.3Previous cesarean section no 686 (74.3) 1.0 1.0 yes 237 (25.7) 0.6 0.6Emergency cesarean section no 291 (31.5) 1.0 1.0 yes 632 (68.5) 1.3 1.6Pre-pregnancy BMI <20 177 (19.2) 1.0 1.0 20-25 518 (56.1) 2.5 2.3 >25 228 (24.7) 3.9 3.8

ResultsTable IV. Risk of intraoperative blood loss ≥1000 ml during the cesarean section (II)

Variable n (%) Crude OR

Adjusted OR

Duration of regular painful cont. (h) 0 445 (48.2) 1.0 1.0 1-8 232 (25.1) 0.5 0.2 ≥8 246 (26.7) 1.1 0.3Placental abruption as indication no 879 (95.2) 1.0 1.0 yes 44 (4.8) 7.1 7.3Placenta previa as indication no 904 (97.9) 1.0 1.0 yes 19 (2.1) 7 9.2Birth weight (g) <3000 247 (26.8) 1.5 2.4 3000-3999 505 (54.7) 1.0 1.0 ≥4000 171 (18.5) 2.7 4.1

Discussion Intraoperative laceration : 5.2% Higher in Emergency

Intraoperative laceration Blood transfusion Injury to the fetus

Associated with intraoperative complication in Emergency op. Skills of the surgeon History of previous s/cec Others

Discussion Intraoperative laceration 의 risk factor

High birth weight Low station of the presenting part -> reducing the injury

modification of c/sec Ventouse or forceps

Fetal distress : speed of c/sec Andersen et al. :204 patients

Time interval -> neonatal outcome 에 영향을 못 미침 Surgical technique -> gentle , nontraumatic delivery

Discussion Intraoperative laceration 의 risk factor (II)

Emergency op Increasing maternal age

Intraoperative blood loss 의 risk factor Placental abruption Placenta previa Increasing prepregnancy BMI High birth weight <- positive effect of Ut. Cont. on blood loss

Discussion Intraoperative blood loss 의 risk factor

Manual removal of placenta Uterine exteriorization before closure of the

uterotomy -> lood loss 를 감소시킴 . Emergency op. & fetal distress: “speed” -> blood

loss 에 영향 못 미침 -> Misgav Ladach method

Confounding factor Educational level of the surgeon

Discussion In obstetrics,

Benefit 과 risk 를 고려 c/sec 은 m/c surgical intervention in women Maternal morbidity and mortality 는 별다른

주목을 받지 못함 .

Mode of delivery→carefully presenting balanced informatation about the risks and benefits of vaginal delevery & c/sec.