Intraoperative surgical complication during caesarean section: An observational study of the incidence and risk factors

This survey of intraoperative surgical complications during caesarean section was an attempt to learn whether morbidity is influenced by the surgeon's educational level, and whether women with an existing uterine scar areat increased risk of surgical problems. The study enrolled 7782 women who gave birth at 1 of 3 teaching hospitals in Copenhagen, 929 of whom (12%) underwent caesarean delivery. Just over two thirds of operative deliveries were emergencies. Standard surgery used the modified Pfannenstiel abdominal and lower-segment transverse uterine incision. The 143 intraoperative complications developing in 112 women yielded a rate of 12.1%. The rates were 14.5% for emergency procedures and 6.8% for elective section. Nearly half the affected women had a laceration of the uterine body, cervix, vagina, bladder, or bowel. Nine patients required blood transfusions during surgery. All three women with uterine ruptures had undergone previous caesarean sections. Three women with uncontrollable bleeding required hysterectomy. The surgeon's educational level (before, during, or after completion of specialist training) did not relate significantly to the risk of laceration. Previous caesarean section, experienced by one fourth of women, was positively, but not significantly, related to the risk. The chief risk factors for laceration were the station of the presenting part at or below the ischial spines and a birth weight of 4000 g or more. Fetal distress and dystocia also were significant risk factors. Adjusted analysis ruled out emergency section as a significant risk factor. The risk of losing 1000 mL or more of blood also was not related to the surgeon's educational status. Blood loss was most closely related to placenta previa and placental abruption, and an increasing body mass index before pregnancy conferred some increase in the risk of bleeding. A birth weight less than 3000 g or more than 4000 g correlated significantly with intraoperative blood loss. Regular painful contractions lasting longer than 1 hour appeared to protect against significant bleeding.