Intraoperative surgical

complication during cesarean

section :
an observational study of the
incidence and risk factors
부산백병원 산부인과
조인호
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 Number
Age (mean) 30.3 years
Parity (mean) 0.7
Pre-pregnancy body mass index 23.3kg/height2
(mean)
Previous cesarean section 25.7%
Gestational age (mean) 38.7weeks
Birth weight (mean) 3.315kg
 Results
Table 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
97 (10.5) 1.0 1.0
education
under specialist education 434 (46.8) 1.2 1.2
specialist 397 (42.7) 0.9 1.2
Previous 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 2.3
Maternal 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
Results
Table III. Risk of intraoperative laceration of the cervix, vagina and bladder
during cesarean section (II)
Crude Adjusted
Variables n (%)
OR OR
Fetal distress as indication
no 687 (74.0) 1.0 1.0
Yes 241 (26.0) 2.3 3.7
Dystocia as indication
no 623 (67.1) 1.0 1.0
yes 305 (32.9) 2.6 2.3
Birth 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 5.3
Interaction 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
Results
Table IV. Risk of intraoperative blood loss ≥1000 ml
during the cesarean section (I)
Crude Adjusted
Variable n (%)
OR 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 1.3
Previous cesarean section
no 686 (74.3) 1.0 1.0
yes 237 (25.7) 0.6 0.6
Emergency cesarean section
no 291 (31.5) 1.0 1.0
yes 632 (68.5) 1.3 1.6
Pre-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
 Results
Table IV. Risk of intraoperative blood loss ≥1000 ml during the
cesarean section (II)
Crude Adjusted
Variable n (%)
OR 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 0.3
Placental abruption as indication
no 879 (95.2) 1.0 1.0
yes 44 (4.8) 7.1 7.3
Placenta previa as indication
no 904 (97.9) 1.0 1.0
yes 19 (2.1) 7 9.2
Birth 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.