Complications associated with higher order compared to lower order cesarean sections.

BACKGROUND: The rate of multiple cesarean sections is persistently on the rise because of cultural demands for large families, and multiple cesarean sections are an important cause of maternal morbidity and mortality.

OBJECTIVES: This study was designed to detect the complications associated with higher order compared to lower order cesarean sections.

MATERIALS AND METHODS: The hospitals record of women who had a cesarean section performed after three or more previous cesarean sections, and those who had a cesarean section for the second time over 2 years reviewed. Women with ≥ 3 cesarean sections admitted for elective cesarean section after 38 weeks' gestation, and those with ≥ 3 cesarean sections admitted in labor for emergency cesarean section were included in group 1. Women with history of previous one lower segment cesarean section (LSCS), who refused trial of labor and women with one LSCS who had an emergency cesarean section after failed trial of labor (TOL) were included in group 2. Antenatal, intraoperative and postoperative data were reviewed. Statistical analysis done using SPSS version 20 (Chicago, Illinois, USA), to detect the complications associated with higher order compared to lower order cesarean sections. Primary outcome measures; complications associated with higher order compared to lower order cesarean sections. Secondary outcome measures; intraoperative, and postoperative complications.

RESULTS: Four hundred and fifty (450) women undergoing repeat cesarean section studied; 32.2% (145/450) had ≥ 3 previous cesarean sections (group 1), and 67.8% (305/450) had previous one cesarean section (group 2). In group 1, 77.2% (112/145) had previous three cesarean sections, 12.4% (18/145) had previous four cesarean sections, 9% (13/145) had previous five cesarean sections, and 1.4% (2/145) had previous six cesarean sections. The proportion of unbooked admission, and emergency cesarean sections were significantly high in group 2 compared to group 1 (11.1% (34/305) and 73.1% (223/305) versus 4.83% (7/145) and 40.7% (59/145); respectively) (p < 0.05, 95% CI; 0.1-0.2) and p < 0.01, 95% CI; 0.4-11.4; respectively. The risk of dense omental adhesions, and bladder injuries were significantly high in group 1 compared to group 2 (4.14% (6/145) and 1.38% (2/145) versus 0.66% (2/305) and 0% (0/305); respectively), (p = 0.01 (95% CI; 0.6-1.6) and p = 0.01 (95% CI; 0.5-5.5); respectively). Logistic regression analysis showed that the bladder injury was 5 times more (odds ratio 5.0 (95% CI; 0.035-711.8)) and the blood transfusion was 4.7 times more (odds ratio 4.7 (95% CI; 0.147-151.5)) in women with > 3 repeat cesarean sections compared to women with previous one cesarean section (insignificant difference p = 0.52 and 0.38; respectively).

CONCLUSION: The risk of dense omental adhesions and bladder injury was significantly high in women with previous ≥ 3 cesarean sections compared to women with previous one cesarean section. Logistic regression analysis showed that the bladder injury was five times more and the blood transfusion was 4.7 times more in women with > 3 repeat cesarean sections compared to women with previous one cesarean section (insignificant difference).