INTRODUCTION
Cesarean birth has been a major source of interest and concern over the last few decades. In the past 35 years, the rate of cesarean section has steadily increased from 5% to approximately 25%.1 So pregnancy with history of previous cesarean section is prevalent in present-day obstetric practice. Precise quantification of the risk attributable to a prior cesarean section is difficult. It has been associated with increased risk of placental abruption and placenta previa in subsequent pregnancies, conditions resulting in increased likelihood of preterm delivery, low birth weight, and perinatal death.
A retrospective analysis of catastrophic complication of previous cesarean section by Cynthia Chagotte2 showed that 2.4% of the patients after one or more cesarean section had an extremely serious complication like uterine rupture and placenta previa or accreta with accompanying hemorrhage. Other complications like impending rupture, bladder discomfort, preterm delivery, operative interference, and incidental morbidity can occur during pregnancy, labor and in repeat cesarean section.3 There are more technical difficulties and increased chance of injury to the surrounding structures during repeat C-section and postoperative complications are likely to be increased.4 The risk of injury to bladder is increased threefold in repeat cesarean section.5 Although maternal mortality after scar rupture is low, the major risk is to the fetus that can suffer from anoxic brain damage or die if not delivered very urgently. This study was designed to find out the maternal antepartum and intrapartum complications as well as perinatal mortality and morbidity in patients with history of previous cesarean section.
MATERIALS AND METHODS
This study was conducted in Yenepoya Medical College Hospital, a tertiary care referral center in rural part of Karnataka (Southern India). Retrospective analysis of medical records of 143 women with previous one or two cesarean section who delivered during the time period January 2014 to January 2015 was carried out.
The exclusion criteria included women with previous classical cesarean section, those with extreme prematurity (less than 32 weeks), and those who opted for VBAC.
Data were collected by preparing a data collection sheet, which included the patient's particulars, antepartum clinical, laboratory, and intrapartum or peioperative, postoperative findings as well as perinatal outcome of the fetus. Collected data were compiled and analyzed using Statistical Package for the Social Sciences statistical package.
RESULTS
During the study period, January 2014 to January 2015, a total number of 143 pregnant patients were included in this study who were admitted with history of one or more cesarean sections. The mean age of the study population was 27.4 years (<20—40); 76.22% cases were aged 21 to 30 years (Table 1).
All the study populations were multigravida having various types of previous obstetrical history. Graph 1 shows that 74.12% patients had one and 20.98% had two previous C-sections.
Majority (74.82%) of the cases were admitted with term, only 13.99% were with preterm, but 11.19% with postdatism (Graph 2).
Table 2 reveals that in more than half of the cases antepartum period was uneventful. Another 17.48% cases had some complications related with previous surgery like placenta previa, scar tenderness, chronic abdominal pain. In 16.79% cases there were some medical disorders like GDM, PIH, urinary tract infection, etc.
Among the study population, 46.15% needed emergency cesarean section and the rest (53.85%) of the cases were terminated on elective basis by cesarean section. Only 5.59% cases required blood transfusion during operation.
Table 3 shows that in 13.99% cases extensive peritoneal adhesion with uterus and posterior surface of anterior abdominal wall and bladder was adherent in 16.78% cases.
Postoperative complications are shown in Table 4. Here majority (72.72%) had no complication. Important complications were wound infection (7.69%), anemia (3.50), postpartum hemorrhage (PPH; 1.40%), etc.
Table 1
Age incidence of study population
| Age in years | Number of patients | Percentage | Mean age |
|---|---|---|---|
| <20 | 3 | 2.10 | |
| 21—25 | 38 | 26.57 | |
| 26—30 | 71 | 49.65 | 27.4 years |
| 31—35 | 22 | 15.38 | |
| 36—40 | 7 | 4.90 | |
| 41 and above | 2 | 1.40 | |
| Total | 143 |
Table 2
Antepartum complications
Table 3
Types of intraoperative problems
Table 4
Types of postoperative problems
Table 5
Perinatal fetal outcome
| Condition of baby | Number of cases | Percentage |
|---|---|---|
| Healthy | 114 | 79.72 |
| Birth asphyxia | 3 | 2.09 |
| Premature | 7 | 4.90 |
| IUGR | 7 | 4.90 |
| Neonatal jaundice | 8 | 5.59 |
| Neonatal infection | 2 | 1.40 |
| Neonatal death | 1 | 0.70 |
| IUD | 1 | 0.70 |
Perinatal fetal outcome has been shown in Table 5. Majority (79.72%) of the babies were healthy; the rest had some complications like prematurity (4.90%), intrauterine growth restriction (IUGR; 4.90%), birth asphyxia (2.09%), neonatal infection (1.4%), and neonatal jaundice (5.59%). Perinatal death was found in two cases, one of them was intrauterine device (IUD) and the other was early neonatal death.
DISCUSSION
In modern practice, with the objective of safe motherhood and mother baby package program the aim of obstetricians is to achieve a healthy mother and healthy baby. To achieve this goal, cesarean section plays a vital role and increasing trend of cesarean section is also related to it to a certain extent. Thus, repeat cesarean section is the commonest contributory factor for increased rate of C-section. It varies from country to country and center to center; 95% of all cesarean sections are in USA, 23% in Norway, 24 to 30% in India, and the lowest 8% in Hungary.6
This study was done in the Department of Obstetrics and Gynaecology of Yenepoya Medical College Hospital, among 143 patients with history of one or more cesarean sections who were admitted for termination of pregnancy either on emergency or elective basis.
Majority (76.22%) of the study population were of 21 to 30 years, which is more or less similar to other study results done in SSMC Mitford Hospital where 69.2% cases were between 20 and 29 years.7 Here 74.12 and 20.98% cases had history of previous one and two cesarean sections respectively. Among all patients, a significant number had history of previous pregnancy loss, e.g., spontaneous abortion (2.10%), stillbirth (1.4%), neonatal death (0.7%), and other 0.7% had ectopic pregnancies.
Among the study population, there were some common complications associated with previous cesarean section like placenta previa (3.50%), scar tenderness (8.39%), and chronic abdominal pain (5.59%). A significant number (16.79%) of cases had some medical disorders like GDM, PIH, and UTI. Majority (74.82%) cases came with term pregnancy; only 11.19% were preterm and required emergency termination for GDM, severe preeclampsia, multiple pregnancies, antepartum hemorrhage, etc. Here, total 39.86% cases underwent emergency cesarean section. The elective cesarean section is 50.35% in comparison to those of Khawaja et al8 in Pakistan (11.33%) and Asaduzzaman9 in Bangladesh (34.6%).
As all the patients underwent cesarean section both perioperative and postoperative findings were observed meticulously. In 13.99% cases there were extensive adhesion among uterus, omentum and anterior abdominal wall causing difficulties in opening the abdomen. Urinary bladder was found adherent in 16.78% cases and in one of them it was injured during operation. In 10.49% cases lower segment was found so thin that suturing was found difficult. The overall perioperative complication was much less (12.1%) in the study of Bergholt and Stenderup.10
This study reveals that majority (72.72%) cases had no postoperative complication. Here important complications were PPH (1.40%), wound infection (7.69%), anemia (3.50%), etc. The rate of complication is significantly less in this study in comparison to other two studies done by Chowdhury et al7 and Asaduzzaman.8
In this study, 20.28% babies developed complications, which is statistically comparable to the study of Dey and Hatai11 in India. Among them, 4.90% babies were premature, 2.09% had birth asphyxia, and other 5.59% developed neonatal jaundice. Here number of perinatal mortality was two, of them one was a case of intrauterine fetal death and the other baby died in early neonatal period. These findings are a bit different from the study of Tadesse et al12 in Ethiopia where stillbirth and neonatal death were 2.8 and 4.7% respectively.
CONCLUSION
This is a very limited study which revealed that previous cesarean section-related antenatal complications were not very high, but a significant number of cases had perioperative complications. There was no maternal mortality but perinatal fetal mortality rate was 1.40%. Further larger study with the scope of trial of vaginal delivery would be important to evaluate the pregnancy outcome in patients with a history of previous cesarean section.