Abstract
BackgroundThe worldwide incidence of birth by Caesarean Section (CS) is rising. Many births after a previous CS are by repeat surgery, either by an elective CS or after a failed trial of labour. Adhesion formation is associated with increased maternal morbidity in patients with repeat CSs. In spite of large-scale studies the relation between the incidence of adhesion formation and CS surgical technique is unclear. This study aims to assess maternal and neonatal morbidity and mortality after repeat CSs in a rural hospital in a low-income country (LIC) and to analyse the effect of surgical technique on the formation of adhesions.MethodsA cross-sectional, retrospective medical records study of all women undergoing CS in Ndala Hospital in 2011 and 2012.ResultsOf the 3966 births, 450 were by CS (11.3%), of which 321 were 1st CS, 80 2nd CS, 36 3rd CS, 12 4th and one 5th CS (71, 18, 8, 3 and 0.2% respectively). Adhesions were considered to be severe in 56% of second CSs and 64% of third CSs. In 2nd CSs, adhesions were not associated with closure of the peritoneum at 1st CS, but were associated with the prior use of a midline skin incision. There was no increase in maternal morbidity when severe adhesions were present. Adverse neonatal outcome was more prevalent when severe adhesions were present, but this was statistically non-significant (16% vs 6%).ConclusionsOur results give insight into the practice of repeat CS in our rural hospital. Adhesions after CSs are common and occur more frequently after midline skin incision at 1st CS compared to a transverse incision. Reviewing local data is important to evaluate quality of care and to compare local outcomes to the literature.
Highlights
The worldwide incidence of birth by Caesarean Section (CS) is rising
Adhesions were considered to be severe in 56% (44/79) of 2nd CS and in 64% (23/36) of 3rd CS (p = 0.08)
For 1st CS, the skin incision was more often transverse when operated in Ndala, compared with those who underwent surgery in other hospitals: 71% (54/76) vs 8% (3/38), p < 0.01
Summary
The worldwide incidence of birth by Caesarean Section (CS) is rising. Many births after a previous CS are by repeat surgery, either by an elective CS or after a failed trial of labour. Adhesion formation is associated with increased maternal morbidity in patients with repeat CSs. In spite of large-scale studies the relation between the incidence of adhesion formation and CS surgical technique is unclear. This study aims to assess maternal and neonatal morbidity and mortality after repeat CSs in a rural hospital in a low-income country (LIC) and to analyse the effect of surgical technique on the formation of adhesions. In many African countries, the total fertility rate (TFR) is high, making VBAC after previous CS an essential strategy in reducing the rising rate of CSs and its associated morbidities [17]. Rates of VBAC vary between 38 and 48% across African countries and hospitals [13, 17, 18]
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