A total of 2310 deliveries occurred at KCMC during the study period of which 1138 had Caesarean section. This makes a caesarian section rate of 49.1% Among those delivered by CS, five women were excluded because uterine rupture was found intraoperatively, thus 386 participants were enrolled in the study. All of them agreed and signed their consent; this gives a participation rate of 100%.refer figure 1.
Baseline characteristics of the participant.
Majority of the study participants 295(76.4%) were aged between 20 to 34 years, with a mean age of 28.6 +/- 5.5 years, 230(59.6%) had formal education 210(54.4%) from rural areas. Majority 298(77.2%) of participants were term deliveries and 235(60.9%) were self-referred from home. Out of 386 study participants, 294(76.2%) had an emergency CS delivery and 92(23.8%) elective CS delivery, refer Table 1
Table 1: Characteristics of the study participants (N=386)
Variables
|
Number of patients
|
Percentage
|
Age in years
|
|
|
<20
|
17
|
4.4
|
20-34
|
295
|
76.4
|
35
|
74
|
19.2
|
[Mean, (SD)]
|
[28.6; 5.5]
|
|
Education
|
|
|
Non-formal
|
30
|
7.8
|
Primary
|
126
|
32.6
|
Secondary
|
129
|
33.4
|
College and above
|
101
|
26.2
|
Occupation
|
|
|
Housewife
|
41
|
10.6
|
Peasant/farmer
|
139
|
36.0
|
Business
|
104
|
26.9
|
Employed
|
89
|
23.1
|
Other (student, tailor)
|
13
|
3.4
|
Residence
|
|
|
Urban
|
176
|
45.6
|
Rural
|
210
|
54.4
|
BMI group
|
|
|
<18.5
|
2
|
0.5
|
18.5-24.9
|
67
|
17.4
|
25.0-29.9
|
125
|
32.4
|
30
|
192
|
49.7
|
Parity
|
|
|
Primipara
|
174
|
45.1
|
Multipara
|
191
|
49.5
|
Grand multipara
|
21
|
5.4
|
Gestational age
|
|
|
Term
|
298
|
77.2
|
Late preterm
|
51
|
13.2
|
Early preterm
|
37
|
9.6
|
ANC attendance
|
|
|
Never
|
8
|
2.1
|
<4
|
76
|
19.7
|
4
|
302
|
78.2
|
Referral case
|
|
|
Yes
|
151
|
39.1
|
No
|
235
|
60.9
|
CS type
|
|
|
Elective
|
92
|
23.8
|
Emergency
|
294
|
76.2
|
Anemia
|
|
|
No
|
294
|
76.2
|
Yes
|
92
|
23.8
|
Rate of caesarean section related complications among women delivered at KCMC hospital
Out of 386 study participants, 106 reported having had one or more complications during the study period. This makes a complication rate of 27.5%. Among study participants with complications, 56(14.5%) had one complication, 19(5%) had two complications and 31(8%) had three or more complications. Refer figure 2
The immediate postoperative complications among women delivered by Caesarean section at KCMC hospital (N=386)
Out of 386 study participants, 93 reported one or more complications, in the first 24 hours of the operation (“immediate complication”), this makes immediate complication rate of 24%. Among those with immediate complications 48(12.4%) of the participants had one complication, 34(8.8%) had two complications and 11(2.8%) had three or more complications.
The most common complications reported were anaesthesia related complications 53(13.7%) followed by blood transfusion 35(9.1%) and PPH 31(8%). The least were thromboembolism 1(0.3%), peritonitis 1(0.3%) and maternal death 1(0.3%). There was no significant variation of these complications by type of CS (whether elective or emergency), Refer Table 2.
Table 2 : The immediate post-operative complications among women delivered by Caesarean section at KCMC hospital (N=386)
Complications
(Type)
|
All CS
(N=386)
|
Elective CS
(N=92)
|
Emergency CS
(N=294)
|
P value
|
All complications
|
93(24.1)
|
19(20.7)
|
74(25.2)
|
0.377
|
Anesthesia complication
|
53(13.7)
|
11(12.0)
|
42(14.3)
|
0.571
|
Blood transfusion
|
35(9.1)
|
8(8.7)
|
27(9.2)
|
0.887
|
PPH
|
31(8.0)
|
8(8.7)
|
23(7.8)
|
0.331
|
Hysterectomy
|
11(2.8)
|
3(3.3)
|
8(2.7)
|
0.786
|
Admission to ICU
|
7(1.8)
|
2(2.2)
|
5(1.7)
|
0.767
|
Re-laparotomy
|
4(1.1)
|
1(1.1)
|
3(1.0)
|
0.956
|
Wound infection
|
3(0.8)
|
0(0.0)
|
3(1.0)
|
0.331
|
Wound dehiscence
|
2(0.5)
|
0(0.0)
|
2(1.4)
|
0.261
|
Maternal death
|
2(0.5)
|
0(0.0)
|
2(0.7)
|
0.428
|
Peritonitis
Thromboembolism
|
1(0.3)
1(0.3)
|
0(0.0)
0(0.0)
|
1(0.3)
1(0.3)
|
0.575
0.575
|
*P value<0.05 is statistically significant
Early postoperative complications following caesarean section
Out of 386 study participants,37 had one or more complication that was reported between 24 to 72 hours of the CS delivery (“early complications”), this makes Early post-operative complication rate of 9.6%. Among those with early complications 24(6.2%) had one complication,10(2.6%) had two complications and 3(0.8%) had three or more complications.
The most common reported complications were puerperal sepsis 18(4.7%), followed by anaesthesia related complications 17 (4.4%), blood transfusion 6 (1.6%), PPH (0.5%) and ICU admission 2(0.5%). Refer to Figure 3
The risk factors for postoperative complications
From our findings it shows that multiparity (OR=1.96, 95% CI: 1.20-3.20) grand multiparity (OR=6.9, 95% CI: 2.5-14.0), Antenatal clinic attendance of <4 visits (OR=1.77, 95% CI: 1.05-2.97), longer duration of surgery (OR=2.44, 95% CI: 1.52-3.92) were associated with all the post operative complications.
Anaesthesia-related complications were positively and significantly associated with grand multiparity (OR=3.1, 95% CI: 1.13-8.68) and longer duration of surgery (OR=2.33, 95% CI: 1.37-3.99).
Blood transfusion was significantly related with multiparity (OR=2.42, 95% CI: 1.18-4.93), grand multiparity (OR=6.75, 95% CI: 2.18-20.83), early preterm delivery (OR=2.77, 95% CI: 1.19-6.46), pre-operative anaemia (OR=2.92, 95% CI: 1.54-5.54), antenatal attendance <4 visits (OR=1.96, 95% CI: 1.03-3.84) and longer duration of surgery (OR=2.13, 95% CI: 1.15-3.90).
In this study the most prevailing significant factors related to PPH during or after CS included less antenatal visits (OR=2.23, 95% CI: 1.04-4.77) and longer duration of surgery (OR=3.16,95%CI:1.51-6.61), pre-operative anaemia (OR=1.44,95% CI: 0.66-3.14) were found to have positive association to PPH. Refer table 3.
Table 3: The risk factors for postoperative complications among women who deliver by cesarean section (N=386)
Variables
|
All complications
|
Anaesthesia
|
BT
|
PPH
|
OR (95%CI)
|
OR (95%CI)
|
OR (95%CI)
|
OR (95%CI)
|
Age (years)
15-19
|
1.52(0.54-4.25)
|
0.26(0.03-2.02)
|
1.76(0.47-6.48)
|
1.58(0.33-7.35)
|
20-34
|
ref
|
ref
|
ref
|
ref
|
35
|
1.17(0.67-2.07)
|
0.81(0.40-1.60)
|
1.75(0.86-3.55)
|
1.43(0.61-3.35)
|
Parity
|
|
|
|
|
Primiparous
|
ref
|
ref
|
ref
|
ref
|
Multiparous
|
1.96(1.20-3.20)
|
1.60(0.91-2.80)
|
2.42(1.18-4.93)
|
2.02(0.89-4.62)
|
Grand multiparous
|
6.90(2.50-14.0)
|
3.1(1.13-8.68)
|
6.75(2.18-20.83)
|
5.70(1.65-19.84)
|
BMI (Kg/m2)
|
|
|
|
|
18.5-24.9
|
ref
|
ref
|
ref
|
ref
|
25.0-29.9
|
1.65(0.43-6.37)
|
0.82(0.42-1.63)
|
0.86(0.34-2.19)
|
1.70(0.43-6.40)
|
30
|
1.21(0.64-2.25)
|
1.21(0.65-2.25)
|
1.21(0.66-2.81)
|
2.60(0.75-9.20)
|
Gestation age
|
|
|
|
|
Term
|
ref
|
ref
|
ref
|
ref
|
Late preterm
|
1.16(0.60-2.22)
|
1.16(0.60-2.22)
|
1.60(0.68-3.72)
|
1.02(0.34-3.08)
|
Early preterm
|
1.33(0.63-2.78)
|
1.33(0.64-2.78)
|
2.77(1.19-6.46)
|
2.31(0.87-6.15)
|
Anaemia
|
|
|
|
|
No
|
ref
|
ref
|
ref
|
ref
|
Yes
|
2.19(1.33-3.63)
|
1.13(0.62-2.06)
|
2.92(1.54-5.54)
|
1.44(0.66-3.14)
|
ANC visit
|
|
|
|
|
4
|
ref
|
ref
|
ref
|
ref
|
<4
|
1.77(1.05-2.97)
|
1.31(0.72-2.39)
|
1.96(1.03-3.84)
|
2.23(1.04-4.77)
|
Cervical Dilation (cm)
|
|
|
|
0-3
|
ref
|
ref
|
ref
|
ref
|
4-9
|
0.81(0.50-1.32)
|
0.81(0.50-1.32)
|
0.79(0.4-1.54)
|
0.72(0.32-1.60)
|
10
|
0.75(0.24-2.38)
|
0.75(0.24-2.38)
|
1.42(0.39-5.20)
|
1.30(0.28-6.09)
|
Duration of Surgery
|
|
|
|
<60min
|
ref
|
ref
|
ref
|
ref
|
60min
|
2.44(1.52-3.92)
|
2.33(1.37-3.99)
|
2.13(1.15-3.90)
|
3.16(1.51-6.61)
|
Birth weight (kg)
<2.5
|
1.79(1.03-3.11)
|
0.99(0.51-1.95)
|
3.60(1.83-7.08)
|
1.81(0.79-4.15)
|
2.5-3.9
|
ref
|
ref
|
Ref
|
ref
|
4.0
|
1.05(0.42-2.58)
|
1.03(0.37-2.80)
|
1.25(0.35-4.46)
|
1.58(0.48-5.71)
|
Previous scar
|
|
|
|
|
<2
|
ref
|
ref
|
ref
|
ref
|
2
|
0.87(0.38-1.96)
|
1.09(0.46-2.58)
|
2.62(0.82-8.40)
|
1.86(0.58-5.91)
|
Preeclampsia
|
|
|
|
|
No
|
ref
|
ref
|
ref
|
ref
|
Yes
|
1.18(0.60-2.31)
|
1.49(0.71-3.12)
|
0.45(0.13-1.54)
|
0.45(0.1-1.97)
|
Multivariable logistic regression of the adjusted odds ratio (aor) for the risk factors of postoperative complications
After adjusting for maternal age, BMI, cadre of the surgeon, number of previous caesarean deliveries and pre-eclampsia, it was found that longer duration of surgery (> 60 minutes) was significantly associated with all type of complications.
Anaesthesia related complications were still found to have positive association to multiparity (aOR=2.25, 95% CI: 0.42-11.90), grand multiparity (aOR=2.67,95% CI: 0.12-57.60), maternal obesity(aOR=1.97, 95% CI: 0.24-15.90), early preterm (aOR=2.33, 95% CI: 0.12-43.80), anaemia (aOR=2.22,95% CI 0.8-6.2), and longer surgery(aOR=2.30,95% CI: 0.85-6.5).
Blood transfusion remained significantly associated with grand multiparity (aOR=7.0, 95%CI: 1.4034.35), and preoperative anaemia (aOR =4.34, 95 CI: 1.9-9.45).
PPH was positively associated with grand multiparity 6.4(1.5-24.24). Refer table 4
Table 4: Multivariable logistic regression of the adjusted odds ratio (aor) for the risk factors of postoperative complications (N = 386)
Variables
|
All complications
|
Anaesthesia
|
BT
|
PPH
|
aOR(95%CI)
|
aOR(95%CI)
|
aOR(95%CI)
|
aOR(95%CI)
|
Multiparity
|
3.80(0.75-19.27)
|
2.25(0.42-11.90)
|
2.49(0.80-7.50)
|
2.1(0.89-5.06)
|
Grand multiparity
|
3.00(0.19-47.96)
|
2.67(0.12-57.60)
|
7.0(1.40-34.35)
|
6.4(1.5-24.24)
|
Maternal obesity
|
4.20(0.48-37.13)
|
1.97(0.24-15.90)
|
0.75(0.20-2.37)
|
2.9(0.80-10.9)
|
Early preterm
|
2.04(0.58-7.15)
|
2.33(0.12-43.80)
|
2.04(0.50-7.15)
|
1.3(0.43-4.13)
|
|
|
|
|
|
Anaemia
|
2.50(0.90-6.39)
|
2.22(0.80-6.20)
|
4.34(1.90-9.45)
|
1.38(0.62-3.1)
|
Longer surgery
|
2.90(1.02-8.50)
|
2.30(0.85-6.50)
|
1.04(0.38-2.82)
|
1.54(0.4-5.01)
|
Note: Adjustment was done by maternal age, BMI, the expertise of the operating surgeon, number of previous CS, duration of the surgery and pre-eclampsia.