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OBSTETRICS
Abstract
Objective: To compare the complications and outcomes of
Caesarean section (CS) in women who have had three or more
previous lower segment Caesarean sections with those in women
with one previous CS.
Methods: We performed a retrospective study of 371 patients
undergoing repeat CS. Of these, 115 (31%) had previously had
three or more Caesarean sections (group 1) and 256 (69%) had
previously had one CS (group 2). All 371 patients had the repeat
CS performed at Abha Maternity Hospital, Saudi Arabia between
June 2002 and May 2004. Demographic data, complications, and
outcomes were compared using the Student t and chi-square tests.
Results: There were statistically significant differences between the
two groups with respect to mean maternal age, parity, gestation at
delivery, and experience of the surgeon (P < 0.05). CS was
performed as an emergency in 38 (32.9%) and 186 (72.6%) of
patients in groups 1 and 2 respectively (P < 0.05).
The consultant was involved in the decision to perform CS in
215 (84.6%) of patients with one previous CS. There were
significant differences between the two groups in the type of skin
incision, the presence of dense adhesions during surgery, and
bladder injury (P < 0.05). There were no statistically significant
differences in birth weight, stillbirth rate, low Apgar score, blood
loss during surgery, duration of surgery, or the duration of
postoperative hospital stay.
Conclusion: The prevalence of dense intra-abdominal adhesions and
of bladder injury during CS was higher in women with a history of
three or more previous CS than in women with one previous CS.
Placenta previa and Caesarean hysterectomy occurred with equal
frequency in each group, and wound dehiscence and uterine
rupture were rare.
Rsum
Objectif : Comparer les complications et les issues de la csarienne
(CS) entre les femmes ayant dj subi trois csariennes du
segment infrieur ou plus et les femmes nayant dj subi quune
CS.
Mthodes : Nous avons men une tude rtrospective portant sur
371 patientes qui subissaient une CS de nouveau. De ce groupe,
115 (31 %) avaient dj subi trois CS ou plus (groupe 1) et
256 (69 %) navaient dj subi quune CS (groupe 2). Toutes les
INTRODUCTION
193
OBSTETRICS
Group 1
n = 115
Group 2
n = 256
Significance
P
31.8 4.7
30.0 5.6
0.006
4.3 1.7
3.4 3.0
0.005
436 191
415 229
NS
37.3 2.7
38.7 2.4
0.013
104.4 15.7
103.9 14.9
NS
6.8 2.0
6.3 3.2
NS
2972 818
2941 747
NS
0.9 1.2
0.8 1.2
NS
55.2 15.7
51.7 12.8
NS
rupture with subsequent adverse fetal and maternal consequences.5,6 Because of the paucity of clinical trials, there is
no consensus on the maximum number of Caesarean sections that a woman can undergo with safety.
Some authors have found no increase in maternal morbidity
in women with a history of multiple CS and have therefore
encouraged them to pursue further pregnancies.7,8 At the
same time, anecdotal case reports of women having more
than ten Caesarean sections have been documented.9 With
the improved safety of anaesthesia, the availability of safe
blood transfusion, and the use of prophylactic antibiotics,
many Caesarean sections are performed uneventfully.
This study was conducted to compare the short-term complications and outcomes of CS in women who had a history
of three or more previous Caesarean sections with those
who had a history of one previous lower segment CS.
MATERIALS AND METHODS
Group 1
n = 115 (%)
Group 2
n = 256 (%)
Significance
Bladder injury
2 (1.7)
0 (0.00)
c2 = 5.16
Bowel injury
1 (0.86)
0 (0.00)
c2 = 2.23
Caesarean hysterectomy
1 (0.86)
1 (0.39)
c2 = 2.23
Wound infection/dehiscence
4 (3.4)
5 (1.9)
c2 = 0.78
Blood transfusion
4 (3.4)
10 (3.9)
c2 = 0.04
1 (0.86)
2 (0.78)
c2 = 0.01
Other*
2 (1.7)
2 (2.7)
c2 = 0.033
0 (0.0)
1 (0.39)
c2 = 0.39
P = 0.023
P = NS
P = NS
P = NS
P = NS
P = NS
P = NS
P = NS
Skin incision
Lower transverse
Vertical midline
Emergency Caesarean section
214 (83.5)
c2 = 40.75
62 (54)
42 (16.5)
P = 0.000
38 (33.0)
186 (72.6)
c2 = 45.7
53 (46.0)
P < 0.001
*Urinary tract infection, chest infection, atelectasis
NS: not significant.
RESULTS
195
OBSTETRICS
Group 1
n = 115 (%)
Group 2
n = 256 (%)
Significance
Placenta previa
4 (3.4)
8 (3.1)
c2 = 0.03
Abruptio placenta
0 (0.0)
7 (2.7)
Stillbirth
4 (3.4)
2 (0.78)
6 (5.2)
8 (3.1)
c2 = 0.96
19 (16.5)
130 (50.7)
c2 = 38.07
P = NS
c2 = 3.21
P = NS
c2 = 3.63
P = NS
P = NS
(7 at 5 minutes)
Unbooked patients
P < 0.001
Grade of surgeon
Senior specialist
54 (46.9)
54 (21.0)
c2 = 48.5
Specialist
50 (43.4)
139 (54.2)
P < 0.001
Resident
11 (9.7)
62 (24.8)
13. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine
rupture during labor among women with a prior cesarean delivery. N Engl J
Med 2001;345(1):38.
14. Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior
cesarean section. Obstet Gynecol 1985;66:8992.
3. Mcllwaine GM, Colse SJ, Macnaughton MC. The rising caesarean section
ratea matter of concern? Health Bulletin 1985;43:3015.
15. Makoha FW, Felimban HM, Fathuddien MA, Roomi F, Ghabra T. Multiple
cesarean section morbidity. Int J Gynaecol Obstet 2004:87:22732.
197