Perioperative management of caesarean section-related haemorrhage in a maternal near-miss population: a retrospective study

Abstract

Background: Maternal near-miss (MNM) is a risk stratification for maternal morbidity. The purpose of this study was to describe the perioperative care given in the management of this particular population of women who have undergone a caesarean section (CS).

Methods: This was a retrospective, descriptive study at a single tertiary institute over a one-year period (1 January to 31 December 2018) at the Chris Hani Baragwanath Academic Hospital. The aim of this study was to describe the anaesthetic and surgical management of CS-related haemorrhage in an MNM population. The primary objectives were to determine the MNM rate from CS related obstetric haemorrhage during the study period and to describe the intervention strategies employed in perioperative management for women with CS-related obstetric haemorrhage. The secondary objectives were to determine factors associated with massive transfusion and major estimated blood loss. The primary outcome was the MNM rate for CS deliveries.

Results: A total of 8 306 women had CS of whom 105 (1.26%) were classified as MNM due to bleeding during and after the procedure. The median age was 28, with a median parity of 2 (44%), and overall estimated median (IQR) blood loss volume of 1 800 (1 200–2 100) ml. The leading cause of haemorrhage was postpartum haemorrhage (87%). Eighteen (17%) of the women had relook surgery for postpartum CS sepsis. Age and parity of ≥ 3 had a univariate association with major estimated blood loss. The use of general anaesthesia and parity of ≥ 3 had an adjusted association with the institution of massive transfusion protocol (adjusted odds ratio [aOR] 5.28, 95% confidence interval [CI] 1.03–27.01 and aOR 3.88, 95% CI 1.47–10.25, respectively).

Conclusion: MNM from bleeding during or after a CS occurred in approximately 1 in 80 women who delivered by CS. These women required multiple interventions to arrest the haemorrhage and to achieve haemodynamic stability. Women with a higher parity and undergoing general anaesthesia were associated with severe bleeding. Approximately 1 in 4 women required an exploratory laparotomy and less than 7% required a hysterectomy.