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.