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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 39-46

Anaesthetic complications during elective caesarean delivery and outcomes: A nigerian multi-centre cohort study


1 Department of Anaesthesia & Intensive Care, Faculty of Clinical Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
2 Department of Anaesthesia & Intensive Care, College of Medicine, University of Ibadan, Ibadan, Nigeria
3 Department of Anaesthesia & Intensive Care, Babcock University Teaching Hospital, Ilishan, Ogun State, Nigeria
4 Department of Anaesthesia & Intensive Care, Faculty of Clinical Sciences, Olabisi Onabanjo University, Ago-Iwoye, Nigeria

Date of Submission13-Jul-2021
Date of Acceptance21-Oct-2021
Date of Web Publication14-Mar-2022

Correspondence Address:
Dr. Simeon O Olateju
Department of Anaesthesia & Intensive Care, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOACC.JOACC_62_21

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  Abstract 


Background: Elective caesarean deliveries are planned procedures which are not without complications and unfavorable outcomes. We aimed to assess anaesthetic complications, risk factors and outcomes during caesarean delivery in Nigerian hospitals. Materials and Methods: Using a standardized template, we conducted a multi-centre prospective cohort study of parturients presenting for elective caesarean deliveries over a seven-day period in 49 hospitals. Demographic data of enrolled parturients, anaesthetic and surgical characteristics, complications; maternal and neonatal outcomes; ICU admissions and indications were collected. Results: A total of 237 parturients were studied. Previous caesarean section 50 (21%) and preeclampsia 25 (10.5%) were the most common indications for surgery. Regional technique was the most frequently used anaesthetic technique 221 (93.2%). Hypotension was more common with regional technique 29 (13%) than with general anaesthesia 6 (1%). The vast majority (71.8%) of those that developed complications had co-morbidities. Six patients were admitted to the ICU. Obstetric haemorrhage and severe preeclampsia were the most common indications for ICU admissions, 50% and 33% respectively. Two intraoperative cardiac arrests occurred with one survivor. There was one fresh stillbirth, three neonatal admissions and no neonatal death. Conclusion: Hypotension was the most common intraoperative complication during elective caesarean section whilst obstetric haemorrhage remained the major indication for ICU admissions with good outcomes.

Keywords: Elective caesarean delivery, hypotension, intraoperative complications, maternal mortality, neonatal outcomes


How to cite this article:
Olateju SO, Osinaike BB, Salami OF, Adetoye AO, Fatungase OM, Aaron OI, Faponle AF, on behalf of NiSOS. Anaesthetic complications during elective caesarean delivery and outcomes: A nigerian multi-centre cohort study. J Obstet Anaesth Crit Care 2022;12:39-46

How to cite this URL:
Olateju SO, Osinaike BB, Salami OF, Adetoye AO, Fatungase OM, Aaron OI, Faponle AF, on behalf of NiSOS. Anaesthetic complications during elective caesarean delivery and outcomes: A nigerian multi-centre cohort study. J Obstet Anaesth Crit Care [serial online] 2022 [cited 2022 May 19];12:39-46. Available from: https://www.joacc.com/text.asp?2022/12/1/39/339544




  Introduction Top


Caesarean delivery (CD) was categorized as elective if performed prior to the onset of labour and as emergency after an established labour.[1] Obi and Umeora[2]; Borkar Patil and Upadhye[1] reported an elective CD rate of 19.3% and 38% respectively. Planned caesarean deliveries have become safer than before because they are done mostly under regional anaesthesia. Generally, complications can still occur with poor maternal and neonatal outcome. Soren et al.[3] identified placenta previa and preeclampsia as the main maternal risk factors in their study. With these, the need for early detection of high risk parturients and aggressive management of complications should not be compromised for favourable feto-maternal outcomes.

Difficult airway remains a major challenge in obstetric anaesthesia because of the physiological changes in pregnancy. Postspinal hypotension and other severe obstetric complications may result in poor outcomes or even death.

The definitions of complications used in this study is the same as that used in the International Surgical Outcome Study (ISOS), African Surgical Outcome Study (ASOS) and the Nigerian Surgical Outcomes Study (NISOS).[4],[5] We conducted a seven-day observational study on the anaesthetic complications during elective caesarean delivery and outcomes in selected Nigerian hospitals. Our primary outcome was to determine the type and incidence of anaesthetic complications during caesarean delivery. Secondary outcomes were identification of risk factors for feto-maternal complications and ICU admissions.


  Materials and Methods Top


Following approval by the National Health Research Ethics Committee of Nigeria and registration on Clinical trials.org (ID-NCT 03551912) and written informed consent, we conducted an observational, multi-centre prospective cohort study on all parturients presenting for elective caesarean delivery in a 7-day period (July 9 -16, 2018). All geo-political regions in Nigeria were represented. The protocol for anaesthesia administration, surgery, and ICU (maternal and neonatal) admissions were standardized across different participating hospitals. All neonates with Apgar score of less than 7 at 5 minutes were admitted into neonatal intensive care unit (NICU). For the purposes of this study, hypotension was defined as a systolic blood pressure <90 mmHg.

Data on patient demographics, institutional type, anaesthetic and surgical manpower, use of surgical checklist, anaesthetic technique, estimated blood loss, Apgar score, ICU admission, NICU admission and feto-maternal outcomes were collected. Patients were followed up until discharge or thirty days post-delivery, whichever was shorter.

Descriptive statistics (Statistical Package for Social Sciences [SPSS] version 23) were used to define distribution of parameters amongst the mothers with and without complications. Nonparametric data among the groups were compared using Mann-Whitney's test. Categorical variables were compared using Fisher's exact Test. Continuous variables were presented as mean (SD). Multivariate logistic regression modelling was used for risk factors for the development of complications. A P value of <0.05 was considered statistically significant.


  Results Top


A total of 237 patients in 49 hospitals had their data for analysis [Figure 1] Demographic data are shown in [Table 1].
Figure 1: Flow diagram of parturients from recruitment to outcome

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Table 1: Patient characteristics, anaesthetic and obstetric data

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Seventeen (7.2%) of the parturients were hypertensive, 16 (6.8%) were obese, whilst 10 (4.2%) had gestational diabetes. Seven (3.0%) were HIV positive, 5 (2.1%) had sickle cell disease, one (0.4%) had coronary artery disease and one (0.4%) was asthmatic.

Previous caesarean section 50 (21.1%) and preeclampsia 25 (10.5%) were the most common indications for surgery. Other indications for surgery were maternal request 21 (8.9%), postdatism 18 (7.6%), placenta previa 10 (4.2%) and pre-existing cardiac disease one (0.4%). Most of the caesarean deliveries 221 (93.2%) were performed under spinal anaesthesia. Thirty-nine (16.5%) parturients had intraoperative complications of which hypotension was the most common 30 (77%). Obstetric and anaesthetic characteristics and outcomes of patients with complications are shown in [Table 2]. Complications occurred more frequently in cases performed under spinal anaesthesia 37 (16.7%) compared to those under general anaesthesia 2 (12.5%). Surgical check list was used in 97 (42%) of patients. Of this, 20.6% had complications compared with 79.4% in those without surgical checklist. Difficult intubation occurred in one of the six general anaesthesia cases. Of the 50 previous caesarean section patients, 12 (24%) developed intraoperative hypotension (P = 0.007) and 15 patients had blood loss of over 1L (range 1.1- 4L). Two patients were transfused. In addition, two of the previous CS patients had cardiac arrest with one survivor and the other one died in the ICU. The survivor was referred from a General Hospital to a tertiary facility for further management.
Table 2: Obstetric and anaesthetic characteristics in relations with complications and outcome

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Maternal risk factors (weight, co-morbidity, previous caesarean section, anaesthesia technique and blood loss) for development of intraoperative complications in the study are described in [Table 3]. Most patients (72%) with complications had co-morbidities. Two-thirds of those with complications were from non-teaching hospitals compared to teaching hospitals but this was not statistically significant [(26, 66.7%) vs. 13 (33.3%), P = 0.384)]. Multivariate logistic regression analysis identified maternal co-morbidity [(OR = 2.97, 95% CI = 1.12-4.81, P = 0.006)] and previous caesarean section [(OR = 2.72, 95% CI = 1.02–4.63, P = 0.016)] as independent risk factors for complications.
Table 3: Maternal characteristics and risk factors for development of intraoperative complications

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Six patients were admitted to the ICU [Table 4]. Three suffered major obstetric haemorrhage, 2 had severe preeclampsia, and one had severe hypotension of unexplainable cause. Anaesthetic technique, maternal co-morbidity and intra-operative complications did not affect foetal outcomes [Table 5] except one fresh stillbirth from the mother that survived cardiac arrest. Of the 30 (12.6%) neonates that had Apgar scores <7 at 1-minute, only 3 (1.3%) failed to achieve a higher score at 5 minutes. One (33.3%) out of three NICU admissions belonged to mothers with intraoperative complications, this is not statistically significant (P = 0.08). There was no record of neonatal death.
Table 4: Patient characteristics, anaesthetic complications and outcome of ICU admissions

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Table 5: Relationship between Apgar score and mothers with or without complications

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  Discussion Top


Our study found a 16.7% complication rate in parturients undergoing caesarean delivery (CD). This is slightly higher than the 13.3% reported in a single-centre Nigerian study.[6] Caesarean delivery with complications was 26.7% in a 7-day prospective perioperative patients outcomes in ASOS that involved 247 hospitals from 25 countries of which Nigerian hospitals were categorized as middle –income country.[4] The higher incidence rate of complications recorded in ASOS study when compared with ours may be as a result of inclusion of emergency CD and low-income countries where there are poorer facilities and inadequate manpower. This suggests that emergency delivery was an added risk. Of the complications in the index study, intraoperative hypotension accounted for 77%. This is contrary to 46.5% reported in a retrospective study in Israel.[7] Hypotension following spinal anaesthesia is due to sympathectomy with reduction in venous return. Fluid management and use of appropriate vasoactive drugs are usually effective in reversing hypotension. Other contributory factors are severe haemorrhage and supine hypotension syndrome. Pugel and colleagues in their reviews observed significant reductions in complication and in-hospital mortality in a previous data on surgical safety checklist.[8] However, Sumikura believed that the original checklist for caesarean section should be questioned as most of the patients are awake.[9] In this current study, the use of surgical checklist was below average with complications arising more from where checklist was not used. Irrespective of the anaesthetic technique used in obstetrics, safety checklist should always be used as it is quite promising in the reduction of feto-maternal morbidity and mortality.

Pregnancy-induced physiological airway changes may make intubation difficult. One patient in this study had a difficult intubation which was successfully managed by conventional use of laryngeal mask airway. The use of video laryngoscope may facilitate airway management better in such situation. Video laryngoscopy was done in the airway management in an obstetric unit with 100% success rate on first attempt.[10] This event has proved the usefulness of a video laryngoscope in obstetric theatre and therefore should be recommended for easy accessibility in anticipation of difficult airway. The declining use of general anaesthesia should further reduce difficult intubation scenarios in obstetrics. However, it is believed that reduced skill of anaesthetist in airway management might be associated with increase trend in regional anaesthesia[11],[12] Anaesthetic technique may affect neonatal outcomes. Much like the study by Obi and Umeora,[2] our study showed no difference in neonatal outcomes between general anaesthesia and regional anaesthesia. However, it is possible that the number of GA cases was too small to show a difference.

Previous caesarean section is the most common indication for another caesarean delivery. The previous caesarean incidence of 21.1% in this study is contrary to 53% found in the study by Saygi et al.[13] A recent study in Jordan by Khasawneh and colleagues that involved both elective and emergency caesarean deliveries found a higher incidence of 58.6%.[14] Difficult surgical dissection from scarring and adhesions may account for the increased likelihood of severe haemorrhage, anaemic hypoxia, cardiac arrest and death. Cardiac arrest during caesarean section is an uncommon complication and often featured as case reports.[15],[16],[17] Haemorrhagic shock is the leading cause of cardiac arrest in these reports and early high-quality cardiopulmonary resuscitation had increased survival. Referral to a tertiary centre after initial stabilization may also improve the chances of survival as was done for the survivor of cardiac arrest in our study.

During the study period, 6 (2.5%) patients were admitted into the ICU. This is similar to 2.8% in a study by Harde et al.[18] Even though previous literatures documented that hypertensive disorder was the most common indication for obstetric ICU admissions,[19],[20],[21] our study showed obstetric haemorrhage to be more common, accounting for 50% of the ICU admissions. This can be explained by the very high rate of previous caesarean sections, which is an important risk factor for severe obstetric haemorrhage. Also, the exclusion of emergency caesarean deliveries in our study may have contributed to this difference. The experience of the perioperative team may also be a critical factor in feto-maternal outcomes.

The most frequent cause of maternal death over a period of 10 years (2009-2018) in Australia was thrombo-embolism followed by obstetric haemorrhage with only 5 out of 251 deaths due to anaesthetic complication.[22] In comparison, we reported one (16.7%) death in our obstetric admissions into general ICU as a result of obstetric haemorrhage during our seven-day cohort study. Our finding is also higher than a prospective study done over two years in India with mortality 4 (6.6%) out of which two deaths was due to peripartum cardiomyopathy and one as a result of obstetric haemorrhage.[18] The lesser mortality in their study, a developing country like ours might be connected to availability of a dedicated postanesthesia intensive care unit in their centre. We are not aware of any dedicated Obstetric ICU in our Nigerian hospitals. Patel et al.[23] have reported that there are few centres with dedicated Obstetric ICU in the United States. In a retrospective South African study by Ntuli and colleague,[24] 8 (5.8%) had anaesthetic complications and were admitted into the general ICU out of which 3 (38%) had mortality. Although, the specific complications were not mentioned, higher mortality in their study could have resulted from longer duration study of 5 years. Another reason might be related to missing data from patient files affecting the reliability of the data as with retrospective studies. However, their authors claimed that all the patient files were reviewed to minimize this.

Provision of 24 hour obstetric services and standard patient care in the developed countries may be responsible for a better postcaesarean outcome from complications when compared with underdeveloped and developing countries like ours. Moreover, early antenatal care (ANC) booking and follow-up is suggested for a favourable maternal and foetal outcome. In an Ethiopian study by Mengesha and others, they found that mothers who did not book for ANC were 9.6 times more likely to develop poor maternal outcome of caesarean delivery compared to those who had ANC follow-up during their pregnancy (AOR = 9.6, 95% CI (3.09, 38.9)).[25] Financial constraints may be a major factor why mothers don't access good health care facility in the under developed and developing countries. In contrast, in spite of free caesarean delivery applied since 2009 by Republic of Benin government in West Africa, incidence of stillbirth continues to be recorded.[26] Severe maternal haemorrhage, a suspected reason for the fresh stillbirth recorded in the current study has been identified to be associated with perinatal death in a study by McClure et al.[27] Olateju et al.[28] reported 88.9% rate of health insurance scheme registration amongst women that showed willingness to receive epidural labour analgesia. This would grossly reduce the overall cost during antenatal care and delivery. It is, therefore, advisable for women who have no access to free obstetric care to register for health insurance scheme before pregnancy or very early in pregnancy to benefit from these advantages.

It was found in a retrospective study by Maayan-Metzger and colleagues on maternal hypotension during elective caesarean section that maternal intraoperative hypotension was not found to predict any perinatal complications.[7] Their finding is similar to the effect of overall maternal complications on neonatal outcome as observed in our study. However, this description is not absolute due to the missing data in our study. Nonetheless, the use of Apgar score in the determination of neonatal outcome is subjective.[29] Despite this limitation, it remains an important tool for standardized assessment of newborns globally, and especially in institutions like ours where umbilical venous pH determination is not routinely done.[30] Our study suggests that despite its subjective nature, Apgar scores remain a reliable measure of neonatal wellbeing.

Our study has some limitations. The non-availability of more objective measures of foetal wellbeing such as acid-base measurement is clearly a limitation. However, this is readily available in western countries but rare in many low- and middle-income countries. Also, a one-week study period may have been too short. Notwithstanding, a longer period could have yielded more cases, but it would also have been logistically more challenging to achieve. Except in few cases where it was obvious that intra-operative hypotension was due to severe haemorrhage, other causes of hypotension for example, aortocaval compression and high spinal were not considered as contributory factors that have possibility of affecting the maternal and neonatal outcome. Although this study was prospective, we still unavoidably recorded missing data which might have affected the overall outcome.


  Conclusion Top


The overall rate of anaesthetic complications during elective caesarean deliveries is low and the commonest was intra-operative hypotension. These were mostly observed in parturients with previous caesarean section in addition to co-morbid conditions which constituted risk factors for the development of complications. However, obstetric haemorrhage was the commonest indication for ICU admission followed by hypertensive disorder and generally the maternal and child outcomes were good with very low maternal and neonatal mortality. Finally, we are of the opinion that maternal and neonatal mortality is preventable. We recommend early identification of high risk patients, adequate manpower, improved skills, well-equipped facilities to include dedicated obstetric theatre and ICU. These would facilitate preventive and prompt treatment of life threatening complications for better maternal and neonatal outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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