1. Intraoperative surgical complication during cesarean section : an observational study of the incidence and risk factors 부산백병원 산부인과 조인호 Acta Obstet Gynecol Scand 2003 : 82: 251-256

2. Introduction Kerr introduced (1926) The retrovesical, transverse, lower segment Ut. incision -> to reduce the incidence of Ut. rupture in subsequent pregnancies. Today, it most commonly used. Cesarean section -> m/c gynecologic-obstetric operation But, intraoperative surgical complications have been presented. The incidence of morbidity related to cesarean section in Copenhagen County.

3. Materials and methods The Univ. hosp in Gentofte, Herlev, Glostrup 기간 : August 1 st 1995 - July 30 th 1996 대상 : 7782 women c/sec rate: 929 (11.9%) Emergency c/sec rate : 636(68.5%) c/sec 방법 : Modified Pfannenstiel abdominal and lower seg. transv. Ut. Incision 연구 방법 : Medical records and parthograms were reviewed.

4. Results Incidence of intraoperatve surgical complications Type of complication TotalEmergency Elective Cervical laceration 3.6%(33) 4.6%(29) 1.4%(4) Corporal laceratoin 0.3%(3) 0.3%(2) 0.3%(1) Vaginal laceration 1.2%(11) 1.7%(11) 0.0%(0) Bladder laceration 0.5%(5) 0.8%(5) 0.0%(0) Bowel laceration 0.0%(0) Lacerations in total 5.2%(48) 6.8%(43) 1.7%(5) Blood transfusion 1.0%(9) 1.1%(7) 0.7%(2) EBL ≥ 1000ml 9.2%(77) 9.0%(57) 6.8%(20) Uterine rupture 0.3%(3) 0.5%(3) 0.0%(0) Hysterectomy 0.2%(2) 0.2%(1) 0.3%(1) Total12.1%(112)14.5%(92) 6.8%(20)

5. Results Demographic and obstetric charcteristics of the study population VariableNumber Age (mean) 30.3 years Parity (mean) 0.7 Pre-pregnancy body mass index (mean) 23.3kg/height 2 Previous cesarean section 25.7% Gestational age (mean) 38.7weeks Birth weight (mean) 3.315kg

6. Results Table III. Risk of intraoperative laceration of the cervix, vagina and bladder during cesarean section (I) Variablesn (%)Crude ORAdjusted OR Educational level of surgeon not under specialist education 97 (10.5)1.0 under specialist education434 (46.8)1.2 specialist397 (42.7)0.91.2 Previous cesarean section no689 (74.2)1.0 yes239(25.8)1.32.1 Emergency cesarean section no293 (31.5)1.0 yes635 (68.5)4.22.3 Maternal age(10 years)928 (100)1.82.1 Station of the presenting part above ischial spines820 (88 4)1.0 ischial spines or below108 (11.6)4.35.9

7. Results Table III. Risk of intraoperative laceration of the cervix, vagina and bladder during cesarean section (II) Variablesn (%) Crude OR Adjusted OR Fetal distress as indication no687 (74.0)1.0 Yes241 (26.0)2.33.7 Dystocia as indication no623 (67.1)1.0 yes305 (32.9)2.62.3 Birth weight (g) <3000g249 (26.8)1.0 3000-3999507 (54.7)0.92.4 ≥4000172 (18.5)2.15.3 Interaction between birth weight ≥4000 g and station at ischial spines or below no895 (96.4)1.0 yes33 (3.6)1.90.2

8. Results Table IV. Risk of intraoperative blood loss ≥1000 ml during the cesarean section (I) Variablen (%) Crude OR Adjusted OR Educational level of surgeon not under specialist education96 (10.4)1.0 under specialist education432 (46.8)1.11.3 specialist395 (42.8)1.11.3 Previous cesarean section no686 (74.3)1.0 yes237 (25.7)0.6 Emergency cesarean section no291 (31.5)1.0 yes632 (68.5)1.31.6 Pre-pregnancy BMI <20177 (19.2)1.0 20-25518 (56.1)2.52.3 >25228 (24.7)3.93.8

9. Results Table IV. Risk of intraoperative blood loss ≥1000 ml during the cesarean section (II) Variablen (%) Crude OR Adjusted OR Duration of regular painful cont. (h) 0445 (48.2)1.0 1-8232 (25.1)0.50.2 ≥8246 (26.7)1.10.3 Placental abruption as indication no879 (95.2)1.0 yes44 (4.8)7.17.3 Placenta previa as indication no904 (97.9)1.0 yes19 (2.1)79.2 Birth weight (g) <3000247 (26.8)1.52.4 3000-3999505 (54.7)1.0 ≥4000171 (18.5)2.74.1

10. Discussion Intraoperative laceration : 5.2% Higher in Emergency Intraoperative laceration Blood transfusion Injury to the fetus Associated with intraoperative complication in Emergency op. Skills of the surgeon History of previous s/cec Others

11. Discussion Intraoperative laceration 의 risk factor High birth weight Low station of the presenting part -> reducing the injury modification of c/sec Ventouse or forceps Fetal distress : speed of c/sec Andersen et al. :204 patients  Time interval -> neonatal outcome 에 영향을 못 미침  Surgical technique -> gentle, nontraumatic delivery

12. Discussion Intraoperative laceration 의 risk factor (II) Emergency op Increasing maternal age Intraoperative blood loss 의 risk factor Placental abruption Placenta previa Increasing prepregnancy BMI High birth weight <- positive effect of Ut. Cont. on blood loss

13. Discussion Intraoperative blood loss 의 risk factor Manual removal of placenta Uterine exteriorization before closure of the uterotomy -> lood loss 를 감소시킴. Emergency op. & fetal distress: “speed” -> blood loss 에 영향 못 미침 -> Misgav Ladach method Confounding factor Educational level of the surgeon

14. Discussion In obstetrics, Benefit 과 risk 를 고려 c/sec 은 m/c surgical intervention in women Maternal morbidity and mortality 는 별다른 주목을 받지 못함. Mode of delivery→carefully presenting balanced informatation about the risks and benefits of vaginal delevery & c/sec.