Abstract

Background: The cesarean section is one of the most common operative procedures throughout the world with global rate increasing both developed and developing countries. Objective: To compare and evaluate the intraoperative surgical findings on elective versus emergency caesarean section and fetomaternal outcomes. Methods and materials: This study was descriptive comparative carried out at obstetrics and gynecology department of Tripoli university hospital during 1st January to 31th March 2023. The selected sample included 130 pregnant women which divided into two groups (65 patients had delivered by elective CS and another 65 patients had delivered by emergency CS). The collected data was entered, coded and analyzed by using SPSS version 25. The P value of less than 0.05 was considered as statistically significant. Results: We studied 130 pregnant women who's evaluated and compared the feto maternal outcomes on elective verses emergency caesarean section aged between 21 to 48 years, the mean maternal age among elective CS was 33.46 ± 4.169 SD and the mean maternal age among emergency CS was 32.03 ± 5.598 SD. The main indication of CS had reported was previous caesarean section both for elective and emergency caesarean delivery which accounts (41/63.1%) and (15/23.1%) respectively with highly statistically significant results reported (P – value = 0.000). And on compare the intraoperative surgical findings, the rate of adhesion more prevalent on elective CS while the rate of bleeding was more frequently on emergency CS with statistically significant results (P – value = 0.001 and 0.011) respectively. Although, most of patients (83.1%) did not expressed intra operative complications but 6.9% (9) had hysterectomy (6 of 9 on emergency CS while 3 of 9 on elective CS) and 3.8% (5) had expressed urinary tract injury (3 of 5 on emergency CS while 2 of 5 on elective CS). And 19.2% (25) of neonates had admitted to neonatal intensive care unit which represented 15.3% (20) of them had delivered by emergency CS while 3.9% (5) of them had delivered by elective CS with statistically significant results (P-value=0.001). Conclusion: On summary, the raising rate of caesarean section either by elective or emergency manner had significant adverse impacts on feto maternal outcomes with high rate of maternal bleeding, adhesion, abnormal placentation and overall increase risk of neonatal and maternal intensive care unit admission. Therefore, optimal perinatal assessment throughout pregnancy period is essential to reduce rate of unnecessary caesarean section and minimize related morbidity and mortality of caesarean delivery particularly emergency type.

Keywords:Caesarean Section; Intra Operative Surgical Findings; Feto Maternal Outcomes; Libya

Abbreviations: BT = Blood Transfusion; CPD = Cephalopelvic Disproportion; CS = Caesarean Section; LSCS = Lower Segment Caesarean Section; NICU = Neonatal Intensive Care Unit

Introduction

The caesarean section is one of the most common operative procedures throughout the world with global rate increasing both on developed and developing countries [1]. On determine the maternal factors contributed to CS were previous Lower Segment Caesarean Section (LSCS) and Eclampsia while the fatal factors for CS were cephalopelvic disproportion (CPD) and breech [2,3]. Also, there are various adverse maternal and fatal outcomes linked to caesarean section [3,4]. Several studies had reported rising on intra operative surgical risks and subsequent complications with caesarean delivery such as placenta accrete, hysterectomy, blood transfusion receiving rate, increase on operation time, intensive care unit admission and hospital stay [5,6].

Objective

To compare and evaluate the intraoperative surgical findings on elective versus emergency caesarean section and fetomaternal outcomes.

Methods and Materials

This study was descriptive comparative cross-sectional study which carried out at obstetrics and gynecology department of Tripoli university hospital during 1^st January to 31^th March 2023.The selected sample included 130 pregnant women which divided into two groups (65 patients had delivered by elective CS and another 65 patients had delivered by emergency CS) which collected postoperatively by simple random technique throughout predesigned structural questionnaire during the time period.

Results

Among 130 pregnant women who's evaluated and compared the feto maternal outcomes on elective verses emergency caesarean section aged between 21 to 48 years, the mean maternal age among elective CS was 33.46 ± 4.169 SD and the mean maternal age among emergency CS was 32.03 ± 5.598 SD. (Table 1)

Table 1: Maternal Age of Elective Versus Emergency Caesarean Section Distribution, Tripoli, Libya, 2023.

On determine the obstetrical characteristics on elective CS, 90.7% (59) were multigravida, 89.3% (58) were multiparity, 86.1% (56) were miscarriage rate and 33.8% (22) had previous experience of caesarean section. (Table 2) While on assess the obstetrical characteristics on emergency CS, 69.2% (45) were multigravida, 63.1% (41) were multiparity, 58.4% (38) were miscarriage rate and 40% (26) had previous experience of caesarean section. (Table 2)

Table 2: Obstetrical Characteristics of Elective Versus Emergency Caesarean Section distribution, Tripoli, Libya, 2023.

Regarding the gestational age at time of delivery, the mean GA on elective CS was 37.86 ± 0.659 SD while mean GA on emergency CS was 36.82 ± 2.214 SD. (Table 3)

Table 3: Gestational Age of Elective Versus Emergency Caesarean Section Distribution, Tripoli, Libya, 2023.

Regarding the blood group (ABO and rhesus) classifications, the most frequent class was A rhesus positive which scored 45.4% (59) followed by O rhesus positive which accounts 28.5% (37). And on compare between elective versus emergency caesarean section on terms of blood group classifications, the A rhesus positive had reported more on elective CS (31 of 59) while O rhesus positive documented on emergency CS (22 of 37). (Figure 1)

Figure 1: Blood Group (ABO and rhesus) Classifications of Elective Versus Emergency Caesarean Section Distribution, Tripoli, Libya, 2023.

The main indication of CS had reported was previous caesarean section both for elective and emergency caesarean delivery which accounts (41/63.1%) and (15/23.1%) respectively with highly statistically significant results reported (P – value = 0.000). (Table 4)

Table 4: Indications of Elective Versus Emergency Caesarean Section Distribution, Tripoli, Libya, 2023.

And on compare the intraoperative surgical findings, the rate of adhesion more prevalent on elective CS while the rate of bleeding was more frequently on emergency CS with statistically significant results (P – value = 0.001 and 0.011) respectively. 56 of 65 elective CS had adhesion with reported percentage was 86.2% while 9 (13.8%) did not had it 50 of 65 emergency CS had bleeding with documented percentage was 76.9%while 15 (23.1%) did not had it. Also, the rate of varicosity was more on emergency CS which accounts 20% (13 of 65) while 6.1% (4 of 65) among elective CS. Also, the abnormal placental invasion and placental lesions were highly reported on emergency CS 10.7% (7 of 65) while 4.6% (3 of 65) on elective CS. Although, most of patients (83.1%) did not expressed intra operative complications but 6.9% (9) had hysterectomy (6 of 9 on emergency CS while 3 of 9 on elective CS) and 3.8% (5) had expressed urinary tract injury (3 of 5 on emergency CS while 2 of 5 on elective CS). (Table 5)

Table 5: Intraoperative Complications of Elective Versus Emergency Caesarean Section distribution, Tripoli, Libya, 2023.

On assessed the feto maternal outcomes, 21.5% (28) had admitted to maternal intensive care unit with equal results reported both for elective CS (14/10.75%) and emergency CS (14/10.75%) which revelled highly statistically significant results (P – value = 0.000). And 16.2% (21) of patients had received blood transfusion which documented to be frequent on emergency CS was 9.3% (12 of 21) on compare to elective CS was 6.9% (9 of 21) with statistically significant results between blood transfusion and types of caesarean section (P – value = 0.004). (Figure 2 – Table 6)

Figure 2: Blood Transfusion of Elective Versus Emergency Caesarean Section distribution, Tripoli, Libya, 2023.

Table 6: Blood Transfusion of Elective Versus Emergency Caesarean Section Distribution, Tripoli, Libya, 2023.

Regarding the neonatal status at time of delivery, majority of them were alive 86.9% (113) while just 13.1% (17) of new-borns had died which 9.3% (12 of 17) had delivered by emergency CS while 3.8% (5 of 17) had delivered by elective CS with statistical insignificant results (P value = 0.069). (Figure 3 – Table 7)

Figure 3: Neonatal status of elective versus emergency caesarean section distribution, Tripoli, Libya, 2023.

Table 7: Neonatal status of elective versus emergency caesarean section distribution, Tripoli, Libya, 2023.

And 19.2% (25) of neonates had admitted to neonatal intensive care unit which represented 15.3% (20) of them had delivered by emergency CS while 3.9% (5) of them had delivered by elective CS with statistically significant results (P – value = 0.001). (Figure 4 – Table 8)

Figure 4: Neonatal Intensive Care Unit of Elective Versus Emergency Caesarean Section distribution, Tripoli, Libya, 2023.

Table 8: Neonatal Intensive Care Unit of Elective Versus Emergency Caesarean Section distribution, Tripoli, Libya, 2023.

Regarding the neonatal complications, 83.8% (109) of them did not had complications but 6.2% (8) had preterm birth delivered by emergency CS and 1.5% (2) had both fetal distress and congenital anomaly delivered by elective CS. (Table 9)

Table 9: Neonatal Complications of Elective Versus Emergency Caesarean Section distribution, Tripoli, Libya, 2023.

Of note, the overall statistical rate distribution of elective versus emergency CS on January, February and March 2023 at obstetrics and gynaecology department of Tripoli university hospital was 70.2% (737) of them had delivered by caesarean section which divided into 43.8% (323) for elective CS versus 56.2% (414) for emergency CS. (Figure 5 - 6)

Figure 5: Overall Caesarean Section Trends Over January, February and March 2023 Distribution, Tripoli, Libya, 2023.

Figure 6: Overall Elective Versus Emergency Caesarean Section Over January, February and March 2023 Distribution, Tripoli, Libya, 2023.

Discussion

We studied 130 pregnant women which evaluated and compared the feto maternal outcomes among elective versus emergency caesarean section.The most frequent indication on present study was previous CS for both elective and emergency CS, our study consistent with several studies and literature review [7-10]. On recent study in Ethiopia (2023) had reported that the intra-operative surgical complications was accounts 10.7% of overall caesarean delivery with documented complications were bleeding 3.6% (18), incision extension 1.4% (7) and adjacent internal organ injury 0.2% (1) [11]. Also, this study had reported that the rate of maternal complications were three times more frequent among emergency delivery on compare to elective delivery [11]. On Al-Zirqi, et al study (2008) had revealed that rate of severe obstetrical haemorrhage linked significantly with emergency delivery as present study [12]. And the rate of blood transfusion was higher on patients had severe anaemia particularly on haemoglobin less than 9.5 g/dl which had significant risks as reported by Ehrenthal, et al study (2012) [13]. In recent systematic review (2022) had reported that the overall total numbers of relevant study were 312 bladder injures and 7 ureteric injuries with mean injury rates documented were 267 and 9 events per 100,000 cases respectively [14]. And most of these injuries occurs secondary to caesarean section and hysterectomy [15-17]. The presence of adhesions among repeated CS had reported to be correlated with CS techniques difficulty which attributed to longer the operation time of delivery as well as bladder injury risks, on our study the rate of adhesion documented to be higher on elective CS than emergency CS [18-25]. Various studies had reported that the fetal complications such as prematurity, birth asphyxia, respiratory morbidity and neonatal intensive care unit admission were higher on emergency CS group on compare to elective CS group, this result corresponding and consistent to our study [7,26-28].