Case Report on the Complications Associated with Caesarean Section (CS) and Their Relation

Case Report on the complications associated with Caesarean Section (CS) and their relation to the increasing rates of CS in the UK

History

NF is a 39 year old para 2+1 who presented to maternity assessment with a 2 hour history of PV bleeding at 36+5 weeks gestation. She reported a blood loss of about a teaspoon and also complained of crampinglower abdominal pain.

She was known to have an anterior type III Placenta Praevia, diagnosed at 30 weeks, and was scheduled for an elective caesarean section, with tubal ligation as per maternal request, at 37 weeks.

Her previous obstetric history comprised 2 live births; 1998 a normal delivery at term (2.7kg, female)followed in 2005 by an elective Caesarean Birth at 37 weeks for breech presentation (2.4kg male). She also had a miscarriage in 2012 at 6+3 weeks.

Her past medical history includes a diagnosis of depression managed with 20mg Citalopram ODS. She is otherwise well, has no known drug allergies and is on no other regular medication.

Despite having stable observations and a reassuring CTG it was decided that in light of her gestation, history and recent APH, the most appropriate action was to perform an emergency CS. She was given prophylactic antibiotics before theatre and was subsequently delivered. The CS was uncomplicated with an estimated blood loss of 750ml.

NF was initially well post-natally, however, 2 days post CS she was complaining of feeling unwell with a severe headache. At this time her blood results revealed a raised WCC of 26 x 109/L,abnormally high even for the pregnant state, therefore it was decided to commence 625mg oral Co-Amoxiclav TID. The next day, she developed watery diarrhoeaand began vomiting. She was pale, tachycardic (110/minute) but apyrexial. Her wound was assessed and looked clean and dry with no signs of infection. Her repeat blood tests revealed that her WCC (29.3 x 109/L)and CRP (188 mg/L) were increasing. As no source of infection had been found, ablood and stool culture were sent to the lab.

The following day, the diarrhoea and vomiting improved. However a rising WCC (29.9 x 109/L) and CRP (298 mg/L)prompted a change to intravenous Co-Amoxiclav.

On day 5 post CS, NFstill suffered diarrhoea and vomiting and had now developed abdominal pain with tenderness in her left iliac fossa. At this point her stool culture returned positive for C. difficile toxin. An abdominal X-ray (AXR) was organised and revealedbowel wall oedema but no dilated bowel loops. With the involvement of the infection control team, it was decided to discontinue the Co-Amoxiclav and start oral Metronidazole 400mg TID for 10-14 days, as per protocol (see Appendix 1)1.Over the next 2 days, NF’s abdominal pain increased and her abdomen became distended therefore a repeat AXR was arranged which later confirmed the suspicion of a small bowel ileus. The C. difficile severity score was now 2 (see appendix 11) and the antibiotics were appropriately changed to oral Vancomycin and IV Metronidazole and general surgical involvement was sought.

As the wound was healing well, her sutures were removed, however shortly after this NF experienced severe abdominal pain and noticed a mass protruding through the skin margin.After examination, she was promptly consented for ‘rectus sheath and skin resuturing and bowel exploration +/- bowel resection’ and taken back to theatre. In theatre her bowel was inspected and a 36cm section of infarcted small bowel identified after prolapsing into 2 small holes in the rectus sheath caused by wound dehiscence. This section of bowel was resected,an anastomosis was created and the incision was resutured.

Following the surgery, NF made a quick and uncomplicated recovery and was discharged from hospital 5 days later with a continuing course of oral Vancomycin and oral Metronidazole and follow up in place.

Discussion

The rates of CS in the UK are increasing year on year. In 1985 the World Health Organisation recommended that no more than 15% of deliveries should be by section2, and yet in the UK,this mode of delivery makes up over a quarter of all births.The rate has gone from 13.4% in 1985 to 28.9% in 2012 in Scotland3, which is one of the highest rates in the UK.

This is concerning, as this case demonstrates, the procedure is not without risk. Complications include haemorrhage and thrombosis as well as risks to future pregnancies4. For example, Placenta Praevia is 3 times more likely in women with 1 previous section and can be up to 45 times more likely in those having had 4 or more previous sections5. Infection is also common and despite the use of prophylactic antibiotics having made a significant reduction in the overall risk, it has been reported that wound infection may still occur in 2.5% to 16% of all CS5. Whilst C.Difficile infection (CDI) is a rare complication associated with antibiotic use, the overall rate of CDI following a single dose of prophylactic antibiotics has been described as 1.5%6.

It is largely unclear as to why the need for an operative delivery has increased over the past few decades.The Royal College of Obstetrics and Gynaecologists (RCOG) suggests that changing demographic characteristics and increasing maternal ageplay an important role7. In 2004 the National CS Sentinel Audit identified the indications given for CS, and found that 7% were for maternal request in the absence of any medical indications8. Although this could add to the increasing number of CS, a literature review in 2005, suggested that this isunlikely to be the case9. In 2011, however, the NICE guidelines were updated and suggested that women who are requesting a CS, should be offered a referral to a perinatal mental health specialist10.

The rising UK CS rate is having a negative impact on patient outcomes and is becoming a significant burden on the NHS. The wide variation in CS rates nationally4 suggest that a reduction in the rate is possible but it may still be some time until strategies are put into place that will achieve this.

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References

1 Health Protection Network. Guidance on Prevention and Control of Clostridium difficile Infection (CDI) in Care Settings in Scotland. Health Protection Network Scottish Guidance 3. (2014 Edition). Health Protection Scotland, Glasgow, 2014

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2 World Health Organization. Appropriate technology for birth. Lancet 1985; 2: 436-7

3ISD Scotland. Births in Scottish hospital 2011/12.

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4 Bragg, F. et al. Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study. BMJ 2010; 341

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5 Bernstein, PS. Risks associated with caesarean delivery. Medscape 2005

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6Williams, M. Caesarean section: summary of updated NICE guidance. BMJ 2011.

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7 Munro, D. Caesarean rates still too high. WIN 2010; Vol. 18. Issue 4 pg 36-37

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8 Royal College of Obstetricians and Gynaecologists. National Sentinel Caesarean Section Audit Published. (2004)

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9 McCourt C, Weaver J, Statham H, Beake S, Gamble M, Creedy D. Elective Caesarean Section and Decision Making: A critical review of the literature. Birth 2007; 34: 65-79

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10NICE. Caesarean Section, clinical guideline 132. Updated 2012.

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Appendix 1

Sarah BrownUniversity of Glasgow