New UCSF research offers hospitals a way to track and ultimately reduce the risks of surgical complications.
Cesarean delivery is the most common inpatient surgery in the U.S. but it also carries inherent surgical risks, including vascular, visceral, soft tissue, and nerve damage, which can lead to significant maternal health complications and even death.
Despite the high frequency of cesarean delivery in the U.S., research into the surgical complications of the procedure has not addressed many of these complications or have been overly broad in identifying complications.
To address this gap, researchers at UC San Francisco have developed a novel, population-based measure to define and track severe surgical complications among patients undergoing cesarean delivery and used the measure to examine prevalence and risk factors in cesarean patients in California.
Using data from nearly 600,000 births in California, the researchers have found that about one in 60 cesarean deliveries involve a serious surgical complication, with higher rates among patients undergoing intrapartum cesarean (during labor) or those with placenta accreta (a condition where the placenta attaches too deeply into the uterine wall). This is a striking rate given that roughly 1.1 million cesareans are performed each year in the U.S., translating to an estimated 18,000 patients annually who may experience serious intraoperative surgical complications.
Their research appears August 21 in Obstetrics and Gynecology.
“The new measure relies on routinely collected hospital claims data and could serve as a foundation for monitoring surgical quality and guiding improvement efforts across hospitals,” said study first author Alexander Butwick, MBBS, FRCA, MS, Professor and Division Chief of Obstetric Anesthesia at UCSF. “This work marks a major step toward better defining and addressing surgical risk in obstetric care.”
The study was conducted as a retrospective cross-sectional study of patients who underwent cesarean delivery in any California hospital between 2016 and 2021. The researchers constructed a composite index of severe perioperative surgical morbidity (SPSM) based on maternal discharge or claims data. Their measure included intra-abdominal or pelvic visceral and vascular injuries, hysterectomy, pelvic or retroperitoneal hematoma, wound complications, ileus or bowel obstruction, acute peritonitis, and shock. SPSM prevalence was calculated overall and stratified by pre-labor and intra-partum cesarean deliveries. Intrapartum cesarean deliveries usually happen after labor has started—either spontaneously or through induction—when there’s a concern for the mother or baby.
Among 594,655 cesarean deliveries, 10,182 had SPSM. The most common categorized morbidities were wound complications; followed by bladder, genitourinary, or pelvic injury; ileus or bowel obstruction, and intraoperative bowel injury. SPSM prevalence was higher among patients undergoing intrapartum compared with pre-labor cesarean delivery. This may be related to increased risk of uterine atony (lack of muscle tone) and more complicated surgical delivery in patients who have attempted labor prior to cesarean delivery.
Patients with placenta accreta spectrum disorder, a condition associated with major intraoperative hemorrhage, had the highest SPSM risk. This finding highlights the considerable surgical complexity, altered anatomy, and technical difficulties in the surgical management of patients with placenta accreta spectrum disorder. The authors observed that patients with other hemorrhage risk factors, such as placenta previa and chorioamnionitis, had an increased risk of SPSM, which may also be related to surgical complexity.
“Prior studies of perioperative morbidity reported higher complication rates because they mixed in medical and anesthetic complications with surgery-specific complications,” said Butwick. “Our approach isolates serious surgical complications, so we get a more accurate sense of the surgical risk for cesarean patients. These findings underscore the need for systematic measurement and evaluation of surgical quality of care among patients undergoing cesarean delivery to identify opportunities for morbidity reduction.”
The study was undertaken by the and the UCSF Department of Obstetric Anesthesia and UCSF Hope Consortium, which looks at pregnancy outcomes including preterm birth, preeclampsia, and intrauterine growth restriction, which increase the risk for death and short-term and long-term disability and death. The international HOPE Consortium brings together academic, public health, and community partners to look at risk and resiliency for adverse pregnancy and infant outcomes.
Additional Authors: Rebecca J. Baer, MPH, Naghma Farooqi, MD, Olof Stephansson, MD, PhD, Laura Jelliffe-Pawlowski MS, PhD.
Funding: The study was funded by the Department of Anesthesia and Perioperative Medicine, University of California, San Francisco.
About UCSF Health: UCSF Health is recognized worldwide for its innovative patient care, reflecting the latest medical knowledge, advanced technologies and pioneering research. It includes the flagship UCSF Medical Center, which is a top-ranked specialty hospital, as well as UCSF Benioff Children’s Hospitals, with campuses in San Francisco and Oakland; two community hospitals, UCSF Health St. Mary's and UCSF Health Saint Francis; Langley Porter Psychiatric Hospital and Clinics; UCSF Benioff Children’s Physicians; and the UCSF Faculty Practice. These hospitals serve as the academic medical center of the University of California, San Francisco, which is world-renowned for its graduate-level health sciences education and biomedical research. UCSF Health has affiliations with hospitals and health organizations throughout the Bay Area. Visit http://www.ucsfhealth.org/. Follow UCSF Health on Facebook, Threads or LinkedIn.
