Mitigating Caesarean Section Complications

Abstract

Caesarean section (C-S), a common life-saving obstetric intervention, can result in immediate life-threatening or long-term complications for the mothers and their babies. Hence, C-S should be done only when medically indicated and in a timely and safe manner. The risk of complications is heightened by unnecessary C-S deliveries and the inappropriate timing and conduct of the procedure, especially in LMIC. In both HIC and LMIC settings, women with low socio-economic status are more at risk due to upstream structural factors that propagate health inequity during the reproductive age and downstream health system factors that preclude access to quality maternity care. Effective interventions ought to address social inequality, promote healthy lifestyles, and increase access to quality maternity care as an integral part of a multisectoral approach to primary health care. These interventions should address the risk factors along a continuum of care from preconception and antenatal periods which operate mainly at the community level; antenatal and intrapartum factors at the primary health facility levels; and intraoperative and post-operative factors mainly at the secondary level and tertiary level facilities. The scale of the interventions at the various levels will depend on the magnitude of the risk, which varies by HIC and LIC status and from one country to another and within countries. The rapidly increasing information technology and access to other medical technologies like point-of-care ultrasound, AI, and the use of evidence-based protocols have started positively impacting maternity care and may further improve C-S outcomes when accessible and properly utilised.

1. Introduction

Compared to vaginal delivery, delivery by C-S in both HIC and LMIC is wrought with a higher risk of complications despite the much better overall quality of medical care in HIC [1, 2]. In both HIC and LMIC, women with social disadvantage are most affected [1, 2, 3]. This implies similar structural drivers for the complications arising from caesarean births in HIC and LMIC embedded within the social and healthcare systems. The main difference between HIC and LMIC is the number of people affected that is subject to the proportions of the population that are socially disadvantaged. In some HIC, the socially disadvantaged women have higher rates of C-S and paradoxically higher complications [3]. Hence, it may not be the method of delivery per se, but the underlying causes stem from the socio-economic status in which they live as well as the timing of the C-S as an intervention.

In LMIC, it is the less-than-optimum rate of C-S that is associated with high incidences of adverse neonatal and maternal outcomes in LMIC, especially among women with poor access to health care [1, 4]. The rapidly rising rates of C-S rates in LMIC, especially among women in the upper wealthy quintiles [4], often not medically indicated, are not likely to have the desired impact on maternity outcomes in LMIC as they form a small proportion of the general population. Instead, it may confer an unintended risk of complications among women in the upper wealth quintiles similar to that observed in HIC associated with non-medically indicated C-S [4, 5] in a way creating a double burden of C-S-related complications in LMIC.

The complications of caesarean section are well known and include foetal and maternal complications which can further be grouped as early and later complications of caesarean sections (Table 1). Several structural and health system deficiencies that increase the risk of C-S delivery complications have been previously documented [6, 7, 8, 9].

Early	Late
Intraoperative and postpartum bleeding	Placental accreta spectrum disorder
Wound hematoma	C-S scar pregnancy
Wound site infection	Future risk of repeat C-S
VTE	Ruptured uterus
ICU admission	Adhesions
Blood transfusion	Chronic pelvic pain
Hysterectomy	Maternal death
Urinary tract abnormalities
Visceral injuries
Maternal death

Table 1.

Maternal complications of caesarean section.

Several researchers have also proposed various ways in which labour and delivery can be made safer, whether by natural vaginal delivery or by medically indicated C-S [9]. The identification of patients at risk before conception and the health system factors in the patient’s context during pregnancy, labour and delivery and targeted interventions for all parturients especially women at risk of C-S delivery can help avert severe complications associated with C-S birth [9]. Here, we highlight opportunities for upstream risk reduction at the community level and downstream risk reduction at various levels within the health system. In Figure 1, we lay a conceptual framework of the levels at which interventions can be directed depending on the context to mitigate the various complications associated with C-S delivery (Table 2).

Figure 1.

Conceptual framework of levels for mitigation of C-S complications.

Early	Late
Bruises	Atopy
Joint dislocation
Fractures	Asthma
Transient apnoea	Childhood obesity

Table 2.

Foetal complications of caesarean section.

Source: Ref. [10, 11].

1.1 Long-term complications of caesarean section

Maternal long-term complications of C-S include C-S scar defect which may be associated with postmenstrual bleeding: C-S scar pregnancy, intra-abdominal adhesions, chronic pelvic pain and the risk of C-S in subsequent pregnancies. Early diagnosis of C-S scar pregnancy is crucial as it is associated with increased maternal morbidity and mortality.

Intra-abdominal adhesion may be associated with difficulties in future C-S like delayed incision to delivery time and an increase in adhesion score. When adhesions are attached to visceral organs, this can lead to injuries to the bladder or bowel (Table 3) [12].

Caesarean section scar pregnancy	Bladder and bowel injury
Intra-abdominal adhesions	Delayed incision to delivery time
Chronic pelvic pain

Table 3.

Long-term complications of caesarean section.

Source: Ref. [12].

2. Risk factors for caesarean section related complications

2.1 Pre-conception risk factors for caesarean section related complication

Preconception risk factors include barriers to health care at the community level and the physiological and sociodemographic characteristics of women. In both high-income and low-income countries, similar barriers to health care are prevalent, and these include rural settings, vulnerable groups, low socioeconomic status, distance from the health facility and the quality of health services at the primary levels [6, 7, 8]. Barriers to access to health care prevent optimising and control of the common health conditions affecting women in different settings, resulting in life-threatening complications and delivery by emergency C-S that is associated with more adverse outcomes. These are usually proximal manifestations of distal governance and fiscal policies at national, provincial and local governmental levels that propagate inequity in access to economic resources and social services [6, 7, 8, 9, 13].

The patient-related preconception risk factors include obesity and associated complications such as hypertension, diabetes and other medical disorders such as cardiac disease, thyroid dysfunction, renal disease, autoimmune diseases and chronic infectious diseases. These may inherently lead to abnormal physiological changes in pregnancy resulting in maternal metabolic, haemodynamic and haematological derangements (e.g., hyperglycaemia, haemoconcentration, and venous thrombosis) and abnormal foetal growth patterns (IUGR or macrosomia). In addition, the chronic medication may cause congenital malformations or cross the placenta and adversely affect the baby. Alternatively, the physiological changes of pregnancy may worsen the maternal medical conditions such as cardiac disease. All these may predispose to emergency C-S delivery so as to avert severe maternal or foetal outcomes although the patients may be metabolically or haemodynamically unstable. Others like coagulopathies and anticoagulants may predispose to severe haemorrhage during C-S.

The most frequent early complications of caesarean delivery are haemorrhage, venous thromboembolism, surgical site infection and anaesthetic complications, all potentially increasing the risk of peripartum maternal death [14]. The risks for each of these complications of C-S may be classified as antenatal, intrapartum/labour-related, and intraoperative (Table 4).

Health system-related risk factors	Patient-related risk factors
Barriers to health care	Obesity
Low socioeconomic status	Hypertension
Distance from health facility	Thyroid dysfunction
Quality of healthcare services	Renal disease
	Autoimmune disease
	Coagulopathies

Table 4.

Pre-conception risk factors for caesarean section-related complications.

Source: Ref. [6, 7, 8, 9].

2.2 Risk for caesarean section-related haemorrhage

Antenatal risks include previous C-S delivery, uterine overdistension due to multiple pregnancy/polyhydramnios/foetal macrosomia, coagulopathy, inadequate ANC attendance and anaemia [15, 16, 17]. Others include transverse lie and placenta praevia or abruptio placentae [16, 18]. These predispose to uterine atony and failed haemostasis at the hysterotomy site which are precursors for intraoperative and postpartum haemorrhage, caesarean hysterectomy/peripartum hysterectomy [16, 17]. Although these operate at community level, they can be identified if there is adequate awareness at community level as well as through timely attendance of quality antenatal care (Table 5).

Previous caesarean delivery	Transverse lie
Uterine over distension	Placentae previa
Coagulopathy	Abruptio placentae
Anaemia

Table 5.

Antenatal risk factors for caesarean section-related haemorrhage.

Source: Ref. [15, 16, 17].

2.3 Intrapartum risk factors of haemorrhage during caesarean section

Intrapartum/labour-related factors for severe haemorrhage include induced labour, prolonged labour, obstructed labour and the timing of the caesarean section whether, elective, first stage or second stage, or caesarean section after failed assisted vaginal delivery [15, 19]. Compared to the elective or first stage C-S, second stage C-S or C-S after prolonged labour, failed induction, obstructed labour or failed instrumental delivery tend to be complicated by tears in the lower segment, endometritis secondary to multiple vaginal examinations and rupture of membranes, and increased tendency of uterine atony [16]. These risks can be accentuated by delays in seeking maternity care, failure to screen and refer high risk patients to higher levels of care, and inadequate assessment and selection of patients for induction of labour, trial of labour and trial of scar, as well as poor quality monitoring of labour especially at lower-level facilities (Figure 2).

Figure 2.

Intrapartum risk factors of haemorrahage during caesarean section [15, 19].

2.4 Intraoperative risk factors for haemorrhage

Intraoperative risks of haemorrhage include non-meticulous tissue handling and inadequate haemostasis, severe adhesions necessitating significant adhesiolysis, injury to uterine vessels, bladder and other viscera, retained products of conception, inadvertent suturing of the bladder to the upper segment or inadequate closure of the hysterotomy site, especially when caesarean section is done due to prolonged or obstructed labour by less-experienced surgeons [16, 20]. These predispose to subcutaneous and subfascial haematomas, intraperitoneal haemorrhage, bladder flap and broad ligament haematomas and post-partum haemorrhage arising from the hysterotomy incision. Women with previous C-S are at risk of dense adhesions which increase with the number of previous C-S deliveries [21]. In South Africa, bleeding during or after C-S accounted for almost 30% of the 233 maternal deaths in 2021 [22]. These risks are likely to be encountered at second level facilities or district hospitals that receive patients identified as high risk from the community health facilities (Table 6).

Severe adhesions

Non-meticulous tissue handling

Visceral injury

Retained products of conception

Inadequate closure of hysterotomy site

Inadequate haemostasis

Table 6.

Intraoperative haemorrhage risk factors of haemorrhage during caesarean section.

Source: Ref. [16, 20].

2.4.1 Risk factors for caesarean section-related infection

A patient is classified as having a caesarean surgical site infection (SSI) if, within 30 days of delivery, she develops superficial incisional (limited to the skin), deep incisional (subcutaneous fascia and muscles) or involving the peritoneal cavity, the uterus and or other abdominopelvic organs [23]. This may manifest peri-incisional abdominal wall cellulitis, superficial wound sepsis with or without dehiscence, necrotising fasciitis, peritonitis, peritoneal abscesses, bladder flap abscesses, endometritis or endomyometritis [24].

The prenatal risk factors include poor access to ANC, obesity, DM, smoking, multiple pregnancy, anaemia and previous C-S [23, 25].

The intrapartum risk factors include premature rupture of membranes, prolonged rupture of membranes, chorioamnionitis, prolonged labour, and a high number of vaginal exams before the caesarean delivery [23, 26].

The intraoperative risk factors for SSI include emergency C-S, large incisions, non-meticulous handling of tissues, inadequate haemostasis, subcutaneous hematoma, non-timely administration of appropriate prophylactic antibiotic, severe haemorrhage, hypothermia and prolonged operating time (Table 7) [26].

Prenatal risk factors	Intrapartum risk factors
Poor access to antenatal care	Prolonged rupture of membranes
Smoking	Chorioamnionitis
Multiple pregnancy	Prolonged labour
Preterm rupture of membranes	High number of vaginal exams before caesarean section
Anaemia	Prolonged rupture of membranes
Previous caesarean section
Obesity
Diabetes

Table 7.

Risk factors for caesarean section-related infection.

Source: Ref. [23, 25, 26].

2.4.2 Risk factors for venous thrombosis

Caesarean section confers a four-fold increase in the risk of venous thromboembolism and a 10-fold risk of maternal death from VTE (PE and DVT) compared to vaginal birth [27, 28, 29]. The physiological changes of normal pregnancy geared at the prevention of bleeding from the placental site after the third stage of labour substantially increase the VTE during pregnancy and in the puerperium [30]. This is secondary to the physiological increased serum clotting factors [29, 31] and reduced antithrombin sensitivity, stasis resulting from compression of the inferior vena cava by the gravid uterus and left iliac vein by the uterus and right iliac artery, respectively, as well as pooling of blood in the lower limbs secondary to oestrogen-mediated physiological changes [31].

Prenatally, women with the following risk factors will be at increased risk of VTE: age > 35, high parity (>3), high BMI, smoking and mechanical heart valves, systemic infection, as well as congenital or acquired thrombophilia [31].

Following C-S, the risk of VTE is accentuated by the vascular injury due to the operative procedures, stasis, and relative increase in hypercoagulation post-partum compared to the prenatal period, especially among women who undergo emergency C-S [28, 32].

2.5 Anaesthetic complications related with caesarean section

The most common complications arising from anaesthesia during C-S are desaturation, cardiac arrest, awareness and death [33]. One systematic study found that anaesthetic complications accounted for almost 14% of deaths after C-S in low- and middle-income countries [34]. Most of these complications are preventable as they were attributed to inadequate experience or training leading to less optimum practice, especially for patients undergoing C-S associated with severe obstetric or medical conditions [33, 34].

The physiological changes of pregnancy can make anaesthesia challenging with a difficult airway being one of the major challenges [35]. Patient factors like high BMI, co-morbidities, previous C-S, anaesthetist technique and blood loss are other factors associated with anaesthetic-related complications [35]. The use of the safety checklist has been associated with decreased complications as compared to when it is not used [36].

2.6 Risk factors for paediatric complications

Chawanpaiboon et al. [37] found that a surgeon’ skill was associated with short-term neonatal complications like bruises and dislocation of hip injury. The presence of these injuries emphasises the need for adequate skills training in all physicians carrying out this life-saving procedure. Acquisition of techniques for foetal delivery when confronted with varied foetal presentations and positions at different GA is necessary to decrease the rate of C-S complications [37].

Neonates born by C-S express a higher risk of transient apnoea and respiratory morbidity, neonatal hypoglycaemia, neonatal ICU admission and longer hospital stay than those delivered vaginally [38]. In labour and vaginal delivery, it is hypothesised that increased catecholamine surge facilitates lung clearance and glucose control in the neonatal period [38].

The impact of the mode of delivery is not limited to early neonatal life. In one systematic review, children born by C-S were found to have a more than 20% increased risk of asthma and almost 60% increased risk of obesity during the teenage life than those born vaginally [39]. These were corroborated by a subsequent meta-analysis by Słabuszewska-Jozwiak et al. [11]. Early-term delivery (37 weeks GA) is associated with a doubled risk of neonatal complications. Strict adherence to optimising the timing of delivery is beneficial to the neonates and the healthcare system [40]. The ACOG recommends that medically indicated elective C-S should be done at 39 weeks . This is to reduce the risk of neonatal complications like transient apnoea of the newborn which in some cases leads to a prolonged hospital stay [38, 41, 42]. Non-medically-indicated should be discouraged due to this increase in respiratory morbidity [43].

3. Targeted multilevel interventions to reduce the risk of caesarean section related complications

Efforts targeted at health facility-based risk factors for complications of C-S are downstream are unable to address the persistent numbers of women who are born in high-risk social settings reaching reproductive age annually at 15 years of age or less and remaining at risk of poor reproductive health outcomes for the next 25–35 years. Concurrent upstream interventions that aim to reduce social disparity as well as upstream interventions within the health systems that promote access to quality health care at various levels are needed, according to Yuan et al. [44].

3.1 National, regional and community initiatives

C-S and maternity services in general should form part of an integral primary health care system aimed at ensuring the health of entire populations within countries. This is closely linked to the level of economic development and disparities within countries which resonate with long-term economic planning, man-made and natural calamities, and the quality of governance at national and regional levels, as well as cultural barriers [45, 46, 47, 48, 49].

These are related to the literacy rate, road and hospital infrastructure, utilisation of health facilities and the quality of health care available from the entry-level of the primary healthcare system up to the tertiary units [50, 51].

The persistent cultural barriers to access to better health care are mostly propagated by patrilineal and male-dominated cultural and religious institutions [52, 53] which can be modified gradually with quality education, among other skills emphasises context-based health problems and practical solutions, to all children including boys in the community who will inevitably become some of the decision-makers in the near future [48, 54].

Hence, sustainable development goals should not only target the girl child, but all children should be empowered with cognitive and practical skills to enable them to participate actively and gainfully in adult life in the economy of their countries according to the natural and financial resources within their context. The better literacy rate and quality of education of the population will not only create awareness about the risks but also lead to the desire at the individual, household and community levels for quality maternity services and demand for accountability for budgets committed to health care in general [6, 13].

In addition, the population is likely to have civic and political leaders with better awareness, organisational skills and commitment towards economic development and improved social services including healthcare, emergency medical service/ambulance systems that have a direct positive impact on timely access to maternity and caesarean section services.

Depending on the local barriers to health care delivery in HIC and LMIC, different interventions informed by the local context need to be considered. For instance, in the USA, extending health insurance coverage to maternity care and tax incentives and tax credits that promote the construction of public infrastructure for women of reproductive age and integration of maternity and paediatric health services within the community-based primary health care units were proposed as practical innovations with the potential to concurrently improve the management of chronic conditions and access to prenatal care [3]. In Tanzania and Mozambique, successful community ambulance and health education initiatives have been reported that had a great impact on maternal outcomes through timely access to healthcare facilities [55, 56].

The better economic outlook and employment opportunities that come with better education may also empower households to plan for alternate means of transport or health care where the public means are overwhelmed [3]. Hence, these general interventions at the national, regional and community levels, informed by contextual structural drivers of social inequality not only improve timely access to health care and quality services to communities but can also be a vehicle for targeted pre-conception interventions such as reduction in weight, correction of micronutrient and macronutrient malnutrition, cessation of smoking and optimum control of chronic non-communicable diseases such as diabetes and heart disease [57].

Increasing antenatal care attendance and triage to higher-level facilities for high-risk antenatal care will promote better control of chronic disease from the first trimester and reduce the risk of emergency C-S associated with foetal or maternal complications due to poorly controlled chronic maternal conditions [58].

Prevention of C-S complications pre-conception would require optimising the underlying medical condition, substituting medications that are likely to cause congenital malformations, and counselling those whose disease is not well controlled or those at higher risks of postponing pregnancy [59].

Although this may seem more feasible in a well-functioning primary health care system that is common in HIC, better access to health education and counselling of women identified as high risk during the antenatal period, after delivery coupled with a follow-up plan at an appropriate level of care can help affirm the decisions to avoid pregnancy or initiate early antenatal care and referral to the limited tertiary facilities in LMIC in the next pregnancy.

The success of these pre-pregnancy interventions will depend on the HIC/LMIC status of the country, the household wealth quintile and the level of education which determine the budgets allocated to health care at the national and household level and the level of cognition of risk as well as self-determination of access to health care, contraception and family size [60].

HIC are likely to have better primary health care facilities; hence, the level of control of chronic non-communicable diseases ought to be better. However, like in LMIC, women in the lowest wealth quintiles are likely to have less access to health care but are more adversely affected by the health and nutrition transition that increases the risk of C-S delivery due to complications associated with obesity, diabetes and hypertension predating pregnancy [3]. Women in LMIC are not only at risk of protein-energy malnutrition but also are predisposed to the risk of obesity arising out of the nutrition transition driven by aggressive marketing of high-energy low micronutrient diets by multinational companies [61]. Hence, interventions such as regular exercise, a balanced diet, micronutrient supplementation depending on the deficiencies in the geographical area or diet and cessation of smoking, drugs and alcohol consumption can help those at risk to optimise their peri-conceptional health status [62].

3.2 Antenatal and intrapartum initiatives at the primary health facility level

3.2.1 Mitigation of prenatal risk factors

These antenatal risk factors can be mitigated by implementing policies that foster adequate attendance of quality antenatal care, identification of women at risk of obstetric haemorrhage and C-S delivery and appropriate referral for attendance of high-risk ANC and planned delivery at hospitals with 24 hrs C-S, ICU, blood transfusion services and multidisciplinary teams of obstetricians, anaesthesiologists, paediatricians and critical care specialists [6, 19, 63].

The proportion of women in LMIC who are accessing antenatal care and delivering at health facilities has steadily increased in LMIC over the years [64, 65, 66]. However, a significant number of those attending antenatal care still do not deliver within health facilities [66, 67].

Early utilisation of maternity care in LMIC is sometimes precluded by the attitude of the maternity care providers, leading to women presenting with prolonged labour and an increased risk of intrapartum C-S and attendant complications [68]. Hence, adequate staffing, a good attitude, as well as compensation and timely leave that prevents burn can sustain staff morale and a good attitude that are essential for quality maternity services associated with reduced risk of C-S delivery [69].

3.2.2 2 interventions to reduce intrapartum caesarean section related complications

A significant proportion of women still get adverse outcomes despite delivery within the health facilities [15, 19]. This may arise due to delays in seeking maternity care at the health facility, understaffing with resultant less adequate monitoring of labour, lack of skills or reliable methods to predict women at risk of prolonged or obstructed labour who would have been referred for an elective C-S or an early emergency C-S to mitigate the severe complications of intrapartum C-S.

These could be mitigated by the use of evidence-based risk prediction tools for successful vaginal delivery like the foetal head circumference:maternal height ratio to identify those women who are at risk of C-S in the second stage of labour or due to prolonged labour of failed assisted vaginal delivery [70, 71], as well as the use of the updated WHO partogram for the assessment of the progress of labour. This, where resources permit, can be aided by the use of the point-of-care intrapartum ultrasound scan for better identification of women with poor progress of labour.

3.2.3 Intrapartum ultrasound

Intrapartum ultrasound is more reproducible with a good prediction of the arrest of labour, which can lead to timeous intervention [72, 73]. Women who can progress to spontaneous delivery or operative can be predicted to some extent with ultrasound [73].

When a foetal position is wrongly assigned, this can lead to inappropriate use of instrumental delivery resulting in the delayed decision to C-S delivery time and an increase in C-S-related morbidity and mortality when C-S is finally performed [74].

3.2.4 Transperineal ultrasound and prediction of vaginal delivery

The use of transperineal ultrasound in labour can assist to predict women who are likely not going to progress and end up with caesarean delivery. Early identification of these women can prevent emergency C-S which carries more complications and can also allow time for a planned C-S [75]. The use of transperineal ultrasound is based on the understanding anatomic and functional characteristics of pelvic musculature which play a major role in the descent of the foetal head [76]. Veelen et al. [77] found that smaller levator hiatal dimensions on pelvic floor contraction were associated with operative delivery or caesarean section.

3.3 Interventions to reduce intraoperative caesarean section-related complications, at secondary and tertiary level health facilities

The use of ultrasound can help identify women at risk of visceral injury and excessive haemorrhage during C-S. Thus, in LMIC, where specialists are few, the use of point-of-care ultrasound can be of great help in the triage patients to the appropriate level of care for delivery [78, 79, 80].

3.3.1 The use of ultrasound for risk stratification in patients with previous caesarean section

In patients with previous C-S, delivery protocols for pre-operative assessment should be used for assessing placenta location, placenta accreta spectrum , abdominal wall and visceral adhesions. This will assist to predict and anticipate complications and allow better surgical planning. The use of point-of-care ultrasound to identify women at risk of adhesions through performing the sliding sign can be helpful.

During evaluation of PAS, the uterine outline, placental clear zone, myometrial thickness, placental bulge and vascularity are assessed. Absence of PAS signs like increased vascularity with large lacunae and feeding vessels are associated with an increased risk of C-S hysterectomy and massive transfusion.

When the thickness of the lower uterine segment is <3 mm in conjunction with bulging of the presenting part into the bladder and a myometrial thickness < 2 mm, a high index of suspicion of impending rupture should be entertained and the possibility of bladder injury during the C-S is anticipated [80].

3.3.2 Management of caesarean section according to expertise

Classification of C-S according to surgical difficulty has a positive influence on outcomes. This allows for the choice of personnel and resources needed before the C-S [80]. Three levels have been suggested:

• Level I—standard C-S which can be done by an obstetrician and gynaecologist assisted by a trainee.

• Level II—specialist C-S performed by two senior obstetricians, have blood available, and a urologist on standby

• Level III—MDT C-S delivery with a senior obstetrician and gynaecologist, senior anaesthetist and urologist and blood products available.

In LMIC, where personnel are not readily available, skilling of physicians is important for identifying women who need a referral and also for the ability to safely perform C-S, especially emergency C-S.

3.4 Strategies to reduce the risk of intraoperative haemorrhage

Identifying patients at risk of haemorrhage and having measures available to reduce the risk of bleeding improves maternal outcomes [81]. A multidisciplinary team approach is necessary to reduce intraoperative blood loss. Surgeons, anaesthetists and haematologists work together to stratify patients according to the risk of severe haemorrhage and initiate early interventions necessary to prevent related complications [81]. Several interventions can be used which include but are not limited to the following [81, 82, 83]

1. Use of pharmacological agents such as uterotonics and tranexamic acid

2. Cell salvage which can be used for blood loss of more than 500 ml

3. Meticulous handling of tissues and understanding the anatomy

4. Use of diathermy to cauterise bleeders

5. Use of compression sutures in cases of uterine atony, stepwise devascularisation

6. Early recourse to hysterectomy.

Point-of-care test to determine coagulation status should also be used to direct the resuscitation methods.

3.5 Strategies for reducing the risk of postoperative infection

The prenatal strategies to reduce the risk of surgical site sepsis include ensuring adequate balanced maternal nutrition and supplementation with vitamins and trace elements, prevention and treatment of anaemia, genital urinary and other systemic infections in the prenatal period, optimising the control of diabetes in pregnancy [26, 84].

The peri-operative strategies include douching with povidone-iodine or chlorohexidine before the operation, skin antisepsis with povidone-iodine or chlorohexidine, antibiotic prophylaxis with appropriate doses of first-generation cephalosporins or clindamycin and an aminoglycoside and prevention of hypothermia during surgery [26, 85, 86].

Routine use of the surgical safety checklist recommended by WHO is associated with reduced C-S complications, particularly maternal mortality, the risk of sepsis and the need for a laparotomy after C-S. The impact is greatest where there is stricter adherence to the use of the surgical checklist [87]. The use of the surgical checklist is further reported to improve the quality of care by better documentation of estimated blood loss, improved prophylactic antibiotic use, and reduced length of hospitalisation [88].

3.6 Strategies for reducing the risk of postoperative venous thromboembolism (VTE)

These can be mitigated by the identification of women at risk pre-conception and prenatally, reducing some risk factors such as smoking and high BMI, perioperative mechanical thromboprophylaxis for all women undergoing C-S by use of pneumatic compression devices (where available) till full ambulation and pharmacological prophylaxis for all those with risk factors or those without access to pneumatic compression devices [29, 89].

4. Tertiary level interventions for reducing the risk of caesarean section-related postoperative complications

Patients with severe complications referred to tertiary health facilities during the antenatal period should be managed by a multidisciplinary team (MDT) comprising senior midwives, obstetricians, intensivist, anaesthetists, neonatologists and consultants from relevant surgical departments. However, greater impact of tertiary institutions can be achieved through outreach and skilling of doctors in lower-level facilities where there is most need [90].

In a multiple-site randomised controlled trial in West Africa whose intervention included iterative maternal mortality audits and enhancement of evidence-based practices and clinical skills, Dumont et al. [90] reported that outreach from tertiary hospitals to lower-level referral hospitals that receive patients from community-based first level maternity improved the quality of care and significantly reduced maternal mortality. White et al. [91] found that several such quality improvements have been carried globally with success often reported at the participating health units. However, the successful scale up of these interventions is quite rare. Similar interventions at the tertiary level did not have additional value [90]. Usually, patients referred to tertiary level have already faced significant delays, most having severe complications that require critical care or rehabilitation. Quality improvement at community and lower health facility levels that ensure appropriate screening and early referral of the cases likely to suffer severe C-S complications yielded better results.

Pattinson et al. [92] reported a great reduction in institutional maternal mortality due to haemorrhage after C-S following implementation of the Essential Steps in Managing Obstetric Emergencies and Emergency Obstetric Simulation Training Program (ESMOE) intervention in hospitals compared to controls. Previous confidential enquiries into maternal deaths in South Africa had noted that maternal deaths due to obstetric haemorrhage following caesarean delivery mostly occurred in district/regional hospitals. ESMOE was introduced where doctors were skilled in performing C-S and managing complications intra-operatively and nurses in monitoring patients post-operatively. This allowed for early identification and management of patients with post-partum haemorrhage. This is a clear demonstration that outreach and in-reach programs are needed as part of skills improvements. In some LMIC, peripheral health units are staffed with junior health workers with less expertise who often are faced with difficulty when performing complicated C-S sections. Programs like the ESMOE in South Africa can greatly improve outcomes of patients having C-S in similar settings.

Online learning platforms can also be used to improve and transform surgical skills. Online resources such as peer-reviewed videos on performing C-S could be used in conjunction with practical standardised care for training, especially in LMIC [80]. Routine Objective Structured Assessment of Technical Skills (OSATS) with positive feedback to trainees performing C-S for competency has been recommended [93].

4.1 Skilling doctors for difficult caesarean sections

4.1.1 Caesarean section for abnormal foetal presentation or position

Abnormal presentation or position may lead to difficulties in delivering the foetus during C-S. When the challenges are not anticipated and the surgeon is not skilled, this can result in serious complications for both the mother and the foetus [94]. Anticipating the difficulties helps the surgeon to plan better [95]. The most reported include difficulty to access the lower uterine segment, complicated foetal extraction and placental abnormalities [95].

4.1.2 Impacted foetal head

This complication occurs commonly in patients whose attempted instrumental delivery has been unsuccessful, in obstructed labour, or may be encountered in theatre [96]. It is associated with a high risk of maternal morbidity and neonatal mortality and morbidity [97]. Several manoeuvres have been proposed to assist in delivering an impacted head, like push or pull methods, reverse breech extraction, and Partwardhan’s method. Peak et al. [97] noted that the breech extraction method was associated with fewer maternal and neonatal complications. The acquisition of proven techniques for the safe delivery of babies with abnormal presentations and positions at various gestational ages is useful in decreasing C-S complications [37].

4.1.3 Difficulty in accessing the lower segment

The presence of adhesions may make it difficult to access the lower uterine segment, which may result in a delay from incision to delivery time, which can result in poor neonatal outcomes [12]. Commonly, the challenge arises in women with previous caesarean delivery or with uterine fibroids [95]. Preoperative ultrasound to detect adhesion may better prepare the surgeon [98]. Prior anticipation of the presence of intraabdominal adhesions also assists in choosing an experienced team of obstetric and anaesthetic doctors to manage the patient and preparation of blood and blood products that may be needed [98]. Surgeons should also be equipped with the skills necessary to prevent complications like bowel and bladder injury and techniques of adhesiolysis during laparotomy.

4.1.4 Placental abnormalities

The common placental abnormalities include placenta praevia, especially when located anteriorly, and placenta accreta spectrum. These patients are at increased risk of haemorrhage, especially patients with anterior placenta praevia requiring preterm delivery secondary to antepartum haemorrhage [99, 100]. Pre-operative assessment of the placental location can assist in planning the incision site away from the placenta, when possible, which may decrease the degree of haemorrhage. Adequate planning and involvement of a multidisciplinary team is important, which includes the senior obstetrician, intensivist, neonatologist, maternal and foetal medicine specialist and blood bank services [80, 101]. Patients with placental abnormalities should further be observed for postpartum haemorrhage (PPH) and receive PPH prophylaxis when caesarean hysterectomy is not performed [102].

5. Prevention of unnecessary caesarean sections

In low-income countries, the C-S rate is still below 10%, which is indicative of poor access to medically indicated C-S [103]. However, it has been observed that increasing the C-S rate above 10–20% has not shown any benefit in decreasing maternal and neonatal mortality [103, 104, 105, 106, 107].

5.1 Strategies for the prevention of first caesarean section

Even in LMIC where the rate of C-S is considered inadequate, the rapid rising use of non-medically indicated C-S requires regulation as subsequent delivery by C-S is associated with much more risk of complications especially given the limited resources [4]. Mascarello et al. [108] in a systematic review reported a three-fold risk of maternal death and postpartum infection among women with C-S without indication.

Primary C-S is associated with a repeat C-S in 90% of the cases [109].

Understanding the complications related with C-S delivery and the prevention of the first C-S may help decrease the burdens associated with this procedure.

The American Congress of Obstetricians and Gynaecologists (ACOG) revised the approach to management of labour, allowing more time in the latent phase with the recommendation that the parturient reaches the active phase at a cervical dilation of 6 cm. The duration of the second stage was also revised to 2 hrs for multigravida and 3 hrs for primigravida or parturients with epidural analgesia. This can significantly decrease the need for caesarean delivery [41].

The use of assisted operative delivery needs to be considered whenever appropriate and if performed by a skilled personnel a lifesaving procedure that can reduce the rate of intrapartum C-S [110].

Failed induction has been noted as one of the common indications of C-S. Hence, clear protocols on induction of labour should be made available to obstetric institutions. A medically indicated induction should not be carried out unless there is a favourable bishop score. If delivery is indicated and the cervix is not favourable means should be undertaken to ripen the cervix [110].

The WHO recommends against performing C-S on maternal request due to associated complications [106]. Appropriate counselling on future reproductive health is important when considering C-S delivery for non-medically indicated C-S [110]. To be able to reduce the overall morbidity and mortality related to caesarean delivery prevention of the first C-S may be one of the most effective ways.

5.2 Strategies for reducing the rate of unnecessary repeat caesarean sections

Spek et al. [111] found non-medically indicated C-S, especially among women in the higher wealthy quintiles, and opting out of trial of vaginal birth after C-S for almost all women, including those with one previous C-S, were the main drivers for the high C-S rates. They recommended that quality maternity care including trial of labour with adequate monitoring could be beneficial in the reduction of the observed C-S rates associated with socioeconomic disparity.

Health education during the antenatal period, delivery in nurse-led maternity units, one-on-one nursing during labour coupled with feedback, positive attitude and respect from medical teams, adequate analgesia, use of evidence-based guidelines for the management of labour as well as polite teamwork have been reported to be associated with reduced recourse to delivery by C-S [104].

Practitioners are less inclined to perform vaginal delivery due to fear of litigation with the slightest unforeseen outcomes [104, 112]. This has created a notion for both doctors and patients that C-S delivery is a safer route when compared to vaginal delivery [113]. With rising medico-legal fees, caesarean section seems to have been on the rise [114]. There is a huge influence played by social media, resulting in fear of negative impact on reputation and defensive caesarean delivery. In these circumstances, interventions that may reduce the use of non-medically indicated C-S include promotion of evidence-based practice guidelines in the private sector, regulatory interventions to reduce litigations costs as well as the cost of C-S [104, 112].

Further increases in C-S rates in excess of 10–19% in the general population no longer confer an advantage in terms of improving maternal and foetal outcomes but are associated with increased risk of C-S complications. High rates of C-S may depict inequity and poor quality of care arising from unnecessary interventions [115]. In an audit of C-S indications in the US, Valdes et al. [116] found that socially marginalised women were more likely to undergo C-S in the lower-risk Robson TGCS, suggesting disproportionally higher rates of unnecessary C-S than more affluent women who had better rates of success with VBAC. They recommended further exploration of this phenomenon to reduce the risks of unnecessary C-S among socially disadvantaged population groups.

5.3 The role of artificial intelligence

In the era of advances in technology, Artificial Intelligence (AI) simulators with recorded training can be distributed to areas where it is not always feasible to have senior personnel in person. The use of AI applications such as smartphone software apps can also assist in the early detection of some C-S complications. One study from the United Kingdom reported a four-fold early detection of wound sepsis when an AI device for the detection of wound infection was used [117, 118] in a systematic review and meta-analysis reported that the diagnostic accuracy of digital telemedicine for surgical site infection ranged between 69.5 and 100%.

A recent study in Rwanda reported that image-based surgical site infection algorithms showed promise when used by community health workers for early detection of post-C-S wound sepsis [119]. Elsewhere, AI prediction models have been used to predict the mode of delivery. Pre-assigned models can help decrease the number of emergency C-S sections which are associated with more complications than elective C-S [120].

6. Conclusion

Caesarean section, a common obstetric operation, can be made safer by risk reduction strategies that begin in the preconception period along a continuum of care that includes health promotion and timely screening and management of prevalent health conditions at the community level, quality and accessible antenatal care, optimum intrapartum care and safe elective or emergency caesarean delivery when medically indicated. These strategies need to be part of a comprehensive social service delivery that seeks to address the social inequality that predisposes vulnerable women to increased risk of C-S complications at various levels of healthcare beginning at the community level to the tertiary level.

Conflict of interest

The authors have no conflict of interest.