Anesthetic considerations for high order cesarean sections: a prospective cohort study

In a previous retrospective study we demonstrated that perioperative complications occurred in a minority of high order repeat cesarean sections (HOR-C/S). In this prospective study we compared the incidence of complications in patients who have had four or more cesarean sections to those that had three or less.

This was a prospective, observational cohort study of parturients undergoing C/S at a single tertiary care hospital over a 1 year period. We compared the incidence of conversion from regional to general anesthesia, duration of surgery and incidence of major blood loss in HOR-C/S to control.

We studied a total of 831 parturients, 129 underwent HOR-C/S. The incidence of conversion from regional to general anesthesia was similar in both groups (RR = 0.97, 95% CI 0.2, 4.3). The median duration of surgery was 40 min (range 10-145 min) in the HOR-C/S group and 30 min (range 10-150 min) in the control group (p < 0.001). The incidence of prolonged surgery was increased in the HOR-C/S group (RR = 3.6, 95% CI 2.4, 5.4). The incidence of intraoperative blood transfusion was higher in the HOR-C/S group (RR = 3.4, 95% CI 1.1, 10.2).

Patients who have HOR-C/S are more likely to have prolonged surgery and require blood transfusion than controls. However, in our population, this was not associated with an increased incidence of conversion from regional to general anesthesia. Provided causes of severe hemorrhage such as abnormal placentation have been ruled out, HOR-C/S is not an absolute contraindication to regional block.