Severe Perioperative Surgical Morbidity With Cesarean Delivery

To evaluate the prevalence and risk factors for severe perioperative surgical morbidity among patients undergoing cesarean delivery.

This was a retrospective cross-sectional study of patients who underwent cesarean delivery in any California hospital between 2016 and 2021. Linked birth certificate and maternal discharge data identified cesarean delivery hospitalizations. We constructed a composite index for severe perioperative surgical morbidity, including intra-abdominal or pelvic visceral and vascular injuries, hysterectomy, pelvic or retroperitoneal hematoma, wound complications, ileus or bowel obstruction, acute peritonitis, and shock. Severe perioperative surgical morbidity prevalence was quantified overall and stratified by prelabor and intrapartum cesarean deliveries. We developed a multivariable Poisson log-linear regression model to identify independent risk factors for severe perioperative surgical morbidity. In secondary analyses, severe perioperative surgical morbidity prevalence and risk factors were assessed separately by prelabor and intrapartum cesarean delivery.

Among 594,655 cesarean deliveries, 10,182 (171/10,000, 95% CI, 168-175) had severe perioperative surgical morbidity. The most common categorized morbidities were wound complications (59/10,000, 95% CI, 57-61); bladder, genitourinary, or pelvic injury (45/10,000, 95% CI, 43-47); ileus or bowel obstruction (33/10,000, 95% CI, 32-35); shock (15/10,000, 95% CI, 14-16); and intraoperative bowel injury (14/10,000, 95% CI, 13-15). Severe perioperative surgical morbidity prevalence was higher among patients undergoing intrapartum compared with prelabor cesarean delivery (203/10,000, 95% CI, 198-209 vs 146/10,000, 95% CI, 142-150). Patients with placenta accreta spectrum disorder had the highest severe perioperative surgical morbidity risk (adjusted risk ratio 15.3, 95% CI, 14.0-16.7).

Nearly 1 in 60 patients who undergo cesarean delivery in California experienced severe perioperative surgical morbidity, with a higher prevalence occurring among intrapartum compared with prelabor cesarean deliveries. 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.