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 cramping lower 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 diarrhoea and 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, a blood 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.
Sarah Brown
University of Glasgow
On day 5 post CS, NF still 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 revealed bowel
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
Sarah Brown
University of Glasgow
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 age play 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 is unlikely
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.
Word count: 983
Sarah Brown
University of Glasgow
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
Accessed from http://www.hps.scot.nhs.uk/about/HPN.aspx
2 World Health Organization. Appropriate technology for birth. Lancet 1985; 2: 436-7
3ISD Scotland. Births in Scottish hospital 2011/12.
Accessed from http://www.isdscotland.org/Health-Topics/Maternity-and-Births/Births/
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
Accessed from http://www.bmj.com/content/341/bmj.c5065
5 Bernstein, PS. Risks associated with caesarean delivery. Medscape 2005
Accessed from http://www.medscape.org/viewarticle/512946_4 on 30/10/13
6Williams, M. Caesarean section: summary of updated NICE guidance. BMJ 2011.
Accessed from http://www.bmj.com/rapid-response/2011/12/05/re-caesarean-sectionsummary-updated-nice-guidance
7 Munro, D. Caesarean rates still too high. WIN 2010; Vol. 18. Issue 4 pg 36-37
Accessed from http://www.inmo.ie/MagazineArticle/PrintArticle/8366
8 Royal College of Obstetricians and Gynaecologists. National Sentinel Caesarean Section
Audit Published. (2004)
Accessed from http://www.rcog.org.uk/news/national-sentinel-caesarean-section-auditpublished
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
Accessed from http://www.ncbi.nlm.nih.gov/pubmed/17324181
10NICE. Caesarean Section, clinical guideline 132. Updated 2012.
Accessed from http://guidance.nice.org.uk/CG132
Sarah Brown
University of Glasgow
Appendix 1
Sarah Brown
University of Glasgow