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Nearly 1 in 60 patients with cesarean delivery suffered severe perioperative surgical morbidity, more often with intrapartum delivery, a California billing code study of almost 600,000 cases reported.

The finding underscores a pressing need to improve surgical care quality in this population, according to Alexander Butwick, MBBS, FRAC, MS, a professor of anesthesia in the Department of Anesthesia and Perioperative Care, at University of California San Francisco (UCSF), and colleagues.

The cross-sectional analysis appears in Obstetrics and Gynecology.

“We are already aware that the maternal mortality rate in the United States far exceeds that of other high-income countries,” Butwick told Medscape Medical News. While indices exist to track such complications, none had specifically addressed surgical outcomes. “Therefore, the impetus for this study was to develop an index that is surgery-specific, that is, that captures only surgical complications that occur in patients who undergo cesarean delivery,” Butwick said.

Approximately 32% of all deliveries in the US occur by cesarean section. Previous studies of severe cesarean complications used inconsistent definitions, making it hard to compare results, Butwick noted. With approximately 1.1 million US cesarean sections annually, “our intention is that this index would have the potential to be used as a benchmark for obstetric surgical quality of care.”

The study’s standardized index, built from billing data and expert review, captures serious complications such as organ injury, major bleeding, wound breakdown, and hysterectomy. “Our measure could help hospitals benchmark themselves against peers. From there, we need to dig into detailed medical record data to understand why complications occur and develop targeted quality-improvement strategies,” Butwick said.

The 1 in 60 cesareans affected was higher than what Butwick expected. “Extrapolated nationwide, that’s close to 19,000 cases every year,” he said, with especially high risk for the often more complex and urgent intrapartum procedures.

Serious Morbidities

Among 594,655 singleton cesarean deliveries in California during 2016 to 2021, 10,182 (171/10,000; 95% CI, 168-175) had some severe perioperative surgical morbidity, the most common being:

• shock (403/10,000; 95% CI, 323-492),
• intraoperative bladder, genitourinary, or pelvic injury (278/10,000; 95% CI, 212-353),
• wound complication, hematoma, infection, or abscess (181/10,000; 95% CI, 128-242).

Risk Factors for Severe Morbidity

• Timing: Intrapartum vs prelabor cesarean delivery (203/10,000; 95% CI, 198-209 vs 146/10,000, 95% CI, 142-150)
• Race/Ethnicity: Non-Hispanic Black, Asian, American Indian, or Alaska Native
• Other characteristics: Chronic hypertension, two or more previous cesarean deliveries, placenta previa, surgery with labor or induction underway, chorioamnionitis, and a gestational age < 37 weeks or > 40 weeks; placenta accreta spectrum disorder has the highest morbidity
• Setting: Nonurban hospital or one with annual cesarean volumes of 217-605 per year

Commenting on the study but not involved in it, Dawnette A.M. Lewis, MD, MPH, director of the Center for Maternal Health at Northwell Health in New Hyde Park, New York, found that the California study lacked clarity in that; it was based on combining different types of indication for cesarean delivery, with some contributing to a higher morbidity rate than others. “Patients with prior cesarean deliveries, for example, might have preexisting scar tissue, which can contribute to more complications,” as can surgery after labor has started, as the study noted. “If the paper had explored rates for each indication category separately, I think it would have been a better analysis,” Lewis said.

Ultimately, presurgical preparedness is key, she added, noting that California has been a leader in quality initiatives to prevent cesarean delivery and preoperative checklists that include everything from prophylactic antibiotics and skin cleansing to abdominal repair methods and suturing types.

“At our center, we take a ‘time out’ to discuss each surgery before it happens, whether the delivery is scheduled in advance or after labor has been unsuccessfully attempted,” Lewis said. For patients with known placenta accrete syndrome, an emergency multidisciplinary system encompassing anesthesiologists, gynecologic oncologists and blood bank personnel is in place.

According to Butwick, recognition is the first remedial step. Hospitals, researchers, clinicians, patients, and policymakers need to be aware of the scale of this problem. “From there, we need to dig into detailed medical record data to understand why complications occur and develop targeted quality-improvement strategies.”

The next research phase should apply this measure beyond California, in other states and nationwide, to see how rates vary by hospital and region. “That will help identify where systems are working well and where improvements are needed,” he said.

Because the index relied on billing codes, it needs to be validated against detailed clinical data. “We also couldn’t assess how differences in hospital practices, surgical technique, or care pathways might affect complication rates,” Butwick said.

“Our goal is not to discourage cesarean delivery when it’s medically necessary but to initiate discussion about potential opportunities to make surgery safer for the thousands of patients who undergo it each year.”

This study was funded internally by the Department of Anesthesia and Perioperative Medicine, UCSF. The authors and Lewis disclosed no potential conflicts of interest.