Adhesion-Prevention Strategy in C-Sections: Focus on Risk Reduction

Cesarean deliveries are now the most commonly performed abdominal surgery in the United States.¹   In 2005, an estimated 30.3 % of all births involved C-section procedures², and preliminary estimates from the Centers for Disease Control and Prevention indicate that the incidence of C-sections will continue to rise in the coming decade.³

The increased use of C-section procedures presents some important health considerations for specialists in maternal fetal medicine.  According to the results of a study published in the American Journal of Obstetrics & Gynecology in May 2007¹:

• Among women who underwent a second C-section, 46% (100 out of 217), developed pelvic adhesions.
• Among women treated with a third C-section, 75% (48 out of 64) developed adhesions.
• Among women treated with a fourth C-section, five out of six (83%) developed pelvic adhesions.
• The development of adhesions was also shown to have an impact on time-to-delivery. On average, infant delivery was delayed 5.6 minutes among women who had a second C-section as compared to an average primary C-section. The comparative delay increased to 8.5 minutes and 18.1 minutes, respectively, for third and fourth C-sections

The Rationale for Proactive Strategies to Prevent Adhesions in C-Sections

Time to infant delivery once anesthesia has been administered and risk of surgical complexity at repeat C-section are of critical concern, particularly in cases of emergent C-section. Based on these findings and continuing trends in the incidence and impact of C-sections, obstetrical practices are increasingly considering strategies to help reduce the risk of adhesions. In some practices, strategies focus on restrictions in the use of C-section procedures among patients. The availability of proven adhesion prevention strategies has also built support for a more proactive strategy to reduce risk, especially among patients treated with multiple C-section procedures. Following a comprehensive review of options, our division led a practice-wide initiative to incorporate adhesion prevention strategies to reduce the risk of adhesions in most C-section procedures.

In considering this plan, which was introduced in 2005, we identified several factors in support of a more proactive adhesion prevention strategy:

• As a busy obstetrical practice performing several thousand C-section procedures each year, our department is clearly positioned to be affected by trends in surgery that might increase the risk of adhesions among our patients. Based on available data it became apparent that an increased risk of post-surgical adhesions among our patients could have a significant impact in terms of treatment complications and delayed delivery time.
• The use of an adhesion barrier was already in place in formulary at the hospital and was widely used in gynecologic oncology procedures where the risk of post-operative adhesions is well-established.
• Based on established familiarity with adhesion prevention strategies in gynecologic oncology, support for a preventative strategy in obstetrics was in place among labor and delivery management teams familiar with both the proven efficacy of adhesion prevention strategies and the potential impact of adhesion development on our patients.
• The introduction of an adhesion prevention strategy would require only minimal additional staff training and monitoring.
• Data related to the safety and efficacy of adhesion prevention barriers was widely available.
• Importantly, to deliver maximum benefit we determined that a preventative strategy to reduce the risk of adhesions in C-sections must be positioned as a complement to superior surgical technique at every stage.

The availability of more conclusive data related to the risk of adhesions among C-section patients will help to shape even more effective prevention strategies in the years ahead. In this area, however, the rapid increase in C-section procedures challenges us to identify the optimal strategies to reduce patient risk as quickly as possible. While available data related to the morbidity associated with C-section adhesions are limited, we concluded that available data are sufficient at this stage to support a broad preventative intervention strategy as outlined. We are continuing to monitor results based on this strategy to draw more precise conclusions related to treatment experience.

References:

1. Morales KJ, Gordon MC, Bates GW Jr. Post cesarean delivery adhesions associated with delayed delivery of infant. Am J Obstet Gynecol 2007;196:461.e1-461.e6.

2. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S, Munson ML. Births: Final data for 2005. National vital statistics reports; vol 56 no 6. Hyattsville, MD: National Center for Health Statistics 2007.

3. Hamilton BE, Martin JA, Ventura SJ. Births Preliminary data for 2006. National vital statistics reports; vol 56 no 7. Hyattsville, MD: National Center for Health Statistics. 2007.