AFJOG

African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 3 | 2024 | 32 ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 3 | 2024 | An Assessment of Risk factors for Post Caesarean Section Sepsis in Tembisa Provincial Tertiary Hospital It is well known that women with preoperative anaemia have a high risk of postpartum haemorrhage. The 2015- 2017 triennial Saving Mothers report showed that at least 43% of maternal deaths were anaemic, and nearly 40% of women with pregnancy related sepsis had anaemia. 6 The importance of normal haemoglobin in tissue perfusion and healing cannot be overstated, especially postoperative haemoglobin levels. 16 The decline in human immunodeficiency virus (HIV) related causes of maternal morbidity and mortality has been one of the success stories since the introduction of Highly Active Antiretroviral Therapy (HAART). The Saving Mothers report 2015-2017 estimates at least a 40% drop in HIV related maternal mortality. 6 Despite this success it is still important to be vigilant as there are still mothers who present with advanced states of immunosuppression. CS deliveries increases the risk of sepsis in mothers with advanced immunosuppression. However, if the HIV viral load is suppressed the risk is similar to HIV negative mothers. 17 Diabetes mellitus in pregnancy is usually associated with a high BMI and has an added effect on the risk of post CS sepsis. 11-15 Hypertensive disorders are also implicated, the possible pathogenesis is the endothelial damage which reduces tissue perfusion leading to hypoxia. 14 Furthermore, maternal infections like chorioamnionitis and urinary tract infections increase the risk of post CS sepsis. 13,14 It is generally accepted that an emergency CS, particularly those done post labour onset have a higher risk of postoperative sepsis than planned elective CS. 15-20 The pathogenesis involves prolonged labour, prolonged rupture of membranes, multiple digital examinations, need to push the presenting part back, and trauma to the pelvic organs. 7,14,17,18 Other factors include prolonged operating time, surgeon experience, type of incision, and staples for skin closure. 11,16-19 Antibiotic prophylaxis prior to surgery and postoperative antibiotic use is key to reducing postoperative sepsis. Timing of prophylaxis, indication, dosage, and class of antibiotic are factors that influence the risk of sepsis and should be carefully considered in women with a high index of suspicion for postoperative sepsis. 11,14,20 Post CS sepsis is multifactorial and requires a multidisciplinary approach. While there are classical causes of sepsis, it is imperative for each unit/hospital to identify the main drivers of sepsis in their local setting. This will assist in instituting measures to curb postoperative sepsis and improve maternal and neonatal outcomes. South Africa is still lagging behind in preventing avoidable maternal deaths, with maternal mortality ratio (iMMR) of 111.7/100 000. 4 This iMMR is far above the Sustainable Development Goal for maternal mortality of 70/100 000. 21 Monitoring and appropriately managing post CS sepsis would contribute to reducing morbidity and mortality associated with post CS sepsis. 6,9 The South African Saving Mothers report (2017) highlighted pregnancy-related sepsis as one of the most common causes of maternal mortality (36.5%) in regional and tertiary hospitals. 6 The Tembisa Provincial Tertiary hospital (TPTH)maternity unit is a busy unit inGauteng, with an average of 15 600 deliveries per annum. Although data is lacking, there are numerous women who require repeat admission and recurrent follow-up for the management of post CS sepsis. The purpose of this study is to establish the incidence of post CS sepsis, and explore factors that contribute to post CS sepsis in this specific hospital setting. The findings will inform the develop of local protocols and recommendations to reduce the morbidity and mortality associated with post CS sepsis. MATERIALS AND METHODS This was an observational case control prospective study using survey data from women who had CS deliveries at TPTH in Johannesburg, South Africa. This included women who presented to the postnatal clinic, emergency department and women who were re-admitted at the TPTH for surgical site infection (sepsis) during the study period. The study assessed factors associated with postoperative CS sepsis. Women’s data was captured over a three-month period, from 01 December 2020 to 28 February 2021. The sample consisted of postpartum women aged between 15 and 45 years. Focus was on early sepsis and 14 days was used as a cut-off for the enrolment into the study. Most women have their sutures removed at day 7-10 which was extended to 14 days to cover for removal days falling on weekends. Signed informed consent was obtained prior to enrolment in the study. A self-completion questionnaire was given to participants on day one of the CS. Women were encouraged to present for follow-up after delivery if they experienced any surgical site concerns or any other post-delivery complications. The language of instruction was English, and interpretation was provided by the questionnaire dispenser to those who needed assistance. Women who consented to participate in the study completed a demographic and obstetric history questionnaire at enrolment into the study and the clinical characteristics and post-delivery outcomes were captured later by the researcher from the maternal obstetric case records and ward admission files. Approval for this study was obtained from the University of Pretoria, Faculty of Health Sciences Research Ethics Committee (Protocol number: 645/2020). Data was collected onto a spreadsheet and analysed using STATA 17 . Statistical tools including descriptive statistics, test of means, proportions, tests of independence and logistic regression were used as part of data analysis to assess the associational relationship between the incidence of developing sepsis and women’s socio-demographic, clinical characteristics and obstetric history. In this study, sepsis was used as a proxy for any of the three types of surgical site infections. RESULTS A total of 742 women who were post CS were enrolled in the study, of which 43 (5.8%) developed surgical site sepsis (sepsis) (Table 1). Four hundred and forty-six (60%) women attended antenatal care for the duration of the pregnancy.