The global incidence of cesarean delivery has increased markedly in recent decades.  Despite advancements in surgical techniques, cesarean sections (CS) still carry inherent risks, including the need for surgical reintervention.  A return to the operating room during the puerperal period, often due to complications like hemorrhage, infection, or wound issues, is termed relaparotomy. This unplanned reoperation, usually within the same hospital stay, is primarily performed to control bleeding, manage sepsis, or repair surgical injuries.

Relaparotomy following CS is uncommon but critical, as it is associated with high maternal morbidity and mortality. The reported incidence ranges from 0.5% to 2.8%, with mortality reaching up to 71% in severe cases.  Factors such as emergency cesarean deliveries, sepsis, coagulopathies, and inadequate postoperative monitoring contribute to the risk. Common indications include intraperitoneal hemorrhage, rectus sheath hematoma, burst abdomen, uterine rupture, and persistent postpartum hemorrhage. Infections and wound complications also lead to surgical reintervention.

Postpartum complications often stem from uterine atony, retained placental fragments, or trauma during delivery. Uterine atony remains the leading cause of early postpartum hemorrhage. Risk factors for these complications include overdistension of the uterus, rapid labor, or prior cesarean deliveries. Active management during the third stage of labor and timely intervention can mitigate these risks.

With rising cesarean rates, particularly in high-volume centers, relaparotomy is becoming a more pressing concern. Understanding the underlying causes, identifying risk factors, and implementing preventive strategies are essential in reducing the incidence and improving outcomes. The implications of relaparotomy are significant, from prolonging hospital stay and delaying recovery to increasing maternal morbidity, separating mother from newborn, and in some cases, leading to maternal death.

This study is a prospective and descriptive evaluation of patients returning to the operation theatre after cesarean delivery during the puerperal period at North Bengal Medical College and Hospital.

This prospective and descriptive study was conducted over a period of 12 months, from November 2022 to October 2023, in the Department of Obstetrics and Gynaecology at North Bengal Medical College and Hospital. The aim of the study was to analyze cases of reoperation within six weeks following a primary cesarean section, particularly those resulting from complications such as intra-abdominal hemorrhage, postpartum hemorrhage (PPH), rectus sheath hematoma, and sepsis. Ethical clearance was obtained from the Institutional Ethics Committee, and informed written consent was secured from all participating patients prior to inclusion in the study.

The study population consisted of patients who underwent relaparotomy within six weeks of a primary cesarean delivery. Inclusion criteria were patients experiencing complications directly related to the primary cesarean section—such as intra-abdominal hemorrhage, PPH, rectus sheath hematoma, or sepsis—who also provided consent for participation. Patients were excluded if the relaparotomy was performed after a gynecological surgery (e.g., abdominal or vaginal hysterectomy, laparoscopic hysterectomy, or staging laparotomy for ovarian tumors), if the second surgery was unrelated to the primary cesarean section, or if the patient declined participation.

Each case was documented with detailed demographic and obstetric variables, including age, parity, body mass index (BMI), gestational age at delivery, antenatal booking status, indication for primary cesarean section, whether the procedure was elective or emergency, and the presence of any comorbid conditions. Specific information was also collected regarding the relaparotomy, including the indication for reoperation, time interval between the two surgeries, intraoperative findings, surgical procedures performed, and patient outcomes.

All relevant clinical parameters were noted, including vital signs such as systolic and diastolic blood pressure, heart rate, and respiratory rate. In addition, obstetric and surgical history was thoroughly reviewed, with emphasis on complications observed during or after the primary cesarean section. A standardized format was used to collect the data, ensuring consistency in documentation across all cases.

Data were analyzed using appropriate statistical tools. Categorical variables were expressed as numbers and percentages, while continuous variables were reported as mean values with standard deviations. Statistical significance was tested using the Chi-square test for categorical data and the U-test for nonparametric data, with a p-value of less than 0.05 considered statistically significant. Statistical analysis was carried out using the SPSS software (Version 21.0, SPSS Inc., Chicago, USA).

During the study period, a total of 25 patients who underwent relaparotomy within six weeks following a primary cesarean section were included in the analysis. The age of the study participants ranged from 18 to over 35 years, with a mean age of 28.80 ± 4.92 years. The majority of patients (68%) were between 18 and 30 years of age, with the highest representation (40%) in the 26–30-year age group, followed by 28% in the 18–25-year age group.

Regarding obstetric history, 56% of the patients were multigravida, while 44% were primigravida. In terms of nutritional status, assessed using body mass index (BMI), most patients (76%) had a normal BMI ranging from 18.5 to 24.9 kg/m², with a mean BMI of 24.40 ± 2.14 kg/m². Twenty percent of patients were overweight (BMI 25–29.9), while only one patient (4%) had obesity (BMI ≥ 30). None of the patients were underweight.

Gestational age at the time of cesarean delivery showed that 56% of cases were preterm deliveries (<37 weeks), while 44% were term deliveries (37–42 weeks). The mean gestational age was 36.52 ± 2.93 weeks, indicating a significant proportion of high-risk or complicated pregnancies.

Out of the 25 cesarean deliveries, 64% were emergency procedures and 36% were elective. The most common indication for primary cesarean section was obstructed labor, accounting for 40% of cases. This was followed by non-progression of labor and previous cesarean section, each contributing to 20% of cases. Other indications included breech presentation, IVF conception, severe preeclampsia, cephalopelvic disproportion, and rupture uterus following a trial of vaginal birth after cesarean (VBAC), each accounting for 4% of cases.

Associated comorbidities were identified in several patients. Hypertensive disorders were present in 40% of cases, while 36% had evidence of sepsis. Liver disorders were seen in 16% of patients, and 8% had anemia. These comorbidities likely contributed to the complexity of postoperative recovery and increased the risk for relaparotomy.

The most frequent indication for relaparotomy was intraperitoneal hemorrhage, seen in 40% of cases. Other causes included rectus sheath hematoma (16%), burst abdomen (8%), atonic postpartum hemorrhage (8%), abdominal distension (8%), rupture uterus (8%), morbid adherent placenta (4%), secondary PPH (4%), and broad ligament hematoma (4%).

Regarding surgical interventions, hysterectomy and evacuation of hemoperitoneum with hemostasis were the most commonly performed procedures during relaparotomy, each accounting for 28% of the cases. Drainage of blood clots from the rectus sheath and peritoneal cavity was performed in 16% of patients, while repair of the anterior abdominal wall was done in 12%. Other procedures included drainage of pus or ascitic fluid (8%), repair of the uterus (4%), and drainage of a broad ligament hematoma (4%).

Internal iliac artery ligation was performed in five patients—two undergoing hysterectomy, two undergoing evacuation of hemoperitoneum, and one with a broad ligament hematoma. Among the 25 patients, seven (28%) succumbed to complications despite surgical intervention. The primary causes of mortality included septic shock (42.85%), multi-organ failure (28.57%), and ongoing bleeding with disseminated intravascular coagulation (28.57%).

Tables and figures

Table 1. Sociodemographic and clinical characteristics of the patients (n=25)

Table 2. Indication of caesarean section for the patients (n=25)

Table 3. Indication of re-laparotomy for the patients (n=25)

Table 4. Procedure for re-laparotomy for the patients (n=25)

Cesarean delivery (CD) is one of the most commonly performed surgical procedures in obstetrics, with rates increasing worldwide. Despite being generally safe, it carries risks of significant maternal morbidity, including complications that may necessitate relaparotomy.  Relaparotomy, though uncommon, is a serious event often indicative of severe complications like hemorrhage, sepsis, or wound dehiscence.  The need for a return to the operating room represents a critical challenge for both clinicians and patients, often associated with poor maternal outcomes.

In this prospective study conducted at North Bengal Medical College and Hospital, 25 cases of relaparotomy were examined following primary cesarean deliveries. The most affected age group was 26–30 years, with a mean age of 28.80 years, aligning with reproductive trends seen in other Indian studies. ,   Most patients were multigravida, had normal BMI, and over half of the deliveries were preterm—factors that may increase surgical complexity and complications.

The majority (64%) of primary cesarean sections were performed as emergency procedures. This is a significant finding, as emergency cesareans have been consistently linked with higher complication rates compared to elective procedures. Obstructed labor was the most common indication for cesarean, followed by non-progression of labor and previous cesarean section. These findings mirror observations by Seal et al., who noted a high rate of complications in second-stage cesareans, particularly when performed by less experienced surgeons.

Comorbidities such as hypertensive disorders (40%) and sepsis (36%) were frequently observed in this study, suggesting a strong link between underlying maternal health and surgical outcomes. These conditions may predispose patients to increased intraoperative and postoperative complications, necessitating vigilant monitoring. Intraperitoneal hemorrhage was the leading cause for relaparotomy, accounting for 40% of cases, followed by rectus sheath hematoma and burst abdomen. This trend is consistent with studies by Kessous et al. and Ahmed et al., which identified hemorrhagic complications as the predominant indication for re-exploration. ,   Hemorrhage not only increases the risk of mortality but may also necessitate extensive surgical interventions like hysterectomy or internal iliac artery ligation, as seen in this study.

Procedures most commonly performed during relaparotomy included hysterectomy and evacuation of hemoperitoneum, each in 28% of cases. These interventions highlight the severity of conditions leading to reoperation. Despite surgical efforts, the mortality rate in this study was 28%, with deaths primarily due to septic shock, multi-organ failure, and disseminated intravascular coagulation (DIC).

Relaparotomy following cesarean delivery is a rare but serious complication associated with significant maternal morbidity and mortality. In this study, the most common indications for reoperation were intraperitoneal hemorrhage, rectus sheath hematoma, and wound-related complications, often occurring in the context of emergency cesarean sections and pre-existing maternal comorbidities such as hypertension and sepsis. Surgical interventions ranged from hysterectomy to drainage procedures, reflecting the severity of these complications. A mortality rate of 28% highlights the critical need for early diagnosis, prompt surgical management, and intensive postoperative care.

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