International Journal of Medicine and

Pharmaceutical Sciences (IJMPS)

ISSN(P): 2250-0049; ISSN(E): 2321-0095
Vol. 4, Issue 6, De c 2014, 69-76
TJPRC Pvt. Ltd.

ASSESSMENT OF BLOOD TRANSFUSION PRACTICES AT CAESAREAN

SECTION IN A TEACHING HOSPITAL IN SOUTH-WESTERN NIGERIA
KOLA M OWONIKOKO, ADEOLU ADEOYE, ADEWALE S ADEYEMI & ADET UNJ I OADENIJ I
Depart ment of Obstetrics and Gynaecology, Ladoke Akintola University of Technology Teaching Hospital,
Ogbomoso, Oyo, Nigeria

ABSTRACT
Objecti ves: To determine the need for and factors influencing blood transfusion at caesarean section(CS) and
effect on delay in carrying out CS at LAUTECH Teaching Hospital, Ogbo moso, Nigeria
Method: The records of all cases of Caesarean delivery at LAUTECH Teaching Hospital, Ogbo moso between
January 1st 2011 and 31st December 2013 were retrieved. Data were entered and subjected to simp le descriptive statistical
analysis using the Statistical Package for Social Sciences (SPSS) version 16.
Results: The caesarean section rate was 25.3%. Unbooked patient were 53(20.3%) and 68% of CS were done as
emergency. A total of 261units of blood were grouped and cross -matched with only 57units (21.8%) of blood transfused to
27 patients. Indications for blood transfusion were antepartum haemorrhage (68.4%), obstructed labour with anaemia
(31.6%). Direct delay in decision-delivery time of 1-2hours occurred in 7.7% of patients and greater than 2hours in 92.3%
of cases due to waiting for b lood availability.
Conclusion: Majority of patients for CS do not require blood transfusion. Therefore, the compulsory grouping
and cross-matching of b lood should be made less stringent. Provision of mini -blood bank at the labour ward will ensure
timely availab ility of b lood for surgery and prevent undue burden on the central blood bank system.

KEYWORDS: Blood Transfusion, Caesarean Section, SPSS

INTRODUCTION
Haemorrhage fro m obstetric causes is the most common cause of maternal mo rtality in the developing world 1 .
Prevention of mortality fro m haemorrhage will require immediate blood transfusions among other life saving measures.
However, there are few functioning blood bank in health care facilities in sub -Saharan Africa. Caesarean section (CS) has
been recognised as a common indication for blood transfusion in obstetrics practice and its performance is often delayed by
non-availability of b lood in many centres 1,2 .
The advent of blood transfusion services drastically reduced the mortality associated with blood loss during
caesarean delivery. However, with the significant advances in the technique and practices of surgery, there is a need to
critically examine the blood transfusion practices during and after caesarean section in respe ct of the need and indications
for blood transfusion during or after caesarean delivery.
A review of blood transfusion at Lagos State University Teaching Hospital (LASUTH), Ikeja, Nigeria showed
that total of 654 units of blood were grouped and cross -matched for 327 CS. Out of this number, only 89 (13.6%) units
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Kola M Owonikoko, Adeolu Adeoye , Ade wale S Adeyemi & Adetunji Oadeniji

were transfused to 41 patients. The most common indication for transfusion were bleeding fro m placenta praevia
(9 patients with 21 units of blood) and cephalo-pelvic disproportion (8 patients with 13 units)3 . Similarly, at the University
of Nigeria Teaching Hospital Nsukka, the transfusion rate was 25.2% [4]. The indications were placenta praevia 59.1%,
severe pre-eclampsia 11.1%, previous caesarean section 17%, and obstructed labour 28% 4, 5 .
A prospective observational multi-centre study done in 19 Teaching Hospitals across United States of America
reported a transfusion rate of 3.2% among 23,486 wo men who had primary caesarean section and 2.2% among the 33,683
wo men who had repeat CS. The common indicat ions for the blood transfusion were placenta praevia and severe anaemia 6 .
A review o f blood transfusion during CS in West Mead Hospital Australia showed that only 14(0.63%) of 2212
patients who had CS required blood transfusion, major indication been placenta praevia. They concluded that in a tertiary
centre and in the absence of significant risk factors for haemorrhage, routine grouping and cross -matching of blood for CS
does not enhance patient care and that O Rhesus negative blood may be given in instances of unforeseen haemorrhage 7 .
In a cross-sectional study conducted in Lady Willingdon Hospital Lahore, 75% of patients requiring b lood
transfusion during caesarean section were un-booked. Distribution of cases by indication of blood transfusion in caesarean
section showed placenta praevia in 90 patients (56.0%), pre-eclampsia in 12 patients (7.5%), previous caesarean section in
24 patients (15.0%) and obstructed labour in 34 patients (21.0%) 8 .
In India, of the 1769 wo men who underwent CS, the blood transfusion rate of 12.21% was obtained9 . The risk of
blood transfusion was found to be higher in women with pre-operative anaemia, un-booked status, placenta praevia and
abruption placenta. The conclusion was that routine grouping and cross-matching of blood in all cases of caesarean section
is not justified but is acceptable in high risk cases 10,11 .
In general, it is mandatory to have blood kept in the blood bank for CS in certain obstetric conditions such as
antepartum haemorrhage and an anaemic pregnant woman going for CS but not in cases when the indication for caesarean
delivery is for fetal distress, mal-presentation or maternal request. Surgery need not be delayed on account of
non- availability of blood in such cases12 .
The aims of this study is to determine the need for and factors influencing blood transfusion in CS and the effect
of delay in carrying out CS due to waiting for blood to be cross -matched at LAUTECH Teaching Hospital, Ogbomoso,
Nigeria.

MATERIALS AND METHODS

This was a retrospective descriptive study of women who had CS at LA UTECH Teaching Hospital (LTH),
Ogbomoso between January 1st 2011 and 31st December 2013. The approval for the study was obtained from the Hospital
Research and Ethics Co mmittee. The records of all cases of Caesarean delivery carried out during the study period were
retrieved. Information extracted fro m the records included demographic parameters of the patients, past obstetrics history,
booking status, indication for caes arean section, interval between decision and delivery time, neonatal outcome, special
care baby units admission and blood transfusion parameters. The operating theatre records as well as data relating to the
number of deliveries during this study period were obtained and reviewed. Booked cases were those patients that registered
and accessed antenatal care in the Depart ment of Obstetrics and Gynaecology, LTH, while unbooked cases were those
patients referred in labour, to LTH, Ogbo moso fro m other health facilit ies for various obstetrics indications, requiring

Impact Factor (JCC): 5.1064

Index Copernicus Value (ICV): 3.0

Assessment of Blood Transfusion Practices at Caesarean Section

in a Te aching Hospital in South-Western Nigeria

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caesarean deliveries, irrespective of their booking status at the source of referral. The Caesarean Sections were performed
via the trans-peritoneal approach and a curvilinear incision on the lower ute rine segment under spinal or general
anaesthesia by experienced Obstetricians (Senior Reg istrars and Consultants). The placentae were delivered by cord
traction and in a difficult situation by manual extraction. Data were entered and analysed using SPSS 16.0 Windows
Evaluation version, Ch icago, USA. Descriptive statistics (minimu m, maximu m, mean and standard deviation) were
calculated for continuous variables. Multivariate analysis was done to explore relationship between various indications for
CS and blood transfusion. A p-valueless than 0.05wasconsidered to bestatisticallysignificant and confidence level was set
at 95%.

RESULTS
A total of 1,104 deliveries were recorded during the period of the study out of which 279 had CS. The caesarean
section rate was 25.3%. Ho wever, only 261 case notes (93.6% retrieval rate) found with complete informat ion required,
were eventually included in the study. Unbooked patient were 53(20.3%) and 68% of the CS were done as emergency with
232 (88.9%) of CS being primary. A total of 261units of blood were grouped and cross -matched, but only 57 were
transfused. This gave cross -matched: transfusion ratio of 4.6:1. Of the patients transfused, 21(10.1%) were booked
patients. [Table 1].
Table 2 showed the indications for sections, number of patients transfused and units of blood transfused for each
case. Commonest indication was obstructed labour (71/ 261, 27.2%), fo llo wed by fetal distress in 18.4% and 11.2% was
due to previous caesarean section. Major cause of blood transfusion was p lacenta praevia where 30 units of blood were
transfused (6 patients had 2 units each and another 6 patients, each had a total of 3 units of blood transfused) and
obstructed labour with anaemia with total of 18 units (6 patients had 1unit each and another 6 patients with 2 units) of
blood transfused. Other cases with blood transfusion were abruption placentae. [p< 0.001].
Table 3 was a cross-tabulation of demographic and obstetric factors, pre-operative and post-operative packed cell
volume (PCV), Estimated Blood Loss and duration of decisiondelivery intervals, between transfused and non-transfused
groups. There was a statistical significance in the parity (1.580.5versus1.440.51; P<0.042; C.I =-0.130, -0.385), amount
of estimated blood loss (520.4393.65 versus 877.78160.73; P <0.001; C.I= -398.32,-316.37) and decision delivery
time (0.800.57versus1.800.51; P<0.03; C.I=-0.430, -1.130) in both groups. There was no statistical difference between
the mean age of the 2 groups (30.53.14 versus 30.44.16, P =0.22; C.I =-0.164, -0.711), likewise no significant
differences were noted with pre and post-operation PCV in both groups.
Table 4 showed the frequency of units of blood transfused and indication of CS. It showed that 6 patients had
1unit each, 12 patients had 2 units each and 9 patients had 3units of blood each. It was also found out that 208 (81.6%) of
the patients incurred addition cost of N3500 ($24.0) to overall cost of CS in other to get blood cross -matched for them
while other 53(18.4%) had between N7, 000 N10, 000($48.0 - $66.7) additional cost to get blood ready for their surgery.
In term of neonatal outcome, greater nu mber 18(6.9%) of neonates of the transfused group and 8(3.1%) of
non-transfused group had low Apgar score at 5 minutes of live with moderate - severe birth asphyxia and subsequent
admission into Baby Special Care Unit.

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Kola M Owonikoko, Adeolu Adeoye , Ade wale S Adeyemi & Adetunji Oadeniji

DISCUSSIONS
Worldwide, the trend now is an increasing CS delivery and decrease use of homologous blood transfusion.
An improvement in obstetrics surgical practice as well as unwillingness of the patient to receive blood transfusion partly
account for this 14 .
Also the readiness of the Obstetrician and Anaesthetist to accept taking patient with low haematocrit level,
patients refusing blood transfusion for fear of acquiring blood borne infections, practice of restrictive blood transfusion in
most health facilities, relat ively young age and healthy condition of obstetric patients were other reasons for low blood
transfusion in obstetrics.
In this study, the caesarean section rate was 23.5% which is higher than the recommended figure of WHO
(5-15%) in any facility 15 but can be explained by the fact that this is a referral centre where a lot of cases were already
complicated at presentation and most indications were justifiable. However, this figure was lower than rates found in
another tertiary institution in this environment by Akinola et al in LASUTH where the caesarean section rate was 40% [3]
reasons likely be because this centre services a higher population than ours. The caesarean section rate in India of 26% [8]
and in U.S.A of 25.2% [6] is in tandem with our finding.
The transfusion rate among parturients that had CS was 10.3%, this is in -line with recommendation transfusion
rate in literature of 1-14%16 and this compares favourably with rates found in other studies, Akinola et al 12.5%, Bilal et al
12.1%3,8 . However, this is higher than what Chua et al found of transfusion rate of 0.63% in Australia 7 , Aubrey Bassler et
al found a transfusion rate of 5.4% in the United States of America 6 . But a lo wer rate than Imarengiaye et al found of
25.2% in Nsukka Nigeria 4 .
Age and parity of the patients who receives blood transfusion and those who did not does not show any statistic al
differences however, our find ings revealed that booked patients had 4folds of receiv ing blood transfusion than unbooked
patients. This is contrary to the findings of Imarengaiye et al4 who reported six folds increase risk of blood transfusion
among the unbooked patients. Reason for this may due to the fact that the indications for most of this patient are prone to
massive blood loss. It was also found out that emergency CS increases risk of b lood transfusion as close to two -third of
patients that had blood transfusion had emergency CS. This finding is in agreement with other previous studies 4,17 .
In view of either primary or repeat CS, 11.6% of patients with primary CS had blood transfusion while none with
repeat CS receive blood transfusion. This is probably due to potential bleeding nature of these cases, for examp le
antepartum haemorrhage, prolonged obstructed labour with uterine atony after delivery. This finding is consistent with
LASUTH report but in contrary view with Imarengiaye et al who found hig h risk of blood transfusion among women with
repeat CS3,4 .
Concerning, the indications for CS and blood transfusion, similar reasons were imp licated antepartum
haemorrhage and pre- operative anaemia in previous studies3-5,7,8 , The highest transfusion was s een in case of placenta
praevia where 12pateints received 30units of blood. This amount to almost 70% of patients with placenta praevia received
blood transfusion. A similar revelation was made by other researchers 3-7 . Other indications for CS and risks for b lood
transfusion were Abruptio placentae where 3patients received 3units of blood each and obstructed labour in which
12patients received 18units of blood. This finding is in agreement with previous workers on this issue3-7 .

Impact Factor (JCC): 5.1064

Index Copernicus Value (ICV): 3.0

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The correlation between estimated blood loss and risk of blood transfusion was found to be significant in this
study. The mean EBL among transfused group is 877.78160.73mls compared with 520.4393.65mls among the
non-transfuse patient (P<0.001). Th is strong association was also found by previous studies 3,4 . In term o f pre-operative
PCV and the risk for blood transfusion, no statistical association was found, unlikely what was obtained by Akinola et al 3 ,
reason for this difference lies in the fact that mean pre-op pcv in the 2groups was closed to the acceptable PCV o f 30%
before surgery (29.811.18 and 32.061.40 for transfused and non -transfused group respectively).
In term of units of blood transfused, 6patients with obstructed labour received 1unit of blood each i.e.10.5%of
patient that had blood transfusion. This is slightly lower than 17% and 13.3% reported by Akinola and Imaremg iaye
respectively 3,4 but significantly lo wer than 43.1% of 1units of blood transfused by Ozumba et al 5 . The query here is that of
justification of transfusion of 1unit of blood. Suggestions now is that decision to transfuse with specific unit(s) of blood
should not be solely determine by haemoglobin concentration but consideration of the other factors like patient stability,
oxygen saturation among other factors 13,18 .
Despite the mandatory grouping and cross -matched blood for patients undergo CS the vast majority of them did
not require blood transfusion; this study revealed 78.2% requires no blood transfusion and similar findings were obta ined
in Lagos State University Teaching Hospital 86.4% 3 , University of Nigeria Teaching Hospital 74.8% 4 , Australia 99.37% 7 ,
and India 87.79%8 . Only 57 of 261units of blood cross -matched were used which give a cross -match transfusion ratio of
4.6:1. The cross-match transfusion ratio is an index for evaluating the efficiency of blood bank ordering practice 17 .
The cost of cross-match a unit of blood in our hospital is N3500 (US$24.0) and this give a total of N714, 000 (US$4, 760)
for unused cross-matched blood. This huge amount of resources is wasteful if blood is not return early before denaturation
into blood bank. Again, this unused blood cause a burdensome for the blood bank personal to keep the blood in optimal
condition for use in an environmental of epileptic supply of electricity. This finding and problem of blood storage has been
highlighted by other authors 3,4 . Practice now tends toward defining criteria for cross -matching blood for patients with high
risk for b leeding such as ante-partum haemo rrhage, pre-operative anaemia and so on.
It is of great interest to note that due to compulsory availability of blood before commencement of CS there was a
direct delay in decision-delivery time of 1-2 hours in 7.7% of cases, greater than 2hours in 92.3% of cases. Delayed in
most cases was due to financial constraint on the part of the patient and her relatives. Unfortunately, this leads to increas e
in maternal and fetal morbid ity, though no fetal mortality occur. Quite number of babies16 (6.2%) suffered moderate to
severe asphyxia with low Apgar score at 5minute of life wh ich required ad mission into neonatal intensive care unit which
further put addition constraints on already overstretched pockets and social separation between the mother and the ne w
baby. Fro m this study, it can be observed that blood transfusion is rarely done during most CS. This finding was in line
with prev ious reviews in Nigeria and abroad 3-7 . Almost all cases where blood transfusion was done were due to identifiab le
risk factors like antepartum haemorrhage fro m p lacenta praevia or abruption placenta and pre -operative anaemia. Routine
grouping and cross-matching of blood for all patients going for Caesarean section has been found to contribute to huge
waste of scare resources and delay in decision-delivery time with attendant complications. It also, adds an undue economic
burden to the already overstretched pockets of our patients. We therefore, reco mmend that there should be less stringent
measures on compulsory grouping and cross-matching of blood for patients going for caesarean section except in
antepartum haemorrhage and anaemia in pregnancy. There should be separate blood bank for obstetric use in preparation
for the occasional need for massive blood transfusion.

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Kola M Owonikoko, Adeolu Adeoye , Ade wale S Adeyemi & Adetunji Oadeniji

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Assessment of Blood Transfusion Practices at Caesarean Section

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APPENDICES
Table 1: Patients Booking Status, Type of CS and Blood Us age

Table 2: Indicati ons for CS, Number of Patients and Units of Blood Transfused

Table 3: Comparison between Characters of Patients Transfused and Non-Transfused CS

Table 4: Indicati on for Transfusion and Frequency Blood Usage

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