Risk of Maternal Morbidity with Increasing Number of Cesareans

Abstract

Objective To estimate the risk of perioperative morbidity with increasing number of cesareans.

Study Design We conducted a retrospective cohort study from 2004 to 2010. Patients delivered by cesarean were included. Outcome measures were a composite organ injury (bowel or bladder), hysterectomy, hemorrhage requiring transfusion, severe morbidity, or surgical site complications. The Cochran–Armitage's test of trend was used to assess increasing incidence of each morbidity with number of prior cesareans. Multivariable logistic regression was used to estimate adjusted risks for each morbidity with increasing number of cesareans compared with primary cesarean.

Results Of the 15,872 women in the cohort, 5,144 had cesarean delivery: 3,113 primary, 1,310 one prior, 510 two prior, and 211 three or more prior cesareans. There was a significant increase in organ injury, hysterectomy, and surgical site complications with increasing number of cesareans. In multivariable analysis, the risk of organ injury and hysterectomy was increased compared with primary cesarean after two prior cesareans, and after three or more cesareans for hemorrhage requiring transfusion and surgical site complications.

Conclusion The risks of organ injury and hysterectomy are increased after two or more prior cesareans, and risks of hemorrhage and surgical site complications are increased after three or more cesareans.

Keywords

maternal morbidity - cesarean - complications - repeat cesarean

Note

This study was presented as a poster presentation at the 37th Annual Meeting of the Society for Maternal-Fetal Medicine, January 23–28, 2017, Las Vegas, NV.

Ethical Approval

This study was conducted with the approval of the Institutional Review Board: IRB Approval no. 201404055.

• References

• 1 Martin JA, Hamilton BE, Osterman MJ, Driscoll AK, Mathews TJ. Births: final data for 2015. Natl Vital Stat Rep 2017; 66 (01) 1
• 2 Menacker F, Declercq E, Macdorman MF. Cesarean delivery: background, trends, and epidemiology. Semin Perinatol 2006; 30 (05) 235-241
• 3 Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: final data for 2016. Natl Vital Stat Rep 2018; 67 (01) 1-55
• 4 Caughey AB, Cahill AG, Guise JM, Rouse DJ. ; American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014; 210 (03) 179-193
• 5 Silver RM, Landon MB, Rouse DJ. , et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107 (06) 1226-1232
• 6 Özcan S, Karayalçın R, Kanat Pektas M. , et al. Multiple repeat cesarean delivery is associated with increased maternal morbidity irrespective of placenta accreata. Eur Rev Med Pharmacol Sci 2015; 19 (11) 1959-1963
• 7 Smid MC, Vladutiu CJ, Dotters-Katz SK, Boggess KA, Manuck TA, Stamilio DM. Maternal obesity and major intraoperative complications during cesarean delivery. Am J Obstet Gynecol 2017; 216 (06) 614.e1-614.e7
• 8 Obstetric Care Consensus No. 2: levels of maternal care. Obstet Gynecol 2015; 125 (02) 502-515
• 9 Lynch CM, Kearney R, Turner MJ. Maternal morbidity after elective repeat caesarean section after two or more previous procedures. Eur J Obstet Gynecol Reprod Biol 2003; 106 (01) 10-13
• 10 McMahon MJ, Luther ER, Bowes Jr WA, Olshan AF. Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 1996; 335 (10) 689-695
• 11 Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014; 311 (08) 806-814
• 12 Arlier S, Seyfettinoğlu S, Yilmaz E. , et al. Incidence of adhesions and maternal and neonatal morbidity after repeat cesarean section. Arch Gynecol Obstet 2017; 295 (02) 303-311
• 13 Clark EA, Silver RM. Long-term maternal morbidity associated with repeat cesarean delivery. Am J Obstet Gynecol 2011; 205 (06, Suppl): S2-S10
• 14 Morales KJ, Gordon MC, Bates GW. Jr. Postcesarean delivery adhesions associated with delayed delivery of infant. Am J Obstet Gynecol 2007; 196 (05) 461-466