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ORIGINAL RESEARCH |
From the Departments of Obstetrics and Gynecology at the 1University of Utah, Salt Lake City, Utah; 2Ohio State University, Columbus, Ohio; 3University of Alabama at Birmingham, Birmingham Alabama; 4University of Texas Southwestern Medical Center, Dallas, Texas; 7University of Chicago, Chicago, Illinois; 8University of Pittsburgh, Pittsburgh Pennsylvania; 9Wake Forest University School of Medicine, Winston-Salem, North Carolina; 10Columbia University, New York, New York; 11Wayne State University, Detroit, Michigan; 12University of Cincinnati, Cincinnati, Ohio; 13Brown University, Providence, Rhode Island; 14Northwestern University, Chicago, Illinois; 15University of Miami, Miami, Florida; 16University of Tennessee, Memphis, Tennessee; 17University of Texas Health Science Center at San Antonio, San Antonio, Texas; 18University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 19University of Texas Health Science Center at Houston, Houston, Texas; 20Case Western Reserve University, Cleveland, Ohio; and 6The George Washington University Biostatistics Center, Washington, DC, and the 5National Institute of Child Health and Human Development, Bethesda, Maryland.
Address reprint requests to: Address correspondence to: Robert M. Silver, MD, Department of Obstetrics and Gynecology University of Utah School of Medicine, 30 North 1900 East, Room 308, Salt Lake City, UT 84132; e-mail: Bob.Silver{at}hsc.utah.edu.
OBJECTIVE: Although repeat cesarean deliveries often are associated with serious morbidity, they account for only a portion of abdominal deliveries and are overlooked when evaluating morbidity. Our objective was to estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries.
METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999–2002).
RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively.
CONCLUSION: Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.
LEVEL OF EVIDENCE: II-2
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