ABSTRACT
OBJECTIVE: This study aimed to evaluate if a secondary repeat cesarean after a trial of labor (TOLAC) without uterine rupture is associated with increased morbidity as compared with a scheduled elective repeat cesarean delivery (ERCD). STUDY DESIGN: This was a retrospective cohort study of repeat cesarean delivery (CD) in a single obstetrical practice between 2005 and 2022. Patients were included if they had a singleton pregnancy at term with one prior CD and had a repeat CD this pregnancy resulting in live birth. Patients were excluded if they had a prior myomectomy, more than one prior CD, uterine rupture in a prior or current pregnancy, or placenta previa in this pregnancy. We compared baseline characteristics and outcomes between patients who had a repeat cesarean after TOLAC and ERCD. The primary outcome was a composite of maternal morbidity that included hysterectomy, blood transfusion, cystotomy, bowel injury, intensive care unit admission, thrombosis, reoperation, or maternal mortality. RESULTS: A total of 930 women met inclusion criteria. A total of 176 (18.9%) patients intended to labor and 754 (81.1%) planned an ERCD. There was no difference in the primary outcome between patients with a repeat cesarean after TOLAC compared with patients with ERCD (2.8 vs. 1.2%, p = 0.158). Patients with repeat cesarean after labor had significantly more 1-minute Apgar scores less than 7, but no difference in 5-minute Apgar scores. We were powered to detect a difference in the primary outcome from 1.2% in the ERCD group to 3.3% in the repeat cesarean after labor group. Results did not differ when we analyzed patients who intended to TOLAC versus patients who actually labored prior CD. CONCLUSION: For women with one prior CD the morbidity of repeat cesarean after labor is not more than the morbidity of planned repeat CD. Our study can be helpful in delivery planning counseling for patients with one prior CD. KEY POINTS: · Uterine rupture is a known risk of TOLAC.. · This study aimed to understand morbidity associated with labor.. · No added morbidity of repeat cesarean after labor is inferred in this study..
ABSTRACT
OBJECTIVE: This study aimed to estimate the association between adverse maternal outcomes and the number of repeated cesarean deliveries (CDs) in a single obstetrical practice. STUDY DESIGN: Retrospective cohort study of all CDs between 2005 and 2020 in a single maternal fetal medicine practice. We used electronic records to get baseline characteristics and pregnancy/surgical outcomes based on the number of prior CDs. We performed two subgroup analyses for women with and without placenta previa. Chi-square for trend and one-way analysis of variance (ANOVA) were used. RESULTS: A total of 3,582 women underwent CD and met inclusion criteria. Of these women, 1,852 (51.7%) underwent their first cesarean, 950 (26.5%) their second, 382 (10.7%) their third, 191 (5.3%) their fourth, 117 (3.3%) their fifth, and 84 (2.3%) their sixth or higher CDs. The incidence of adverse outcomes (placenta accreta, uterine window, uterine rupture, hysterectomy, blood transfusion, cystotomy, bowel injury, need for a ventilator postpartum, intensive care unit admission, wound complications, thrombosis, reoperation, and maternal death) increased with additional CDs. However, the absolute rates remained low. In women without a placenta previa, the likelihood of adverse outcome did not differ across groups. In women with a placenta previa, adverse outcomes increased with increasing CDs. However, the incidence of placenta previa did not increase with increasing CDs (<5% in each group). The incidence of a uterine dehiscence increased significantly with additional CDs: first, 0.2%; second, 2.0%; third, 6.6%; fourth, 10.3%; fifth, 5.8%; and sixth or higher, 10.4% (p < 0.001). CONCLUSION: Maternal morbidity increases with CDs, but the absolute risks remain low. For women without placenta previa, increasing CDs is not associated with maternal morbidity. For women with placenta previa, risks are highest, but the incidence of placenta previa does not increase with successive CDs. The likelihood of uterine dehiscence increases significantly with increasing CDs which should be considered when deciding about timing of delivery in this population. KEY POINTS: · Maternal morbidity increase with each CD.. · Absolute adverse outcomes remains low in highest order CDs.. · In women without placenta previa, there is no added morbidity with additional CDs..