Risk for maternal and neonatal complications in a subsequent pregnancy after planned cesarean delivery in a first birth, compared with emergency cesarean delivery: a nationwide comparative cohort study

Editorial comment. For article see: BJOG, 2014;121(2):216–223Planned cesarean delivery (pCD) is performed to avoid risks for neonatal complications or to honor a parturient’s request. The risks for a pCD compared with an emergency CD (eCD) in a consecutive pregnancy are still unknown. This prospective cohort study was undertaken to compare second-birth outcomes among women who had a pCD or eCD at the first birth. Data on births during 2000 to 2007 were extracted from the Dutch Perinatal Registry. Second-birth outcomes were determined for women who had a pCD or eCD at the first birth. Neonatal complications included neonatal mortality, stillbirth, preterm birth, low Apgar score, and birth trauma. Maternal complications were mortality, uterine rupture, placental abruption, postpartum hemorrhage (PPH), and blood transfusion. Crude odds ratios (ORs) and adjusted ORs (aORs) were calculated using univariate and multivariate logistic regression in SAS 9.2, with corrections for gestational age at delivery, macrosomia, spontaneous start of labor, delivery mode, maternal age, ethnicity, hypertensive disorders, and socioeconomic status. A total of 11,445 and 29,665 women had a pCD and eCD, respectively. The median maternal ages in the pCD and eCD groups were 30 years (interquartile range [IQR], 27–31 years) and 29 years (IQR, 27–32 years), respectively (P < 0.0001). Gestational ages at delivery were 38 weeks (IQR, 37–39 weeks) and 40 weeks (IQR, 39–41 weeks), respectively (P < 0.0001). In the pCD parturients, surgery was performed for breech presentation in 75%, transverse position in 3%, and unspecified reasons in 22%. Uterine rupture complicated 1.8 of 1000 deliveries at second births. In the pCD group, 83% of the women having a trial of labor (TOL) had a successful vaginal birth as compared with 66% of the parturients in the eCD group (OR, 2.5; 95% confidence interval [CI], 2.3–2.6; P < 0.001). In the pCD group, 26 (0.3%) of 8593 women undergoing TOL had uterine rupture compared with 43 (0.2%) of 29,664 women who had a prior eCD (OR, 1.6; 95% CI, 1.0–2.5; P = 0.06). Stillbirth occurred in 4.8 of 1000 and 3.2 of 1000 deliveries in the pCD and eCD groups, respectively (aOR, 1.5; 95% CI, 1.0–2.1; P = 0.03). Prematurity occurred in 4.3% and 3.8% of deliveries in the pCD and eCD groups, respectively (OR, 1.1; 95% CI, 1.0–1.3; P = 0.03). Low Apgar score, neonatal mortality, and the composite of adverse neonatal outcomes did not differ between the groups. Postpartum hemorrhage occurred in 5.8% and 5.0% of deliveries in the pCD and eCD groups, respectively. In the second pregnancy, PPH occurred more often after a TOL compared with pCD. After correction for mode of delivery, a significantly increased risk remained for the women with a previous pCD (aOR, 1.1; 95% CI, 1.0–1.2; P = 0.02). The number of blood transfusions did not differ between the groups, and no parturient died. The composite adverse maternal outcomes in the pCD and eCD groups were 6.0% and 5.2%, respectively (aOR, 1.1; 95% CI, 1.0–1.3; P = 0.006). The results showed a moderately increased risk for PPH and a small or moderately increased risk for uterine rupture and stillbirth as effects of prior pCD delivery on second births. Because of maternal and fetal risks, these considerations should be thoroughly discussed when counseling women who request a pCD. Having TOL before CD seems to lower the risk for adverse maternal outcomes in a consecutive pregnancy. Women should be encouraged to have a vaginal delivery or at least a TOL with contractions in their first pregnancy.N. Kok, L. Ruiter, M. Hof, A. Ravelli, B. W. Mol, E. Pajkrt, and B. Kazemie