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Consequences of a Primary Elective Cesarean Delivery Across the Reproductive Life

Miller, Emily S. MD MPH; Hahn, Katherine MD; Grobman, William A. MD, MBA

doi: 10.1097/AOG.0b013e3182878b43
Original Research

OBJECTIVE: To estimate cumulative risks of morbidity associated with the choice of elective cesarean delivery for a first delivery.

METHODS: A decision analytic model was designed to compare major adverse outcomes across a woman's reproductive life associated with the choice of elective cesarean delivery compared with a trial of labor at a first delivery. Maternal outcomes assessed included maternal transfusion, hysterectomy, thromboembolism, operative injury, and death. Neonatal outcomes assessed included cerebral palsy and permanent brachial plexus palsy in the offspring.

RESULTS: Choosing an initial cesarean delivery resulted in a 0.3% increased risk of a major adverse maternal outcome in the first pregnancy. In each subsequent pregnancy, the difference in composite maternal morbidity increased such that by the fourth pregnancy, the cumulative risk of a major adverse maternal outcome was nearly 10% in the elective primary cesarean delivery group, three times higher than women who initially underwent a trial of labor. Although the choice of an initial cesarean delivery resulted in 2.4 and 0.41 fewer cases of cerebral palsy and brachial plexus palsy, respectively, per 10,000 women in the first pregnancy, by a fourth pregnancy, the risk of a adverse neonatal outcome was higher among offspring of women who had chosen the initial elective cesarean delivery (0.368% compared with 0.363%).

CONCLUSION: Maternal morbidity associated with the choice of primary elective cesarean delivery increases in each subsequent pregnancy and is greater in magnitude than that associated with the choice of a trial of labor. These increased risks are not offset by a substantive reduction in the risk of neonatal morbidity.

Women undergoing primary elective cesarean delivery incur greater morbidity over their reproductive life; the marginal benefit in neonatal outcome is attenuated with additional pregnancies.

Department of Obstetrics and Gynecology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois; and the Department of Internal Medicine, Georgetown University, Washington, DC.

Corresponding author: Emily S. Miller, MD, MPH, 250 E Superior Street, Suite 05-2185, Chicago, IL 60611; e-mail:

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at the Society for Maternal-Fetal Medicine annual meeting, February 11-16, 2013, San Francisco, California.

Society for Maternal-Fetal Medicine Health Policy Committee: Sean Blackwell, Suneet Chauhan, William Grobman, Andrew Helfgott, Dan O’Keeffe, Carolina Reyes, George Saade, Catherine Spong.

The opinions expressed in this article are those of the authors and do not necessarily reflect the policies or views of the Society for Maternal-Fetal Medicine. This publication is neither designed nor intended to establish an exclusive standard of perinatal care.

Dr. Spong, Associate Editor of Obstetrics & Gynecology, was not involved in the review or decision to publish this article.

© 2013 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.