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Risks of Adverse Outcomes in the Next Birth After a First Cesarean Delivery

Kennare, Robyn Grad Dip PH; Tucker, Graeme BSc; Heard, Adrian MPH; Chan, Annabelle FAFPHM

doi: 10.1097/01.AOG.0000250469.23047.73
Original Research

OBJECTIVE: To estimate the risks of cesarean first birth, compared with vaginal first birth, for adverse obstetric and perinatal outcomes in the second birth.

METHODS: Population-based retrospective cohort study of all singleton, second births in the South Australian perinatal data collection 1998 to 2003 comparing outcomes for 8,725 women who underwent a cesarean delivery for their first birth with 27,313 women who underwent a vaginal first birth. Predictor variables include age, indigenous status, smoking, pregnancy interval, medical and obstetric complications, gestation, patient type, hospital category, and history of ectopic pregnancy, miscarriage, stillbirth or termination of pregnancy.

RESULTS: The cesarean delivery cohort had increased risks for malpresentation (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.65–2.06), placenta previa (OR 1.66, 95% CI 1.30–2.11), antepartum hemorrhage (OR 1.23, 95% CI 1.08–1.41), placenta accreta (OR 18.79, 95% CI 2.28–864.6), prolonged labor (OR 5.89, 95% CI 3.91–8.89), emergency cesarean (relative risk 9.37, 95% CI 8.98–9.76) and uterine rupture (OR 84.42, 95% CI 14.64-infinity), preterm birth (OR 1.17, 95% CI 1.04–1.31), low birth weight (OR 1.30, 95% CI 1.14–1.48), small for gestational age (OR 1.12, 95% CI 1.02–1.23), stillbirth (OR 1.56, 95% CI 1.04–2.32), and unexplained stillbirth (OR 2.34, 95% CI 1.26–4.37). The range of the number of primary cesarean deliveries needed to harm included 134 for one additional preterm birth, up to 1,536 for one additional placenta accreta.

CONCLUSION: Cesarean delivery is associated with increased risks for adverse obstetric and perinatal outcomes in the subsequent birth. However, some risks may be due to confounding factors related to the indication for the first cesarean.


A first delivery by cesarean increases risks for adverse obstetric and perinatal outcomes in the subsequent birth compared with vaginal first birth.

From the 1Pregnancy Outcome Unit and 2Health Statistics Unit, Epidemiology Branch, Department of Health, Adelaide, South Australia.

Corresponding author: Robyn Kennare, Grad Dip PH, Pregnancy Outcome Unit, Department of Health, P.O. Box 6, Rundle Mall, Adelaide, South Australia 5000, Australia; e-mail:

© 2007 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.