Short- and Long-term Outcomes after Cesarean Section

Rosalie M Grivell; Jodie M Dodd

Disclosures

Expert Rev of Obstet Gynecol. 2011;6(2):205-215. 

In This Article

Outcome for Infants in a Subsequent Pregnancy

A number of studies have evaluated the effect of prior CS and antepartum stillbirth in a subsequent pregnancy.[84–86] Using linked pregnancy data from 120,633 singleton births in Scotland, UK, the risk of stillbirth was higher in women with a prior CS compared with previous vaginal birth (HR: 2.23; 95% CI: 1.48–3.36), a risk evident beyond 34 weeks gestation.[86] Similarly, the risk of unexplained stillbirth after 39 weeks in women with a previous CS was twice that of women with a previous vaginal birth (absolute risk 1.1 out of 1000 women vs 0.5 out of 1000 women).[86]

By contrast, a US cross-sectional study using data from 1995 to 1997 found the risk of term intrauterine fetal death was 1.5 out of 1000 births for women with no prior CS birth compared with 1.3 out of 1000 births for women with prior CS.[84] A Canadian study has also demonstrated no increase in the risk of unexplained antepartum stillbirth following cesarean birth.[85]

The systematic review by Guise and colleagues evaluated the risk of perinatal death for infants of women with a prior cesarean birth.[67] While the additional risk of perinatal death from uterine rupture for women attempting vaginal birth was 1.4 (range: 0–9.8) out of 10,000, classification and reporting inconsistencies make it difficult to establish the effect of prior cesarean birth on subsequent antenatal fetal death.[67]

Infant outcomes are also influenced by planned mode of birth in the presence of a previous CS. Landon and colleagues report a significantly increased chance of poor perinatal outcome in term infants incorporating a composite outcome of stillbirth, hypoxic–ischemic encephalopathy or neonatal death following VBAC. Infants born following trial of labor were at three-fold increased risk of one or more of the outcomes compared with infants born following elective repeat cesarean (OR: 2.90; 95% CI: 1.74–4.81).[68] When individual outcomes were examined, while there was no difference in the incidence of neonatal death or intrapartum stillbirth or antepartum stillbirth after 39 weeks, infants born following trial of labor were at significantly increased risk of antepartum stillbirth at 37–38 weeks (OR: 2.93; 95% CI: 1.27–6.75) and hypoxic ischemic encephalopathy (12 cases in the trial of labor group compared with none in the elective repeat CS group).[68]

Carlsson Wallin and colleagues assessed pregnancy outcomes in women following one CS (69,133 pregnancies), and compared them with outcomes following a single vaginal birth (487,610 pregnancies).[87] After adjustment for indication for the first CS, infants born to women with one prior CS were at increased risk of both low Apgar score (adjusted OR: 1.6; 95% CI: 1.5–1.8) and perinatal death (OR: 1.1; 95% CI: 1.0–1.2).[87] However, for women with no medical indication for primary CS, CS was not associated with an increased risk of adverse infant outcome.[87]

Landon and colleagues report infant outcomes following a trial of labor and following a planned CS among women with a prior cesarean birth.[68] The incidence of hypoxic–ischemic encephalopathy was greater among infants born following trial of labor, although the absolute risks remain small (0.08% for term infants with a trial of labor; p < 0.001). For term infants, there was a significant association between trial of labor and the combined outcomes of stillbirth, neonatal death or hypoxic–ischemic encephalopathy when compared with infants of women birthing by elective repeat cesarean delivery (OR: 2.72; 95% CI: 1.49–4.97),[68] but again the absolute risks remain small.

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