Why Should You Care Whether You Have a Cesarean?

by | May 15, 2024 | Cesarean Surgery

Birth [that is powered by the innate human capacity of the woman and fetus] is more likely to be safe and healthy because there is no unnecessary intervention that disrupts normal physiologic processes. Some women and/or fetuses will develop complications that warrant medical attention to assure safe and healthy outcome. However supporting the normal physiologic processes of labor and birth, even in the presence of such complications, has the potential to enhance best outcomes for the mother and infant.

 

— American College of Nurse-Midwives, Midwives Alliance of North America, National Association of Certified Professional Midwives4

After posting a graphic on social media stating that half of cesareans could safely be prevented, a commenter wrote: “Why do we want to prevent them?” “Good question,” I thought. “I think I’ll answer it in my next blog post.” I’ve actually done that in general terms in the quote that opens this post, but I expect she was interested in specifics, which may also be true for some of you. So, for her and any of you out there who have the same question, this blog post is for you.

Here’s our roadmap: I’ll start with complications inherent to having a baby via major surgery, follow that with the probabilities of you or your baby experiencing specific complications according to whether you have a cesarean delivery or a vaginal birth, and follow that with the probabilities of your experiencing future reproductive complications according to whether you have had a prior cesarean compared or only vaginal births. Finally, as usual, I’ll finish up with “Your Takeaway,” which for this post will be links to a couple of other posts containing tips and strategies for preventing a preventable cesarean.

And, just to be clear, while I’m going to argue that cesarean delivery is the riskier proposition, I am not saying we shouldn’t be doing them. Appropriate, timely cesarean delivery clearly has the potential to save lives and prevent permanent harm to mothers and babies. However, the sweet spot for the cesarean rate is between 10 and 15 percent, and the U.S. cesarean rate has hovered at 33 percent since 2009,41 which means we’re doing way too many cesareans in this country, and as the rest of this blog post will attest, those avoidable cesareans are doing a tremendous amount of harm.

Complications Inherent to Delivering Via Major Surgery

To begin with, inherent to surgical delivery compared with vaginal birth is:

  • More intense and longer-lasting pain.22, 44, 97
  • More difficult and lengthy recovery,55, 73, 115 which includes limitations on driving and lifting.97
  • The potential for chronic pelvic pain from the formation of internal scar tissue (adhesions) or from cesarean-scar endometriosis,6, 8, 15, 47, 62, 65, 79, 84, 112, 119 which happens when cells that make up the uterine lining seed into the abdominal, uterine, or skin wound at the time of the surgery; grow there; and cause cyclic pain.

Moreover, the issues of pain and recovery are magnified after a cesarean because, unlike recovery from other surgeries, you are also caring for a newborn while you deal with them.

In addition, having an unplanned cesarean increases the probability of viewing the birth negatively20, 73, 91—no surprise there—but also of more severe distress, including full-blown post-traumatic stress disorder.5, 14, 87, 91, 98 The research is inconclusive on whether unplanned cesarean increases likelihood of postpartum depression, but some studies find that it does.13, 73, 98

Excess Complication Rates with First Cesarean Versus First Vaginal Birth

This brings us to our comparison list of specific complications with having a first cesarean. As I said, I’ve divided my list into two subsections: first, the consequences of having a first cesarean compared with a first vaginal birth, which I’ll cover here, and second, the effects of having had a cesarean on future reproductive complications, which I’ll cover next.

Before we get to that, though, I need to explain what I mean by “excess complication rates.”

Let’s suppose I have a study that reports an incidence of 6 per 1,000 for a particular complication with cesarean delivery versus 2 per 1,000 with vaginal birth. That would make the excess with cesarean 6 per 1,000 minus 2 per 1,000, or 4 more occurrences of that complication per 1,000 cesarean deliveries. Now suppose I have a second study reporting on the incidence of the same complication that reports an incidence of 3 per 1,000 with cesarean delivery versus 1 per 1,000 with vaginal birth. The excess difference in this study would be 3 minus 1, or 2 per 1,000 cesarean deliveries. Finally, suppose I have a third study reporting an incidence of 7 per 1,000 for that complication with cesarean delivery versus 5 per 1,000 with vaginal birth, which would also be an excess of 2 per 1,000 cesarean deliveries. Taking the three studies together, the excess differences would range from 2 to 4 per 1,000 cesarean deliveries. To give you a sense of the likelihood of experiencing these complications as a result of having a cesarean, I’m going to group excess occurrence rates according to 1 to 9 more excess occurrences per 100, 1,000, 10,000, and 100,000 cesarean deliveries. Also, some complications are unique to having surgery. I’ve highlighted these by noting that the incidence with vaginal birth is zero.

Maternal complications: 
  • Excess maternal complications with cesarean falling in the range of 1 to 9 more per 100 include:
    • surgical incision complications or infection27, 51, 63 (incidence with vaginal birth = 0)
    • readmission to the hospital after discharge68, 72, 105
  • Excess maternal complications with cesarean falling in the range of 1 to 9 more per 1,000 include:
    • surgical wound hematomas (blood-filled swelling)69 (incidence with vaginal birth = 0)
    • major infection (not defined)69
    • anesthetic complications (not defined)69
    • re-operation70 (incidence with vaginal birth = 0)
    • urinary tract infection51, 63
  • Excess maternal complications with cesarean falling in the range of 1 to 9 more per 10,000 include:
    • cardiac arrest69
    • hysterectomy69
    • wound disruption69
    • thromboembolism (deep venous clots)69
    • septicemia (bloodstream infection)1
  • Excess maternal complications with cesarean falling in the range of 1 to 9 more per 100,000 include:
    • amniotic fluid embolism (a rare condition in which amniotic fluid or fetal cells enter the maternal bloodstream and trigger an overwhelming, sometimes fatal, allergic reaction)66
    • death24, 45
Newborn complications:
    • Excess newborn complications with cesarean falling in the range of 1 to 9 more per 100 include:
      • surgical cuts3, 25, 39, 100, 111 (vaginal birth rate = 0)
      • not breastfeeding or failure of breastfeeding21
    • Excess newborn complications with cesarean falling in the range of 1 to 9 more per 1,000 include:
      • breathing complications, especially with delivery at term (i.e., after 36 weeks) but before 39 weeks.26, 31, 42, 43, 60, 67, 77, 93, 95, 117
    • Excess newborn complications with cesarean falling in the range of 1 to 9 more per 10,000 include:
      • death: The study that found this used U.S. national statistics to compare newborn deaths in women at low risk for complications having elective cesareans, meaning no medical indication, with women planning vaginal birth.75

    Cesarean delivery also has long-term potential consequences for babies. Children delivered by cesarean are slightly more likely to develop asthma54, 85 or an autoimmune disease, including type 1 diabetes, inflammatory bowel disease, and juvenile arthritis,12, 54, 56, 93, 94 and they are more likely to be overweight in childhood.54, 93, 103

    As for why these associations, one explanation for the association between cesarean and autoimmune disease is differences with cesarean in the baby’s intestinal microbiome, that is, the organisms that colonize the baby’s intestines.93 This is because the baby doesn’t pass through the vagina, which is where it would pick up these organisms. Also, it is usual to give antibiotics prior to cesarean surgery to reduce the risk of infection, and the antibiotic crosses into the fetal circulation.93 (Note: ongoing breastfeeding can help remedy this because it transfers beneficial organisms to the baby that help build a healthy intestinal microbiome.10)

    The association with childhood overweight may also be explained by differences in the baby’s intestinal microbiome.93 Other explanations include less likelihood of breastfeeding with cesarean delivery,64 which increases probability of being overweight in childhood, as well as other effects of mode of delivery on inflammation, immune, or endocrine function independent of intestinal colonization.50, 93

    As for asthma, it, too, is an immune system disorder—in this case a dysfunctional reaction to certain triggers—so the effects of cesarean delivery on the microbiome could also apply.104 Another theory is that cesarean-born newborns are more likely to have breathing difficulties, and this is associated with increased risk of asthma.7

Excess Reproductive Complication Rates Consequent to Having a Prior Cesarean

The increased probability of complications with cesarean delivery doesn’t end with healing from the surgery. Cesareans have a long tail that extends throughout reproductive life. I’ve combined maternal and newborn complications in this section because unlike the initial cesarean, where complications arise at the birth and can be divided into those affecting the mother and those affecting the baby, having had a prior cesarean causes maternal complications that affect future pregnancies from conception through birth, and almost all of them necessarily pose risks to the baby as well.

Reproductive complications:
  • Reproductive complications:
    • Excess reproductive complications of one prior cesarean falling in the range of 10 or more per 100:
      • dense adhesions (internal scar tissue) (range in incidence 12 to 50 percent) (incidence with vaginal birth = 0)40, 74, 76, 81-83
    • Excess reproductive complications of one prior cesarean falling in the range of 1 to 9 more per 100:
      • less likely to have a second child, sometimes by choice but also because of inability to conceive 36, 38, 57, 58
      • miscarriage54
      • probably preterm birth at second birth with first birth cesarean versus first birth vaginal (9 out of 12 studies)9, 29, 34, 46, 49, 102, 108-110, 113, 114, 118
      • maternal blood transfusion30
      • maternal intensive care admission30
      • newborn need for breathing assistance30
      • newborn hospital stay longer than 7 days30
    • Excess reproductive complications at second delivery with first delivery cesarean versus first vaginal birth falling in the range of 1 to 9 more per 1,000:
      • placental abruption (the placenta detaches partially or completely before birth)9, 17, 52, 71, 116
      • placenta previa (the placenta overlays the cervix)9, 17, 37, 71, 116
      • placenta accreta (the placenta grows into the uterine muscle or even through it)19
      • stillbirth2, 9, 80, 86
      • newborn possibly small-for-gestational-age (weights in the 10th percentile or lower for gestational age) (3 of 6 studies)9, 17, 46, 49, 99, 102
      • the uterine incision scar gives way during labor35 (incidence with vaginal birth = 0)
      • hysterectomy52
      • maternal hospital readmission30
    • Excess reproductive complications of prior cesarean falling in the range of a 1 to 9 more per 10,000:
      • cesarean-scar ectopic pregnancy (the embryo implants inside the uterine scar) or early placenta accreta (the placenta develops within the cesarean scar, causing symptoms early in pregnancy)90, 92, 107 (incidence with vaginal birth = 0)
      • pregnancy loss due to cesarean-scar ectopic pregnancy or early placenta accreta90, 92, 107 (incidence with vaginal birth = 0)
      • the uterine incision scar gives way during pregnancy23, 35 (incidence with vaginal birth = 0)

    Abnormal placental attachment, cesarean scar ectopic pregnancy, and the uterine scar giving way increase the likelihood of severe hemorrhage, hysterectomy, injury to other organs or blood vessels during urgent cesarean surgery, abnormal clotting, a clot in the deep leg veins, and fluid in the lungs, as well as preterm birth and therefore its consequences, all of which increase the likelihood of death in baby and mother.28, 32, 33, 35, 59, 71, 76, 78, 88, 89, 101, 106 Dense adhesions make future cesareans, and, in fact, any future pelvic surgery more complicated and difficult and more likely to result in operative injury to internal organs or blood vessels.11, 18 And, as I said, any pregnancy or labor complication carrying severe consequences for the mother can also have severe potential consequences for the baby.

    Finally, as the number of repeat cesareans goes up, so does the incidence of abnormal placental attachment35 This in turn increases the probability of severe hemorrhage and hysterectomy,35, 61 preterm delivery and its consequences,16 and maternal and perinatal death in subsequent pregnancies and births. Placenta accreta, for example, the most dangerous of the placental attachment abnormalities, and fortunately the rarest, is associated with a 52 percent hysterectomy rate and a maternal mortality rate of 50 per 100,000.53 (For comparison’s sake, the US national maternal mortality rate the year before the COVID-19 pandemic was 20 per 100,000.48) The probability of dense adhesions goes up as well,35 resulting in increased risk of operative injury to bladder and bowel.16, 76, 83, 96

Your Takeaway

As I promised in my intro, here are a couple of blog posts with practical tips and ideas on how you can avoid an avoidable cesarean, “How Can You Avoid an Avoidable First Cesarean?” and “Policies and Practices that Avoid an Avoidable Cesarean.”

References

  1. Acosta CD, Knight M, Lee HC, et al. The continuum of maternal sepsis severity: incidence and risk factors in a population-based cohort study. PLoS One 2013;8(7):e67175.
  2. Al Khalaf SY, Heazell AEP, Kublickas M, et al. Risk of stillbirth after a previous caesarean delivery: A Swedish nationwide cohort study. BJOG 2024.
  3. Alexander JM, Leveno KJ, Hauth J, et al. Fetal injury associated with cesarean delivery. Obstet Gynecol 2006;108(4):885-90.
  4. American College of Nurse-Midwives, Midwives Alliance North America, National Association of Certified Professional Midwives. Supporting healthy and normal physiologic childbirth: a consensus statement by ACNM, MANA, and NACPM; 2012.
  5. Andersen LB, Melvaer LB, Videbech P, et al. Risk factors for developing post-traumatic stress disorder following childbirth: A systematic review. Acta Obstet Gynecol Scand 2012.
  6. Andolf E, Thorsell M, Kallen K. Caesarean section and risk for endometriosis: a prospective cohort study of Swedish registries. BJOG 2013.
  7. Bager P, Wohlfahrt J, Westergaard T. Caesarean delivery and risk of atopy and allergic disease: meta-analyses. Clin Exp Allergy 2008;38(4):634-42.
  8. Bektas H, Bilsel Y, Sari YS, et al. Abdominal wall endometrioma; a 10-year experience and brief review of the literature. J Surg Res 2010;164(1):e77-81.
  9. Bjellmo S, Andersen GL, Hjelle S, et al. Does caesarean delivery in the first pregnancy increase the risk for adverse outcome in the second? A registry-based cohort study on first and second singleton births in Norway. BMJ Open 2020;10(8):e037717.
  10. Bogaert D, van Beveren GJ, de Koff EM, et al. Mother-to-infant microbiota transmission and infant microbiota development across multiple body sites. Cell Host Microbe 2023;31(3):447-60 e6.
  11. Boukerrou M, Lambaudie E, Collinet P, et al. A history of cesareans is a risk factor in vaginal hysterectomies. Acta Obstet Gynecol Scand 2003;82(12):1135-9.
  12. Cardwell CR, Stene LC, Joner G, et al. Caesarean section is associated with an increased risk of childhood-onset type 1 diabetes mellitus: a meta-analysis of observational studies. Diabetologia 2008;51(5):726-35.
  13. Carter FA, Frampton CM, Mulder RT. Cesarean section and postpartum depression: a review of the evidence examining the link. Psychosom Med 2006;68(2):321-30.
  14. Carter J, Bick D, Gallacher D, et al. Mode of birth and development of maternal postnatal post-traumatic stress disorder: A mixed-methods systematic review and meta-analysis. Birth 2022;49(4):616-27.
  15. Chang Y, Tsai EM, Long CY, et al. Abdominal wall endometriomas. J Reprod Med 2009;54(3):155-9.
  16. Cook JR, Jarvis S, Knight M, et al. Multiple repeat caesarean section in the UK: incidence and consequences to mother and child. A national, prospective, cohort study. BJOG 2013;120(1):85-91.
  17. Daltveit AK, Tollanes MC, Pihlstrom H, et al. Cesarean delivery and subsequent pregnancies. Obstet Gynecol 2008;111(6):1327-34.
  18. David-Montefiore E, Rouzier R, Chapron C, et al. Surgical routes and complications of hysterectomy for benign disorders: a prospective observational study in French university hospitals. Hum Reprod 2007;22(1):260-5.
  19. De Mucio B, Serruya S, Aleman A, et al. A systematic review and meta-analysis of cesarean delivery and other uterine surgery as risk factors for placenta accreta. Int J Gynaecol Obstet 2019;147(3):281-91.
  20. Declercq E, Sakala C, Corry MP, et al. Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection; 2006.
  21. Declercq E, Sakala C, Corry MP, et al. New Mothers Speak Out:. National Survey Results Highlight Women’s Postpartum Experiences. . New York: Childbirth Connection; 2008.
  22. Declercq E, Sakala C, Corry MP, et al. Listening to Mothers III: New Mothers Speak Out. New York: Childbirth Connection; 2013.
  23. Dekker GA, Chan A, Luke CG, et al. Risk of uterine rupture in Australian women attempting vaginal birth after one prior caesarean section: a retrospective population-based cohort study. BJOG 2010;117(11):1358-65.
  24. Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, et al. Postpartum maternal mortality and cesarean delivery. Obstet Gynecol 2006;108(3):541-8.
  25. Dessole S, Cosmi E, Balata A, et al. Accidental fetal lacerations during cesarean delivery: experience in an Italian level III university hospital. Am J Obstet Gynecol 2004;191(5):1673-7.
  26. Farchi S, Di Lallo D, Franco F, et al. Neonatal respiratory morbidity and mode of delivery in a population-based study of low-risk pregnancies. Acta Obstet Gynecol Scand 2009;88(6):729-32.
  27. Ferraro F, Piselli P, Pittalis S, et al. Surgical site infection after caesarean section: space for post-discharge surveillance improvements and reliable comparisons. New Microbiol 2016;39(2):134-8.
  28. Flood KM, Said S, Geary M, et al. Changing trends in peripartum hysterectomy over the last 4 decades. Am J Obstet Gynecol 2009;200(6):632 e1-6.
  29. Forde B, DeFranco EA. Association of Prior Cesarean Delivery With Early Term Delivery and Neonatal Morbidity. Obstet Gynecol 2020;135(6):1367-76.
  30. Galyean AM, Lagrew DC, Bush MC, et al. Previous cesarean section and the risk of postpartum maternal complications and adverse neonatal outcomes in future pregnancies. J Perinatol 2009;29(11):726-30.
  31. Gerten KA, Coonrod DV, Bay RC, et al. Cesarean delivery and respiratory distress syndrome: does labor make a difference? Am J Obstet Gynecol 2005;193(3 Pt 2):1061-4.
  32. Gielchinsky Y, Rojansky N, Fasouliotis SJ, et al. Placenta accreta–summary of 10 years: a survey of 310 cases. Placenta 2002;23(2-3):210-4.
  33. Grobman WA, Gersnoviez R, Landon MB, et al. Pregnancy outcomes for women with placenta previa in relation to the number of prior cesarean deliveries. Obstet Gynecol 2007;110(6):1249-55.
  34. Gugusheff J, Patterson J, Torvaldsen S, et al. Is mode of first birth a risk factor for subsequent preterm birth? Aust N Z J Obstet Gynaecol 2021;61(1):86-93.
  35. Guise JM, Eden K, Emeis C, et al. Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full Rep) 2010(191):1-397.
  36. Gurol-Urganci I, Bou-Antoun S, Lim CP, et al. Impact of Caesarean section on subsequent fertility: a systematic review and meta-analysis. Hum Reprod 2013;28(7):1943-52.
  37. Gurol-Urganci I, Cromwell DA, Edozien LC, et al. Risk of placenta previa in second birth after first birth cesarean section: a population-based study and meta-analysis. BMC Pregnancy Childbirth 2011;11:95.
  38. Gurol-Urganci I, Cromwell DA, Mahmood TA, et al. A population-based cohort study of the effect of Caesarean section on subsequent fertility. Hum Reprod 2014;29(6):1320-6.
  39. Haas DM, Ayres AW. Laceration injury at cesarean section. J Matern Fetal Neonatal Med 2002;11(3):196-8.
  40. Hamel KJ. Incidence of adhesions at repeat cesarean delivery. Am J Obstet Gynecol 2007;196(5):e31-2.
  41. Hamilton BE, Martin JA, Ventura SJ. Births: preliminary data for 2009. Natl Vital Stat Rep 2010;59(3):1-29.
  42. Hansen AK, Wisborg K, Uldbjerg N, et al. Elective caesarean section and respiratory morbidity in the term and near-term neonate. Acta Obstet Gynecol Scand 2007;86(4):389-94.
  43. Hansen AK, Wisborg K, Uldbjerg N, et al. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ 2008;336(7635):85-7.
  44. Hardy-Fairbanks AJ, Lauria MR, Mackenzie T, et al. Intensity and unpleasantness of pain following vaginal and cesarean delivery: a prospective evaluation. Birth 2013;40(2):125-33.
  45. Harper MA, Byington RP, Espeland MA, et al. Pregnancy-related death and health care services. Obstet Gynecol 2003;102(2):273-8.
  46. Hemminki E, Shelley J, Gissler M. Mode of delivery and problems in subsequent births: a register-based study from Finland. Am J Obstet Gynecol 2005;193(1):169-77.
  47. Horton JD, Dezee KJ, Ahnfeldt EP, et al. Abdominal wall endometriosis: a surgeon’s perspective and review of 445 cases. Am J Surg 2008;196(2):207-12.
  48. Hoyert DL. Maternal mortality rates in the United States, 2019. In: Health E-Stats: National Center for Health Statistics; April 2021.
  49. Huang X, Lei J, Tan H, et al. Cesarean delivery for first pregnancy and neonatal morbidity and mortality in second pregnancy. Eur J Obstet Gynecol Reprod Biol 2011;158(2):204-8.
  50. Huh SY, Rifas-Shiman SL, Zera CA, et al. Delivery by caesarean section and risk of obesity in preschool age children: a prospective cohort study. Arch Dis Child 2012;97(7):610-6.
  51. Hung HW, Yang PY, Yan YH, et al. Increased postpartum maternal complications after cesarean section compared with vaginal delivery in 225 304 Taiwanese women. J Matern Fetal Neonatal Med 2016;29(10):1665-72.
  52. Jackson S, Fleege L, Fridman M, et al. Morbidity following primary cesarean delivery in the Danish National Birth Cohort. Am J Obstet Gynecol 2012;206(2):139 e1-5.
  53. Jauniaux E, Bunce C, Gronbeck L, et al. Prevalence and main outcomes of placenta accreta spectrum: a systematic review and meta-analysis. Am J Obstet Gynecol 2019;221(3):208-18.
  54. Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med 2018;15(1):e1002494.
  55. Kealy MA, Small RE, Liamputtong P. Recovery after caesarean birth: a qualitative study of women’s accounts in Victoria, Australia. BMC Pregnancy Childbirth 2010;10:47.
  56. Khashan AS, Kenny LC, Lundholm C, et al. Mode of obstetrical delivery and type 1 diabetes: a sibling design study. Pediatrics 2014;134(3):e806-13.
  57. Kjerulff KH, Paul IM, Weisman CS, et al. Association Between Mode of First Delivery and Subsequent Fecundity and Fertility. JAMA Netw Open 2020;3(4):e203076.
  58. Kjerulff KH, Zhu J, Weisman CS, et al. First birth Caesarean section and subsequent fertility: a population-based study in the USA, 2000-2008. Hum Reprod 2013;28(12):3349-57.
  59. Knight M, Kurinczuk JJ, Spark P, et al. Cesarean delivery and peripartum hysterectomy. Obstet Gynecol 2008;111(1):97-105.
  60. Kolas T, Saugstad OD, Daltveit AK, et al. Planned cesarean versus planned vaginal delivery at term: Comparison of newborn infant outcomes. Am J Obstet Gynecol 2006;195(6):1538-43.
  61. Kwee A, Bots ML, Visser GH, et al. Emergency peripartum hysterectomy: A prospective study in The Netherlands. Eur J Obstet Gynecol Reprod Biol 2006;124(2):187-92.
  62. Leite GK, Carvalho LF, Korkes H, et al. Scar endometrioma following obstetric surgical incisions: retrospective study on 33 cases and review of the literature. Sao Paulo Med J 2009;127(5):270-7.
  63. Leth RA, Moller JK, Thomsen RW, et al. Risk of selected postpartum infections after cesarean section compared with vaginal birth: a five-year cohort study of 32,468 women. Acta Obstet Gynecol Scand 2009;88(9):976-83.
  64. Li HT, Zhou YB, Liu JM. The impact of cesarean section on offspring overweight and obesity: a systematic review and meta-analysis. Int J Obes (Lond) 2013;37(7):893-9.
  65. Lipscomb GH, Givens VM, Smith WE. Endometrioma occurring in abdominal wall incisions after cesarean section. J Reprod Med 2011;56(1-2):44-6.
  66. Lisonkova S, Kramer MS. Amniotic fluid embolism: A puzzling and dangerous obstetric problem. PLoS Med 2019;16(11):e1002976.
  67. Liston FA, Allen VM, O’Connell CM, et al. Neonatal outcomes with caesarean delivery at term. Arch Dis Child Fetal Neonatal Ed 2008;93(3):F176-82.
  68. Liu S, Heaman M, Joseph KS, et al. Risk of maternal postpartum readmission associated with mode of delivery. Obstet Gynecol 2005;105(4):836-42.
  69. Liu S, Liston RM, Joseph KS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ 2007;176(4):455-60.
  70. Lurie S, Sadan O, Golan A. Re-laparotomy after cesarean section. Eur J Obstet Gynecol Reprod Biol 2007;134(2):184-7.
  71. Lydon-Rochelle M, Holt VL, Easterling TR, et al. First-birth cesarean and placental abruption or previa at second birth. Obstet Gynecol 2001;97(5 Pt 1):765-9.
  72. Lydon-Rochelle M, Holt VL, Martin DP, et al. Association between method of delivery and maternal rehospitalization. JAMA 2000;283(18):2411-6.
  73. Lydon-Rochelle MT, Holt VL, Martin DP. Delivery method and self-reported postpartum general health status among primiparous women. Paediatr Perinat Epidemiol 2001;15(3):232-40.
  74. Lyell DJ, Caughey AB, Hu E, et al. Peritoneal closure at primary cesarean delivery and adhesions. Obstet Gynecol 2005;106(2):275-80.
  75. MacDorman MF, Declercq E, Menacker F, et al. Neonatal mortality for primary cesarean and vaginal births to low-risk women: application of an “intention-to-treat” model. Birth 2008;35(1):3-8.
  76. Makoha FW, Felimban HM, Fathuddien MA, et al. Multiple cesarean section morbidity. Int J Gynaecol Obstet 2004;87(3):227-32.
  77. Many A, Helpman L, Vilnai Y, et al. Neonatal respiratory morbidity after elective cesarean section. J Matern Fetal Neonatal Med 2006;19(2):75-8.
  78. Miller DA, Goodwin TM, Gherman RB, et al. Intrapartum rupture of the unscarred uterus. Obstet Gynecol 1997;89(5 Pt 1):671-3.
  79. Minaglia S, Mishell DR, Jr., Ballard CA. Incisional endometriomas after Cesarean section: a case series. J Reprod Med 2007;52(7):630-4.
  80. Moraitis AA, Oliver-Williams C, Wood AM, et al. Previous caesarean delivery and the risk of unexplained stillbirth: retrospective cohort study and meta-analysis. BJOG 2015;122(11):1467-74.
  81. Morales KJ, Gordon MC, Bates GW, Jr. Postcesarean delivery adhesions associated with delayed delivery of infant. Am J Obstet Gynecol 2007;196(5):461 e1-6.
  82. Myers SA, Bennett TL. Incidence of significant adhesions at repeat cesarean section and the relationship to method of prior peritoneal closure. J Reprod Med 2005;50(9):659-62.
  83. Nisenblat V, Barak S, Griness OB, et al. Maternal complications associated with multiple cesarean deliveries. Obstet Gynecol 2006;108(1):21-6.
  84. Nominato NS, Prates LF, Lauar I, et al. Caesarean section greatly increases risk of scar endometriosis. Eur J Obstet Gynecol Reprod Biol 2010;152(1):83-5.
  85. O’Connor A, McCarthy FP, Kelly L, et al. Mode of delivery and asthma in childhood and adolescence: Findings from the Millennium Cohort Study. Clin Exp Allergy 2023;53(4):459-64.
  86. O’Neill SM, Kearney PM, Kenny LC, et al. Caesarean delivery and subsequent stillbirth or miscarriage: systematic review and meta-analysis. PLoS One 2013;8(1):e54588.
  87. Olde E, van der Hart O, Kleber R, et al. Posttraumatic stress following childbirth: a review. Clin Psychol Rev 2006;26(1):1-16.
  88. Olive EC, Roberts CL, Algert CS, et al. Placenta praevia: maternal morbidity and place of birth. Aust N Z J Obstet Gynaecol 2005;45(6):499-504.
  89. Pariente G, Wiznitzer A, Sergienko R, et al. Placental abruption: critical analysis of risk factors and perinatal outcomes. J Matern Fetal Neonatal Med 2011;24(5):698-702.
  90. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 2006;107(6):1373-81.
  91. Rowlands IJ, Redshaw M. Mode of birth and women’s psychological and physical wellbeing in the postnatal period. BMC Pregnancy Childbirth 2012;12:138.
  92. Sadeghi H, Rutherford T, Rackow BW, et al. Cesarean scar ectopic pregnancy: case series and review of the literature. Am J Perinatol 2010;27(2):111-20.
  93. Sandall J, Tribe RM, Avery L, et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet 2018;392(10155):1349-57.
  94. Sevelsted A, Stokholm J, Bonnelykke K, et al. Cesarean section and chronic immune disorders. Pediatrics 2015;135(1):e92-8.
  95. Silasi M, Coonrod DV, Kim M, et al. Transient tachypnea of the newborn: is labor prior to cesarean delivery protective? Am J Perinatol 2010;27(10):797-802.
  96. Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107(6):1226-32.
  97. Going home after a C-section. Mount Sinai. (Accessed Dec 12, 2023, at https://www.mountsinai.org/health-library/discharge-instructions/going-home-after-a-c-section#.)
  98. Skov SK, Hjorth S, Kirkegaard H, et al. Mode of delivery and short-term maternal mental health: A follow-up study in the Danish National Birth Cohort. Int J Gynaecol Obstet 2022;159(2):457-65.
  99. Smith GC, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet 2003;362(9398):1779-84.
  100. Smith JF, Hernandez C, Wax JR. Fetal laceration injury at cesarean delivery. Obstet Gynecol 1997;90(3):344-6.
  101. Spiliopoulos M, Kareti A, Jain NJ, et al. Risk of peripartum hysterectomy by mode of delivery and prior obstetric history: data from a population-based study. Arch Gynecol Obstet 2011;283(6):1261-8.
  102. Taylor LK, Simpson JM, Roberts CL, et al. Risk of complications in a second pregnancy following caesarean section in the first pregnancy: a population-based study. Med J Aust 2005;183(10):515-9.
  103. Terashita S, Yoshida T, Matsumura K, et al. Caesarean section and childhood obesity at age 3 years derived from the Japan Environment and Children’s Study. Sci Rep 2023;13(1):6535.
  104. Thavagnanam S, Fleming J, Bromley A, et al. A meta-analysis of the association between Caesarean section and childhood asthma. Clin Exp Allergy 2008;38(4):629-33.
  105. Thompson JF, Roberts CL, Currie M, et al. Prevalence and persistence of health problems after childbirth: associations with parity and method of birth. Birth 2002;29(2):83-94.
  106. Tikkanen M. Placental abruption: epidemiology, risk factors and consequences. Acta Obstet Gynecol Scand 2011;90(2):140-9.
  107. Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012;207(1):14-29.
  108. Vahanian SA, Hoffman MK, Ananth CV, et al. Term cesarean delivery in the first pregnancy is not associated with an increased risk for preterm delivery in the subsequent pregnancy. Am J Obstet Gynecol 2019;221(1):61 e1- e7.
  109. Van Winsen KD, Savvidou MD, Steer PJ. The effect of mode of delivery and duration of labour on subsequent pregnancy outcomes: a retrospective cohort study. BJOG 2021;128(13):2132-9.
  110. Visser L, Slaager C, Kazemier BM, et al. Risk of preterm birth after prior term cesarean. BJOG 2020;127(5):610-7.
  111. Weiner Z, Ben-Shlomo I, Beck-Fruchter R, et al. Clinical and ultrasonographic weight estimation in large for gestational age fetus. Eur J Obstet Gynecol Reprod Biol 2002;105(1):20-4.
  112. Wicherek L, Klimek M, Skret-Magierlo J, et al. The obstetrical history in patients with Pfannenstiel scar endometriomas–an analysis of 81 patients. Gynecol Obstet Invest 2007;63(2):107-13.
  113. Williams C, Fong R, Murray SM, et al. Caesarean birth and risk of subsequent preterm birth: a retrospective cohort study. BJOG 2021;128(6):1020-8.
  114. Williams CM, Asaolu I, Chavan NR, et al. Previous cesarean delivery associated with subsequent preterm birth in the United States. Eur J Obstet Gynecol Reprod Biol 2018;229:88-93.
  115. Woolhouse H, Perlen S, Garland SJ, et al. Physical health and recovery in the first 18 months postpartum: does cesarean section reduce long-term morbidity? Birth 2012;39(3).
  116. Yang Q, Wen SW, Oppenheimer L, et al. Association of caesarean delivery for first birth with placenta praevia and placental abruption in second pregnancy. BJOG 2007;114(5):609-13.
  117. Zanardo V, Padovani E, Pittini C, et al. The influence of timing of elective cesarean section on risk of neonatal pneumothorax. J Pediatr 2007;150(3):252-5.
  118. Zhang Y, Zhou J, Ma Y, et al. Mode of delivery and preterm birth in subsequent births: A systematic review and meta-analysis. PLoS One 2019;14(3):e0213784.

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