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To estimate cumulative risks of maternal and perinatal morbidity associated with the choice of elective cesarean for a first delivery.
A decision analytic model was designed to compare major adverse outcomes across a woman's reproductive life associated with the choice of primary elective cesarean versus a trial of labor at a first delivery. Maternal outcomes assessed included maternal transfusion, hysterectomy, thromboembolism, operative injury, and death. Perinatal outcomes assessed included cerebral palsy (CP) and permanent brachial plexus (BP) palsy in the offspring.
Choosing an initial cesarean resulted in a 0.3% increased risk of a major adverse maternal outcome in the first pregnancy. In each subsequent pregnancy, the difference in maternal morbidity increased between strategies, such that by the fourth pregnancy, the cumulative risk of a major adverse maternal outcome was nearly 10% in the elective primary cesarean group, three times higher than among women who initially underwent a trial of labor. Although the choice of an initial cesarean resulted in 2.4 and 0.41 fewer cases of CP and BP palsy, respectively, per 10,000 women in the first pregnancy, by a fourth pregnancy, the risk of either adverse neonatal outcome was higher among offspring of women who had chosen the initial elective cesarean (0.368% vs. 0.363%).
Maternal morbidity associated with the choice of a primary elective cesarean increases in each subsequent pregnancy and is greater in magnitude than that associated with the choice of trial of labor. These increased risks are not offset by a substantive reduction in the risk of neonatal morbidity.