Background
Prior studies have reported an increased risk for preterm delivery following a term
cesarean delivery. However, these studies did not adjust for high-risk conditions
related to the first cesarean delivery and are known to recur.
Objective
The objective of the study was to determine whether there is an association between
term cesarean delivery in the first pregnancy and subsequent spontaneous or indicated
preterm delivery.
Study Design
This was a retrospective cohort study of women with the first 2 consecutive singleton
deliveries (2007–2014) identified through a linked pregnancy database at a single
institution. Women with a first pregnancy that resulted in cesarean delivery at term
were compared with women whose first pregnancy resulted in a vaginal delivery at term.
Exclusion criteria were known to recur medical or obstetrical complications during
the first pregnancy. A propensity score analysis was performed by matching women who
underwent a cesarean delivery with those who underwent a vaginal delivery in the first
pregnancy. The association between cesarean delivery in the first pregnancy and preterm
delivery in the second pregnancy in this matched set was examined using conditional
logistic regression. The primary outcome was overall preterm delivery <37 weeks in
the second pregnancy. Secondary outcomes included type of preterm delivery (spontaneous
vs indicated), late preterm delivery (34–36 6/7 weeks), early preterm delivery (<34
weeks), and small-for-gestational-age birth.
Results
Of a total of 6456 linked pregnancies, 2284 deliveries were matched; 1142 were preceded
by cesarean delivery and 1142 were preceded by vaginal delivery. The main indications
for cesarean delivery in the first pregnancy were dystocia in 703 (61.5%), nonreassuring
fetal status in 222 (19.4%), breech presentation in 100 (8.8%), and other in 84 (7.4%).
The mean (SD) gestational ages at delivery for the second pregnancy was 38.8 (1.8)
and 38.9 (1.7) weeks, respectively, for prior cesarean delivery and vaginal delivery.
The risks of preterm delivery in the second pregnancy among women with a previous
cesarean and vaginal delivery were 6.0% and 5.2%, respectively (adjusted odds ratio,
1.46, 95% confidence interval, [CI] 0.77–2.76). In an analysis stratified by the type
of preterm delivery in the second pregnancy, no associations were seen between cesarean
delivery in the first pregnancy and spontaneous preterm delivery (4.6% vs 3.9%; adjusted
odds ratio, 1.40, 95% confidence interval, 0.59–3.32) or indicated preterm delivery
(1.6% vs 1.4%; adjusted odds ratio, 1.21, 95% confidence interval, 0.60–2.46). Similarly,
no significant differences were found in late preterm delivery (4.6% vs 4.1%; adjusted
odds ratio, 1.13, 95% confidence interval, 0.55–2.29), early preterm delivery (1.6%
vs 1.2%; adjusted odds ratio, 1.25, 95% confidence interval, 0.59–2.67), or neonates
with birthweight less than the fifth percentile for gestational age (3.6% vs 2.2%;
adjusted odds ratio, 1.26, 95% confidence interval, 0.52–3.06).
Conclusion
After robust adjustment for confounders through a propensity score analysis related
to the indication for the first cesarean delivery at term, cesarean delivery is not
associated with an increase in preterm delivery, spontaneous or indicated, in the
subsequent pregnancy.
Key words
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Article info
Publication history
Published online: February 22, 2019
Accepted:
February 18,
2019
Received in revised form:
February 14,
2019
Received:
December 31,
2018
Footnotes
The authors report no conflicts of interest.
Cite this article as: 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;221:61.e1-7.
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© 2019 Elsevier Inc. All rights reserved.
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Access this article on ScienceDirectLinked Article
- Term cesarean delivery in the first pregnancy and increased risk for preterm delivery in the subsequent pregnancyAmerican Journal of Obstetrics & GynecologyVol. 222Issue 6
- PreviewWe read with great interest the article by Vahanian et al1 in the July 2019 issue. They used propensity scores to ascertain whether cesarean delivery in labor at term is a risk factor for preterm delivery in a subsequent pregnancy and found no association between cesarean delivery and preterm birth. Preterm birth is responsible for a massive health care burden, costing society more than 25 billion dollars per year in the United States alone.
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- The role of second-stage cesarean delivery in contributing to preterm deliveryAmerican Journal of Obstetrics & GynecologyVol. 222Issue 6
- PreviewWe thank Dr de Vries et al1 for their thoughtful comments regarding our recent publication “Term cesarean delivery in the first pregnancy is not associated with an increased risk for preterm delivery in the subsequent pregnancy.” Using propensity score analysis to evaluate for potential confounders, we found no association between previous cesarean delivery and subsequent preterm delivery. The nature of the study design did not allow for us to evaluate second-stage cesarean deliveries as a separate risk factor.
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