Prior Cesarean Surgery Increases Future Likelihood of Stillbirth

Last month yet another study appeared reporting that compared with first vaginal birth, first cesarean increased the likelihood of late antepartum fetal death in the next pregnancy. The study encompassed 10,712 women with one prior birth who had pregnancy duration of 34 weeks or more and were carrying a single, normally-formed fetus. With first delivery via cesarean (22%), the fetal death rate at or beyond 34 weeks’ gestation in the next pregnancy was 2.5 per 1000 compared with 0.5 per 1000 with first birth vaginally, or 2 more late antepartum fetal deaths per 1000 with first delivery via cesarean surgery.

I say “yet another study” because it joins eight others. Six of the eight, one each in Scotland, England , Germany, and Canada and two in Australia, one in South Australia and the other in New South Wales, also reported more late fetal deaths with first cesarean delivery. In two of them, the difference failed to achieve statistical significance, meaning the difference may have been due to chance, but the number of women having a first cesarean was too small to reliably detect a difference. A third study among the six did not perform a significance calculation. The seventh study, conducted in Missouri,  reported an excess among black women but not white women. Mortality rates varied substantially from study to study, but excesses with prior cesarean were similar, ranging from 0.3 to 1.6 per 1000 (mean 1.1 per 1000). The eighth study, a U.S. national study , reported no difference (0.7 per 1000 first cesarean delivery vs. 0.8 per 1000 first birth vaginal) in women with one prior birth, no underlying medical conditions, and a fetus with no structural or chromosomal abnormalities. The gap actually may be wider than appears. Some of the studies restricted analysis to unexplained deaths, which excluded deaths secondary to placenta previa, and accreta and placental abruption, all of which are associated with prior cesarean.

The consistency of this finding is compelling, but you may be thinking that it shouldn’t be surprising because some of the reasons that may lead to cesarean in the first pregnancy would increase the risk of fetal demise in the next pregnancy. Ah, but unlike the other studies, which used population databases, this one was conducted at a single hospital, which means investigators could explore the effect of confounding factors. They found that the association remained statistically significant after controlling for maternal age, height, weight, hypertension, and diabetes, and it strengthened when they confined analysis to women known to have first births to a full-term live infant (n = 4425): 6 per 1000 with first delivery by cesarean versus 1 per 1000 with first birth vaginal, or 5 more late antepartum deaths per 1000 in women with first cesarean delivery in this subgroup. The cause of the excess is unknown, but it would appear that a scarred uterus becomes a less hospitable environment for pregnancy.

Certainly, this risk should not deter performing a cesarean when the health of mother or baby is at stake or everything has been tried, but it seems unlikely that the baby can be born vaginally. However, with one in three first time mothers delivering via cesarean surgery, for many cesareans, clearly, this is not the case. Many cesareans could be prevented with better labor management and by having more patience. As the ninth study concludes, “Our findings reinforce the importance of considering the impact cesarean birth may have on future pregnancies when making decisions regarding method of birth” (p. 16). Amen to that.

Authoritative Knowledge, Cesarean Birth, Guest Posts ,

  1. | #1

    I agree with you that we need to decrease the number of cesarean births for many reasons. However, I must disagree with your assertion that “Many cesareans could be prevented with better labor management and by having more patience.” Do you have any science that would indicate that the labor management suggested in this link actually results in better cesarean birth utilization? I have spent the last six years developing software tools that can prove or disprove your assertion. All you need to do is to have the obstetrical care providers that use these “better labor management” skills also use my software and once and for all we will have a scientific answer. The software is free and is the only software available that can measure and compare labor management skills. Until then, anyone can claim that they have the “better labor management”.

  2. | #2

    Change will have to come from the mothers. Economic factors seem to be the only ones that make an impact on doctors and hospitals today. Women must discover the C-section rates of their doctors and of the hospitals that they plan to use. It is hard to do this. They will “stonewall” you with all kinds of stories about how you cannot compare apples to oranges. That may be true. But you can certainly draw some conclusions from the over all number of C-sections performed. I wish women would be more pro-active BEFORE they have their first C-section.
    Don’t use a doctor with a high rate of sectioning women. Don’t go to a hospital with a high rate. Anything over 24% is high. In the 1960s the C-section rate was 7%.
    I have been more and more discouraged by the growing rate of surgical birth. http://www.childbirthsolutions.com discusses this and encourages your comments.
    Nothing will change unless we make it change. The doctors and hospitals have no incentive to change by themselves. They do not really care what type of birth you have. If you have a surgical birth it is more convenient for them. Easier to plan, schedule, staff and control. Why mess up a great trend? No, if we want things to improve for MOTHERS and BABIES, then we must force the change on the “establishment”. And we had better do it soon.

  3. avatar
    Susan Brockmann
    | #3

    yes yes Bonnie!!

  4. | #4

    @Gustavo San Roman, MD
    There is abundant evidence supporting the Lamaze healthy birth practices. Each one has a white paper that includes citations. Here, for example, is the link to “Let labor begin on its own”: http://www.lamaze.org/ChildbirthEducators/ResourcesforEducators/CarePracticePapers/LaborBeginsOnItsOwn/tabid/487/Default.aspx. The Lamaze healthy birth practices originated in the World Health Organization’s principles for safe, healthy birth described in its publication *Care in Normal Birth: A Practical Guide*. They are also supported by *Evidence Basis for the Ten Steps of Mother-Friendly Care* http://motherfriendly.org/Resources/Documents/CIMS_Evidence_Basis.pdf, *A Guide to Effective Care in Pregnancy and Childbirth*, and my and Amy Romano’s forthcoming book *Optimal Care in Childbirth: The Case for a Physiologic Approach*.

  5. avatar
    Joyce Wade
    | #5

    In 1990, when I worked as a nurse in a Harvard-based hospital in Boston, there was a “common-sense”-approach to “better labor management.” If a woman stated she wanted natural childbirth upon admission to the labor floor she was given one-on-one nursing care–it was almost written in stone. The anesthesiologists were also forbidden from her room (all other patients were consented for possible epidural on admission). The nurse would never ask if she wanted pain meds or epidural and the woman was informed on admission if she changed her mind she would have to tell us this. I know that today, everything we do in caring for women & children has to be evidence-based; but I’m an old-timer that wishes we still could use common sense sometimes. That’s why I’m thankful for you, Henci, for the great service you provide in this arena.

  6. | #6

    @Joyce Wade
    In point of fact, there is no conflict between “common sense” and “evidence-based”–not to mention “logical”–when it comes to what care best promotes safe, healthy birth. Thank you for your kind words.

  1. | #1

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