title: Maternal morbidity associated with multiple repeat cesarean deliveries.
abstract: OBJECTIVE
  Although repeat cesarean deliveries often are associated with serious morbidity, they account for only a portion of abdominal deliveries and are overlooked when evaluating morbidity. Our objective was to estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries.
  
  
  METHODS
  Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002).
  
  
  RESULTS
  There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively.
  
  
  CONCLUSIONS
  Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.
  
  
  METHODS
  II-2.
authors.affiliation: Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah 84132, USA. Bob.Silver@hsc.utah.edu
authors.forename: Robert M
authors.initials: RM
authors.lastname: Silver
authors.forename: Mark B
authors.initials: MB
authors.lastname: Landon
authors.forename: Dwight J
authors.initials: DJ
authors.lastname: Rouse
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Leveno
authors.forename: Catherine Y
authors.initials: CY
authors.lastname: Spong
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Thom
authors.forename: Atef H
authors.initials: AH
authors.lastname: Moawad
authors.forename: Steve N
authors.initials: SN
authors.lastname: Caritis
authors.forename: Margaret
authors.initials: M
authors.lastname: Harper
authors.forename: Ronald J
authors.initials: RJ
authors.lastname: Wapner
authors.forename: Yoram
authors.initials: Y
authors.lastname: Sorokin
authors.forename: Menachem
authors.initials: M
authors.lastname: Miodovnik
authors.forename: Marshall
authors.initials: M
authors.lastname: Carpenter
authors.forename: Alan M
authors.initials: AM
authors.lastname: Peaceman
authors.forename: Mary J
authors.initials: MJ
authors.lastname: O'Sullivan
authors.forename: Baha
authors.initials: B
authors.lastname: Sibai
authors.forename: Oded
authors.initials: O
authors.lastname: Langer
authors.forename: John M
authors.initials: JM
authors.lastname: Thorp
authors.forename: Susan M
authors.initials: SM
authors.lastname: Ramin
authors.forename: Brian M
authors.initials: BM
authors.lastname: Mercer
mesh_terms: D017604:Cesarean Section, Repeat / Q000009:adverse effects*; D015897:Comorbidity; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000706:statistics & numerical data; D016015:Logistic Models; D009017:Morbidity; D016017:Odds Ratio; D010921:Placenta Accreta / Q000453:epidemiology; D010923:Placenta Previa / Q000453:epidemiology; D011247:Pregnancy; D011446:Prospective Studies; D014219:Trial of Labor