Risk of complications in a second pregnancy following caesarean section in the first pregnancy: a population-based study

Lee K Taylor, Judy M Simpson, Christine L Roberts, Emily C Olive and David J Henderson-Smart
Med J Aust 2005; 183 (10): 515-519.


Objective: To estimate the risks of maternal and perinatal morbidity and mortality in a second pregnancy, attributable to caesarean section in a first pregnancy.

Design and setting: Cross-sectional analytic study of hospital births in New South Wales, based on linked population databases.

Participants: 136 101 women with one previous birth who gave birth to a singleton infant in NSW in 1998–2002.

Main outcome measures: Crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) for maternal and perinatal morbidity and mortality.

Results: 19% of mothers had a caesarean section in their first pregnancy. Compared with mothers who had had primary vaginal births, mothers who had had primary caesarean section and undewent labour in the second birth were at increased risk of uterine rupture (aOR, 12.3; 95% CI, 5.0–30.1; P < 0.0001), hysterectomy (3.5; 1.5–8.4; P < 0.01), postpartum haemorrhage (PPH) following vaginal delivery (1.6; 1.4–1.7; P < 0.0001), manual removal of placenta (1.3; 1.1–1.6; P < 0.01), infection (6.2; 4.7–8.2; P < 0.0001) and intensive care unit (ICU) admission (3.1; 2.1–4.7; P < 0.0001); among mothers who did not undergo labour (ie, had an elective caesarean section), there was a lower risk of PPH (0.6; 0.5–0.7; P < 0.0001) and ICU admission (0.4; 0.3–0.5; P < 0.0001). For infants there was increased risk of preterm delivery (1.2; 1.1–1.3; P < 0.0001) and neonatal intensive care unit admission following labour (1.6; 1.4–1.9; P < 0.0001) in the birth after primary caesarean section. The occurrence of stillbirth was not modified by labour.

Conclusions: Caesarean section in a first pregnancy confers additional risks on the second pregnancy, primarily associated with labour. These should be considered at the time caesarean section in the first pregnancy is being considered, particularly for elective caesarean section for non-medical reasons.

Please login with your free MJA account to view this article in full

  • Lee K Taylor1
  • Judy M Simpson2
  • Christine L Roberts3
  • Emily C Olive4
  • David J Henderson-Smart5

  • 1 NSW Department of Health, Sydney, NSW.
  • 2 University of Sydney, Sydney, NSW.



We thank Kim Lim (data linkage) and Alan Willmore, Jill Kaldor and Tim Churches (maintenance of the SAS-based data warehouse on which the source and linked datasets were held and analysed) of the NSW Department of Health Centre for Epidemiology and Research.

Competing interests:

Lee Taylor is supported by a National Health and Medical Research Council (NHMRC) Capacity Building Grant in Population Health Research to the Health Evaluation and Research Outcomes Network (HERON). HERON is a collaborative program auspiced by the Institute for Health Research, the University of New South Wales, University of Technology Sydney, the Cancer Council of NSW and the NSW Department of Health. Christine Roberts is supported by an NHMRC Public Health Practitioner Fellowship. The NHMRC did not control or influence the decision to submit the final manuscript for publication.

  • 1. Smith GCS, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet 2003; 362: 1779-1784.
  • 2. Thomas J, Paranjothy S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National sentinel caesarean section audit report. London: RCOG Press, 2001.
  • 3. National Center for Health Statistics. Health, United States, 2002. With Chartbook on Trends in the Health of Americans. Hyattsville: NCHS, 2002.
  • 4. Belizan JM, Althabe F, Barros FC, Alexander S. Rates and implications of caesarean sections in Latin America: ecological study. BMJ 1999; 319: 1397-1400.
  • 5. Lin H-C, Xirasagar S. Institutional factors in cesarean delivery rates: policy and research implications. Obstet Gynecol 2004; 103: 128-136.
  • 6. Koc I. Increased cesarean section rates in Turkey. Eur J Contracept Reprod Health Care 2003; 8: 1-10.
  • 7. Chanrachakul B, Herabutya Y, Udomsubpayakul U. Epidemic of cesarean section at the general, private and university hospitals in Thailand. J Obstet Gynaecol Res 2000; 26: 357-361.
  • 8. Laws PJ, Sullivan EA. Australia’s mothers and babies 2002. Perinatal Statistics Series No. 15. Sydney: National Perinatal Statistics Unit, 2004. (AIHW Catalogue No: PER 28)
  • 9. Gregory KD, Korst LM, Cane P, et al. Vaginal birth after cesarean and uterine rupture rates in California. Obstet Gynecol 1999; 94: 985-989.
  • 10. Lydon-Rochelle M, Holt VL, Easterling TR, Martin D. First-birth cesarean and placental abruption or previa at second birth. Obstet Gynecol 2001; 97: 765-769.
  • 11. Crane JM, Van den Hof MC, Dodds L, et al. Maternal complications with placenta previa. Am J Perinatol 2000; 17: 101-105.
  • 12. Smith GCS, Pell JP, Cameron AD, Dobbie R. Risk of perinatal death associated with labour after previous cesarean delivery in uncomplicated term pregnancies. JAMA 2002; 287: 2684-2690.
  • 13. Mozurkewich EL, Hutton EK. Elective repeat cesarean delivery versus trial of labour: a meta-analysis of the literature from 1989 to 1999. Am J Obstet Gynecol 2000; 183: 1187-1197.
  • 14. Guise JM, Berlin M, McDonagh M, et al. Safety of vaginal birth after cesarean: a systematic review. Obstet Gynecol 2004; 103: 420-429.
  • 15. Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004; 351: 2581-2589.
  • 16. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995; 102: 101-106.


remove_circle_outline Delete Author
add_circle_outline Add Author

Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Responses are now closed for this article.