In the JournalsPerspective

Cesareans increase risk for offspring complications, decrease risk for maternal complications

Children delivered by cesarean were at higher risk for obesity and asthma, but cesarean deliveries were linked to a lower risk of pelvic prolapse and urinary incontinence among mothers, according to a systematic review and meta-analysis recently published in PLOS Medicine.

Researchers said this lower risk for pelvic organ relapse and urinary incontinence should be weighed against a higher risk for infertility. “Although previous systematic reviews have assessed individual outcomes, we have found no other published reviews synthesizing the evidence for all long-term risks and benefits of cesarean delivery relating to mother, baby, and subsequent pregnancies,” Oonagh E. Keag, MBchB, of the department of obstetrics and gynecology at the Royal Infirmary of Edinburgh, United Kingdom, and colleagues wrote. “There is a lack of documented evidence about medium- to long-term outcomes in women and their babies after a planned cesarean delivery or a planned vaginal birth.”

According to the authors, nearly one in three pregnancies in North America results in a cesarean delivery.

Researchers looked at 79 cohort studies and one randomized controlled trial containing more than 29.9 million participants. According to Keag and colleagues, these studies were performed in high-income countries and had follow-up data of 1 year or more from index delivery date.

They found offspring delivered via cesarean delivery had higher risk for:

  • asthma before turning 12 years old (OR = 1.21; 95% CI, 1.11-1.32); and
  • obesity before turning 5 years old (OR = 1.59; 1.33-1.9).

Researchers also found that compared with vaginal delivery at 37 or more weeks, cesarean delivery was associated with lower risk for:

  • pelvic organ prolapse (OR = 0.29; 95% CI, 0.17-0.51) in the mother; and
  • urinary incontinence (OR = 0.56; 95% CI, 0.47-0.66) in the mother.

However, pregnancy after cesarean delivery was linked to higher risk for:

  • miscarriage (OR = 1.17; 95% CI, 1.03-1.32);
  • stillbirth (OR = 1.27; 95% CI, 1.15-1.4);
  • placenta previa (OR = 1.74; 95% CI, 1.62-1.87);
  • placenta accreta (OR = 2.95; 95% CI, 1.32-6.6); and
  • placental abruption (OR = 1.38, 95% CI, 1.27-1.49).

“We chose our outcomes a priori. Whilst this minimized bias, we have been unable to include some data from well-conducted prospective randomized trials,” Kaeg and colleagues wrote. “Examples include [two studies] both of which looked at neurodevelopmental outcomes at two years of age in children delivered by planned cesarean delivery vs. planned vaginal delivery. Neither study demonstrated statistically significant differences in the two delivery groups; therefore, including these would not have substantially altered the conclusions of our review.”

Researchers said their findings are “valuable” to doctors and expectant mothers alike.

“These findings might help enhance discussions between clinicians and patients regarding mode of delivery, meaning that patients will be better informed of the potential long-term risks and benefits of cesarean delivery for themselves, their offspring, and any future pregnancies,” Kaeg and colleagues wrote. - by Janel Miller

Disclosure: The authors did not declare any relevant financial disclosures.

Children delivered by cesarean were at higher risk for obesity and asthma, but cesarean deliveries were linked to a lower risk of pelvic prolapse and urinary incontinence among mothers, according to a systematic review and meta-analysis recently published in PLOS Medicine.

Researchers said this lower risk for pelvic organ relapse and urinary incontinence should be weighed against a higher risk for infertility. “Although previous systematic reviews have assessed individual outcomes, we have found no other published reviews synthesizing the evidence for all long-term risks and benefits of cesarean delivery relating to mother, baby, and subsequent pregnancies,” Oonagh E. Keag, MBchB, of the department of obstetrics and gynecology at the Royal Infirmary of Edinburgh, United Kingdom, and colleagues wrote. “There is a lack of documented evidence about medium- to long-term outcomes in women and their babies after a planned cesarean delivery or a planned vaginal birth.”

According to the authors, nearly one in three pregnancies in North America results in a cesarean delivery.

Researchers looked at 79 cohort studies and one randomized controlled trial containing more than 29.9 million participants. According to Keag and colleagues, these studies were performed in high-income countries and had follow-up data of 1 year or more from index delivery date.

They found offspring delivered via cesarean delivery had higher risk for:

  • asthma before turning 12 years old (OR = 1.21; 95% CI, 1.11-1.32); and
  • obesity before turning 5 years old (OR = 1.59; 1.33-1.9).

Researchers also found that compared with vaginal delivery at 37 or more weeks, cesarean delivery was associated with lower risk for:

  • pelvic organ prolapse (OR = 0.29; 95% CI, 0.17-0.51) in the mother; and
  • urinary incontinence (OR = 0.56; 95% CI, 0.47-0.66) in the mother.

However, pregnancy after cesarean delivery was linked to higher risk for:

  • miscarriage (OR = 1.17; 95% CI, 1.03-1.32);
  • stillbirth (OR = 1.27; 95% CI, 1.15-1.4);
  • placenta previa (OR = 1.74; 95% CI, 1.62-1.87);
  • placenta accreta (OR = 2.95; 95% CI, 1.32-6.6); and
  • placental abruption (OR = 1.38, 95% CI, 1.27-1.49).

“We chose our outcomes a priori. Whilst this minimized bias, we have been unable to include some data from well-conducted prospective randomized trials,” Kaeg and colleagues wrote. “Examples include [two studies] both of which looked at neurodevelopmental outcomes at two years of age in children delivered by planned cesarean delivery vs. planned vaginal delivery. Neither study demonstrated statistically significant differences in the two delivery groups; therefore, including these would not have substantially altered the conclusions of our review.”

Researchers said their findings are “valuable” to doctors and expectant mothers alike.

“These findings might help enhance discussions between clinicians and patients regarding mode of delivery, meaning that patients will be better informed of the potential long-term risks and benefits of cesarean delivery for themselves, their offspring, and any future pregnancies,” Kaeg and colleagues wrote. - by Janel Miller

Disclosure: The authors did not declare any relevant financial disclosures.

    Perspective

    Cesarean delivery remains one of the most common surgical procedures worldwide and now accounts for approximately one in three births in the United States. Immediate complications of cesarean delivery include increased bleeding, infection, damage to nearby pelvic structures, venous thromboembolism, maternal length of stay and neonatal respiratory morbidity. Keag et al recently identified the long-term risks of cesarean delivery in a meta-analysis and systematic review. These include an increased rate of placenta previa and accreta in subsequent pregnancies, and an increased risk of childhood asthma and obesity for the offspring of such deliveries. This study identified a decreased rate of urinary incontinence with cesarean delivery compared to vaginal delivery. Importantly, however, other studies have shown that this potential benefit is limited to the first year after cesarean delivery and that at 2 and 5 years there is no difference in the rate of stress urinary incontinence.

    This study found an increased rate of miscarriage, stillbirth, and placental abruption in subsequent pregnancies, findings that are not typically ascribed to cesarean delivery. Important findings not highlighted in this study include the increased risk in subsequent pregnancies of uterine rupture, visceral injury, blood transfusion, hysterectomy, adhesive disease, hysterotomy scar pregnancy, and incisional endometriosis.

    Careful assessment of the balance between the risk of pelvic floor dysfunction with vaginal delivery and the surgical and obstetric risks of cesarean has led the American Congress of Obstetricians and Gynecologists (ACOG) to conclude that vaginal delivery remains the safest option for most pregnant women. While the impact of incontinence and prolapse should not be dismissed, neither should a life-threatening condition. In contrast, the rising rates of cesarean delivery have led to rising rates of invasive placentation (placenta accreta, increta and percreta) which can be deadly both for mother and infant and require intense resource utilization to achieve safe outcomes.

    An important question, therefore, is how obstetric providers will implement efforts to safely prevent the primary cesarean delivery. Efforts by ACOG have focused on standardized interpretation and management of fetal heart rate tracings, external cephalic version for breech presentation, trial of labor for women with twin gestations when the first twin is in cephalic presentation, consistent management of first and second stage of labor, appropriate maternal weight gain, and avoiding cesarean delivery on maternal request.

    This analysis from Keag et al. contributes to knowledge of the long-term risks of cesarean delivery. What remains for obstetric providers is to effectively identify women and children that will most benefit from this intervention. Hospital systems, payers, and most importantly patients should expect that their providers are practicing consistent with current guidelines to safely prevent the first cesarean delivery.

    • Dana R. Gossett and Jeffrey D Sperling
    • Professor of Obstetrics, Gynecology, and Reproductive Sciences, Grace Marie Waldrop Chair of Obstetrics and Gynecology Division Director, University of California at San Francisco (Gossett) Clinical Fellow in Maternal-Fetal Medicine, University of California San Francisco (Sperling)

    Disclosures: Neither Gossett nor Sperling have any relevant financial disclosures.