cesarean delivery case study

• Introduction
• Conclusions
• Article Information

eTable 1. Histopathology and International Classification of Diseases ( ICD ) to Identify Colorectal Cancer

eTable 2. Characteristics of Excluded Cases and Controls Due to Lack of Birth Records, Sweden, 1991-2017

eTable 3. E-Values for the Association Between Birth via Cesarean Delivery and Risk of Early-Onset Colorectal Cancer

eTable 4. Birth via Cesarean Delivery and Risk of Early-Onset Colorectal Cancer According to Anatomic Site

eFigure. Flow Chart of Study Population

Data Sharing Statement

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Cao Y , Nguyen LH , Tica S, et al. Evaluation of Birth by Cesarean Delivery and Development of Early-Onset Colorectal Cancer. JAMA Netw Open. 2023;6(4):e2310316. doi:10.1001/jamanetworkopen.2023.10316

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Evaluation of Birth by Cesarean Delivery and Development of Early-Onset Colorectal Cancer

• 1 Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
• 2 Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, Missouri
• 3 Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
• 4 Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston
• 5 Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston
• 6 Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
• 7 Department of Surgery, Washington University School of Medicine, St Louis, Missouri
• 8 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
• 9 Broad Institute of MIT and Harvard, Cambridge, Massachusetts
• 10 Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
• 11 Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
• 12 Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
• 13 Division of Women’s Health, Department of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
• 14 Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
• 15 Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York

Question   Is birth by cesarean delivery associated with risk of early-onset colorectal cancer (CRC)?

Findings   In this nationwide case-control study of 564 individuals with incident early-onset CRC and matched control individuals in Sweden, compared with birth by vaginal delivery, birth by cesarean delivery was not associated with early-onset CRC in the overall population. While no association was observed among males, a positive association was found among females.

Meaning   In this study, females born by cesarean delivery had greater odds of early-onset CRC, suggesting that early-life gut dysbiosis may contribute to early-onset CRC in females.

Importance   The incidence of early-onset colorectal cancer (CRC), diagnosed younger than 50 years of age, has increased worldwide. Gut dysbiosis throughout the life course is hypothesized as a leading mechanism, yet epidemiologic data are limited.

Objective   To prospectively examine the association between birth by cesarean delivery and early-onset CRC among offspring.

Design, Setting, and Participants   In this population-based, nationwide case-control study in Sweden, adults diagnosed with CRC between 18 and 49 years of age from 1991 to 2017 were identified through the Epidemiology Strengthened by Histopathology Reports in Sweden (ESPRESSO) cohort. Up to 5 general population control individuals without CRC were matched with each case on age, sex, calendar year, and county of residence. Pathology-confirmed end points were linked with the Swedish Medical Birth Register and other national registers. Analyses were conducted from March 2022 through March 2023.

Exposure   Birth by cesarean delivery.

Main Outcomes and Measures   The primary outcome was development of early-onset CRC in the overall population and by sex.

Results   We identified 564 case patients with incident early-onset CRC (mean [SD] age, 32.9 [6.2] years; 284 [50.4%] male) and 2180 matched controls (mean [SD] age, 32.7 [6.3] years; 1104 [50.6%] male). Compared with vaginal delivery, birth by cesarean delivery was not associated with early-onset CRC in the overall population (adjusted odds ratio [aOR], 1.28; 95% CI, 0.91-1.79) after multivariable adjustment for matching and maternal and pregnancy-related factors. A positive association was found for females (aOR, 1.62; 95% CI, 1.01-2.60), but there was no association for males (aOR, 1.05; 95% CI, 0.64-1.72).

Conclusions and Relevance   In this nationwide, population-based case-control study, birth by cesarean delivery was not associated with early-onset CRC compared with birth by vaginal delivery in the overall population in Sweden. However, females born by cesarean delivery had greater odds of early-onset CRC compared with individuals born through vaginal delivery. This finding suggests that early-life gut dysbiosis may contribute to early-onset CRC in females.

Colorectal cancer (CRC) incidence has increased among individuals younger than 50 years of age in the US 1 - 3 and multiple European countries, including Sweden, 4 with more advanced clinicopathological and distinct molecular features compared with CRC in older individuals. 2 , 5 - 7 While contributors to the increase in early-onset CRC remain to be identified, obesity, 8 , 9 prolonged sitting, 10 diabetes, 11 and metabolic syndrome 12 were all found to be positively associated with early-onset CRC, 5 supporting in-depth investigations of early-life origins of metabolic dysregulation. The gut microbiome, mechanistically involved in CRC pathogenesis, 13 - 21 captures substantial variations (approximately 22%-36%) in the aforementioned metabolic traits 22 - 25 and is therefore hypothesized to be at the crossroads between exposome and early-onset CRC. 26 - 29

In addition, in the US, each successive birth cohort has had a higher incidence of early-onset CRC than the previous one. 1 While the underlying reasons are unknown, this trend supports the hypothesis that early life exposures and changes in exposures throughout the life course over successive birth cohorts may contribute to the rising incidence of early-onset CRC. 30 Intriguingly, in many developed countries with an increasing incidence of early-onset CRC, a parallel increase in cesarean delivery rates has also been documented. 31 For instance, in Sweden, the rate of cesarean delivery increased from 5% in 1973 to 12.3% in 1983 and stabilized at 17% in recent years. 32 , 33 In the US, the rate of cesarean delivery was 5% between 1950 and the 1970s but rose to 24% in 1986, reached a peak of 33% in 2009, and stabilized around 30% thereafter. 34 Given the increasing prevalence of birth via cesarean delivery, understanding its associations with future health outcomes has become a critical unmet need. Documented short-term risks associated with birth via cesarean delivery include altered immune development; an increased likelihood of allergy, atopy, and asthma; and reduced intestinal gut microbiome diversity. 35 Studies on the long-term effects of cesarean delivery in offspring are limited; however, emerging evidence suggests that cesarean delivery may be associated with a higher risk of immune-mediated chronic inflammatory diseases, 36 , 37 obesity throughout the life course, 38 - 41 and diabetes, 42 likely mediated through early-life gut dysbiosis 43 - 45 that persists throughout adulthood.

Thus far, to our knowledge, the association between birth by cesarean delivery and risk of early-onset CRC has not been examined in epidemiologic studies. To address this critical knowledge gap, we leveraged data collected from Swedish registries to test the hypothesis that birth via cesarean delivery is a factor associated with early-onset CRC.

We conducted a nationwide, population-based case-control study using the Epidemiology Strengthened by Histopathology Reports in Sweden (ESPRESSO) cohort. In brief, the ESPRESSO study is a comprehensive data-harmonizing effort involving all 28 pathology departments in Sweden and any gastrointestinal (GI) pathology reports generated for clinical care or research purposes between 1965 and 2017. 46 This consortium has enrolled more than 2.1 million unique individuals with detailed information on GI topography, morphologic appearance, and pathologist’s diagnostic impression. The unique Swedish personal identity number was used to link ESPRESSO data to several national registers containing validated, prospectively recorded data on demographics and disease diagnoses 47 and the Swedish Medical Birth Register (MBR), with data on mode of birth since 1973. The MBR covers around 98% of all births in Sweden and contains data from the first antenatal visit until delivery and discharge from the delivery hospital. Completeness of pregnancy and neonatal outcomes in the MBR is bolstered by cross-comparison with the Total Population Register to identify missing records and standardization of electronic health records across the country as well as by Sweden’s universally accessible obstetric care. 48 , 49 This study was approved by the Stockholm Ethics Review Board. Informed consent was waived, as the study was registry based. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline for case-control studies.

We identified individuals in the ESPRESSO study with GI tract histopathologic findings compatible with a diagnosis of incident CRC between age 18 and 49 years from 1991 to 2017 (eTable 1 in Supplement 1 ). We then cross-referenced potential cases with their inpatient and outpatient records for International Classification of Diseases, Seventh Revision (ICD-7) , Eighth Revision (ICD-8) , and Ninth Revision (ICD-9) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes consistent with CRC (eTable 1 in Supplement 1 ), thus requiring both compatible histopathologic findings and registry-level case confirmation. Information on the date of diagnosis and tumor location were retrieved. Incident cases of CRC were matched with up to 5 control individuals from the general population based on age at index (continuous), sex (categorical), calendar year (continuous), and county of residence 50 (categorical). 46 We excluded cases and controls with prior inflammatory bowel disease (IBD) and hereditary cancers.

We identified mothers to cases and controls through the MBR and extracted information on the mode of birth. For covariates, a list of maternal and pregnancy-related factors was selected a priori, including maternal history of cesarean delivery, maternal age at delivery, maternal country of birth, whether the mother lived with a partner, maternal educational level, and parity. Birth characteristics were also extracted from the MBR, including gestational age (weeks), birth weight (grams), and birth length (centimeters). We leveraged both the MBR and the National Patient Register to retrieve information on diagnoses of maternal comorbidities, including diabetes (pregestational and gestational), hypertension, preeclampsia, and IBD.

We evaluated the association between birth by cesarean delivery and odds of early-onset CRC as the primary analysis. As secondary analyses, we investigated whether the findings in the primary analysis differed according to sex and anatomic site of the tumor.

Multivariable conditional logistic regression was used to estimate adjusted odds ratios (aORs) and 95% CIs. In addition to condition on matching factors (age, sex, calendar year, and county of residence), we adjusted for maternal and pregnancy-related factors as the main multivariable analyses: previous cesarean delivery (yes, no), maternal age (≤24, 25-29, 30-34, or ≥35 years), maternal country of birth (Nordic, non-Nordic), living with a partner (yes, no), maternal educational level (elementary, secondary, or college), and parity (1, 2, 3, or ≥4). Additionally, in a separate model, we adjusted for birth characteristics, including gestational age (<36, 37-39, 40-42, or ≥43 weeks), birth weight 51 (<2500, 2500 to <3000, 3000 to <3500, 3500 to <4000, or ≥4000 g), and birth length 52 (continuous), to assess whether the findings were mediated by these factors. Missingness was minimal (only for maternal educational level, gestational age, birth weight, and length, all less than 5%), and missing data were imputed using multiple imputation by chained equations methods with 5 iterations. 53

We conducted the following sensitivity analyses: (1) restricted to cases and controls aged 35 years or older to further minimize the impact of hereditary CRCs, (2) restricted to cases and controls without a maternal history of cesarean delivery to minimize potential confounding, and (3) restricted to cases and controls without maternal history of diabetes, gestational diabetes, hypertension, preeclampsia, and IBD up to the time of delivery to minimize confounding. E-values, which quantify the minimum effect required for an unmeasured confounder on both exposure and outcome to nullify the observed exposure-outcome associations, were calculated to evaluate the effects of unmeasured confounding. 54 , 55 All analyses were performed in SAS, version 9.4 (SAS Institute Inc). Data were analyzed from March 2022 through March 2023.

We identified 705 individuals aged 18 to 49 years with incident early-onset CRC in ESPRESSO from 1991 to 2017 and 3509 eligible controls after matching on age, sex, calendar year, and county of residence. After linking with birth records, a total of 564 cases (mean [SD] age, 32.9 [6.2] years; 280 [49.6%] female and 284 [50.4%] male; 154 [27.3%] with rectal cancer) and 2180 controls (mean [SD] age, 32.7 [6.3] years; 1076 [49.4%] female and 1104 [50.6%] male) remained in the final analyses ( Table 1 , Table 2 , and eFigure in Supplement 1 ), with similar characteristics as those among cases and controls not linked with birth records (eTable 2 in Supplement 1 ). All of the included 564 cases were matched with at least 1 control, with the majority (505 [89.5%]) matched with 3 to 5 controls. Compared with mothers of matched controls, mothers of the case patients had similar age at delivery and distribution of country of birth, proportion who lived with a partner, educational level, and parity but were more likely to have a history of cesarean delivery, diabetes, and IBD. No apparent differences were observed for gestational length, birth weight, and birth length. A higher percentage of early-onset CRC cases (55 of 564 [9.8%]) were born through cesarean delivery compared with controls (175 of 2180 [8.0%]).

Overall, individuals who were born through cesarean delivery did not have significantly higher odds of early-onset CRC (aOR, 1.28; 95% CI, 0.91-1.79) ( Table 3 ) after multivariable adjustment of matching and maternal and pregnancy factors, including previous cesarean delivery, maternal age, country of birth, living with a partner, educational level, and parity. A positive association was found among females (aOR, 1.62; 95% CI, 1.01-2.60), but there was no association among males (aOR, 1.05; 95% CI, 0.64-1.72). An unmeasured confounder would need to be associated with both birth via cesarean delivery and early-onset CRC with an OR of at least 2.62 to nullify the association observed among females (eTable 3 in Supplement 1 ). We also observed similar associations after further adjusting for birth characteristics, including gestational age, birth weight, and birth length ( Table 3 ).

For females, the association was also similar after restricting to those aged 35 years or older at the index date (aOR, 2.13; 95% CI, 1.02-4.48), those without maternal history of cesarean delivery (aOR, 1.63; 95% CI, 1.00-2.66), or those without maternal history of diabetes, gestational diabetes, hypertension, preeclampsia, or IBD (aOR, 1.70; 95% CI, 1.05-2.74) ( Table 4 ).

We further examined whether the positive association for females differed according to anatomic sites of CRC (colon vs rectal). For colon cancer, the aOR was 1.77 (95% CI, 1.05-3.01), while for rectal cancer, the aOR was 1.29 (95% CI, 0.42-4.02) (eTable 4 in Supplement 1 ).

In this population-based case-control study that included 564 patients with early-onset CRC, we found no association between birth by cesarean delivery and early-onset CRC compared with birth by vaginal delivery in the overall population. However, we identified an association between birth by cesarean delivery and higher odds of early-onset CRC among females, and this association was not mediated by birth characteristics. To our knowledge, this is among the first analyses leveraging prospectively collected data to examine the association between birth by cesarean delivery and risk of CRC, with a focus on early-onset CRC. Although preliminary, our findings lend initial support to the hypothesis that early-life gut dysbiosis may contribute to the rising incidence of early-onset CRC in females, calling for validation and mechanistic studies. If validated, modeling studies 56 are needed to elucidate the contribution of cesarean delivery to the rising incidence of early-onset CRC, especially among women.

The mechanisms linking birth by cesarean delivery to higher risk of early-onset CRC remain unexplored, although effects on the developing gut microbiome are a suspected mediator. 26 Among various perinatal factors affecting the transfer of the maternal microbiome, cesarean delivery exerts the strongest disruption, affecting both the diversity and the composition of early infancy microbiome, 57 with reported differences persisting through the first year of life. 43 , 45 , 58 , 59 For instance, gut bacterial colony load was significantly less at birth in infants born by cesarean delivery, with relatively reduced abundance of Bacteroides and Bifidobacterium species up to 6 months of life. 43 , 60 While preclinical studies have shown Bifidobacterium species to have anticancer properties in CRC through different mechanisms, 61 , 62 longitudinal studies with long-term follow-up and repeated microbiome profiling are needed to uncover the evolutionary dynamics of affected species and strains, 63 including interaction with host genetics. 64 Furthermore, early infancy is considered a critical period during which microbial differences significantly influence immune maturation. 43 , 65 - 67 In particular, the colon is the site of the greatest microbial colonization by cell count and biomass and possesses the largest immune exposure by density and surface area. 68 , 69 Accumulating evidence suggests that deficient or aberrant immune maturation may have an association with disease development later in life, 70 - 72 such as with the development of IBD—a condition that also has been associated with early-onset CRC. 73

Cesarean delivery has been associated with modest increased risk of obesity 38 - 42 , 74 and diabetes, 37 , 42 both of which are factors associated with early-onset CRC. 5 , 8 , 9 , 12 Recent evidence suggested that adolescents born by cesarean delivery had significantly lower levels of adiponectin and higher levels of insulin resistance compared with adolescents born by vaginal delivery, 75 further supporting the possibility that cesarean delivery may be associated with higher subsequent risk of early-onset CRC. More research is needed to elucidate the complex interplays between cesarean delivery, insulin resistance, and the microbiome-immune-cancer axis throughout the life course.

Notably, we observed an association between birth by cesarean delivery and early-onset CRC among females but not among males. Although the rise in early-onset CRC in Sweden was similar in women and men, 76 , 77 our findings suggest that risk factors and/or strengths of associations may differ by sex. Sex dimorphism has previously been observed in associations between cesarean delivery and chronic diseases. A prior study from Kaiser Permanente’s Northwest Region (US) reported an elevated risk of asthma among females (aOR, 1.53; 95% CI, 1.11-2.10) but not among males (aOR, 1.08; 95% CI, 0.81-1.43) born via cesarean delivery. 78 While evidence in humans is thus far limited, preclinical work suggests that sex hormones influence interactions between microbial signaling, the enteric immune system, and mucosal barrier functioning. 79 However, whether this physiology influences the development of early-onset CRC represents an important area of future study. To date, there is also a paucity of data exploring multigenerational trends in the microbiome and influence on disease development, although some researchers have hypothesized this may play a role in mother-daughter dyads and disease trends as rates of cesarean delivery have increased. 80 , 81

Strengths of our study include the use of national registries with extended follow-up to prospectively examine the association between birth via cesarean delivery and the odds of early-onset CRC, such that the findings are not influenced by maternal recall bias. Further, accuracy of CRC diagnosis may have been increased by the requirement of congruency in histopathologic findings and diagnostic codes. We were also able to adjust for a list of maternal factors to account for potential confounding.

There are also several limitations to this study. First, even though we leveraged a nationwide population-based cohort, the rate of cesarean delivery was relatively low in Sweden between 1970 and the 1980s compared with many developed countries, limiting our sample size and power, especially for additional analyses by CRC anatomic sites and elective vs emergency cesarean delivery (information available since 1999). As the mother usually does not experience rupture of the amniotic membrane until surgery, a newborn delivered by elective cesarean delivery has limited microbial colonization from the birth canal compared with a newborn born via emergency cesarean delivery, which is usually performed after the onset of physical labor and the rupture of membranes. 82 A prior study suggested that elective cesarean delivery but not emergency cesarean delivery was associated with an increased risk of childhood acute lymphoblastic leukemia. 83 Future studies are needed to elucidate whether this pertains to CRC and/or early-onset CRC. In addition, we did not adjust for indications for cesarean delivery (eg, fetopelvic disproportion, breech presentation, or fetal distress 32 ) unless they were known to be associated with risk of CRC, such as IBD. Second, no information on antibiotic prophylaxis for cesarean delivery and intrapartum antibiotic use was available. Although concerns about early-life exposure to broad-spectrum antibiotics and associated pervasive effects on the development of the gut microbiome and various disorders later in life are growing, 84 , 85 long-term data are limited. A recent randomized clinical trial 86 compared the microbiome composition of infants born via cesarean delivery with and without intrauterine antibiotic exposure and reported that cesarean delivery itself, but not antenatal antibiotic exposure, negatively affected microbiota development. Finally, residual confounding (eg, socioeconomic status of the family) could not be ruled out. Our findings were generally robust, supported by E-value analyses and sensitivity analyses including restricting to individuals without maternal history of a list of major comorbidities. We also attempted to conduct sibling analyses; however, only 6% of sibling pairs had different modes of delivery, and this study was underpowered to evaluate the association among siblings. Lack of information on maternal adiposity and weight gain during pregnancy 87 (body mass index data were only available since 1992) limited our capability to further assess their roles in the association identified. Validations in more racially and ethnically diverse populations, especially from other countries with rising incidence of early-onset CRC, are needed.

In this population-based case-control study, compared with birth by vaginal delivery, birth by cesarean delivery was not associated with early-onset CRC in the overall population in Sweden. Females born via cesarean delivery had greater odds of developing early-onset CRC compared with individuals born through vaginal delivery, but there was no association among males.

Accepted for Publication: March 13, 2023.

Published: April 27, 2023. doi:10.1001/jamanetworkopen.2023.10316

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Cao Y et al. JAMA Network Open .

Corresponding Author: Jonas F. Ludvigsson, MD, PhD, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, PO Box 281, SE-17177 Stockholm, Sweden ( [email protected] ).

Author Contributions: Drs Cao and Ludvigsson had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Cao, Otegbeye, Ludvigsson.

Acquisition, analysis, or interpretation of data: Cao, Nguyen, Tica, Zong, Roelstraete, Chan, Warner, Stephansson, Ludvigsson.

Drafting of the manuscript: Cao, Nguyen, Tica, Zong.

Critical revision of the manuscript for important intellectual content: Cao, Tica, Otegbeye, Zong, Roelstraete, Chan, Warner, Stephansson, Ludvigsson.

Statistical analysis: Cao, Otegbeye, Zong, Roelstraete.

Obtained funding: Cao, Ludvigsson.

Administrative, technical, or material support: Cao, Tica, Chan, Ludvigsson.

Supervision: Cao, Chan, Stephansson, Ludvigsson.

Conflict of Interest Disclosures: Dr Cao reported receiving personal fees from Geneoscopy for consulting outside the submitted work. Dr Chan reported serving as an investigator on studies supported by Pfizer, Freenome, and Zoe Ltd; receiving personal fees from Pfizer Inc, Boehringer Ingelheim, and Bayer Pharma AG; and receiving grants from Pfizer Inc, Zoe Ltd, and Freenome outside the submitted work. Dr Ludvigsson reported coordinating a study, on behalf of the Swedish inflammatory bowel disease quality register, that received funding from Janssen; receiving financial support from MSD to develop a paper reviewing national health care registers in China; and discussing potential research collaboration with Takeda outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by R37CA246175 (Dr Cao) and R35CA253185 (Dr Chan) from the US National Cancer Institute; K23DK125838 from the National Institute of Diabetes and Digestive and Kidney Disease (Dr Nguyen); a Research Fellowship Award and Career Development Award (Dr Nguyen) and a Senior Investigator Award (Dr Chan) from the Crohn’s and Colitis Foundation; the Research Scholars Award from the American Gastroenterological Association (Dr Nguyen); the Stuart and Suzanne Steele Research Scholars Award from Massachusetts General Hospital (Dr Chan); and the Swedish Cancer Foundation (Dr Ludvigsson). Dr Tica was supported by Washington University Pediatric Gastroenterology Research Training Program grant T32DK077653 from the National Institute of Diabetes and Digestive and Kidney Diseases. Dr Otegbeye was supported by Washington University School of Medicine Surgical Oncology Basic Science and Translational Research Training Program grant T32CA009621 from the National Cancer Institute.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

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• Published: 17 April 2024

Risk factors for relaparotomy after a cesarean delivery: a case-control study

• Uri Amikam 1 , 2 ,
• Yael Botkovsky 2 ,
• Alyssa Hochberg 2 , 3 ,
• Aviad Cohen 1 , 2 ,
• Ishai Levin 1 , 2 ,
• Yariv Yogev 1 , 2 ,
• Liran Hiersch 1 , 2 &
• Anat Lavie 1 , 2  

BMC Pregnancy and Childbirth volume  24 , Article number:  284 ( 2024 ) Cite this article

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Relaparotomy following a cesarean delivery (CD) is an infrequent complication, with inconsistency regarding risk factors and indications for its occurrence. We therefore aimed to determine risk factors and indications for a relaparotomy following a CD at a single large tertiary center.

A retrospective case-control single-center study (2013–2023). We identified all women who had a relaparotomy up to six weeks following a CD (study group). Maternal characteristics, obstetrical and surgical data were compared to a control group in a 1:2 ratio. Controls were women with a CD before and immediately after each case in the study group, who did not undergo a relaparotomy. Included were CDs occurring after 24 gestational weeks. CD performed at different centers and indications for repeat surgery unrelated to the primary surgery (e.g., appendicitis) were excluded. Logistic regression was used to adjust for potential confounders.

During the study period, 131,268 women delivered at our institution. Of them, 28,280 (21.5%) had a CD, and 130 patients (0.46%) underwent a relaparotomy. Relaparotomies following a CD occurred during the first 24 h, the first week, and beyond the first week, in 59.2%, 33.1%, and 7.7% of cases, respectively. In the multivariable logistic regression analysis, relaparotomy was significantly associated with Mullerian anomalies (aOR 3.33, 95%CI 1.08–10.24, p  = 0.036); uterine fibroids (aOR 3.17, 95%CI 1.11–9.05, p  = 0.031); multiple pregnancy (aOR 4.1, 95%CI 1.43–11.79, p  = 0.009); hypertensive disorders of pregnancy (aOR 3.46, 95%CI 1.29–9.3, p  = 0.014); CD during the second stage of labor (aOR 2.54, 95%CI 1.15–5.88, p  = 0.029); complications during CD (aOR 1.62, 95%CI 1.09–3.21, p  = 0.045); and excessive bleeding during CD or implementation of bleeding control measures (use of tranexamic acid, a hemostatic agent, or a surgical drain) (aOR 2.23, 95%CI 1.29–4.12, p  = 0.012). Indications for relaparotomy differed depending on the time elapsed from the CD, with suspected intra-abdominal bleeding (36.1%) emerging as the primary indication within the initial 24 h.

We detected several pregnancy, intrapartum, and intra-operative risk factors for the need for relaparotomy following a CD. Practitioners may utilize these findings to proactively identify women at risk, thereby potentially reducing their associated morbidity.

Peer Review reports

Cesarean delivery (CD) is the most common obstetrical surgery, with a rising incidence worldwide, increasing from approximately 12% in the year 2000 to 22–25% in 2018 [ 1 , 2 ] and reaching more than 32% in the United States in 2021 [ 3 ], making it one of the most common operations performed worldwide.

Although CD is considered a safe procedure, it confers a two-fold higher risk for severe maternal morbidity compared to vaginal delivery [ 4 ]. Amongst the maternal short-term complications after CD is hemorrhage, need for blood products transfusion, intra-abdominal infection, and injury to adjacent organs [ 5 , 6 , 7 ], which may warrant a repeat laparotomy (relaparotomy). Relaparotomy is defined as an abdominal operation performed after an initial surgery including skin opening [ 8 , 9 ] and entrance into the abdominal cavity [ 10 ]. A relaparotomy has major implications for the patient and her family and necessitates separating the parturient from her newborn. It also confers potential high maternal morbidity and mortality [ 11 , 12 ].

Data regarding relaparotomy after a CD is conflicting. In previous studies, the incidence of this complication ranges widely, with up to a more than ten-fold difference among various reports (0.07-0.9%) [ 5 , 7 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ]. Moreover, data demonstrates conflicting results regarding risk factors for the need for repeat surgery. For example, while some described multiple pregnancies as a risk factor [ 7 , 16 ], others did not find such an association [ 5 , 14 ]. Furthermore, some studies were limited only to re-surgeries due to excessive bleeding [ 9 , 19 ]. In addition, previous studies defined the time from the initial CD to the relaparotomy differently, with some limited to the same hospitalization as the original CD [ 13 , 20 ], whilst others included cases occurring up to one week [ 7 , 9 ], and even six weeks [ 5 ], after the CD. Additionally, there is a paucity of data regarding the indications for relaparotomy following CD stratified by the time interval from the CD to the repeated surgery, with only a few studies [ 5 , 15 ] elaborating on it. Lastly, most of the previous studies comprised a relatively small number of cases ranging between 18 and 64 [ 5 , 7 , 12 , 13 , 14 , 16 , 17 , 18 ], with only one comprising 80 patients [ 15 ].

Due to the infrequency of this complication and the wide variability in reported data, our objective was to ascertain the incidence of a relaparotomy after a CD and to identify risk factors for its occurrence, at a single tertiary center. Our secondary aim was to describe the indications for the relaparotomy according to the time elapsed from the initial surgery.

Study population

We conducted a retrospective case-control study between January 2013 and October 2023 in a large single-tertiary, university-affiliated, medical center, with over 12,000 deliveries annually. The local institutional review board (IRB) approved the study (TLV-0618-22).

The study group comprised patients who had a CD at our institution and needed a relaparotomy for indications related to the CD within six weeks following delivery. Relaparotomy was defined as the need for a repeated surgical intervention which included opening of the skin and entrance into the abdominal cavity. For each patient in the study group, controls were compared in a 1:2 ratio. Controls were women with a CD at > 24 weeks of gestation before and after each case in the relaparotomy group who did not require a relaparotomy. By selecting women who had a CD before and after each case, we aimed to minimize confounders related to the specific conditions in the operating theatre. At our institution, all CDs are performed by two surgeons; at least one of whom is a senior obstetrician or a resident in the second half of his residency period. All relaparotomies are performed by senior obstetrician-gynecologist surgeons.

Included in the study group were women who underwent both surgeries (i.e., CD and a relaparotomy) at our institution, were > 24 weeks of gestation at the CD, and who underwent intra-peritoneal exploration at the relaparotomy. Exclusion criteria included cases where repeat surgery was performed due to an indication unrelated to the primary surgery (appendicitis, etc.), or if the repeated surgery was performed more than 6 weeks following the CD. The study group was further divided into three groups based on the time interval from the CD to the relaparotomy: early relaparotomy (within 24 h), intermediate relaparotomy (between one to seven days), and late relaparotomy (between 7 days and 6 weeks).

Data collection

Medical records of all women who delivered at our institution during the defined study period were reviewed, and the patients who had a relaparotomy were identified. Patients’ data were anonymized and de-identified before the analysis. Data were extracted from the departmental electronic patient database and the operating records of the CD and relaparotomy surgeries. Antenatal follow-up test results and pregnancy outcomes are consistently recorded in the database during prenatal check-ups, upon admission for delivery, and postpartum.

Demographic and obstetric variables of the study cohort were recorded, including maternal age; pre-pregnancy body mass index (kg/m 2 ); maternal comorbidities, including chronic hypertension, and thrombophilia; uterine fibroids; Mullerian anomalies, including bicornuate uterus, unicornuate uterus, didelphic uterus, and septate uterus; pregnancy achieved by assisted reproductive technology (ART); gravidity; parity; multiple pregnancy; aspirin treatment during pregnancy; low molecular weight heparin (LMWH) use during pregnancy; prior CD; and pregnancy complications, including hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM), placenta previa, and placenta accreta spectrum (PAS). Delivery and surgery characteristics that were examined included: gestational age at delivery; preterm delivery (< 37 gestational weeks); neonatal birthweight; fever during labor (a temperature of 38.0 °C (100.4 °F) or higher taken at least twice at least 8 h apart); placental abruption (suspected on a clinical basis and confirmed on placental pathology examination); amniotic fluid color; time of day of the CD; surgeon’s experience and intra-operative findings, including surgery duration, CD defined as complicated (including intraabdominal adhesions, uterine incision extensions, calling for assistance during surgery, or bladder injury), or CD with excessive bleeding or use of bleeding control measures (including estimated blood loss (EBL) ≥ 1000 ml, tranexamic acid (TXA) use during surgery, use of a hemostatic agent (such as Gelfoam®, and Surgicell®), and use of surgical suction drain. EBL was assessed clinically during the CD and recorded in the operation room (OR) notes. Any intra-abdominal adhesions observed were recorded and described in the OR report. In the study group, the indication for relaparotomy, the time interval from the CD, and the relaparotomy findings were recorded.

The indications for CD were divided into elective or urgent. An elective CD was defined as a scheduled CD performed for maternal, fetal, or placental indications that posed a risk for vaginal delivery, such as a placenta previa or non-vertex presentation. An urgent CD was defined as a non-elective CD, including all CDs that occurred during labor and delivery, such as those due to labor dystocia, or a non-reassuring fetal heart.

Indications for the relaparotomy were divided into several categories, including suspected intra-abdominal bleeding; bleeding from the subcutaneous tissue; uterine atony and post-partum hemorrhage (PPH); infection, defined as sepsis, peritonitis, scar infection, or abscess formation; evisceration, defined as a defect in the integrity of the fascia; and suspected injury to adjacent organs, including the urinary tract system and the gastrointestinal system.

Post-surgery complications, which occurred after the CD or after the relaparotomy, were evaluated and included: maternal death; a thrombotic event in the post-partum period (up to 6 weeks following the CD); intensive care unit (ICU) admission; paralytic ileus; post-partum fever; need for readmission; and hospitalization length. The rate of future deliveries at our institution was also recorded until the end of the study period in October 2023.

Statistical analysis

Parameters were compared between the study and control groups. Univariate analysis was performed using the Mann–Whitney U test, chi-square, and Fisher’s exact tests as appropriate. Multivariable logistic regression analysis was used to identify factors associated with relaparotomy after CD. Variables that were found to be significantly different between the groups ( p  < 0.05) in the univariate analysis entered the initial regression model. Differences were considered significant when the two-sided P -value was < 0.05. Statistical analysis was performed using SPSS 25.0 (IBM Corporation, Chicago, USA) software.

During the study period, 131,268 women delivered at our institution. Of them, 28,280 (21.5%) had a CD. Overall, 130 patients (0.46%) underwent relaparotomy after CD. These women were compared to a control group, which included 260 women, who had a CD before and after each case in the study group.

Maternal demographics and gestational characteristics are presented in Table  1 . In the univariate analysis, relaparotomy after a CD, compared to the control group, was associated with the following: Mullerian anomalies (6.2% vs. 3.1%, p  = 0.014); uterine fibroids (6.9% vs. 3.5%, p  = 0.009); ART (27.7% vs. 10.4%, p  < 0.001); multiple pregnancy (11.5% vs. 3.8%, p  = 0.003); HDP (13.8% vs. 4.2%, p  < 0.001); and LMWH use during pregnancy (9.2% vs. 3.8%, p  = 0.03).

The labor and CD characteristics are presented in Table  2 . In the univariate analysis, relaparotomy after a CD, compared to the control group, was associated with the following: preterm labor (25.4% vs. 14.2%, p  = 0.007); placental abruption (9.2% vs. 1.9%, p  < 0.001); lower birthweight (2875 ± 799 gram vs. 3062 ± 642 gram, p  = 0.015); CD during the second stage of labor (14.6% vs. 5.8%, p  = 0.004); longer CD duration (41.5 ± 28.2 min vs. 30.4 ± 11.6 min, p  < 0.001); increased rate of complicated CD (47.7% vs. 26.9%, p  < 0.001); and an increased rate of CD with excessive bleeding or use of bleeding control measures (46.9% vs. 18.5%, p  < 0.001). Regarding postoperative complications, which occurred after the CD or the relaparotomy, women in the study group had a higher incidence of ICU admission (43.8% vs. 0.8%, p  < 0.001); paralytic ileus (6.2% vs. 0.4%, p  < 0.001); post-partum fever (16.9% vs. 0.8%, p  < 0.001); a longer duration of hospitalization (9.9 ± 7.9 days, 5.4 ± 4.1days, p  < 0.001); and lower rates of future deliveries (6.2% vs. 22.3%, p  < 0.001).

Multivariable logistic regression examining risk factors associated with a relaparotomy following a CD is presented in Supplementary Table 1 . The risk factors found were Mullerian anomalies (adjusted odds ratio (aOR) 3.33, 95% CI 1.08–10.24, p  = 0.036); uterine fibroids (aOR 3.17, 95% CI 1.11–9.05, p  = 0.031); pregnancy conceived by ART (aOR 4.8, 95% CI 2.28–10.1, p  < 0.001); multiple pregnancy (aOR 4.1, 95% CI 1.43–11.79, p  = 0.009); HDP (aOR 3.46, 95% CI 1.29–9.3); placental abruption (aOR 4.62, 95% CI 1.09–19.59, p  = 0.038); CD during the second stage of labor (aOR 2.54, 95% CI 1.1–5.88, p  = 0.029); CD duration (aOR 1.12, 95% CI 1.1–1.3, p  = 0.048); complicated CD (aOR 1.62, 95% CI 1.09–3.21, p  = 0.045); and excessive bleeding or use of bleeding control measures (aOR 2.23, 95% CI 1.29–4.12, p  = 0.012). Notably, LMWH use during pregnancy, pre-term delivery, non-clear amniotic fluid, and neonatal birthweight, were not found to be statistically significant in the logistic regression model.

The median time from the CD to the relaparotomy was 17.5 h (IQR 5-58.3), and 59.2% of the relaparotomy cases occurred in the first 24 h after the CD, with only 7.7% occurring between one week and up to 6 weeks after the initial surgery Additionally, the mean duration of relaparotomy was 68.8 (± 49.6 standard deviation) minutes, and nine patients (6.9%) needed a second relaparotomy (data not shown in the Tables).

Table  3 presents the indications for the relaparotomy, and stratification by the time interval from the CD. The main indication for relaparotomy was suspected intra-abdominal bleeding (45.4%). Nine patients (6.9%) needed a second relaparotomy, and 13 patients (10%) underwent a hysterectomy in the first or second relaparotomy. There were no women who underwent a third relaparotomy. In the early period, the main indication was suspected intra-abdominal bleeding (36.1%); in the intermediate period, it was scar disruption (10%); and in the late period, the main indications were infection and GI injury/bowel obstruction (3.1% each).

Figure  1 presents the relaparotomy intervention that was performed. As depicted, the most common intervention was bleeding control including electrocautery and surgical sutures, and the second most common intervention was ligation of the large vessels including the uterine and iliac arteries.

Surgical interventions performed during the relaparotomy

* N  = 130 cases, in two cases there was more than one intervention

** In seven cases, a hysterectomy was performed during the second relaparotomy

Figure  2 presents the source of bleeding found during the relaparotomy. The most common source was the uterine scar (31%), with the source of bleeding not found in 30% of the cases.

The source of bleeding identified during the relaparotomy

* N  = 89 cases, in two cases there was more than one source

The present comparative study evaluated the incidence, risk factors, and indications for relaparotomy following a CD during the puerperium in a single-tertiary, university-affiliated, medical center. Our key findings were: (1) The incidence of relaparotomy was 0.46%. (2) Risk factors for relaparotomy included uterine anomalies, uterine fibroids, ART conception, multiple pregnancy, HDP, placental abruption, CD during the second stage of labor, increased surgery duration, complicated CD, and excessive bleeding during the CD and use of bleeding control measures. (3) Most of the relaparotomies occurred during the first 24 h after the CD and the most common indication was suspected intra-abdominal bleeding. (4) The most common finding in the relaparotomy was bleeding from the uterine scar, and the most common intervention was control of the source of bleeding.

The incidence of relaparotomy during the study period was approximately 1:200 CDs, which is in accordance with previous studies describing a rate ranging between 0.23 and 0.7% [ 5 , 7 , 15 , 16 ].

In our study, women who conceived by ART had an increased risk for relaparotomy. This finding remained significant even after controlling for possible confounders related to ART such as multiple pregnancy and HDP [ 21 ]. Only one previous study examined the association between ART and relaparotomy [ 7 ], and found an increasing trend that did not reach statistical significance (aOR 1.83, 95% CI 0.94–3.59). A possible explanation for this association is the known risk factor for third-stage of labor complications in patients undergoing ART, including a higher risk for PPH [ 22 , 23 ] which is a risk factor for relaparotomy [ 15 ].

A fibroid uterus and Mullerian anomalies were also found to be associated with relaparotomy after a CD. These findings were not examined in previous studies. This association can be explained by the higher risk for PPH seen in a fibroid uterus [ 24 ], and the increased risk for placental abruption and adherent placenta in Mullerian anomalies [ 25 ].

Furthermore, we identified an association between multiple pregnancies and an increased likelihood of requiring relaparotomy after a CD. Twin gestations frequently contribute to over-distention of the uterus, a recognized factor that heightens the risk of uterine atony and PPH [ 16 ]. This observation aligns with our discovery that the second most common indication for relaparotomy was uterine atony.

Placental abruption and HDP were also independent risk factors for relaparotomy after a CD, with both entities previously described as risk factors for a relaparotomy [ 7 , 9 , 15 ]. One postulated explanation for this association is the higher risk for PPH in patients suffering from HDP [ 26 ] and from placental abruption [ 27 ]. Another possible explanation is the increased risk for coagulation disorders that may result in disseminated intravascular coagulation seen in these patients [ 28 , 29 ], which was detected in almost 30% of women in the study group.

Additionally, CD during the second stage of labor, and longer duration of the CD were found to be associated with the need for relaparotomy, similar to the findings in previous studies [ 5 , 7 , 14 , 16 ]. A previous study found that CDs in the second stage compared to those performed in the first stage are related to increased maternal complications including uterine atony and endometritis [ 30 ], which were found as causes for relaparotomy in 22.3% of the cases in our cohort. Longer duration of the CD was previously found to increase the risk of postoperative blood transfusion and infection [ 31 ]. Although it was not found to be associated with increased risk for relaparotomy, this could be explained by the relatively small number of patients in their cohort as compared to ours (6565 versus 28,280 women) and that they included cases up to one week after CD.

Additional risk factors for relaparotomy related to CD characteristics were complicated CD and excessive bleeding or use of bleeding control measures. While some of the parameters we included were not previously described in the literature, including the use of TXA during the CD, a hemostatic agent, and a surgical drain, others were previously described as being associated with relaparotomy, including calling a 3rd person for assistance and excessive bleeding in the CD [ 5 ]. Furthermore, we found that uterine incision extension was associated with an increased risk of relaparotomy. The uterine incision extension can cause GU injury, which was the indication for relaparotomy in eight patients (6.2%). Our findings emphasize the importance of meticulous surgical techniques to try and minimize the relaparotomy rate and maternal morbidity due to the relaparotomy.

Interestingly, the seniority of the surgeon in the CD was not found to be associated with the risk of undergoing a relaparotomy. This finding aligns with a previous study [ 16 ] and is contradictory to some studies [ 5 , 14 ], which, surprisingly, found higher relaparotomy rates when the primary surgeon was an attending physician. However, their findings might be influenced by selection bias, as surgeries considered more surgically complex are likely assigned to experienced surgeons a priori.

In our cohort, 59.2% of relaparotomy cases occurred during the first 24 h after the CD. Previous studies found similar results with 51.2–61.7% of relaparotomy cases occurring in the first 24 h [ 5 , 15 , 32 ], in contrast to the 19% found by Huras et al. [ 17 ]. However, the latter study did not specify the indication for the relaparotomy according to the timing from the CD, and hence it is difficult to explore this difference in rates. The main indication for relaparotomy was bleeding in 68.5% of the cases (including intra-abdominal bleeding, subcutaneous hematoma, etc.). These results are compatible with previous studies that found bleeding to be the greatest risk factor for relaparotomy [ 15 , 16 ].

Regarding the source of bleeding, in 30% of the relaparotomies that occurred for suspected bleeding, the source was not found. While one previous study reported that in 60.7% of the cases, no source was found [ 14 ], others reported results similar to ours, with no identifiable source in 12.5-33% of cases [ 7 , 19 , 20 ]. We postulate that the high variation between these studies could be explained by the relatively low number of cases in those studies, ranging between 28 and 64.

Regarding maternal outcomes, there were no cases of maternal death, similar to previous studies [ 5 , 7 , 16 ]. A second relaparotomy was required in 9 women (6.9%), similar to the 6.2% previously described [ 7 ], and lower than the 19.7% described by Seal etl al [ 33 ]. . In total, 13 women (10%) underwent a hysterectomy (six patients in the first relaparotomy and seven patients in the second relaparotomy). This finding is similar to previous studies which described rates between 7 and 10.6% [ 16 , 19 , 20 , 33 ] and is lower than the 33.3% found by Kessous et al. [ 15 ]. This discrepancy could be explained by the timing of their study which took place between 1989 and 2009, possibly representing a different approach towards hysterectomy. Another possible explanation could be the rate of primiparous women in the study group, which was 10% in the study by Kessous et al. [ 15 ], and 36.2% in our study.

The rate of future deliveries in the relaparotomy group was significantly lower compared to the control group. The rate of future deliveries after relaparotomy has not been described in previous studies, whilst a previous study found that women who suffered from complications after uterine rupture had lower rates of future deliveries as compared to women who did not suffer from complications [ 34 ]. Even after excluding the cases of hysterectomy, there was a higher rate of future deliveries at our institution in the control group. There are some possible explanations for these findings. First, women who suffered from complications in their previous delivery may opt to deliver at a different hospital in their following delivery. Another possible explanation could be a higher rate of post-traumatic stress disorder following childbirth (PTSD-FC) in the relaparotomy group, causing these women to subsequently avoid future pregnancies. A previous study found higher rates of PTSD-FC in deliveries complicated by distressing events [ 35 ]. Subsequent investigations should aim to elucidate whether this discrepancy is attributed to psychological factors or to biological influences, such as infertility resulting from pelvic adhesions.

Our study has several strengths. Firstly, it is the largest series regarding relaparotomy following a CD reported to date, enabling to explore more precisely possible risk factors for relaparotomy and maternal outcomes. Secondly, we examined a variety of antepartum and intrapartum factors not previously described in the literature, including Mullerian anomalies and TXA use during the CD. Lastly, in our study, we included women during the entire postpartum period, and hence were able to provide more accurate details.

Our study is not without limitations. The study was conducted at a single tertiary medical center in Israel, and the study cohort exhibited a predominantly homogeneous profile. Consequently, the generalizability of our findings to other populations may be limited. Furthermore, due to the retrospective nature of our study, some parameters could not be assessed, such as the time interval from the last LMWH and aspirin dose and the CD. Additionally, we recorded cases that had a CD and a relaparotomy at our institution, but could not assess if there were cases that had the CD at our hospital and subsequently underwent additional surgical intervention at a different hospital.

In conclusion, relaparotomy following a CD is a rare event that confers significant maternal complications and has numerous identifiable risk factors. Our findings could potentially aid clinicians in proactively identifying women at risk of requiring a relaparotomy after a CD, thereby contributing to the mitigation of associated morbidity.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Adjusted odds ratio

Assisted reproductive technology

• Cesarean delivery

Estimated blood loss

Gestational diabetes mellitus

• Hypertensive disorders of pregnancy

Intensive care unit

Low molecular weight heparin

Operation room

Placenta accreta spectrum

Postpartum hemorrhage

Post-traumatic stress disorder following childbirth

Tranexamic acid

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Department of Obstetrics and Gynecology, Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, 6 Weizmann St, Tel Aviv, Israel

Uri Amikam, Aviad Cohen, Ishai Levin, Yariv Yogev, Liran Hiersch & Anat Lavie

Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

Uri Amikam, Yael Botkovsky, Alyssa Hochberg, Aviad Cohen, Ishai Levin, Yariv Yogev, Liran Hiersch & Anat Lavie

Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel

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UA, AL and LH conceived and designed the study; UA, YB and AH participated in data acquisition; UA performed data analysis; UA, AH, YB and AL interpreted data for the work; UA, AH, AL, LH and YY drafted the article and all other co-authors revised it for important intellectual content; all authors gave final approval of the final version and agree to be accountable for all aspects of the work.

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All methods were conducted in compliance with applicable guidelines and regulations. This study adhered to the principles outlined in the Declaration of Helsinki. The study was approved by the ethics committee of Tel Aviv Sourasky Medical Center Institutional Review Board (IRB) (approval number 0618 − 22). Due to the retrospective nature of the study, the need for informed consent was waived by Tel Aviv Sourasky Medical Center’s local IRB (IRB TLV-0618-22).

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Amikam, U., Botkovsky, Y., Hochberg, A. et al. Risk factors for relaparotomy after a cesarean delivery: a case-control study. BMC Pregnancy Childbirth 24 , 284 (2024). https://doi.org/10.1186/s12884-024-06455-6

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• Maternal complications
• Relaparotomy
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Cesarean myomectomy: a case report and review of the literature

• Priyanka Garg   ORCID: orcid.org/0000-0003-0336-4750 1 , 2 &
• Romi Bansal 2  

Journal of Medical Case Reports volume  15 , Article number:  193 ( 2021 ) Cite this article

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Routine myomectomy at the time of cesarean section has been condemned in the past due to fear of uncontrolled hemorrhage and peripartum hysterectomy. It is still a topic of debate worldwide. However, in recent years, many case studies of cesarean myomectomy have been published validating its safety without any significant complications.

Case presentation

We describe the case of a 27-year-old gravida 2 para 1 live birth 1 North Indian woman with one previous lower segment caesarean section (LSCS) at 35 weeks with labor pains and scar tenderness. Her recent ultrasound (USG) report suggested a single live intrauterine pregnancy with an intramural fibroid of 8.6 × 6.5 cm located in the left anterolateral wall of the lower uterine segment. The patient was taken up for emergency cesarean section along with successful removal of the myoma, which was bulging into the incision line, causing difficulty in closure of the uterine wound. Prophylactically, oxytocin infusion, bilateral ligation of uterine arteries, and injection vasopressin (diluted) was administered to decrease the blood loss. The patient was discharged after 7 days without any complications.

Conclusions

Routine myomectomy at the time of cesarean section is not a standard procedure and is not accepted worldwide. However, it may be considered a safe option in carefully selected cases in the hands of an experienced obstetrician with appropriate hemostatic technique. Large multicenter randomized controlled trials should be conducted to evaluate the best practice guidelines for cesarean myomectomy.

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Leiomyomas are the most common benign tumors of the reproductive tract in women of childbearing age. Their exact incidence in pregnancy is hard to estimate. However, literature reports a prevalence of 2–4% [ 1 ]. The incidence is rising due to delayed childbearing and a rapid increase in the number of cesarean sections over the last few years. The majority of the patients are either asymptomatic or have mild symptoms and need conservative management only. Myomectomy during cesarean section is routinely avoided due to increased vascularity of the gravid uterus leading to massive hemorrhage, unnecessary obstetric hysterectomy, and increased perioperative morbidity and mortality. However, in modern obstetrics, with advancements in anesthesia, adequate availability of blood products, selective devascularization techniques, and a multidisciplinary approach, obstetricians are increasingly choosing to perform myomectomy during cesarean section, thus saving the patient from future morbidity due to multiple surgeries, anesthetic complications, and out-of-pocket expenditure [ 2 ]. Here, we report the case of a successful myomectomy done during an emergency cesarean section without any complications. We intend to break the traditional thumb rule of avoiding myomectomy at the time of cesarean section, and be open to the procedure after careful case selection.

A 27-year-old gravida 2 para 1 live birth 1 North Indian woman with one previous lower segment caesarean section (LSCS) presented to our outpatient department (OPD) at 35 weeks with complaints of intermittent pain in the lower abdomen that was radiating to her back for the last 5 hours. There was no associated complaint of leaking or bleeding per vaginum . Her antenatal period was uneventful. However, she was diagnosed as having a fibroid on the left side of the uterus but reported no complications that could be attributed to it. Her general and systemic examination was unremarkable. All the antenatal investigations were normal. Her recent ultrasound (USG) report suggested a single live intrauterine pregnancy with an intramural fibroid measuring 8.6 × 6.5 cm located in the left anterolateral wall of the lower uterine segment.

On admission, her heart rate was 96 beats per minute, blood pressure was 110/70 mmHg, and mild pallor was present. Abdominal examination revealed a term size uterus with longitudinal lie. Mild uterine contractions were present with positive scar tenderness. On auscultation, fetal heart rate was 142 beats/minute. Vaginal examination depicted a 2 cm dilated cervix, which was 20–30% effaced, presenting part at −3 station with intact membranes. She was taken up for emergency LSCS given previous cesarean section with preterm labor and scar tenderness. Her preoperative hemoglobin was 12.1 gm%, hematocrit was 34.5%, and blood group was O positive. Adequate blood products were arranged and informed written consent was obtained from the patient and her relatives after explaining to them about the risk of excessive bleeding, need for blood transfusion, and peripartum hysterectomy. During surgery, the abdomen was opened by an infra-umbilical vertical incision for adequate access. There was a single large intramural fibroid occupying most of the lower uterine segment. The previous scar was intact but thinned out, possibly because of the stretching effect of the fibroid. A lower segment transverse incision was made below the inferior margin of the fibroid, and a 2.54 kg female baby was delivered, with an APGAR score of 9 at 1 minute. As the fibroid was bulging into the incision line and causing difficulty in closure of the uterine wound, the decision of myomectomy was taken (Fig. 1 ). Prophylactically, oxytocin infusion, bilateral ligation of uterine arteries, and injection of vasopressin (diluted) was injected to decrease the blood loss. The fibroid was then enucleated and the myoma bed closed with delayed absorbable sutures followed by closure of the uterine wound. A complete hemostasis was achieved. The total duration of the surgery was approximately 50 minutes and the amount of blood lost around 1100 mL, which is almost comparable to other cesarean sections. Broad-spectrum antibiotics and analgesics were administered in the postoperative period. Her post-surgery hemoglobin was 11.4 gm% and hematocrit was 33%, thus not requiring any blood transfusion. The patient was discharged on the seventh postoperative day with a normal involuting uterus. On follow-up at 6 weeks, the uterus was completely involuted, and repeat USG did not show any fibroid. On further follow-up to 6 months, she was asymptomatic and had an uneventful course.

Intraoperative image depicting the fibroid bulging into the incision line

We report a case of successful myomectomy performed at the time of an emergency cesarean section, with an intent to disintegrate the long-established belief of avoiding it due to fear of complications. Pregnancy with fibroid is a high-risk situation. Although the majority of such cases are asymptomatic or have mild symptoms, 10–40% of cases can present with antenatal complications in the form of pregnancy loss, degenerative changes, malpresentation, abruption placenta, preterm labor, dysfunctional labor or uterine inertia, and increased chances of operative delivery, thus increasing maternal and fetal morbidity and mortality [ 3 ]. Treatment is usually conservative during the antenatal period in the form of bed rest, adequate hydration, and analgesics. Myomectomy is rarely required in the case of intractable abdominal pain due to twisting of pedunculated sub-serosal fibroid, red degeneration unresponsive to conservative treatment, or massively enlarged myoma causing abdominal discomfort to the patient [ 1 ]. In a recent study, a successful myomectomy was performed during the first trimester at 11 weeks for a large myoma of 14 cm that was a cause of severe discomfort to the patient [ 4 ]. The patient continued with pregnancy to term and delivered a healthy baby. Another uneventful myomectomy was performed in the second trimester by Bhatla et al . without any adverse impact on pregnancy [ 5 ]. Myomectomy during cesarean section is still a topic of debate in the modern era. Until the last decade, it was considered a dreadful surgery except for pedunculated sub-serosal fibroids. However, many researches have concluded that the procedure is not dangerous and does not lead to complications in the hands of an experienced obstetrician [ 6 ]. Kwawukume performed cesarean myomectomies on 12 patients and reported that enucleation was much easier in pregnancy due to increased softness of the tissue [ 7 ]. A retrospective case–control study, comparing 40 women with fibroids who underwent cesarean myomectomy with 80 women with fibroids forming the control group who underwent cesarean section alone, reported no significant difference in the incidence of hemorrhage between the two groups (12.5% and 11.3%, respectively) [ 8 ]. Similar findings were reported in another study, with no significant differences in hemoglobin levels, incidence of blood transfusions, or postoperative pyrexia. However, not all myomas need to be removed, but only those causing difficulty in delivery of the fetus or wound closure and sub-serosal fibroids. In our case, myomectomy was inevitable as the myoma was in the incision line, making wound closure impossible. Every possible effort should be made to reduce the blood loss. Bilateral ligation of uterine arteries immediately after delivery of the fetus significantly reduces both intraoperative and postoperative blood loss and risk of peripartum hysterectomy [ 9 ]. It also reduces the recurrence of myomas and minimizes the need for future surgery, with no apparent effect on fertility [ 10 ]. This was a key step in our case which prevented the dreaded complications. Also, the postpartum uterus is better adapted physiologically to control bleeding than in any other phase of a woman’s lifetime. The patient and relatives should be properly counseled and informed that removal of myoma is possible, and a final decision can be taken at the time of cesarean based upon the size, number, and location of the fibroid.

The idea of performing myomectomy at the time of cesarean section appears winsome in a low-resource country like India, where fibroids are common. If performed safely, it can avoid the additional morbidity of a future surgery, thus justifying the cost-effectiveness of the procedure. However, the importance of an expert obstetrician, equipped center with adequate manpower and blood products, and careful case selection cannot be ignored.

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Garg, P., Bansal, R. Cesarean myomectomy: a case report and review of the literature. J Med Case Reports 15 , 193 (2021). https://doi.org/10.1186/s13256-021-02785-7

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Planned Induction of Labour Versus Planned Caesarean Delivery in Women with Severe Pre-eclampsia at Term—a Randomized Controlled Trial

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• Published: 15 May 2024

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• Bheshna Sahu   ORCID: orcid.org/0009-0009-4257-4698 1 , 2 ,
• Snehamay Chaudhuri 1 &
• Debnath Ghosh 1  

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The aim of this study is to investigate whether planned caesarean delivery compared to planned induction of labour in women with severe pre-eclampsia at gestational age of more than 37 weeks of pregnancy will reduce maternal morbidity and/or perinatal morbidity.

This randomized controlled study was conducted from April 2021 to March 2022 at Department of Obstetrics and Gynecology of Midnapore Medical College, West Bengal. Data were analysed with respect to socio demographic status, clinical presentation, complications and their management.

One hundred and seventy-six women with severe pre-eclampsia were screened for eligibility, and 140 were included in the study. In 58.6% patients, the induction was successful. Type of delivery was successful in vaginal 37 (90.2%) and instrumental (ventouse and forceps) in four (19.8%) of the cases. In induction group, the most common reason for LSCS was MSL with foetal bradycardia. Foetal distress was seen in 22.90% of induction group, while absent in LSCS group.

In our study, we found that there was no differences in the primary maternal outcome and the secondary maternal outcome between the two groups. The primary neonatal outcome was significantly poor in induction group, whereas good in LSCS group. So LSCS is better option in patients with severe pre-eclampsia at term. Key words—Severe Pre-eclampsia, Induction of labour.

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Acknowledgements

We are grateful to all women, the doctors, nurses, trainees and other staff of our hospital without whose collaboration this study would not have been possible.

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Bheshna Sahu, Snehamay Chaudhuri & Debnath Ghosh

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Dr. BS involved in conception and design, analysis and interpretation of data, drafting the article, revising it critically for important intellectual content and final approval of the version to be published. Dr. SC involved in conception and design, analysis and interpretation of data, drafting the article, revising it critically for important intellectual content and final approval of the version to be published. Dr. DG involved in conception and design, analysis and interpretation of data, drafting the article, revising it critically for important intellectual content and final approval of the version to be published.

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Dr. Bheshna Sahu is a MBBS, MS Obstetrics and Gynecology; Dr. Snehamay Chaudhuri is a MBBS, MD Obstetrics and Gynecology, DNB Obstetrics and Gynaecology; Dr. Debnath Ghosh is a MBBS, MS Obstetrics and Gynecology.

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Sahu, B., Chaudhuri, S. & Ghosh, D. Planned Induction of Labour Versus Planned Caesarean Delivery in Women with Severe Pre-eclampsia at Term—a Randomized Controlled Trial. J Obstet Gynecol India (2024). https://doi.org/10.1007/s13224-024-01981-x

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Evaluation of preoperative ultrasound signs associated with bladder injury during complex Cesarean delivery: case-control study

Affiliations.

• 1 Department of Obstetrics and Gynecology, Kasr Al Ainy School of Medicine, University of Cairo, Cairo, Egypt.
• 2 EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK.
• PMID: 38243910
• DOI: 10.1002/uog.27590

Objective: Intraoperative hemorrhage and peripartum hysterectomy are the main complications in patients presenting with a low-lying placenta or placenta previa undergoing repeat Cesarean delivery (CD). Patients with a high probability of placenta accreta spectrum (PAS) at birth also have a higher risk of intraoperative urologic injury. The aim of this study was to evaluate the ultrasound signs and intraoperative features associated with these injuries.

Methods: This was a retrospective case-control study of consecutive singleton pregnancies included in a prospective cohort of patients with a history of at least one prior CD and diagnosed prenatally with an anterior low-lying placenta or placenta previa at 32-36 weeks' gestation. All patients underwent investigational preoperative transabdominal and transvaginal ultrasound examination within 48 h prior to delivery. Ultrasound anomalies of uterine contour and uteroplacental vascularity, and gross anomalies of the lower uterine segment (LUS) and surrounding pelvic tissue at delivery, were recorded using a standardized protocol, which included evaluation of the extent of uterine contour anomalies. The diagnosis of PAS was established when one or more placental lobules could not be separated digitally from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens, and was confirmed by histopathology. Data were compared between cases complicated by intraoperative bladder injury and controls from the same cohort matched at a 1:3 ratio by parity and the number of prior CDs using conditional logistic regression.

Results: There were 16 (9.4%) patients with an intraoperative bladder injury in a cohort of 170 managed by the same multidisciplinary team during the study period. There were no patients diagnosed with ureteric or bladder trigone damage. There were 14 (87.5%) patients with a bladder injury that had histopathologic evidence of PAS at birth, including 11 (68.8%) cases described on microscopic examination as placenta increta and three (18.8%) as placenta creta. There was a significant (P = 0.03) difference between cases and controls in the distribution of the intraoperative LUS vascularity, whereby the higher the number of enlarged vessels, the higher the odds of bladder injury. Multivariable regression analysis revealed that both gestational age at delivery and LUS remodeling on transabdominal ultrasound were associated with bladder injury. A longer gestational age was associated with lower risk of injury. A higher LUS remodeling grade on transabdominal ultrasound was associated with an increased risk of bladder injury. Patients with Grade-3 remodeling (involving > 50% of the LUS) had 9-times higher odds of a bladder injury compared to patients with Grade-1 remodeling (involving < 30% of the LUS).

Conclusions: Preoperative ultrasound examination is useful in the evaluation of the risk of intraoperative bladder injury in patients with a history of prior CD presenting with a low-lying placenta or placenta previa. The larger the remodeling of the LUS on transabdominal ultrasound, the higher the risk of adverse urologic events. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Keywords: bladder injury; complex Cesarean section; placenta previa accreta; ultrasound imaging; uterine dehiscence.

© 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

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Determinants of Cesarean Section Deliveries in Public Hospitals of Addis Ababa, Ethiopia, 2018/19: A Case-Control Study

Areaya gebreegziabher hailu.

1 Department of Public Health, Gamby Medical and Business College, Bahir Dar, Ethiopia

Tsegaye Kebede Fanta

Fissaha tekulu welay.

2 Department of Midwifery, Adigrat University, Adigrat, Ethiopia

Natnael Etsay Assefa

Surafel aregawi hadera.

3 Department of Midwifery, Aksum University, Axum, Ethiopia

Gebrekiros Aregawi Gebremeskel

Hagos weldeslassie gebremedhin.

4 Department of Reproductive Health, Sante Medical College, Addis Ababa, Ethiopia

Guesh Gebreayezgi Asefa

5 Department of Epidemiology and Biostatistics, School of Public Health, Akum University, Axum, Ethiopia

Associated Data

The datasets during and/or analyzed on the current study are available from the corresponding author on reasonable request.

The objective of this study was to assess the determinants of cesarean section deliveries in public hospitals of Addis Ababa, Ethiopia, 2019.

A hospital-based unmatched case-control study was conducted to study 780 (260 cases and 520 controls) women who delivered in public hospitals of Addis Ababa from August 22 to September 20, 2019. The cases were all mothers who delivered through caesarean section, and controls were all mothers who delivered vaginally in the same time in the study area. Data were collected from the randomly selected women and looking into their cards. Data were entered on EpiData 3.1 and exported to SPSS version 20 for cleaning and analyzing. Binary logistic regression and AOR with 95% CI were used to assess the determinants of caesarean section.

Majority of the study participants were in the age category 20–34 years. Nearly more than 1/3 rd of the participants (32.7% cases and 34.6% controls) have attended primary school. Most of the cases 217 (83.5%) and few of the controls 21 (4%) possess previous caesarean section. One hundred three (52.3%) of the cases and 329 (63.6%) controls were multi-parous. Previous caesarean delivery (AOR = 6.93, 95% CI; (3.39, 14.16)), singleton pregnancy (AOR = 0.34, 95% CI; (0.12, 0.83)), birth weight less than 2500 gm (AOR = 0.29, 95% CI; (0.18, 0.92)), birth weight greater than 4000 gm (AOR = 16.15 (8.22, 31.74)), completely documented partograph (AOR = 0.13, 95% CI; (0.078, 0.23)), and pregnancy-induced hypertension (AOR = 2.44, 95% CI; (1.46, 4.08)) were significant determinants of caesarean delivery in this study.

Previous caesarean section, number of delivery, birth weight, partograph documentation, and pregnancy-induced hypertension had significant association with caesarean section delivery in this study.

1. Introduction

The proportion of caesarean section (CS) to the total births is considered as one of the important indicators of emergency obstetric care [ 1 ]. Currently, the WHO states that CS has paramount importance on reducing maternal and perinatal mortality and morbidity, provided that there is justified medical indication. However, in the absence of clear medical justification, CS has no medical benefit, rather it is associated with short- and long-term health risks as compared with vaginal delivery [ 2 ].

CS rates have been rising progressively worldwide with a wide variation between countries and regions. It is globally known that CS delivery can present several risks than a vaginal birth even if it has become nowadays one of obstetric intensive cares regarding its benefits for mother and baby [ 3 ].

Many studies indicated medical and nonmedical factors that are likely to be associated with the rising rate of CS which include social and obstetric maternal factors (age, educational status, income, preference, height, weight, parity, premature rupture of the amniotic fluid membrane, and multiple pregnancy), fetal factors (macrosomia, breech presentation, etc.), and indications (cephalopelvic disproportion, hypertensive disorders of pregnancy, antepartum hemorrhage, previous caesarean section, and fetal distress) [ 4 – 10 ].

Though the rate of CS is increasing in a normal pregnancy, CS has eight-fold higher maternal mortality and 8–12 times higher morbidity than vaginal delivery [ 11 , 12 ]. Nowadays, the CS rate has become more prevalent without a clear medical justification though it is associated with an increased morbidity and mortality of mothers and children [ 13 – 17 ].

In 2015, the WHO suggested CS can save the life of the mother and infant as well only when it is medically justified [ 2 ]. The Ethiopian Demographic Health Survey (EDHS) 2016 reported over utilization of CS rates in Addis Ababa (21.4%) [ 18 ]. However, there is uncertainty if the determinants leading to CS delivery are up to the WHO recommendation. Thus, this study is intended to determine what factors are really predisposing mothers to CS delivery. Moreover, this study would help to have an extensive and up-to-date picture on the problem.

2. Main Text

2.1. methods.

A quantitative facility-based unmatched case-control study design was applied to study a total of 780 participant mothers from August 22 to September 20, 2019. The mothers were interviewed after they gave birth either by spontaneous vaginal delivery or caesarean section. Mothers who delivered a baby after fetal viability (28 weeks) were included, while those who were admitted to the postnatal ward after home delivery were excluded from this study. The sample size was calculated using Epi Info version 3.5.1 statistical software using the double population formula for the unmatched case-control study. Hence, considering the previous exposure of macrosomia baby ( p 1=52% for cases and p 2=1.6%) and 10% nonresponse rate, the calculated value was 260 for cases and 520 for controls. Finally, the total number of samples was 780 mothers. The study was conducted on six public hospitals administered by Addis Ababa Health Bureau. Thus, the sample size was allocated proportionally based on the average delivery load in the past three months (February, March, and April). Cases and controls were selected exclusively using the systematic random sampling technique. The data were collected using a questionnaire and checklist. The questionnaire was structured, pretested, translated, and adapted from previous articles. Medical records of parturient mothers were used to extract information such as partograph, gestational age at delivery, fetal presentation, indication of CS, and birth weight of the fetus, while the information of the other variables were primary data taken from interview of postnatal mothers.

The data for this study were collected after ethical clearance was obtained from Gamby Medical and Business College and Addis Ababa public health research and emergency management care process. The participants were informed about the objective clearly and were also informed that the information they provided is only used for research purposes and kept confidential. Finally, the collected data were entered on EpiData3.1 and exported to SPSS version 20 for analysis. The variables with p < 0.25 on bivariate logistic regression were taken to multivariable logistic regression to control possible confounding factors. Finally, adjusted odds ratio with 95% confidence interval was used to measure strength of association between the predictors and occurrence of CS. Statistical significance was declared at p < 0.05.

Cases are mothers who delivered by caesarean section, whereas controls are those who delivered vaginally.

In this study, complete and partial partograph documentation is defined as if all the component of partograph was correctly filled and some components were missed, respectively, at the time of reviewing mother's card. Meanwhile, partograph is reported as undocumented if and only if the labor was not followed by Partograph at all.

Prolonged premature rupture of membrane is defined as duration of rupture of the membrane greater than 12 hours before the onset of labor [ 19 ].

Duration of labor: the duration of labor in this study is measured from the onset of true labor including the latent phase of first stage of labor to third stage of labor.

3.1. Socioeconomic and Demographic Characteristics

The study recruited 780 mothers (260 cases and 520 controls) making a response rate of 100%. Majority of the participants (82.3% cases and 86% controls) were in the age category of 20–34 years. Nearly one third of enrolled mothers (32.7% cases and 34.6% controls) have attended primary school ( Table 1 ).

Socioeconomic and demographic characteristics of cases and controls in public hospitals of Addis Ababa, Ethiopia, 2019.

3.2. Obstetric Characteristics of the Participants

More than half of cases and nearly 2/3 rd of controls were multi-parous. Twenty-seven (10.4%) of cases and fifty (9.6%) of controls had previous stillbirth. Eighty-nine (34.2%) of cases and fifty-two (10%) of controls had faced fetal distress during labor. Most (83.5%) of the cases and 4% of controls had previous CS delivery ( Table 2 ).

Obstetric characteristics of the participants of the study in public hospitals of Addis Ababa, Ethiopia, 2019.

Fully documented partograph was higher in controls than cases, whereas more proportion of partially and not documented partograph was higher in cases than controls ( Figure 1 ).

Bar graph showing status of partograph documentation for cases and controls among women who delivered in public hospitals of Addis Ababa, Ethiopia, 2019.

In Table 3 , the Robson classification is used to compare the risk of delivering via CS among the ten groups of the delivering women. In this study, 2/3 rd (67.4%) of group five and more than half of group eight (54.5%) and group two (51.5%) of the Robson classification were delivered through CS delivery ( Table 3 ).

Robson classification and risk of CS of the participants of the study in public hospitals of Addis Ababa, Ethiopia, 2019.

3.3. Determinants of Caesarean Section Deliveries

Women who had previous CS and had completely documented partograph (AOR = 6.93, 95% CI; (3.39, 14.16) and (AOR = 0.13, 95% CI; (0.078, 0.23), respectively, were more likely to undergo CS than their counter parts ( Table 4 ).

Logistic regression analysis results for determinants of CS delivery in public hospitals of Addis Ababa, Ethiopia, 2019.

COR = crude odds ratio, AOR = adjusted odds ratio ∗ Statistically significant at p < 0.05.

4. Discussion

CS is a life-saving procedure. Thus, the procedure should not be done without clear medical indication. In this study, mothers who underwent previous CS were 6.93 times more likely to deliver by CS for the consecutive birth compared with those who gave birth via vaginal delivery. This finding is consistent with the studies conducted in Bahir Dar, Harar, Addis Ababa, Mekelle, and Dessie [ 20 – 24 ]. This might be due to the fear of uterine rupture associated with waiting longer time.

Pregnancy-induced hypertension during labor was found risky for CS delivery. Hence, it is similar with the study conducted in Bukavu Provincial Hospital in Democratic Republic of Congo [ 25 ]. The possible reason could be long duration of vaginal delivery in case of pregnancy-induced hypertension.

In this study, neonatal birth weight ≥4000 gm was more likely to deliver through CS than birth weight of 2500–4000 gm. Perhaps, it is in line with the study done in eastern Ethiopia; Felege Hiwot Hospital, Oman, and DR Congo [ 20 , 25 , 26 ]. This is because macrosomia babies would face birth difficulty if vaginal delivery is allowed.

This study showed that completely filled partograph was 87% less likely to go to CS room than undocumented partograph. Studies conducted in Adigrat and Mekelle agreed with this study [ 23 , 27 ]. This might be due to close monitoring of partograph decreasing the likelihood of CS rate.

Furthermore, singleton pregnancy was found as a protective factor for caesarian delivery.

4.1. Limitations of the Study

• Some very important factors like maternal height and body mass index (BMI) were not included as they are not routinely registered on medical cards at the setups where the research was conducted
• Scare to add qualitative part would not have given a chance for women to discuss more information about the decision-making process (attitude and perception of physicians and family)

5. Conclusion

In this study, only the obstetric characteristics were significant. Previous CS, number of delivery, birth weight, partograph documentation, and pregnancy-induced hypertension had significant association with CS delivery. Future studies need to examine the attitude of service providers and their influence on the growing CS delivery rate.

Acknowledgments

The authors would like to thank Gamby Medical and Business College for giving a hand up on accomplishment of the study. Next, the authors express their gratitude to the respective hospitals CEO for providing the necessary baseline information. Last but not least, the authors would like to acknowledge data collectors, supervisor, and study participants.

Data Availability

Ethical approval.

Before starting the data collection process, ethical clearance was obtained from the Addis Ababa Health Bureau ethical clearance committee (tel: +251-115-51–3911, FAX: 251-115-51-56-89, P.O. box: 30738, Addis Ababa, Ethiopia) to each selected hospitals.

Informed, written, and signed consent was obtained from each head of every facility involved in the study and participant mothers after the purpose and benefits of the study are discussed. Participants were informed about the minimal risk that it had in taking part in the study, their volunteerism, and the right to leave the interview at any time they want. Confidentiality of the study participant's information was also kept secure.

Conflicts of Interest

The authors declare that they have no competing interests.

Authors' Contributions

AG proposed and designed the study and developed the manuscript. TK supervised, advised, and helped in the analysis. GG assisted interpretation of the result and preparation of the draft of the manuscript. FT assisted on proposal development and the final write up of the data collection tool. NE performed the statistical analysis of the study. All authors read and approved the final manuscript.