Multiple Repeat Caesarean Section

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Key points

  • Repeat caesarean section is an important cause of maternal morbidity and mortality.
  • The increasing incidence of primary caesarean section in the UK may lead to an increase in the incidence of multiple repeat caesarean section.
  • There have been no prospective national studies to estimate the incidence or outcomes of multiple repeat caesarean section.
  • This study will investigate the incidence, management and outcomes for mother and infant of multiple repeat caesarean section. It will allow comparison between the risks associated with multiple repeat caesarean and those described in fewer repeat procedures.

Surveillance Period

January 2009 – January 2010

Background

The incidence of primary caesarean section is rising throughout the world and the UK also demonstrates this trend[1]. This is thought to be due to the introduction of fetal monitoring in labour, maternal preference, maternal obesity, and possibly defensive obstetric practice. After having three lower segment caesareans women are advised to undergo repeated elective caesarean in any subsequent pregnancies, rather than attempt a vaginal delivery[2]. This practice is thought to reduce the risk of uterine rupture which can be life-threatening for both mother and baby. All caesarean procedures however, have associated risks; venous thromboembolism and haemorrhage - which are leading causes of maternal mortality, infection, and damage to the viscera. Repeated caesareans are also associated with placental invasion into the myometrium and peripartum hysterectomy. Babies born via caesarean are more likely to experience breathing difficulties and require admission to a specialist unit.

Current knowledge concerning the maternal-fetal outcomes and management of multiple repeat caesarean is limited and mainly derived from hospital-based retrospective case analysis out-side of the UK[3][4][5][6].  Complication rates are variously reported as not significantly different to lower order caesareans, or increased. A large cohort study of elective caesareans in North American tertiary centres described an increase in maternal morbidity with higher order procedures[7]. No population-wide studies of incidence or complications have been undertaken.

This study will determine the national incidence of multiple repeat caesarean section in the UK and identify the accompanying complications and their respective rates. It will allow comparison between the risks associated with multiple repeat caesarean and those described in fewer repeat procedures. It will also ascertain the current UK practice in such cases with regards to timing of elective caesarean and postnatal counselling for future pregnancies.

Objectives

  • To use the UK Obstetric Surveillance System to describe the current epidemiology of multiple repeat caesarean section in the UK.
  • To use the results of this study to provide accurate information to counsel women about the risks of future pregnancies, and to enable appropriate future service planning.

Research questions

  • What is the current incidence of multiple repeat caesarean section in the UK?
  • How is multiple repeat caesarean section managed in the UK?
  • What are the outcomes for mother and infant of multiple repeat caesarean section, and how do these compare with the risks of undergoing fewer caesareans?

Case definition

Any woman giving birth to an infant via her 5th or more elective or emergency caesarean section (i.e. who has previously undergone four or more other caesarean procedures).

Funding

RCOG/UKOSS Annual Award 2008

Ethics committee approval

The study has been approved by the London MREC (study ref 08/H0718/72).

Investigators

  • Joanna Cook, St. Mary's Hospital, Imperial College Healthcare NHS Trust
  • Mandish Dhanjal, Sheba Jarvis, Floria Cheng, Queen Charlotte's & Chelsea Hospital, Imperial College Healthcare NHS Trust
  • Marian Knight, NPEU

Download the Data Collection Form (DCF)

UKOSS Multiple Repeat Caesarean Section CONTROL Form 

UKOSS Multiple Repeat Caesarean Section CASE Form

References

  1. ^ Office for national statistics. Caesarean deliveries in NHS hospitals (2004).
  2. ^ Birth after previous caesarean birth Green top guidelines RCOG 2007.
  3. ^ Khashoggi TY Higher order multiple repeat caesarean sections: maternal and fetal outcome Ann Saudi Med 2003; 23(5): 278-82.
  4. ^ Rashid M, Rashid RS, Higher order repeat caesarean sections: how safe are five or more? BJOG 2004;111(10):1090-4.
  5. ^ Kirkinen P. Multiple caesarean sections: outcomes and complications Br J Obstet Gynaecol. 1988; 95(8): 778-82.
  6. ^ Juntunen K, Makarainen L, Kirkinen P, Outcome after a high number (4-10) of repeated caesarean sections BJOG 2004; 111(6): 561-3.
  7. ^ Silver RM, Landon MB, Rouse DJ, Leveno KJ, et al Maternal morbidity associated with multiple repeat caesarean deliveries Obstet Gynaecol 2006; 107(6): 1226-1232.

Updated: Tuesday, 07 July 2020 14:44 (v4)