A recent perspective published in PLOS Medicine highlights the potential long-term risks associated with cesarean section (C-section) deliveries during labor, particularly in relation to preterm births in subsequent pregnancies. As the global rate of C-sections rises, this study calls attention to the implications of emergency procedures during labor for maternal and fetal health.
The rate of C-sections has steadily increased worldwide, with a 12.4% rise from 1990 to 2014. In England, over a third of women now deliver via C-section, with 24% of these being emergency procedures and 5% occurring after the cervix is fully dilated. In North America, the rate of full dilation C-sections has surged by 44% over the past decade.
Several factors contribute to this increase, including evolving clinical practices, concerns about litigation, and shifting cultural expectations. While C-sections can be life-saving in complicated pregnancies, especially when performed in emergency situations, there are concerns about the long-term effects, particularly in subsequent pregnancies.
Emergency C-sections, especially those performed during advanced labor stages, have been associated with increased risks in future pregnancies. Studies indicate a strong link between in-labor C-sections and the likelihood of spontaneous preterm birth (sPTB) and mid-trimester pregnancy loss. The risks are more pronounced when the cervix is more dilated at the time of surgery, with the highest risk seen when the cervix is fully dilated.
While the majority of women who undergo an in-labor C-section will not face significant risks in future pregnancies, those who do experience preterm birth following the procedure are at a heightened risk of recurrent preterm births. Research shows that women who had an in-labor C-section and later experienced preterm birth have a 2.7-fold higher risk of recurring sPTB compared to those with other preterm birth risk factors. Furthermore, the risk increases to 5.65 for mid-trimester pregnancy loss. Notably, 54% of women who experience preterm birth following an in-labor C-section go on to have another preterm delivery.
The increased risks observed in women with in-labor C-sections may be explained by cervical damage sustained during surgery. The cervix plays a crucial role in preventing premature labor, and when C-sections are performed during advanced stages of labor, the incision may cause trauma to the cervix. This can lead to cervical insufficiency, a condition where the cervix is weakened and unable to maintain a pregnancy, resulting in preterm birth or miscarriage.
As labor progresses, the fetus descends into the pelvis, making surgical delivery more challenging and increasing the likelihood of cervical injury. These injuries can include tears, infections, or the need for sutures that compromise cervical integrity.
Advanced imaging techniques, such as transvaginal ultrasound (TVUS), help provide more insights into the role of cervical damage. Cesarean scars, visible as disruptions in the uterine wall, offer a clue to the extent of the damage, which may affect future pregnancies.
Standard interventions, such as transvaginal cerclage (TVC), are commonly used to prevent sPTB by placing a suture in the cervix to provide additional support. However, TVC has been found to be less effective in women with a history of in-labor C-sections. One study showed that women with prior in-labor C-sections were 10 times more likely to deliver before 30 weeks compared to those with other preterm birth risk factors. Among women who had both an in-labor C-section and TVC, 46% experienced either sPTB or mid-trimester loss.
For women with cervical damage from in-labor C-sections, transabdominal cerclage (TAC) may offer a more effective alternative. TAC bypasses the damaged cervical tissue, offering better protection against preterm labor than TVC. A retrospective cohort study found that TAC significantly reduced sPTB rates before 30 weeks compared to TVC, making it a promising option for women with a history of in-labor C-sections and recurrent preterm births.
As C-sections remain the most common surgical procedure worldwide, with nearly a quarter of women undergoing the procedure, understanding the long-term risks associated with in-labor C-sections is critical. The potential for cervical damage during these surgeries highlights the need for tailored management strategies to prevent adverse outcomes in future pregnancies.
Clinicians and patients must recognize the risks and work together in shared decision-making to improve maternal and fetal health outcomes. As the prevalence of in-labor C-sections continues to rise, addressing these concerns through better training in instrumental delivery and labor management is crucial. Further research into the mechanisms of cervical damage and the effectiveness of interventions like TAC could shape future clinical guidelines and improve outcomes for women at risk of preterm birth.
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