Evidence Report/Technology Assessment 

Number 133 

Cesarean Delivery on Maternal Request 

Prepared for: 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, MD 20850 

www.ahrq.gov 

Contract No. 290-02-0016

Prepared by: 

RTI International-University of North Carolina 

Research Triangle Park, North Carolina 

Investigators 

Meera Viswanathan, Ph.D. 

Anthony G. Visco, M.D. 

Katherine Hartmann, M.D., Ph.D. 

Mary Ellen Wechter, M.D. 

Gerald Gartlehner, M.D. 

Jennifer M. Wu, M.D. 

Rachel Palmieri, B.S. 

Michele Jonsson Funk, Ph.D. 

Linda Lux, M.P.H. 

Tammeka Swinson, B.A. 

Kathleen N. Lohr, Ph.D. 

AHRQ Publication No. 06-E009 

March 2006
This report is based on research conducted by the RTI International–University of North Carolina 

(RTI-UNC) Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare 

Research and Quality (AHRQ), Rockville, MD (Contract No. 290-02-0016). The findings and 

conclusions in this document are those of the author(s), who are responsible for its content, and do 

not necessarily represent the views of AHRQ. No statement in this report should be construed as 

an official position of AHRQ or of the U.S. Department of Health and Human Services. 

The information in this report is intended to help clinicians, employers, policymakers, and others 

make informed decisions about the provision of health care services. This report is intended as a 

reference and not as a substitute for clinical judgment. 

This report may be used, in whole or in part, as the basis for the development of clinical practice 

guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage 

policies. AHRQ or U.S. Department of Health and Human Services endorsement of such 

derivative products may not be stated or implied. 

 
ii

This document is in the public domain and may be used and reprinted without permission except 

those copyrighted materials noted for which further reproduction is prohibited without the 

specific permission of copyright holders. 

Suggested Citation: 

Viswanathan M, Visco AG, Hartmann K, Wechter, ME, Gartlehner G, Wu JM, Palmieri R, Funk 

MJ, Lux, LJ, Swinson T, Lohr KN. Cesarean Delivery on Maternal Request. Evidence 

Report/Technology Assessment No. 133. (Prepared by the RTI International-University of 

North Carolina Evidence-Based Practice Center under Contract No. 290-02-0016.) AHRQ 

Publication No. 06-E009. Rockville, MD: Agency for Healthcare Research and Quality. 

March 2006. 
iii

Preface 

 The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-Based 

Practice Centers (EPCs), sponsors the development of evidence reports and technology 

assessments to assist public- and private-sector organizations in their efforts to improve the 

quality of health care in the United States. This project was funded by the National Institutes of 

Health Office of Medical Applications of Research (NIH OMAR). The reports and assessments 

provide organizations with comprehensive, science-based information on common, costly 

medical conditions and new health care technologies. The EPCs systematically review the 

relevant scientific literature on topics assigned to them by AHRQ and conduct additional 

analyses when appropriate prior to developing their reports and assessments. 

 To bring the broadest range of experts into the development of evidence reports and health 

technology assessments, AHRQ encourages the EPCs to form partnerships and enter into 

collaborations with other medical and research organizations. The EPCs work with these partner 

organizations to ensure that the evidence reports and technology assessments they produce will 

become building blocks for health care quality improvement projects throughout the Nation. The 

reports undergo peer review prior to their release. 

 AHRQ expects that the EPC evidence reports and technology assessments will inform 

individual health plans, providers, and purchasers as well as the health care system as a whole by 

providing important information to help improve health care quality. 

 We welcome comments on this evidence report. They may be sent by mail to the Task Order 

Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, 

Rockville, MD 20850, or by e-mail to epc@ahrq.gov. 

Carolyn M. Clancy, M.D. 

Director 

Agency for Healthcare Research and Quality 

Barnett Kramer, M.D., M.P.H. 

Director 

Office of Medical Applications of Research 

National Institutes of Health 

Jean Slutsky, P.A., M.S.P.H. 

Director, Center for Outcomes and Evidence 

Agency for Healthcare Research and Quality 

Beth A. Collins Sharp, R.N., Ph.D. 

Acting Director, EPC Program 

Agency for Healthcare Research and Quality 

Susan Meikle, M.D., M.S.P.H. 

EPC Program Task Order Officer 

Agency for Healthcare Research and Quality 

v

Structured Abstract 

Objectives. The RTI International—University of North Carolina at Chapel Hill Evidencebased Practice Center (RTI-UNC EPC) systematically reviewed the evidence on the trend and 

incidence of cesarean delivery (CD) in the United States and in other developed countries, 

maternal and infant outcomes of cesarean delivery on maternal request (CDMR) compared with 

planned vaginal delivery (PVD), factors affecting the magnitude of the benefits and harms of 

CDMR, and future research directions. 

Data sources. We searched MEDLINE®, Cochrane Collaboration resources, and Embase 

and identified 1,406 articles to examine against a priori inclusion criteria. We included studies 

published from 1990 to the present, written in English. Studies had to include comparison 

between the key reference group (CDMR or proxies) and PVD. 

Review methods. A primary reviewer abstracted detailed data on key variables from 

included articles; a second senior reviewer confirmed accuracy. 

Results. We identified 13 articles for trends and incidence of CD, 54 for maternal and infant 

outcomes, and 5 on modifiers of CDMR. The incidence of CDMR appears to be increasing. 

However, accurately assessing either its true incidence or trends over time is difficult because 

currently CDMR is neither a well-recognized clinical entity nor an accurately reported indication 

for diagnostic coding or reimbursement. 

Virtually no studies exist on CDMR, so the knowledge base rests chiefly on indirect evidence 

from proxies possessing unique and significant limitations. Furthermore, most studies compared 

outcomes by actual routes of delivery, resulting in great uncertainty as to their relevance to 

planned routes of delivery. Primary CDMR and planned vaginal delivery likely do differ with 

respect to individual outcomes for either mothers or infants. However, our comprehensive 

assessment, across many different outcomes, suggests that no major differences exist between 

primary CDMR and planned vaginal delivery, but the evidence is too weak to conclude 

definitively that differences are completely absent. 

Given the limited data available, we cannot draw definitive conclusions about factors that 

might influence outcomes of planned CDMR versus PVD. 

Conclusions. The evidence is significantly limited by its minimal relevance to primary 

CDMR. Future research requires developing consensus about terminology for both delivery 

routes and outcomes; creating a minimum data set of information about CDMR; improving study 

design and statistical analyses; attending to major outcomes and their special measurement 

issues; assessing both short- and long-term outcomes with better measurement strategies; dealing 

better with confounders; and considering the value or utility of different outcomes.
vii

Contents 

Executive Summary........................................................................................................................ 1 

Chapter 1. Introduction ................................................................................................................ 11 

Context for Systematic Evidence Review of Cesarean Delivery on Maternal Request ........... 11 

Clinical and Epidemiological Issues......................................................................................... 14 

Key Questions and Analytic Framework.................................................................................. 15 

KQ 1: Trend and Incidence of Cesarean Delivery................................................................ 18 

KQ 2: Effect of Planned Route of Delivery on Outcomes.................................................... 18 

KQ 3: Magnitude of Benefits and Harms ............................................................................. 22 

KQ 4: Future Research.......................................................................................................... 22 

A Note on Terminology........................................................................................................ 23

Organization of This Evidence Report ..................................................................................... 23 

Technical Expert Panel (TEP) .................................................................................................. 23 

Chapter 2. Methods...................................................................................................................... 25 

Literature Review Methods....................................................................................................... 25 

Inclusion and Exclusion Criteria........................................................................................... 25 

Literature Search and Retrieval Process ............................................................................... 26 

Literature Synthesis .................................................................................................................. 29 

Development of Evidence Tables and Data Abstraction Process......................................... 29 

Quality and Strength of Evidence Evaluation....................................................................... 29 

External Peer Review................................................................................................................ 35 

Chapter 3. Results ........................................................................................................................ 37 

Key Question 1: Trends and Incidence of Cesarean Delivery................................................. 37 

Literature Relevant to the Epidemiologic Questions............................................................ 38 

Overall Estimates of Incidence and Trends .......................................................................... 38 

Country-Specific Incidence and Trend Data......................................................................... 38 

Key Question 2: Outcomes of Cesarean Delivery on Maternal Request.................................. 50 

Maternal Outcomes for Primary Cesarean Deliveries .......................................................... 60 

Maternal Outcomes Relevant to Subsequent Cesarean Deliveries....................................... 93 

Neonatal Outcomes............................................................................................................. 100 

Key Question 3 What factors affect the magnitude of the benefits and harms identified 

 in KQ 2?.............................................................................................................................. 107 

Chapter 4. Discussion ................................................................................................................ 111 

Results..................................................................................................................................... 111 

KQ 1: Incidence and Trends of Cesarean Delivery on Maternal Request.......................... 111 

KQ 2: Outcomes of Cesarean Delivery on Maternal Request ............................................ 112 

KQ 3: Modifiers of Cesarean Delivery on Maternal Request............................................. 123 

Limitations of Our Review ..................................................................................................... 123 

Limitations of the Evidence Base ........................................................................................... 124 

Lack of Consistent Terminology ........................................................................................ 124 
viii

Inappropriate Comparisons: Planned versus Actual Delivery Modes ................................ 124 

Inappropriate Study Designs............................................................................................... 124 

Inadequate Controls for Confounders................................................................................. 125 

Inadequate Assessment of Modifiers of Outcomes ............................................................ 125 

Inadequate Quality of Studies............................................................................................. 125 

Inappropriate Outcome Measures: Timing, Severity, and Utility....................................... 126 

Future Research Directions (Key Question 4)........................................................................ 126 

Terminology........................................................................................................................ 127 

Appropriate Study Design................................................................................................... 128 

Appropriate Statistical Methods and Reporting.................................................................. 128 

Appropriate Comparisons ................................................................................................... 128 

Important Outcomes............................................................................................................ 129 

Severity ............................................................................................................................... 129 

Appropriate Measures......................................................................................................... 129 

Confounders........................................................................................................................ 130 

Utility of Outcomes............................................................................................................. 130 

New Areas for Research ..................................................................................................... 131 

Conclusions............................................................................................................................. 131 

References and Included Studies ................................................................................................ 133 

Figures 

Figure 1. Possible pathways for planned vaginal and planned cesarean deliveries..................... 13 

Figure 2. Total and primary cesarean rate and vaginal birth after previous cesarean (VBAC) 

 rate — United States, 1989-2004............................................................................................ 14 

Figure 3. Analytic framework for cesarean delivery on maternal request................................... 19 

Figure 4. Disposition of articles for cesarean on maternal request article disposition ................ 28 

Figure 5. Prevalence of neonatal respiratory morbidity by gestational week following elective 

cesarean or vaginal and labored cesarean ............................................................................. 109 

Tables 

Table 1. Key Questions posed by AHRQ on behalf of OMAR................................................... 16 

Table 2. Glossary of terms........................................................................................................... 26 

Table 3. Inclusion/exclusion criteria for cesarean delivery upon maternal request..................... 26 

Table 4. Focused searches and unduplicated results.................................................................... 27 

Table 5. Summary relevance rating ............................................................................................. 30 

Table 6. United States, incidence and trend data......................................................................... 39 

Table 7. United Kingdom, incidence and trend data ................................................................... 40 

Table 8. Ireland, incidence and trend data ................................................................................... 43 

Table 9. Australia, incidence and trend data................................................................................ 44

Table 10. Norway, incidence and trend data................................................................................ 48 

Table 11. Denmark, incidence and trend data.............................................................................. 48 

Table 12. Finland, incidence and trend data ................................................................................ 49 
ix

Table 13. Possible endpoints from planned route of delivery and relevance as proxies to 

 CDMR..................................................................................................................................... 51 

Table 14. Comparison groups...................................................................................................... 52 

Table 15. Maternal and neonatal outcomes reported................................................................... 56 

Table 16. Inclusion of possible confounders ............................................................................... 61 

Table 17. Mortality ...................................................................................................................... 63 

Table 18. Infection....................................................................................................................... 64 

Table 19. Hemorrhage ................................................................................................................. 69 

Table 20. Thromboembolism....................................................................................................... 74 

Table 21. Surgical complications................................................................................................. 77 

Table 22. Maternal length of stay ................................................................................................ 83 

Table 23. Urinary incontinence.................................................................................................... 84 

Table 24. Anorectal function ....................................................................................................... 89 

Table 25. Description of studies addressing placenta previa relative to a history of previous 

cesarean delivery..................................................................................................................... 95 

Table 26. Description of study quality and inclusion and exclusion criteria for update of placenta 

previa....................................................................................................................................... 98 

Table 27. Respiratory morbidity................................................................................................ 103 

Table 28. Potential effect modifiers for planned CDMR and planned vaginal delivery ........... 107 

Table 29. Characteristics of included studies for key question 3 .............................................. 108 

Table 30. Number of cases (and percentage) of neonatal respiratory morbidity by gestational 

week following elective cesarean delivery ........................................................................... 109 

Table 31. Summary of maternal outcomes, directions of effect, and strength of evidence....... 113 

Table 32. Summary of neonatal outcomes, directions of effect, and strength of evidence ....... 120 

Appendixes 

Appendix A: Exact Search Strings 

Appendix B: Sample Review Forms/Quality Rating Forms 

Appendix C: Evidence Tables 

Appendix D: Listing of Excluded Studies 

Appendix E: Acknowledgments 

Appendixes and Evidence Tables for this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/cesarean/cesarreq.pdf. 
1

Executive Summary 

Introduction 

The RTI International–University of North Carolina at Chapel Hill Evidence-based Practice 

Center (RTI-UNC EPC) conducted this systematic evidence review on cesarean delivery on 

maternal request (CDMR) for the Agency for Healthcare Research and Quality (AHRQ). This 

review summarizes the available literature, frames the discussions regarding benefits and harms 

for an upcoming State of the Science (SOS) Conference organized by the National Institutes of 

Health (NIH), Office of Medical Applications of Research (OMAR), and highlights the 

limitations of the evidence base. We received advice and input from an independent Technical 

Expert Panel (TEP). 

For this review, we defined CDMR as a cesarean delivery for a singleton pregnancy, on 

maternal request, at term, and in the absence of any maternal or fetal indication for cesarean 

delivery. We recognized that the available literature does not explicitly define CDMR as a 

specific study group to allow for comparison with other planned routes of delivery. Given this 

lack of evidence on CDMR per se, the SOS conference planning committee requested that we 

include proxies for CDMR such as cesarean deliveries for breech presentation. 

We also recognized that the ideal comparison groups to address the potential benefits and 

harms of CDMR would be planned vaginal delivery and planned CDMR in a low-risk 

population. Planned vaginal delivery does not always result in spontaneous labor followed by 

spontaneous vaginal delivery. Therefore, the ideal evidence demands a comparison of intent: 

planned vaginal delivery with planned CDMR rather than the comparison of actual delivery 

routes such as spontaneous vaginal delivery with unlabored cesarean. In the absence of such 

high-quality evidence, we compiled a summary of the best available literature, using proxies for 

CDMR, frequently relying on studies that define groups by actual route of delivery and not 

planned route of delivery. 

We systematically reviewed the evidence on three key questions (KQs): (1) trend and 

incidence of cesarean delivery over time, (2) effect of approach to delivery (CDMR compared 

with planned vaginal delivery) on maternal and neonatal outcomes, and (3) factors that affect the 

magnitude of the benefits and harms identified in KQ2. Additionally, we described future 

research directions as KQ4. 

Several factors make interpretation of the available evidence challenging: (1) comparisons 

are generally made by actual, not planned, routes of delivery (the latter being a preferred intentto-treat approach); (2) available proxies are of variable relevance to CDMR; (3) practice patterns 

vary widely over time and among providers, (4) confounders are common and rarely accounted 

for; (5) statistical power is frequently inadequate, particularly for rare outcomes; (6) timing of 

outcomes and their measurement is inappropriate; (7) investigators use unvalidated 

questionnaires; and (8) severity and utility ratings of various outcomes are typically lacking. 

Methods 

We searched MEDLINE®, Cochrane Collaboration resources, and Embase. Based on key 

questions and discussion with our TEP, we generated a list of article inclusion and exclusion 
2

criteria. We excluded studies that: (1) did not report on women of reproductive age; (2) were 

published in languages other than English; (3) did not report information pertinent to the key 

clinical questions; (4) had fewer than 50 subjects for randomized controlled trials (RCTs) or 100 

subjects for observational studies; and (5) were not original studies. Additionally, and in 

consultation with the TEP, we excluded studies that did not provide data on both planned 

cesarean delivery and planned vaginal delivery for KQ 1 and KQ 2. As a consequence of this 

search strategy, we cannot address outcomes or modifiers unique to vaginal delivery, without 

reference to a cesarean delivery comparison group. Our aim was to compare primary planned 

cesarean delivery (cesarean delivery on maternal request, or CDMR) with planned vaginal 

delivery. Time and resources did not permit us to review comprehensively the benefits and 

harms associated with repeat cesarean deliveries. However, we did summarize outcomes 

particularly relevant to subsequent cesarean deliveries such as subsequent uterine rupture, 

subsequent fertility, and placenta previa by examining recent systematic reviews or updating a 

recent meta-analysis. 

We reviewed each abstract and article systematically against a priori criteria to determine 

inclusion in the review. Two reviewers separately evaluated the abstracts for inclusion or 

exclusion. If one abstractor concluded that the article should be included in the review, we 

retained it. We assigned each excluded article a reason for exclusion. We entered the data from 

abstraction forms into evidence tables and checked for consistency and accuracy. Staff 

reconciled all disagreements about information in evidence tables. 

The vast majority of studies reported results on actual route of delivery rather than planned 

route of delivery (intent to treat). The comparison groups varied widely. We found it impossible 

to arrive at any meaningful summary of the literature without explicitly categorizing the 

comparison groups and the studies themselves. We developed a four-tier classification system of 

relevance to CDMR based on the following criteria: (1) whether studies analyzed outcomes by 

planned route of delivery (trials of route of delivery); (2) whether CDMR was included as a 

comparison group (high relevance); (3) whether comparison groups comprised planned cesareans 

(moderate relevance), and (4) whether studies involved undefined “elective” or a mix of planned 

and unplanned, unlabored cesareans (low relevance). 

We rated trials of routes of delivery and studies of high and moderate relevance for quality, 

assigning scores of good, fair, or poor. For RCTs, our rating system evaluated (1) randomization 

approach and implementation; (2) post-randomization exclusion; (3) masking; (4) operational 

definitions and measurements; (5) loss to followup; and (6) statistical analysis. For 

nonrandomized observational cohorts, we evaluated (1) study design; (2) study population; 

(3) comparability of subjects; (4) statistical analysis; (5) measure of effect and loss to followup. 

We summarized the strength of evidence for each outcome, judging the evidence to be strong for 

results that are clinically important, consistent, and free from serious doubts about 

generalizability, bias, or flaws in research design. We judged evidence to be moderate for studies 

of strong design, with some inconsistencies or concern about generalizability, bias, research 

design flaws or for studies of weaker design with consistent evidence. We judged evidence to be 

weak for studies of weaker design with inconsistent results or studies of strong design with 

inconclusive results. 

From our review of 1,406 abstracts, we found 69 articles comprising 65 studies that 

addressed one or more key questions. Of these, 13 addressed KQ1, 54 addressed KQ2, and 5 

addressed KQ3. 
3

Results 

KQ1: Incidence and Trends of Cesarean Delivery on Maternal Request 

KQ 1 referred to the incidence and trends in cesarean deliveries over time in developed 

countries; it made specific reference to primary cesarean before onset of labor, CDMR, medical 

indications, and malpresentation as proportions of total cesarean deliveries. The absence of data 

to answer this question is striking. Regarding incidence, the available literature yielded rates of 

cesarean deliveries as a proportion of all deliveries for a wide array of time points and countries. 

For 2001 in the United States, data suggest rates of more than 25 percent. Elsewhere in the 

developed world for 2001, rates of cesarean delivery ranged from 14 percent in The Netherlands 

to 35 percent in Italy. Since 2001, the rates of cesarean delivery have risen in the United States; 

recent figures put the rate at more than 29 percent for 2004. 

The rate of cesarean deliveries is rising worldwide. Both “elective” cesarean deliveries 

(sometimes defined as unlabored) and “nonelective” cesarean deliveries contribute to this rise; 

however, the proportions vary by country, study, and time period. Four studies distinguished 

between prelabor primary and repeat cesareans. An Irish study reported an unlabored primary 

cesarean delivery rate of 18.9 percent of all cesarean deliveries during the 12-year period from 

1989 to 2000. One study in Australia showed that prelabor primary cesarean delivery as a 

percentage of all deliveries rose from 4.1 percent in 1980 to 4.8 percent in 1987. In the United 

States, primary prelabor cesarean delivery rates were approximately 5 percent of all deliveries in 

1996 and approximately 7 percent in 2001. In 2001, “primary elective” prelabor cesarean rate as 

a proportion of all cesarean deliveries was 28.3 percent in the United States. 

The extent to which CDMR is contributing to the rise in cesareans remains unclear. Finally, 

we did not find sufficient data to comment on medical indications or malpresentation as a 

proportion of all cesarean deliveries. 

KQ 2: Outcomes of Cesarean Delivery on Maternal Request 

Overall, few moderately relevant studies were available, and the strength of evidence is weak 

for nearly all outcomes. 

Maternal outcomes for primary cesarean deliveries. Mortality. Four studies suggested no 

evidence of difference in maternal mortality associated with planned vaginal versus planned 

cesarean delivery. These studies provided weak evidence overall. 

Infection. The 12 studies that included maternal infection as an outcome provided weak 

evidence that the risk of maternal infection was lower with planned cesarean than with 

unplanned cesarean delivery and lower for vaginal than for cesarean delivery. 

Anesthetic complications. Two studies showed a lower rate of anesthetic complications with 

planned vaginal than with planned cesarean delivery; the third reported no significant difference 

between these two routes of delivery. These studies provided weak evidence suggesting a lower 

rate of anesthetic complications with planned vaginal delivery. 

Hemorrhage and blood transfusion. Eleven studies provided moderate strength of evidence 

showing a lower risk of hemorrhage and blood transfusion in planned cesareans than in vaginal 

delivery. These studies also yielded evidence of lower hemorrhage or blood transfusion in 

planned cesareans than in unplanned cesareans. 
4

Hysterectomy. Three studies yielded weak evidence on the association between emergency 

hysterectomy after childbirth and either planned vaginal or planned cesarean delivery. The rarity 

of the outcome results in insufficient statistical power to draw firm conclusions regarding the risk 

associated with either delivery route. 

Thromboembolism. Eight studies provided weak evidence for an association between 

thromboembolism and planned vaginal or planned cesarean delivery. Studies reported no 

consistent direction or magnitude of effect. 

Surgical complications. Ten studies provided weak evidence on surgical complications 

associated with planned vaginal and planned cesarean delivery. Studies generally showed a 

lower risk of surgical complications in planned “elective” cesarean than unplanned “emergency” 

or “labored” cesarean deliveries. 

Breastfeeding. One study provided weak evidence that although women with planned vaginal 

deliveries may initiate breastfeeding sooner than women with planned cesarean deliveries, they 

do not report any difference in the duration of breastfeeding. Other evidence suggests that 

women are more likely to bottlefeed following a cesarean delivery (planned or unplanned) 

compared with a vaginal delivery. 

Postpartum pain. Four articles (from three studies) reported on postpartum pain using 

various pain measures at different time periods. Together, these studies provide weak evidence 

of no significant difference in pain between modes of delivery, but they draw from populations 

with breech deliveries and may, therefore, overestimate the pain in the planned vaginal delivery 

group. 

Psychological outcomes: postpartum depression. Two studies provide weak evidence 

suggesting no differences in postpartum depression by delivery route. As with pain, studies with 

breech populations likely overestimated the rate of complications, interventions, and possible 

negative psychological outcomes in the planned vaginal delivery group. 

Psychological outcomes: other. Seven articles (from six studies) yielded weak evidence 

about a range of other psychological outcomes. The data were consistent in reporting that women 

who had an unplanned cesarean birth or an instrumental vaginal delivery were more likely to 

experience adverse psychological outcomes than were women who either underwent a 

spontaneous vaginal or a planned cesarean birth. The variety of outcomes and measures makes a 

summative assessment of other outcomes challenging. 

Maternal length of stay. Four studies provided moderate evidence that length of stay is 

higher for cesarean delivery, planned or otherwise, than for vaginal delivery.

Urinary incontinence. Nine articles (from eight studies) provided weak evidence that rates of 

stress urinary incontinence for planned “elective” cesarean section were either lower than or no 

different from those for vaginal delivery. Numerous problems limit evidence on this outcome: 

lack of high-quality prospective studies that compare planned routes of delivery, have adequate 

power, include comprehensive long-term followup, account for multiple deliveries, account for 

variations in practice patterns including use of epidural anesthesia and episiotomy, use validated 

urinary questionnaires administered at consistent time points from delivery, and define 

incontinence in a standardized fashion by its occurrence, severity, and impact on quality of life. 

Anorectal function. Seven articles (from six studies) provided weak evidence showing a 

reduced risk of anal incontinence in planned cesarean deliveries compared with unplanned 

cesarean or instrumental vaginal deliveries. Evidence was inconsistent about differences between 

planned cesarean and spontaneous vaginal delivery. 
5

Pelvic organ prolapse. We found no evidence on the association between pelvic organ 

prolapse and planned vaginal or planned cesarean delivery. 

Sexual function. One study provided weak evidence that sexual function does not differ by 

planned route of delivery. 

Maternal outcomes relevant to subsequent cesarean delivery. Subsequent fertility issues.

Studies not included in this review suggests a higher risk with all cesarean deliveries (unplanned 

or planned), but we found no reliable evidence of difference relevant to CDMR.

Subsequent uterine rupture. A recent update of a systematic review on the outcomes of 

vaginal birth after cesarean (VBAC) provided moderate evidence on subsequent uterine rupture. 

The update found no statistically significant differences between trial of labor after cesarean and 

elective repeat cesarean delivery with regard to rates of asymptomatic uterine rupture rates. The 

update noted that two studies of fair or good quality found a small but higher risk of symptomatic

uterine rupture in trial of labor after cesarean than in elective repeat cesarean delivery. 

Placenta previa. Given that placenta previa is the most common placental implantation 

anomaly, we updated a recent meta-analysis examining the relationship between placenta previa 

and a history of cesarean delivery. Our update supports the earlier meta-analytic conclusion that 

the odds of placenta previa are associated with advancing maternal age and increasing parity. 

The literature provided moderate evidence that the risk of placenta previa increases with 

previous cesarean delivery. 

Subsequent stillbirth. Studies not included in this review suggest a higher risk with all 

cesarean deliveries (unplanned or planned), but we found no reliable evidence of difference 

relevant to CDMR. 

Neonatal outcomes. Fetal mortality. We found no studies that addressed fetal (in utero) 

deaths. 

Neonatal mortality. Two studies provided weak evidence on neonatal mortality. The studies 

suggested a higher risk for all cesareans (planned or unplanned) than for spontaneous vaginal 

delivery. The studies did not control for underlying maternal or neonatal indications for cesarean 

or were underpowered for such a rare outcome, leading to limited ability to draw conclusions on 

this outcome. 

Unexpected (iatrogenic) prematurity. We found no study that addressed unexpected 

prematurity and allowed comparisons by type of cesarean with intended or actual vaginal birth. 

Respiratory morbidity. Measures of respiratory morbidity range from transient tachypnea of 

the newborn (TTN) to severe respiratory distress syndrome (RDS) with long-term sequelae. Nine 

articles yielded moderate evidence that the risk of variably defined “respiratory morbidity” was 

higher for all cesarean births than for vaginal deliveries. This risk reduces with advancing 

gestational age. Studies did not assess meconium aspiration syndrome by mode of delivery. 

Transition issues. One study reported on this outcome, but the significant issues of 

appropriate categorization in this study make interpreting the data difficult. We consider the 

available evidence insufficient to judge the direction of effect. 

Neonatal asphyxia or encephalopathy. Two studies provided weak evidence of a higher risk 

of neonatal encephalopathy associated with operative vaginal deliveries and “emergency” or 

“labored” cesareans than with spontaneous vaginal delivery. 

Intracranial hemorrhage. One study provided weak evidence on intracranial 

(subdural/cerebral, intraventricular, and subarachnoid) hemorrhage. The prelabor cesarean 

deliveries included those done for maternal or neonatal indications, so they likely involved 
6

cesareans for placenta previa and fetal anomalies, which may independently increase the risk of 

intracranial hemorrhage. Despite the higher theoretical risk for prelabor cesarean deliveries, this 

study did not find any significant difference between spontaneous vaginal delivery and prelabor 

cesarean deliveries. It did show consistently higher rates of intracranial hemorrhage for assisted 

vaginal deliveries and cesarean deliveries in labor. 

Facial nerve injury. One study provided weak evidence that the risk of facial nerve injury 

varies by mode of delivery; the risk is higher for forceps and the combined use of forceps and 

vacuum delivery than for spontaneous vaginal delivery. These findings suggested that CDMR 

posed no risk for facial nerve injury greater than that associated with planned vaginal delivery. 

Brachial plexus injury. One study provides weak evidence that the incidence of brachial 

plexus injury is lower in cesarean delivery than in vaginal delivery. 

Fetal laceration. Two studies provided weak evidence on fetal lacerations based on data 

limited to cesarean deliveries. They reported a higher rate of fetal lacerations among emergency 

and labored cesarean than among elective cesarean delivery. 

Neonatal length of hospital stay. One study provided weak evidence that the neonatal length 

of hospital stay is higher for “elective” cesarean delivery than for vaginal delivery. 

Long-term neonatal outcomes. We did not find any evidence on long-term neonatal 

outcomes. 

KQ 3: Modifiers of Cesarean Delivery on Maternal Request 

The evidence on effect modifiers is sparse and pertains to only a few outcomes for KQ 2. 

Five studies provided evidence on the modifiers of CDMR, specifically neonatal respiratory 

distress, infectious morbidity, and urinary incontinence. 

With regard to respiratory morbidity, results showed a consistent decrease in respiratory 

morbidity as gestational age rises, despite differences in inclusion criteria and definitions of 

elective cesarean delivery. Gestational age appears to play a lesser role as a risk factor for fetal 

respiratory distress in planned vaginal delivery than in planned cesarean. 

With regard to infectious morbidity, the single study we found suggested no effect of 

physician experience, incision type, maternal age, or prophylactic antibiotics on infectious 

morbidity; it did suggest that the risk was higher among obese or black patients than among other 

women. Pelvic floor exercises decreased the risk of urinary incontinence; pre-pregnancy body 

mass index increased it. 

Given the lack of evidence directly comparing effect modifiers in a population with planned 

CDMR with those in a population with planned vaginal delivery, inferences about effect 

modifiers must be drawn cautiously. Furthermore, most studies did not adjust for confounders, so 

results must be interpreted as crude estimates. 

Conclusions

The incidence of CDMR appears to be increasing. However, accurately assessing its true 

incidence or trends over time is difficult because currently CDMR is neither a well-recognized 

clinical entity nor an accurately reported indication for diagnostic coding or reimbursement. 

More information is available on this question from nations other than the United States, and 

they differ from this country in health systems, cultural attitudes, patient demographics, and 

other factors. Drawing inferences from non-US sources, therefore, must be done with caution. 
7

Virtually no studies exist on CDMR per se, so the knowledge base rests chiefly on indirect 

evidence from proxies such as cesareans performed for breech presentation. These proxies each 

possess unique and significant limitations. Furthermore, the vast majority of studies to date 

compared outcomes by actual routes of delivery, not planned routes of delivery. Therefore, 

significant uncertainty remains regarding the “ideal” route of delivery. Primary CDMR and 

planned vaginal delivery likely do differ with respect to individual outcomes for either mothers 

or infants. However, our comprehensive assessment, across many different outcomes, suggests 

that no major differences exist between primary CDMR and planned vaginal delivery, but the 

evidence is too weak to conclude definitively that differences are completely absent. If a woman 

chooses to have a cesarean delivery in her first delivery, she is more likely to have subsequent 

deliveries by cesarean. With increasing numbers of cesarean delivery, risks occur with increasing 

frequency. 

Given the limited data available, we cannot make definitive conclusions about factors that 

might influence outcomes of planned CDMR versus planned vaginal delivery. Neither is the 

knowledge base adequate to comment definitively on many factors that influence the outcomes 

of actual cesarean and vaginal deliveries. 

Our review was focused on primary CDMR. We note that a comprehensive assessment of the 

risks and benefits of CDMR extends beyond the first cesarean. Future research needs to account 

for complications and risks associated with repeat cesarean deliveries such as adhesions, placenta 

previa and accreta, and subsequent stillbirths. 

Significant resources will need to be allocated to study CDMR if the nation is to be well 

informed about the benefits and harms to mothers and infants in both the first and subsequent 

pregnancies. To realize the maximum gain from such work, research intended to answer 

questions about maternal and neonatal outcomes of CDMR must study them by intent-to-treat 

methods. This means comparing outcomes of planned CDMR with those of planned vaginal 

delivery, not comparing outcomes by actual routes of delivery. 

Future research efforts need to focus on a substantial set of problems: developing consensus 

about terminology for both delivery routes and outcomes; creating a minimum data set of 

information about CDMR; improving study design and statistical analyses; attending to major 

outcomes and their special measurement issues; assessing both short- and long-term outcomes 

with better measurement strategies; dealing better with confounders; and considering the value or 

utility (in quality-of-life terms) of different outcomes. Examining the costs and cost-effectiveness 

of different pathways of delivery and considering the impact of CDMR on the medicolegal 

system also warrant attention. 

Finally, if we are to gain meaningful data on short- and long-term maternal and neonatal 

outcomes associated with CDMR (whether or not compared with planned vaginal delivery), we 

should define success as a healthy mother and infant in the broadest sense of well-being possible. 

Studies ought to be well-designed, prospective, and with adequate sample sizes and clearly 

described power analyses for both common and rare outcomes. Accumulating such high-quality 

evidence is possible with cooperation from all stakeholders; acquiring it is imperative if women 

and care providers are to be able to make informed decisions about CDMR. 
Evidence Report 

11 

Chapter 1. Introduction

Context for Systematic Evidence Review of Cesarean 

Delivery on Maternal Request 

The National Institutes of Health (NIH) Office of Medical Applications of Research 

(OMAR) reviews and evaluates clinically relevant NIH research program information and serves 

to promote the effective transfer of this information to the health care community. OMAR 

accomplishes this objective through its Consensus Development Program, which includes major 

Consensus Development conferences and State-of-the-Science conferences (SOS, when there is 

less definitive evidence available). OMAR, given the wide recognition of the limited literature 

available to guide clinical practice of cesarean delivery on maternal request (CDMR), planned an 

SOS Conference for March 2006. As background, OMAR commissioned this systematic review 

through the Agency for Healthcare Research and Quality (AHRQ) as a means of summarizing 

the available literature, framing the discussions regarding benefits and harms, and highlighting 

the limitations of the entire evidence base. 

For the purposes of this review, cesarean delivery on maternal request is defined as a 

cesarean delivery for a singleton pregnancy, on maternal request, at term, and in the absence of 

any maternal or fetal indication for cesarean delivery. The panel chair of the SOS Conference, 

and a panel of independent technical experts (TEP) recognized that the available literature does 

not explicitly define CDMR as a specific study group to allow for comparison with other planned 

routes of delivery. Given this lack of evidence on CDMR per se, the TEP and SOS conference 

panel chair requested that we include proxies for CDMR such as cesarean deliveries for breech 

presentation. 

We recognize that the ideal comparison groups to address the potential benefits and harms of 

CDMR would be planned vaginal delivery vs. planned CDMR in a low-risk population. We also 

note that planned vaginal delivery does not always result in spontaneous labor followed by 

spontaneous vaginal delivery. 

The ideal evidence, therefore, demands a comparison of intent: planned vaginal delivery 

compared with planned CDMR rather than the comparison of actual delivery routes such as 

spontaneous vaginal delivery compared with unlabored cesarean. Such a comparison, based on 

intent to treat, is critical to assess the purported benefits of CDMR in reducing the risk of pelvic 

floor disorders (urinary incontinence, pelvic organ prolapse*

 [loss of pelvic support], anal 

incontinence) because it is unclear whether or to what extent pelvic floor damage is caused by 

pregnancy itself, the first stage of labor [regular contractions to full cervical dilatation], or the 

second stage of labor [full dilatation to delivery—pushing phase]). 

In the absence of such high-quality evidence, we compiled a summary of the best available 

literature, using proxies for CDMR, frequently relying on studies that define groups by actual

route of delivery and not planned route of delivery. Studies comparing actual and not planned 

route of delivery may provide inaccurate estimates of benefits and harms by reporting only 

outcomes of a limited group. For instance, a comparison of spontaneous vaginal delivery with 

 

*

 Pelvic organ prolapse describes a group of conditions when one or more of the organs in the pelvis (the bladder, uterus, small

intestines or rectum) fall into the vagina or through the vagina outside the body. Different terms describing prolapse include 

“cystocele” or “dropped bladder”; “uterine prolapse” or “dropped uterus”; “rectocele” or “enterocele.”130
12 

unlabored cesarean may overestimate the risk of third-degree lacerations in the planned vaginal 

delivery group by not accounting for the group of women who ultimately underwent a cesarean 

delivery after attempting a vaginal delivery. Similarly, such a comparison would overestimate 

the risk of wound infection in the planned cesarean delivery group by not accounting for the 

higher rate of wound infection in women who ultimately underwent a cesarean delivery after 

attempting a vaginal delivery. 

In addition, comparing actual routes of delivery rather than planned routes of delivery yields 

an inadequate assessment of potential confounders that, by definition, may influence both the 

route of delivery and the maternal or neonatal outcomes of interest. For instance, prolonged fetal 

bradycardia (fetal distress) can influence the need for an emergency delivery by cesarean, 

vacuum, or forceps and can also negatively affect neonatal outcomes. Studies that examine 

actual routes of delivery typically fail to account for such confounders. 

To clarify the nature of these complex pathways and to highlight the potential confounders 

inherent in these comparisons, we present a framework of possible pathways for primiparous 

women with singleton pregnancies at term (see Figure 1). The pathways begin with planned 

routes of delivery, describe common labor events and potential confounders, and ultimately lead 

to various actual routes of delivery. As noted already, available studies often include comparison 

groups of actual routes of delivery for primiparous women with singleton pregnancies at term. 

On the left of Figure 1, we list the range of planned routes of delivery before labor. These 

include planned vaginal delivery and planned cesarean delivery for fetal indications, maternal 

indications, or upon maternal request. Given the lack of evidence on CDMR, planned cesarean 

for maternal indications or planned cesarean for fetal indications serve as proxies for CDMR, 

accounting for potential confounding effects when possible. For example, we consider cesarean 

delivery for breech as a proxy for CDMR for maternal outcomes. However, we do not consider 

this group as an appropriate proxy when assessing neonatal outcomes, because underlying 

pathology may result in both breech presentation and poor neonatal outcomes. (A later section of 

this chapter presents a note on terminology and glossary dealing further with the variable 

language for this topic.) 

The middle section of Figure 1 includes labor events in either the first or second stage of 

labor that could necessitate a particular route of delivery and influence outcomes. These involve 

circumstances such as significant and prolonged fetal bradycardia (decrease in fetal heart rate), 

meconium-stained amniotic fluid (amniotic fluid containing material from fetal bowel 

movement), arrest of labor (slow or absent progress during the active phase of labor), cord 

prolapse (when the umbilical cord falls into the vagina prior to delivery), and placental abruption 

(placental detachment from the wall of the uterus). Generally, studies do not control for these 

potential confounders. 

On the right of Figure 1, we show actual routes of delivery. In our review, most studies 

compare outcomes among various actual routes of delivery. As noted above, the ideal 

comparison would be between various planned routes of delivery. We attempt to describe such 

comparisons when available. 

Our pathway for describing various routes of delivery for primiparous women with singleton 

pregnancies at term is not meant to represent a comprehensive flowchart of the multitude of 

prelabor and intrapartum events that may occur and that may alter the planned course of delivery. 

For instance, we do not describe planned vaginal delivery for either maternal or fetal indications 
13

Figure 1. Possible pathways for planned vaginal and planned cesarean deliveries 

Singleton 

Pregnancy

Planned

Vaginal

Delivery

Planned Cesarean for 

Maternal Request

Spontaneous 

Labor

Induced

Labor

Labor Before Scheduled 

Date of Cesarean

No Labor Prior to Scheduled

Date of Cesarean

Planned

Cesarean

Delivery

Uneventful First Stage of Labor

Uneventful Second 

Stage of Labor

First Stage of Labor Event

Requiring Emergency Delivery

-Prolonged fetal bradycardia

-Cord prolapse

-Placental abruption

First Stage of Labor Event

Not Requiring Emergency Delivery

-Arrest of labor

-Meconium (amniotic fluid)

-Nonreassuring fetal heart rate

Second Stage of Labor Event

Not Requiring Emergency 

Cesarean

-Maternal exhaustion

-Arrest of second stage

-Arrest of descent

Second Stage of Labor Event

Requiring Emergency 

Cesarean

Planned Delivery Route Labor Events 

Planned Delivery Route Labor Events 

Planned Cesarean for 

Fetal Indications:

-Breech

-Birth defects

Labor Before Scheduled

Date of Cesarean

Indication for Cesarean

Still Present

Indication for Cesarean

No Longer Present

(Spontaneous conversion 

to vertex)

No Labor Before Scheduled

Date of Cesarean

Planned Cesarean for 

Maternal Indications:

-Previa

-Preeclampsia

-Uterine scar

Labor Before Scheduled

 Date of Cesarean

No Labor Before Scheduled

Date of Cesarean

Note: Text in bold represents ideal comparison groups for this review.
14 

(or both). However, we do include pathways for cesarean delivery for neonatal and maternal 

indications because these serve as the only available proxies for CDMR. 

Significant advances in operative techniques, anesthesia, availability of antibiotics, and 

neonatal care over the past several decades have resulted in a decline in maternal and neonatal 

mortality.1

 For this reason and in consultation with our TEP, AHRQ, and the SOS Conference 

panel chair, we limited our searches to articles published in or after 1990. 

The remainder of this chapter describes the clinical and epidemiological issues related to 

CDMR, describes the four key questions (KQs) addressed by our systematic review, and presents 

an analytical framework for approaching the KQs. 

Clinical and Epidemiological Issues 

The Centers for 

Disease Control and 

Prevention (CDC) 

reported that 29.1 

percent of all births in 

the United States 

resulted from cesarean 

deliveries in 2004, an 

increase of 40 percent 

from 1996 and the 

highest percentage ever 

reported in the United 

States (see Figure 2).2

After declines between 

1989 and 1996, the 

total cesarean rate and 

the primary cesarean 

rate (i.e., percentage of 

cesareans among 

women with no previous cesarean delivery, which was 20.6 percent in 2004) have increased each 

year.

2

Among women with previous cesarean deliveries, the rate of vaginal birth after previous 

cesarean (VBAC) has dropped over time; the likelihood that subsequent deliveries would be 

cesarean was approximately 91 percent in 2004. Recent analysis from the Healthcare Cost and 

Utilization Project Nationwide Inpatient Sample suggests that “elective primary cesarean 

deliveries,” defined as a procedure that occurred before labor and without a previous history of 

cesarean delivery, rose from 19.7 percent of all cesarean deliveries in 1994 to 28.3 percent in 

2001, an increase of approximately 43.6 percent.3

 This statistic includes cesarean deliveries 

performed for malpresentation, antepartum bleeding, herpes, severe hypertension, uterine scar, 

multiple gestation, macrosomia (excessive weight or size of the infant, relative to gestational 

age), unengaged head (fetal head not applied to cervix), “soft tissue condition,” other 

hypertension, preterm, fetal anomaly, and unspecified indications; the contribution of CDMR to 

this statistic is unknown. The higher level of comfort that obstetricians feel with the risks 

Figure 2. Total and primary cesarean rate and vaginal birth after previous 

cesarean (VBAC) rate — United States, 1989-2004 
15 

associated with cesarean deliveries compared with those associated with vaginal deliveries may 

explain the rise in primary cesarean deliveries in part;4

 physicians also may be justifying 

cesarean deliveries after a brief and “gentle” trial of labor.5

The topic of CDMR has drawn heightened interest and publicity. This attention can be 

attributed to the increased awareness that what happens in the delivery room has lifelong 

implications for both mother and child. The concerns associated with the increased rate of 

cesarean deliveries include the likelihood of higher risks from surgery, such as mortality, 

infection, anesthetic complications, hemorrhage, need for blood transfusions, and neonatal 

respiratory distress. 

One purported benefit of CDMR is protection against pelvic floor disorders such as urinary 

incontinence, pelvic organ prolapse, and anal incontinence. Substantial controversy exists 

regarding appropriate clinical practice and whether CDMR should be made more widely 

available, in part to take advantage of this possible benefit and also to allow ease of scheduling 

the delivery for patients and providers. A recent editorial in the American College of 

Obstetricians and Gynecologists (ACOG) Clinical Review strongly suggested that CDMR be 

made more widely available to women.1 This recommendation was directed specifically toward 

nulliparous women or those who have undergone pelvic reconstructive surgery. Conversely, 

organizations such as the International Federation of Gynecology and Obstetrics (FIGO) support 

vaginal birth and believe that the practice of CDMR lacks ethical justification.6

 However, the 

ACOG Ethics Committee determined that the physician is ethically justified in performing a 

CDMR if he or she believes that it promotes the overall health and welfare of the woman and her 

fetus but is equally justified in refusing to perform one if the physician believes it to be 

detrimental to the woman and her fetus.7

 

Significant variability associated with obstetrical practice and labor management makes it 

difficult to quantify the risk of CDMR. Given these uncertainties, no clear evidence guides 

informed decisionmaking regarding CDMR. As women’s life expectancy has increased to 80.1 

years of age over the past several decades,8 and as women remain active well into their 

postmenopausal years, attention to the antecedents of long-term maternal health outcomes is 

increasingly important. 

Key Questions and Analytic Framework 

Table 1 presents the final key questions posed by AHRQ on behalf of OMAR. Figure 3 

depicts the analytic framework we used to address the four key questions, given the flowchart for 

the various planned vaginal and planned cesarean pathways (in Figure 1). 

Given the time and resources available for this systematic review, we focused on the 

maternal and neonatal outcomes of high priority to the SOS conference planning committee. The 

maternal short-term outcomes include mortality, infection, anesthetic complications, hemorrhage 

or blood transfusion, hysterectomy, thromboembolism, surgical complications, breastfeeding, 

postpartum pain, psychological outcomes, and length of stay. The long-term maternal outcomes 

include urinary incontinence, anorectal function, pelvic organ prolapse, sexual function, 

subsequent fertility issues, subsequent placenta previa, subsequent uterine rupture, and 

subsequent stillbirth. 
16 

Table 1. Key Questions posed by AHRQ on behalf of OMAR 

Key Questions 

1. What is the trend and incidence of cesarean delivery over time in the United States and in other 

countries? 

a. What is the contribution of primary pre-labor cesarean deliveries? 

b. Of the primary pre-labor cesarean deliveries what is the contribution of cesarean delivery on maternal 

request, for medical indications, and for malpresentation? 

2. What are the short-term (under one year) and long-term benefits and harms to mother and baby 

associated with cesarean by request versus attempted vaginal delivery? 

Maternal 

Maternal outcomes—short term 

 1. Mortality* 

 2. Infection* 

 3. Anesthesia* 

 4. Hemorrhage/blood transfusion* 

 5. Hysterectomy* 

 6. Thromboembolism 

 7. Surgical complications 

 8. Unplanned ICU admission 

 9. Wound breakdown 

10. Breastfeeding 

11. Pain (labor and postoperative) 

12. Psychological 

13. Readmission to hospital 

14. Maternal length of stay 

15. Maternal recovery 

Maternal outcomes—long term 

 1. Urinary function* 

 2. Anorectal function* 

 3. Pelvic organ prolapse* 

 4. Sexual function* 

 5. Endometriosis 

 6. Pelvic pain 

 7. Future fertility 

 8. Subsequent ectopic pregnancies 

 9. Subsequent uterine rupture* 

10. Subsequent placental implantation issues* 

11. Subsequent stillbirth* 

12. Psychological 

13. Subsequent surgery 

14. Fistulae 

Fetal/Neonatal 

Fetal/Neonatal outcomes—short term 

 1. Fetal mortality* 

 2. Neonatal mortality* 

 3. Unexpected (iatrogenic) prematurity* 

 4. Respiratory distress syndrome* 

 5. Metabolic complications 

 6. Transition issues 

 7. Transient tachypnea of the newborn* 

 8. Persistent pulmonary hypertension of the newborn 

 9. Encephalopathy/asphyxia* 

10. Cerebral accident and stroke 

11. Unplanned NICU/special care nursery 

12. Birth Injury 

13. Brachial plexus injury* 

14. Fractures 

15. Lacerations 

16. Infections 

17. Length of stay 

18. Breastfeeding 

Neonatal outcomes—long term 

 1. Bonding and early behavioral issues 

 2. Long-term development outcome 

* Indicates outcomes considered of higher priority by the Conference Planning Committee
17 

Table 1. Key Questions posed by AHRQ on behalf of OMAR (continued) 

Key Question 

3. What factors influence benefits and harms? 

a. Fetal gender 

b. Fetal size 

c. Parity 

d. Socioeconomics 

e. Race/ethnicity 

f. Maternal BMI 

g. Maternal medical conditions 

h. Pregnancy dating 

i. Type of labor (e.g. augmented) 

j. Physician experience/specialty 

k. Delivery volume/level of perinatal care 

l. Time of day of delivery 

4. What future research directions need to be considered to get evidence for making appropriate decisions 

regarding cesarean on request or attempted vaginal delivery? 

The analytic framework and this review concentrate on outcomes associated with 

primiparous births. Such an approach excludes two important outcomes that are particularly 

relevant to a comprehensive assessment of short-term and long-term risks associated with 

CDMR: (1) placental implantation abnormalities (previa, accreta, and percreta) and (2) uterine 

rupture generally associated with a trial of labor after cesarean. 

Because the rate of VBAC is decreasing, women who undergo a first cesarean are likely to 

deliver future children through a similar route. Although we do not fully understand the 

mechanism by which placenta previa occurs,9 studies indicate that the risks of placenta previa 

and similar placental implantation abnormalities increase with the number of cesarean 

deliveries.10-12 

In consultation with the TEP and the SOS Conference panel chair, we determined that a 

comprehensive assessment of these two outcomes—placental implantation abnormalities and 

uterine rupture—was beyond the scope and resources allocated for this review. However, given 

the importance of these two outcomes and the likelihood that they may significantly affect shortand long-term maternal and neonatal morbidity and mortality associated with hemorrhage or 

prematurity, respectively, we updated recently completed and well-designed systematic evidence 

reviews on these topics. 

Neonatal outcomes included in this systematic evidence review include fetal mortality, 

neonatal mortality, unexpected (iatrogenic) prematurity, respiratory morbidity including transient 

tachypnea, respiratory distress syndrome, and persistent pulmonary hypertension, transition, 

neonatal encephalopathy and asphyxia, intracranial hemorrhage, facial nerve injury, brachial 

plexus injury, fetal laceration, neonatal length of stay, and long-term issues. 

In consultation with our TEP, AHRQ, and the SOS Conference panel chair, we determined 

that this systematic evidence review would not examine outcomes unique to vaginal delivery in 

the absence of a cesarean comparison group. The examination of outcomes and modifiers of 

vaginal deliveries in studies without cesarean comparison groups was outside the scope and 

resources allocated to this review. 
18 

The following sections describe our conceptual approach to addressing the four KQs in 

greater detail. 

KQ 1: Trend and Incidence of Cesarean Delivery 

This question includes trend and incidence of cesarean delivery over time and covers the 

contribution of primary prelabor cesarean deliveries. KQ 1 further seeks to determine the 

contribution of CDMR and other cesareans for other indications such as repeat elective cesarean 

deliveries, unlabored cesareans for medical indications (maternal or neonatal), unlabored 

cesareans for malpresentation, and labored cesareans after a planned vaginal delivery (Figure 3). 

These groupings will be particularly relevant to both maternal and neonatal outcomes because 

short- and long-term risks may be associated with the degree of effort exerted to achieve a 

vaginal delivery.13

Despite the theoretical importance of these distinctions, obtaining accurate data on the rate of 

cesarean delivery truly on maternal request in the absence of maternal or neonatal indications is 

challenging. Determining the true prevalence of CDMR in this country is difficult because such 

deliveries are often coded with other indications, possibly reflecting insurance coverage issues.4

However, some evidence suggests that such deliveries do occur and possibly at an increasing 

rate.5,14 

We queried other sources of data to answer this key question. These include CDC, National 

Vital and Health Statistics, the World Health Organization, and sources from other nations such 

as Statistics Canada, the Australian Department of Human Services, and the United Kingdom 

Department of Health. 

We defined “developed countries” as the United States, Canada, the United Kingdom, 

Western Europe, Israel, Australia, New Zealand, and Japan. We also tracked citations from other 

countries, such as Brazil. 

KQ 2: Effect of Planned Route of Delivery on Outcomes 

Several factors make interpretation of the available evidence challenging. We summarize 

them in the following section. 

Comparison of planned routes of delivery (intent to treat). As explained above, the 

appropriate comparison is that of intent: planned vaginal delivery compared with planned

CDMR. The majority of studies included in this systematic review report outcomes by actual

route of delivery. A design centered on actual delivery route often allows investigators to 

distinguish between labored and unlabored cesarean deliveries. In studies limited to unlabored 

cesareans, women who present in labor before their scheduled date of delivery are, by definition, 

excluded. Excluding these women may overestimate potential benefits (e.g., reduction in pelvic 

floor disorders) and potential harms (e.g., neonatal respiratory morbidity) associated with CDMR 

because the studies then cannot account for any effect that labor has on outcomes of interest.15-17
19 

Figure 3. Analytic framework for cesarean delivery on maternal request 
20 

Studies that include both labored and unlabored planned cesareans may have a rate of labor that 

exceeds the rate of labor expected for a population planning CDMR and may allow for a longer 

period of time in labor before cesarean delivery. 

Appropriate proxies for CDMR. We expected high-quality data on CDMR per se to be 

limited because CDMR is rarely listed as an indication for a cesarean delivery Available studies 

include a wide range of indications for cesarean that are highly variable in their relevance to 

CDMR. Use of cesarean for breech or other malpresentations is currently the closest proxy for 

CDMR. However, studies of cesarean deliveries for breech were designed with neonatal 

outcomes as primary endpoints; therefore, they may be limited in their ability to serve as proxies 

for CDMR for maternal outcomes. For instance, the International Term Breech trial (hereafter 

Breech Trial) allowed patients who presented in labor to be randomized to a cesarean delivery18

without adjusting for the length of the labor before cesarean or the length of time the membranes 

had been ruptured. As indicated above, the ideal comparison would involve intent and compare 

planned vaginal with planned CDMR. Thus, any protocol for CDMR would have some women 

going into labor before their planned cesarean; data from such deliveries ought to be analyzed as 

part of the planned CDMR group. However, the extent to which cesarean for breech serves as an 

accurate surrogate for CDMR is unclear because of uncertainty as to whether the time period 

between presentation in labor and cesarean delivery for breech is similar to that of CDMR. Issues 

such as prolonged rupture of membranes before the decision to perform a cesarean may increase 

the risk of other complications, such as maternal and neonatal infections and length of hospital 

stay. 

Another major limitation to the use of breech as a proxy for CDMR is that when comparing 

study groups based on intent to treat, the risk of requiring a cesarean in the planned vaginal 

delivery group is likely to be significantly higher than if the fetus were vertex (head first). 

Changing practice patterns. Practice patterns have changed considerably for both cesarean 

and vaginal deliveries over the past two decades. Historically, quantifying the risks and benefits 

of vaginal and cesarean births has been difficult, as the data on the risks associated with cesarean 

were based on older studies when cesarean deliveries were routinely performed under general 

anesthesia, after prolonged labor, and without the benefit of prophylactic antibiotics and 

thromboprophylaxis. Such surgical procedures are not comparable to CDMR under current 

standard practices. The absolute risks associated with a planned CDMR are likely to be lower in 

today’s environment than they were previously,19-23 and they are dropping.24 Similarly, clinical 

management of planned vaginal delivery has also been improving, as in the declining use of 

episiotomy.25,26 

The TEP and the SOS Conference panel chair decided to exclude studies published before 

1990 to focus the systematic review on studies with practice patterns similar to contemporary 

norms. However, the studies we examine in this review do not necessarily include “best 

practices” for either vaginal or cesarean routes of delivery and demonstrate variable practice 

patterns among providers. For instance, studies generally do not clarify whether prophylactic 

antibiotics were administered for cesarean; this step, of course, can affect rates of maternal 

infection. Similarly, studies of vaginal delivery may reflect overuse of episiotomy, inappropriate 

thresholds for performing cesarean delivery, and inadequate management of labor. Therefore, a 

comparison of planned vaginal and planned cesarean ought to include the best clinical practice 

patterns for each of these intended routes of delivery. In the absence of information on the extent 
21 

to which studies deviate from ideal practice patterns, how the balance of harms and benefits may 

shift in an ideal practice environment remains unclear. 

Confounders. As noted earlier, ideal comparisons include planned vaginal delivery vs. 

planned cesarean delivery. The comparison of actual routes of delivery may result in inadequate 

assessment of confounders that influence both route of delivery and maternal or neonatal 

outcomes. For instance, confounders such as multiple gestations, placenta previa, and 

polyhydramnios (excess amniotic fluid) may increase the likelihood of preterm labor and 

delivery, may influence the recommended route of delivery, and may also result in poor maternal 

and neonatal outcomes. 

Statistical power. The consequences of a fundamental shift to higher rates of CDMR are 

profound. They should be examined in well-designed studies that are adequately powered to 

detect clinically meaningful differences. The available literature that we discuss generally has 

sample sizes lower than are necessary to achieve adequate power, especially for rare outcomes. 

Appropriate timing of outcome measurements. Decisions made in the delivery room have 

lifelong implications for the mother and infant. Ideal studies require that outcomes be assessed at 

time periods appropriate for that particular end result of care. Studies of the association between 

parturition-related variables including routes of delivery and pelvic floor disorders (urinary 

incontinence, pelvic organ prolapse, anal incontinence, and sexual dysfunction) are often limited 

to the immediate postpartum period. Assessing whether the condition results in long-term 

impairment is difficult in these studies. 

Long-term outcome studies, although relatively uncommon, are often retrospective in design; 

they draw associations between current pelvic floor complaints and previous obstetrical events, 

sometimes decades earlier. These studies are often unable to collect specific information 

regarding planned routes of delivery or even sufficient detail regarding actual routes of delivery. 

Therefore, they frequently are unable to control for many important confounders such as interval 

pregnancies and deliveries and other factors that have been implicated in the development of 

pelvic floor disorders, such as length of labor, use of vacuum or forceps, obesity, smoking, 

constipation or chronic straining, or previous reconstructive pelvic surgery. 

Measurement of outcomes (comprehensiveness, severity, and utility). Ideally, a 

systematic review of the outcomes of planned route of delivery should provide a comprehensive 

assessment of outcomes, accounting for the severity of symptoms and the utility of various 

outcomes to patients. For instance, accurate measurement of neonatal respiratory morbidity 

should include the risks of all forms of harm associated with planned route of delivery, including 

potentially higher risks of meconium aspiration in planned vaginal deliveries27 and potentially 

higher risks of transient tachypnea of the newborn and respiratory distress syndrome in planned 

cesarean deliveries. 

The issue of severity rating is particularly important for pelvic floor outcomes such as urinary 

incontinence, pelvic organ prolapse, or anal incontinence. An undifferentiated measure of urinary 

incontinence that does not account for severity would mask the considerable difference in quality 

of life between a small amount of leakage that occurs rarely and severe, daily urinary leakage. 

Similarly, neonatal outcomes such as respiratory morbidity need to be categorized and analyzed 

by degree of severity. For instance, transient tachypnea of the newborn (TTN) and respiratory 

distress syndrome (RDS) represent extremes of severity; investigators should not group them 

into a single measure of respiratory morbidity, because doing so may obscure meaningful 

differences between groups. 
22 

Factoring in both severity and utility when assessing the overall benefit and harm of CDMR 

is critically important. A woman considering a planned route of cesarean delivery needs to assess 

comprehensively both short- and long-term risks, to both herself and her infant, and in both the 

current pregnancy and future pregnancies. Currently, clinicians and others have little or no way 

to judge the “priority” of a range of possible outcomes. For instance, urinary incontinence needs 

to be described in a manner that relates both its occurrence and severity and that provides a 

utility weighting relative to other potential outcomes such as wound infection. Similarly, in 

assessing overall harms and benefits to the neonate, the potentially higher risk of neonatal 

respiratory morbidity (TTN and RDS) associated with a planned CDMR needs to be weighed 

against the potential reduction in the rate of other outcomes such as stillbirths after 39 weeks, 

intrapartum deaths, and shoulder dystocias (emergency occurring when infant’s shoulder gets 

“stuck”) associated with a planned vaginal delivery. 

KQ 3: Magnitude of Benefits and Harms 

As suggested by our analytic framework (Figure 3), the choice of CDMR or a planned 

vaginal delivery, as well as the rates and severity of subsequent maternal and fetal or neonatal 

benefits and harms, may be influenced by several maternal, fetal, provider, and health care 

system characteristics. Given that few studies control for or assess the effect of such factors on 

maternal and fetal outcomes, we acknowledge the challenges of measuring the magnitude of 

these factors on maternal and fetal or neonatal outcomes. As in KQ 2, we stratified the analysis 

into unlabored and labored cesarean deliveries as well as planned vaginal deliveries. 

KQ 4: Future Research 

We anticipate that even after this comprehensive systematic review has been discussed at the 

SOS conference and published, appreciable uncertainty will remain about the risks associated 

with CDMR. Suggestions to address these limitations of the literature, put forward in our 

discussion of KQ 4, will guide the development and direction of future research. 

Understanding some of the gaps in the literature at this point may help readers interpret our 

analyses and findings for KQs 1, 2, and 3. Especially important are problems related to the 

characterization of CDMR and other modes of delivery that typically serve as proxies for 

CDMR. These include cesareans for breech and other ambiguous categorizations, which may be 

called “elective,” “planned,” “nonemergency,” “unlabored,” and “scheduled” cesareans. This 

variability in language is not trivial, and readers of this evidence report are cautioned against 

assuming that various research teams in fact mean the same thing by the same term or that use of 

different terms accurately depicts different situations. 

In addition, we have assessed maternal and neonatal outcomes and weighted them based on 

the level of relevance to CDMR, the quality of individual study, and the overall strength of 

evidence for each particular outcome measure. In taking this approach, we have identified 

several outcomes that require substantial additional research. The analytic framework provides 

the infrastructure for designing future studies by highlighting particularly relevant comparison 

groups. Although a comprehensive assessment that balances outcomes based on their relative 

rates and utilities or disutilities is the ideal, this goal is probably still unattainable. 
23 

A Note on Terminology 

The purpose of this systematic review is to address CDMR, but the paucity of literature on 

the topic requires the use of proxies. As noted above, studies in this review use nonstandardized 

terms such as “elective,” “scheduled,” “planned,” “labored,” “unlabored,” “urgent,” “emergent,” 

and “emergency” cesarean deliveries. Table 2 provides a glossary of these general terms as they 

are commonly used. Not all studies use these exact definitions; in fact, they may use definitions 

that differ significantly from those employed in other studies. For instance, the term “primary 

elective” cesarean is widely interpreted as referring to a woman’s first cesarean delivery, planned 

for a wide range of maternal and fetal indications and generally distinguished from emergency 

cesarean delivery and labored cesarean delivery after planned vaginal delivery. However, one 

study included 9 percent of women undergoing a repeat cesarean in their “primary elective” 

cesarean group. The authors of this study defined the term “primary elective” cesarean as a 

“planned operation in which the patient had been admitted to the hospital at least 8 hours before 

the cesarean without symptoms of labor,”28 p. 2 allowing for inclusion of repeat cesareans. 

In discussing studies, we clearly specify each study’s definition with respect to medical 

indications for cesarean and laboring status. In recognition of the variation across definitions, we 

elected to use the term that the authors used, denoting such terms by using quotation marks, 

rather than try to impose a single, overarching term such as elective cesarean delivery or CDMR. 

Organization of This Evidence Report 

Chapter 2 describes our methods, including our search strategies and inclusion/exclusion 

criteria; we also document our approach to rating the relevance of each study to CDMR, grading 

the quality of articles, and rating the strength of evidence. In Chapter 3, we present the results of 

our literature search and synthesis of retained articles for three issues (KQs 1, 2, and 3). Chapter 

4 further discusses the findings, presents our conclusions, and offers recommendations for future 

research (KQ 4). References follow Chapter 4. Appendixes* include a detailed description of our 

search strings (Appendix A), abstraction and quality-rating forms (Appendix B), detailed 

evidence tables (Appendix C), list of excluded studies (D), and acknowledgments (Appendix E). 

Technical Expert Panel (TEP) 

We identified seven technical experts in the field of obstetrics to provide assistance 

throughout the project; they included specialists in maternal fetal medicine, general obstetrics 

and gynecology, urogynecology, family medicine, pediatrics, and nurse-midwifery. The TEP 

(Appendix D) was expected to contribute to AHRQ’s broader goals of (1) creating and 

maintaining science partnerships as well as public-private partnerships and (2) meeting the needs 

of an array of potential customers and users of its products. Thus, the TEP was both an additional 

resource and a sounding board during the project. 

To ensure robust, scientifically relevant work, we called on the TEP to provide reactions to 

work in progress and advice on substantive issues or possibly overlooked areas of research. TEP 

members participated in conference calls and discussions through e-mail to 

 

*

 Appendixes and Evidence Tables for this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/cesarean/cesarreq.pdf
24 

Table 2. Glossary of terms 

Cesarean Delivery 

Cesarean delivery on maternal request (CDMR): A cesarean delivery for a singleton pregnancy, on maternal 

request, at term, and in the absence of any maternal or fetal indication for cesarean delivery. 

Elective cesarean delivery: Generally includes a planned cesarean for a wide range of maternal and fetal 

indications, generally distinguished from emergency cesarean delivery and labored cesarean delivery after 

planned vaginal delivery. This category includes CDMR. This category may also include patients that go into 

labor prior to their scheduled delivery date. 

Emergency cesarean delivery: A cesarean delivery that is performed expeditiously, in which delay may result in 

significant maternal or neonatal harm, sometimes referred to as emergent. 

Labored cesarean delivery: A cesarean delivery that is performed after the onset of labor. This category could 

include planned and unplanned cesarean deliveries. 

Planned cesarean delivery: A subset of elective cesarean delivery where the intent to deliver by cesarean is 

determined prior to labor. Of note, this category includes all deliveries resulting from a decision to pursue an 

intended cesarean delivery, including patients that present in active labor before their scheduled delivery 

date and are allowed to deliver vaginally either spontaneously or with vacuum or forceps assistance. Use of 

this category facilitates comparison based on intended routes of delivery. 

Primary cesarean delivery: A cesarean delivery in a woman without a prior history of cesarean. 

Repeat cesarean delivery: A cesarean delivery in a woman with a prior history of cesarean delivery. 

Scheduled cesarean delivery: A term used synonymously with planned cesarean delivery. 

Unlabored cesarean delivery: A cesarean delivery performed before the onset of labor. This category may 

include planned and unplanned cesarean deliveries as well as emergency cesarean deliveries in the 

absence of labor. 

Unplanned cesarean delivery: A cesarean delivery that occurs in a woman who planned a vaginal delivery but 

who required a cesarean delivery for either a maternal or neonatal indication that arose prior to or during 

labor. This category includes emergency cesareans whose indications became evident prior to or during 

labor. 

Urgent cesarean delivery: A cesarean delivery in which surgery needed to be performed in a timely manner but 

not as an immediate emergency delivery. 

Vaginal Delivery 

Assisted vaginal delivery: A vaginal delivery that requires the use of forceps, vacuum, or both. 

Planned vaginal delivery: A delivery resulting from a decision to pursue an intended vaginal delivery. This 

category includes spontaneous vaginal delivery, vacuum-assisted vaginal delivery, forceps-assisted vaginal 

delivery, and unplanned cesarean deliveries. Use of this category facilitates comparison based on intended 

routes of delivery. 

Spontaneous vaginal delivery: A vaginal delivery that occurs without the assistance of forceps or vacuum. This 

category may include both spontaneous onset of labor and induced labor. 

• refine the analytic framework and key questions at the beginning of the project; 

• discuss the preliminary assessment of the literature, including inclusion/exclusion 

criteria; and 

• provide input on the information and categories included in evidence tables. 

Because of their extensive knowledge of the literature, which includes numerous articles 

authored by TEP members themselves, and their active involvement in professional societies and 

as practitioners in the field, we also asked TEP members to participate in the external peer 

review of the draft report. TEP proceedings included the panel chair of OMAR’s SOS 

Conference. 
25

Chapter 2. Methods 

In this chapter, we document the procedures that the RTI International–University of North 

Carolina Evidence-based Practice Center (RTI–UNC EPC) used to develop this comprehensive 

evidence report on cesarean delivery on maternal request (CDMR). It will be used as the core 

background document for an upcoming State of the Science (SOS) conference sponsored by the 

Office of Medical Applications Research (OMAR) of the National Institutes of Health (NIH). 

We first describe our strategy for identifying articles relevant to our four key questions, our 

inclusion/exclusion criteria, and the process we used to abstract relevant information from the 

eligible articles and generate our evidence tables. We also discuss our criteria for grading the 

quality of individual articles and the strength of the evidence as a whole. Finally, we explain the 

peer-review process. 

Literature Review Methods 

Inclusion and Exclusion Criteria 

Our inclusion and exclusion criteria are documented in Table 3. As noted in Chapter 1, we 

limited our searches to articles published in or after 1990 because of the significant advances in 

operative techniques, anesthesia, availability of antibiotics, and neonatal care over the past 

several decades that have resulted in a decline in maternal and neonatal mortality.1

 We also 

restricted our searches to developed countries so that we could have comparable data on the 

standard of care. Based on recommendations from the Technical Expert Panel (TEP), we tracked 

citations from Brazil, which has long been documented to have high rates of cesarean 

deliveries;29,30 however, no study from Brazil met our inclusion criteria. 

Because our searches focused on the comparison of planned cesarean delivery to planned 

vaginal delivery, we recognized that we were unlikely to capture relevant studies on placental 

implantation abnormalities. On the advice of our TEP, our summary of this topic consists of an 

update of a recent systematic review on placenta previa.31 Because of time and resource 

limitations, however, we could not address other placental implantation abnormalities such as 

accreta (abnormally firm attachment of the placenta to the uterine wall) and percreta (extension 

of the placenta through the entire wall of the uterus) that may also be associated with a history of 

cesarean deliveries. 

Similarly, our search strategy focused on primary cesarean deliveries, excluding studies 

limited to repeat cesarean deliveries. For that reason, we could not capture studies that examined 

outcomes such as uterine rupture related to subsequent deliveries in women with prior cesarean 

deliveries. Again on the advice of our TEP, we address this important topic using information 

from an update of a recent review on vaginal birth after cesarean (VBAC).32

We excluded studies that (1) did not report on women of reproductive age; (2) were 

published in languages other than English (given the available time and resources); (3) did not 

report information pertinent to the key clinical questions; (4) had fewer than 50 subjects for 

randomized controlled trials (RCTs) or 100 subjects for observational studies; and (5) were not 

original studies. Additionally, and in consultation with the TEP, we excluded studies that did not 
26

Table 3. Inclusion/exclusion criteria for cesarean delivery upon maternal request 

Category Criteria 

Study population Humans, females, all races, ethnicities, and cultural groups 

Study settings and geography Developed nations: United States, Canada, United Kingdom, Western 

Europe, Japan, Australia, New Zealand, Israel 

Time period 1990-2005 

Publication languages English only 

Sample size Sample sizes must be appropriate for the study question addressed in 

the paper. 

RCTs: 50 or more participants 

Observational studies: 100 or more participants 

Admissible evidence (study design and 

other criteria) 

Original research studies that provide sufficient detail regarding methods 

and results to enable use and adjustment of the data and results 

Eligible study designs include RCTs: double-blinded and single-blinded; 

observational studies: prospective and retrospective cohort studies, case 

control studies, and cross-sectional; and meta-analyses. 

Ineligible study designs include single case reports or small case series. 

Patient populations must be of reproductive age or older. 

KQ 1 and KQ 2 

All studies must include a comparison of planned cesarean deliveries 

with planned vaginal deliveries. 

include data on both planned cesarean delivery and planned vaginal delivery for KQ 1 and KQ 2. 

As a consequence of this search strategy, we cannot address outcomes from vaginal delivery 

alone, without reference to a cesarean delivery comparison group. A review of the outcomes 

from vaginal delivery alone was beyond the scope and resources available. As a consequence of 

this limitation, we are not able to address modifiers of vaginal deliveries alone in KQ 3. 

We also excluded studies that reported on an undefined group of cesarean deliveries; many of 

the maternal and neonatal indications that would have been included were so highly associated 

with significant morbidity as to preclude any meaningful extrapolation to CDMR. 

Literature Search and Retrieval Process 

Databases. We used multifaceted search strategies to include current and valid research on 

the key questions. We used standard electronic databases: MEDLINE®, Cochrane Collaboration 

resources, and Embase. We also hand-searched the reference lists of relevant articles to make 

sure that we did not missing any relevant studies. We consulted with the TEP about any studies 

or trials that are currently under way or that may not be published yet. 

Search terms. Based on the inclusion/exclusion criteria above, we generated a list of 

Medical Subject Heading (MeSH) search terms (Appendix A).*

 Our TEP also reviewed these 

terms to ensure that we were not missing any critical areas, and this list represents our collective 

decisions as to the MeSH terms used for all searches. We needed to conduct several focused 

searches to capture a wide pool of relevant studies because the term “cesarean delivery on 

 

*

 Appendixes and Evidence Tables for this report are provided electronically 

athttp://www.ahrq.gov/downloads/pub/evidence/pdf/cesarean/cesarreq.pdf
27

maternal request” is not a standard indexing term (Table 4). The SOS Conference panel had set 

priorities for outcomes of interest, and those guided our selection of the specific outcomes for 

this review. Our initial searches did not capture key citations dealing with neonatal outcomes; 

based on the advice of the TEP, we conducted additional searches to capture relevant citations. 

Table 4. Focused searches and unduplicated results 

Focused Searches 

Unduplicated 

Results 

Initial search on elective cesarean delivery and similar terms in MEDLINE®, Cochrane 

Collaboration resources, and Embase 

926

Additional search on neonatal outcomes limited to RCTs 48

Additional search on neonatal outcomes limited to observational studies 93

Additional search on adverse events in neonates 90

Additional searches on placenta previa 116 

Additional search on update of Faiz and Ananth’s review of placenta previa31 98 

Handsearch 34 

Total 1,406 

Figure 3 presents the yield and results from our search, which we conducted from April 

through June 2005. Beginning with a yield of 1,402 articles, we retained 65 articles comprising 

62 studies that we determined were relevant to address our key questions and met our 

inclusion/exclusion criteria (Figure 4). Peer reviewers suggested several additional citations, of 

which 4 articles comprised 3 new studies that did not duplicate ones we had already identified 

and excluded. We reviewed titles and abstracts of the remaining suggestions against the basic 

inclusion criteria above; we retained relevant articles, all published after our search cutoff date, 

and used them as appropriate in the discussion in Chapter 4. 

Article selection process. Once we had identified articles through the electronic database 

searches, review articles, and bibliographies, we examined abstracts of articles to determine 

whether studies met our criteria. Two reviewers separately evaluated the abstracts for inclusion 

or exclusion, using an Abstract Review Form (see Appendix B). If one abstractor concluded that 

the article should be included in the review, we retained it. The group included four physicians—

Anthony Visco, MD (Scientific Director); Katherine Hartmann, MD, PhD (Senior Advisor); 

Jennifer Wu, MD; and Gerald Gartlehner, MD, MPH (Study Coordinator). It also included one 

health services researcher—Meera Viswanathan, PhD (Study Director) and three 

epidemiologists—Michele Jonsson Funk, PhD, Rachel Palmieri, BS, and Shauna Hay, BS. 

Four hundred and ninety articles required full review because of missing or uninformative 

abstracts. For the full article review, one reviewer read each article and decided whether it met 

our inclusion criteria, using a Full Text Inclusion/Exclusion Form (Appendix B). Articles 

excluded at the full-article review stage and reasons for their exclusion are listed in Appendix D. 
28

Figure 4. Disposition of articles for cesarean on maternal request article disposition 
29

Literature Synthesis 

Development of Evidence Tables and Data Abstraction Process 

The staff members who conducted this systematic review jointly developed the data 

abstraction tables (Appendix B†

) and evidence tables (Appendix C). We designed the tables to 

provide sufficient information to enable readers to understand the studies and to determine their 

quality; we gave particular emphasis to essential information related to our key questions. The 

format of the evidence tables was based on successful designs used for prior systematic reviews. 

We trained abstractors in entering data into the tables by having them abstract several articles 

and then reconvening as a group to discuss the utility of the table design. The abstractors 

repeated this process through several iterations until they decided that the tables included the 

appropriate categories for gathering the information contained in the articles. 

All team members shared the task of initially entering information into the data abstraction 

forms. Another member of the team also reviewed the articles and edited all initial table entries 

for accuracy, completeness, and consistency. The two abstractors reconciled all disagreements 

concerning the information reported in the abstraction forms. The full research team met 

regularly during the article abstraction period and discussed global issues related to the data 

abstraction process. 

We then entered the data from the abstraction forms into evidence tables and once again 

checked for consistency and accuracy. 

The final evidence tables are presented in their entirety in Appendix C. Studies are presented 

in the evidence tables alphabetically with the last name of the first author. A list of abbreviations 

and acronyms used in the tables appears at the beginning of that appendix. 

Quality and Strength of Evidence Evaluation 

Rating the relevance of individual articles. The vast majority of studies reported results on 

actual route of delivery rather than planned route of delivery (intent to treat), which led to the 

limitations introduced in Chapter 1. Initial review of the literature demonstrated several 

ambiguous definitions that presented the authors of this review with several challenges. The use 

of the phrase “elective cesarean delivery” was particularly problematic because of its wide range 

of definitions. Some investigators used the term “elective” to refer to situations in which a 

vaginal delivery was contraindicated, such as with placenta previa. Others used it to describe 

situations in which vaginal delivery could have been attempted, such as with breech presentation, 

active herpes simplex virus, or repeat cesarean delivery. Still others used it but failed to define it 

further, precluding reviewers from understanding either the labor status or the indications for the 

cesarean. 

We found it impossible to arrive at any meaningful summary of the literature without 

explicitly addressing the issues of how to characterize the groups in these studies and, thus, how 

to categorize the studies themselves. To address this ambiguity, we developed a four-tier 

classification system of relevance to CDMR based on the following criteria: (1) whether studies 

 

†

 Appendixes cited in this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/cesarean/cesarreq.pdf. 
30

analyzed outcomes by planned route of delivery (trials of route of delivery); (2) whether CDMR 

was included as a comparison group (high relevance); (3) whether comparison groups comprised 

planned cesareans (moderate relevance), and (4) whether studies involved undefined “elective” 

or a mix of planned and unplanned, unlabored cesareans (low relevance). 

Table 5 presents relevance ratings for all studies included in this review. The first three 

categories of relevance—high (H), moderate (M), and low (L)—are explained below. 

Because we view the first criterion above as the ideal comparison, we assigned trials of 

routes of delivery,‡

 comparing prospectively assigned planned routes of delivery for breech 

presentation, a relevance rating of “T” to distinguish them from other studies that dealt with 

actual delivery routes. However, we note that trials of route of delivery for breech presentation 

are limited in their relevance to CDMR for primarily vertex (head first) presentation for four 

main reasons: (1) they cannot be included in a summary of neonatal outcomes because the 

confounding effect of breech presentation in the sample of women could negatively influence 

neonatal outcomes; (2) the extent to which cesarean for breech serves as an accurate surrogate 

for CDMR is unclear because of uncertainty as to whether the time period between presentation 

in labor and cesarean delivery for breech is similar to that for CDMR; (3) the risk that a cesarean 

would be performed in the planned vaginal breech delivery group is likely to be significantly 

higher than if the fetus were vertex; and (4) the inclusion of multiparous patients, including some 

with previous cesarean deliveries, results in significantly different risks and benefits than for the 

central focus of this review, namely, primary CDMR. 

Table 5. Summary relevance rating 

Number of Studies Included for Degree of 

Relevance to 

CDMR and Rating Definition of Category KQ 1 KQ 2* KQ 3 

H High (H) Cesarean delivery on maternal request 133 0 0 

M Moderate (M) Cesarean delivery planned for maternal 

and/or neonatal indications and can 

include both labored and unlabored 

334-36 16†28,37-53 448,53-55

L Low (L) Unspecified “elective” cesarean delivery, 

can be a mix of planned and unplanned 

deliveries that are either unlabored or do 

not give clear indication of labor status 

93,56-63 1964-82 182

Trials of delivery 

for neonatal 

indications (T) 

Intended mode of delivery (planned 

cesarean versus planned vaginal) 

0 2†18,20,83,84 0 

* Excludes studies from the placenta previa update † Includes multiple articles from a single study 

Many studies included a combination of planned and unplanned, labored and unlabored 

cesarean births for maternal or neonatal indications in an “elective” cesarean group. Using our 

relevance classification scheme, we sorted this range of studies into groups of literature with 

high, moderate, and low relevance to CDMR. Studies with a cesarean delivery group performed 

solely on maternal request, without any maternal or neonatal indications, were considered the 

most highly relevant to the central question of this systematic review; we assigned them a 

 

‡

 These studies of trial of routes of delivery assigned women to either planned vaginal delivery or planned cesarean delivery 

(often called “trials of labor”), but did not require a randomized design. 
31

relevance rating of A. As expected, however, we found no such published studies for KQ 2 and 

KQ 3 and only one such study for KQ 1. 

Studies in the moderately relevant category were all planned cesareans, but they included 

labored, unlabored, or a mix of labored and unlabored cesarean deliveries. Some studies included 

cesareans planned and performed, before labor, for maternal or neonatal indications (or both). 

Such studies may understate the risk of CDMR, because an accurate assessment of outcomes 

should include both labored and unlabored cesareans when comparison groups are separated by 

intent; that is, planned CDMR versus planned vaginal delivery. The group also included studies 

involving planned and performed cesareans for maternal and/or neonatal indications but with a 

mix of labored and unlabored deliveries. These may overestimate the risk of planned CDMR if 

the rate of labored cesareans in the study exceeds the rate of labor before scheduled delivery in a 

population considering CDMR. 

Studies of low relevance did not define the “elective” cesarean delivery group, or they 

included a mix of planned and unplanned unlabored cesarean deliveries. The chief uncertainty 

concerns the degree to which the “elective” cesarean delivery group included emergency or 

labored cesareans. Emergency indications that would potentially be included in such a category 

include abruption, maternal trauma, and fetal distress; each could increase maternal or neonatal 

morbidity considerably. 

Rating the quality of individual articles. We developed our approach to assessing the 

quality of individual articles (see Appendix B for Quality Rating Forms) based on the domains 

and elements for RCTs and nonrandomized observational studies recommended in the evidence 

report by West and colleagues, Systems to Rate the Strength of Scientific Evidence.85 

We also elected to limit our quality ratings to studies with at least moderate relevance 

because low-relevance studies were generally designed for purposes other than addressing 

planned cesarean delivery. 

The only study eligible to be rated with an RCT form was the International Term Breech 

Trial (hereafter Breech Trial).18,20,83 Two of the criteria listed below (randomization approach, 

post-randomization exclusions) apply to the entire study; all others (masking, operational 

definitions and measures, loss to followup, and statistical analysis) apply to each article 

individually. We elected to rate each article in the Breech Trial individually because of 

significant variations in the article-specific criteria. 

1. Randomization approach and implementation: This item judged whether the approach 

described a valid method of randomization, whether allocation concealment was achieved, 

and whether balance was documented across study groups. 

Approach: If the study assigned the groups in a manner inconsistent with true randomization 

methods, it had the potential to automatically receive a poor rating for this category and 

overall. If the study had merely stated that if “randomly assigned” the groups and either had 

no balance or did not report on balance, it would have received a poor rating. A study with 

no documentation of concealment or with inadequate concealment methods would have been 

rated poor if the study had poor balance of allocation or if balance was not documented. A 

study with potentially poor concealment would have been rated fair if they documented good 

balance. 
32

2. Post-randomization exclusions: This item captured how many post-randomization 

exclusions were explicitly stated. 

Approach: In typical randomized trials, intention-to-treat analysis is expected. Any 

exclusions after randomization would have been considered inappropriate and would have 

led to a rating of poor. 

3. Masking: This item was relevant only to outcome assessors. 

Approach: If the outcome assessors were adequately masked within the possibilities of the 

study design, we rated the category as good. If there was a mix of masking among the 

outcomes, we rated the category as fair. If masking was not done at all and not attempted, 

we rated the category as poor. 

4. Operational definitions and measurements: This item judged the quality of the 

operational definitions of the outcomes (i.e., were they adequately described) and whether 

they were adequately collected (i.e., was the method sufficient and appropriate). 

Approach: We rated this category on the basis of an average across all outcomes for each 

timepoint and the ability to define and measure them. Good definitions and measurement 

include the following: validated questionnaires, detailed time points in question, details 

about what was asked of the patient, medical chart abstractions, and clinical examination or 

assessment. Failure to use such methods resulted in a rating in the fair-to-poor range, 

depending on how the article collected the information. 

5. Loss to followup: This item collected percentages of followup at every time point in the 

study at which data were collected; we used it to determine if followup was adequate. 

Approach: In general, we considered followup greater than or equal to 90 percent in the 

short term and 80 percent in the long term to be good. 

6. Statistical analysis: This factor included whether the investigators conducted the study in 

an appropriate manner and took the effect of multiple comparisons into account. This item 

also reviewed the study’s use of multivariate statistical techniques and/or participant 

restriction or stratification to control for confounding. 

Approach: We rated this category on the basis of an average across all outcomes for each 

time point. Articles that reported appropriate statistical tests, point estimates, tests for 

homogeneity, stratification, and confidence intervals were rated as good. Articles that 

reported P-values alone were rated as fair, and articles that did not report statistical analysis 

were rated as poor. 

Two article abstractors independently rated each article on each of the categories as indicated 

by the quality assessment form. We reconciled differences by consensus, giving each item equal 

weight. Specifically, articles that received good ratings on all categories would have been 
33

eligible to be rated as good studies overall. None of the three articles received a good rating. If an 

article received one or two fair or poor ratings, or the equivalent of a deficiency, it was rated as 

an overall fair-quality article. The original article from the Term Breech Trial, published in 2000, 

received a quality rating of fair.20 Articles with three or more fair ratings or a poor randomization 

design or implementation with a fatal flaw were rated as a poor-quality article. The two followup articles from the Breech Trial, published in 200218 and 200483 respectively, received a quality 

rating of poor. 

We used the following criteria to rate the quality of nonrandomized observational studies: 

1. Study design: Given the difficulties of identifying planned cesarean delivery 

retrospectively, we assigned prospective studies a higher score. 

Approach: To receive a rating of fair for this component of study design, we required a 

study to be prospective. 

2. Study population: We sought documentation in the publication of the degree to which the 

study population was representative of women with uncomplicated spontaneous vaginal 

births in the study facilities or the broader population sampled. 

Approach: To receive a rating of good for this component of study design and conduct, 

we required a study to describe clearly (1) the base population from which cohort 

participants were sought, (2) the number of women in that base population (a 

denominator), and (3) the proportion of eligible women who were ultimately enrolled in 

the cohort. 

Studies with all three items were rated as good; studies lacking one item were classified 

as fair; and studies lacking more than one item were rated as poor. 

3. Comparability of subjects. For cohort studies, we sought five tiers of documentation 

showing that the study had (1) specific inclusion/exclusion criteria for all groups, (2) 

applied criteria equally to all groups, (3) comparable study groups at baseline with 

reference to variables not unique to mode of delivery, (4) study groups comparable to 

nonparticipants with regard to confounding factors, and (5) study groups comparable with 

regard to followup. 

 In addition, for case-control studies, we sought documentation on whether the study had 

(1) explicit case definition, (2) case ascertainment not influenced by exposure status, and 

(3) controls similar to cases except that they did not have the condition of interest and did 

have an equal opportunity for exposure. 

Approach: We rated a cohort study as having good comparability of subjects if at least 

four of five elements were present. We rated studies as having fair comparability if two 

or three elements were present. Studies with fewer than two elements were rated as poor. 

 We required case-control studies to have all three elements of the case-control rating to 

rate a good for the overall category. We rated case-control studies that were missing one 
34

element for the case-control rating as fair and those missing two or more elements rated 

as poor. 

4. Statistical analysis: We sought documentation on whether the study reported on the 

following aspects of statistical analysis: (1) appropriate statistical tests; (2) modeling and 

multivariate techniques or multiple comparisons; (3) power calculations and achieved 

sample size; (4) assessment of confounding by bivariate analysis, stratified analysis, or 

multivariable modeling; (5) reporting of adjusted estimates for main effects that took into 

account identified confounding or modifying factors (stratified or separate analyses were 

acceptable for simple constructs); and (6) presentation of adjusted results with a measure 

of statistical precision such as a confidence interval or P-value. 

Approach: We assigned a rating of good for the category of statistical analysis if studies 

provided at least five of the six elements above. We assigned a rating of fair if studies 

reported on three or four elements and a rating of poor if studies reported on fewer than 

three elements. 

5. Result and loss to followup: For all studies, we sought documentation on whether the 

study reported a measure of effect for outcomes and provided an appropriate measure of 

precision. In addition, for panel studies, we sought documentation of two follow-up 

measures: (1) analysis of how respondents differed from nonrespondents if loss exceeded 

20 percent, and (2) if absolute loss to followup exceeded 25 percent. 

Approach: For studies with cross-sectional measures, we assigned a rating of fair if the 

study reported a measure of effect with an appropriate measure of precision. Studies 

without a measure of effect were rated poor. Panel studies needed to have an absolute 

loss to followup at or below 25 percent. If the differential loss to followup from panel 

studies exceeded 20 percent, the investigators needed to report on bias from followup to 

receive a good rating. We rated a study as poor for this component if it had more than 25 

percent loss to followup or more than 20 percent loss without comparison for response 

bias. 

For categories 1 and 5 above, studies could receive a maximum rating of fair. For categories 

2, 3, and 4, studies could receive a maximum rating of good. We summarized the ratings across 

all five categories to assign an overall rating as follows: 

• good, if the study received a fair on both categories with a maximum of fair rating and 

good on all three categories with a maximum rating of good; 

• fair, if the study received three to five fair scores with fewer than two good scores; or 

• poor, if the study received two or fewer fair or good scores. 

Grading the strength of available evidence. Our scheme follows the criteria applied by 

West et al.85 That system included three domains: quality of the research, quantity of studies 

(including number of studies and adequacy of the sample size), and consistency of findings. Two 

senior staff members assigned grades by consensus. 
35

We graded the body of literature and present our findings in Chapter 4. The possible grades 

in our scheme are as follows: 

I. Strong: The evidence is from studies of strong design; results are both clinically 

important and consistent with minor exceptions at most; results are free from serious 

doubts about generalizability, bias, or flaws in research design. Studies with negative 

results have sufficiently large samples to have adequate statistical power. 

II. Moderate: The evidence is from studies of strong design, but some uncertainty remains 

because of inconsistencies or concern about generalizability, bias, research design flaws, 

or adequate sample size. Alternatively, the evidence is consistent but derives from studies 

of weaker design. 

III. Weak: The evidence is from a limited number of studies of weaker design. Studies with 

strong design either have not been done or are inconclusive. 

IV. No evidence: No published literature. 

External Peer Review 

As is customary for all evidence reports and systematic reviews done for the Agency for 

Healthcare Research and Quality (AHRQ), the RTI-UNC EPC requested review of this report 

from a wide array of individual outside experts in the field, including our TEP, and from relevant 

professional societies and public organizations. AHRQ also requested review from its own staff 

and appropriate federal agencies. We initially asked 33 individuals or organizations about their 

interest and availability for peer review. Ultimately, we sent 18 invitations for peer review: to 5 

TEP members, 6 relevant organizations, and 7 individual experts. Reviewers included clinicians 

(e.g., obstetrics, urogynecology, family practice, pediatrics), representatives of professional 

societies and advocacy groups, and potential users of the report. 

We charged peer reviewers with commenting on the content, structure, and format of the 

evidence report, providing additional relevant citations, and pointing out issues related to how 

we had conceptualized and defined the topic and key questions. We also asked them to complete 

a peer review checklist. We received 15 responses in addition to comments from AHRQ staff. 

The individuals listed in Appendix E gave us permission to acknowledge their review of the 

draft. We compiled all comments and addressed each one individually, revising the text as 

appropriate. 

37

Chapter 3. Results 

This chapter presents the results of our evidence review for the first three key questions 

(KQs): (KQ 1) trend and incidence data; (KQ 2) outcomes of cesarean delivery on maternal 

request (CDMR), proxies for CDMR, and various comparison routes of delivery; and (KQ 3) 

modifiers of outcomes. These KQs are the principal focus of a March 2006 State of the Science 

(SOS) conference being convened by the Office of Medical Applications of Research (OMAR) 

at the National Institutes of Health (NIH). KQ 4, on future research, is covered in Chapter 4 of 

this report. Appendix C* provides the detailed evidence tables for KQ 2. 

As explained in Chapters 1 and 2, we rated studies for their relevance to the comparisons of 

interest for the SOS conference, using four categories. Three categories related mainly to 

observational studies: high (H), moderate (M), and low (L) relevance; none of these compared 

outcomes prospectively by planned route of delivery for both cesarean and vaginal delivery. The 

fourth category comprised two studies comparing outcomes from prospectively assigned planned 

routes of delivery: a nonrandomized study of a “trial of labor” (assigned by department) and the 

other a randomized trial, known as the International Term Breech Trial (Breech Trial); they are 

both denoted by T; both studies used intent-to-treat analyses. 

With one exception for KQ 1, no included studies were rated highly relevant. Of the 

remainder, most are of only low relevance because they were designed to address hypotheses or 

clinical issues other than the ones of interest for this systematic review. 

We have already noted the extreme profusion of terms in this field and the fact that 

clinicians, investigators, and others do not apply them consistently across this evidence base. 

Moreover, the terms and phrases do not map consistently (or necessarily accurately) to the 

conceptual framework and definitions that we articulated for this systematic review. For that 

reason, in reporting on studies in this chapter we have put quotation marks around certain terms 

or phrases to indicate that they represent the usage of the authors of those studies, not necessarily 

our usage. 

Key Question 1: 

Trends and Incidence of Cesarean Delivery 

The SOS planning group specified that the first issue we should address involved the 

following points concerning the epidemiology of cesarean delivery in general and CDMR (or 

possible proxies) in particular. They posed the questions as follows: 

First, what is the trend and incidence of cesarean delivery over time in the United States and 

in other developed countries? 

Secondarily: 

a. What is the contribution of primary prelabor cesarean deliveries? 

b. Of the primary prelabor cesarean deliveries, what is the contribution of cesarean delivery 

on maternal request (i.e., CDMR), for medical indications, and for malpresentation? 

We answer these questions on the basis of both published articles and web-based sources (a 

form of gray literature). However, we report incidence data before trend data, because the former 

 

*

 Appendixes and Evidence Tables for this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/cesarean/cesarreq.pdf
38

are a part of the latter. Because of the focus on the United States and then other developed 

countries, our main approach in this section is by country. 

Literature Relevant to the Epidemiologic Questions 

Overall, we identified 13 published studies reporting the incidence and trends of modes of 

cesarean section. Of the 13 articles, we gave 1 study a relevance rating of high,33 3 studies a 

rating of moderate,34-36 and 9 studies a rating of low.3,56-63 We also found web-based sources for 

four regions: United Kingdom86 and three states in Australia (Victoria,87-89 South Australia,90 and 

New South Wales91). All of the Web-based sources were moderately relevant to CDMR. Two 

published studies were conducted in the United States,3,56 3 in the United Kingdom,33,60,61 

3 in Australia,34,57,58 2 in the Republic of Ireland,35,59 and 1 each in Norway,36 Finland,62 and 

Denmark.63 We also found web-based sources reporting rates of “elective” cesarean delivery for 

the United Kingdom86 and three states in Australia (Victoria,87-89,92 South Australia,90 and New 

South Wales91). 

Four articles supplied trend data from the United States3

 and Australia.34,57,58 Three of the 

four web-based sources provided trend data.86,87,91 With the exception of two published studies 

that obtained data from surveys usually sent to medical directors,59,61 all other studies gathered 

data from administrative databases or materials (e.g., birth certificates). Except for one study,33

all were conducted retrospectively. 

Overall Estimates of Incidence and Trends 

Rates of incidence and trends of cesarean delivery vary by country. In general, countries 

report rising trends of cesarean delivery, with recent incidence rates at 29 percent for the United 

States2

 and 23 percent for the United Kingdom.86 In the following section, we present data on 

incidence and trends of cesarean delivery by country. We also present rates of primary prelabor 

cesarean, CDMR, cesarean for medical indications, and for malpresentation, when available; 

studies rarely provided sufficient information to answer this key question. Four studies report on 

primary prelabor cesarean,3,34,35,56 and one study reports on CDMR.33 Other studies use variable 

definitions of “elective” or “planned” cesarean delivery, denoted in quotes in the text. We 

present summary tables for each country, with each study listed in alphabetical order by last 

name of first author. 

Country-Specific Incidence and Trend Data 

United States. Incidence. In 2001, the rate of cesarean delivery was more than 25 percent.3

Studies from two sources suggest similar primary prelabor “elective” cesarean rates: 4.25 

percent56 and approximately 5 percent3

 of all deliveries in 1995. The definition of elective 

primary cesarean delivery in both studies includes malpresentation, antepartum bleeding, herpes, 

severe hypertension, uterine scar, multiple gestation, macrosomia, unengaged head, soft tissue 

condition, other hypertension, preterm, fetal anomaly, and unspecified, resulting in a definition 

of “elective” cesarean delivery that has low relevance to CDMR (Table 6). 
39

Table 6. United States, incidence and trend data 

Source 

Groups 

Relevance Rating 

Study Objective 

Source 

Time period 

Definitions and InclusionExclusion Criteria Incidence and Trend Data 

Gregory et al., 

200156

Groups 

G1: total 

cesareans 

G1a: primary 

prelabor elective 

Low 

Objective: to describe 

variation in elective 

primary cesarean rates 

by nonclinical factors 

Retrospective 

Discharge data and 

American Hospital 

Association data 

1/1/1995–12/31/1995 

Primary prelabor 

elective: first cesarean 

delivery, patient did not 

labor and underwent 

cesarean delivery with 

respect to the following 

13 categories: 

malpresentation, 

antepartum bleeding, 

herpes, severe 

hypertension, uterine 

scar, multiple gestation, 

macrosomia, unengaged 

head, soft tissue 

condition, other 

hypertension, preterm, 

fetal anomaly, and 

unspecified. 

Emergency: decision 

made after labor 

Excluded: Hospitals with 

< 200 deliveries, women 

with history of cesarean 

Incidence: 

G1: 463,196 

G1a: 19,664 (4.25% of total deliveries) 

Trend: 

NR 

Meikle et al., 

20053

Groups 

G1: primary 

prelabor elective 

Low 

Objective: to describe 

national trends for 

elective primary cesarean 

delivery from 1994 to 

2001, with attention to 

changes in indications 

Retrospective 

NIS database 

1994–2001 

Primary prelabor 

elective: first cesarean 

delivery: a procedure that 

occurred before labor 

and without a previous 

history of cesarean 

delivery. Used 13 

indications for elective 

cesarean previously 

reported in Gregory et al. 

above 56

Excluded: women who 

labored and previous 

cesarean deliveries 

Incidence: 

See below for 2001 

Trend: 

G1: Primary prelabor elective cesarean 

deliveries (% of all deliveries) 

1994: 16,036 (19.7%) 

2001: 281,698 (28.3%) 

Trends. Meikle et al. reported a rise in the primary elective cesarean deliveries as a 

proportion of all deliveries from approximately 5 percent in 1994 to approximately 7 percent in 

2001.3

 The authors also reported a rise in elective primary cesarean deliveries as a proportion of 

all cesarean deliveries from 19.7 percent in 1994 to 28.3 percent in 2001. 

United Kingdom. Incidence. One study from Scotland offers the only evidence of high 

relevance to CDMR that we identified.33 From a prospective administrative dataset for 1994, the 

authors reported total cesarean deliveries (including multiple and unknown gestation) of 16 

percent. The authors also reported a CDMR rate of 7.7 percent and an “elective” cesarean 

delivery rate for breech presentation of 19.1 percent of all singleton cesarean deliveries (Table 

7). Two other studies from the United Kingdom did not define “elective” section, resulting in 
40

Table 7. United Kingdom, incidence and trend data 

Source 

Groups 

State 

Relevance Rating 

Study Objective 

Source 

Time period 

Definitions and InclusionExclusion Criteria Incidence and Trend Data 

Barley et al., 

200460

Groups 

G1: total cesarean 

deliveries 

G1a: elective 

cesarean 

Low 

Objective: To examine 

cesarean rates and 

socioeconomic status 

Retrospective 

National Health Service 

(NHS) episode statistics 

database 

1/1/2001-12/31/2002 

Elective: not defined Incidence: 

Total NHS births: 336,324 

G1: N not reported (20.1%) 

G1a: N not reported (8.9%) 

Trend: 

NR 

Government 

Statistical 

Service86

Groups 

G1: total cesarean 

deliveries 

G1a: emergency 

cesareans 

G1b: elective 

cesareans 

England 

Moderate 

Objective: NA 

Surveillance data from 

the Hospital Episode 

Statistics system, 

accessed via the web 

Elective: planned 

procedure before, or at 

the onset of, labor 

(carried out immediately 

following the onset of 

labor, when the decision 

was made before labor) 

Emergency: 

Not defined

Incidence: 

See below for 2003–4 

Trend: 

 Total % of all deliveries 

Year Deliveries G1 G1a G1b 

1990-1 652,100 12.4 7.1 5.3 

1991-2 643,800 12.9 7.4 5.5 

1992-3 624,600 13.8 8.1 5.6 

1993-4 620,200 15.0 8.9 6.1 

1994-5 604,300 15.5 9.0 6.5 

1995-6 592,600 16.3 9.5 6.9 

1996-7 594,500 17.0 9.7 7.3 

1997-8 585,000 18.2 10.4 7.9 

1998-9 577,500 19.1 11.1 8.0 

1999-0 565,300 20.6 12.0 8.6 

2000-1 549,600 21.5 12.7 8.8 

2001-2 541,700 22.0 12.7 9.3 

2002-3 548,000 22.0 12.7 9.3 

2003-4 575,900 22.7 13.1 9.6 

Khor et al., 200061

Groups 

G1: total cesarean 

deliveries 

G1a: elective 

cesareans 

G1b: emergency 

cesareans 

Low 

Objective: To assess the 

national obstetric 

anaesthetic practices in 

relation to cesarean 

sections. 

Retrospective 

Royal College of 

Obstetrics and 

Gynecology annual 

surveys 

1/1/1997-3/31/1998 

Elective: not defined 

Emergency: not defined 

Incidence: 

Total deliveries: 608,853 

G1: 111,919 

G1a: 39,308 (40.5% of G1) 

G1b: 57,797 (59.5% of G1) 

Note: G1a+G1b do not sum to G1 due 

to incomplete returns 

Trend: 

NR 

Para, parity. 
41

Table 7. United Kingdom, incidence and trend data (continued) 

Source 

Groups 

State 

Relevance Rating 

Study Objective 

Source 

Time period 

Definitions and InclusionExclusion Criteria Incidence and Trend Data 

Wilkinson et al., 

199833 

Groups 

G1: total deliveries 

G1a: para 0 

G1b: para 1, no 

prior cesarean 

delivery 

G1c: para 1, with 

prior cesarean 

delivery 

Scotland 

High 

Objective: to determine 

the indications for 

singleton cesarean 

sections in Scotland in 

1994 

Prospective 

Administrative database 

1/1/1994-12/31/1994 

Elective: decision made 

before labor and 

primarily for breech 

presentation 

Emergency before labor: 

performed for suspected 

growth retardation and/or 

fetal distress 

Emergency during labor: 

performed for failure to 

progress and/or fetal 

distress 

Included: singleton 

pregnancy 

Incidence: 

All cesarean deliveries 

8,098 

Elective cesareans 

G1: 3,150 

G1a: 884 

G1b: 571 

G1c: 1,695 

Maternal request (subset of elective): 

623 (7.7%) of all 8,098 singleton 

cesarean deliveries 

623 (19.1%) of all 3,150 elective 

singleton cesarean deliveries 

Emergency pre-labor: 

G1: 1,127 

G1a: 592 

G1b: 293 

G1c: 242 

Emergency in labor: 

G1: 3,821 

G1a: 2,616 

G1b: 617 

G1c: 588 

Overall total (data available, singleton): 

G1: 8,098 

G1a: 4,092 

G1b: 1,481 

G1c: 2,525 

Trend: 

NR 
42

low relevance to CDMR. These studies used different sources. One study, using data from the 

Royal College of Obstetrics and Gynecology annual surveys, reported a total cesarean rate of 

18.5 percent and an “elective” cesarean rate of 9.5 percent of all births from January 1997 to 

March 1998.61 The other study, using data from the National Health Service (NHS) episode 

statistics database, reported a total cesarean rate of 20.1 percent and an “elective” cesarean rate 

of 8.9 percent of all births for 2001–2002.60 

Trend. Web-based National Health Service data provide evidence that is moderately relevant 

to CDMR. They report trends for “emergency” and “elective” (defined as planned procedure 

before, or at the onset of labor) cesarean deliveries as a proportion of all births from 1990 to 

2003–4.86 During this period, the rate of all cesareans rose from 12 percent to 23 percent. Both 

elective and emergency cesareans contributed to this rise. Relative to all births, the rate of 

elective cesarean deliveries rose from 5.3 percent in 1990 to 9.6 percent in 2003, and the rate of 

emergency cesarean deliveries rose from 7.1 percent in 1990 to 13.1 percent in 2003. 

Ireland. Incidence. Two studies using different sources reported data on Ireland for elective 

cesarean deliveries. One study, rated moderately relevant, provided incidence data from the 

National Maternity Hospital database annual report on the rate of all cesarean deliveries and 

“nonemergency prelabor” cesarean deliveries in 2000 as 15.1 percent. Over a 12-year period 

from 1989–2000, the authors reported a nonemergency prelabor cesarean delivery rate of 3 

percent of all deliveries and 30 percent of all cesarean deliveries (Table 8).35 Of these 

nonemergency prelabor cesarean deliveries, 24 percent were among primaparous women, 39 

percent were primary cesarean deliveries among primiparous women, and 37 percent were 

among repeat cesarean deliveries. We calculated the total primary prelabor nonemergency 

cesarean rate to be 18.9 percent of cesarean deliveries during the 12-year period from 1989-2000. 

Farah et al. reported elective and emergency cesarean rates of 7.5 percent and 10.3 percent of all 

births, respectively, based on a retrospective survey of maternity unit directors.59 The authors did 

not define “elective”; as a result, their study has low relevance to CDMR. 

Australia. Incidence. The majority of studies, from both published and web-based sources, 

defined “elective” cesarean deliveries as a procedure planned before the onset of labor (Table 

9).34,87-92 Two other articles either did not define “elective” cesarean or defined it as cesarean 

before and during labor, and hence did not exclude cesareans for fetal distress or other 

emergencies.57,58 

The most recent figures from these studies indicate rates of all cesarean and elective cesarean 

delivery of 23.5 percent and 13 percent, respectively, in New South Wales in 2001;91 27.4 

percent and 14.1 percent, respectively, in Victoria in 2002;87and 30 percent and 13.3 percent, 

respectively, in South Australia in 2003.90

Trend. Trend data was reported on New South Wales,57,58,91 Victoria,87-89,92 and Western 

Australia.34 Studies from the New South Wales database reported nearly constant rates of 

“elective” cesarean delivery or “cesarean before labor” over a period from 1990 to 199657–

1997.58 Web-based data for New South Wales from 1996 to 2001 showed a rise in the rate of all 

cesareans from 17.6 percent to 23.5.91 During this period, the rate of “elective” cesareans rose 

from 9.4 percent to 13.0 percent and the rate of “emergency” cesareans rose from 8.2 percent to 

10.5 percent.91
43

Table 8. Ireland, incidence and trend data 

Source 

Groups 

Relevance Rating 

Study Objective 

Source 

Time period 

Definitions and InclusionExclusion Criteria Incidence and Trend Data 

Farah et al., 

200359

Groups: 

G1: total cesarean 

deliveries 

G1a: elective 

G1b: emergency 

Low 

Objective: To ascertain 

the national cesarean 

delivery rate for the year 

1998 

Retrospective 

Survey (maternity unit 

directors) 

1/1/1998–12/31/1998 

Labored status and 

indication not reported 

Incidence 

Total deliveries: 51,133 

N (% of total deliveries) 

G1: 9,077 (17.8%) 

G1a: N not reported (7.5%) 

G1b: N not reported (10.3%) 

Trend: 

NR 

Foley et al., 

200535

Groups: 

G1: total deliveries 

G1a: nulliparous 

deliveries 

G1b: multiparous 

deliveries 

Moderate 

Objective: to study the 

relationship between an 

increasing cesarean 

delivery rate and term 

neonatal seizures and 

peripartum deaths 

Retrospective 

National Maternity 

Hospital database annual 

report 

1/1/1989–12/31/2000 

Nonemergency prelabor 

cesarean delivery 

Incidence of cesarean deliveries in 

2000: 15.1% (N not reported) 

Incidence over 12 years (1989-2000): 

G1: 77,350 

G1a: 31,660 

G1b: 45,690 

All nonemergency prelabor cesarean 

deliveries: 2547 (3% of all deliveries, 

30% of all cesareans) 

Primary prelabor cesarean deliveries 

G1a: 611 (24% of all nonemergency 

prelabor cesarean deliveries) 

Primary prelabor cesarean deiveries 

G1b: 1,002 (39% of all nonemergency 

prelabor cesarean deliveries) 

Repeat nonemergency prelabor 

cesarean delivery 

G1b: 934 (37% of all nonemergency 

prelabor cesarean deliveries) 
44

Table 9. Australia, incidence and trend data 

Source 

Groups 

State 

Relevance Rating 

Study Objective 

Source 

Time period 

Definitions and InclusionExclusion Criteria Incidence and Trend Data 

Chan et al., 200590

Groups 

G1: elective 

cesareans 

G2: emergency 

cesareans 

South Australia 

Moderate

Objective: NA 

Data from the South 

Australian perinatal data 

collection of births, 

accessed via the web 

Elective: planned procedure 

before the spontaneous 

onset of labor 

Emergency: undertaken for a 

complication: (a) before the 

onset of labor or (b) during 

labor, whether that labor is of 

spontaneous onset or 

following induction of labor

Incidence 

Total deliveries in 2003: 17,517 

N (% of total deliveries): 

G1: 2,334 (13.3%) 

G2: 2,929 (16.7%)

Centre for 

Epidemiology 

Research, 200291

Groups 

G1: emergency 

cesareans 

G2: elective 

cesareans 

New South Wales 

Moderate 

Objective: NA 

Data from the New 

South Wales Mothers 

and Babies 2001 report, 

accessed via the web 

Elective: planned or 

unplanned cesarean delivery 

performed before the onset 

of labor 

Emergency: performed after 

the onset of labor whether or 

not the onset of labor was 

spontaneous

Incidence: 

See below for 2001 

Trend: 

 Total % of all deliveries 

Year Deliveries G1 G2 

1996 85,302 8.2 9.4 

1997 86,920 8.3 9.9 

1998 85,072 8.7 10.3 

1999 85,967 9.0 10.6 

2000 86,460 9.9 11.5 

2001 84,379 10.5 13.0 
45

Table 9. Australia, incidence and trend data (continued) 

Source 

Groups 

State 

Relevance Rating 

Study Objective 

Source 

Time period 

Definitions and InclusionExclusion Criteria Incidence and Trend Data 

Read et al., 199034

Groups 

G1: total cesarean 

deliveries 

G1a: emergency 

cesarean 

deliveries 

G1b: elective 

cesarean 

deliveries 

Australia 

Moderate 

Objective: to describe 

trends and patterns in 

the incidence of 

cesarean deliveries in 

Western Australia 

Retrospective 

Administrative database 

1980-1987 

Elective: a planned 

procedure done before the 

onset of labor and before 

spontaneous rupture of the 

membranes and without any 

procedure to produce labor 

Emergency: undertaken at 

short notice for a 

complication before the 

onset of labor or during labor 

whether of spontaneous 

origin or induced 

Excluded: infants < 500g 

Incidence 

See below for 1987 

Trend: 

 

 Prelabor Total Percent 

 primary deliveries prelabor 

 elective* (parity primary* 

 known, 

 singleton)* 

1980 766 18,501 4.1% 

1981 834 21,719 3.8% 

1982 836 21,876 3.8% 

1983 853 22,551 3.8% 

1984 828 22,418 3.7% 

1985 999 22,749 4.4% 

1986 1,058 23,290 4.5% 

1987 1,139 23,538 4.8% 

*: calculated by authors of this report 

 Total % of all deliveries 

Year Deliveries G1 G1a G1b 

 (all parity, 

 multiple 

 gestations) 

1980 20,520 11.23 5.89 5.35 

1981 21,954 11.79 6.09 5.70 

1982 22,110 12.54 6.18 6.35 

1983 22,785 13.28 6.75 6.53 

1984 22,663 13.86 6.98 6.88 

1985 23,015 15.17 7.33 7.84 

1986 23,561 16.64 7.79 7.86 

1987 23,836 16.90 8.25 8.65 
46

Table 9. Australia, incidence and trend data (continued) 

Source 

Groups 

State 

Relevance Rating 

Study Objective 

Source 

Time period 

Definitions and InclusionExclusion Criteria Incidence and Trend Data 

Riley and King, 

2003;87 

Riley and Halliday, 

2001;92 

Riley and Halliday, 

1999;88 and 

Riley and Halliday, 

199889

Groups 

G1: cesarean 

deliveries 

G1a: emergency 

cesareans 

G1b: elective 

cesareans 

Victoria 

Moderate 

Objective: NA 

Data from the Victorian 

Perinatal Data Collection 

Unit, accessed via the 

web 

Elective: planned procedure 

that takes place before or 

after the spontaneous onset 

of labor 

Emergency: undertaken for a 

complication before or after 

the onset of labor 

Incidence: 

See below for 2000 

Trend: 

 Total % of all deliveries 

Year Deliveries G1 G1a G1b 

1992 63,795 17.7 8.0 9.7 

1993 63,795 18.1 7.9 10.2 

1994 63,983 18.7 8.3 10.4 

1995 62,372 19.1 8.1 11.0 

1996 62,028 19.7 8.4 11.3 

1997 61,311 20.2 8.5 11.7 

1998 61,072 21.0 8.9 12.1 

1999 61,587 22.8 11.3 11.5 

2000 61,569 23.4 11.5 11.9 

2001 61,064 25.3 12.3 13.0 

2002 61,959 27.4 13.3 14.1 

Roberts, et al., 

199957

Groups 

G1: elective 

cesarean 

deliveries 

New South Wales 

Low 

Objective: to examine 

trends in the distribution 

of births at and beyond 

term in New South 

Wales and in particular, 

to determine whether 

any changes are 

associated with changes 

in the obstetric practices 

of induction and elective 

cesarean deliveries 

Retrospective 

New South Wales 

Midwives database 

1/1/1990–12/31/1996 

Elective: no labor Incidence: 

See below for 1996 

Trend: 

 

Year N (G1) % 

1990 5,006 6.5 

1996 5,031 6.6 
47

Table 9. Australia, incidence and trend data (continued) 

Source 

Groups 

State 

Relevance Rating 

Study Objective 

Source 

Time period 

Definitions and InclusionExclusion Criteria Incidence and Trend Data 

Roberts et al., 

200258

Groups 

G1: total cesarean 

deliveries 

G1a: cesarean 

deliveries 

during labor 

G1b: cesarean 

deliveries 

before labor 

New South Wales 

Low 

Objective: to examine 

recent trends in obstetric 

intervention rates among 

women at low-risk of 

poor pregnancy outcome

Retrospective 

New South Wales 

Midwives database 

1/1/1990–12/31/1997 

Cesarean before labor 

Cesarean after labor 

Included: women with low 

risk pregnancy during 

antenatal care (20 to 34 

years of age with no medical 

or obstetric complications 

and a singleton cephalicpresenting infant of normal 

size; 10th-90th birthweight 

percentile, born at term; 37 

to 41 weeks gestation) 

Incidence 

Primiparous: 

G1: 15,974 

G1a: N not reported (9.8% of all births) 

G1b: N not reported (2.5% of all births) 

Multiparous: 

G1: 25,652 

G1a: N not reported (3.1% of all births) 

G1b: N not reported (8.4% of all births) 

Trend: Before Labor 

 Primiparous Multiparous 

Year N % N % 

1990 15,274 2.2 25,043 8.1 

1991 15,617 2.1 26,698 8.2 

1992 16,193 1.9 27,493 7.5 

1993 15,886 2.1 26,515 7.9 

1994 15,959 2.3 26,745 8.0 

1995 15,825 2.1 26,202 8.0 

1996 15,726 2.0 25,387 8.2 

1997 15,974 2.5 25,652 8.4 

Data from Victoria showed a rise in the rate of cesarean deliveries in a 10-year period from 1992 

to 2002 from 17.7 percent to 27.4 percent in 2002.87-89,92 During this period, the rate of “elective” 

cesarean delivery rose from 9.7 percent of all deliveries to 14.1 percent and the rate of 

“emergency” cesarean deliveries rose from 8 percent to 13.3 percent. 

One study from Western Australia reported on an earlier time period from 1980 to 1987. The 

study reported a cesarean delivery rate in 1980 of 11.2 percent; by 1987 it had risen to 16.9 

percent.34 The rate of “emergency” cesareans rose during this period from 5.8 percent to 8.3 

percent; the elective cesarean rate increased from 5.4 percent to 8.7 percent. 

The only study reporting rates of primary prelabor cesarean delivery used data from an 

administrative database from 1980 to 1987 in Western Australia. Using data provided in the 

publication, we calculated that primary prelabor cesarean deliveries rose from 4.1 percent of all 

deliveries in 1980 to 4.8 percent in 1987.34 More recent data from another study indicate a rate of 

cesarean before labor of 2.5 percent for primiparous women in 1997 in New South Wales. The 

authors do not report primary prelabor cesarean rates for multiparous women. 

Norway. Incidence. One study of moderate relevance to CDMR reported the rate of 

“elective” cesarean performed for feto-pelvic disproportion, breech, diabetes, hypertension, preeclampsia, twins, and low birthweight as 4.5 percent over a 10-year period (January 1986 to 

December 1995).36 The rate of all cesarean deliveries during this period was 12.5 percent (Table 

10). 
48

Table 10. Norway, incidence and trend data 

Source 

Groups 

Relevance Rating 

Study Objective 

Source 

Time period 

Definitions and InclusionExclusion Criteria Incidence and Trend Data 

Vangen et. al., 

200036

Groups 

G1: total cesarean 

delivery 

G1a: elective 

cesarean 

delivery 

Moderate 

Objective: to study the 

prevalences and risk 

factors for cesarean 

section among different 

groups of immigrants in 

comparison to ethnic 

Norwegians 

Retrospective 

medical birth registry 

and statistics 

1/1/1986–12/31/1995 

Elective: performed for the 

following reasons: feto-pelvic 

disproportion, breech, 

diabetes, hypertension, 

preeclampsia, twins and low 

birthweight, and unknown 

Emergent: performed for the 

following reasons: feto-pelvic 

disproportion, prolonged 

labor, fetal distress, breech, 

diabetes, hypertension, preeclampsia, twins and low 

birthweight. and unknown 

Incidence 

Total births: 553,491 

N (% of total deliveries) 

G1: 69,249 (12.5%) 

G1a: N not reported (4.5%) 

Trend 

NR 

Denmark. Incidence. The single Danish study reported a total cesarean rate of 11.9 percent 

and an “unplanned” cesarean rate of 7.7 percent of all deliveries in 1989 (Table 11).63 The 

authors did not comment on planned cesareans, resulting in low relevance to CDMR; we infer 

that the remainder, that is, 4.2 percent, were planned cesareans. 

Table 11. Denmark, incidence and trend data 

Source 

Groups 

Relevance Rating 

Study Objective 

Source 

Time period 

Definitions and InclusionExclusion Criteria Incidence and Trend Data 

Lidegaard, et al, 

199463

Groups 

G1: all cesarean 

deliveries 

G1a: unplanned 

cesarean 

deliveries 

Low 

Objective: to correlate 

the use of birth-related 

technologies, the 

perinatal mortality, and 

the cesarean delivery 

rates in Denmark 

Retrospective 

survey of maternity ward 

directors 

1/1/1989–12/31/1989 

Labored status and 

indication not reported 

Publication uses term 

“unplanned” cesareans 

Included: births and 

cesareans after 35 

completed weeks of 

gestation 

Incidence 

Total births: 179,572 

G1: 11.9% of all deliveries 

G1a: 7.7% of all deliveries 

Trend 

NR 

Finland. Incidence. One Finnish study reported a total cesarean rate of 13.9 percent and 

“elective” cesarean rates of 7.1 percent, as a proportion of all births from July 1985 through June 

1986 (Table 12).62 The authors did not define elective cesarean delivery resulting in low 

relevance to CDMR. 
49

Table 12. Finland, incidence and trend data 

Source 

Groups 

Relevance Rating 

Study Objective 

Source 

Time Pperiod 

Definitions and InclusionExclusion Criteria Incidence and Trend Data 

Jarvelin et al., 

199362

Groups 

G1: all cesarean 

deliveries 

G1a: elective 

cesarean 

delivery 

Low 

Objective: to examine 

indications for the 

induction of labor and 

variations in the current 

policy of induction at 

different levels of 

obstetric specialization 

and to compare the 

outcome of induced and 

spontaneous labor 

Prospective 

administrative database 

7/1/1985–6/30/1986 

Elective: not defined Total deliveries: 9,362 

G1: 13.9% of all deliveries 

G1a: 7.1% of all deliveries 
50

Key Question 2: 

Outcomes of Cesarean Delivery on Maternal Request 

As noted in Chapter 1, planned cesarean or planned vaginal delivery each have a range of 

numerous possible endpoints. Table 13 lists such endpoints for planned cesarean deliveries and 

for planned vaginal deliveries, noting the relevance to CDMR (ratings of high, moderate, or low, 

and, by definition, not applicable [NA] for vaginal deliveries). 

We present three tables to summarize the literature with reference to their particular study 

populations, relevance, and outcomes. Table 14 presents actual comparison groups for each 

study and the associated relevance rating. Table 15 catalogs the maternal and neonatal outcomes 

pertinent to this review that appeared in each study. Table 16 lists confounders, specifically 

preterm deliveries, placental previa, multiple gestations, and multiparity, for each study. 

The underlying concerns for the SOS conference relate to maternal and neonatal outcomes, 

as depicted in the analytic framework of Chapter 1 (Figure 3). This section presents results for 

maternal outcomes for primary cesarean deliveries as directed by the SOS Conference panel 

chair and in consultation with the Technical Expert Panel (TEP). Our systematic search strategies 

focused on primary cesarean delivery, however, we provide a summary of outcomes particularly 

relevant to subsequent cesarean deliveries such as subsequent uterine rupture, placenta previa, 

and subsequent stillbirth. We conclude this section with a summary of results for neonatal 

outcomes. 

We organized maternal outcomes by proximity to the delivery and then, generally, by 

severity of the outcome. Maternal outcomes related to pelvic floor disorder, urinary 

incontinence, pelvic organ prolapse, and fecal incontinence appear last. Neonatal outcomes are 

similarly listed by proximity to delivery and severity of outcome. 
51

Table 13. Possible endpoints from planned route of delivery and relevance as proxies to CDMR 

Possible Endpoints from Planned Cesarean Delivery 

Relevance as 

Proxies to CDMR 

Planned cesarean delivery on maternal request (no maternal or neonatal indications) High 

Trial of cesarean for specific indications such as breech Moderate 

Planned cesarean performed for neonatal indications (unlabored) Moderate 

Cesarean planned and performed for maternal indications, unlabored Moderate 

Cesarean planned and performed for neonatal or maternal indications, unlabored Moderate 

Cesarean planned and performed but presented in labor for neonatal indications Moderate 

Cesarean planned and performed but presented in labor for maternal indications Moderate 

Cesarean planned and performed but presented in labor for neonatal or maternal indications Moderate 

Cesarean planned and performed but mix of labor and unlabored for neonatal indications Moderate 

Cesarean planned and performed but mix of labor and unlabored for maternal indications Moderate 

Cesarean planned and performed but mix of labor and unlabored for neonatal or maternal 

indications 

Moderate 

Mix of planned and unplanned cesarean, unlabored, for maternal or neonatal indications Low 

Planned cesarean unspecified as to indications or labor /”elective” unspecified as to 

indications or labor 

Low 

Possible Endpoints from Planned Vaginal Delivery 

Trial of vaginal delivery for specific indications such as breech NA* 

Spontaneous vaginal delivery NA 

Vacuum NA 

Forceps NA 

Vacuum and/or forceps NA 

Mix of spontaneous and assisted vaginal deliveries NA 

Vaginal unspecified NA 

Unplanned unlabored cesarean for neonatal indications NA 

Unplanned unlabored cesarean for maternal indications NA 

Unplanned unlabored cesarean for neonatal or maternal indications NA 

Unplanned labored cesarean for neonatal indications NA 

Unplanned labored cesarean for maternal indications NA 

Unplanned labored cesarean for neonatal or maternal indications NA 

Unplanned mix of labored and unlabored cesarean for neonatal indications NA 

Unplanned mix of labored and unlabored cesarean for maternal indications NA 

Unplanned mix of labored and unlabored cesarean for neonatal or maternal indications NA 

Unplanned cesarean unspecified or “emergency” NA 

* NA, not applicable 
52

Table 14. Comparison groups 

Study and Population Characteristics 

Planned Route of 

Delivery 

Planned Cesarean Delivery (CD) Mix of 

Planned 

and 

Unplan

-ned 

CD 

“Elective” 

Unspeci

fied 

Analyzed by planned 

(P) or actual (A) 

delivery 

P A A A A A A 

Labored (L) or 

unlabored (UL) 

Both UL L Both Both UL NR 

Indications for 

cesarean delivery 

(mat, fet, both) 

Both Both Both Mat Both Both NR 

Source 

Relevance Rating* Actual route of 

delivery (CD, VD) 

CD and 

VD 

CD CD CD CD CD CD 

Hannah et al., 200218 T ● 

Hannah et al., 200483 T ●

Hannah et al., 200020 T ●

Leiberman et al., 199584 T ●

 

Badawi et al., 199837 M ● 

Burrows et al., 200439 M ● 

Bergholt et al., 200338 M ● 

Dessole et al., 200440 M ● ● 

Farrell et al., 200141 M ● 

Farrell et al., 200142 M ● 

Fawcett et al., 199243 M ● 

Groutz et al., 200444 M ● 

Hillan, 199545 M ● 

Lal et al., 200346 M ● 

Levine et al., 200147 M ● 

Morrison et al., 199548 M ● 

Nice et al., 199649 M ● 

Sanchez-Ramos et al., 

200150 M ● 

Schindl et al., 200351 M ● 

van Ham et al., 199728 M ● 

Zanardo et al., 200452 M ● 

Zanardo et al., 200453 M ● 

 

Allen et al., 200364 L ● 

Dani et al., 199965 L ●

Durik et al., 200066 L ●

Golfier et al., 200167 L ●

Irion et al., 199868 L ●

Koroukian, 200469 L ●

AVD, assisted vaginal delivery; CD, cesarean delivery; FAVD, forceps-assisted vaginal delivery; Mat, maternal; Fet, Fetal; NR, 

not reported; SVD, Spontaneous vaginal delivery; VAVD, vacuum-assisted vaginal delivery; VD, vaginal delivery. 

*Relevance ratings: T, trial of planned route of delivery; M, moderate; L, low. 

HStudy reported on planned route (intent to treat) for adverse outcomes and by actual route for primary outcomes.
53

Table 14. Comparison groups (continued) 

Study and population characteristics

Planned 

Vaginal 

Delivery 

(VD) Unspecified, Planned VD Assumed Planned VD 

Mix of 

planned and 

unplanned 

vaginal 

delivery 

P A A A A A A A A A A A A 

Both L L L L L L UL L Both NR or 

“Emergency” 

L Both 

Both NA NA NA NA NA NA Both Both Both Both Both Both 

CD and 

VD 

SVD VAVD FAVD VAVD 

and/or 

FAVD 

SVD 

and 

AVD 

Unspecified VD CD CD CD CD CD CD 

● 

●

●

● 

 

 ● ● ● ● 

● ● ● 

 ● 

 ●

 ● ● ● 

● ● ● 

 ● ● 

 ● ● 

 ● ● 

 ● ● 

 ● ●

 ● ● 

 ● 

● 

H ● ● 

 ● ● 

 ● 

●

 

 ● ● ● 

● ● ● 

 ● ● 

● 

●

 ● ● ● 
54

Table 14. Comparison groups (continued) 

Study and Population Characteristics 

Planned Route of 

Delivery Planned Cesarean Delivery (CD) 

Mix of 

Planned 

and 

Unplan

-ned 

CD 

“Elective” 

Unspeci

fied 

Analyzed by planned 

(P) or actual (A) 

delivery 

P A A A A A A 

Labored (L) or 

unlabored (UL) 

Both UL L Both Both UL NR 

Indications for 

cesarean delivery 

(mat, fet, both) 

Both Both Both Mat Both Both NR 

Source 

Relevance Rating* Actual route of 

delivery (CD, VD) 

CD and 

VD 

CD CD CD CD CD CD 

Krebs and Langhoff-Roos, 

200370 L ● 

MacArthur et al., 200172 L ●

MacArthur et al., 199771 L ●

Mason et al., 199973 L ●

Persson et al., 200074 L ● 

Phipps et al., 200575 L ●

Reichert et al., 199376 L ●

Rubaltelli et al., 199877 L ●

Ryding et al., 199878 L ●

Schytt et al., 200479 L ●

Sutton et al., 200180 L ● 

Towner et al., 199981 L ● 

Wilson et al., 199682 L ●
55

Table 14. Comparison groups (continued) 

Study and population characteristics

Planned 

Vaginal 

Delivery 

(VD) Unspecified, Planned VD Assumed Planned VD 

Mix of 

Planned and 

Unplanned 

Vaginal 

Delivery 

P A A A A A A A A A A A A 

Both L L L L L L UL L Both NR or 

“Emergency” 

L Both 

Both NA NA NA NA NA NA Both Both Both Both Both Both 

CD and 

VD 

SVD VAVD FAVD VAVD 

and/or 

FAVD 

SVD 

and 

AVD 

Unspecified VD CD CD CD CD CD CD 

 ● 

● ● ● ● 

 ● ● ● ● ● 

 ● ● ● ● 

 ● ●

 ● 

● 

● 

 ● ● ● ● 

● ● ● 

 ● ● ● 

 ● ● ● ● ● 

 ● ● ● 
56

Table 15. Maternal and neonatal outcomes reported 

Outcomes Maternal Outcomes Relevant to Primary CDMR Maternal 

Outcomes 

Relevant to 

Subsequent 

Cesarean 

Delivery

Neonatal Outcomes

Relevance rating 

Mortality 

Infection 

Anesthetic complications 

Hemorrhage/blood transfusion 

Hysterectomy 

Thromboembolism 

Surgical complications 

Breastfeeding 

Postpartum pain 

Psychological outcomes (postpartum 

depression)

Psychological outcomes (other) 

Maternal length of stay 

Urinary incontinence 

Anorectal function 

Pelvic organ prolapse 

Sexual function 

Subsequent fertility issues 

Subsequent uterine rupture 

Subsequent stillbirth 

Fetal mortality 

Neonatal mortality 

Unexpected (iatrogenic) prematurity 

Respiratory morbidity 

Transition 

Neonatal asphyxia/encephalopathy 

Intracranial hemorrhage 

Facial nerve injury 

Hannah et al., 200218

T ● ● ● ● ● ● ●

Hannah et al., 200483

T ● ● ● ● ● ● ●

Hannah et al., 200020

T ● ● ● ● ● ● ● ●

Leiberman et al., 199584

T ● ●

Badawi et al., 199837 M ●Bergholt et al., 200338

M ● ● ● ●

Burrows et al., 200439

M ● ● ●

Dessole et al., 200440

M 

Farrell et al., 200141 M ●Farrell et al., 200142 M ●Fawcett et al., 199243

M ● ● ●

T, trial of planned route of delivery; M, moderate; L, low 
57

Table 15. Maternal and neonatal outcomes reported (continued) 

Outcomes Maternal Outcomes Relevant to Primary CDMR Maternal 

Outcomes 

Relevant to 

Subsequent 

Cesarean 

Delivery

Neonatal Outcomes

Relevance rating 

Mortality 

Infection 

Anesthetic complications 

Hemorrhage/blood transfusion 

Hysterectomy 

Thromboembolism 

Surgical complications 

Breastfeeding 

Postpartum pain 

Psychological outcomes (postpartum 

depression)

Psychological outcomes (other) 

Maternal length of stay 

Urinary incontinence 

Anorectal function 

Pelvic organ prolapse 

Sexual function 

Subsequent fertility issues 

Subsequent uterine rupture 

Subsequent stillbirth 

Fetal mortality 

Neonatal mortality 

Unexpected (iatrogenic) prematurity 

Respiratory morbidity 

Transition 

Neonatal asphyxia/encephalopathy 

Intracranial hemorrhage 

Facial nerve injury 

Groutz et al., 200444 M ●Hillan et al., 199545 M ● ●Lal et al., 200346 M ●Levine et al., 200147 M ●Morrison et al., 199548

M ●

Nice et al., 199649 M ●Sanchez-Ramos et al., 200150

M ● ● ●

Schindl et al., 200351 M ● ● ● ● ● ● ●van Ham et al., 199728

M ● ● ● ● ● ● 

Zanardo et al., 200452

M ● 

Zanardo et al., 200453

M ● ● 

Allen et al., 200364 L ● ● ● ●Dani et al., 199965 L ●Durik et al., 200066 L ● ●
58

Table 15. Maternal and neonatal outcomes reported (continued) 

Outcomes Maternal Outcomes Relevant to Primary CDMR Maternal 

Outcomes 

Relevant to 

Subsequent 

Cesarean 

Delivery

Neonatal Outcomes

Relevance rating 

Mortality 

Infection 

Anesthetic complications 

Hemorrhage/blood transfusion 

Hysterectomy 

Thromboembolism 

Surgical complications 

Breastfeeding 

Postpartum pain 

Psychological outcomes (postpartum 

depression)

Psychological outcomes (other) 

Maternal length of stay 

Urinary incontinence 

Anorectal function 

Pelvic organ prolapse 

Sexual function 

Subsequent fertility issues 

Subsequent uterine rupture 

Subsequent stillbirth 

Fetal mortality 

Neonatal mortality 

Unexpected (iatrogenic) prematurity 

Respiratory morbidity 

Transition 

Neonatal asphyxia/encephalopathy 

Intracranial hemorrhage 

Facial nerve injury 

Golfier et al., 200167 L ● ● ● ●Irion et al., 199868 L ● ● ● ● ●Koroukian, 200469 L ● ● ● ● ●Krebs and LanghoffRoos, 200370 L ● ● ● ● ● ● ● ● ●MacArthur et al., 200172

L ●

MacArthur et al., 199771

L ●

Mason et al., 199973 L ●Persson et al., 200074

L ●

Phipps et al., 200575 L ●Reichert et al., 199376

L ●

Rubaltelli et al., 199877

L ●

Ryding et al., 199878 L ●Schytt et al., 200479 L ●
59

Table 15. Maternal and neonatal outcomes reported (continued) 

Outcomes Maternal Outcomes Relevant to Primary CDMR Maternal 

Outcomes 

Relevant to 

Subsequent 

Cesarean 

Delivery

Neonatal Outcomes

Relevance rating 

Mortality 

Infection 

Anesthetic complications 

Hemorrhage/blood transfusion 

Hysterectomy 

Thromboembolism 

Surgical complications 

Breastfeeding 

Postpartum pain 

Psychological outcomes (postpartum 

depression)

Psychological outcomes (other) 

Maternal length of stay 

Urinary incontinence 

Anorectal function 

Pelvic organ prolapse 

Sexual function 

Subsequent fertility issues 

Subsequent uterine rupture 

Subsequent stillbirth 

Fetal mortality 

Neonatal mortality 

Unexpected (iatrogenic) prematurity 

Respiratory morbidity 

Transition 

Neonatal asphyxia/encephalopathy 

Intracranial hemorrhage 

Facial nerve injury 

Sutton et al., 200180 L ●Towner et al., 199981 L ● ● ● ● ● ● Wilson et al., 199682

L ●
60 

We present results for each outcome by relevance to CDMR. With respect to the quality of 

individual studies, we then examine studies rated “T” and the studies judged to be moderately 

relevant for quality (categorized as good, fair, or poor). We had no highly relevant studies for 

this question, and we did not grade low relevance studies for quality because we believed such 

grading would be unfair to studies that were obviously designed and conducted for other 

purposes. Thus, we focus mainly on studies of moderate relevance graded either good or fair 

quality; we only summarize information from poor studies (regardless of relevance) or those of 

low relevance (regardless of quality). 

Below we present a general discussion of the direction of evidence in the following text for 

outcomes with more than three studies; summary tables document specific results. Because of 

the extreme range and diversity of outcome measures, reference groups used for comparisons, 

methods for reporting data, and statistical tests used, these tables are necessarily complex. We 

focus on percentages of women with the outcome in question in the various cesarean and vaginal 

delivery groups, significance of any results, and (when provided) odds ratios (OR) or relative 

risks (RR) provided by study authors. We do not present summary tables for outcomes with three 

or fewer studies; those results are noted only in text. 

Finally, we do not have summary tables on psychological outcomes for two reasons. First, 

these outcomes had not been specified as being of high priority for the SOS conference, and time 

and resource constraints led us to focus on SOS-priority outcomes. Second, psychological 

outcomes were so numerous and varied that presenting them in summary tables seemed 

impractical. Where appropriate, we have reported or commented on these outcomes in the text 

below. 

Maternal Outcomes for Primary Cesarean Deliveries 

The following outcomes are relevant to both primary and subsequent cesarean deliveries. 

However, we draw upon evidence from studies focusing on primary cesarean deliveries to 

address the maternal outcomes listed below. As noted in Table 16, some of these studies include 

repeat cesarean deliveries. However, no study included in this review is limited to repeat 

cesareans. Outcomes particularly relevant to subsequent cesarean deliveries are addressed in the 

next section. 
61 

Table 16. Inclusion of possible confounders 

Relevance 

Rating 

Nulliparous 

Only 

Includes 

Preterm 

Includes 

Previa 

Includes 

Repeat 

Cesarean 

Delivery 

Includes 

Multiple 

Gestations 

Hannah et al., 

200020 T No No No Yes No 

Hannah et al., 

200218 T No No No Yes No 

Hannah et al., 

200483 T No No No Yes No 

Leiberman et al., 

199584 T Yes No Yes No No 

Badawi et al., 

199837 M No No Yes Yes Unspecified 

Bergholt et al., 

200338 M No Yes Yes Yes Yes 

Burrows et al., 

200439 M No No Unspecified Yes No 

Dessole et al., 

200440 M No Yes Yes Yes Yes 

Farrell et al., 

200141 M Yes Probably Unspecified No Unspecified 

Farrell et al., 

200142 M Yes Probably Unspecified No Unspecified 

Fawcett et al., 

199243 M No No Probably Yes Unspecified 

Groutz et al., 

200444 M Yes No No No Unspecified 

Hillan, 199545 M No Probably Probably Probably Probably 

Lal et al., 200346 M Yes Yes Unspecified No No 

Levine et al., 

200147 M No Yes (≥35 wks) Yes Yes Yes 

Morrison et al., 

199548 M No No Probably Probably Unspecified 

Nice et al., 199649 M No Probably Probably Probably Probably 

Sanchez-Ramos 

et al., 200150 M No Yes (≥35 wks) Unspecified Yes No 

Schindl et al., 

200351 M No No Probably Yes Yes 

van Ham et al., 

199728 M No Yes Yes Yes Probably 

Zanardo et al., 

200452 M No No Yes Yes Yes 

Zanardo et al., 

200453 M No No Yes Yes Yes 

Allen et al., 200364 L Yes No Unspecified No No 

Dani et al., 199965 L No Yes Yes Probably Yes 

Durik et al., 

200066 L No Probably Probably Probably Probably 

Golfier et al., 

200167 L No No Unspecified Probably No 

Irion et al., 199868 L No Yes (≥36 wks) No Probably No 

Koroukian, 200469 L No No No Probably No 

T, trial of planned route of delivery; M, moderate; L, low. 
62 

Table 16. Inclusion of possible confounders (continued) 

Relevance 

Rating 

Nulliparous 

Only 

Includes 

Preterm 

Includes 

Previa 

Includes 

Repeat 

Cesarean 

Delivery 

Includes 

Multiple 

Gestations 

Krebs and 

Langhoff-Roos, 

200370

L Yes Yes Unspecified No No 

MacArthur et al., 

200172 L No Probably Unspecified Probably Unspecified 

MacArthur et al., 

199771 L No Probably Probably Probably Unspecified 

Mason et al., 

199973 L No Probably Probably Probably Probably 

Persson et al., 

200074 L No Probably Probably Probably Yes 

Phipps et al., 

200575 L No Yes Probably Yes Probably 

Reichert et al., 

199376 L No No Yes Yes Unspecified 

Rubaltelli et al., 

199877 L No Yes Yes Probably Yes 

Ryding et al., 

199878 L No Probably Probably Probably Unspecified 

Schytt et al., 

200479 L No Probably Probably Yes No 

Sutton et al., 

200180 L No No Probably Probably No 

Towner et al., 

199981 L Yes Probably Probably No No 

Wilson et al., 

199682 L No No Probably Yes Yes 

Mortality. Four studies reported on maternal mortality associated with mode of delivery 

(Table 17).20,28,64,70 One is the randomized Breech Trial (relevance rating of T); we gave the 

initial report a quality rating of fair. This trial compared planned vaginal with planned cesarean 

for breech and analyzed results using intent-to-treat.20 We rated another study as moderately 

relevant but of poor quality.28 We rated the two remaining studies as having low relevance and 

did not rate quality.64,70 
63 

Table 17. Mortality 

Author, Year 

Relevance/Quality Measure Outcomes for Comparison Groups 

Statistical 

Test 

Results 

Planned CD Planned 

VD 

Hannah et al., 2000 20

T/Fair 

Mortality 0 0.1% NR 

Primary 

Elective CD 

Primary 

Acute CD 

Secondary 

Acute CD 

van Ham et al., 1997 28

Moderate/Poor 

Mortality 3 cases of mortality due to underlying 

pathology, NR by category 

 NR 

Allen et al., 2003 Elective CD SVD AVD CD in labor 64

Low/Not rated Mortality 0 0 0 0 NR 

Elective CD VD Emergency 

CD 

Krebs et al., 2003 70

Low/Not rated 

Mortality None of the 83 deaths reported in the 

sample of 15,441 women were associated 

with mode of delivery 

 NR 

CD, cesarean delivery; VD, vaginal delivery; SVD, spontaneous vaginal delivery; AVD, assisted vaginal delivery; NR, not 

reported. 

The Breech Trial initially reported one death in the planned vaginal group (n = 1,042, or 

0.1%), and none in the planned cesarean group (n = 1,041).20 The patient who died was described 

as “jaundiced before labor, developed disseminated intravascular coagulation after delivery, and 

died of hepatorenal failure at 44 hours postpartum” (p. 1380).20

The moderately relevant (poor) study identified three maternal deaths that had been caused 

by underlying pathology.28 The authors did not characterize these cases as either labored or 

unlabored cesarean deliveries, nor did they comment on indication for cesarean; thus, this study 

provides little information relevant to CDMR. 

Of the two low relevance studies, one study reported some deaths but none associated with 

mode of delivery,70 and the other reported no maternal deaths at all.64

Infection. Twelve studies20,28,39,45,49,51,64,67-70,84 included maternal infection as an outcome 

(Table 18). 

The Breech Trial found no significant differences in the rates of wound infection or maternal 

systemic infection.

20 An earlier nonrandomized study (rated fair) compared a trial of planned 

vaginal with planned cesarean for breech and analyzed results using intent-to-treat. The 

investigators used a composite measure of maternal morbidity (febrile morbidity, endometritis, 

wound infection, urinary tract infection [UTI], and thrombophlebitis) and determined that it was 

significantly higher in the planned cesarean group.84 

Of five moderately relevant studies, two were of fair quality,39,51 and three were of poor 

quality.28,45,49 Only one of these compared planned “intended” vaginal delivery with planned 

“elective” cesarean delivery.51 It did not give a detailed assessment of maternal infection beyond 

reporting a single case of sepsis among the 903 intended vaginal births and none among the 147 

“elective” cesarean births. 

Three studies compared outcomes only between various types of cesarean delivery; this 

restriction limited their utility for addressing the maternal infection issue in terms of planned 

CDMR vs. planned vaginal delivery. Of these, one study found no difference in UTI between 

planned “elective” and unplanned “emergency” cesarean deliveries but did find significantly 
64

Table 18. Infection Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Planned CD 

Planned VD 

Wound infection 1.5% 1.0% 

Hannah et al., 200020

T/Fair 

Maternal systemic infection 1.5% 1.3% 

Primary Prelabor CD 

Repeat Prelabor CD 

Primary Labored CD 

Repeat Labored CD 

SVD (ref grp) 

OperativVD 

Endometritis 3.0% 2.7% 9.4% 4.6% 0.4% 0.7% Adj OR (95% CI) 10.3 

(5.9; 17.9) 

9.9 (5.8; 16.9) 

21.2 (15.4; 29.1) 

14.6 (9.2; 23.1) 

1.0 0.9 

(0.6; 1.5) 

Pneumonia 0.3% 0.5% 0.1% 0.7% 0.1% 0.2% 

Burrows et al., 200439

Moderate/Fair 

Adj OR (95% CI) 4.7 

(1.1; 20.4) 

5.2 (1.5; 18.1) 

1.7 (0.6; 5.2) 

9.3 (3.4; 25.6) 

1.0 2.3 

(1.0; 5.4) 

Planned CD 

Planned Trial of Labor (ref grp) 

Combined measure of maternal morbidity (includes febrile morbidity, endometritis, wound infection, UTI and thrombophlebitis) 

31.0% 17.8% 

Leiberman et al., 199584

T/Fair 

OR (95% CI) 0.48 (0.25; 

0.89) 

1.0 

UTI, urinary tract infection; CD, cesarean delivery; SVD, spontaneous vaginal delivery; AVD, assisted vaginal delivery; ref grp, reference group; NS, reported; Adj, adjusted; OR, odds ratio; RR, risk ratio; CI, confidence interval. 
65 

Table 18. Infection (continued) Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Elective CD 

Emergency CD 

UTI 10.9% 10.3% Wound infection 4.1% 8.3% 

Hillan, 199545Moderate/Poor 

Pelvic infection (intrauterine) 1.4% 6.0% 

Elective CD 

Emergency CD 

Nice et al., 199649

Moderate/Nice 

Wound infection 6.4% 7.6% 

Elective CD 

Emergency CD 

Schindl et al., 200351

Moderate/Fair 

Sepsis 0 0.1% 

Primary Elective CD 

Primary Acute CD 

Secondary Acute CD 

UTI 2.5% 3.4% 3.1% Wound infection 1.0% 1.7% 2.8% Endometritis 1.3% 0.5% 1.6% Pelvic infection (intrauterine) 0.6% 0.1% 1.0% Sepsis 0 0.6% 0.2% 

van Ham et al., 199728

Moderate/Poor 

Pneumonia 0 0.6% 0.4% 

Elective CD 

SVD (ref grp) 

AVD (ref grp) 

CD in Labor (ref grp) 

Wound infection 1.5% 0.4% 2.0% 2.2% 

Allen et al., 200364

Low/Not rated 

 RR vs SVD: 

3.5 (1.8, 6.7); RR vs AVD: 0.8 (0.4, 1.5); RR vs CD in labor: 0.7 (0.4, 1.4) 
66 

Table 18. Infection (continued) Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Elective CD 

Planned VD (ref grp) 

Moderate and severe complications 

6.0% 5.8% 

RR (95% CI) 0.97 

(0.59; 1.57)

1.0 

Mild complications 6.7% 2.4% 

Golfier et al., 200167

Low/Not rated 

RR (95% CI) 0.46 

(0.24; 0.9) 

1.0 

Elective CD (ref grp) 

Attempted VD 

UTI 12.5% 5.2% RR (95% CI) 1.0 0.42 

(0.25; 0.70) 

Endometritis 4.1% 1.8% RR (95% CI) 1.0 0.45 

(0.18; 1.11) 

Pneumonia 0.3% 0.8% 

Irion et al., 199868

Low/Not rated 

RR (95% CI) 1.0 2.49 

(0.26; 23.86) 

Elective CD 

SVD AVD Nonelective 

CD 

Major puerperal infection in entire sample 

2.9% 0.9% 1.1% 4.3% Elective CD 

Uncomplicated SVD(ref grp) 

Major puerperal infection in subset of uncomplicated deliveries 

2.9% 0.8% 

Koroukian, 200469

Low/Not rated 

RR (95% CI) 3.75 

(3.12; 4.51)

1.0 
67 

Table 18. Infection (continued) Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Elective CD 

VD (ref grp) 

Emergency CD (ref grp)

Puerperal fever/pelvic infection 1.5% 0.5% 2.3%  RR vs VD: 

1.2 (1.11; 1.25); RR vs Emergency CD: 0.81 (0.7; 0.92) 

Wound infection 0.9% 0.7% 1.8% 

Krebs and Langhoff-Roos, 200370

Low/Not rated 

 RR vs VD: 

NR; Emergency CD: 0.69 (0.57; 0.83)
68 

lower rates of wound, intrauterine, and chest infections in the planned “elective” cesarean 

group.45 The second reported no significant difference in the rate of UTI, wound infection, and 

endometritis between planned “elective” cesarean and unplanned “acute” and “secondary acute” 

cesarean deliveries.28 The third set of investigators limited their analysis to wound infection and 

distinguished between major and minor infections. However, they did not provide a statistical 

comparison of wound infection rates between planned “elective” and unplanned “emergency” 

cesarean deliveries.49 

The most recent moderately relevant study compared various actual modes of delivery.39 The 

risk of endometritis was significantly higher for both planned “without trial of labor” and 

unplanned “with trial of labor” primary cesarean deliveries than for spontaneous vaginal 

delivery. The risk of pneumonia was higher for both types of cesareans but significantly higher 

only for the planned “without trial of labor” primary cesarean group. 

The remaining five studies were of low relevance because the authors either combined 

planned and unplanned cesareans in their cesarean comparison groups64,70 or did not define 

“elective” cesarean delivery.67-69 Generally, these studies found that the risk of maternal 

infection was lower for planned “elective” cesarean than for unplanned or labored or 

“emergency” cesarean but lower for vaginal delivery than for planned “elective” cesarean.

Anesthetic complications. Of three studies reporting on anesthetic complications associated 

with mode of delivery, two were moderately relevant to CDMR50,51 and one was of low 

relevance.69 

One moderately relevant study (fair quality) reported a 4 percent rate of problems with 

“peridural” anesthesia/postspinal headache in the “elective” cesarean group (6 of 147 women) 

and a 2 percent rate (18 of 903 women) with an intended vaginal birth;51 the authors did not 

provide statistical testing for this outcome. The other study (poor quality) reported no difference 

in anesthetic complications between planned cesarean and planned vaginal delivery.50

The low relevance study obtained data from an administrative database using International 

Classification of Diseases, ninth edition (ICD-9) codes and reported rates of anesthetic 

complications in ascending order per 1,000 women: spontaneous vaginal deliveries, 90; assisted 

vaginal deliveries, 160; unplanned “nonelective” cesarean deliveries, 360; and planned “elective” 

cesarean deliveries, 390.69

Hemorrhage/blood transfusion. Of the 11 articles (Table 19) that evaluated blood loss 

associated with route of delivery, 1 was from the Breech Trial,20 6 were moderately 

relevant,28,38,39,45,50,51 and four were of low relevance.64,67-69 

As with other outcomes, definitions were not standardized. We encountered various 

measures of hemorrhage: blood loss >1,000 ml, blood loss >1,500 ml, blood transfusion, need 

for dilatation and curettage, and undefined postpartum hemorrhage. We chose to report these 

clinically relevant outcomes rather than anemia (change in hemoglobin or hematocrit level). 

The Breech Trial (fair quality) included a heterogeneous group of women: women who were 

multiparous, had a history of a previous cesarean, and presented in labor.20 The planned cesarean 

group had lower rates of postpartum bleeding (1.0%)—defined as estimated blood loss (EBL) 

>1,000ml, EBL >1,500ml, blood transfusion or need for dilatation and curettage—than the 

planned vaginal delivery group (1.3%); the difference was not statistically significant. 

Five of the six moderately relevant studies limited comparisons to only planned “elective” vs. 

unplanned “emergency” cesarean delivery; they defined significant blood loss as blood loss 

>1000 ml,28 transfusion,45,50,51 or both.38 Of these five, two were of fair quality51 38and three were 

of poor quality.28,45,50 The sixth study (fair quality) identified postpartum hemorrhage and 
69

Table 19. Hemorrhage Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Planned CD 

Planned VD 

Postpartum bleeding 1.0% 1.3% Hemorrhage > 1,000 ml 0.4% 0.8% Hemorrhage> 1,500 ml 0.2% 0.4% Hemorrhage requiring transfusion 

0.4% 0.8% 

Hemorrhage requiring D&C 0.3% 0.4% 

Hannah et al., 200020

T/Fair 

Other hemorrhage 0.2% 0.1% 

Primary Prelabor CD 

Repeat Prelabor CD 

Primary Labored CD 

Repeat Labored CD 

SVD (ref grp) 

Operative VD

Postpartum hemorrhage 2.7% 3.2% 3.9% 2.6% 5.0% 4.7% Adj OR (95% CI) 0.7 

(0.4; 1.1) 

0.8 (0.6; 1.2) 

0.8 (0.6; 0.9) 

0.6 (0.4; 0.96) 

1.0 0.8 

(0.7; 0.97) 

Transfusion 0.3% 0.5% 1.1 0.8% 0.2% 0.4% 

Burrows et al., 200439

Moderate/Fair 

Adj OR (95% CI) 2.6 

(0.8; 8.5) 

3.0 (1.1; 8.3) 

4.4 (2.7; 7.1) 

4.2 (1.8; 10.1) 

1.0 2.2 

(1.3; 3.7) 

Adj, Adjusted; AVD, assisted vaginal delivery; CD, cesarean delivery; CI, confidence interval; SVD, spontaneous vaginal delivery; ref grp, reference 

NR, not reported; NA, not applicable; OR, odds ratio; RR, relative risk; VD, vaginal delivery. 
70

Table 19. Hemorrhage (continued) Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Elective CD 

Emergency CD 

Blood transfusion 0.7% 1.1% Estimated blood loss ≥1,000 ml 

6.8% 9.0% 

Bergholt et al., 200338

Moderate/Fair 

Risk of intraoperative blood loss ≥ 1,000 ml during the cesarean delivery from emergency c/s 

NA Crude OR: 

1.3 Adjusted OR: 1.6 (0.7; 3.4) 

Elective CD 

Emergency CD 

Hillan, 199545Moderate/Poor 

Blood transfusion 1.4% 4.5% 

Elective CD 

Attempted Vaginal Breech 

Sanchez-Ramos et al., 200150

Moderate/Poor 

Hemorrhage 1.0% 1.1% 

Elective CD 

Intended VD 

Blood transfusion 0 0.6% 

Schindl et al., 200351

Moderate/Fair 

Sepsis 0 0.1% 

Primary Elective CD 

Primary Acute CD 

Secondary Acute CD 

Blood loss (intraoperative) 4.7% 7.8% 8.7% Blood loss (postoperational) ≥ 1,500 ml 1.5% 2.9% 2.6% 

van Ham et al., 199728

Moderate/Poor 

Blood loss (postoperational) 1,000 to 1,500 ml 

2.8% 3.7% 4.9% 
71

Table 19. Hemorrhage (continued) Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Elective CD (ref grp) 

SVD AVD CD in Labor 

Blood transfusion 0.3% 0.3% 0.8% 0.5% RR (95% CI) 1.0 0.9 

(0.2; 3.8) 

0.4 (0.1; 1.6) 

0.5 (0.1; 2.4) 

 

Early postpartum hemorrhage 

3.8% 5.1% 9.6% 7.5% 

Allen et al., 200364

Low/Not rated 

RR (95% CI) 1.0 0.8 

(0.5; 1.1) 

0.4 (0.3; 0.6) 

0.5 (0.4; 0.8) 

 

Elective CD 

Planned VD 

Golfier et al., 200167

Low/Not rated Blood transfusion 0.3% 1.0% 

Elective CD 

Attempted VD 

Irion et al., 199868

Low/Not rated 

Hysterectomy for hemorrhage 

0.3% 0 
72

Table 19. Hemorrhage (continued) Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Elective CD 

SVD AVD Nonelective 

CD 

Postpartum hemorrhage in entire sample 

1.74% 3.0% 3.13% 2.22% Elective CD 

Uncomplicated SVD (ref grp) 

Postpartum hemorrhage in subset of uncomplicated deliveries 

1.74% 2.42% 3.0% 

RR (95% CI) 0.60 (0.48; 

0.76) 

1.0 

Blood transfusion in entire sample 

Elective CD 

SVD AVD Nonelective 

CD 

 0.07% 0.11% 0.12% 0.37% 

Elective CD 

Uncomplicated SVD (ref grp) 

Blood transfusion in subset of uncomplicated deliveries 

0.07% 0.06% 

Koroukian, 200469

Low/Not rated 

RR (95% CI) 1.16 

(0.41; 3.25)

1.0 
73 

transfusion through ICD-9 codes and reported these outcomes separately.39

Of all six studies, five showed a lower risk of major blood loss with planned “elective” than 

with unplanned “emergency” cesarean delivery.28,38,39,45,51 The differences were statistically 

significant in two studies (both poor).28,45 

The three moderately relevant studies that compared risk of blood transfusion differed in 

their comparison groups. One showed a nonsignificant higher absolute risk with planned 

cesarean (1.1 percent) than with unplanned cesarean (0.7 percent).38 A second reported cases of 

blood transfusions in only the planned vaginal delivery group but provided no statistical 

testing.51 The third study found a higher risk of blood transfusion with both unplanned “with trial 

of labor” and planned “without trial of labor” primary cesareans than with spontaneous vaginal 

deliveries. The higher risk was statistically significant only in the unplanned “with trial of labor” 

group.39

In the only study that did not report a lower rate of blood loss associated with elective 

cesarean birth,50 the rates of blood transfusion were similar between elective cesarean and 

planned vaginal delivery: 1.2 percent vs. 1.1 percent, respectively. 

Of the four studies of low relevance, three defined significant blood loss as requiring a blood 

transfusion;64,67,69 planned “elective” cesarean was associated with a lower rate of blood 

transfusion than that for planned vaginal delivery. Of these three studies, two compared planned 

“elective” cesarean with spontaneous vaginal, assisted vaginal, and unplanned “nonelective” 

cesarean or cesarean in labor.64,69 In both studies, assisted vaginal delivery and nonelective or 

labored cesarean had the highest rates of blood transfusions. These results were statistically 

significant in only one study, which reported an absolute risk reduction for blood transfusion per 

1,000 deliveries of 3.7 for nonelective cesarean, 1.2 for assisted vaginal, 1.1 for spontaneous 

vaginal, and 0.7 for elective cesarean delivery.69 Other analyses comparing elective cesarean 

sections with uncomplicated vaginal deliveries suggested a significantly lower rate of postpartum 

hemorrhage among elective cesarean deliveries but no statistical difference in the rate of blood 

transfusion.69 

Hysterectomy. Three studies reported data on hysterectomy for postpartum 

hemorrhage.20,38,68 One was the Breech Trial article published in 2000 and rated of fair quality.20

Another study that compared planned “elective” with unplanned “emergency” was moderately 

relevant and of fair quality;38 the other was of low relevance.68

The Breech Trial did not report any hysterectomies.20 The moderately relevant study reported 

no significant differences in the rate of hysterectomy between elective cesarean (0.3%, 1 of 293 

deliveries) and emergency cesarean (0.2%, 1 of 635 deliveries).38 The low relevance study 

reported a single case of hysterectomy for hemorrhage in the elective cesarean delivery group.68

Thromboembolism. Eight studies compared thromboembolism by route of delivery (Table 

20). Of these studies, two were in the T relevance category (fair quality).20,84 Two were 

moderately relevant studies, one of fair quality39 and one of poor quality.28 The remaining four 

studies were of low relevance.67-70 

The studies universally lacked consistency in how they defined thromboembolism. 

Definitions varied from a composite outcome of maternal morbidity that included 

“thrombophlebitis” with other measures such as UTI, endometritis, and wound infection84 to a 

single thromboembolic event measure that included obstetrical air embolism, amniotic fluid 

embolism, obstetrical blood clot embolism, other pulmonary embolism, cerebrovascular 

disorders, deep phlebothrombosis, and postpartum or unspecified venous thrombosis.69 Two 
74

Table 20. Thromboembolism Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups Hannah et al., 2000 Planned CD Planned VD 20

T/Fair Deep vein 

thrombophlebitis or pulmonary embolism 

0 0 

Planned CD (ref grp) 

Planned VD 

Combined measure of maternal morbidity (includes febrile morbidity, endometritis, wound infection, UTI and thrombophlebitis) 

31.0% 17.8% 

Leiberman et al., 199584

T/Fair 

OR (95% CI) 1.0 0.48 

(0.25; 0.89) 

Primary Prelabor CD 

Repeat Prelabor CD 

Primary Labored CD 

Repeat Labored CD 

SVD (ref grp) 

Operative 

Deep vein thrombosis 0.2% 0 0.3% 0.1% 0.1% 0.04% 

Burrows et al., 200439

Moderate/Fair 

Adj OR (95% CI) 2.3 (0.3; 17.8) NA 3.9 

(1.7; 8.9) 

1.9 (0.2; 14.2) 

1.0 0.5 

(0.1; 2.2) 

Primary elective CD 

Primary acute CD 

Secondary acute CD 

Thrombosis 0.6% 1.0% 0.3% 

van Ham et al., 199728

Moderate/Poor 

Thrombophlebitis 1.1% 1.8% 3.8% 

Golfier et al., 2001 Elective CD Attemped VD 67

Low/Not rated Deep vein thrombosis 0.1% 0.7% 

Irion et al., 1998 Elective CD Attemped VD 68

Low/Not rated Pulmonary embolism 0.3% 0 

Adj, adjusted; AVD, assisted vaginal delivery; CD, cesarean delivery; CI, confidence interval; NA, not applicable; NR, not reported; OR, odds ratio; rrelative risk; SVD, spontaneous vaginal delivery; VD, vaginal delivery. 
75

Table 20. Thromboembolism (continued) Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Elective CD SVD AVD Nonelective 

CD 

Thrombembolic events in entire sample 

0.19% 0.07% 0.11% 0.45% Elective CD Uncomplicated 

SVD (ref grp) 

Thrombembolic events in subset with uncomplicated deliveries 

0.19% 0.06% 

Koroukian, 200469

Low/Not rated 

 RR (95% CI) 3.45 

(1.70; 7.00) 

1.0 

Elective CD VD 

(ref grp) 

Emergency CD (ref grp) 

Thromboembolism 0.1% 0 0.1% 

Krebs and LanhoffRoos, 200370

Low/Not rated 

 RR vs 

vaginal: 1.31 (0.95; 1.32); RR vs. emergency cesarean: 0.80 (0.38; 1.26) 
76 

studies defined thromboembolic measures as deep venous thrombosis,39,67 whereas another 

defined it as pulmonary embolism.68 Yet another study assigned separate categories according to 

severity, defining “thrombosis” as a major morbidity outcome and “thrombophlebitis” as a minor 

morbidity outcome.28 

From the Breech Trial, Hannah et al. reported no cases of either deep vein thrombophlebitis 

or pulmonary embolism in either the planned vaginal delivery or planned cesarean delivery 

group.20 Leiberman et al. had used the composite outcome defined above; contrary to the 

randomized breech trial, this group reported that this outcome was significantly higher in the 

planned cesarean groups than in the planned vaginal group.84

One moderately relevant study with a vaginal delivery group found that the risk of deep vein 

thrombosis was higher among both planned “without trial of labor” and “unplanned “with trial of 

labor” primary cesarean deliveries; the risk was significant only for the unplanned “with trial of 

labor” cesarean group.39 The other compared outcomes among planned “elective” and unplanned 

“acute” cesarean deliveries but did not contain a vaginal comparison group (a major limitation).28

Thrombosis was part of a composite outcome of postoperative complications; that measure was 

significantly lower in the planned cesareans than in the unplanned cesareans (no statistical 

testing provided). 

Of the four low relevance studies, three showed neither a significant difference nor a 

consistent direction of effect between planned “elective” cesarean and either vaginal delivery70or 

planned vaginal delivery.67,68 The remaining study, from the administrative data set noted above, 

reported the incidence of thromboembolic events in ascending order per 1,000 deliveries: 0.7, 

spontaneous vaginal deliveries; 1.1, assisted vaginal deliveries; 1.9, planned “elective” cesarean 

deliveries; and 4.5, unplanned “non-elective” cesarean deliveries. The rate of thromboembolic 

events was statistically higher in unplanned cesarean than in planned cesarean deliveries.69

Surgical complications. The studies in this group are weighted toward surgical 

complications associated with cesarean deliveries. Our search parameters (reviewed by the 

Technical Expert Panel and the SOS Conference panel chair) were not designed to capture 

perineal and vaginal trauma associated with vaginal delivery. Therefore, we cannot provide a 

comprehensive assessment of the risks for perineal and vaginal trauma. 

Of the 10 studies that compared surgical complications by mode of delivery, 1 was the 

Breech Trial,20 3 were moderately relevant,28,38,51 and 6 were of low relevance64,67-70,75 (Table 

21). 

Similar to the practices seen for other maternal outcomes, we found some studies that defined 

surgical complications as a single composite measure of injury,64,68,69 and others that reported 

specific measures of complications such as bladder or bowel injury.20,28,38,51,67,70,75

The Breech Trial (fair quality) found similar rates of genital tract injury (vertical uterine 

incision, serious extension to transverse uterine incision, cervical laceration extending to lower 

uterine segment, or vulvar/perineal hematoma requiring evacuation) among the planned vaginal 

group (0.6%) and the planned cesarean group (0.6%).20 Neither group experienced genital tract 

fistulae, bowel obstructions, or injury to bladder, ureter, or bowel. 

Two of the three moderately relevant studies were of fair quality38,51 and one was of poor 

quality.28 These three studies varied widely in their choice of comparison groups. The only 

moderately relevant study that compared planned “elective” cesarean with planned vaginal 

delivery “intended vaginal birth” focused primarily on perineal surgical injury.51 In this study, 

33.4 percent of women in the planned vaginal delivery group experienced labial, vaginal, or first 

or second degree perineal lacerations; another 20.2 percent had an episiotomy; and 0.2 percent 
77 

Table 21. Surgical complications 

Author, Year 

Relevance/ 

Quality Rating Measure Outcomes for Comparison Groups 

Statistical Test 

Results 

Planned 

CD 

Planned 

VD 

 

Genital tract injury: 

vertical uterine incision, 

serious extension to 

transverse uterine 

incision, cervical 

laceration extending to 

lower uterine segment, 

vulvar/perineal hematoma 

requiring evacuation. 

0.6% 0.6% P = 1.0 

Hannah et al., 

200020

T/Fair 

Note: There were no 

genital tract fistula, bowel 

obstructions, injury to 

bladder, ureter or bowel. 

 

 Primary 

Elective CD

Primary 

Acute CD

Secondary 

Acute CD 

 

Bladder lesion 1.3% 0.4% 0.9% NS 

Lesion of the uterine 

artery/ligamentum 

latum/bowels 

0.4% 0.6% 0.6% NS 

van Ham et al. 

199728 

Moderate/Poor 

Cervical/vaginal lesions 0 0.2% 0.6% NS 

 Elective CD Emergency 

CD 

 

Cervical 1.4% 4.6% P < 0.05 

Corporal 0.3% 0.3% NS 

Vaginal 0 1.7% < 0.05 

Bladder 0 0.8% NS 

Bowel 0 0 NS 

Bergholt et al., 

200338

Moderate/Fair 

All 1.7% 6.8% P < 0.05 

 Elective CD Intended 

Vaginal 

 

Perineal laceration III/IV 0 0.2% NR 

Labial, vaginal, perineal 

laceration I/II 

0 33.4% NR 

Schindl et al., 

200351

Moderate/Fair 

Episiotomy 0 20.2% NR 

AVD, assisted vaginal delivery; CD, cesarean delivery; CI, confidence interval; NS, not significant; ref grp, reference group; RR, 

relative risk; SVD, spontaneous vaginal delivery; VD, vaginal delivery. 
78 

Table 21. Surgical complications (continued) 

Author, Year 

Relevance/ 

Quality Rating Measure Outcomes for Comparison Groups 

Statistical Test 

Results 

 CD Without 

Labor 

SVD 

(ref grp) 

AVD 

(ref grp) 

CD in 

Labor 

(ref grp) 

 

Intraoperative trauma 

(Laceration of uterine 

artery, bladder, bowel or 

ureter or severe 

extension of uterine 

incision) 

0.1% 0.1% 0.1% 2.6% Only CD in labor is 

significantly different 

from CD without 

labor 

Allen et al., 

200364

Low/Not rated 

 RR vs SVD: 

2.2 (0.3; 

17.5); RR 

vs AVD: 

1.1(0.1; 

9.3); RR vs 

CD in labor: 

0.1 (0.01; 

0.4) 

 

 Elective CD Planned 

VD 

 

Intestinal 0.1% 0 NR 

Wall complications 

(abscess/hematoma) 

2.5% 4.1% NR 

Golfier et al., 

200167

Low/Not rated 

Bladder 0 0.7% NR 

Elective CD 

(ref grp) 

Trial of 

Vaginal 

Delivery 

 

Surgical complications 

(bladder or other organ 

injury) 

0.3% 0.8% 

Irion et al., 

199868

Low/Not rated 

RR (95% CI) 1.0 2.49 

(0.26; 

23.86) 

 
79 

Table 21. Surgical complications (continued) 

Author, Year 

Relevance/ 

Quality Rating Measure Outcomes for Comparison Groups 

Statistical Test 

Results 

 Elective CD SVD AVD Nonelective CD  

Obstetrical Trauma: 

Laceration of cervix, high 

vagical laceration, other 

injury to pelvic organs, 

damage to pelvic joints 

and ligaments, other 

specified obstetrical 

trauma, unspecified 

obstetrical trauma in 

entire sample 

1.09% 7.35% 7.05% 0.57% 

Elective CD 

(ref grp) 

Uncomplicated 

SVD 

 

Obstetrical Trauma: 

Laceration of cervix, high 

vaginal laceration, other 

injury to pelvic organs, 

damage to pelvic joints 

and ligaments, other 

specified obstetrical 

trauma, unspecified 

obstetrical trauma in 

subset of uncomplicated 

deliveries 

1.09% 6.94% Significantly different

RR (95% CI) 1.0 0.16 

(0.16; 

0.20) 

 

 Elective CD SVD AVD Nonelective CD 

 

Obstetrical surgical 

wound complications: 

includes hematoma, 

hemorrhage, or infection 

of cesarean or perineal 

wound in entire sample 

3.0% 0.25% 0.49% 3.61% 

Elective CD 

(ref grp) 

Uncomplicated 

SVD 

 

Obstetrical surgical 

wound complications: 

includes hematoma, 

hemorrhage, or infection 

of cesarean or perineal 

wound in subset of 

uncomplicated deliveries 

3.0% 0.25% Significantly different

Koroukian 

200469

Low/Not rated 

RR (95% CI) 1.0 12.5 

(10.00; 

15.63) 

 
80 

Table 21. Surgical complications (continued) 

Author, Year 

Relevance/ 

Quality Rating Measure Outcomes for Comparison Groups 

Statistical Test 

Results 

 Elective CD VD Emergency 

CD 

(ref grp) 

 

Bladder injury 0.1%, 0 0.20% 

Krebs and 

Langhoff-Roos, 

200370

Low/Not rated 

RR (95% CI) 0.58 (0.23; 

1.02) 

NA 1.0 

 Scheduled 

CD 

Urgent 

CD 

Emergent 

CD 

Phipps et al., 

200575

Low/Not rated 

 

Bladder injury In this case control study, women 

with a bladder injury were statistically 

more likely to have undergone an 

emergent or urgent cesarean than an 

elective cesarean 

 

experienced a third or fourth degree laceration; as expected, no such complications occurred in 

the elective cesarean group. No abdominal surgical complications were reported for either the 

planned cesarean or the planned vaginal delivery group. 

The two remaining moderately relevant studies were limited to comparisons of outcomes 

among cesarean deliveries.28,38 One suggested a higher rate of surgical complications among 

women with unplanned (“emergency” or “labored”) cesarean delivery than among women with 

planned “elective” or “unlabored” cesarean;38 the other did not.28

Three of the six studies of low relevance to CDMR compared surgical complications 

between planned “elective” cesarean and planned vaginal delivery.64,67,68 All three reported 

slightly higher rates of surgical complications in the planned vaginal delivery group although 

these were not statistically significant. 

Three other low relevance studies compared groups based on actual routes of delivery.69,70,75

One study using composite outcomes reported a higher rate of obstetrical (pelvic) trauma in 

spontaneous vaginal delivery (7.35 percent) and assisted vaginal delivery (7.05 percent) than in 

planned “elective” cesarean (1.09 percent) or unplanned “non-elective” cesarean delivery (0.57 

percent). A subanalysis comparing planned cesarean to uncomplicated spontaneous vaginal 

delivery yielded similar findings. Two studies found that the rate of bladder injury was lower in 

planned “elective” cesarean than in unplanned “emergency”70or “emergent” or “urgent” cesarean 

deliveries.75

Breastfeeding. Two articles (rated poor) from the Breech Trial18,83 provided evidence on 

initiation and duration of breastfeeding for women experiencing planned vaginal or planned 

cesarean delivery. The percentages of women initiating breastfeeding “within a few hours” were 

77.6 percent for planned vaginal and 73.3 percent for planned cesarean; the difference bordered 

on statistical significance (P = 0.05).18 The percentages of women breastfeeding at 3 months and 

at 2 years were nearly identical.18,83

Postpartum pain. Four articles comprising three studies addressed postpartum pain.18,43,51,83

Two articles reported later analyses for the Breech Trial (“T,” both rated poor).18,83 The other 

two were moderately relevant, one of fair quality51 and one of poor quality.43 

The Breech Trial examined numerous pain outcomes at 3 months postpartum: any pain, 

location of pain, severity of pain, and use of analgesics during the past 24 hours and found no 
81 

difference in the incidence of pain, severity of pain, or use of analgesics.18 As expected, at 3 

months postpartum women in the planned vaginal delivery group were significantly more likely 

to report pain in the “bottom or genital area,” and women in the planned cesarean delivery group 

were more likely to report pain on the “outside of the abdomen” or “deep inside the abdomen.”18

These difference were no longer significant at 2 years postpartum.83 

Of the two moderately relevant studies, the fair quality study reported maternal pain using a 

visual analog scale (VAS) ranging from 1 (no pain) to 10 (most severe pain),51 that they 

administered at 3 days and at 4 months postpartum. At the 3-day postpartum evaluation, patients 

were also asked to rate retrospectively their pain at delivery. The authors presented results only 

in graphs, with no numerical outcomes for the VAS. They depicted a significantly higher median 

pain level during birth for the vaginal or assisted vaginal delivery groups than for the cesarean 

group. However, the authors commented that “peridural” anesthesia was offered to every woman 

but that only 11 percent chose it.51 At 4 months postpartum, they observed no significant 

difference in “momentary birth-related pain” among the groups. The investigators presented data 

for a group of women who underwent “cesarean on demand” for reasons including anxiety in 

nulliparous women, previous traumatic birth, coordination problems, and safety considerations. 

However, they did not report their data in a way that permitted us to abstract usable information, 

comment on laboring status in this group, or note specific analyses on this subset of patients. 

The other moderate relevant (poor quality) study used a one-item Pain Intensity Scale within 

one week of delivery.43 This study found no difference in mean pain intensity scores among 

unplanned cesareans, planned cesareans, and vaginal delivery. 

Psychological outcomes: postpartum depression. Four articles comprising two studies 

dealt with postpartum depression associated with mode of delivery. The Breech Trial (rated “T”) 

contributed one article of fair quality20 and two of poor quality;18,83 the fourth study was of low 

relevance to CDMR.66 

The Breech Trial report (rated poor) defined depression as a score of more than 12 on the 

validated Edinburgh Postnatal Depression Scale.18 The low relevance study used the validated 

Center for Epidemiologic Studies Depression Scale. Neither study reported significant 

differences at any time point.18,20,83

Psychological outcomes: other. Seven articles representing six studies reported on a variety 

of psychological outcomes other than depression; these studies used outcomes, measures, 

instruments, and time points for outcome measurement that have little in common. The two 

articles from the Breech Trial are rated “T” and are of poor quality,18,83 two are moderately 

relevant,43,51 and three are of low relevance.66,76,78 In general terms, women who experienced an 

unplanned cesarean birth or an instrumental vaginal delivery were more likely to experience 

adverse psychological outcomes than were women who underwent either a spontaneous vaginal 

or a planned cesarean birth. 

The Breech Trial article reporting 3-month outcomes (rated poor) found that women in the 

planned cesarean delivery group were more likely than those in the planned vaginal birth group 

to indicate that they “liked being able to schedule their delivery” and “liked that childbirth 

experience was not very painful.”18 Women in the planned vaginal birth group were more likely 

than those in the planned cesarean group to indicate that they liked that the delivery was natural, 

liked actively participating in the birth, and liked that recovering from the childbirth experience 

was not difficult. These authors reported no differences between planned vaginal and planned 

cesarean births in women feeling reassured about their own health. In general, despite the 

differences in likes and dislikes, the planned vaginal and planned cesarean did not differ as to 
82 

whether women would “participate in the trial if they had to do it all over again” (p. 1828).18 The 

follow-up study reporting outcomes at 2 years (rated poor) found no difference in the experience 

of being a mother, the relationship with husband or partner, or the relationship with husband or 

partner compared with that before the child was born.83

Of the two moderately relevant studies, one fair-rated study51 used the Zerrsen test93 for 

quantifying momentary personal feelings and a modified version of a birth experience 

questionnaire by Salmon and Drew.94

These investigators reported no differences in momentary personal feelings before birth. At 3 

days postpartum, women in the assisted vaginal delivery and emergency cesarean delivery 

groups reported strong negative feelings. These differences dissipated by 4 months postpartum. 

In contrast, women planning a cesarean delivery without medical indications had an expectation 

of a more pleasant birth than did women planning a vaginal delivery or a cesarean for medical 

indications. Of the 44 cesareans performed “on demand,” 20 (45 percent) were for women who 

had had a previous traumatic birth. At 3 days postpartum, the most positive birth experiences 

were reported by the group with planned cesarean without medical indications, followed in 

descending order by those with cesarean for medical indications, vaginal delivery, emergency 

cesarean, and assisted vaginal delivery. Results were similar at 4 months postpartum.The other 

moderately relevant (poor) study, using the Perception of Birth Scale95 found no differences 

between the vaginal and planned cesarean delivery groups or the planned and unplanned 

cesarean groups.43 However, women in the unplanned cesarean group had a more negative 

perception of the birth experience than did women in the vaginal group. 

One low relevance study compared adaptive and ineffective responses during three time 

periods (1973–1980, 1981–1982, and 1989–1990). In the first and the last time periods, women 

in the unplanned cesarean group had a significantly lower percentage of adaptive responses and a 

higher percentage of ineffective responses than women who had a planned cesarean delivery. 

This finding was not statistically significant in the second time period.76 A second study of low 

relevance appraised birth experience, neuroticism, and self-esteem.66 None of these outcomes 

differed at 4 or 12 months among planned cesarean, unplanned cesarean, and vaginal delivery 

groups. A third study of low relevance to CDMR reported that women in the emergency cesarean 

and the assisted vaginal delivery groups had the most negative cognitions and emotions 

regarding the delivery overall compared with elective cesarean and normal vaginal delivery.78

Maternal length of stay. Four studies reported on length of stay; one was the Breech Trial 

(fair quality)20 and three were of moderate relevance (poor quality)28,43,50 (Table 22). The studies 

varied in comparison groups. Two investigated outcomes by intended route of delivery: planned 

vaginal vs. planned cesarean delivery,20,50 and both reported a significantly higher median length 

of stay in the planned cesarean group. A third study reported length of stay separately for 

“planned” and “unplanned” cesarean deliveries and found significantly higher length of hospital 

stay among “unplanned” and “planned” cesarean compared with vaginal deliveries.43 The fourth 

study limited outcomes to cesarean deliveries and found that the length of stay following a 

planned “elective” cesarean was shorter than among unplanned “acute” deliveries.28 However, 

the authors provided no statistical test results. The results were consistent in demonstrating a 

longer hospital stay following planned or unplanned cesarean than following vaginal delivery. 
83 

Table 22. Maternal length of stay 

Author, Year 

Relevance/Quality 

Rating Measure Outcomes for Comparison Groups 

Statistical 

Test Results

Hannah et al., 2000 Planned CD Planned VD 20

T/Fair Median 

length of 

hospital 

stay in days 

4 2.8 P<0.0001 

Fawcett et al., Planned CD Unplanned CD VD 

Moderate/Poor Mean length 

of hospital 

stay in days 

(range) 

4.9 (3-12) 4.8 (3-10) 2.5 (1-14) P<0.05 

Sanchez-Ramos et al., Elective CD Attempted VD 

200150

Moderate/Poor 

Mean length 

length of 

hospital 

stay in days 

(range) 

4 (4,4) 2 (2,3) P=0.0001 

Primary 

Elective CD 

Primary acute 

CD 

Secondary 

Acute CD 

van Ham et al., 199728

Moderate/Poor 

Mean length 

of stay (SD) 

7.2 (2.4) 7.8 (3.1) 7.6 (1.9) NS, details 

NR 

CD, cesarean delivery; CI, confidence interval; NR, not reported; NS, not significant; SD, standard deviation; VD, vaginal 

delivery. 

Urinary incontinence. Nine articles comprising eight studies reported on urinary 

incontinence associated with mode of delivery (Table 23). Two articles were from the Breech 

Trial.18,83 Two were moderately relevant,41,44 and five were of low relevance.70,73,74,79,82

The Breech Trial was designed primarily to focus on neonatal outcomes following planned 

vaginal vs. planned cesarean for breech. As such, it has significant limitations to outcomes 

related to pelvic floor disorders since the study included multiparous women, allowed 

randomization in labor, suffered from a high degree of crossover, was performed in 26 countries, 

used nonvalidated instruments in multiple languages, and more than 50 percent of participants 

required assistance in completing the questionnaires. The 2002 Breech Trial article (poor quality) 

suggested that planned cesarean delivery significantly reduced the risk of urinary incontinence 

compared with planned vaginal delivery at 3 months, with a relative risk of 0.62 (95% CI, 0.41-

0.93).18 In the 2-year postpartum article (poor quality), the rates of urinary incontinence 

remained higher in the planned vaginal group than in the planned cesarean group, but the 

difference was no longer statistically significant.83 The rates of urinary incontinence were about 

three times as high at 2 years in both groups as at 3 months postpartum. The authors suggested 

that a change in the reference period in the outcome measurement may explain this difference. At 

3 months, women were asked about urinary incontinence in the past 7 days; by contrast, at 2 

years, women were queried about the past 3 to 6 months.83 

The two moderately relevant studies (both fair) were prospective cohort studies; they 

investigated symptoms of stress urinary incontinence according to actual mode of delivery and 

adjusted for preexisting urinary incontinence. One study found that planned “elective” cesareans 

performed before labor and cesareans performed during the first stage of labor appeared to be 

significantly protective against urinary incontinence compared with spontaneous vaginal 
84

Table 23. Urinary incontinence Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Controls for 

Previous 

Incontinence 

Time 

Period 

Planned CD 

Planned VD 

SUI 4.50% 7.30% No 3 mos PP 

Hannah et al., 200218

T/ Poor 

OR (95% CI) 0.62 

(0.41; 0.93)

Planned CD 

Planned VD 

SUI 17.80% 21.80% No 2 yrs PP 

Hannah et al., 200483

T/Poor 

 OR (95% CI) 0.81 

(0.63; 1.06)

Elective CD 

SVD Forceps All CD 

(ref grp) 

CD in 2nd Stage of Labor 

SUI 4.00% 23.00% 35.00% 8.00% 5.00% Yes 6 wks PP RR (95% CI) 2.8 

(1.5; 5.3) 

4.3 (2.2; 8.2) 

 5.00% 22.00% 33.00% 10.00% 3.00% Yes 6 mos PP 

Farrell et al., 200141

Moderate/Fair 

 RR (95% CI) 2.1 

(1.1; 3.7) 

3.1 (1.7; 5.9) 

Elective CD 

SVD (ref grp) 

CD for Obstructed Labor 

SUI 3.40% 10.30% 12% Yes 1 yr PP 

Groutz et al., 200444

Moderate/Fair 

P = 0.02 P = 0.7

CD, cesarean delivery; CI, confidence interval, NR, not reported: NS, not signficant; OR, odds ratio; PP, postpartum; ref grp, reference group; RR, rel

vaginal delivery; VD, vaginal delivery. 
85

Table 23. Urinary incontinence (continued) Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Controls for 

Previous 

Incontinence 

Time 

Period 

Elective CD 

VD Emergency 

CD 

Krebs et al., 200370Low/Not rated Hospitalization 

for either urinary incontinence or vaginal descensus 

0.60% 0.60% 0.5% as 

reported in article, 1.4% as calculated by authors of this report 

 No NR 

Planned CD 

VD Emergency 

CD 

Mason et al., 1999 Forceps Ventouse 73

Low/Not rated SUI 15.90% 34.90% 17.10% 32.10% 40.10% No NR 

Persson et al., 200074

Low/Not rated 

Surgery for urinary incontinence 

 
86

Table 23. Urinary incontinence (continued) Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Controls for 

Previous 

Incontinence 

Time 

Period 

 Elective 

CD 

SVD (ref grp) 

Instrumental VD Emer- gency CD

SUI for primiparous women 

0 19.9% 21.8% 11.5% No 1 yr PP 

OR (95% CI) NA 1.0 1.1 

(0.8; 1.6) 

0.6 (0.3; 1.0) 

SUI for multiparous women 

12.9% 25.4% 38.5% 12.7% No 1 yr PP 

Schytt et al., 200479

Low/Not rated 

OR (95% CI) 0.5 

(0.3; 0.9) 

1.0 1.5 

(1.0; 2.3) 

0.5 (0.3; 1.0) 
87

Table 23. Urinary incontinence (continued) Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Controls for 

Previous 

Incontinence 

Time 

Period 

Elective CD 

SVD (ref grp) 

Forceps CD in 1st 

Stage of Labor 

CD in 2nd Stage of Labor 

SUI among all women with no previous incontinence 

8.90% 24.40% 27.00% 12.00% 7.70% Yes 3 mos PP 

OR (95% CI) 0.3 

(0.1; 0.6) 

 1.3 

(0.8; 2.3) 

NR NR 

Elective CD 

SVD (ref grp) 

Forceps CD in 1st 

Stage of Labor 

CD in 2nd Stage of Labor 

SUI in primaparous subset 

0.00% 24.50% 25.20% 6.10% 8.30% NR 3 mos PP 

Wilson et al., 199682

Low/ Not rated 

OR (95% CI) 0.2 

(0.0; 0.6) 

 1.0 

(0.5; 1.9) 

NR NR 
88 

deliveries.41 Overall, the risk of postpartum urinary incontinence at 6 weeks was as follows: 

forceps, 35 percent; spontaneous vaginal delivery, 23 percent; cesarean in labor, 9 percent; and 

elective cesarean, 4 percent. In the other moderately relevant study, the prevalence of stress 

urinary incontinence 1 year postpartum was not significantly different among primiparous 

women who underwent a spontaneous vaginal delivery (10.3 percent) from the rate among 

women who had a cesarean delivery for obstructed labor (12.0 percent), but was significantly 

lower for women who underwent an elective cesarean (3.4 percent) (P = 0.02).44 

Three of the five low relevance studies compared symptoms of stress urinary incontinence by 

actual route of delivery. Two concluded that cesarean delivery had a protective effect relative to 

vaginal delivery.73,82 The third showed lower rates of stress urinary incontinence for women who 

had a cesarean delivery compared with women who had a vaginal delivery; these results were 

statistically significant for primiparous women only.79 

The remaining two studies of low relevance to CDMR linked surgical administrative 

databases and birth registries to assess the association between route of delivery and surgery for 

stress urinary incontinence74or hospitalization for either stress incontinence or “vaginal 

descensus.”70 They yielded conflicting information about urinary incontinence issues. 

Anorectal function. Of the seven articles comprising six studies (Table 24) that reported on 

anal incontinence associated with mode of delivery, two were from the Breech Trial.18,83 Two 

others were moderately relevant,42,46 and three were of low relevance.70-72

Six articles assessed symptoms of anal incontinence.18,42,46,71,72,83 The seventh, a populationbased study, linked an administrative database and birth registry of primiparous women who 

delivered singleton breech infants at term to assess the association between route of delivery and 

anal sphincter rupture over a period of up to 23 years.70

Of the six studies reporting on symptoms, all but one included flatal incontinence in addition 

to involuntary loss of solid or liquid stool in their definition of anal incontinence. The remaining 

study limited its definition of anal incontinence to frank incontinence and fecal urgency.71 

Three studies assessed women for preexisting anal incontinence.42,46,71 No study used a 

validated instrument. The time period for the assessment of anal incontinence ranged from 3 

months18 to 2 years.83

The two Breech Trial reports (rated poor)18,83 used different measures at two time points; 

questions related to fecal incontinence were added after some participants had already completed 

the study. At 3 months, the authors queried participants regarding whether they had experienced 

fecal incontinence in the past 7 days.18 At 2 years, however, the participants were asked about 

fecal incontinence over the previous 3 to 6 months.83 Neither article reported a significant 

difference in rates of fecal incontinence between planned vaginal and planned cesarean. 

The two moderately relevant studies were of fair quality.42,46 One reported new onset 

symptoms of anal incontinence in 3 of 80 women (3.8 percent) in the planned “elective” cesarean 

group, 6 of 104 women (5.8 percent) in the unplanned “emergency” cesarean group, and 8 of 100 

(8 percent) in the vaginal delivery group.46 This progression suggested an increasing risk of fecal 

incontinence with emergency cesarean and vaginal delivery compared with elective cesarean. 

However, the authors limited their statistical comparison to overall cesarean (elective and 

emergency) against vaginal delivery (P = 0.427). They also noted a higher risk of severe fecal 

incontinence after elective cesarean, 2 of 80 women (2.5 percent), than after emergency 

cesarean, 1 of 104 women (0.96 percent); the latter rate was similar to that for vaginal delivery, 1 

of 100 women (1 percent). The authors suggested that elective cesarean is not always protective 
89

Table 24. Anorectal function Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Controls for Previous Incontinence 

Planned CD Planned VD

Fecal incontinence 

0.8% 1.5% No 

Hannah et al., 200218

T/Poor 

 RR (95% CI) 0.54 

(0.18-1.62) 

1.0 

Planned CD Planned VD

Fecal incontinence 

2.4% 2.2% No 

Hannah et al., 200483

T/Poor 

RR (95% CI) 1.10 

(0.47-2.58) 

1.0 

Elective CD SVD Forceps All CD (ref 

grp) 

CD in 2nd Stage of Labor 

Flatal incontinence 

31% 16% 34% 19%* 17% Yes 

RR (95% CI) 0.8 

(0.5; 1.5) 

1.8 (1.0; 3.1) 

Flatal incontinence 

0% 17% 44% 18% 21% Yes 

RR (95% CI) 1.0 

(0.6; 1.8) 

2.5 (1.4; 4.5) 

Fecal incontinence 

4% 4% 9% 2% 2% Yes 

Farrell et al., 200142

Moderate/Fair 

RR (95% CI) 1.7 

(0.5; 5.9) 

3.6 (1.0; 13.4) 

CD, cesarean delivery; CI, confidence interval; NR, not reported; NS, not signficant; PP, postpartum; SVD, spontaneous vaginal delivery; VD, vagina

*: Note this figure is reported as both 19% and 31% in a single table in the article; the figure of 31% appears to be a typographical error. 
90

Table 24. Anorectal function (continued) Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Controls for Previous Incontinence 

Elective CD Emergency 

CD 

VD (Noninstrumental) 

New anal incontinence 

3.8% 5.8% 8% Yes 

Lal et al., 200346

Moderate/Fair 

Severe fecal incontinence 

2.5% 0 1% Yes 

Elective CD VD Emergency 

CD 

Krebs and Langhoff-Roos, 200370

Low/Not rated Anal sphincter rupture 0 1.7% 0 No 

Elective CD SVD 

(ref grp) 

Forceps Vaccum Breech Emergency 

CD 

Fecal incontinence in all women 

7.3% 9.6% 13.6% 10.3% 13.8% 7.5% No 

Fecal incontinence in primiparous subset 

5.4% 8.8% 13.9% 9.3% 12.0% 4.8% No 

 Multiple regression of primiparous women combined emergency and elective 

cesareans and showed that cesareans overall had a lower risk of fecal incontinence than did spontaneous vaginal deliveries (OR = 0.58; 95% CI, 0.35-0.97) 

No 

MacArthur et al., 200172

Low/Not rated 

 Fecal incontinence in multiparous subset 

8.0% 10.0% 12.2% 14.3% 15.0% 12.3% No 
91

Table 24. Anorectal function (continued) Author, Year Relevance/Quality Rating Measure Outcomes for Comparison Groups 

Controls for Previous Incontinence 

Elective CD SVD 

(ref grp) 

Forceps Vaccum Emergency 

CD 

Fecal incontinence in all women 

0 3.2% 7.2% 22.2% 5.3% Yes 

 NS 

significant “because of small numbers,” 

P = 0.027 P = 0.002 NR Yes 

Fecal incontinence in primiparous subset 

0 2.6% 5.8% 21.4% 8.5% Yes 

MacArthur et al., 199771

Low/Not rated 

Fecal incontinence in multiparous subset 

0 3.4% 12.5% 25.0% 1.9% Yes 
92 

and that symptoms of fecal incontinence associated with elective delivery can be severe. 

However, these results need to be interpreted with caution given the low incidence rates overall. 

The other moderately relevant study reported a significantly lower rate of flatal incontinence 

at 6 months in the planned “elective” cesarean group (0 percent) than in the unplanned “in labor” 

cesareans (21 percent).42 The authors of the study noted that the risk of flatal incontinence was 

higher with forceps-assisted delivery than with spontaneous vaginal delivery and that the risk of 

both flatal and fecal incontinence was higher in both groups than in all cesarean deliveries. 

Of the three low relevance studies, one reported that primiparous women had no cases of anal 

incontinence in the elective cesarean group (0 of 13 women).71 For the other modes of delivery, 

the rates of anal incontinence in descending order were as follows: vacuum delivery, 3 of 14 

women (21.4 percent); emergency cesarean, 5 of 59 women (8.5 percent); forceps delivery, 5 of 

86 women (5.8 percent); and spontaneous vaginal delivery, 5 of 189 women (2.6 percent). 

Similarly, among multiparous women, no case of anal incontinence occurred in the elective 

cesarean group (0 of 48 women). The overall rates of fecal incontinence in descending order 

were as follows: vacuum delivery, 1 of 4 women (25.0 percent); forceps delivery, 3 of 24 women 

(12.5 percent); spontaneous vaginal delivery, 13 of 379 women (3.4 percent); and emergency 

cesarean, 1 of 54 women (1.9 percent). The authors reported no statistically significant difference 

among groups and attribute this to small numbers. The authors performed logistical regression 

modeling and found that both vacuum and forceps were statistically associated with anal 

incontinence, P = 0.002 and P = 0.027, respectively. 

Another low relevance study was a prospective questionnaire study comparing symptoms 

and actual route of delivery.72 Cesareans overall had a lower risk of fecal incontinence than did 

spontaneous vaginal deliveries (OR = 0.58; 95% CI, 0.35-0.97). This study also found a higher 

risk of fecal incontinence associated with forceps deliveries than with spontaneous vaginal 

delivery (OR = 1.94; 95% CI, 1.30-2.89). 

The other low relevance study from the administrative database reported no case of anal 

sphincter rupture in either the elective (n = 7,503) or emergency cesarean groups (n = 5,575).70

They did report, however, 41 of 2,363 cases (1.7 percent) in the vaginal delivery group. No 

group had any hospitalizations for either anal incontinence or fistula. 

Pelvic organ prolapse. One low relevance study that examined pelvic organ prolapse 

associated with various actual modes of delivery, using an administrative data set compared 

hospitalizations for either vaginal descensus or urinary incontinence between 5 and 18 years after 

delivery.70 The publication appears to have a typographical error. The rate of hospitalization for 

either prolapse or urinary incontinence was reported as 42 of 7,503 (0.6%) for elective cesarean, 

13 of 2,363 (0.55%) for vaginal delivery, and 80 of 5,575 (1.4%) for emergency cesareans. 

However, the actual manuscript reports the rate of hospitalization in the emergency cesarean 

group as “80/5575 (0.5%).” The authors report that difference in hospitalization for either pelvic 

organ prolapse or urinary incontinence did not differ statistically, but they state that they are 

unsure how to interpret these results accurately. The potential error seems limited to the 

emergency cesarean group. 

Sexual function. Two articles comprising the Breech Trial,18,83 received a relevance rating of 

T, were of poor quality, and included sexual function outcomes. Sexual function was measured 

differently at three months and two years after delivery. At three months, measures included sex 

since birth and pain during sex on most recent occasion. At two years, measures included 

aparuenia, dysparuenia, the presence and extent of sexual problems and happiness with sexual 

relations. No statistically significant differences were noted at either time point for any measure. 
93 

However, we note that none of the measures was validated and the instruments were 

administered in multiple languages and with the assistance of translators. 

Maternal Outcomes Relevant to Subsequent Cesarean Deliveries 

As noted in Chapter 2, our search strategy focused on outcomes of primary cesarean 

deliveries. However, we recognize that any decision related to CDMR needs to balance the 

comprehensive risks and benefits for both mother and infant, for short- and long-term 

complications associated with first and future cesarean deliveries. The following outcomes, as 

such, are particularly relevant to subsequent cesarean deliveries. We augment the following 

discussion by summarizing or updating other systematic reviews on the following topics. 

Subsequent fertility issues. We identified a single study that examined subsequent fertility 

issues including admissions for infertility, ectopic pregnancy, and hospitalization for 

miscarriage. It study reports similar rates among elective cesarean, emergency cesarean, and 

vaginal delivery.70 The study controls for mode of delivery in the first pregnancy but not 

subsequent pregnancies and therefore does not contribute usable data to answer the question. 

Subsequent uterine rupture. We identified a single study reporting a higher rate of uterine 

rupture in emergency cesarean delivery (3/636, 0.5%) compared to “elective” cesarean delivery 

(0/294).38 This study did not include a vaginal delivery comparison group, thus limiting its 

utility. Nonetheless, this issue is of interest to the SOS conference, and we attempted to address 

it through a summary of results of the recent update32 of the AHRQ systematic review on vaginal 

birth after cesarean.96 The update noted that several large cohort studies of fair or poor quality 

investigated the incidence of uterine rupture of a cesarean scar and factors that affect the risk, but 

classification and terminology were inconsistent across the studies. Reports used two definitions: 

“asymptomatic uterine rupture of a cesarean scar” to indicate the opening of a prior incision with 

no signs or symptoms, also called uterine dehiscence; and “symptomatic uterine rupture of a 

cesarean scar” to indicate uterine separation diagnosed at laparotomy performed because of fetal 

heart rate disturbances, maternal bleeding, or other signs of maternal or neonatal consequences. 

The update found no statistically significant differences between trial of labor after cesarean and 

elective repeat cesarean delivery with regard to asymptomatic uterine rupture rates. It also 

reported two studies of fair or good quality97 that yielded a higher (but small) risk of 

symptomatic uterine rupture in women receiving a trial of labor after previous cesarean than 

among women receiving elective repeat cesarean delivery, with “an increased risk of 2.7/1,000 

deliveries”96 (page 3). 

Placenta previa. Summary of recent meta-analysis. One frequently cited repercussion of 

cesarean delivery is abnormal placentation, in particular, placenta previa in subsequent 

deliveries. For this outcome, we summarized and then updated a recent review by Faiz and 

Ananth.31 This meta-analysis examined etiology and risk factors for placenta previa by reviewing 

58 observational studies published between 1966 and 2000. These 58 studies included 32 

hospital-based retrospective cohort studies, 15 hospital-based case-control studies, 6 populationbased case-control studies, and 5 population-based retrospective cohort studies. Study 

populations ranged from 6,576 to 1,825,998 pregnancies. Placenta previa prevalence estimates 

were between 1.0 and 19.7 per 1,000 births. Faiz and Ananth derived placenta previa rates of 3.5 

to 4.6 per 1,000 pregnancies based on study type and geographic location. 

In all, 21 studies evaluated by Faiz and Ananth investigated the association between placenta 

previa and previous cesarean delivery; of these, they considered 4 to be well-designed studies. 
94 

They calculated random-effects pooled odds ratios that ranged from 1.9 (95% CI, 1.7-2.2) for 

well-designed studies to 3.5 (95% CI, 2.7-4.6) for poorly designed studies. 

Advancing maternal age and increasing parity were also associated with increased odds of 

placenta previa, with the highest risk found in women of both advanced age and advanced parity. 

As an example provided in the meta-analysis, for a woman age 40 or older, with three previous 

pregnancies, the odds ratio of placenta previa in this meta-analysis was 11.96 (95% CI, 10.80-

13.24); by contrast, for a woman 20 to 24 years of age and of parity one, the odds ratio was1.61 

(95% CI, 1.50-1.72). These associations could prove important confounders in any association 

between previous cesarean delivery and placenta previa. 

Our update of recent meta-analysis. Applying the same search methods that Faiz and Ananth 

used for their meta-analysis,31 we examined the literature on placenta previa published between 

2000 and 2005. We identified 131 articles, reviewed 34 full-text articles, and included all 13 

articles that met inclusion criteria (namely, published between March 2000 and May 2005, 

English language, observational study of placenta previa diagnosed in third trimester or at 

delivery, with evaluation of cesarean delivery as a risk factor for placenta previa). We excluded 

case reports and studies without a comparison group. We included five hospital-based casecontrol studies, four hospital-based retrospective cohort studies, two population-based 

retrospective cohort studies, and one hospital-based and one clinic-based cross-sectional study. 

As in the recent meta-analysis, our summary table (Table 25) is presented by study design. Our 

populations ranged from 272 to 370,374 and up to 740,748 deliveries; prevalence estimates for 

placenta previa ranged from 1.9 to 5.2 per 1,000 pregnancies. Using Faiz and Ananth’s quality 

scoring system for study design (1–5) and method of diagnosis of placenta previa (1–4), we 

assigned two quality scores to each study: 5 and 4 represented the best quality, respectively. We 

gave seven studies quality scores of 4 and six studies quality scores of 3 for diagnostic technique, 

taking into account how well the technique was specified. For quality of study design, six studies 

received scores of 4 or 5, five studies received scores of 3, and two studies scores of 2 (Table 

26). 

Adjusted odds ratios for placenta previa, relative to one or more prior cesarean deliveries 

ranged from 1.32 (95% CI, 1.04-1.68) to 4.7 (95% CI, 1.9-11.4). Two studies reported increased 

odds of placenta previa related to the number of previous cesareans and increased parity, as also 

demonstrated in the Faiz and Anath meta-analysis. The unadjusted odds ratio for six prior 

cesareans compared with three prior cesareans was 3.8 (95% CI, 1.9-7.4). The highest odds ratio 

reported was 8.76 (95% CI, 1.58-48.53) for women with parity 4 and four prior cesarean 

deliveries, but the confidence interval was very wide. One study demonstrated that placenta 

previa diagnosed during second trimester ultrasound was less likely to resolve in women with a 

previous cesarean than in women without a prior cesarean delivery.98 A single study of women 

with placenta previa, demonstrated a higher adjusted odds of hysterectomy in those with prior 

cesarean delivery than those without any prior cesarean.99

Subsequent stillbirth. We excluded studies of repeat cesarean delivery in accordance with 

our understanding that this systematic review was to focus on primary CDMR. Thus, our 

exclusion criteria yielded a pool of studies that is unlikely to be exhaustive for subsequent 

stillbirth. Only one study that met inclusion criteria for this systematic review also included data 

on subsequent stillbirths. It did not show a difference in rates of subsequent stillbirth among 

elective cesarean, emergency cesarean, and vaginal delivery.70 
95

Table 25. Description of studies addressing placenta previa relative to a history of previous cesarean delivery Author Study Location Study dates Study Design Data Source Study Population Size 

Effect Meas

Crude (COR) or Adjusted (AOR

or Prevalence 

Crane et al., 200099

Canada 1988-1995 

Retrospective cohort, population-based 

Nova Scotia Atlee Perinatal Database, all deliveries in Nova Scotia 

308 PPs 93,996 deliveries 

OR for hysterectomy during CD for 

COR 11.90(3.70,38.26) AOR 16.92(3.51,81.70) (Adjusted for placenta accreta, matage, antepartum bleed) 

Lydon-Rochelle et al., 2001100USA 1987-1996 

Retrospective cohort, population-based 

Washington State Birth Events Record Database from hospital discharge data 

493 PPs 95,630 subjects 

OR for PP at second birth, relative 

birth:

AOR 1.4(1.1,1.6) (Adjusted for age) 

Francois et al., 2001101

USA 1997-2000 

Retrospective cohort, hospital-based 

Good Samaritan Regional Medical Center, ICD-9 codes 

55 PPs 29,268 deliveries 

Percentage of PP deliveries with hi

9.1% 

Dashe et al., 200298

USA 1991-2000 

Retrospective cohort, hospital-based 

Ultrasound and obstetric database at Parkland Hospital 

230 PPs persisted 714 PPs diagnosed 

OR for persistent PP relative to prio

at each gestational age category: 

15-19 wks:

COR 2.6(1.2,5.4) AOR 2.3(1.1,4.9) 20-23 wks:COR 4.7(1.8,12.2) AOR 4.9(1.7,14.0) 24-27 wks:COR 5.3(1.8,15.4) AOR 4.5(1.3,14.9) 28-31 wks:COR 1.2(0.6,2.7) AOR 1.1(0.4,2.6) 32-35 wks: COR 1.5(0.6,3.6) AOR 1.8(0.7,4.9) (Adjusted for age, parity, type of PP

CD, cesarean delivery; NR, not reported, PP placenta previa; VD, vaginal delivery; USA, United States of America.
96

Table 25. Description of studies addressing placenta previa relative to a history of previous cesarean delivery (continued) Author Study Location Study Dates Study Design Data Source 

Study Population Size 

Effect Measur

Crude (COR) or Adjusted (AOR) 

or Prevalence 

Rasmussen et al., 2000102Norway 1967-1992 

Retrospective cohort, hospital- based 

Medical Birth Registry of Norway and population census 

826 PPs 370,374 subjects 740,748 deliveries 

OR for PP in second pregnancy relative 

pregnancy:COR: 1.61(1.28-2.03) AOR: 1.32(1.04-1.68) (Adjusted for age, prior placental previa

Sheiner et al., 2001101

Israel 1990-1998 

Retrospective cohort, hospital- based 

Soroka University Medical Center medical records 

298 PPs 78,524 pregnancies 

Prevalence of prior CD:

In patients with previa: 20.5% In patients without previa: 9.8% (P < 0.0OR for PP, relative to prior CD:

AOR 1.8 (1.4-2.4) (Adjusted for ethnicity, age, parity, preghypertension, infertility treatments, habiperinatal death) 

Hossain et al, 2004103

Bangladesh 2000 or 2001-2002 

Cross-sectional, clinicbased Mymensingh Centre for Nuclear Medicine and 

Ultrasound 

34 PPs 2,536 subjects 

Prevalence of PP in those with prior CD

Prevalence of PP in those with prior VD

Makoha et al., 2004104

Saudi Arabia 1997-2000 

Cross-sectional, hospital-based 

Maternal and Children’s Hospital clinical records 

162 PPs 3,191 subjects 

Prevalence of PP associated with the n

 1: 3.9%  2: 3.2%  3: 5.1%  4: 6.9%  5: 9.4%  6+: 16.9% (P = 0.005 for 3-6+) OR for PP, relative to the quantity of priprior CDs:

COR: 4 vs.3: 1.4(0.8,2.2) COR: 5 vs.3: 1.9(1.0,3.5) COR: 6 vs.3: 3.8(1.9,7.4) 
97

Table 25. Description of studies addressing placenta previa relative to a history of previous cesarean delivery (continueAuthor Study Location Study Dates Study Design Data Source Study Population Size 

Effect Meas

Crude (COR) or Adjusted (AOR

or Prevalen

Gilliam et al., 2002105

USA 1986-1989 

Case-control, hospital-based 

University of Illinois Perinatal Center and the Cook County Perinatal Center registries 

316 PPs 2051 controls 

OR for the number of prior CDs vs. 

1 vs. 0: COR: 1.18(0.84,1.64) 

2 vs. 0: COR: 2.56(1.64,4.00) 3+ vs. 0: COR: 3.62(1.45,9.10) 

OR for PP, relative to parity and pr

Parity 1, 1 prior CD: AOR: 1.28(0.8

Parity 2, 2 prior CDs: AOR: 1.95(1.Parity 3, 3 prior CDs: AOR: 4.09(1.Parity 4, 4 prior CDs: AOR: 8.76 (1Parity 4, 1 prior CD: AOR: 1.72(1.1

Eniola et al., 2002106

Nigeria NR 

Case-control, hospitalbased Obafemi Awolowo University Teaching 

Hospitals Complex 

136 PPs 136 controls 

OR for PP, relative to prior CD: 

COR: 5.3(2.3,12.5) AOR: 4.7(1.9,11.4) (Adjusted for age, education, gravidprior retained placenta, abortion) 

Johnson et al., 2003107

USA 1990-1992 

Case-control, hospitalbased 5 major obstetrics hospitals, identified 

potential subjects by ICD9, then interviewed 

192 PPs 622 controls 

Prevalence of prior CD among paro

Cases: 28.6% Controls: 27.1% 

Tuzovic et al., 2003108

Croatia 1992-2001 

Case-control, hospitalbased Women’s Hospital, Zagreb University School 

of Medicine 

202 PPs 1004 controls 

OR for PP, relative to prior CD:

1 prior CD: COR: 1.45(0.73,2.9) 

≥ 1 prior CDs: COR: 2.0(1.17,3.44) 

≥ 2 prior CDs: COR: 7.32 (2.1,25) 

Laughon et al., 2005109

USA 2000-2003 

Case-control, hospitalbased University of North Carolina hospital medical 

records, ultrasound database, perinatal database 

88 PPs 264 controls 

OR for PP, relative to 1 prior CD:

OR 3.95(1.49,10.50) OR for PP, relative to each addition

OR 2.93 (1.60, 5.39) 
98

Table 26. Description of study quality and inclusion and exclusion criteria for update of placenta previa 

Quality Ra

Author 

Placenta 

Previas per 

1,000 births Inclusion Criteria Exclusion Criteria Study Question Design (1-5) 

Crane et al., 200099

3.3 All deliveries >20 

weeks in the province of Nova Scotia 

NR To describe the maternal 

complications of previa, to describe the factors associated with complications 

Logistic regression, adjusted for confounders 5 

Ultde4 

LydonRochelle et al., 2001100

5.2 Primiparas with 

singleton live birth followed by a singleton birth during study period, in civilian hospital in Washington

Placental abruption or previa at first-birth 

To evaluate the association between first birth cesarean delivery and placenta abruption or previa at second birth 

Logistic regression, clear inclusion and exclusion criteria, looked for interaction and confounding 5 

ICde3 

Francois et al., 2003110 1.9 Placenta previa or marginal previa 

(≤ 1 cm from os) 

Low-lying placenta > 1 cm from os 

To compare the occurrence of placenta previa between singleton and multiple gestation 

No comparison group for prevalence of prior CD in deliveries without PP 2 

Co4 

Dashe et al., 200298 NR Complete or incomplete PP by 

ultrasound, liveborn singletons ≥ 25 weeks

Low lying placenta, women delivered vaginally for incomplete previas 

To measure the persistence of placenta previa associated with diagnosis at increasing gestational age, to estimate effect of prior cesarean on previa persistence 

Analyzed only the cohort of PP that had been diagnosed by ultrasound during pregnancy and confirmed at delivery = “persistent previa” Adjusted 3 

Ultde4 

Rasmussenet al., 2000102 2.3 NR Women with only one delivery in study 

period, first delivery before study period, sibships with multiple births, those without complete information 

To evaluate trends for placenta previa and whether previa is associated with previous pregnancies, cesarean deliveries, or socioeconomic factors 

Logistic regression, adjusted for confounders, appropriate exclusions, but included PP in first delivery 4 

Unasda3 

CD, cesarean delivery; ICD-9, International Classification of Diseases, 9th Revision; NA, not available; OR, odds ratio; PP, placenta previa; VD, vagi
99

Table 26. Description of study quality and inclusion and exclusion criteria for update of placenta previa review (continued) Author 

Placenta 

Previas Per 

1000 Births Inclusion Criteria Exclusion Criteria Study Question Quality Ra

Sheiner et al., 2001101 3.8 All singleton deliveries with complete PP NR To determine the incidence of and the 

epidemiological risk factors and outcome for pregnancies complicated by placenta previa 

Logistic regression, adjusted for confounders 5 

Ultde4 

Hossain et al., 2004103

NR Presented for 

ultrasound at ≥ 28 

wks, partial, marginal, or complete previas 

Less than 28 wks gestation 

To assess the prevalence of lower segment placenta (placenta previa) and its association with previous cesarean delivery, parity, and maternal age 

Unclear exclusion criteria, no measures of significance given 2 

Ultlat3 

Makoha et al., 2004104

NR Women with ≥ 1 CD 

with complete, partial or marginal PP 

Prior uterine rupture, scar dehiscence, or rupture of CD scar; prior classical CD; any missing data from any indicator variable 

To quantify maternal risk associated with cesarean delivery and to determine if a third cesarean is a threshold for increased morbidity 

All patients had prior CD, addressed confounders, risk for potential bias in choice of subjects 3 

Ult3 

Gilliam et al., 2002105 NR Partial or total previa, singleton pregnancy, 

multiparous 

NR To estimate the likelihood 

of placenta previa after multiple cesarean deliveries and to adjust for parity and the effect of other risks factors for previa 

Adjusted for confounders 4 

Mefro3 

Eniola et al., 2002106 NR Controls: first delivery after case delivery 

without previa at >37wks, ≥ 2500 g, included twins 

NR To determine the risk 

factors for placental previa in Nigeria 

Logistic regression, adjusted for confounders 4 

Co4 
100

Table 26. Description of study quality and inclusion and exclusion criteria for update of placenta previa review (continued) Author 

Placenta 

Previas Per 

1000 Births Inclusion Criteria Exclusion Criteria Study Question Quality Ra

Johnson et al., 2003107 NR Singleton birth Multiples, < 20 wks gestation, <500 g birth 

weight 

To evaluate the risk of placenta previa associated with a history of induced abortion 

No significance reported, OR not reported for CD and not adjusted 3 

ICsuspdia3 

Tuzovic et al., 2003108 3.8 Complete, partial, marginal PP Low-lying placenta, incomplete data, 

multiple gestations, placenta abruption, succenturiate placenta, placenta acreta 

To evaluate potential risk factors and assess perinatal outcome for pregnancies complicated by placenta previa 

Univariate analysis with stratification, presented crude OR 3 

Ultde4 

Laughon et al., 2005109 NR Singleton pregnancies with ultrasound during 

second trimester, complete PP 

Low-lying placenta To determine whether the 

apparent increased risk in placenta previa associated with cesarean delivery is due to abnormal placentation or lower likelihood of resolution of previa diagnosed in second trimester 

Case-control OR for PP at delivery were not described as adjusted, multiple sources of bias 3 

Ultde4 
101 

Neonatal Outcomes 

We examined all included studies for a range of neonatal outcomes summarized below in text 

and tables. Evidence Table 2 (Appendix C)†

 provides the detailed information on all articles 

cited below. The approaches to determining relevance and grading the quality of individual 

studies are the same as for maternal outcomes (above). 

Fetal mortality. We did not identify any studies with data on fetal mortality. 

Neonatal mortality. A moderately relevant study of fair quality reported no neonatal 

mortality in either the elective cesarean delivery or the trial of vaginal delivery group, but it was 

underpowered to detect differences.53,81 

The low relevance study reported neonatal deaths by mode of delivery.81 The authors 

reported death before discharge in 1 per 10,000 infants delivered spontaneously, 3 per 10,000 

delivered by vacuum extraction, 5 per 10,000 delivered with the use of forceps, 6 per 10,000 

delivered with the use of vacuum extraction and forceps combined, and 8 per 10,000 delivered 

by cesarean. The death rate did not differ significantly between infants delivered spontaneously 

and those delivered by vacuum extraction (OR = 1.5; 95% CI, 0.8-2.8, by forceps delivery (OR = 

1.9; 95% CI, 0.60- 5.4), or vacuum extraction combined with forceps delivery (OR = 2.6; 95% 

CI, 0.4- 5.4). Significantly more deaths occurred among infants delivered by cesarean delivery 

than among those delivered spontaneously (OR = 3.7; 95% CI, 2.6-5.4). The death rate was the 

same for infants born by cesarean delivery during labor and for those born by cesarean delivery 

with no labor (0.8 per 1,000). These results did not adjust for underlying maternal or neonatal 

indications that might have dictated the choice of delivery route.

Unexpected (iatrogenic) prematurity. We found no studies that addressed unexpected 

(iatrogenic) prematurity as an outcome. The only valid method to determine whether the problem 

of unexpected prematurity exists is to analyze studies that included cesarean deliveries 

performed solely because of maternal choice in comparison with studies involving other modes 

of delivery. Because we did not identify articles that received a high relevance rating 

(specifically, maternal choice cesarean), we cannot comment on this outcome. 

Other studies we reviewed may have included some “elective” cesarean deliveries. However, 

all had some maternal or neonatal indication that led to cesarean, and potentially a preterm 

delivery, such as placenta previa, breech, hypertension, or fetal distress; they would not provide 

an appropriate base on which to comment on this particular outcome. 

Respiratory morbidity. Of the eight studies (nine articles) that included respiratory 

morbidity as an outcome, we rated four as moderately relevant, all of fair quality,47,48,51-53 and 

four as low relevance.65,77,80,81 (Table 27). 

Studies generally defined respiratory morbidity clinically as transient tachypnea of the 

newborn (TTN), respiratory distress syndrome (RDS), and persistent pulmonary hypertension 

(PPH). Our search strategy required a comparison of planned cesarean with planned vaginal 

delivery; as a consequence, our review did not include studies of meconium aspiration syndrome 

(MAS). One study reported “respiratory adaptation problems” without further explanation.51

However, some studies reported surrogate outcomes such as neonatal intensive care unit (NICU) 

admission or need for positive pressure ventilation (PPV).53 

The inverse relationship between respiratory morbidity and gestational age is well known. 

However, two of the eight studies included extremely premature infants under 27 weeks’ 

 

†

 Appendixes and Evidence Tables for this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/cesarean/cesarreq.pdf
102 

gestation;65,77 a third study included infants with gestational age ≥ 35 weeks;47 and a fourth study 

of an administrative database included infants between 2,500 and 4,000 grams but did not report 

gestational age.81 The remaining four studies included infants ≥ 37 weeks.48,51-53,80

Four studies provide a subanalysis of outcomes by gestational age.48,52,53,77,80 No study 

reported on severity of respiratory morbidity by gestational age. 

With respect to the four moderately relevant studies, three included TTN and RDS as 

outcomes.47,48,52,53 Additionally, the Levine study included PPH,47 and the Zanardo study 

reported the incidence of PPV.53 Two moderately relevant studies provided a subanalysis by 

gestational age.48,52,53

Three of these studies reported a significantly higher risk of respiratory morbidity associated 

with elective cesarean delivery than with vaginal delivery.47,48,52,53 

Both moderately relevant studies with gestational age subanalyses showed a reduction in 

respiratory morbidity associated with advancing gestational age.48,52,53 One study found that the 

risk of RDS but not TTN was significantly higher with “elective” cesarean from 37 weeks 

through 38 weeks and 6 days gestation.52,53 However, neither RDS or TTN was significantly 

different from 39 weeks through 41 weeks and 6 days gestations. 

The other moderately relevant study combined RDS or TTN requiring an NICU admission 

into a composite measure of respiratory morbidity in the subanalysis for gestational age.48 The 

rate of respiratory morbidity was significantly higher among prelabor cesarean deliveries than 

among vaginal deliveries from 37 weeks through 39 weeks and 6 days gestation, but the rate did 

not differ significantly between these groups thereafter. 

The fourth moderately relevant study compared “elective cesarean” with intended vaginal 

delivery. The authors reported a single case of “respiratory adaptation problems” in 147 elective 

cesareans, but they did not report any statistical testing.51
103

Table 27. Respiratory morbidity Author, Year Relevance/ Quality Rating 

Measure Outcomes for Comparison Groups 

Elective CD VD (ref 

grp) 

All CD 

TTN 3.10% 1.10% 3.50% OR (95% CI) 2.8 (2.1; 3.8) 1.0 3.3 (2.6; 3.9) RDS 0.20% 0.16% 0.47% OR (95% CI) 3.0 (1.6; 5.3) 1.0 1.3 (0.; 3.8) PPH 0.37% 0.08% 0.40% 

Levine et al., 200147

Moderate/Fair 

OR (95% CI) 4.6 (1.3; 11) 1.0 4.9 (2.2; 8.8) 

Prelabor CD 

VD (ref grp) 

CD in labor 

TTN 2.26% 0.41% 0.84% RDS 1.28% 0.11% 0.38% RDS+TTN 3.55% 0.51% 1.22% 

Morrison et al., 199548

Moderate/Fair 

OR (95% CI) 6.8 (5.2; 

8.9) 

1.0 2.3 (1.6; 

3.5) 

Elective CD VD (ref grp)

TTN 0.93% 0.85% RDS 2.26% 0.39% OR (95% CI) 2.60 (1.35; 

5.90) 

1.0 

Need for positive pressure ventilation (PPV) 

3.4% 1.4% 

Zanardo et al., 2004;53

Zanardo et al., 200452

Moderate/Fair 

OR (95% CI) 2.05 (1.25; 

5.67) 

1.0 

TTN, transient tachypnea of the newborn; RDS, Respiratory distress syndrome; PPH, persistent pulmonary hypertension; AVD, assisted vaginal deliv

NS, not significant; NR, not reported; OR, odds ratio; CI, confidence interval. 
104

Table 27. Respiratory morbidity (continued) Author, Year Relevance/ Quality Rating 

Measure Outcomes for Comparison Groups 

Elective CD Intended 

VD 

Schindl et al., 200351

Moderate/Fair Respiratory 

adaptation problems 

0.70% 0.00% 

Elective CD VD 

(ref grp) 

AVD Emergency 

CD 

RDS 1.43% 0.49% 0.06% 26.65% OR (95% CI) 1.88 (1.42; 

2.48) 

1.0 NR OR: 3.46 

(2.69; 4.44) 

TTN 1.42% 0.51% 0.80% 14.66% 

Dani et al., 199965

Low/Not rated 

OR (95% CI) 1.86 (1.48; 

2.33) 

1.0 NR 2.86 (2.25; 

3.63) 

Elective CD VD 

(ref grp) 

Forceps Delivery 

Emergency CD 

RDS NR NR NR NR 

Sutton et al., 200180

Low/Not rated 

OR (95% CI) 2.64 (1.42; 

4.90) 

1.0 4.47 (2.11; 

9.44 

4.07 (2.13; 7.78) 

Unlabored CD 

Spontaneous vaginal (ref grp) 

Vacuum extraction 

Forceps Forceps 

and Vacuum 

Labored CD Labored CD 

with Attempt at Vacuum or Forceps 

LaboCD, AttemVacuForc

Mechanical Ventilation 

0.71 0.258 0.39 0.45 0.50 1.03 1.56 1.02 

Towner et al., 199981

Low/Not rated 

OR (95% CI) 2.8 (2.4; 3.3) 1.0 1.5 (1.3; 1.8) 1.8 (1.4; 2.3) 1.9 (1.1; 3.4) OR: 4 (3.6; 

4.3) 

OR: 6 (4.3; 8.3) 

OR: 3.0) 

Elective CD VD 

(ref grp) 

Forceps (Subset of Vaginal) 

Emergency CD 

Rubaltelli et al., 199877

Low/Not rated 

TTN 1.5% NR 3.8% 4.2% 
105

We also reviewed four low relevance studies. Two reported on PPV alone.80,81 Two studies 

provide a subanalysis by gestational age.77,80 

Both studies limited to PPV found a higher risk of PPV among prelabor cesareans than 

among vaginal deliverues.80,81 Indications for PPV in this study included TTN, RDS, MAS, 

pulmonary hypertension, infection without neurological symptoms, pneumothorax, amniotic 

fluid aspiration, and pneumomediastinum. Of these studies, only one provided a subanalysis by 

gestational age, finding a significantly higher risk for PPV at gestational age of 37 to 38 weeks 

compared with >38 weeks.80 

Two of the four low relevance studies defined respiratory morbidity as RDS or TTN.65,77

Both studies showed a higher risk of TTN among “elective” cesarean deliveries than among 

vaginal deliveries. One study showed a higher risk of RDS among “elective” cesareans than 

among vaginal delivery.65 The other study did not report overall incidence rates of RDS by mode 

of delivery, but in the subanalysis by gestational age, the investigators showed declines in the 

rates of RDS and TTN with increasing gestational age.77

Overall, the results showed a higher risk of respiratory morbidity from TTN or RDS among 

elective cesarean births than among vaginal delivery and a consistent reduction in risk with 

advancing gestational age approaching equality at 39 through 40 weeks. 

We further analyzed these studies to assess the effect of labor on the incidence of respiratory 

morbidity. One of four studies that compared TTN and RDS between prelabor and labored 

cesarean deliveries showed a lower risk of respiratory morbidity in labored cesarean deliveries.48

However, the three remaining studies showed a higher risk of respiratory morbidity in labored 

cesarean deliveries.47,80,81 We cannot determine whether the higher riskof respiratory morbidity 

associated with labored cesarean deliveries in these three studies is due to TTN, RDS, or MAS. 

Similarly, we can not determine whether the higher rate can be attributed to a higher rate of 

emergency cesareans for complications related to prematurity because the data are not presented 

in a manner that allowed us to answer this question. 

We did not identify any studies that compared MAS between modes of delivery. Two studies 

that focused on TTN and RDS excluded MAS.47,48 Others reported on positive pressure 

ventilation for indications that included MAS.77,80 An accurate and comprehensive assessment of 

neonatal respiratory morbidity would ideally account for TTN, RDS, and MAS by planned route 

of delivery and separated by gestational age. 

Transition. One study of low relevance that reported on feeding difficulty as a measure of 

transition found a higher risk with all modes of delivery except for spontaneous vaginal 

delivery.81 The risk was not significantly higher for vacuum, forceps, vacuum or forceps, or 

cesarean “during labor after a failed attempt at vaginal delivery.” By contrast, it was significantly 

higher after cesarean “during labor with no attempt at vaginal delivery” and cesarean “without 

labor.” This study did not distinguish between planned and unplanned cesarean deliveries. 

Women who had a cesarean delivery without labor or with labor, with no attempt at vaginal 

delivery, may have had maternal or neonatal indications for emergency cesarean delivery that 

also influenced neonatal transition. 

Neonatal asphyxia and encephalopathy. Encephalopathy is a broad category. We limited 

our review to outcomes that were associated with hypoxic-ischemic encephalopathy. Two studies 

included outcomes related to neonatal encephalopathy, one of moderate relevance and fair 

quality,37 and one of low relevance.81 The moderately relevant study defined neonatal 

encephalopathy as either seizures alone or any two of the following conditions that lasted for 

longer than 24 hours: abnormal consciousness, difficulty maintaining respiration (of presumed 
106

central origin), difficulty feeding (of presumed central origin), or abnormal tone and reflexes. It 

found a significantly lower risk of newborn encephalopathy associated with “elective cesarean 

section” than with spontaneous vaginal delivery (OR = 0.17; 95% CI, 0.05-0.56. Both 

instrumental vaginal delivery and emergency cesarean delivery were associated with 

significantly higher rates of newborn encephalopathy than spontaneous vaginal delivery 

(respectively, OR = 2.34; 95% CI, 1.16-4.70, and OR = 2.17, 95% CI, 1.01-4.64). 

The low relevance study used Current Procedural Terminology (CPT and ICD-9 codes for 

convulsions and central nervous system (CNS) depression as outcomes. The authors found a 

higher risk of both convulsions and CNS depression among “unlabored cesarean sections” than 

among spontaneous vaginal delivery. However, these results were significant only for CNS 

depression (OR, 2.2; 95% CI,1.3-3.6).81 This study showed a significantly higher risk of both 

convulsions and CNS depression with vacuum, vacuum and forceps, and cesarean during labor 

than with spontaneous vaginal delivery. 

Intracranial hemorrhage. One low relevance study reported on subdural or cerebral 

hemorrhage, intraventricular hemorrhage, and subarachnoid hemorrhage among various modes 

of delivery.81 Overall, the hemorrhage rates were similar between spontaneous vaginal delivery 

and “prelabor” cesareans. The results showed a consistently higher risk for all three injuries with 

vacuum, forceps, vacuum and forceps, and cesarean during labor but were not universally 

statistically significant. 

Facial nerve injury. One low relevance study specifically addressed facial nerve injury 

through use of ICD-9 and CPT code data.81 The study found no significant differences in the 

incidence of facial nerve injury associated with vacuum (OR = 1.7; 95% CI, 0.9-2.1) or 

“prelabor” cesarean delivery (OR = 1.5; 95% CI, 0.8-2.6) compared with facial nerve injury 

incidence associated with spontaneous vaginal delivery. However, the study found a significantly 

higher rate of facial nerve injury among forceps delivery (OR = 13.6; 95% CI, 10.0-18.4), the 

composite attempt at vacuum and forceps (OR = 8.5; 95% CI, 3.9-18.0), and the subgroup of 

cesareans that failed an attempt at vaginal delivery with either vacuum or forceps (OR = 3.8; 

95% CI 1.2-12.1). 

Brachial plexus injury. One low relevance study reported on brachial plexus injury related 

to mode of delivery.81 The rate of brachial plexus injury was significantly higher in vacuum, 

forceps, and the combined attempt at vacuum and forceps than in spontaneous vaginal delivery 

(respectively: OR = 2.3; 95% CI, 1.8-2.9; OR= 3.2; 95% CI, 2.3-4.6; and OR = 6.0; 95% CI, 3.3-

10.7). It was significantly lower in cesareans overall as well as in cesareans performed “during 

labor” than in spontaneous vaginal delivery (respectively, OR = 0.4; 95% CI, 0.3-0.5; OR = 0.2; 

95% CI, 0.1-0.4). The rate was lower in “prelabor” cesarean deliveries than in spontaneous 

vaginal delivery, (OR = 0.5; 95% CI, 0.3-1.0). 

Fetal laceration. Two moderately relevant studies of poor quality included fetal lacerations 

as a neonatal outcome by mode of delivery.28,40 One study reported on mild, moderate, and 

severe fetal lacerations among “scheduled,” “unscheduled,” and “emergency” cesarean 

deliveries.40 The study found a significantly higher rate of fetal lacerations among emergency 

cesareans (OR = 1.7) than among either scheduled cesareans (OR = 0.34) or unscheduled 

cesareans (OR = 0.57). The authors calculated the odds ratios by comparing the odds for each of 

the three categories with the composite odds for all fetal lacerations among all three types of 

cesareans. All moderate and severe fetal lacerations were in the emergency cesarean group. 

The other study compared outcomes among “primary elective” cesareans, “primary acute” 

cesareans, and “secondary acute” cesareans.28 This study reported a “fetal complication” rate of 
107

1.3 percent. The authors noted that the “most frequent fetal complication was an accidental 

incision of the fetal skin while opening the uterus” (p. 4).28 The rates of fetal complication 

(which we interpret to mean primarily fetal laceration) by mode of delivery in descending order 

of incidence were “secondary acute” cesarean (1.5%), “primary acute” cesarean (1.4%), and 

“primary elective cesarean (0.8%). 

Neonatal length of stay. One study of moderate relevance and fair quality reported on length 

of hospital stay in two articles.52,53 The mean length of stay was higher in the “elective” cesarean 

group (6 days) than in the vaginal delivery group (4 days). The authors did not report statistical 

test results. 

Long-term bonding, behavioral issues, and physical development. We found no studies 

that addressed any of these issues. 

Key Question 3 

What factors affect the magnitude of the benefits and harms 

identified in KQ 2? 

We limited this key question to studies comparing planned CDMR with planned vaginal 

delivery and to studies assessing effect modifiers in planned CDMR. The outcomes of interest 

initially were those specified for KQ 2. 

We did not include studies that evaluated effect modifiers exclusively in populations with 

planned vaginal delivery (i.e., studies without planned CDMR as a control group). An extensive 

body of literature exists on effects of factors such as comorbidities, settings, patient 

characteristics, and many others on the outcomes of vaginal delivery. Effect modifiers for 

vaginal deliveries, however, were beyond the scope of this review. 

We defined effect modifiers as maternal or fetal characteristics that modify the effect of 

either planned CDMR or planned vaginal delivery on an outcome of interest. In addition, we 

included time of day of delivery, physician experience, quality of nursing, labor support, type of 

delivery, pregnancy dating, and level of perinatal care as general characteristics. Table 28 

summarizes effect modifiers that we considered of primary interest. 

Table 28. Potential effect modifiers for planned CDMR and planned vaginal delivery 

Maternal Characteristics Fetal Characteristics General 

Maternal age Sex Time of day of delivery 

Parity Fetal size Physician experience or 

specialty 

Race or ethnicity Gestational age Labor support 

Body mass index Quality of nursing 

Socioeconomic status Level of perinatal care 

Medical characteristics Type of labor 

Pregnancy dating 

We did not regard differences in interventions, such as antibiotic prophylaxis or operation 

techniques, as being effect modifiers. Differences in outcomes based on interventions are 

attributable to cause and effect relationships rather than to interacting variables. 

Only five studies met our inclusion criteria and assessed factors that have the potential to 

alter the benefits and harms of planned CDMR or planned vaginal delivery.48,53-55,82 We did not 
108

find any evidence for most of the KQ 2 outcomes of interest. The outcomes reported in the 

existing evidence were limited to fetal respiratory morbidity, infectious morbidity, and urinary 

incontinence. 

We rated three studies as moderately relevant53-55,82 and one as being of low relevance.48 

Only two studies controlled for confounding factors by employing a multivariate regression 

model to determine effect modifiers.54,82 Results of all remaining studies are crude estimates, 

uncontrolled for confounders. Characteristics of included studies are presented in Table 29 (in 

order by relevance and then quality rating). 

Table 29. Characteristics of included studies for key question 3 

Author, 

Year 

Relevance, 

Quality 

Study Design 

Population 

Sample 

Size 

Definition 

of “Elective 

Cesarean” 

Definition 

of Planned 

Vaginal 

Delivery 

Outcome of 

Interest 

Effect Modifier 

Adjusted for 

Confounders 

Myles et al., 

200254

Moderate 

Good 

Retrospective 

cohort study 

Patients with 

elective cesarean 

214 Patients who 

had 

reassuring 

fetal heart 

tones and 

did not have 

active labor 

or rupture of 

the 

membranes 

prior to 

surgery 

Not 

applicable 

Post-cesarean 

infectious 

morbidity 

BMI, race 

Yes 

van den Berg 

et al., 200155

Moderate 

Fair 

Retrospective 

cohort study 

 

Patients with 

elective cesarean 

433 Surgery was 

performed 

after 37th 

week of 

pregnancy 

without 

compli-cating 

factors 

influencing 

the timing of 

delivery and 

without 

preceding 

labor 

Not 

applicable 

Neonatal 

respiratory 

distress 

Gestational age 

No 

Zanardo 

200453

Moderate 

Fair 

Retrospective 

cohort study 

 

Patients with 

elective cesarean 

1,284 Delivered 

before onset 

of labor 

Not 

applicable 

Neonatal 

respiratory 

distress / 

gestational age 

No 

Morrison et 

al., 199548

Low 

Not rated 

Retrospective 

cohort study 

All deliveries 

36,461 Before onset 

of labor 

Not reported Neonatal 

respiratory 

distress 

Gestational age 

No 

Wilson et al., 

199682

Low 

Not rated 

Cross-sectional 

survey 

Women 3 months 

postpartum 

1,505 Not reported Not reported Urinary 

incontinence 

Pelvic floor 

exercises, 

Body mass index 

Yes 
109

Three retrospective cohort studies assessed the influence of gestational age on neonatal 

respiratory distress after “elective cesarean.”48,53,55 Populations were not limited to those with 

CDMR. All three studies determined gestational age using chart information on menstrual 

history and ultrasound data obtained in the first trimester, but their definitions of “elective 

cesarean” and neonatal respiratory distress varied. Three moderately relevant studies48,53,55

included patients who had “elective cesarean delivery” after 37 weeks of pregnancy in the 

absence of complicating factors influencing the timing of delivery and neonatal outcomes. One 

of these two studies, however, included only patients with spinal anesthesia.53 By contrast, the 

third study, rated as having low relevance, did not exclude patients with comorbidities or patients 

undergoing general anesthesia.48 All three studies based respiratory distress on the presence of 

clinical symptoms of respiratory distress such as tachypnea, retractions, nasal flaring, or 

cyanosis. In addition, two studies used radiographic features of RDS and TTN as additional 

criteria.48,53

Despite these differences, results consistently presented a decrease of respiratory morbidity 

with increasing gestational age. Table 30 and Figure 5 summarize the prevalence of neonatal 

respiratory morbidity following “elective cesarean section” at different gestational ages. 

Cuzick’s test for trend indicated a statistically significant trend for the combined data of the 

included studies (P = 0.012). These findings are also consistent with a Dutch study published in 

English as an abstract only.111 

Table 30. Number of cases (and percentage) of neonatal respiratory morbidity by gestational week following 

elective cesarean delivery 

Gestational Age Morrison et al.48 van den Berg et al.55 Zanardo et al.53

37 weeks to 37 weeks, 6 

days 

27 of 366 (7.4%) 8 of 95 (8.4%) Not reported 

38 weeks to 38 weeks, 6 

days 

45 of 1,063 (4.2%) 8 of 183 (4.4%) 32 of 765 (4.2%) (total 

for less than 38 weeks, 

6 days 

39 weeks or more 11 of 912 (1.2%) 1 of 55 (1.8%) 9 of 519 (1.7%) 

Figure 5. Prevalence of neonatal respiratory morbidity by gestational week following elective cesarean or 

vaginal and labored cesarean 

0

1

2

3

4

5

6

7

8

9

37 38 39

Gestational weeks

Percent

Morrison

1998 -

unlabored

cesarean

van den Berg

2001

Zanardo 2004

Morrison

1998-vaginal,

labored

cesarean

p = 0.012 for trend
110

Only one study (low relevance) provided data on the effect of gestational age on neonatal 

respiratory morbidity for patients with vaginal delivery and labored cesarean.48 Gestational age 

appeared to have a lesser effect on neonatal respiratory morbidity in combined patients with 

vaginal delivery or labored cesarean delivery. In this population, in gestational week 37, only 

1.68 percent of neonates suffered from respiratory morbidity. The prevalence declined to 0.48 

percent for deliveries at or after week 39. 

A different retrospective cohort study (moderate relevance) did not find gestational age to be 

a risk factor for post-cesarean infectious morbidity.54 In this study, after multivariate analysis 

BMI and race were the only risk factors that remained statistically significant for post-cesarean 

infectious morbidity in patients undergoing “elective cesarean.” The relative risk for 

postoperative infectious morbidity in obese patients was 1.6 (95% CI, 1.2-2.0). In addition, black 

patients had a significantly higher rate of infection (RR not reported). Other factors such as 

physician’s experience, incision type, maternal age, and prophylactic antibiotics were 

statistically significant in the univariate analysis but did not maintain statistical significance in 

the multivariate model. 

A cross-sectional survey (low relevance; response rate 70.5 percent) of 1,505 women 3 months 

after delivery examined the relation between obstetric factors and incontinence.82 For both 

vaginal and cesarean deliveries, combined pelvic floor exercises significantly reduced the 

prevalence of incontinence at 3 months (OR = 0.6; 95% CI, 0.4-0.9). Prepregnancy BMI 

significantly increased the risk of incontinence (OR = 1.07; 95% CI, 1.04-1.10), but the clinical 

significance of this finding might be questionable. Results were not stratified by planned CDMR 

and planned vaginal delivery. However, women with previous incontinence had higher rates of 

incontinence at 3 months than those without previous incontinence (elective cesarean: 38.1 

percent vs. 8.8 percent; vaginal delivery: 28.2 percent vs. 24.8 percent). 
111

Chapter 4. Discussion

This chapter first discusses our findings for three key questions (KQ) relating to incidence 

and trends for cesarean delivery on maternal request (CDMR), maternal and neonatal outcomes 

of a variety of delivery routes relative to CDMR or proxies for CDMR, and factors that may 

influence those outcomes. We also address KQ 4, which concerns limitations of the evidence 

base and our recommendations for future research. 

As explained in Chapters 2 and 3, few studies dealt directly with CDMR, so we developed 

relevance ratings of studies in addition to the typical ratings done with respect to the quality of 

individual studies. Relevance ratings could be high (essentially nonexistent in this evidence 

base), moderate, or low; quality ratings, derived from commonly adopted approaches, could be 

good, fair, or poor. In all, we included 69 articles that pertained to KQ 1, 2, or 3. 

We also developed definitions for the strength of the evidence base for these three issues. 

Chapter 2 provides details; the basic categories are as follows: 

I. Strong evidence: The evidence is from studies of strong design; results are both clinically 

important and consistent with minor exceptions at most; results are free from serious 

doubts about generalizability, bias, or flaws in research design. Studies with negative 

results have sufficiently large samples to have adequate statistical power. 

II. Moderate evidence: The evidence is from studies of strong design, but some uncertainty 

remains because of inconsistencies or concern about generalizability, bias, research 

design flaws, or adequate sample size. Alternatively, the evidence is consistent but 

derives from studies of weaker design. 

III. Weak evidence: The evidence is from a limited number of studies of weaker design. 

Studies with strong design either have not been done or are inconclusive. 

IV. No evidence: No published literature. 

For KQ 1, one study was of high relevance and remaining studies were of fair or poor 

quality; thus, information to answer KQ 1 was weak. With respect to KQ 2, generally only weak 

evidence was available to characterize most maternal and neonatal outcomes involving a 

comparison of planned CDMR with planned vaginal delivery (KQ 2). Evidence to address the 

question of modifiers of outcomes of planned CDMR and planned vaginal delivery (KQ 3) was 

also at best only weak. 

Results 

KQ 1: Incidence and Trends of Cesarean Delivery on Maternal 

Request 

KQ 1 referred to the incidence and trends in cesarean deliveries over time in developed 

countries; it made specific reference to primary cesarean before onset of labor, CDMR, medical 

indications, and malpresentation as proportions of total cesarean deliveries. The absence of data 

to answer this question is striking. Regarding incidence, the available literature yielded rates of 

cesarean deliveries as a proportion of all deliveries for a wide array of time points and countries. 
112

For 2001 in the United States, data suggest rates of more than 25 percent.3 Elsewhere in the 

developed world for 2001, rates of cesarean delivery ranged from 14 percent in the Netherlands 

to 35 percent in Italy.112 Since 2001, the rates of cesarean delivery have risen in the United 

States; recent figures put the rate at more than 29 percent for 2004.2 

The rate of cesarean deliveries is rising worldwide. Both “elective” cesarean deliveries 

(sometimes defined as unlabored) and “nonelective” cesarean deliveries contribute to this rise; 

however, the proportions vary by country, study, and time period. Four studies distinguished 

between prelabor primary and repeat cesareans. An Irish study reported an unlabored primary 

cesarean delivery rate of 18.9 percent of all cesarean deliveries during the 12-year period from 

1989 to 2000.35 One study in Australia showed that prelabor primary cesarean delivery as a 

percentage of all deliveries rose from 4.1 percent in 1980 to 4.8 percent in 1987.34 In the United 

States, primary prelabor cesarean delivery rates were approximately 5 percent of all deliveries in 

19963,56 and approximately 7 percent in 2001.3 In 2001, “primary elective” prelabor cesarean rate 

as a proportion of all cesarean deliveries was 28.3 percent in the United States.3

 

The extent to which CDMR is contributing to the rise in cesareans remains unclear. We 

found a single study addressing CDMR, but its data are more than a decade old and were drawn 

from a single area (Scotland).33 All other studies that we identified either made no attempt to 

define “elective” cesarean or included such a variety of indications that precluded them from 

being acceptable proxies for CDMR. Thus, we identified no recent data regarding the rate of 

CDMR. 

A more fundamental problem is that administrative records used to compile such statistics do 

not contain the details necessary to discern whether the expectant mother desired a vaginal 

delivery or a cesarean delivery; nor do they provide insight into the decisionmaking process that 

produced a preference (either the mother’s or the clinician’s) or who else may have been 

involved in that process. 

Finally, we did not find sufficient data to comment on medical indications or malpresentation 

as a proportion of all cesarean deliveries. 

KQ 2: Outcomes of Cesarean Delivery on Maternal Request 

We discuss below maternal and neonatal outcomes of interest to the State-of-the-Science 

(SOS) planning committee. Overall, few moderately relevant studies were available, and the 

strength of evidence is weak (category III) for nearly all outcomes. We summarize the direction 

of effect and strength of evidence and enumerate the number of trials of planned vaginal delivery 

to planned cesarean delivery or studies of moderate relevance to CDMR in two tables below: 

Table 31 (immediately below) deals with maternal outcomes (both primary cesarean and 

subsequent cesarean deliveries; Table 32 (later) covers neonatal outcomes. 

Maternal outcomes for primary cesarean deliveries. Mortality. Four studies20,28,64,70

suggested no evidence of difference in maternal mortality associated with planned vaginal versus 

planned cesarean delivery. These studies provide weak evidence overall. The 2000 report from 

the International Term Breech Trial (hereafter Breech Trial; which randomized women to 

planned vaginal vs. planned cesarean for breech) received a quality rating of fair.20 The only 

moderately relevant study was of poor quality. The remaining two studies were of low relevance 

to CDMR and were not graded for quality. 
113

Table 31. Summary of maternal outcomes, directions of effect, and strength of evidence 

Maternal Outcome Direction of Effect Strength of Evidence 

Maternal Outcomes Relevant to Primary Cesarean Deliveries 

Maternal mortality No evidence of difference between cesarean and vaginal 

delivery (planned or actual) 

II 

Infection Lower risk with planned “elective” than labored or 

emergency cesarean; higher risk with cesarean overall 

compared with vaginal delivery 

III 

Anesthetic complications Lower risk with planned vaginal delivery from limited 

evidence 

III 

Hemorrhage/blood transfusion Lower risk with planned “elective” than vaginal or 

unplanned cesarean delivery 

II 

Hysterectomy No evidence of difference from underpowered studies II 

Thromboembolism No consistent evidence of direction or magnitude of 

difference 

III 

Surgical complications Lower risk of surgical complications with elective or 

unlabored cesarean compared with labored or 

emergency cesarean births, lower risk of perineal trauma 

with elective cesarean compared with spontaneous 

vaginal deliveries and assisted vaginal deliveries 

III 

Breastfeeding No evidence of difference in the duration of 

breastfeeding, previous reviews suggest higher risk of 

bottle feeding compared with breastfeeding for cesareans 

overall compared with vaginal delivery 

III 

Postpartum pain No evidence of difference III 

Psychological outcomes: 

postpartum depression 

No evidence of difference; however, trial of breech 

presentation likely overestimates challenges, 

interventions, and resultant negative psychological 

outcomes in the planned vaginal delivery group 

III 

Psychological outcomes: other Lower risk of negative birth experience with planned 

cesarean or spontaneous vaginal delivery compared with 

unplanned cesarean or instrumental vaginal delivery, 

other outcomes too varied to summarize 

III 

Maternal length of stay Longer hospital stay with planned and unplanned 

cesarean compared with vaginal delivery 

II 

Urinary incontinence Lower risk with primary elective cesarean than vaginal 

delivery, protective effect may diminish with increasing 

age, parity, and BMI 

III 

Anorectal function Lower risk with planned cesarean deliveries compared 

with unplanned cesarean or instrumental vaginal 

deliveries. Inconsistent evidence of difference between 

planned cesarean and spontaneous vaginal delivery 

III 

Pelvic organ prolapse No evidence IV 

Sexual function No evidence of difference III 

Maternal Outcomes Relevant to Subsequent Cesarean Deliveries 

Subsequent fertility issues Higher risks with all cesarean, no reliable evidence of 

difference relevant to CDMR 

IV 

Subsequent uterine rupture No difference in asymptomatic uterine rupture, small 

higher risk of symptomatic rupture with trial of labor 

compared with elective repeat cesarean 

II 

Subsequent placenta previa Higher risk with cesarean, risk increases with advancing 

maternal age, parity, and number of prior cesareans 

II 

Subsequent stillbirth Higher risks with all cesarean, no reliable evidence of 

difference relevant to CDMR 

IV 
114

An often quoted statistic included in a letter to the editor by Hall and Bewley, extrapolates a 

higher relative risk (RR) of mortality associated with elective (RR: 2·84. 95% CI 1.72–4.70) and 

emergency cesarean (RR: 8·84, 95% CI 5.60–13.94) compared with vaginal delivery.113

However, careful examination of the original source of their data finds that “elective” cesareans 

included no CDMR. In fact, “in many cases of elective cesarean section the woman had 

significant underlying medical problems, such as primary pulmonary hypertension, or other 

cardiac disease.”114

Furthermore, comparisons are not made by planned routes of delivery but rather actual routes 

of delivery. In an appropriate analysis, mortality associated with planned vaginal deliveries 

would include maternal deaths following both actual vaginal deliveries and unplanned cesarean 

deliveries. 

Overall, the incidence of maternal mortality was very low. This finding may be an artifact of 

our restricting our review to studies from developed countries where maternal mortality is 

generally low (e.g., in the range of 1 in 10,000 cases).115 Other factors related to the overall low 

rate of maternal mortality include ready access to antibiotics, emergency cesarean, anesthetic 

specialists, and blood banking capabilities. 

Infection. The 12 studies that included maternal infection as an outcome provided weak 

evidence regarding its association with planned vaginal and planned cesarean 

delivery.20,28,39,45,49,51,64,67-70,84 Generally, the risk of maternal infection was lower with planned 

cesarean than with unplanned cesarean delivery and lower for vaginal than for cesarean delivery. 

The failings in this evidence stem primarily from a lack of appropriate comparison groups, a 

lack of consistency in outcome definitions, and the frequent use of composite outcomes that 

combine infectious and noninfectious outcomes or combine infectious outcomes of differing 

severity. Some studies reported specific maternal infections, whereas others grouped infectious 

outcomes into a single measure of maternal infectious morbidity or combined infectious 

outcomes with unrelated outcomes such as blood loss, bladder paralysis, ileus, hematoma, or an 

undefined “other” category. Also problematic was that studies that used composite measures of 

infectious morbidity often combined outcomes with significantly different severities such as 

urinary tract infection (UTI), endometritis, and pneumonia. These limitations preclude our ability 

to make conclusive assessments of the maternal infection literature. 

Anesthetic complications. Two studies showed a lower rate of anesthetic complications with 

planned vaginal than with planned cesarean delivery;51,69 the third reported no significant 

difference between these two routes.50 This is at best weak evidence suggesting a lower rate of 

anesthetic complications with planned vaginal delivery. The finding results from only two 

articles: one based on administrative data and the other that did no statistical testing. Given the 

increase in the use of regional anesthesia (epidural and spinal) in both planned vaginal and 

planned cesarean deliveries, analyzing anesthetic outcomes by intent-to-treat is especially 

important as was done by two of the three studies.50,51 The weakness of this evidence is 

attributable to the paucity of studies, the lack of consistent definitions, and the inclusion of 

possible confounders (potentially higher rate of general anesthesia used for emergency cesareans 

and potentially higher rates of vacuum, forceps, and cesareans in labor associated with the use of 

epidurals. 

Hemorrhage and blood transfusion. Eleven studies provided moderate strength of evidence 

showing a lower risk of hemorrhage and blood transfusion in planned cesareans than in vaginal 
115

delivery.20,28,38,39,45,50,51,64,67-69 These studies also yielded evidence of lower hemorrhage or blood 

transfusion in planned cesareans than in unplanned cesareans. 

Of these 11 studies, 1 was the initial report from the Breech Trial,20 6 studies were of 

moderate relevance,28,38,39,45,50,51 and 4 were of low relevance.64,67-69 Of the moderately relevant 

studies, 3 were of fair quality38,39,51 and 3 of poor quality.28,45,50 

The majority of the evidence showed a lower risk of blood loss associated with planned 

cesarean than with both planned vaginal delivery and unplanned cesarean delivery; this finding 

was consistent across the Breech Trial and two other fair-quality studies.20,38,51

Several challenges arise in interpreting this body of evidence. The studies often compared 

actual, rather than planned, routes of delivery; frequently, they compared only various types of 

cesarean delivery and lacked a vaginal comparison group. Studies also varied in their definition 

of excess blood loss from a gross estimation of increased blood loss to an objective and clinically 

meaningful definition of blood transfusion. Some studies used retrospective data (e.g., at times 

relying on International Classification of Diseases, Ninth Edition [ICD-9] codes, which may be 

of questionable reliability for this outcome). 

Hysterectomy. Three studies (the Breech Trial, one study of moderate relevance, and one of 

low relevance) yielded weak evidence on the association between emergency hysterectomy after 

childbirth and either planned vaginal or planned cesarean delivery. These studies generally 

lacked the power to examine rare outcomes: a total of three peripartum hysterectomies were 

performed in all included studies. Although a hysterectomy is certainly a profound event for 

women who experience it, the number reported in these studies is insufficient to draw firm 

conclusions regarding the risk associated with either delivery route. 

Thromboembolism. We have only weak evidence about any association between 

thromboembolism and planned vaginal or planned cesarean delivery. Studies did not consistently 

report a significantly higher rate of thromboembolic events associated with planned cesarean. In 

the only moderately relevant study (fair quality) that compared cesarean and vaginal deliveries,39

the rate of deep vein thrombosis was higher for both planned “without labor” and unplanned 

“with trial of labor” cesareans, but the risk was significant only for the unplanned group. The 

remaining moderately relevant study (poor quality) limited comparisons to various types of 

cesareans and reported a higher (nonsignificant) thrombosis rate in the unplanned cesarean 

group.28

Of the four low-relevance relevant studies, three did not show either a significant difference 

or consistent direction for thromboembolism risk between planned cesarean and planned vaginal 

delivery.67,68,70 The fourth study reported that the rate of thromboembolic events was statistically 

higher in unplanned cesareans than in planned cesarean deliveries;69 a subanalysis showed that 

thromboembolism was lower in “uncomplicated” vaginal delivery than in elective cesarean 

delivery. 

For risks of thromboembolism, the number of moderately relevant studies was small; 

outcomes were rare (usually under 1% for either arm); definitions were inconsistent; and results 

from the two trials of planned vaginal versus cesarean delivery for breech conflicted.20,84 The 

lack of consistent direction of effect limits our ability to draw any firm conclusions regarding the 

risk of thromboembolism associated with CDMR. 

Surgical complications. Ten studies provided weak evidence on surgical complications 

associated with planned vaginal and planned cesarean delivery. These included the Breech 

Trial,20 3 studies of moderate relevance (2 of fair quality38,51 and 1 of poor quality28), and 6 of 
116

low relevance.64,67-70,75 Studies generally showed a lower risk of surgical complications in 

planned “elective” cesarean than in unplanned “emergency” or “labored” cesarean deliveries. 

When investigators expanded definitions of surgical complications to include obstetrical perineal 

trauma and compared actual instead of planned routes of delivery, the evidence shows a 

significantly higher rate of obstetrical trauma among spontaneous vaginal deliveries and assisted 

vaginal deliveries than among elective cesarean deliveries. Of course, perineal trauma does not 

occur when cesarean delivery is scheduled; consequently, planned vaginal birth and emergency 

cesareans are the only routes expected to be associated with perineal trauma, so it would be more 

common in those circumstances. Clearly, surgical complications such as fourth-degree 

lacerations or abdominal wound infections are associated with actual vaginal and cesarean 

deliveries, respectively. 

We had not designed this review to provide a comprehensive assessment of obstetrical 

trauma among vaginal deliveries. Nonetheless, obstetrical injury can be reduced by changing 

clinical practice. For example, reducing routine use of episiotomy (according to a recent review 

from this same team) is likely to reduce the risk of obstetrical injury.116 A recent review suggests 

that antenatal perineal massage may reduce perineal trauma during birth and pain afterwards.117

We encountered significant challenges in summarizing the risk of surgical complications 

associated with a planned “elective” cesarean delivery. Chief among these were the variable 

relevance of included studies; use of individual measures in some studies and composite 

measures in others; and differences in comparison groups across studies, comparison in some 

studies with only various types of cesarean deliveries, and the recurring problem of analysis 

based on actual, not planned, route of delivery. Despite the consistently low risk of surgical 

complications overall associated with planned “elective” or “unlabored” cesarean deliveries, the 

wide variability in specific outcomes studied and the widespread use of inconsistent composite 

outcomes limits both the utility of these data and our ability to draw definitive conclusions. 

Breastfeeding. Two Breech Trial articles (poor quality) provided weak evidence that 

although women with planned vaginal deliveries may initiate breastfeeding sooner than women 

with planned cesarean deliveries, they do not report any difference in the duration of 

breastfeeding.18,83 No studies among our included articles addressed the probability of either 

successfully starting breastfeeding if planned or attaining appropriate infant growth and 

development as measures of successful nutritional support from nursing. A meta-analysis of 

cesarean childbirth and psychosocial outcomes found that women with cesarean deliveries 

(planned and unplanned combined) were more likely to bottle feed than breastfeed compared 

with women with vaginal deliveries.118

Postpartum pain. Four articles (from three studies) reported on postpartum pain using 

various pain measures at different time periods.18,43,51,83 One was the Breech Trial (two articles 

were graded poor18,83), and the other two were of moderate relevance. Together, these studies 

provide weak evidence of no differences. No study reported a significant difference in pain 

between modes of delivery. 

Psychological outcomes: postpartum depression. Two studies (the Breech Trial and another 

study of low relevance) provided weak evidence suggesting no differences in postpartum 

depression by delivery route. As with pain, the Breech Trial likely overestimated the rate of 

complications, interventions, and possible negative psychological outcomes in the planned 

vaginal delivery group. 
117

Psychological outcomes: other. Seven articles (from six studies) yielded weak evidence 

about a range of other psychological outcomes; they included two articles from the Breech Trial 

(poor quality),18,83 two moderately relevant studies (one of fair quality51 and one of poor 

quality43), and three of low relevance.66,76,78 The data were consistent in reporting that women 

who had an unplanned cesarean delivery or an instrumental vaginal delivery were more likely to 

experience adverse psychological outcomes than were women who either underwent a 

spontaneous vaginal or a planned cesarean birth. Nonetheless, the variety of outcomes and 

measures makes a summative assessment of this literature extremely challenging. No studies, 

making appropriate comparisons, addressed maternal-infant attachment and satisfaction with the 

birth experience. 

Maternal length of stay. Four studies, the original article from the Breech Trial (fair 

quality)20 and three of moderate relevance (poor quality)28,43,50 provided moderate evidence that 

length of stay is higher for cesarean delivery, planned or otherwise, than for vaginal delivery. 

Numerous external factors influence length of hospital stay, however, including insurance 

coverage, regional practice patterns, physician and patient preference, and neonatal hospital stay. 

Better measures of maternal recovery would assess quality of life, but this literature did not 

report on such measures. 

Urinary incontinence. Nine articles (from eight studies) provided weak evidence that rates of 

stress urinary incontinence for planned “elective” cesarean delivery were either lower than or no 

different from those for vaginal delivery.18,41,44,70,73,74,79,82,83 The two Breech Trial articles were of 

poor quality; the two moderately relevant studies were of fair quality.41,44 Five were of low 

relevance.70,73,74,79,82 

We had several challenges in interpreting the body of evidence about urinary incontinence. 

The articles that reported on symptoms of stress urinary incontinence generally defined this 

condition as some involuntary leakage of urine associated with various maneuvers such as 

coughing, laughing, or sneezing, but the particular definitions varied considerably, and no study 

used a validated urinary incontinence questionnaire. One study accounted for severity of urinary 

incontinence but compared groups by symptoms only.79 The use of questionnaires, while 

appropriate for this outcome, may introduce both selection and recall bias when sent to women 

who were not prospectively recruited for enrollment. Another problem identified is that the time 

period for the assessment of urinary incontinence was generally short-term and varied widely 

from 6 weeks to 2 years postpartum. The two studies that linked surgical administrative 

databases and birth registries reported outcomes from 18 to 23 years after delivery.70,74 Because 

these two studies are limited to surgery or hospitalization for urinary incontinence, they most 

likely select for severe incontinence and may not fully capture the prevalence and association of 

mild and moderate urinary incontinence with mode of delivery. All the other studies reported on 

symptoms of urinary incontinence and captured milder forms of incontinence, but the followup 

periods were short. 

Finally, only four studies accounted for preexisting urinary incontinence.41,44,79,82 In short, 

numerous problems limit evidence on this outcome: lack of high-quality prospective studies that 

compare planned routes of delivery, have adequate power, include comprehensive long-term 

followup, account for multiple deliveries, account for variations in practice patterns including 

use of epidural anesthesia and episiotomy, use validated urinary questionnaires administered at 

consistent time points from delivery, and define incontinence in a standardized fashion by its 
118

occurrence, severity, and impact on quality of life. We note that future research should include 

studies of pathophysiological pathways for pelvic floor disorders. 

Recent studies have attempted to identify unique populations to study the influence of mode 

of delivery on future risks of urinary incontinence and have arrived at conflicting results. 

Buchsbaum et al. compared urinary incontinence in a group of nulliparous nuns with their parous 

sisters and found no statistically significant difference between these groups suggesting a 

familial influence not related to mode of delivery.119 Conversely, Goldberg et al. compared 

urinary incontinence among identical twin sisters and found that incontinence was associated 

with age, obesity, and mode of delivery with vaginal delivery conferring an increased risk 

relative to cesarean delivery (OR 2.28, CI 1.14-4.55).120 We note that a fundamental difference 

between these two studies is the age of the populations. The mean age of patients in the 

Buchsbaum study was 61 years compared with 47 years in the Goldberg study. This difference 

suggests that urinary incontinence is likely multifactorial and that any reduced risk associated 

with CDMR may be overridden by age. Future research should consider risks of urinary 

incontinence associated with cumulative pregnancies and deliveries, as any protective effect 

afforded by CDMR may also be reduced with increasing parity. 

Anorectal function. Seven articles (from six studies) provided weak evidence showing a 

reduced risk of anal incontinence in planned cesarean deliveries compared with unplanned 

cesarean or instrumental vaginal deliveries. There was inconsistent evidence of difference 

between planned cesarean and spontaneous vaginal delivery. The two Breech Trial articles (poor 

quality)18 did not show any significant differences in fecal incontinence at either 3 months or 2 

years, but several factors make it difficult to draw conclusions from this trial. It was designed to 

focus primarily on neonatal outcomes following planned vaginal versus planned cesarean for 

breech. It used different measures of anorectal function at each of the two time points, included 

multiparous women, allowed randomization in labor, had a high degree of crossover, was 

performed in 26 countries, and used nonvalidated instruments in multiple languages with more 

than 50 percent of participants requiring assistance in completing the questionnaire. 

Of the remaining five articles, two were moderately relevant (fair quality)42,46 but varied in 

their comparison groups, timing of assessment, and questionnaires used. One assessed severity 

and reported lower rates (3 of 80 women) of new onset anal incontinence in the elective cesarean 

group;46 two of these cases were of higher severity, suggesting that pregnancy itself might lead to 

anal incontinence. The other study reported a significantly lower rate of flatal incontinence but 

not fecal incontinence at 6 months in the planned “elective” cesarean than in the unplanned “in 

labor” cesareans.42 The remaining studies were of low relevance to CDMR. 

As with studies on urinary incontinence, the limited sample sizes and lack of a consistent 

direction of effect precludes definitive interpretation. Other factors also impede interpretation: 

studies used various instruments, often either completely unvalidated or unvalidated in the 

language of the study population; and studies were small and thus unable to characterize this 

disorder fully; studies lacked a consistent time period for assessment of anal incontinence and 

varied in the definitions used (some restricting their definition to incontinence of fecal matter and 

others including incontinence of flatus). Until studies adopt a more uniform set of operational 

definitions and outcome measures, information on this outcome will continue to be scanty and 

problematic. 

Pelvic organ prolapse. We found no evidence on the association between pelvic organ 

prolapse and planned vaginal or planned cesarean delivery. A single study of low relevance 
119

(from an administrative data set) examined hospitalization for either “vaginal descensus” or 

urinary incontinence as one of several secondary outcomes associated with actual modes of 

delivery.70 Because of a possible typographical error in the results section of the article, we could 

not make any definitive comments about this article or outcome. 

Sexual function. Two Breech Trial articles (poor quality) provided weak evidence that sexual 

function does not differ by planned route of delivery.18,83 This study used unvalidated measures 

that were administered in multiple languages and required the assistance of translators. 

Maternal outcomes relevant to subsequent cesarean delivery. As noted in previous 

chapters, our systematic review focused on primary cesarean deliveries. The following 

discussion is limited to summaries or updates of existing systematic reviews for three outcomes 

that we believe are of interest to the SOS conference panel. 

Subsequent fertility issues. We found no evidence on the association between subsequent 

fertility issues and planned vaginal or planned cesarean delivery among our included articles. A 

review of cesarean deliveries on future pregnancy noted that the procedure is a risk factor for 

lowered fertility, for uncompleted pregnancy, for complications in the next pregnancy and birth, 

and for health problems in the next infant. The study notes that all reviews potentially suffer 

from selection bias by indication and that reproductive outcomes after a cesarean delivery can be 

attributed to either the cesarean or to factor causing it.121 As with subsequent stillbirth, the issue 

of potential bias reduces the utility of these findings to CDMR. 

Subsequent uterine rupture. A recent update32of a systematic review96 on the outcomes of 

vaginal birth after cesarean (VBAC) provided moderate evidence on subsequent uterine rupture. 

The update found no statistically significant differences between trial of labor after cesarean and 

elective repeat cesarean delivery with regard to rates of asymptomatic uterine rupture rates. The 

update noted that two studies of fair or good quality found a small but higher risk of symptomatic

uterine rupture in trial of labor after cesarean than in elective repeat cesarean delivery (2.7 per 

1,000).97,122 A large multicenter prospective observational study of 33,699 women carrying 

singleton pregnancies following earlier cesarean delivery provided similar evidence: the study 

reported an incidence of uterine rupture of 0.7 (124 per 17,898 deliveries) for a trial of labor and 

no cases of uterine rupture for elective repeat cesarean delivery (0 of 15,801 deliveries). 

Maternal death and hysterectomy did not differ between groups.123

Placenta previa. Given that placenta previa is the most common placental implantation 

anomaly, we updated a recent meta-analysis by Faiz and Ananth examining the relationship 

between placenta previa and a history of cesarean delivery.31 Our update supports the earlier 

meta-analytic conclusion that placenta previa is associated with advancing maternal age and 

increasing parity. The literature provided moderate evidence that the risk of placenta previa 

increases with previous cesarean delivery. 

Subsequent stillbirth. The only study we found (low relevance to CDMR) did not show a 

difference in the rates of subsequent stillbirth among elective cesarean, emergency cesarean, and 

vaginal delivery.70 This study followed a cohort of breech deliveries and did not control for 

breech presentation in subsequent deliveries; the results are of limited utility to CDMR. A recent 

retrospective cohort study by Smith et al. suggested a twofold higher risk of stillbirth in 

subsequent pregnancies in women who had had a previous cesarean than in women who had 

delivered only vaginally (3.8 per 1,000 vs. 2.3 per 1,000, respectively).124 The authors did not 

record the indication for the first cesarean delivery, however, and the higher risk of stillbirth 

observed may have been associated with the medical conditions that warranted the cesarean 
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deliveries in the first place, not the cesarean deliveries themselves. The issue of potential bias 

reduces the utility of these findings to CDMR. 

Neonatal outcomes. Table 32 provides the direction of effect and strength of evidence for 

the neonatal outcomes for which we sought evidence in this review. The evidence was either 

weak or nonexistent for every outcome examined. 

Table 32. Summary of neonatal outcomes, directions of effect, and strength of evidence 

Neonatal Outcomes Direction of Effect Strength of Evidence 

Fetal mortality No evidence IV 

Neonatal mortality Higher risk for “cesarean” than for spontaneous vaginal 

delivery; no controls for underlying maternal or neonatal 

indications for cesarean 

III 

Unexpected (iatrogenic) 

prematurity 

No evidence allows comparison of unlabored cesarean 

and planned vaginal birth 

IV 

Respiratory morbidity Higher risk with cesarean; risk drops with advancing 

gestational age; no study evaluated meconium aspiration 

syndrome by mode of delivery 

II 

Transition Insufficient evidence to judge direction or magnitude of 

effect 

III 

Neonatal asphyxia/ 

encephalopathy 

Inconsistent evidence of risk with elective cesarean; 

higher risk for operative vaginal deliveries and 

emergency or labored cesareans than for spontaneous 

vaginal delivery 

III 

Intracranial hemorrhage No difference between prelabor cesarean and 

spontaneous vaginal delivery; higher risk for assisted 

vaginal deliveries and cesarean deliveries in labor than 

for spontaneous vaginal delivery 

III 

Facial nerve injury No difference between vacuum or prelabor cesarean 

delivery and spontaneous vaginal delivery; higher risk for 

forceps and combined vacuum and forceps than for 

either a vaginal or cesarean delivery 

III 

Brachial plexus injury Lower risk for all cesareans than for spontaneous vaginal 

delivery; higher risk for vacuum, forceps, and combined 

vacuum and forceps delivery than for spontaneous 

vaginal delivery 

III 

Fetal lacerations Lower risk for elective cesarean than for unplanned 

cesarean 

III 

Neonatal length of stay Higher risk of longer hospital stay with elective compared 

with vaginal delivery 

III 

Long-term outcomes No evidence IV 

Fetal mortality. We found no studies that addressed fetal (in utero) deaths. Fetal mortality 

can occur at any gestational age, including at term or postterm.125 A purported benefit of CDMR 

is the prevention of fetal (in utero) death in late-term or post-term pregnancies. A comprehensive 

assessment of CDMR ought to compare fetal deaths at all gestational ages by planned route of 

delivery. 

Neonatal mortality. One study of moderate relevance (fair quality)53 and one of low 

relevance81 provided weak evidence on neonatal mortality. The moderately relevant study 

compared “elective” cesarean with vaginal delivery. This study reported no neonatal mortality 

but was underpowered for such a rare outcome.53 
121

The low relevance study used a large administrative data set that offered a sample size 

sufficient to examine rare outcomes, but its retrospective classification of mode of delivery 

limited its usefulness. For instance, the classification of the cesarean deliveries was limited to 

either “labored” or “unlabored.” The unlabored cesarean deliveries likely included emergency 

cesareans and those performed for serious maternal and neonatal indications such as placenta 

previa, severe preeclampsia, breech presentation, fetal distress, and major fetal anomalies. Such 

maternal and neonatal disorders could seriously affect neonatal mortality and seriously confound 

the underlying association between neonatal mortality and mode of delivery.

Unexpected (iatrogenic) prematurity. We found no study that addressed unexpected 

prematurity and allowed comparisons by type of cesarean with intended or actual vaginal 

delivery. 

Respiratory morbidity. Measures of respiratory morbidity range from transient tachypnea of 

the newborn (TTN) to severe respiratory distress syndrome (RDS) with long-term sequelae. 

Overall, nine articles (for eight studies) yielded moderate evidence on the association of neonatal 

respiratory problems and delivery route.47,48,51-53,65,77,80,81 Four studies of moderate relevance (fair 

quality) suggested that the risk of variably defined “respiratory morbidity” was higher for all 

cesarean births than for vaginal deliveries. This finding is consistent with the long-held belief 

that neonatal passage through the birth canal improves the neonatal pulmonary transition from 

amniotic fluid to breathing air. No study assessed TTN and RDS and also stratified results by 

gestational age. 

We did not find sufficient evidence to determine whether gestational age alone accounts for 

the differential risk of respiratory neonatal morbidity associated with cesarean delivery. Five 

articles (from four studies) that accounted for gestational age consistently reported a significant 

reduction in the risk of neonatal morbidity as gestational age advanced, approaching equality at 

39 to 40 weeks.48,52,53,77,80 

Clinicians believe that the experience of labor itself results in a lower risk of neonatal 

respiratory morbidity (TTN and RDS), but we found no conclusive evidence that labor before 

cesarean delivery offers a protective effect. This may be due to confounders such as inclusion of 

meconium aspiration syndrome in a composite measure of respiratory distress. 

One of four studies that compared TTN and RDS between prelabor and labored cesarean 

deliveries showed a lower risk of respiratory morbidity in labored cesarean deliveries.48

However, the remaining three studies showed a higher risk of respiratory morbidity in labored 

cesarean deliveries.47

We cannot determine whether the higher risk of respiratory morbidity associated with 

labored cesarean deliveries in these three studies is due to TTN, RDS, or MAS. Similarly, we 

cannot determine whether the higher rate can be attributed to a higher rate of emergency 

cesarean for complications relating to prematurity. 

The pathophysiological mechanism by which labor may influence the risk of respiratory 

morbidity associated with TTN and RDS is unclear and may extend beyond the physical effects 

of labor on the fetus (thoracic compression). 

Finally, we found insufficient evidence to be able to comment on meconium aspiration 

syndrome. 

Transition issues. The same low relevance study81reported on this outcome, but the 

significant issues of appropriate categorization in this study make interpreting the data difficult. 

We consider the available evidence insufficient to judge the direction of effect. 
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Neonatal asphyxia or encephalopathy. Two studies provided weak evidence of a higher risk 

of neonatal encephalopathy associated with operative vaginal deliveries and “emergency” or 

“labored” cesareans than with spontaneous vaginal delivery. One case-control study of moderate 

relevance (fair quality) found a significantly reduced risk of neonatal encephalopathy associated 

with planned “elective” cesareans deliveries.37 The large administrative database study (low 

relevance) found an increased risk of convulsions and central nervous system depression 

associated with “prelabored” cesareans than with spontaneous vaginal deliveries.81

These studies have differing relative strengths. The moderately relevant study has a superior 

proxy for planned cesarean delivery, but as a case-control study it cannot be used to comment on 

absolute risks. The low relevance study is appropriate for calculating absolute risks; however, the 

study defined the key comparison group as “unlabored” cesarean and may, therefore, include 

cesareans performed because of nonreassuring fetal status, which represents a significant 

confounder for route of delivery and for this particular outcome. 

Intracranial hemorrhage. The administrative database study (low relevance) also provided 

weak evidence on intracranial (subdural/cerebral, intraventricular, and subarachnoid) 

hemorrhage.81 The prelabor cesarean deliveries included those done for maternal or neonatal 

indications, so they likely involved cesareans for placenta previa and fetal anomalies, which may 

independently increase the risk of intracranial hemorrhage. Despite the higher theoretical risk for 

prelabor cesarean deliveries, this study did not find any significant difference between 

spontaneous vaginal delivery and prelabor cesarean deliveries. It did show consistently higher 

rates of intracranial hemorrhage for assisted vaginal deliveries and cesarean deliveries in labor. 

The results suggest that CDMR poses no greater risk for intracranial hemorrhage than does 

planned vaginal delivery. 

Facial nerve injury. The administrative database study (low relevance) provided weak 

evidence that the risk of facial nerve injury varies by mode of delivery; the risk is higher for 

forceps and the combined use of forceps and vacuum delivery than for spontaneous vaginal 

delivery.81 These findings suggested that CDMR posed no risk for facial nerve injury greater 

than that associated with planned vaginal delivery. 

Brachial plexus injury. The administrative database study (low relevance) provides weak 

evidence that the incidence of brachial plexus injury is lower in cesarean delivery than in vaginal 

delivery;81 these results are consistent with a priori expectations. In this study, the rate of 

brachial plexus injury was significantly higher in vacuum, forceps, and the combined attempt at 

vacuum and forceps deliveries than in spontaneous vaginal delivery. The rate of brachial plexus 

injury was significantly lower for cesareans overall and for those performed after labor than for 

spontaneous vaginal delivery; it was also lower (approaching statistical significance) for 

cesareans performed before labor than for spontaneous vaginal delivery. Clinicians generally 

accept that shoulder dystocias and resultant brachial plexus injuries are primarily associated with 

vaginal deliveries. To what extent brachial plexus injuries resolve spontaneously or results in 

long-term permanent disability has not been clearly documented. 

Fetal laceration. Two studies of moderate relevance (poor quality) provided weak evidence 

on fetal lacerations based on data limited to cesarean deliveries. They reported a higher rate of 

fetal lacerations among emergency and labored cesarean than among elective cesarean 

delivery.28,40 The higher risk of fetal laceration associated with an emergency or labored cesarean 

may have several explanations: entering the uterus more rapidly in cases of fetal distress, having 

a thin lower uterine segment after labor, and having less or no amniotic fluid after rupture of 
123

membranes (which places the fetal skin in almost direct contact with the uterine wall). These 

results suggested that CDMR posed no additional risk for fetal lacerations beyond those 

associated with planned vaginal delivery.

Neonatal length of hospital stay. One study (two articles) of moderate relevance (fair quality) 

provided weak evidence that the neonatal length of hospital stay is higher for “elective” cesarean 

delivery than for vaginal delivery.52,53

Long-term neonatal outcomes. We did not find any evidence on long-term neonatal 

outcomes.

KQ 3: Modifiers of Cesarean Delivery on Maternal Request 

The evidence on effect modifiers is sparse and pertains to only a few outcomes for KQ 2. 

Five studies provided evidence on the modifiers of CDMR, specifically neonatal respiratory 

distress,53,55 infectious morbidity,54 and urinary incontinence.82 

With regard to respiratory morbidity, results showed a consistent decrease in respiratory 

morbidity as gestational age rises, despite differences in inclusion criteria and definitions of 

elective cesarean delivery.48,53,55 Gestational age appears to play a lesser role as a risk factor for 

fetal respiratory distress in planned vaginal delivery than in planned cesarean. 

With regard to infectious morbidity, the single study we found suggested no effect of 

physician experience, incision type, maternal age, or prophylactic antibiotics on infectious 

morbidity; it did suggest that the risk was higher among obese or black patients than among other 

women.54 Pelvic floor exercises decreased the risk of urinary incontinence; prepregnancy body 

mass index (BMI) increased it.82

Given the lack of evidence directly comparing effect modifiers in a population with planned 

CDMR with those in a population with planned vaginal delivery, inferences about effect 

modifiers must be drawn cautiously. Furthermore, most studies did not adjust for confounders, so 

results must be interpreted as crude estimates. 

A multitude of factors can conceivably affect outcomes of planned CDMR and planned 

vaginal delivery. An extensive body of literature exists on how factors such as comorbidities, 

settings, and patient characteristics influence outcomes of vaginal delivery, but reviewing it was 

beyond the scope of this report. Furthermore, indirectly comparing results of these studies with 

results of studies on planned CDMR could be misleading because of the heterogeneity of 

populations, differences in definitions, and varying standards of care. 

Limitations of Our Review 

We designed our search strategies to answer questions for the SOS conference scheduled for 

March 2006. Thus, our aim was to compare primary planned cesarean delivery (cesarean 

delivery on maternal request, or CDMR) with planned vaginal delivery. Time and resources did 

not permit us to review comprehensively the benefits and harms associated solely or primarily 

with vaginal delivery, or with repeat cesarean deliveries. 

In addition, for similar time and resource reasons, we did not conduct dual, independent, 

blinded review of articles for inclusion or abstraction of information into evidence tables. 

Instead, one reviewer performed the initial review, and a second reviewer examined that input 

and recommended changes or corrections when needed. These two reviewers reconciled any 
124

differences by consensus discussion. To enable us to evaluate rigorously any systematic bias in 

our work, however, we did apply dual review for assigning relevance ratings, assessing the 

quality of individual articles, and grading the strength of evidence. 

Limitations of the Evidence Base 

Lack of Consistent Terminology 

Studies lacked consistent and clear definitions of routes of delivery, maternal outcomes, and 

neonatal outcomes. They inconsistently took into account whether “planning” occurred before 

delivery, indications for cesarean, and laboring status in their categories of mode of delivery. 

Moreover, ambiguities and discrepancies in how outcomes were defined and measured were 

frequent. These variations across studies made comparing outcomes for planned routes of 

delivery extremely challenging and sometimes impossible. 

Inappropriate Comparisons: Planned versus Actual Delivery Modes 

As explained in detail in Chapters 1 and 2, the appropriate comparison to address the SOS 

conference issues is that of intent: planned vaginal delivery or planned CDMR. The great 

majority of studies in this systematic review report outcomes by actual route of delivery. Failure 

to use intent-to-treat approaches can bias results. 

The absence of data on appropriate routes of planned deliveries required us to use proxies for 

CDMR. These proxies usually compared actual routes of delivery, not planned routes of 

delivery, similarly leading to bias from failure to account for intent-to-treat. 

The SOS Conference panel and the TEP recommended that, for proxies, we use studies 

comparing routes of delivery for breech presentation. We recognized the significant confounding 

effect this indication would have on neonatal outcomes, so we used it as a proxy only for 

maternal outcomes. As noted in Chapter 1, however, the extent to which studies of breech 

presentation serve as appropriate proxies for maternal outcomes of planned vaginal delivery 

compared with those of planned CDMR is unclear. For instance, the risk of infection may be 

higher in planned cesarean for breech, if the length of time between labor onset or rupture of 

membranes to cesarean delivery is higher than it would be in true CDMR. Conversely, the risk of 

infection in the planned vaginal delivery group may be higher because the number of women 

undergoing a labored cesarean is greater than the number expected in a typical population of 

women with vertex presentations. 

 Inappropriate Study Designs 

No clinical trial addressed the question of true CDMR. The only randomized controlled trial 

of route of delivery was for breech presentations, and it had several limitations that have been 

noted elsewhere in this review. Studies generally relied on retrospective data with attendant 

issues of poorly defined routes of delivery and outcomes. Few studies provided power 

calculations to support their estimates.
125

Inadequate Controls for Confounders 

Studies infrequently accounted for confounders such as morbid obesity, multiple gestations, 

placenta previa, and polyhydramnios (excess amniotic fluid) that influence the recommended 

route of delivery and also lead to poor maternal and neonatal outcomes. The extent to which 

these confounders influenced these outcomes is generally unknown because authors rarely 

controlled for such variables. A striking example of poor assessment of confounding arises in the 

studies of neonatal respiratory morbidity. Several of these studies included preterm infants, 

suggesting failure to account for underlying maternal or neonatal indications that could have 

influenced both route of delivery and respiratory outcomes. 

Inadequate Assessment of Modifiers of Outcomes 

Most studies included in this systematic review do not adequately report on the standards of 

care associated with a particular route of delivery that could potentially modify outcomes. For 

instance, few studies address potential modifiers of outcomes associated with vaginal delivery 

such as too early hospital admission in labor, lack of adequate emotional support, electronic fetal 

monitoring, epidurals for pain management, laboring and pushing in bed, IV fluids, too many 

vaginal exams, strict time limits for duration of labor, valsalva pushing as soon as the cervix is 

completely dilated, lithotomy position for birth, and episiotomy. Similarly, studies do not 

address potential modifiers of outcomes associated with planned cesarean delivery such as 

variations in operative technique (single versus double layer uterine closure, extraabdominal 

uterine exteriorization to facilitate closure of incision or uterine massage, closure of 

vesicouterine (visceral) peritoneum, closure of parietal peritoneum), physician expertise, and 

access to emergency care. We are therefore unable to comment on whether the risks of any 

particular outcome are associated with "ideal" practice environments or whether these risks can 

be appreciably modified by changes in the practice environment. 

Inadequate Quality of Studies 

Nonrandomized observational cohort studies were universally of fair or poor quality; the 

limitations of these studies were noted in Chapter 3 and above. 

A single randomized controlled trial, the Breech Trial, was in principle the best study we had 

available to us because it used intent-to-treat analysis and reported on maternal surgical, pelvic 

floor, and pain outcomes. It offered high quality data on mode of delivery for neonatal outcomes, 

but the findings were specific to breech deliveries and could not be extrapolated to vertex 

pregnancies. We therefore excluded studies of breech deliveries from our review of neonatal 

outcomes. 

For the broader purposes of this review, however, the Breech Trial had some limitations. It 

included multiparous patients and allowed women to be randomized even if in labor; it was not 

designed to address pelvic floor outcomes; and it had a high rate of cross-over. Finally, it used 

unvalidated instruments in multiple languages (as the study was done in 26 countries) and more 

than 50 percent of the participants required assistance in completing the questionnaires; 

moreover, the questionnaires changed throughout the study period, and different questionnaires 

were used at 3 months and at 2 years. 
126

Inappropriate Outcome Measures: Timing, Severity, and Utility 

Studies reporting maternal and neonatal outcomes that were not immediately evident at 

delivery measured outcomes at varying lengths of time from delivery. This lack of a standard 

time period to assess long-term outcomes makes comparing studies problematic. Further, 

outcomes such as urinary incontinence, pelvic organ prolapse, and anal incontinence were 

usually measured a few weeks to a few months from delivery; they are, therefore, of limited 

clinical relevance. Studies that measured pelvic floor disorders more than 2 years from delivery 

were limited to administrative databases; they could not control for variables such as interval 

pregnancies and deliveries, length of labor, use of vacuum or forceps (or both), obesity, smoking, 

constipation or chronic straining, or previous reconstructive pelvic surgery. 

The severity of the maternal and neonatal outcomes we examined for the SOS conference 

varied appreciably with respect to severity; the gravity of the outcomes clearly differs across 

such outcomes as UTI, sepsis, or death (for mothers) or across TTN, RDS, scalp lacerations, and 

intracranial hemorrhage (for infants). However, few studies rated the severity of any particular 

outcome. 

No study provided any assessment of the utility (to either mothers or, by proxy, infants) of 

these different outcomes. Conspicuously absent was any measure of health-related quality of life 

in the face of different outcomes. The issue of severity rating and quality of life is particularly 

relevant to pelvic floor outcomes such as urinary incontinence, pelvic organ prolapse, or anal 

incontinence. 

Future Research Directions (Key Question 4) 

Medicine is often practiced beyond the boundaries of robust research evidence. In such 

instances, providers and patients may experience little discomfort making decisions based on 

well-established patterns of care. However, when new treatments, technologies, or concepts 

appear that result in new patterns of care, substantial anxiety about the best way to chart a course 

may occur. 

CDMR is an exemplar of a challenge to conventional practice that arises quickly, gains 

momentum, and generates numerous questions in its wake. CDMR is particularly challenging 

given the complexity of issues that need to be addressed both individually by the patient and 

provider and by society. Issues relevant to patients and providers include balancing short- and 

long-term risks and benefits for the woman and her infant, assessing such risks in both the first 

pregnancy and any subsequent pregnancies, and determining the validity and value (utility) of 

the benefits asserted. Societal concerns range broadly: the extent of individual autonomy to make 

informed health care decisions, including the choice of CDMR; the impact that CDMR may have 

on health care costs; ethical implications of elective surgery to avoid a physiologic process; 

modern medicalization of birth; influence of consumerism; fear of litigation; and motivations of 

the professional groups who advocate for answers. 

The need for high-quality research evidence to inform care is of paramount importance. For 

instance, some practices, such as the use of routine episiotomy, have been adopted widely but 

remain without evidence of benefit.116 Some practices that had been widely adopted were only 

later proven ineffective: examples include hormone replacement therapy126,127 and a common 

arthroscopic knee surgery.128 Such examples force the biomedical and clinical communities and 
127

patients and consumers to acknowledge that “intuition, unsystematic experience, and 

pathophysiologic rationale are insufficient grounds for clinical decision-making.”129 

Women and their providers make decisions about CDMR every day. An individual woman’s 

desire for a CDMR may be supported or rejected by her prenatal care provider or by the clinician 

to whom she is referred for consultation if the original provider does not perform cesareans or 

does not support CDMR. Some observers suggest that few women would spontaneously request 

a cesarean; they hold that care providers introduce the idea with the intent (and effect) of making 

the option seem “normal” and prompting women to consider and, later, perhaps request CDMR. 

Regardless of the mechanism that leads to these discussions, at present they happen without 

evidence that is sufficient to bear the weight of the decision for or against CDMR. 

An accurate assessment of maternal and neonatal risks and benefits associated with CDMR 

requires a comprehensive and explicit estimation of utility or value that women, their families, 

and others place on each outcome. Setting values separately on short- and long-term outcomes 

for mothers and for infants, in both the first and subsequent pregnancies, is challenging indeed, 

but it is necessary to understand fully the implications of a decision to choose CDMR. 

This systematic review underscores the striking paucity of helpful data related to CDMR. 

The following section provides a framework for structuring future research on these topics, with 

particular reference to the numerous gaps and limitations that we identified. 

Terminology 

The lack of standardized definitions of planned modes of delivery, required to establish valid 

groups for comparison of outcomes, extends to measures of maternal and neonatal outcomes. 

This evidence review points to a need for greater uniformity and sophistication in the collection 

of data, clear operational definition of the exposure groups, and improved operational definitions 

of the outcomes to be compared. 

The fundamental difficulty with summarizing the body of literature identified was the lack of 

standardization of definitions for mode of delivery. Operational definitions varied widely and at 

times were not defined at all. Categorization of type of cesarean took many guises: maternal 

request, planned or unplanned, scheduled or unscheduled, emergency vs nonemergency vs 

urgent, labored or unlabored, “elective,” and specific maternal or neonatal indications for a 

particular mode of delivery. 

For the benefit of this literature as well as the broader literature on birth outcomes, we 

strongly recommend that significant resources be designated to arriving at precise operational 

definitions for all applicable categories of delivery modes, including clear specification of 

maternal and neonatal indications. Without early consensus on these definitions, we are unlikely 

to arrive at reliable estimates of the trend and incidence of CDMR (or other reasons for cesarean 

delivery more generally) or of the benefits and harms associated with any particular mode of 

delivery in comparison with another. 

In addition, we strongly recommend establishing a minimum data set for maternal and 

neonatal outcomes to help clarify the terminology but also to provide a mechanism for doing 

long-term prospective investigations. This will require thoughtful collaboration among 

appropriate stakeholders, including family physicians, midwives, obstetricians, neonatologists, 

pediatricians, urogynecologists, and experts in public health. 
128

Appropriate Study Design 

Although clinical trials are the usual touchstone and highest standard for aiding clinical 

decisionmaking, the feasibility of conducting a trial on CDMR is questionable. Researchers will 

need groups of women who opt to have cesarean births based on their own desire, and not as a 

result of a previous cesarean, or groups of women who are willing to be assigned randomly to 

either scheduled cesarean or conventional expectant management and labor, which could include 

cesarean based on medical need. 

Currently, prospective observational studies provide the best initial approach to defining and 

describing outcomes of planned routes of delivery adequately. However, we recognize that 

prospective studies may be inadequately powered to examine rare outcomes such as maternal or 

neonatal death, hysterectomy, or shoulder dystocia. Universal adoption of consistent terminology 

and recordkeeping on planned route of delivery will increase the usefulness of retrospective data 

in addressing rare outcomes, especially data in large administrative databases. 

Appropriate Statistical Methods and Reporting 

Investigators must address a variety of statistical issues. Paramount are ensuring adequate 

sample size and doing power calculations. Most studies (other than those relying on surveys or 

administrative data) were relatively small. Some may have been underpowered for all but the 

most basic comparisons, and most were underpowered for subgroup analyses. Investigators 

should consider a priori what comparisons they want to make (and report) on the relevant power 

calculations. This is especially critical if researchers wish to track rare outcomes. 

We recognize that some research teams may well have attended to these concerns. If so, they 

did not report them. Thus, we encourage those conducting trials or other studies to report all 

power calculations and otherwise make available data that will enable groups doing systematic 

reviews in the future to understand clearly and possibly use those data in quantitative analyses. In 

addition, we caution that researchers should take care to deal with statistical problems of 

multiple comparisons, possibly with appropriate corrections for statistical significance. Finally, 

we suggest that all research reports directly report or provide information sufficient to 

understand the statistical significance (or lack of it) for all reported comparisons.

Appropriate Comparisons 

Studies designed to compare outcomes of CDMR need to compare outcome by planned

routes of delivery. Such intent-to-treat analysis should not, and need not, be limited to 

randomized controlled trials. At the current time, given the lack of any mechanism to record 

intent in a standardized fashion, prospective studies are the only reliable source for obtaining 

appropriate comparisons based on planned routes of delivery. 

We strongly recommend that clinicians routinely record the planned route of delivery at term 

in prenatal records. Such data would allow for appropriate comparisons based on intent-to-treat 

even with retrospective studies. We acknowledge, however, that liability issues and fear of 

discord with peers, especially for conducting CDMR, might well dissuade clinicians from 

making such notes. 
129

Future studies should limit the use of proxies for CDMR. Caution should be exercised in 

interpreting results of studies that use such proxies, because they often introduce bias from 

uncontrolled confounding effects. All analysts should consider carefully the potential magnitude 

and direction of effect from such bias. 

Important Outcomes 

We draw attention to two specific outcomes, one maternal and one neonatal, that we believe 

require special thinking when investigators are planning future research. For mothers, reduced 

urinary incontinence is often cited as a major benefit of CDMR, and significant resources ought 

to be allocated to provide evidence to support or refute this claim. An outcome such as urinary 

incontinence requires a long-term, comprehensive study that assesses a wide range of variables: 

mode of delivery, number of births, presence and severity of urinary incontinence, and other 

factors that have been suggested as confounders such as constipation, smoking, and chronic 

cough. 

For infants, the primary morbidity associated with prematurity is lung immaturity. The 

evidence is strong for an association between gestational age and lung maturity. For those 

reasons, prospectively and accurately documenting estimated gestational age and respiratory 

outcomes among maternal choice cesareans is critical. If CDMR rates continue to increase, 

clinicians and patients may tend to want to do cesareans at an earlier gestational age for maternal 

convenience arising from discomfort from a gravid uterus. The benefits and harms of such 

practices, particularly for the neonate, must be well understood by all parties, and providing that 

information will require additional research. 

Severity 

The issue of severity rating is particularly important for pelvic floor outcomes such as urinary 

incontinence, pelvic organ prolapse, or anal incontinence. An undifferentiated measure of urinary 

incontinence that does not account for severity would mask the considerable differences in 

quality of life between a small amount of leakage that occurs rarely and severe and daily urinary 

leakage. 

Similarly, neonatal outcomes such as respiratory morbidity need to be categorized and 

analyzed by degree of severity. For instance, TTN and RDS represent extremes of severity; 

investigators should not group them into a single measure of respiratory morbidity because doing 

so may obscure meaningful differences among groups. 

Appropriate Measures 

Future studies will require a comprehensive assessment of outcomes using validated 

questionnaires with a standardized timing of outcome measures, with measures of severity and 

utility. 

Comprehensive outcomes. Ideally, a systematic review of the outcomes of planned route of 

delivery should provide a comprehensive assessment of outcomes, accounting for the severity of 

symptoms and the utility of various outcomes to patients. For instance, accurate measurement of 

neonatal respiratory morbidity should include the risks of all forms of harm associated with 
130

planned route of delivery, including potentially higher risks of meconium aspiration in planned 

vaginal deliveries and potentially higher risks of TTN and RDS in planned cesarean deliveries. 

Validated questionnaires. Researchers should be encouraged to use reliable and valid 

questionnaires for assessing outcomes such as health-related quality of life, maternal-infant 

attachment, birth satisfaction, pelvic floor disorders (urinary incontinence, pelvic organ prolapse, 

and anal incontinence), and sexual function. These instruments must appropriately capture both 

short- and long-term consequences of decisions related to mode of delivery. When validated 

instruments do not exist or are too long to administer in these circumstances, investigatators 

should either develop (and validate) or adapt existing ones into shorter forms. 

Standardized times for outcome measurement. Ideally, outcomes should be measured over 

time periods that are appropriate and clinically relevant. In addition to reaching consensus on 

terminology, researchers in the field should develop consensus on the minimum clinically 

relevant time period from delivery to measurement for outcomes, particularly for outcomes of 

importance beyond the postpartum period. 

Confounders 

Future studies need to describe and control for potential confounders of route of delivery and 

outcomes. The nature of these confounders may vary depending upon the specific outcome of 

interest. 

At a minimum, studies of maternal outcomes should account for age, BMI, parity, previous 

cesarean deliveries, multiple gestation, maternal medical conditions such as diabetes mellitus, 

abnormal placental implantation (e.g., previa and accreta), and epidural use. Studies of neonatal 

outcomes should additionally account for gestational age, fetal presentation, and fetal anomalies 

or medical condition. Finally, future studies should also control for health system variables such 

as access to antibiotics, anesthesia, blood banking, and providers with adequate surgical training 

to perform an emergency cesarean delivery, which together are important components of a high 

standard of care. 

Utility of Outcomes 

Factoring in both severity and utility when assessing the overall benefit and harm of CDMR 

is critically important. A woman considering a planned route of cesarean delivery needs to assess 

comprehensively both short- and long-term risks, to both herself and her infant, and in both the 

current pregnancy and future pregnancies. 

Currently, clinicians and others have little or no way to judge the “priority” of a range of 

possible outcomes. For instance, urinary incontinence needs to be described in a manner that 

relates both its occurrence and severity and that provides a utility weighting relative to other 

potential outcomes such as wound infection. Similarly, in assessing overall harms and benefits to 

the neonate, the potentially higher risk of neonatal respiratory morbidity (TTN and RDS) 

associated with a planned CDMR needs to be weighed against the potential reduction in the rate 

of other outcomes such as stillbirths after 39 weeks, intrapartum deaths, and shoulder dystocias 

(an emergency occurring when the infant’s shoulder gets “stuck”) associated with a planned

vaginal delivery.
131

New Areas for Research 

Costs. A thorough evaluation of the costs associated with CDMR is warranted given the 

finite health care resources available in this country. Such a cost analysis needs to be done from 

various perspectives: the patient and her family, the health system (e.g., hospital, physician 

group), the health plan or insurance carrier (both public, as in Medicaid, and private), and the 

health care system more generally. To be most informative, such a cost analysis would factor in 

the costs associated with subsequent deliveries. It should account for all appropriate intrapartum 

and postpartum expenses attributable to each pathway of delivery, for both mother and infant. 

We draw attention, in this regard, to the flowchart figure in Chapter 1, which documents the 

considerable complexity of the pathways as they diverge from initial planned route to the actual 

route of delivery, particularly in that the planned and actual routes diverge at different points. 

Whether the costs associated with the higher numbers of planned cesareans in the CDMR arm 

(primarily surgical costs) will be balanced by the costs associated with planned vaginal delivery 

(labor and delivery nursing time, supplies, epidural management, medications, and the surgical 

costs associated with labored cesareans) remains to be determined. Psychosocial burdens and the 

influence of satisfaction with the birth experience, infant feeding, and neonatal and infant 

development, including any decrements in maternal and infant attachment, remain uninformed 

by adequate comparisons; more to the point, their costs cannot be reduced to simple economic 

terms. 

Apart from gaining data simply on costs per se, the question of cost-effectiveness may arise. 

Which delivery path is more cost effective is impossible to say for two reasons. First, as we have 

documented, little is known about the comparative effectiveness of different modes of delivery. 

Second, no studies compare the costs of CDMR with those of planned vaginal delivery. Thus, the 

task of examining any issues related to cost-effectiveness lies well into the future. 

Medical and legal concerns. If the rate of CDMR were to continue to increase, how and to 

what degree this pattern would affect the medicolegal environment within which obstetrics is 

currently practiced in developed countries (particularly the United States) remains an open 

question. Future research in this area would help us understand to what extent a decision to 

perform a cesarean after labor in a woman who planned a vaginal delivery was influenced by the 

provider’s fear of litigation. Future research could also investigate whether medicolegal exposure 

or malpractice insurance premiums rise or fall depending on patterns of CDMR vs. planned 

vaginal delivery. 

Conclusions

The incidence of CDMR appears to be increasing. However, accurately assessing its true 

incidence or trends over time is difficult because currently CDMR is neither a well-recognized 

clinical entity nor an accurately reported indication for diagnostic coding or reimbursement. 

More information is available on this question from nations other than the United States, and 

they differ from this country in health systems, cultural attitudes, patient demographics, and 

other factors. Drawing inferences from non-US sources, therefore, must be done with caution. 

Virtually no studies exist on CDMR per se, so the knowledge base rests chiefly on indirect 

evidence from proxies such as cesareans performed for breech presentation. These proxies each 

possess unique and significant limitations. Furthermore, the vast majority of studies to date 
132

compared outcomes by actual routes of delivery, not planned routes of delivery. Therefore, 

significant uncertainty remains regarding the “ideal” route of delivery. Primary CDMR and 

planned vaginal delivery likely do differ with respect to individual outcomes for either mothers 

or infants. However, our comprehensive assessment, across many different outcomes, suggests 

that no major differences exist between primary CDMR and planned vaginal delivery, but the 

evidence is too weak to conclude definitively that differences are completely absent. If a woman 

chooses to have a cesarean delivery in her first delivery, she is more likely to have subsequent 

deliveries by cesarean. With increasing numbers of cesarean delivery, risks occur with increasing 

frequency. 

Given the limited data available, we cannot draw definitive conclusions about factors that 

might influence outcomes of planned CDMR vs. planned vaginal delivery. Neither is the 

knowledge base adequate to comment definitively on many factors that influence the outcomes 

of actual cesarean and vaginal deliveries. 

Our review focused on primary CDMR. We note that a comprehensive assessment of the 

risks and benefits of CDMR extends beyond the first cesarean. Future research needs to account 

for complications and risks associated with repeat cesarean deliveries such as adhesions, placenta 

previa and accreta, and subsequent stillbirths. 

Significant resources will need to be allocated to study CDMR if the nation is to be well 

informed about the benefits and harms to mothers and infants in both the first and subsequent 

pregnancies. To realize the maximum gain from such work, research intended to answer 

questions about maternal and neonatal outcomes of CDMR must study them by intent-to-treat 

methods. This means comparing outcomes of planned CDMR with those of planned vaginal 

delivery, not comparing outcomes by actual routes of delivery. 

Future research efforts need to focus on a substantial set of problems: developing consensus 

about terminology for both delivery routes and outcomes; creating a minimum data set of 

information about CDMR; improving study design and statistical analyses; attending to major 

outcomes and their special measurement issues; assessing both short- and long-term outcomes 

with better measurement strategies; dealing better with confounders; and considering the value or 

utility (in quality-of-life terms) of different outcomes. Examining the costs and cost-effectiveness 

of different pathways of delivery and considering the impact of CDMR on the medicolegal 

system also warrant attention. 

Finally, if we are to gain meaningful data on short- and long-term maternal and neonatal 

outcomes associated with CDMR (whether or not compared with planned vaginal delivery), we 

should define success as a healthy mother and infant in the broadest sense of well-being possible. 

Studies ought to be well-designed, prospective, with adequate sample sizes and clearly described 

power analyses for both common and rare outcomes. Accumulating such high-quality evidence 

is possible with cooperation from all stakeholders; acquiring it is imperative if women and care 

providers are to be able to make informed decisions about CDMR. 
133

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preparation and obstetric history. J Psychosom 

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95. Cranley MS, Hedahl KJ, Pegg SH . Women's 

perceptions of vaginal and cesarean deliveries. 

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96. Guise J, et al. Vaginal Birth After Cesarean 

(VBAC). 2003. 

97. McMahon MJ, Luther ER, Bowes WAJr, et al. 

Comparison of a trial of labor with an elective 

second cesarean section. N Engl J Med 

1996;335(10):689-95. 

98. Dashe JS, McIntire DD, Ramus RM, SantosRamos R, Twickler DM. Persistence of placenta 

previa according to gestational age at ultrasound 

detection. Obstet Gynecol 2002; 99(5 Pt 1):692-

7. 

99. Crane JM, Van den Hof MC, Dodds L, Armson 

BA, Liston R. Maternal complications with 

placenta previa. Am J Perinatol 2000; 17(2):101-

5. 

100. Lydon-Rochelle M, Holt VL, Easterling TR, 

Martin DP. First-birth cesarean and placental 

abruption or previa at second birth(1). Obstet 

Gynecol 2001; 97(5 Pt 1):765-9. 

101. Sheiner E, Shoham-Vardi I, Hallak M, 

Hershkowitz R, Katz M, Mazor M. Placenta 

previa: obstetric risk factors and pregnancy 

outcome. J Matern Fetal Med 2001; 10(6):414-9. 

102. Rasmussen S , Albrechtsen S, Dalaker K. 

Obstetric history and the risk of placenta previa. 

Acta Obstet Gynecol Scand 2000; 79(6):502-7. 

103. Hossain GA, Islam SM, Mahmood S, 

Chakraborty RK, Akhter N, Sultana S. Placenta 

previa and it's relation with maternal age, 

gravidity and cesarean section. Mymensingh Med 

J 2004; 13(2):143-8. 

104. Makoha FW, Felimban HM, Fathuddien MA, 

Roomi F, Ghabra T. Multiple cesarean section 

morbidity. Int J Gynaecol Obstet 2004; 

87(3):227-32. 

105. Gilliam M, Rosenberg D, Davis F. The likelihood 

of placenta previa with greater number of 

cesarean deliveries and higher parity. Obstet 

Gynecol 2002; 99(6):976-80. 

106. Eniola AO, Bako AU, Selo-Ojeme DO. Risk 

factors for placenta praevia in southern Nigeria. 

East Afr Med J 2002; 79(10):535-8. 

107. Johnson LG, Mueller BA, Daling JR. The 

relationship of placenta previa and history of 

induced abortion. Int J Gynaecol Obstet 2003; 

81(2):191-8. 

108. Tuzovic L, Djelmis J, Ilijic M. Obstetric risk 

factors associated with placenta previa 

development: case-control study. Croat Med J 

2003; 44(6):728-33. 

109. Laughon SK, Wolfe HM, Visco AG. Prior 

cesarean and the risk for placenta previa on 

second-trimester ultrasonography. Obstet 

Gynecol 2005; 105 (5 Pt 1):962-5. 

110. Francois K, Johnson JM, Harris C. Is placenta 

previa more common in multiple gestations? Am 

J Obstet Gynecol 2003; 188( 5):1226-7. 

111. Graziosi GC , Bakker CM, Brouwers HA, et al. 

[Elective cesarean section is preferred after the 

completion of a minimum of 38 weeks of 

pregnancy]. Ned Tijdschr Geneeskd 

1998;142(42):2300-3. 

112. Johnston T, Coory M. Cesarean Section 

Deliveries in Queensland. Information Circular 

2005. 

113. Hall MH, Bewley S. Maternal mortality and 

mode of delivery. Lancet 1999 ;354(9180):776. 

114. Why mothers die. Report on confidential 

enquiries into maternal deaths in the United 
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Kingdom 1994-96. London: Stationery Office; 

1998. 

115. National Vital Statistics. National vital statistics 

report deaths: final data for 2003 [Web Page]. 

Available at 

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tats/finaldeaths03/finaldeaths03.htm. (Accessed 

27 January 2006). 

116. Viswanathan M, Hartmann K, Palmieri R et al. 

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Systematic Review. Evidence 

Report/Technology Assessment No. 112. 

Prepared by the RTI-UNC Evidence-based 

Practice Center, under Contract No. 290-02-0016. 

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Quality.;2005. 

117. Beckmann M, Garrett A. Antenatal perineal 

massage for reducing perineal trauma. Cochrane 

Database Syst Rev 2006;(1):CD005123. 

118. DiMatteo MR , Morton SC, Lepper HS, et al. 

Cesarean childbirth and psychosocial outcomes: a 

meta-analysis. Health Psychol 1996;15(4):303-

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119. Buchsbaum GM, Chin M, Glantz C, et al. 

Prevalence of urinary incontinence and 

associated risk factors in a cohort of nuns. Obstet 

Gynecol 2002;100(2):226-9. 

120. Goldberg RP, Abramov Y, Botros S, et al. 

Delivery mode is a major environmental 

determinant of stress urinary incontinence: results 

of the Evanston-Northwestern Twin Sisters 

Study. Am J Obstet Gynecol 2005;193(6):2149-

53. 

121. Hemminki E. Impact of caesarean section on 

future pregnancy--a review of cohort studies. 

Paediatr Perinat Epidemiol 1996;10(4):366-79. 

122. Martin J, et al. Vaginal delivery following 

previous cesarean birth. Am J Obstet Gynecol 

1983;146(3):255-63. 

123. Landon MB, Hauth JC, Leveno KJ, et al. 

Maternal and perinatal outcomes associated with 

a trial of labor after prior cesarean delivery. N 

Engl J Med 2004;351(25):2581-9. 

124. Smith GC, Pell JP, Dobbie R. Caesarean section 

and risk of unexplained stillbirth in subsequent 

pregnancy. Lancet 2003;362(9398):1779-84. 

125. Hilder L, Costeloe K, Thilaganathan B. 

Prolonged pregnancy: evaluating gestationspecific risks of fetal and infant mortality. Br J 

Obstet Gynaecol 1998;105(2):169-73. 

126. Manson JE, Hsia J, Johnson KC, et al. Estrogen 

plus progestin and the risk of coronary heart 

disease. N Engl J Med 2003;349(6):523-34. 

127. Anderson GL , Limacher M, Assaf AR, et al. 

Effects of conjugated equine estrogen in 

postmenopausal women with hysterectomy: the 

Women's Health Initiative randomized controlled 

trial. J Am Med Assoc 2004;291(14):1701-12. 

128. Moseley JB, O'Malley K, Petersen NJ, et al. A 

controlled trial of arthroscopic surgery for 

osteoarthritis of the knee. N Engl J Med 

2002;347(2):81-8. 

129. Guyatt GH, Haynes RB, Jaeschke RZ, et al. 

Users guide to the medical literature: XXV. 

Evidence-based medicine: principles for applying 

the users' guides to patient care. J Am Med Assoc 

2000;284:1291. 

130. Pelvic Floor Disorders Network. What is pelvic 

floor disorder [Web Page]. 2005; Available at 

http://www.pfdn.org/what/index.html#prolapse. 

(Accessed 6 January 1912). 

Appendix A 

Exact Search Strings 

A-1

Exact Search Strings 

Focused Search No. 1 

#3 Search "Cesarean Section"[MeSH] = 21612

#4 Search "Cesarean Section"[MeSH] Field: All Fields, Limits: Publication Date 

from 1990, English, Humans = 

8641

#7 Search request OR elective OR planned OR pre-labor OR non-labor = 61448

#8 Search #4 AND #7 = 1457

#9 Search ("Cesarean Section/statistics and numerical data"[MeSH] OR 

"Cesarean Section/trends"[MeSH]) = 

2569

#10 Search #7 AND #9 = 282

#11 Search #7 AND #9 Field: All Fields, Limits: Publication Date from 1990, 

English, Humans = 

230

#12 Search #4 AND #7 Field: All Fields, Limits: Publication Date from 1990, 

English, Review, Humans = 

103

#13 Search #4 AND #7 Field: All Fields, Limits: Publication Date from 1990, 

English, Meta-Analysis, Humans = 

16

#21 Search "Epidemiologic Methods"[MeSH] OR "Randomized Controlled 

Trials"[MeSH] Field: All Fields = 

2165030

#22 Search #8 AND #21 = 799

#23 Search #8 AND #21 Field: All Fields, Limits: Publication Date from 1990, 

English, Randomized Controlled Trial, Humans = 

225

#24 Search #22 NOT #23 = 574

#29 Search ("Outcome Assessment (Health Care)"[MeSH] OR "Pregnancy 

Outcome"[MeSH]) OR "Reproductive History"[MeSH] OR "Treatment 

Outcome"[MeSH] OR "Outcome and Process Assessment (Health 

Care)"[MeSH] = 

287783

#30 Search #29 AND #24 = 194

#31 Search ("Cesarean Section/adverse effects"[MeSH] OR "Cesarean 

Section/mortality"[MeSH]) = 

2409

#39 Search "Risk Factors"[MeSH] OR "Fetal Death"[MeSH] OR ("Urinary 

Incontinence"[MeSH] OR "Urinary Incontinence, Stress"[MeSH]) OR 

"Respiratory Distress Syndrome, Newborn"[MeSH] OR "Pelvic 

Floor"[MeSH] OR ("Prolapse"[MeSH] OR "Uterine Prolapse"[MeSH] OR 

"Rectal Prolapse"[MeSH]) OR "Fecal =Incontinence"[MeSH] 

309733

#40 Search #8 AND #39 = 220

#41 Search #31 AND #7 = 233

#42 Search #40 OR #41 = 398

#43 Search #40 OR #41 Field: All Fields, Limits: Publication Date from 1990, 311
A-2

English, Humans = 

47 Search "Urinary Incontinence"[MeSH] AND "Delivery, Obstetric"[MeSH] 

Limits: Publication Date from 1990, English, Humans = 

118

EMBASE Search: 

Cesarean AND (Request OR Elective OR Planned OR Pre-Labor OR Non-Labor) = 77

(Several of these were discarded because they were not in English) 

Cochrane Search: 

Reviews: 

Cesarean AND (Request OR Elective OR Planned OR Pre-Labor OR Non-Labor) = 8

Cochrane Clinical Trial Registry (Central OR CCTR) 

Cesarean AND (Request OR Elective OR Planned OR Pre-Labor OR Non-Labor) = 59

Total, unduplicated database = 926
A-3

Focused Search No. 2

#3 Search "Infant, Newborn"[MeSH]Or neonate = 357815 

#8 Search "Cesarean Section"[MeSH] = 21710 

#9 Search #8 AND #3 = 7096 

#15 Search "Infant, Premature"[MeSH] = 24780 

#16 Search #13 NOT #15 = 930 

#12 Search ("Outcome Assessment (Health Care)"[MeSH] OR "Fatal 

Outcome"[MeSH] OR "Pregnancy Outcome"[MeSH]) OR ("Treatment 

Outcome"[MeSH] OR "Outcome and Process Assessment (Health 

Care)"[MeSH]) = 

300710 

#13 Search #9 AND #12 = 1020 

#22 Search #16 AND #21 = 71 

#21 Search "Randomized Controlled Trial"[Publication Type] OR "Randomized 

Controlled Trials"[MeSH]) OR "Single-Blind Method"[MeSH] OR 

"Double-Blind Method"[MeSH] OR "Random Allocation"[MeSH] = 

287666 

#23 Search #16 AND #21 Field: All Fields, Limits: English, Humans = 64 
A-4

Focused Search No. 3 

#6 Search "Infant, Newborn"[MeSH]OR neonate = 357988 

#8 Search "Cesarean Section"[MeSH] = 21716 

#9 Search #6 AND #8 = 7098 

#10 Search infant, premature [MeSH] = 24804 

#11 Search #9 NOT #10 = 6541 

#14 Search ("Outcome Assessment (Health Care)"[MeSH] OR "Fatal Outcome"[MeSH] OR 

"Pregnancy Outcome"[MeSH]) OR ("Treatment Outcome"[MeSH] OR "Outcome and 

Process Assessment (Health Care)"[MeSH]) = 

301265 

#15 Search #11 AND #14 = 930 

#16 Search #11 AND #14 Field: All Fields, Limits: English, Humans = 730 

#22 Search "Epidemiologic Research Design"[MeSH] = 403194 

#23 Search #22 AND #16 = 33 

#26 Search "Delivery, Obstetric"[MeSH] OR "Extraction, Obstetrical"[MeSH] = 40646 

#27 Search #8 AND #26 = 21716 

#28 Search Comparative Study [mh] = 1181123 

#29 Search #27 AND #28 = 2667 

#30 Search epidemiologic study design = 92338 

#31 Search #29 AND #30 = 176 

#32 Search #29 AND #30 Field: All Fields, Limits: English, Humans = 163 

#37 Search ("Randomized Controlled Trial"[Publication Type] OR "Randomized Controlled 

Trials"[MeSH]) OR "Double-Blind Method"[MeSH] OR "Random Allocation"[MeSH] OR 

"Single-Blind Method"[MeSH] Limits: English, Humans = 

243752 

#38 Search #37 AND #29 Limits: English, Humans = 565 

#39 Search #31 OR #38 Limits: English, Humans = 691 

#40 Search #39 AND #14 Limits: English, Humans = 139 
A-5

Focused Search No. 4 

#6 Search Infant, Newborn [mh] AND Cesarean Section/adverse effects [mh] = 454 

#7 Search Infant, Newborn [mh] AND Cesarean Section/adverse effects [mh] 

Field: All Fields, Limits: English, Humans = 

303 

#8 Search Infant, premature [mh] = 24809 

#10 Search #7 NOT #8 = 282 

#11 Search #7 NOT #8 Field: All Fields, Limits: Editorial = 7 

#12 Search #7 NOT #8 Field: All Fields, Limits: Letter = 25 

#13 Search #7 NOT #8 Field: All Fields, Limits: Review = 20 

#14 Search #11 OR #12 OR #13 = 52 

#15 Search #10 NOT #14 = 230 
A-6

Focused Search No. 5 

#1 Search cesarean section 31631 

#2 Search risk 717885 

#3 Search #1 AND #2 5712 

#7 Search "Placenta Praevia/etiology"[MeSH] OR ("Placenta 

Accreta/epidemiology"[MeSH] OR "Placenta Accreta/etiology"[MeSH]) 

712 

#8 Search #3 AND #7 82 

#9 Search #3 AND #7 Field: All Fields, Limits: English, Humans 69 

#10 Search #7 AND #2 Limits: English, Humans 145 

#11 Search #9 OR #10 Limits: English, Humans 145 
A-7

Focused search #6: Faiz & Ananth Meta-Analysis Update: 

Literature Search 

#9 Search "Placenta Praevia"[MeSH]OR "Placental disorder" [tw] OR 

"antepartum hemorrhage" [tw] OR "antepartum bleeding" [tw] OR 

"uteroplacental bleeding" [tw] = 

1551 

#10 Search "maternal age" OR gravidity OR parity OR "cesarean section" OR 

"uterine surgery" OR "uterine instrumentation" OR "abortion" OR 

hypertension OR pre-eclampsia OR eclampsia OR "smoking" OR "drug use" 

= 476526 

#11 Search #9 AND #10 = 717 

#12 Search #9 AND #10 Field: All Fields, Limits: Publication Date from 2000 to 

2005 = 

145 

#13 Search #9 AND #10 Field: All Fields, Limits: Publication Date from 2000 to 

2005, Review = 

13 

#14 Search #9 AND #10 Field: All Fields, Limits: Publication Date from 2000 to 

2005, Meta-Analysis = 

 1 

#16 Search #13 OR #14 Field: All Fields = 14 

#17 Search #12 NOT #16 = 131 

****************************************************************************** 

This was the search as described in the Faiz and Ananth meta-analysis that was used as a 

guideline. This updated the literature through the end of May 2005. 

Faiz AS, Ananth CV. 

Etiology and risk factors for placenta previa: an overview and meta-analysis of observational 

studies. 

J Matern Fetal Neonatal Med. 2003 Mar;13(3):175-90. 

PMID: 12820840 [PubMed - indexed for MEDLINE] 

Search strategy as described in the methods section: Observational studies published in the 

English language between January 1966 and March 2000 were potentially eligible for inclusion 

in this overview. Identification of such studies was based on a comprehensive MEDLINE search, 

as well as by identifying studies cited in the references of published papers. The MEDLINE 

search was based on the following medical subject headings (MeSH): placenta pr(a)evia, 

placental disorders, antepartum h(a)emorrhage, and antepartum and uteroplacental bleeding. The 

other key words used in conjunction with previa were maternal age, gravidity, parity, 

C(a)esarean delivery/section, uterine surgery, uterine instrumentation, abortion, spontaneous 

abortion, induced abortion, elective abortion, chronic hypertension, pregnancy-induced 

hypertension, pre-eclampsia, eclampsia, cigarette smoking and drug use....Published case reports 

on placenta previa and studies on placental abruption were excluded. 
Appendix B 

Sample Review Forms/ 

Quality Rating Forms 
Systematic Review of Cesarean Delivery on Maternal Request 

Data Abstraction Form 

B-1

Reference ID Number: ___ ___ ___ ___ Reviewer’s Initials: ___ ___ Date of Review: ___/___/2005 

Directions: Please complete ALL questions below. 

Note: These questions are for whether an article will be included in the review. There is an opportunity at the bottom of the 

page to request an article for background or the decision analysis even if it doesn’t meet criteria for the review. 

1. Published between 1990 and 2005 Yes No Cannot Determine 

2. Published in English Yes No Cannot Determine 

Yes No Cannot Determine 

3. Study located in any of the following: United States, 

Canada, United Kingdom, Western Europe, Japan, 

Australia, New Zealand 

If No, check 

one of the 

following: 

 Brazil 

 Israel 

 S. Africa 

 Other: 

_________________

4. Includes women of reproductive age or older with 

singleton birth(s) Yes No Cannot Determine 

5. Addresses one or more of the following (check all that apply)

 Trend & incidence of cesarean delivery (KQ1)

 Maternal & infant short- and long-term outcomes of 

elective cesarean. NOTE: A comparison between 

elective cesarean and attempted vaginal delivery is 

required in order to answer this key question (KQ2)

 Factors affect magnitude of the benefits & harms of 

elective cesarean (KQ3)

 Future research directions (KQ4)

Yes No Cannot Determine 

6. Study design is one of the following (check one box if “Yes”):

RCT Observational Study Yes No Cannot Determine 

7. Sample size is appropriate (Please check correct sample size if 

Yes)

 

Yes No Cannot Determine 

If RCT, N>50 (NOTE: This refers to the # 

randomized)

 If Observational, N>100 

 If No, check if maternal psychosocial outcomes 

were measured in the study

Please check one of the options below based on your answers to Q1-Q7 above 

PULL Article Abstract meets ALL inclusion criteria above 

 Abstract meets some inclusion criteria above; we cannot determine 

some criteria 

 Abstract does NOT meet one or more of the inclusion criteria above 

but may be important for the background, the discussion, hand 

searching the references, or the decision analysis 

DO NOT Pull Article Abstract does NOT meet one or more of the criteria above and we do 

not need it for any other purpose
Systematic Review of Cesarean Delivery on Maternal Request 

Data Abstraction Form 

B-2

Reference ID Number: ___ ___ ___ ___ Reviewer’s Initials: ___ ___ Date of Review: ___/___/2005 

Directions: This form contains questions pertaining to whether an article will be included in the review 

or excluded. Please complete ALL of the questions unless otherwise directed. If there is an asterisk next 

to an answer, please complete the necessary information in the left column. 

Inclusion Criteria Does article meet criteria? 

1. Is the article published between January 1990 and May 2005? Yes No 

2. Is the article published in English? Yes No 

3. Is the article original research? 

e.g., RCTs, cohort studies, case control studies, case series >100 

Yes 

(Go to Q5) 

No 

(Go to Q4) 

4. Is the article a meta-analysis or systematic review? Yes* No 

*As directed, please separate these from the rest of the articles when returning (Complete Q7 & Final Status) 

Q7 should be completed for all articles; Q5-6, Q8-10 should be completed for original research ONLY 

5. Is the study located in any of the following: United States, Canada, United 

Kingdom, Western Europe, Japan, Australia, New Zealand 

*If NO, please check one 

of the following: 

 Brazil 

 Israel 

 S. Africa 

 Other: 

___________________ 

Yes No* 

6. Does the study include women of reproductive age or older with term, singleton 

births AND/OR neonates/infants/newborns/etc? Yes No 

7. Does the study address one or more of the following key questions? 

 

*If YES, please check all that apply: 

 Trend & incidence of cesarean delivery (KQ1)

 Maternal & infant short- and long-term outcomes of elective cesarean 

(KQ2)

• NOTE: A comparison between elective cesarean and attempted 

vaginal delivery is required in order to answer this key question 

Factors that affect magnitude of the benefits & harms of elective 

cesarean (KQ3)

• NOTE: This question refers to modifiers of outcomes of 

cesarean (KQ2), NOT the incidence/risk of cesarean (KQ1)

• NOTE: A comparison between elective cesarean and attempted 

vaginal delivery is NOT necessary to answer this question. 

However, if the article addresses only vaginal delivery, it is not 

eligible for this question 

 Future research directions (KQ4) 

Yes* No 

(Continued) 
Systematic Review of Cesarean Delivery on Maternal Request 

Data Abstraction Form 

B-3

Inclusion Criteria Does article meet criteria? 

8. Is the study an RCT or observational study? Yes* No 

 *If YES, please check one 

 of the following:  RCT  Observational Study (STOP! Go to 

Final Status) 

9. Is the sample size appropriate? 

*If YES, please check which scenario applies: 

If RCT, N>50 

(NOTE: This refers to the # randomized) 

 If Observational, N>100 

** If NO, check here if psychosocial outcomes were measured 

Yes* No** 

10. What is the total sample size of this study? N= _______ 

FINAL STATUS OF FULL-TEXT ARTICLE

 Check here if “YES” is circled for all questions above, except Q4 

 STOP! Article will be included in the review & data will be abstracted. 

 Check here if any “NO” is circled above 

(Check one or more of the boxes below for final action) 

 Hand search refs 

  Use for background 

  Use for discussion 

  Use for decision analysis 

  Exclude from everything 
Systematic Review of Cesarean Delivery on Maternal Request 

Data Abstraction Form 

Page 1 of 34 Version 1: 8/15/2005 

SECTION 1: REVIEWER & ARTICLE IDENTIFIERS

1. Abstractor’s Initials: ___ ___ 2. Date of Abstraction: ___ / ___ / ___

3. Article Number: ___ ___ ___ ___ 4. Date of Publication: ___ / ___ / ___

SECTION 2: FUNDING & SETTINGS

5. How was the study funded? (check all that apply) 

 Industry Private Foundation 

 Government Hospital / Managed Care Organization 

 Professional Society Consumer / Patient Foundation 

 Not reported or unclear Other (please specify): 

____________________________ 

6. In what countries does the study take place? (check all that apply) 

 United States Canada United Kingdom (includes England, Scotland, Wales, 1/6 of Ireland) 

 Japan Brazil Israel Australia New Zealand 

 Western Europe (please check all that apply below) 

Andorra Austria Azores Belgium Denmark Faroe Island 

Finland France Germany Gibraltar Greece Greenland 

Iceland Ireland Italy Liechtenstein Luxembourg Madeira 

Malta Monaco Netherlands Norway Portugal San Marino 

Spain Sweden Switzerland 

 

*If countries are other than above, please explain here: _________________________________________________________ 

_____________________________________________________________________________________________________ 

_____________________________________________________________________________________________________ 

7. What is the source of the populations? (check all that apply and describe below) 

 Hospital/Labor & Delivery Unit/Maternity Unit/Outpatient Clinic/NICU (specific) 

 Community based (clustering of above, not quite as specific) 

 Population based (entire city/country/etc such as from an administrative database) 

Description of population:

______________________________________________________________________ 

______________________________________________________________________________________

_______ 

______________________________________________________________________________________

_______ 

8. What are the sources of data? (check all that apply) 

 Survey 

 ________________________________ 
Systematic Review of Cesarean Delivery on Maternal Request 

Data Abstraction Form 

Page 2 of 34 Version 1: 8/15/2005 

 Questionnaire(s) in person 

 ________________________________

 Questionnaire(s) via mail, email, or internet 

 ________________________________

 Administrative database (*describe ) 

 ________________________________ 

 Physical Exam 

 ________________________________ 

 Interview in person 

 ________________________________ 

 Interview via telephone 

 ________________________________ 

 Medical records query 

 ________________________________

 9. Data was collected between ___/___/___ and ___/___/___ (In other words, when was the 

study?)

SECTION 3: INCLUSION & EXCLUSION CRITERIA

10. Please list the criteria for inclusion and/or exclusion (however presented in the article) below: 

Inclusion Exclusion

 

_____________________________________________ _____________________________________________

_____________________________________________ _____________________________________________

_____________________________________________ _____________________________________________

_____________________________________________ _____________________________________________

_____________________________________________ _____________________________________________

_____________________________________________ _____________________________________________

SECTION 4: STUDY DESIGN

11. Is the study a randomized controlled trial of unlabored/planned/elective cesarean delivery compared 

to an attempted vaginal delivery? (NOTE: attempted vaginal delivery could result in a labored cesarean) 

  Yes (Complete section 4A) 

  No (Complete section 4B) 

SECTION 4A: RANDOMIZED CONTROLLED TRIAL (RCT)

12. Briefly describe the randomization method: _________________________________________________ 
Systematic Review of Cesarean Delivery on Maternal Request 

Data Abstraction Form 

Page 3 of 34 Version 1: 8/15/2005 

__________________________________________________________________________________________ 

13. How many randomized groups are in this study? ____________ 

14. Was the randomization method sound?  Yes Notes: 

_________________________________ 

  No 

 _______________________________________ 

 

 _______________________________________ 

15. Describe the randomized groups (Note: Continue to keep this order throughout the rest of the form): 

 

 a. __________________________________________________________________________________ 

 b. _________________________________________________________________________________ 

 c. _________________________________________________________________________________ 

 d. _________________________________________________________________________________ 

 e. __________________________________________________________________________________ 

 f. __________________________________________________________________________________ 

 g. __________________________________________________________________________________ 

16. Were statistical tests of the groups reported?  Yes  No

17. Was true randomization achieved?  Yes  No 

 

 Describe the evidence for or against balance among the groups: ________________________________ 

 ________________________________________________________________________________________ 

 ________________________________________________________________________________________ 

18. Were there any post-randomization exclusions?  Yes  No 

 

 Describe the post-randomization exclusions: _______________________________________________ 

 ________________________________________________________________________________________ 

 ________________________________________________________________________________________ 

19. Give the number of women randomized to each group at the beginning of the study: 

 a. ________ e. ________ 

 b. ________ f. ________ 

 c. ________ g. ________ 
Systematic Review of Cesarean Delivery on Maternal Request 

Data Abstraction Form 

Page 4 of 34 Version 1: 8/15/2005 

 d. ________ TOTAL # randomized in the study = _______ 

 

20. Describe WHEN randomization took place (i.e., in relationship to labor & delivery) 

 _______________________________________________________________________________________ 

 ________________________________________________________________________________________ 

21. Was any form of masking attempted & carried out during the study? (NOTE: This could occur, for example, 

if the staff person interviewing the woman 6 months after delivery does not know what the woman had been randomized to) 

 

  Yes (Describe): ________________________________________________________ 

  No __________________________________________________________________ 

22. Was there any cross-over in this study? 

 

  Yes (Describe): ________________________________________________________ 

  No __________________________________________________________________ 

23. Was an intent-to-treat analysis conducted?  Yes  No 

24. Which analysis is presented?  As randomized (intent-to-treat)

  As happened (removing post-randomization exclusions and crossovers) 

  Both *Abstract both sets of data

SECTION 4B: OBSERVATIONAL STUDY (OBS)

25. What is the design of this observational study? (Check one) 

  Cohort 

  Case-control 

  Large case-series 

  Cross-sectional (e.g., survey, admin dataset, medical record query) 

NOTE: If the study was an RCT that randomized women to groups other than unlabored cesareans vs attempted vaginal birth BUT 

the data is presented using these groups, we will consider the study an observational cohort study. If applicable, please describe: 

__________________________________________________________________________________________ 

__________________________________________________________________________________________ 

26. Is the data collected prospectively or retrospectively?  Prospectively  Retrospectively 

 

27. DESCRIBE AND DEFINE the mode of delivery groups being compared in this study: 

NOTE: If the study ONLY addresses KQ3, we are not comparing mode of delivery groups. You will either have one group of elective 

cesarean or one group of cesarean that includes both elective (unlabored) and non-elective (labored, emergency) cesareans. If the 

study includes both of these cesarean groups, include both groups below. 
Systematic Review of Cesarean Delivery on Maternal Request 

Data Abstraction Form 

Page 5 of 34 Version 1: 8/15/2005 

 a. _____________________________________________________________________________________ 

 b. _____________________________________________________________________________________ 

c. _____________________________________________________________________________________ 

 d. ______________________________________________________________________________________ 

 e. ______________________________________________________________________________________ 

 f. ______________________________________________________________________________________ 

 g. ______________________________________________________________________________________ 

 h. ______________________________________________________________________________________

SECTION 5: FOLLOW UP OF PARTICIPANTS

28. In the table below, please document the timepoints of follow up in the study in relationship to either randomization or the 

beginning of the study. Please also document the number of participants, as a fraction, who were available for follow up at that 

timepoint within each group. The denominator should be the number randomized, with necessary adjustments, or the number 

of participants at the beginning of the study, who are eligible to provide data at that timepoint. (Note: Use the largest numerator 

that was available during each timepoint, even if not all the participants supplied data for every outcome). 

Timepoint of Data Collection Group A Group B Group C Group D Group E 

a. Number enrolled (X/X should =100%) / / / / / 

b. Number randomized (RCT) or selected 

(OBS) at start of study / / / / / 

c. / / / / / 

d. / / / / / 

e. / / / / / 

f. / / / / / 

g. / / / / / 

h. / / / / / 

29. Was any loss-to-followup differential across study groups?  Yes  No 

 

 Describe: ___________________________________________________________________________ 

 ________________________________________________________________________________________ 

 ________________________________________________________________________________________ 
Systematic Review of Cesarean Delivery on Maternal Request 

Data Abstraction Form 

Page 6 of 34 Version 1: 8/15/2005 

SECTION 6: CHARACTERISTICS OF PARTICIPANTS

 Data (Raw data, Point estimates) 

Study Groups

Characteristic How defined/measured 

A 

_______

_______

B 

_______

_______

C 

_______ 

_______ 

D 

_______

_______

Total 

30. Maternal Age 

31. Maternal Race 

32. Maternal BMI 

33. Education 

34. Marital Status 

35. Income/SES 

36. Gravidity/Parity 

37. Previous C/S 

38. Medical 

Conditions 

39. Previous Pelvic or 

Abdominal Surgery 

40. Other 

characteristic of 

participant 

41. Other 

characteristic of 

participant 
Systematic Review of Cesarean Delivery on Maternal Request 

Data Abstraction Form 

Page 7 of 34 Version 1: 8/15/2005 

42. Other 

characteristic of 

participant 

 

43. Is this population of women homogenous with regards to one of the participant characteristics (i.e., all 

nulliparous, all women with previous cesarean deliveries)? 

  Yes* Describe: 

____________________________________________  No 

 ____________________________________________________ 

*NOTE: This study may be included for Key Question 2B---outcomes of elective cesarean vs trial of labor in 

a subpopulation of women---if you answered yes to the question above. 

SECTION 7: CHARACTERISTICS OF THE PREGNANCY, LABOR & DELIVERY

44. How are labor and/or the stages of labor defined in this study? 

 ________________________________________________________________________________________ 

 ________________________________________________________________________________________ 

 ________________________________________________________________________________________ 

 

 Data (Raw data, Point estimates) 

Study Groups

Characteristic How defined/measured 

A 

_______

_______

B 

_______

_______

C 

_______ 

_______ 

D 

_______

_______

Total 

45. Prenatal care 

46. Gestational 

Age/Pregnancy 

Dating 

 

47. Pregnancy related 

conditions (e.g., 

Preeclampsia) 

48. Abnormal 

placentation 
Systematic Review of Cesarean Delivery on Maternal Request 

Data Abstraction Form 

Page 8 of 34 Version 1: 8/15/2005 

49. Presentation 

 Data (Raw data, Point estimates) 

Study Groups

Characteristic How defined/measured 

A 

_______

_______

B 

_______

_______

C 

_______ 

_______ 

D 

_______

_______

Total 

50. Other 

contraindications to 

labor 

 

51. Augmentation of 

labor (e.g., induction) 

52. Rupture of 

membranes 

53. Fetal heart rate 

(i.e., abnormal heart 

rate) 

54. Meconium 

55. Fetal weight 

56. Fetal sex 

57. Anesthesia 

58. Episiotomy 

59. Timing of 

delivery/Length of 

labor 

 

60. Mode of delivery 
Systematic Review of Cesarean Delivery on Maternal Request 

Data Abstraction Form 

Page 9 of 34 Version 1: 8/15/2005 

61. Complications 

during delivery (e.g., 

cord prolapse, 

chorioamnio )

 

62. Characteristic of 

delivery technique 

 Data (Raw data, Point estimates) 

Study Groups

Characteristic How defined/measured 

A 

_______

_______

B 

_______

_______

C 

_______ 

_______ 

D 

_______

_______

Total 

63. Characteristic of 

repair/suture 

technique/materials 

 

64. Other 

characteristic of 

labor/delivery 

 

65. Other 

characteristic of 

labor/delivery 

66. Other 

characteristic of 

labor/delivery 

67. Is this population of infants homogeneous with regards to one of the characteristics (i.e., all breech)? 

  Yes* Describe: 

____________________________________________  No 

 ____________________________________________________ 

*NOTE: This study may be included for Key Question 2B---outcomes of elective cesarean vs trial of labor in 

a subpopulation of infants---if you answered yes to #68. 

SECTION 8: CHARACTERISTICS OF THE SETTING

 Data (Raw data, Point estimates) 

Study Groups

Characteristic How defined/measured A 

_______

_______

B 

_______

_______

C 

_______ 

_______ 

D 

_______

_______

Total 
Systematic Review of Cesarean Delivery on Maternal Request 

Data Abstraction Form 

Page 10 of 34 Version 1: 8/15/2005 

 

68. Time of day of 

delivery 

 

69. Physician 

Experience 

 

70. Standard of 

care/delivery 

volume* 

 

*If a study is comparing two hospitals or delivery units, this question will be especially pertinent 
SECTION 9: OUTCOMES OF ELECTIVE C/S VS. TRIAL OF LABOR

If the study reports outcome data comparing an elective cesarean/unlabored cesarean group to one obegan with a trial of labor, report the outcomes below. There are four sections: maternal short-term 

long-term outcomes, neonatal short-term outcomes, and neonatal long-term outcomes. Short term is year post-delivery. Long term outcomes are those occurring at one year past delivery and beyond. THE STUDY MUST REPORT DATA FOR AN ELECTIVE, UNLABORED CESAREAN GROU

ONE TRIAL OF LABOR GROUP, WHICH COULD INCLUDE LABORED C/S, TO BE INCLU

SECTION! An explanation of the columns in the tables: Code: Outcomes will be grouped with like outcomes, using a numerical code. The codes for each outco

each of the tables in the four sections of outcomes. Outcome: What is the specific outcome? How is it labeled in the study results? Definition: How does the study define the outcome? Measured How: How did the study measure this particular outcome and who measured it? Measured When: At what timepoint was this outcome measured in the study? 

Data: Enter the raw data, with both numerator and denominators, for each mode of delivery group. Als

statistical findings here. If there are no numbers, enter p-values, exact quotes, etc that explain the findiNOTE: Each row in the table corresponds to an outcome at one timepoint. If the outcome is assessed 

timepoint, the data should be reported on as many rows as there are timepoints. 

71. MATERNAL SHORT-TERM OUTCOMES (A)
A1=Mortality 

A2=Intraoperative/Intrapartum Complications (e.g., injury to bladder/ureter/bowel, extension of incisions, perineal lA3=Anesthesia Issues (e.g., complications from) A4=Hemorrhage (e.g., require blood transfusion, require D&C, blood loss, require gravid hysterectomy) A5=Postoperative or postpartum pain A6=Wound Complications (e.g., infection, breakdown, dehiscence) A7=Infection (NOT of the incision) (e.g., pneumonia, UTI, mastitis, other infection) A8=Thromboembolic Complications (e.g., deep-vein thrombosis (DVT), pulmonary embolism) A9=Other Complications (e.g., acute respiratory distress syndrome, hypertension, ileus, bowl obstruction) A10=Breastfeeding (e.g., ability/desire to breastfeed) A11=Psychological (e.g., general feeling regarding birth experience, early post-partum depression, transition issues) A12=Maternal Recovery (e.g., length of stay in hospital, need for ICU admit, hospital readmit) 

Outcome Data by Stud

Outcom

e Code 

Specific 

Name of 

Outcome 

as 

described 

by study 

Definition of 

Outcome (Include 

all details presented 

by study) 

How is the 

outcome 

measured 

& by 

whom? 

When is 

this 

outcome 

measure

d? 

A 

_______ _______ 

B 

_______ _______ 

C 

_______ _______ 

(Example from reference #31) Unlabored C/S SVD *Referent Assisted VD *Referent A6 “Wound 

infection” (see 

table 3) 

Infected abdominal or 

episiotomy wound 

Nova Scotia 

Atlee 

Perinatal 

Database 

Not 

reported 

11 / 721 

(1.5%) 

55 / 12,607 

(0.4%) 

RR=3.5 

(1.8, 6.7)* 

*P<0.001 

70 / 3,613 

(2.0%) 

RR=0.8 

(0.4, 1.5) 

Extr

outc

can b
71. MATERNAL SHORT-TERM OUTCOMES (A)

A1=Mortality A2=Intraoperative/Intrapartum Complications (e.g., injury to bladder/ureter/bowel, extension of incisions, perineal lA3=Anesthesia Issues (e.g., complications from) A4=Hemorrhage (e.g., require blood transfusion, require D&C, blood loss, require gravid hysterectomy) A5=Postoperative or postpartum pain A6=Wound Complications (e.g., infection, breakdown, dehiscence) A7=Infection (NOT of the incision) (e.g., pneumonia, UTI, mastitis, other infection) A8=Thromboembolic Complications (e.g., deep-vein thrombosis (DVT), pulmonary embolism) A9=Other Complications (e.g., acute respiratory distress syndrome, hypertension, ileus, bowl obstruction) A10=Breastfeeding (e.g., ability/desire to breastfeed) A11=Psychological (e.g., general feeling regarding birth experience, early post-partum depression, transition issues) A12=Maternal Recovery (e.g., length of stay in hospital, need for ICU admit, hospital readmit) 

Outcome Data by Stud

Outcom

e Code 

Specific 

Name of 

Outcome 

as 

described 

by study 

Definition of 

Outcome (Include 

all details presented 

by study) 

How is the 

outcome 

measured 

& by 

whom? 

When is 

this 

outcome 

measure

d? 

A 

_______ _______ 

B 

_______ _______ 

C 

_______ _______ 
72. MATERNAL LONG-TERM OUTCOMES (B)

B1=Urinary Function (e.g., urinary incontinence, vesicovaginal fistulas) B2=Pelvic Organ ProlapseB3=Anorectal Function (e.g., fecal/flatus incontinence, rectovaginal fistulas) 

B4=Sexual Function/DyspareuniaB5=Subsequent Uterine Rupture B6=Subsequent Placental Implantation Issues (e.g., previa, accrete) B7=Future Obstetric or Gynecological Issues (e.g., infertility, endometriosis, pelvic pain, subsequent ectopic pregnan

B8=Psychological (e.g., post-partum depression, anxiety) 

Outcome Data by Stud

Outcom

e Code 

Specific 

Name of 

Outcome 

as 

described 

by study 

Definition of 

Outcome (Include 

all details presented 

by study) 

How is the 

outcome 

measured 

& by 

whom? 

When is 

this 

outcome 

measure

d? 

A 

_______ _______ 

B 

_______ _______ 

C 

_______ _______ 

Extra table space for ad

outcomes or extra study 

can be found on the bac
72. MATERNAL LONG-TERM OUTCOMES (B)

B1=Urinary Function (e.g., urinary incontinence, vesicovaginal fistulas) B2=Pelvic Organ ProlapseB3=Anorectal Function (e.g., fecal/flatus incontinence, rectovaginal fistulas) 

B4=Sexual Function/DyspareuniaB5=Subsequent Uterine Rupture B6=Subsequent Placental Implantation Issues (e.g., previa, accrete) B7=Future Obstetric or Gynecological Issues (e.g., infertility, endometriosis, pelvic pain, subsequent ectopic pregnan

B8=Psychological (e.g., post-partum depression, anxiety) 

Outcome Data by Stud

Outcom

e Code 

Specific 

Name of 

Outcome 

as 

described 

by study 

Definition of 

Outcome (Include 

all details presented 

by study) 

How is the 

outcome 

measured 

& by 

whom? 

When is 

this 

outcome 

measure

d? 

A 

_______ _______ 

B 

_______ _______ 

C 

_______ _______ 

EXTRA 

SPACE
73. NEONATAL SHORT-TERM OUTCOMES (C)

C1=Mortality (e.g., neonatal or fetal) C2=APGAR ScoresC3=Birth Injury (e.g., lacerations, fractures, brachial plexus injury, spinal cord injury, intraventricular hemorrhage, subsubarachnoid hemmorhage) C4=Respiratory Complications (e.g., Transient tachypnea, respiratory distress syndrome, persistent pulmonary hyperteventilation/intubation; NOTE: iatrogenic prematurity often results in respiratory complications and should be included in C5=Neurologic Complications (e.g., Encephalopathy/asphyxia, seizures, cerebral accidents, stroke)

C6=Infections (e.g., Group B streptococcus infection, sepsis, pneumonia, necrotizing enterocolitis) 

C7=Other Complications (e.g., gastrointestinal, metabolic) C8=Bonding/Transition (e.g., breastfeeding, bonding) C9=Recovery (e.g., unplanned NICU stay, special care nursery, length of stay) 

Outcome Data by Stud

Outcom

e Code 

Specific 

Name of 

Outcome 

as 

described 

by study 

Definition of 

Outcome (Include 

all details presented 

by study) 

How is the 

outcome 

measured 

& by 

whom? 

When is 

this 

outcome 

measure

d? 

A 

_______ _______ 

B 

_______ _______ 

C 

_______ _______ 

Extra table space for additional 

outcomes or extra study groups 

can be found on the back of this
73. NEONATAL SHORT-TERM OUTCOMES (C)

C1=Mortality (e.g., neonatal or fetal) C2=APGAR ScoresC3=Birth Injury (e.g., lacerations, fractures, brachial plexus injury, spinal cord injury, intraventricular hemorrhage, subsubarachnoid hemmorhage) C4=Respiratory Complications (e.g., Transient tachypnea, respiratory distress syndrome, persistent pulmonary hyperteventilation/intubation; NOTE: iatrogenic prematurity often results in respiratory complications and should be included in C5=Neurologic Complications (e.g., Encephalopathy/asphyxia, seizures, cerebral accidents, stroke)

C6=Infections (e.g., Group B streptococcus infection, sepsis, pneumonia, necrotizing enterocolitis) 

C7=Other Complications (e.g., gastrointestinal, metabolic) C8=Bonding/Transition (e.g., breastfeeding, bonding) C9=Recovery (e.g., unplanned NICU stay, special care nursery, length of stay) 

Outcome Data by Stud

Outcom

e Code 

Specific 

Name of 

Outcome 

as 

described 

Definition of 

Outcome (Include 

all details presented 

by study) 

How is the 

outcome 

measured 

& by 

whom? 

When is 

this 

outcome 

measure

d? 

A 

_______ _______ 

B 

_______ _______ 

C 

_______ _______ 

EXTRA 

SPACE! 
by study 

74. NEONATAL LONG-TERM OUTCOMES (D)D1=Bonding & Behavioral Issues (e.g., transitional issues) D2=Long-term physical development 

Outcome Data by Stud

Outcom

e Code 

Specific 

Name of 

Outcome 

as 

described 

by study 

Definition of 

Outcome (Include 

all details presented 

by study) 

How is the 

outcome 

measured 

& by 

whom? 

When is 

this 

outcome 

measure

d? 

A 

_______ _______ 

B 

_______ _______ 

C 

_______ _______ 

Extra table space for additional 

outcomes or extra study groups 

can be found on the back of this
74. NEONATAL LONG-TERM OUTCOMES (D)

D1=Bonding & Behavioral Issues (e.g., transitional issues) D2=Long-term physical development 

Outcome Data by Stud

Outcom

e Code 

Specific 

Name of 

Outcome 

as 

described 

by study 

Definition of 

Outcome (Include 

all details presented 

by study) 

How is the 

outcome 

measured 

& by 

whom? 

When is 

this 

outcome 

measure

d? 

A 

_______ _______ 

B 

_______ _______ 

C 

_______ _______ 

EXTRA 

SPACE! 
75. SECTION 10: MODIFIERS OF OUTCOMES OF ELECTIVE C/S 

NOTE: The study must meet two criteria to be included in this section 1. The modifier under study needs to have a comparison group. In other words, the outcome should be studied in more th

(i.e., with and without the modifier, several strata of the modifier compared to a referent strata of the modifier). 

2. We only need to see the outcome by strata of modifier within the elective c/s group. If there is only a cesarean group, 

of elective/unlabored cesareans in it, we will collect that data. If the only cesarean group is only comprised of labored ce

the study in this section. 

Extra table space for a

outcomes or extra stud

can be found on the ba
The outcome codes may be found above in section 9. They include A1 through A12, B1 through B8, C1 through C9, and 

Outcome data by 

Modifier 

How is the 

modifier 

defined? What 

are the strata? 

How is the modifier 

measured and by 

whom? 

Outcome 

code from 

section 9 

Specific 

Outcome & 

When 

Measured 

Group A 

____________ ____________ 

(Example from Reference #72) Group

Birth Weight 

(g) from table 4

<3000g 

3000g-3999g 

>4000g 

Not explained but probably 

understood to be weighed by 

nurse in delivery room 

A4 Intraoperative blood 

loss >1000mL 

during the C/S 

247/923 (26.8505/923 (54.7171/923 (18.5

75. SECTION 10: MODIFIERS OF OUTCOMES OF ELECTIVE C/S NOTE: The study must meet two criteria to be included in this section 1. The modifier under study needs to have a comparison group. In other words, the outcome should be studied in more th

(i.e., with and without the modifier, several strata of the modifier compared to a referent strata of the modifier). 

2. We only need to see the outcome by strata of modifier within the elective c/s group. If there is only a cesarean group, 

of elective/unlabored cesareans in it, we will collect that data. If the only cesarean group is only comprised of labored ce

the study in this section. 

EXTRA SPACE! 
The outcome codes may be found above in section 9. They include A1 through A12, B1 through B8, C1 through C9, and 

Outcome data by 

Modifier 

How is the 

modifier 

defined? What 

are the strata? 

How is the modifier 

measured and by 

whom? 

Outcome 

code from 

section 9 

Specific 

Outcome & 

When 

Measured 

Group A 

____________ ____________ 

76. SECTION 11: FUTURE RESEARCH

The article may speak to the need for future research (KQ4). If you want to highlight direct quotes or ide

please give the page number, other location information, and the quote or idea below. 

Page Other location information (e.g., column, Quote, idea, etc. 
Number paragraph number.) 

NOTE: Feel free to highlight or underline on the 

actual article to aid in location 

NOTE: If you’ve given good location information, do

here. 

SECTION 12: PRELIMINARY ASSESSMENT OF QUALITY77. How would you rate the study’s ability to operationalize their definitions of characteristics, outcomes, and mo

 GOOD FAIR POOR 78. Overall, how would you rate this article? (Circle one) 

NOTE: Keep in mind their randomization techniques, loss-to-followup problems, their ability to define everything clearl

and analysis methods.  GOOD FAIR POOR 
Reference ID: _______________ Check one: Maternal Outcomes Short-term Neonat

 Long-term 

Outcome Data by Stud

Outcom

e Code 

(see long 

form) 

Specific 

Name of 

Outcome 

as 

described 

by study 

Definition of 

Outcome (Include 

all details presented 

by study) 

How is the 

outcome 

measured 

& by 

whom? 

When is 

this 

outcome 

measure

d? 

A 

_______ _______ 

B 

_______ _______ 

C 

_______ _______ 
B-25 

Systematic Review of Cesarean Delivery on Maternal Request 

Full Text Review Form: Previa Meta-Analysis Update 

Reference ID Number: ___ ___ ___ ___ Reviewer’s Initials: ___ ___ Date of Review: ___/___/2005 

 

NOTE: This form is to evaluate the inclusion of article pertaining to placenta previa according to the 

original meta-analysis (Ref #1212, Faiz AS & Ananth CV, “Etiology and risk factors for placenta 

previa: an overview and meta-analysis of observational studies.”). Follow the directions after each 

answer you circle. 

1. Is the study published between March 

2000 and May 2005? 

Yes 

Continue 

No 

STOP-Exclude 

2. Is the study published in English? 

Yes 

Continue 

No 

STOP-Exclude 

3. Is the study an observational study of 

placenta previa? 

NOTE: Case reports on placenta previa 

and studies on placental abruption will 

NOT be included 

Yes 

Continue 

No 

STOP-Exclude 

4. Is placenta previa diagnosed in early 

pregnancy (first or second trimester)? 

Yes 

STOP-Exclude 

No 

Continue 

5. Are data about cesarean delivery as a 

risk factor for placenta previa presented? 

Yes 

Continue 

No 

STOP-Exclude 

Please check one option below based on your answers to Q1-Q5.

INCLUDE “Yes” is circled for all questions above 

EXCLUDE  Any “No” is circled above 
B-26 

Systematic Review of Cesarean Delivery on Maternal Request 

Abstract Review Form: Previa Meta-Analysis Update 

Reference ID Number: ___ ___ ___ ___ Reviewer’s Initials: ___ ___ Date of Review: ___/___/2005 

 

NOTE: This form is to evaluate the inclusion of article pertaining to placenta previa according to the 

original meta-analysis (Ref #1212, Faiz AS & Ananth CV, “Etiology and risk factors for placenta 

previa: an overview and meta-analysis of observational studies.”). Follow the directions after each 

answer you circle. 

1. Is the study published between March 

2000 and May 2005? 

Yes 

Continue 

No 

STOP-Exclude 

Cannot 

Determine 

Continue 

2. Is the study published in English? 

Yes 

Continue 

No 

STOP-Exclude 

Cannot 

Determine 

Continue 

3. Is the study an observational study of 

placenta previa? 

NOTE: Case reports on placenta previa 

and studies on placental abruption will 

NOT be included 

Yes 

Continue 

No 

STOP-Exclude 

Cannot 

Determine 

Continue 

4. Is placenta previa diagnosed in early 

pregnancy (first or second trimester)? 

Yes 

STOP-Exclude 

No 

Continue 

Cannot 

Determine 

Continue 

5. Are data about cesarean delivery as a 

risk factor for placenta previa presented? 

Yes 

Continue 

No 

STOP-Exclude 

Cannot 

Determine 

Continue 

Please check one option below based on your answers to Q1-Q5.

Pull Article  Any combination of “Yes” and/or “Cannot Determine” is circled above 

Do NOT Pull Article Any “No” is circled above
B-27 

Assessment of Quality of Individual Articles for RCT’s 

Randomization 

Approach 

Randomization 

Implementation 

Masking of Outcome 

Assessors 

Operational 

Definitions and 

Measurements 

Is there description of the 

approach to 

randomization? 

Yes No 

Is there a fatal flaw in the 

approach (such as lottery 

cards)? 

Yes1

 No 

Explain: 

Is there proven good balance 

with statistical significance? 

Yes No 

Is there good balance 

achieved as shown in table? 

Yes No 

Overall Randomization Approach and Implementation 

(Please circle one) 

Good2

 Fair Poor 

(Please circle one) 

Good Fair Poor 

NR 

Notes: 

(Please circle one) 

Good Fair Poor 

Notes: 

Post-Randomization 

Exclusions 

Loss to Follow-up: Shortterm Loss to Follow-up: 

Long-term Statistical analysis 

(Please circle one) 

Yes No 

Please describe: 

(Please list numbers and 

percentages for each followup time point) 

T1 (describe): 

T2 (describe): 

T3 (describe): 

T4 (describe): 

(Please list numbers and 

percentages for each 

follow-up time point) 

T1 (describe): 

T2 (describe): 

T3 (describe): 

T4 (describe): 

Please circle one) 

Good Fair Poor 

NR 

Notes:

Overall Quality3 

(Please circle one) GOOD FAIR POOR 1

 If fatal flaw in randomization approach exists, overall randomization approach and implementation is poor and overall 

quality of the article/trial is also poor 

2 Approach must be described and there must be good balance in order to achieve an overall randomization and 

implementation score of good 

3 All component ratings must be good with minimal loss to follow-up for the article/trial to receive an overall quality rating of

good. If an article has one or two fair or poor ratings, an overall quality score of fair should be assigned. If an article/trial has 

three or more fair or poor ratings and/or large loss to follow-up, the overall quality should be poor. 
B-28 

Assessment of Quality of Individual Articles for Nonrandomized Observational 

Cohorts 

Domains Elements Score Assessment 

(good, fair, 

poor) 

Study design 

Prospective

 

Yes/No

 

Yes=good/fair

Description of study populations, 

study report 

 

The base population from which cohort 

participants were sought 

Yes/No All 3 yes= 

good; 2 yes 

and 1 NA 

The number of eligible women in that 

base population (a denominator) 

Yes/No 2 yes= fair 

Study 

Population 

The number of eligible women who 

were ultimately enrolled in the cohort 

Yes/No >2 yes= poor 

For all observational studies: 

 Specific inclusion/exclusion 

criteria for all groups

Yes/No 

 Criteria applied equally to all 

groups

Yes/No 

 Study groups comparable at 

baseline w/ reference to variables not 

unique to mode of delivery

Yes/No 

 Study groups comparable to nonparticipants with regard to confounding 

factors (study should thoroughly 

enumeration of the number of cohort 

participants, the characteristics of their 

birth experience, confounders, and 

general descriptive characteristics)

Yes/No 

 Study groups comparable with 

regard to followup

Yes/No 

Continue below for case-control 

studies: 

For case 

control 

studies: 

Good: ALL 

3 Yes: Fair: 

2 Yes; Poor: 

0-1 Yes 

Comparability 

of subjects 

Explicit case definition Yes/No 

For non-case 

controls, 4-5 

yes = good; 

2-3 yes = 

fair; 0-1 yes 

= poor 
B-29 

 

Case ascertainment not influenced by 

exposure status 

Yes/No 

Controls similar to cases except without 

condition of interest and with equal 

opportunity for exposure 

Yes/No 

Overall statistics analysis 

Statistical tests appropriate Yes/No 

Modeling and multivariate techniques 

and/or multiple comparisons taken into 

consideration 

Yes/No 

Power calculation provided and sample 

size achieved 

Yes/No 

Assessment of confounding 

 assessment of confounding and 

modifying factors by bivariate analysis, 

stratified analysis, or multivariable 

modeling

Yes/No 

 reporting of adjusted estimates for 

main effects that took into account 

identified confounding or modifying 

factors (stratified or separate analyses 

were acceptable for simple constructs)

Yes/No 

Statistical 

Analysis 

 presentation of adjusted results 

with a measure of statistical precision 

such as a confidence interval or P-value

Yes/No 

5-6 yes= 

good; 3-4 yes 

= fair;1-2 yes 

= poor 

Overall results 

Measure of effect for outcomes and 

appropriate measure of precision 

Yes/No

Adequacy of follow-up for each study 

group, study describes 

 

 the number of participants in the 

sample at the time of followup,

Yes/No

 analysis of how respondents 

differed from nonrespondents if loss 

exceeded 20 percent, and

Yes/No

Results 

 absolute loss to followup >25 

percent

Yes/No

For panel 

studies, 3-4 

yes=good; 2 

yes=fair; 0-1 

yes=poor; for 

single 

timepoint 

studies, 

yes=good/fair 

5 goods/fair: Good 

3-4 good/fair: Fair 

Overall rating 

0-2 good/fair: Poor 

Appendix C 

Evidence Tables

C-1 

Glossary 

BMI body mass index 

BPD biparetal diameter 

c/d cesarean delivery 

CES-D Center for Epidemiologic Studies – 

Depression Scale 

cm centimeters 

CPD cephalopelvic disproportion 

CT computer tomography 

d day 

Dec December 

Dept department 

EFW estimated fetal weight 

Feb February 

F/U follow-up 

G group 

GA gestational age 

gms grams 

HELLP Hemolysis Elevated Liver Enzymes and 

Low Platelet Count 

Hr(s) hour(s) 

HSV herpes simpleton virus 

HTN hypertension 

hx history 

IQ intraquartile 

IUGR intrauterine growth restriction 

Jan January 

kg kilograms 

LMP last menstrual period 

Ml milliliter 

mm millimeter 

mos months 

multip multiparous 

N number 

NICU Neonatal Intensive Care Unit 

NR not reported 

Ob/Gyn obstetrics/gynecology 

OR odds ratio 

P probability 

post-op post operative 

PP postpartum 

PPH persistent pulmonary hypterension 

primp primiparous 

PROM premature rupture of membranes 

RCT randomized controlled trial 

RDS Respiratory Distress Syndrome 

RR relative risk 

SD standard deviation 

Sept September 

SUI stress urinary incontinence 

TTN transient tachypnea of the newborn 

UK United Kingdom 

u/s ultrasonography 

US United States 

VAS Visual Analog Scale 

VD vaginal delivery 

vs versus 

wks weeks 

w/o without 

w/in within 

yr(s) year(s) 
C-2 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions 

Labor and delivery 

characteristics 

Author 

Allen et al., 2003 

Setting 

Canada, 

Population-based 

Study design 

Retrospective cohort 

Inclusion criteria 

• Pregnancies to Novia Scotia 

resident, ≥ 500 grm birthweight 

• Between 1/1/88 and 12/31/01 

• Liveborn singleton at term (37 

to 42 wks) 

• Born to a nulliparous woman 

Exclusion criteria 

• Major fetal anomaly 

• Labor induced 

• Nonvertex presentation with 

spontaneous labor 

• Preexisting maternal disease 

• Fetal growth restriction ( < 10th 

percentile for GA) 

• Pregnancy complications (i.e., 

gestational diabetes pregnancy 

induced HTN, premature 

rupture of membranes) 

Groups 

G1: c/d without labor 

G2: Spontaneous onset of labor: 

• G2a: Spontaneous vaginal 

delivery 

• G2b: Assisted vaginal delivery 

• G2c: c/d in labor 

Objective of the study 

To estimate the maternal morbidity 

associated with cesarean deliveries 

performed at term without labor 

compared with morbidity associated 

with spontaneous labor 

Definition of elective cesarean 

The term “elective” is not used at all. 

Referent group is cesarean (planned 

and unplanned) without labor for 

maternal and neonatal indications 

Category includes: 

• Breech (86%) 

• Fetal distress (4.2%) 

• Dystocia (5.1%) 

• Malpresentation (1.1%) 

• Maternal HSV (0.4%) 

• Others (2.6%) 

• Diseases of the cervix (0.1%) 

Maternal age, mean ± SD 

G1: 27.3 (5.3) 

G2: 25.3 (5.1) 

P < 0.001 

Maternal weight at delivery in kgs 

± SD 

G1: 81.6 (15.2) 

G2: 78.5 (12.9) 

P < 0.001 

Gravidity 

All nulliparous 

N of previous cesareans 

NA 

Diabetes 

None, all excluded 

Gestational age in wks ± SD 

G1: 39.3 ± 1.2 

G2: 39.8 ± 1.2 

P < 0.001 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 
C-3 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Wound infection, N (%) 

G1: 11/721 (1.5) 

G2A: 55/12,607 (0.4) 

RR = 3.5 (1.8, 6.7) 

P < 0.001 

G2b: 70/3,613 (2.0) 

RR = 0.8 (0.4, 1.5) 

G2c: 32/1,480 (2.2) 

RR = 0.7 (0.4, 1.4) 

Blood transfusions, N (%) 

G1: 2/721 (0.3) 

G2a: 38/12,607 (0.3) 

RR = 0.9 (0.2, 3.8) 

G2b: 27/3,613 (0.8) 

RR = 0.4 (0.1, 1.6) 

G2c: 8/1,480 (0.5) 

RR = 0.5 (0.1, 2.4) 

Puerperal febrile morbidity, N (%) 

G1: 8/721 (1.1) 

G2a: 26/12,607 (0.2) 

RR = 5.4 (2.4, 11.8) 

P < 0.001 

G2b: 14/3,613 (0.4) 

RR = 3.0 (1.2, 7.2) 

P < 0.05 

G2c: 49/1,480 (3.3) 

RR = 0.3 (0.2, 0.7) 

P < 0.05 

Evacuation of hematoma, N (%) 

G1: 1/721 (0.1) 

G2a: 18/12,607 (0.1) 

RR = 1.0 (0.1, 7.3) 

G2b: 3/3,613 (0.1) 

RR = 1.7 (0.2, 16.0) 

G2c: 3/1,480 (0.2) 

RR = 0.7 (0.1, 6.6) 

Early PPH (PP hemorrhage), N (%) 

G1: 28/721 (3.8) 

G2a: 640/12,607 (5.1) 

RR = 0.8 (0.5, 1.1) 

G2b: 346/3,613 (9.6) 

RR = 0.4 (0.3, 0.6) 

P < 0.001 

G2c: 111/1,480 (7.5) 

RR = 0.5 (0.4, 0.8) 

P < 0.001 

NR Relevance 

Low 

Quality Rating 

Not rated 
C-4 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Bergholt et al., 2003 

Setting 

Denmark, hospital-based 

Study design 

Retrospective cohort 

Inclusion criteria 

• Women delivering by c/d at the 

University hospitals in 

Gentofte, Herlev and Glostrup 

Exclusion criteria 

• NR 

Groups 

G1: Emergency c/d (c/d planned 

less than 8 hrs before operation 

actually took place) 

G2: Elective c/d (c/d planned 

more than 8 hrs before operation 

actually took place) 

N 

G1: 636 

G2: 294 

Objective of the study 

To estimate the incidence of 

intraoperative surgical complications 

with the impact of the educational 

level of the surgeon and a history of 

previous cesarean delivery on 

intraoperative complications at 

cesarean childbirth 

Definition of elective cesarean 

An operation planned more than 8 

hours before the operation actually 

took place 

Includes labored births, number NR 

Category includes: 

• Fetal distress 

• Dystocia 

• Placental abruption 

• Multiple gestation 

• Fetal anomalous presentation 

Maternal age ± SD 

Overall: 30.3 ± 4.9 

Maternal BMI, pre-pregnancy, N 

Overall: 23.3 ± 4.3 

Parity overall ± SD 

Overall: 0.7 ± 0.9 

N of previous cesareans, N (%) 

Overall: 237/929 ± 25.7 

Diabetes 

NR 

Gestational age ± SD 

Overall: 38.7 ± 2.7 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight mean kgs ± SD 

Overall: 3.315 ± 0.799 
C-5 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Lacerations, N (%) 

Cervical laceration 

G1: 29/636 (4.6) 

G2: 4/294 (1.4) 

P < 0.05 

Corporal laceration 

G1: 2/636 (0.3) 

G2: 1/294 (0.3) 

NS 

Vaginal laceration 

G1: 11/636 (1.7) 

G2: 0/294 (0)

P < 0.05 

Bladder laceration 

G1: 5/636 (0.8) 

G2: 0/294 (0) 

NS 

Bowel laceration 

G1: 0/636 (0) 

G2: 0/294 (0) 

NS 

All lacerations 

G1: 43/636 (0) 

G2: 5/294 (0) 

P < 0.05 

Blood transfusion, N (%) 

G1: 7/636 (1.1) 

G2: 2/294 (0.7) 

NS 

Estimated blood loss ≥ 1000ml, N 

(%) 

G1: 57/636 (9.0) 

G2: 20/294 (6.8) 

NS 

Hysterectomy, N (%) 

G1: 1/636 (0.2) 

G2: 1/294 (0.3) 

NS 

All intraoperative surgical 

complications, N (%) 

G1: 92/636 (14.5) 

G2: 20/294 (6.8) 

P < 0.001 

 

Uterine rupture (all had previous 

cesareans, so outcome of 

previous cesarean), N (%) 

G1: 3/636 (0.5) 

G2: 0/294 (0.0) 

NS 

Relevance 

Moderate 

Quality rating 

Fair 
C-6 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Bergholt et al., 2003 

(continued) 
C-7 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Risk of intraoperative laceration of 

the cervix, vagina, and bladder 

from emergency c/d 

Crude OR: 4.2 

Adj OR: 2.3 (0.8-6.7) 

Variables include educational level of 

surgeon, previous c/d, pre-pregnancy 

BMI, duration of regular painful 

contractions, placental abruption as 

indication, placenta previa as 

indication, birthweight 

Risk of intraoperative blood loss ≥

1000 ml during the cesarean 

delivery from emergency c/d 

Crude OR: 1.3 

Adj OR: 1.6 (0.7-3.4) 

Variables include educational level of 

surgeon, previous c/d, pre-pregnancy 

BMI, duration of regular painful 

contractions, pacental abruption as 

indication, placenta previa as 

indication, birthweight 

 
C-8 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Burrows, Meyn, Weber 2004 

Setting 

US, Hospital 

Study design 

Retrospective-cohort 

Inclusion criteria 

• Singleton pregnancies at term 

(>37 weeks) 

• One or no deliveries at Magee 

• Hospital 

Exclusion criteria 

• NR 

Groups 

G1: Spontaneous vaginal 

G2: Operative vaginal 

G3: Primary cesarean without 

trial of labor 

G4: Primary cesarean with trial of 

labor 

G5: Repeat cesarean with trial of 

labor 

G6: Repeat cesarean without trial 

of labor 

N at enrollment 

G1: 22,270 

G2: 4,908 

G3: 657 

G4: 3,366 

G5: 768 

G6: 865 

Objective of the study 

To describe postpartum maternal 

morbidity associated with mode of 

delivery in term, singleton 

pregnancies

Definition of elective cesarean 

NR 

Maternal Age, mean yrs ± SD 

G1: 28.7 ± 6.0 

G2: 28.4 ± 6.1 

G3: 30.4 ± 6.0 

G4: 29.2 ± 6.0 

G5: 32.3 ± 4.8 

G6: 32.7± 4.8 

P < 0.001 

Maternal weight on admission, % 

>91 kg 

G1: 16.6 

G2: 13.9 

G3: 25.6 

G4: 25.7 

G5: 29.2 

G6: 26.8 

P < 0.001 

Gravidity, median (range) 

G1: 39 (37-44) 

G2: 39 (37-43) 

G3: 39 (37-42) 

G4: 40 (37-44) 

G5: 39 (37-42) 

G6: 39 (37-43) 

P < 0.001 

N of previous c/d 

NR 

Type of Labor 

NR 

Type of Anesthesia 

NR 

Gestational Age, median wks 

(range) 

G1: 2 (1-18) 

G2: 2 (1-18) 

G3: 1 (1-8) 

G4: 1 (1-11) 

G5: 3 (2-10) 

G6: 1 (1-11) 

P < 0.001

Fetal weight 

NR 

Maternal Race, % 

White, Black 

G1: 81.2, 15.5 

G2: 78.2, 17.7 

G3: 87.5, 9.3 

G4: 81.7, 14.9 

G5: 84.1, 16.1 

G6: 85.7, 12.1 

P0< 0.001 (white only) 
C-9 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Endometritis, N (%) 

G1: 97 (0.4) 

G2: 33 (0.7) 

G3: 20 (3.0) 

G4: 315 (9.4) 

G5: 35 (4.6) 

G6: 23 (2.7) 

Pneumonia, N (%) 

G1: 17 (0.1) 

G2: 9 (0.2) 

G3: 2 (0.3) 

G4: 4 (0.1) 

G5: 5 (0.7) 

G6: 4 (0.5) 

PP hemorrhage, N (%) 

G1: 1,105 (5.0) 

G2: 231 (4.7) 

G3: 18 (2.7) 

G4: 131 (3.9) 

G5: 20 (2.6) 

G6: 28 (3.2) 

Transfusion, N (%) 

G1: 40 (0.2) 

G2: 21 (0.4) 

G3: 3 (0.3) 

G4: 36 (1.1) 

G5: 6 (0.8) 

G6: 4 (0.5) 

Deep venous thrombosis, N (%) 

G1: 15 (0.1) 

G2: 2 (0.04) 

G3: 1 (0.2) 

G4: 10 (0.3) 

G5: 1 (0.1) 

G6: 0

NR Relevance 

Moderate 

Quality Ratings 

Fair 
C-10 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Burrows, Meyn, Weber 2004 

(continued) 

Marital Status 

Married, % 

G1: 61.3 

G2: 58.7 

G3: 59.4 

G4: 66.2 

G5: 71.7 

G6: 76.5 

Pregnancy Related Conditions 

Preeclampsia, N (%) 

G1: 1.9 

G2: 2.7 

G3: 3.5 

G4: 5.9 

G5: 1.3 

G6: 1.2 

P < 0.001 

Episiotomy, % 

G1: 52.1 

G2: 67.6 

G3: 0 

G4: .2 

G5: .1 

G6: 0 

P < 0.001 
C-11 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

 
C-12 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Farrell, Allen, and Baskett, 2001 

Country, Setting 

Canada, hospital-based 

Study design 

Prospective cohort 

Inclusion criteria 

• Nulliparity 

Exclusion criteria 

• Hx of urinary tract 

abnormalities, pelvic surgery 

• Significant medical illness 

• Medications that would alter 

urinary tract function 

Groups 

G1: Cesarean delivery 

G1a: Before labor 

G1b: 1st stage 

G1c: 2nd stage 

G2: Spontaneous vaginal 

delivery 

G3: Instrumental delivery 

G3a: Forceps 

G3b: Vacuum 

N at enrollment 

Total: 690 

Loss participants: 95 delivered at 

another hospital; 2 withdrawn 

(stillbirth = 1; neonatal death = 1) 

N (%) 

G1: 147/593 

G1a: 32/593 

G1b: 70/593 

G1c: 45/593 

G2: 331/593 

G3: 115/593 

G3a: 100/395 

G3b: 15/593 

Follow-up 

• At 6 weeks: 559 completers 

• At 6 months: 484 completers 

Objective of the study 

To estimate the incidence and 

relative risk of postpartum urinary 

incontinence in primaparas by urinary 

continency before pregnancy 

Definition of elective cesarean 

Does not include labored births 

Maternal age, median yrs (range) 

Overall: 28 (15-48) 

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight, grams 

NR 

Urinary incontinence before 

pregnancy, N (%) 

G1a: 5 (6.3) 

G1b: 13 (16.3) 

G1c: 4 (5.0) 

G2: 46 (57.5) 

G3a: 1 (1.3) 

G3b: 11 (13.8) 
C-13 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

NR 6 weeks (%): 

G1: 8 

• G1a: 4 

• G1b: NR 

• G1c: 5 

G2: 23 

G3a: 35 

G3b: NR 

RR for G2 vs G1: 2.8 (1.5, 5.3) 

RR for G3a vs G1: 4.3 (2.2, 8.2) 

6 months (%): 

G1: 10 

• G1a: 5 

• G1b: NR 

• G1c: 3 

G2: 22 

G3a: 33 

G3b: NR 

RR for G2 vs G1: 2.1 (1.1, 3.7) 

RR for G3a vs G1: 3.1 (1.7, 5.9) 

Relevance 

Moderate 

Quality Rating 

Fair 
C-14 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Farrell, Allen, and Basket, 2001 

Setting 

Canada, Hospital 

Study design 

Prospective Cohort 

Inclusion criteria 

• Nulliparity 

• No tx of urinary or alimentary 

tract abnormalities 

• No pelvic surgeries 

Exclusion criteria 

• Medication with impact on 

urinary or alimentary tract 

function 

• Significant medical illness 

Groups 

G1: Spontaneous vaginal 

delivery 

G2: Elective c/d 

G3: C/d in labor 

G4: Forceps delivery 

N (%) 

G1: 333 (56) 

G2 and G3: 147 (25) 

G4: 115 (19) 

Objective of the study 

To estimate the incidence and 

relative risk (RR) of postpartum anal 

incontinence in primiparous women in 

a tertiary Canadian obstetrical unit 

Definition of elective cesarean 

NR 

Category includes: 

Maternal age median yrs (range) 

NR 

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight, median gms 

Overall: 3489 

Urinary incontinence before 

pregnancy, N (%) 

NR 
C-15 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

NR Flatal Incontinence at 6 wks PP, % 

G1: 16 

G2: 31 

G3: 17 

G4: 34

Fecal Incontinence at 6 wks PP, % 

G1: NR 

G2: NR 

G3: NR 

G4: NR

Flatal Incontinence at 6 mos PP, % 

G1: 17 

G2: 0 

G3: 21 

G4: 44

Fecal Incontinence at 6 mos PP, % 

G1: 4 

G2: 4 

G3: 2 

G4: 9

Relevance 

Moderate 

Quality Ratings 

Fair 
C-16 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Fawcett, Pollio, and Tully, 1992 

Setting 

US, hospital-based 

Study design 

Prospective cohort 

Inclusion criteria 

• NR 

Exclusion criteria 

• NR 

Groups 

G1: Unplanned c/d 

G2: Planned c/d 

G3: Vaginal delivery 

N 

G1: 106/473 (22.4%) 

G2: 113/473 (23.9%) 

G3: 254/473 (53.7%) 

Objective of the study 

To examine women’s birth 

experience by replicating Cranley et 

al., 1983 study 

Definition of elective cesarean 

Planned by end of 2nd trimester: 59% 

Planned within 1 to 9 weeks before 

delivery: 41% 

Probably includes labored, number 

NR 

Category includes 

G1: 

• Fetopelvic disproportion (37%) 

• Fetal distress (26%) 

• Breech presentation (18%) 

• Failed induction (4%) 

• Combination (15%) 

G2: 

• Repeat c/d (60%) 

• Breech (18%) 

• Combination (22%) 

Maternal age, mean yrs ± SD 

G1: 31.04 ± 4.5 

G2: 31.56 ± 4.6 

G3: 26.69 ± 4.3 

P < 0.001 

Maternal BMI 

NR 

Primipara, % 

G1: 88 

G2: 12 

G3: 90 

G1 vs G3: P < 0.001 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

Not reported by group 

Fetal weight 

NR 

Father Not Present at Births, N 

G1: 1 

G2: 6 

G3: 1 

Moms who held baby immediately 

after delivery, % 

G1: 18 

G2: 18 

G3: 73 

P < 0.001 

G3 vs G2 and G1: P 0.05 

Hospital stay, mean days (range) 

G1: 4.8 (3-10) 

G2: 4.9 (3-12) 

G3: 2.5 (1-14) 

P < 0.001 

G3 vs G2 and G1: P 0.05 
C-17 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Perception of birth experience, 

mean score ± SD 

Day 1 to 2 PP 

G1: 3.40± 0.59 

G2: 3.45 ± 0.53 

G3: 3.65 ± 0.48 

P < 0.001 

G1 vs G3: P < 0.017 

Pain intensity, mean score ± SD 

Day 1 to 2 PP 

G1: 2.64 ± 0.86 

G2: 2.45 ± 0.73 

G3: 2.64 ± 0.96 

P: NS 

Physical distress, mean score ± 

SD 

G1: 1.39 ± 0.94 

G2: 1.17 ± 0.87 

G3: 1.03 ± 0.95 

P = 0.004 

G1 vs G3: P < 0.17 

NR Relevance 

Moderate 

Quality rating 

Poor 
C-18 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Groutz et al., 2003 

Country, Setting 

Israel, hospital-based 

Study design 

Prospective cohort 

Inclusion criteria 

• Primiparous 

• Delivery at Lis Maternity 

Hospital 

Exclusion criteria 

• Nonsingleton deliveries 

• Instrumental vaginal delivery 

• Those with SUI before 

pregnancy 

Groups 

G1: Spontaneous vaginal 

delivery 

G2: Obstructed labor cesarean 

delivery 

G3: Elective cesarean delivery

N at enrollment 

G1: 145 

G2: 100 

G3: 118

Follow-up 

1 year 

G1: 145 

G2: 100 

G3: 118

Objective of the study 

To compare prevalence of stress 

urinary incontinence by mode of 

delivery 

Definition of elective cesarean 

No trial of labor 

Category includes: 

• Breech (70%) 

• Other indications not specified 

Maternal age, mean yrs ± SD 

G1: 28 ± 4 

G2: 32.5 ± 5.3 

G3: 31.7 ± 5.2 

Maternal height, mean cm ± SD 

G1: 164 ± 6.6 

G2: 162 ± 5.6 

G3: 164 ± 6.7 

Maternal weight, mean kg ± SD 

G1: 60 ± 9.0 

G2: 62.5 ± 1.6 

G3: 63 ± 13.0

Parity, % 

Primiparous: 100% 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age, wks ± SD 

G1: 39.7 ± 1.2 

G2: 40.2 ± 1.3 

G3: 38.8 ± 1.5 

Type of labor 

NR 

Type of anesthesia Epidural 

G1: 134/145 

G2: NR 

G3: NR 

Fetal weight, mean ± SD 

G1: 325 ± 400 

G2: 3450 ± 420 

G3: 3260 ± 617 

P < 0.05 

SUI during Pregnancy, N (%) 

G1: 45 (31) 

G2: 25 (25) 

G3: 33 (28) 
C-19 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

NR Stress incontinence at 1 yr, N (%) 

G1: 15/145 (10.3) 

G2: 12/100 (12) 

G3: 4/118 (3.4) 

G1 vs G2 

P = 0.7 

G1 vs G3 

P = 0.02 

Relevance 

Moderate 

Quality rating 

Fair 
C-20 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Hannah, Hewson, et al., 

2000 

Setting 

Australia, Canada, Chile, Denmark, 

Finland, Germany, Israel, 

Netherlands, New Zealand, Poland, 

Portugal, Romania, Switzerland, 

U.K., U.S., Yugoslavia; 

hospital/labor and delivery 

unit/maternity unit/outpatient 

clinic/NICU 

Study design 

RCT 

Inclusion criteria 

• Singleton, frank or complete 

breech 

• ≥ 37 wks 

Exclusion criteria 

• Evidence of fetopelvic 

disproportion 

• Clinically large infant 

• EFW ≥ 4000 g 

• Fetal hyperextension of head 

• Fetal anomaly 

• Contraindication to either labor or 

vaginal delivery 

Groups 

G1: Planned c/d 

G2: Planned vaginal delivery 

N at randomization 

G1: 

• 1,043/1,043 

• Lost to F/U: 2 

• Analyzed maternal outcomes: 

1,041/1,043 

G2: 

• 1,045/1,045 

• Lost to F/U: 3 

• Analyzed maternal outcomes: 

1,042/1,045 

Objective of the study 

To compare a policy of planned c/d 

with policy of planned vaginal birth 

for selected breech presentation 

Definition of elective cesarean 

Planned cesarean scheduled for 38 

or more wks gestation 

Includes actual vaginal deliveries 

Category includes: 

• breech 

Maternal Age, N (%) 

≥ 30 

G1: 339 (32.6) 

G2: 331 (31.8) 

< 30 

G1: 702 (67.4) 

G2: 711 (68.2) 

Maternal BMI 

NR 

Parity, N (%) 

0 

G1: 547 (52.6) 

G2: 545 (52.3) 

1-4 

G1: 434 (41.7) 

G2: 434 (41.7) 

> 4 

G1: 60 (5.8) 

G2: 63 (6.1) 

Time from randomization to 

delivery ≥ 7days, N (%) 

G1: 156 (15.0) 

G2: 301 (28.9) 

P < 0.0001 

Gestational Age/pregnancy dating 

≥ 41 wks, N (%) 

G1: 67 (6.4) 

G2: 65 (6.2) 

Gestational Age, median wks (5th 

to 95th percentile), N (%) 

G1: 39.3 (37.5; 41.2) 

G2: 39.6 (37.5; 41.8) 

P < 0.0001 

Presentation, N (%) 

Frank 

G1: 655 (62.9) 

G2: 637 (61.1) 

Complete 

G1: 340 (32.7) 

G2: 362 (34.7) 

Uncertain 

G1: 46 (4.4) 

G2: 43 (4.1) 

In labor 

G1: 434 (41.7) 

G2: 456 (43.8) 
C-21 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Maternal Mortality, N (%) 

G1: 0 

G2: 1 (0.1) 

Wound Infection dehiscence or 

breakdown, N (%) 

G1: 16 (1.5) 

G2: 10 (1.0) 

P = .32 

Infection 

G1: 15 (1.4) 

G2: 9 (0.9) 

Dehiscence or breakdown 

G1: 6 (0.6) 

G2: 2 (0.2) 

Maternal recovery 

G1: 4.0 (1.7-7.4) 

G2: 2.8 (0.8-6.9) 

P < 0.0001 

Postpartum bleeding, N (%) 

G1: 10 (1.0) 

G2: 13 (1.3) 

P = 0.68 

Hemorrhage, N (%) 

> 1000 ml 

G1: 4 (.4) 

G2: 8 (.8) 

Hemorrhage 

> 1500 ml 

G1: 2 (.2) 

G2: 4 (.4) 

P = 0.68 

Hemorrhage 

Requiring transfusion 

G1: 4 (.4) 

G2: 8 (.8) 

Hemorrhage 

Requiring D&C 

G1: 3 (.3) 

G2: 4 (.4) 

Hemorrhage 

Other 

G1: 2 (.2) 

G2: 1 (.1) 

Early PP depression 

G1: 3 (.3) 

G2: 0 

Relevance 

T 

Quality Rating 

Fair 
C-22 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Hannah, Hewson, et al., 

2000 

(continued) 

Follow-up 

6 wks PP 

Rupture of membranes 

(N, %) 

G1: 253 (24.3) 

G2: 233 (22.4) 

FHR abnormalities, N (%) 

G1: 13 (1.3) 

G2: 156 (15.2) 

P = < 0.0001 

Fetal weight, estimated gms (%) 

≥ 3000 gms 

G1: 689 (66.2) 

G2: 680 (65.3) 

< 3000 g 

G1: 352 (33.8) 

G2: 362 (34.7) 

Method of estimated fetal weight, N 

(%) 

Clinical only 

G1: 418 (40.2) 

G2: 427 (41.0) 

Ultrasonograph 

G1: 623 (59.9) 

G2: 615 (59.0) 

General anesthesia (N, %) 

G1: 294 (28.2) 

G2: 132 (12.7) 

P < 0.0001 

Epidural/spinal, N (%) 

G1: 682 (65.5) 

G2: 482 (46.3) 

P < 0.0001 

C/d before labor, N (%) 

G1: 470 (45.2) 

G2: 75 (7.2) 

C/d after labor, N (%) 

G1: 471 (45.2) 

G2: 376 (36.1) 

Vag delivery, N (%) 

G1: 100 (9.6) 

G2: 591 (56.7) 

P < 0.0001 

Cord prolapse, N (%) 

Before labor 

G1: 0 

G2: 2 

During labor 

G1: 0 

G2: 12 

P < 0.0001 
C-23 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Maternal Systemic Infection, N (%) 

G1: 16 (1.5) 

G2: 13 (1.0) 

P = 0.71 

PP fever, N (%) 

≥ 38.0 

G1: 16 (1.5) 

G2: 13 (1.3) 

≥ 38.5 

G1: 13 (1.3) 

G2: 10 (1.0) 

Pneumonia, N (%) 

G1: 1 (.1) 

G2: 0 

Infection, N (%) 

G1: 1 (.1) 

G2: 1 (.1) 

Deep vein thromophlebitis or 

pulmonary embolism 

G1: 0 

G2: 0 

 
C-24 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Hannah, Hewson, et al., 

2000 

(continued) 

Chorioamnionitis, N (%) 

G1: 3 (0.3) 

G2: 11 (1.1) 

Time in hosp before deliv ≥ 48 h, N 

(%) 

G1: 74 (7.1) 

G2: 91 (8.8) 

P = 0.19 

Maternal BMI 

NR 
C-25 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

 
C-26 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Hannah, Hodnett, et 

al., 2002 

Setting 

26 different countries, 1,596 of 

1,940 women from 110 centers 

worldwide with singleton fetus, 

in breech presentation at term 

Study design 

RCT 

Inclusion criteria 

• Singleton 

• Frank or complete breech 

• ≥ 37 weeks 

Exclusion criteria 

• NR 

Groups 

G1: Planned c/d 

G2: Planned vag 

N at randomization 

G1: 1,043 

G2: 1,045 

Follow-up 

3 months PP 

Objective of the study 

To compare maternal outcomes of 

planned c/d delivery and planned 

vaginal birth at 3 mos PP 

Definition of elective cesarean 

Planned cesarean scheduled for 38 

or more wks gestation 

Includes actual vaginal deliveries 

Category includes: 

• breech 

Maternal age, N (%) 

≥ 30 y 

G1: 286 (35.8) 

G2: 285 (35.7) 

Married or stable relationship, N (%) 

G1: 745 (93.4) 

G2: 747 (93.6) 

Nulliparity, N (%) 

G1: 399 (50.0) 

G2: 403 (50.5) 

Previous c/d 

G1: 24 (3.0) 

G2: 20 (2.5) 

In labor at randomization, N (%) 

G1: 322 (40.4) 

G2: 341 (42.7) 

Planning to breastfeed, N (%) 

Yes 

G1: 707 (88.6) 

G2: 707 (88.6) 

No 

G1: 42 (5.3) 

G2: 43 (5.4) 

Unknown 

G1: 49 (6.1) 

G2: 48 (6.0) 

Ruptures of membranes, N (%) 

G1: 183 (22.9) 

G2: 163 (20.4) 

Time from delivery to questionnaire 

completion, median months (5th to 

95th percentile) 

G1: 3.1 (2.5-7.5) 

G2: 3.1 (2.5-6.7) 

Questionnaire method, N (%) 

Mail 

G1: 219 (27.4) 

G2: 216 (27.1) 

Telephone/In person 

G1: 563 (70.6) 

G2: 564 (70.7) 

Unknown 

G1: 16 (2.0) 

G2: 18 (2.3) 
C-27 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Breastfed w/in a few hours 

following birth, N (%) 

G1: 571/779 (73.3) 

G2: 602/776 (77.6) 

RR: 0.94 (0.89-1.00)

P = 0.05 

Breastfed at time of completion of 

questionnaire, N (%) 

G1: 533/781 (68.3) 

G2: 539/776 (69.5) 

RR: 0.98 (0.92-1.05)

P = 0.62 

Postoperative or postpartum pain 

(3 months PP), N (%) 

In back 

G1: 90/796 (11.3) 

G2: 97/797 (12.2) 

RR: 0.93 (.71-1.22)

P = 0.64 

In head 

G1: 38/796 (4.8) 

G2: 34/797 (4.3) 

RR: 1.12 (0.71-1.76)

P = 0.63 

On outside of abdomen 

G1: 79/796 (9.9) 

G2: 45/797 (5.7) 

RR: 1.76 (1.24-2.50)

P = 0.002 

Deep inside abdomen 

G1: 70/796 (8.8) 

G2: 37/797 (4.6) 

RR: 1.89 (1.29-2.79)

P < 0.001 

In bottom of genital area 

G1: 14/796 (1.8) 

G2: 44/797 (5.5) 

RR: 0.32 (0.18-.58)

P < 0.001 

In other location 

G1: 13/796 (1.6) 

G2: 16/797 (2.0) 

RR: 0.81 (0.39-1.68) 

P = 0.71) 

Any pain 

G1: 217/796 (27.3) 

G2: 199/797 (25.0) 

RR: 1.09 (0.93-1.29)

P = 0.31 

Experienced urinary incontinence, 

N (%) 

G1: 36/798 (4.5) 

G2: 58/797 (7.3) 

RR: 0.62 (.41-.93)

P = 0.02 

No problem at all 

G1: 4/24 (16.7) 

G2: 17/46 (37.0)

P = 0.09 

A little problem 

G1: 15/24 (62.5) 

G2: 23/46 (50.0)

P = 0.09 

A big problem 

G1: 5/24 (20.8) 

G2: 6/46 (13.0)

P = 0.09 

Experienced fecal incontinence, N 

(%) 

G1: 5/619 (0.8) 

G2: 9/607 (1.5) 

RR: 0.54 (0.18-1.62)

P = 0.29 

No problem at all 

G1: 2/4 (50.0) 

G2: 2/9 (22.2)

P = 0.53 

A little problem 

G1: 2/4 (50.0) 

G2: 7/9 (77.8)

P = 0.53 

Experienced incontinence of 

flatus, N (%) 

G1: 66/616 (10.7) 

G2: 59/606 (9.7) 

RR: 1.10 (.79-1.54)

P = 0.64 

No problem at all 

G1: 40/61 (65.6) 

G2: 23/58 (39.7)

P = 0.006 

A little problem 

G1: 20/61 (32.8) 

G2: 33/58 (56.9)

P = 0.006 

A big problem 

G1: 1/61 (1.8) 

G2: 2/58 (3.5)

P = 0.006 

Relevance 

T 

Quality Rating 

Poor 
C-28 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Hannah, Hodnett, et al., 

2002 

(continued) 

Received help answering 

questionnaire, N (%) 

Yes 

G1: 415 (52.0) 

G2: 421 (52.8) 

No 

G1: 349 (43.7) 

G2: 329 (41.2) 

Unknown 

G1: 34 (4.3) 

G2: 48 (6.0) 

Low perinatal mortality rate, N (%) 

G1: 396 (49.6) 

G2: 394 (49.4) 

High perinatal mortality rate, N (%) 

G1: 402 (50.4) 

G2: 404 (50.6) 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight, grams 

NR
C-29 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Amount of pain, N (%) 

None 

G1: 579/796 (72.7) 

G2: 598/795 (75.2) 

Almost none 

G1: 22/796 (2.8) 

G2: 23/795 (2.9) 

Mild or small amount 

G1: 165/796 (20.7) 

G2: 142/795 (17.9) 

Quite a lot 

G1: 29/796 (3.6) 

G2: 31/795 (3.9) 

Severe or excruciating/terrible 

G1: 1/796 (0.1) 

G2: 1/795 (0.1) 

Took pills or medicine for pain in 

last 24 h, N (%) 

G1: (46/795) 

G2: (46/793) 

1.0 (0.67-1.48)

RR: P>.99 

Experienced PP depression, N (%) 

G1: 80/793 (10.1) 

G2: 46/454 (10.1) 

RR: 0.93 (0.70-1.24)

P = 0.68 

Regarding childbirth experience, N 

(%) 

Liked that it was natural 

G1: 62 (7.8) 

G2: 357 (44.7) 

RR: 0.17 (.14-.22)

P < 0.001 

Liked that childbirth was not very 

painful 

G1: 387 (48.5) 

G2: 329 (41.2) 

RR: 1.18 (1.05-1.31)

P = 0.004 

Liked being able to schedule the 

delivery 

G1: 261 (32.7) 

G2: 131 (16.4) 

RR: 1.99 (1.66-2.40)

P < 0.001 

No sex since birth, N (%) 

G1: 129/795 (16.2) 

G2: 115/796 (14.5) 

RR: 1.12 (.89-1.42)

P = 0.33 

Pain during sex on most recent 

occasion, N (%) 

G1: 111/655 (17.0) 

G2: 126/674 (18.7) 

RR: 0.91 (.72-1.14)

P = 0.43 

Experienced PP depression, N (%) 

G1: 80/793 (10.1) 

G2: 46/454 (10.1) 

RR: 0.93 (0.70-1.24)

P = 0.68 
C-30 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Hannah, Hodnett, et 

al., 2002 

(continued) 

 
C-31 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Liked the method of delivery 

G1: 469 (58.8) 

G2: 478 (59.9) 

RR: 0.98 (.90-1.06)

P = 0.68 

Liked actively participating in birth 

G1: 141 (17.7) 

G2: 381 (47.7) 

RR: 0.37 (.31-.44)

P < 0.001 

Felt reassured about own health 

G1: 539 (67.5) 

G2: 530 (66.4) 

RR: 1.02 (.95-1.09)

P = 0.67 

Felt reassured about infant’s health 

G1: 618 (77.4) 

G2: 547 (68.6) 

RR: 1.13 (1.06-1.20)

P < 0.001 

Liked that recovering from childbirth 

was not difficult 

G1: 410 (51.4) 

G2: 488 (61.2) 

RR: 0.84 (.77-.92)

P < 0.001 

Liked nothing about childbirth 

experience 

G1: 37 (4.6) 

G2: 37 (4.6) 

RR: 1.00 (.64-1.56)

P>.99 

Disliked that childbirth was very 

painful 

G1: 62 (7.8) 

G2: 109 (13.7) 

RR: 0.57 (.42-.76)

P < 0.001 

Disliked that childbirth was not 

natural 

G1: 173 (21.7) 

G2: 117 (14.7) 

RR: 1.48 (1.19-1.83)

P = < 0.001 

 
C-32 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Hannah, Hodnett, et 

al., 2002 

(continued) 

 
C-33 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Disliked the method of delivery 

G1: 113 (14.2) 

G2: 106 (13.3) 

RR: 1.07 (.83-1.36)

P = 0.66 

Disliked not being able to actively 

participate in birth 

G1: 172 (21.6) 

G2: 115 (14.4) 

RR: 1.50 (1.21-1.85)

P < 0.001 

Disliked planning for one method of 

delivery but having another 

G1: 80 (10.0) 

G2: 125 (15.7) 

RR: 0.64 (.49-.83) 

P < 0.001 

Felt worried about own health 

G1: 112 (14.0) 

G2: 95 (11.9) 

RR: 1.18 (.91-1.52)

P = .23 

Felt worried about infant’s health 

G1: 136 (17.0) 

G2: 226 (28.3) 

RR: 1.14 (.93-1.41)

P = .24 

Disliked that recovering from 

childbirth was difficult 

G1: 152 (19.1) 

G2: 133 (16.7) 

RR: 1.14 (.93-1.41)

P = .24 

Disliked nothing about childbirth 

experience 

G1: 334 (41.9%) 

G2: 325 (40.7%) 

RR: 1.03 (.91-1.16)

P = 0.68 

 
C-34 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Whyte, Hannah, et al., 

2004 

Setting 

26 different countries, 917 of 

1,159 women from 85 centers 

involved in a 2-yr postpartum 

follow-up study 

Study design 

RCT 

Inclusion criteria 

• Singleton 

• Frank or complete breech 

• ≥ 37 weeks 

Exclusion criteria 

• NR 

Groups 

G1: Planned c/d 

G2: Planned vag 

N at randomization 

G1: 1,043 

G2: 1,045 

Follow-up 

2 yrs PP 

Objective of the study 

To compare maternal outcomes at 

two years postpartum after 

planned vaginal birth for the 

singleton fetus in breech 

presentation at term. 

Definition of elective cesarean 

Planned cesarean scheduled for 

38 or more wks gestation 

Includes actual vaginal deliveries 

Category includes: 

• breech 

Maternal age, N ≥ 30 yrs (%) 

G1: 184 (40.3) 

G2: 181 (39.3) 

Maternal BMI 

NR 

Nulliparity, N (%) 

G1: 198 (43.3) 

G2: 221 (48.0) 

N of previous cesareans 

NR 

Previous c/d, N (%) 

G1: 13.8 (2.8) 

G2: 8 (1.7) 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 

Married or stable relationship, N (%) 

G1: 439 (96.1) 

G2: 441 (95.9) 

In labor at randomization, N (%) 

G1: 170 (37.2) 

G2: 196 (42.6) 

Planning to breastfeed (N, %) 

Yes 

G1: 398 (87.1) 

G2: 402 (87.4) 

No 

G1: 25 (5.5) 

G2: 31 (6.7) 

Unknown 

G1: 34 (7.4) 

G2: 27 (5.9) 
C-35 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Breastfed at time of completion of 

questionnaire, N (%) 

G1: 35 (7.7) 

G2: 24 (5.3) 

P = 0.14 

Duration of breast feeding, median 

months (5th,95th percentile) 

G1: 8.0 (1.0, 24.1) 

G2: 8.0 (1.0, 23.0) 

P = 0.57 

Ease of caring for child 

G1: 430 

G2: 443 

P = 0.78 

Very easy, N (%) 

G1: 100 (23.3) 

G2: 95 (21.4) 

Easy, N (%) 

G1: 257 (59.8) 

G2: 270 (60.9) 

A little difficult, N (%) 

G1: 68 (15.8) 

G2: 75 (16.9) 

Very difficult, N (%) 

G1: 5 (1.2) 

G2: 3 (0.7) 

Experience of being a mother 

G1: 428 

G2: 446 

P = 0.41 

Very easy, N (%) 

G1: 65 (15.2) 

G2: 74 (16.6) 

Easy, N (%) 

G1: 306 (71.5) 

G2: 310 (69.5) 

Difficult, N (%) 

G1: 51 (11.9) 

G2: 60 (13.5) 

Very difficult, N (%) 

G1: 6 (1.4) 

G2: 2 (0.4) 

Relationship with husband/partner 

G1: 430 

G2: 426 

P = 0.62 

Very happy, N (%) 

G1: 247 (57.4) 

G2: 249 (58.5) 

Somewhat happy, N (%) 

G1: 152 (35.3) 

G2: 147 (34.5) 

Somewhat unhappy, N (%) 

G1: 21 (4.9) 

G2: 25 (5.9) 

Very unhappy, N (%) 

G1: 10 (2.3) 

G2: 5 (1.2) 

Relationship with husband/partner 

now compared to before child 

G1: 428 

G2: 424 

P = 0.39 

Better, N (%) 

G1: 92 (21.5) 

G2: 79 (18.6) 

About the same, N (%) 

G1: 310 (72.4) 

G2: 319 (75.2) 

Relevance 

T 

Quality Rating 

Poor 
C-36 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Whyte, Hannah, et 

al., 2004 

(continued) 

Ruptures of membranes, N (%) 

G1: 89 (19.5) 

G2: 95 (20.7) 

Time from delivery to questionnaire 

completion, median months (5th, 95th 

percentile) 

G1: 24.3 (23.0, 30.8) 

G2: 24.2 (23.0, 29.9) 

Method of completing questionnaire, N 

(%) 

Mail 

G1: 190 (41.6) 

G2: 189 (41.1) 

Telephone/personal interview 

G1: 263 (57.5) 

G2: 267 (58.0) 

Unknown 

G1: 4 (0.9) 

G2: 4 (0.9) 

Received help answering 

questionnaire, N (%) 

Yes 

G1: 240 (52.5) 

G2: 263 (57.2) 

No 

G1: 214 (46.8) 

G2: 194 (42.2) 

Unknown 

G1: 3 (0.7) 

G2: 3 (0.7) 

Low perinatal mortality rate, N (%) 

G1: 270 (59.1) 

G2: 262 (57.0) 

High perinatal mortality rate, N (%) 

G1: 187 (40.9) 

G2: 198 (43.0) 
C-37 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Worse 

G1: 26 (6.1) 

G2: 26 (6.1) 

No sex, N (%) 

G1: 32 (7.0) 

G2: 41 (8.9) 

P = 0.33 

Pain during sex 

G1: 418 

G2: 412 

P = 0.84 

No pain, N (%) 

G1: 376 (90.0) 

G2: 369 (89.6) 

Almost no pain, N (%) 

G1: 5 (1.2) 

G2: 8 (1.9) 

Mild or small amount of pain, N (%) 

G1: 28 (6.7) 

G2: 29 (7.0) 

Quite a lot of pain, N (%) 

G1: 8 (1.9) 

G2: 6 (1.5) 

Severe or excruciating/terrible pain, 

N (%) 

G1: 1 (0.2) 

G2: 0 (0) 

Happiness with sexual relations 

G1: 353 

G2: 349 

P = 0.72 

Very happy, N (%) 

G1: 181 (51.3) 

G2: 172 (49.3) 

Somewhat happy, N (%) 

G1: 149 (42.2) 

G2: 151 (43.3) 

Somewhat unhappy, N (%) 

G1: 18 (5.1) 

G2: 23 (6.6) 

Very unhappy, N (%) 

G1: 5 (1.4) 

G2: 3 (0.9) 
C-38 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Whyte, Hannah, et al., 

2004 

(continued) 

 
C-39 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes 

Relevance and Quality 

Ratings 

Tried to become pregnant since the 

birth of the child, N (%) 

G1: 88 (19.3) 

G2: 105 (22.9) 

P = 0.20 

Number of pregnancies after the 

birth in the Term Breech Trial, N (%) 

1 or more 

G1: 95 (21.0) 

G2: 102 (22.3) 

P = 0.69 

0 

G1: 358 (79.0) 

G2: 356 (77.7) 

P = 0.69 

Currently pregnant or one or more 

infants born after the birth in the 

Term Breech Trial, N (%) 

G1: 78 (17.2) 

G2: 84 (18.3) 

P = 0.67 

Cesarean for one or more infants 

born after the birth in the Term 

Breech Trial, N (%) 

G1: 16 (3.6) 

G2: 13 (2.9) 

P = 0.58 

Urinary incontinence (N, %) 

G1: 81(17.8) 

G2: 100 (21.8) 

0.81 (0.63-1.06) 

P = 0.14 

Problem caused by urinary 

incontinence 

G1:81 

G2: 100 

P = 0.46 

No problem at all, N (%) 

G1: 31 (38.3) 

G2: 37 (37.0) 

A little problem, N (%) 

G1: 47 (58.0) 

G2: 54 (54.0) 

A big problem, N (%) 

G1: 3 (3.7) 

G2: 9 (9.0) 
C-40 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Whyte, Hannah, et al., 

2004 

(continued) 

 
C-41 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Fecal incontinence, N (%) 

G1: 11 (2.4) 

G2: 10 (2.2) 

P = 0.83 

1.10 (0.47-2.58) 

Problem caused by fecal 

incontinence 

G1: 11 

G2: 9 

P = 0.41 

No problem at all, N (%) 

G1: 3 (27.3) 

G2: 2 (22.2) 

A little problem, N (%) 

G1: 7 (63.6) 

G2: 4 (44.4) 

A big problem, N (%) 

G1: 1 (9.1) 

G2: 3 (33.3) 

Incontinence of flatus, N (%) 

G1: 60 (13.1) 

G2: 53 (11.5) 

1.14 (0.80-1.61) 

P = 0.48 

Problem caused by incontinence 

of flatus 

G1: 60 

G2: 53 

P = 0.50 

No problem at all, N (%) 

G1: 33 (55.0) 

G2: 34 (64.2) 

A little problem, N (%) 

G1: 22 (36.7) 

G2: 17 (32.1) 

A big problem, N (%) 

G1: 5 (8.3) 

G2: 2 (3.8) 

Post partum depression, (%) 

G1: 47 (10.5) 

G2: 53 (11.6) 

0.90 (0.62-1.30) 

P = 0.60 
C-42 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Whyte, Hannah, et al., 

2004 

(continued) 

 
C-43 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Painful menstrual periods, N (%) 

G1: 95 (24.7) 

G2: 106 (28.0) 

0.88 (0.70-1.12) 

P = 0.32 

Problem caused by painful 

menstrual period 

G1: 89 

G2: 104 

P = 0.46 

No problem at all, N (%) 

G1: 13 (14.6) 

G2: 26 (25.0) 

A little problem, N (%) 

G1: 67 (75.3) 

G2: 63 (60.6) 

A big problem, N (%) 

G1: 9 (10.1) 

G2: 15 (14.4) 

Irregular menstrual periods, N (%) 

G1: 39 (11.0) 

G2: 53 (15.0) 

0.73 (0.50-1.08) 

P = 0.12 

Problem caused by irregular 

menstrual period 

G1: 37 

G2: 52 

P = 0.83 

No problem at all, N (%) 

G1: 15 (40.5) 

G2: 21 (40.4) 

A little problem, N (%) 

G1: 15 (40.5) 

G2: 23 (44.2) 

A big problem, N (%) 

G1: 7 (18.9) 

G2: 8 (15.4) 
C-44 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Whyte, Hannah, et al., 

2004 

(continued) 

 
C-45 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Heavy menstrual period, N (%) 

G1: 63 (18.4) 

G2: 58 (16.8) 

1.10 (0.79-1.51) 

P = 0.62 

Problem caused by heavy 

menstrual period 

G1: 62 

G2: 56 

P = 0.35 

No problem at all, N (%) 

G1: 15 (24.2) 

G2: 13 (23.2) 

A little problem, N (%) 

G1: 38 (61.3) 

G2: 29 (51.8) 

A big problem, N (%) 

G1: 9 (14.5) 

G2: 14 (25.0) 

Constipation, N (%) 

G1: 124 (27.2) 

G2: 93 (20.2) 

1.35 (1.06-1.70) 

P = 0.02 

Problem caused by constipation 

G1: 122 

G2: 93 

P = 0.32 

No problem at all, N (%) 

G1: 25 (20.5) 

G2: 24 (25.8) 

A little problem, N (%) 

G1: 79 (64.8) 

G2: 58 (62.4) 

A big problem, N (%) 

G1: 18 (14.8) 

G2: 11 (11.8) 

Sexual problems, N (%) 

G1: 36 (7.9) 

G2: 38 (8.3) 

0.96 (0.62-1.49) 

P = 0.90 
C-46 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hannah, Whyte, Hannah, et al., 

2004 

(continued) 

 
C-47 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Problem caused by sexual 

problems 

G1: 36 

G2: 38 

P = 0.73 

No problem at all, N (%) 

G1: 2 (5.6) 

G2: 4 (10.5) 

A little problem, N (%) 

G1: 20 (55.6) 

G2: 22 (57.9) 

A big problem, N (%) 

G1: 14 (38.9) 

G2: 12 (31.6) 
C-48 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hillan, 1995 

Setting 

UK, hospital-based 

Study design 

Retrospective cohort 

Inclusion criteria 

• C/d during study period 

Exclusion criteria 

• NR 

Groups 

G1: Elective c/d 

G2: Emergent c/d 

• G2a: Emergency, no labor 

• G2b: In labor, no data 

available

• G2c: Labor < 12 hrs

• G2d: Labor ≥ 12 hrs

N 

G2: 399 

• G2a: 42 

• G2b: 109 

• G2c: 129 

• G2d: 119 

Objective of the study 

To determine the post operative 

morbidity associated with caesarean 

delivery, including comparisons for 

elective and emergency caesarean 

delivery, subgroups within emergency 

caesarean delivery and first vs 

second stage of labor 

Definition of elective cesarean 

Does not include labored births 

Maternal age 

NR 

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight, grams 

NR 
C-49 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Pyrexia, N (%) 

G1:106/220 (48.2) 

G2: 251/399 (62.9) 

• G2a: 24/42 (57.1)

• G2b: 58/109 (53.2)

• G2c: 82/129 (63.6) 

• G2d: 87/119 (73.1) 

P < 0.001 for G1 vs G2 

P < 0.025 for G2 subgroups 

Blood Transfusion, N (%) 

G1: 3/220 (1.4) 

G2: 18/399 (4.5) 

• G2a: 7/42 (16.7)

• G2b: 2/109 (1.8)

• G2c: 5/129 (3.9)

• G2d: 4/119 (3.4)

P < 0.05 for G1 vs G2 

P < 0.001 for G2 subgroups 

Antibiotic Therapy, N (%) 

G1:35/229 (15.9) 

G2: 130/399 (32.6) 

• G2a: 15/42 (36.6)

• G2b: 31/109 (28.4)

• G2c: 44/129 (34.1)

• G2d: 40/119 (33.6)

P < 0.001 for G1 vs G2 

P NS for G2 subgroups 

Urinary tract infection, N (%) 

G1: 24/220 (10.9) 

G2: 41/399 (10.3) 

• G2a: 4/42 (9.5)

• G2b: 9/109 (8.3)

• G2c: 17/129 (13.2)

• G2d: 11/119 (9.3)

P NS for G1 vs G2 

P NS for G2 subgroups 

Wound infection, N (%) 

G1: 9/220 (4.1) 

G2: 33/399 (8.3) 

• G2a: 7/42 (16.7)

• G2b: 5/109 (4.6)

• G2c: 10/129 (7.8)

• G2d: 11/119 (9.3)

P < 0.05 for G1 vs G2 

P NS for G2 subgroups 

NR Relevance 

Moderate 

Quality Rating 

Poor 
C-50 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Hillan, 1995 

(continued) 
C-51 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Intrauterine infection, N (%) 

G1: 3/220 (1.4) 

G2: 24/399 (6.0) 

• G2a: 3/42 (7.2)

• G2b: 9/109 (8.3)

• G2c: 7/129 (5.4) 

• G2d: 5/119 (4.2)

P < 0.01 for G1 vs G2 

P NS for G2 subgroups 

Chest infection N (%) 

G1: 2/220 (0.9) 

G2: 21/399 (5.3) 

• G2a: 2/42 (4.8)

• G2b: 11/109 (10.1)

• G2c: 7/129 (5.5) 

• G2d: 1/119 (0.8)

P < 0.05 for G1 vs G2 

P < 0.025 for G2 subgroups 
C-52 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Irion et al 1998 

Setting 

Switzerland, hospital-based 

Study design 

Retrospective cohort 

Inclusion criteria 

For attempted vaginal delivery 

• EFW (clinically by U/S) ≤ 3600 

gms 

• BPD (≤ 96 MM) 

• No hyperextension by U/S 

• Normal pelvis by digital exam 

Exclusion criteria 

• NR 

Groups 

G1: Attempted vaginal delivery 

G2: Elective c/d 

N 

G1: 385 

G2: 320 

Objective of the study 

To compare maternal and neonatal 

outcomes in elective cesarean vs 

attempted vaginal delivery for breech 

presentation at term 

Definition of elective cesarean 

Probably ncludes labored births, 

number NR. 

Category not defined 

Mean maternal age, mean yrs ± SD 

G1: 29.0 ± 4.9 

G2: 30.1 ± 5.2 

P = 0.004 

Maternal BMI, mean (IQ range) 

G1: 25.8 (23.9, 28.2) 

G2: 27.5 (24.9, 30.5) 

P < 0.001 

Mean maternal height, mean cm ± 

SD 

G1: 163.8 ± 6.5 

G2: 161.1 ± 7.1 

P < 0.001 

Parity, N (%) 

0 

G1: 273 (70.9) 

G2: 209 (65.3) 

1 

G1: 86 (22.3) 

G2: 81 (25.3) 

≥ 2 

G1: 26 (6.8) 

G2: 30 (9.4) 

P = 0.23 

Fetal biparietal diameter, median (IQ 

range) 

G1: 90 (87, 92) 

G2: 91 (88, 96) 

P < 0.001 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age, median wks (IQ 

range) 

G1: 38 4/7 (37 5/7, 39 2/7) 

G2: 38 1/7 (37 6/7, 39 0/7) 

P = 0.02 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight, estimated gms, 

median (IQ range) 

G1: 3000 (2800, 3300) 

G2: 3300 (3000, 2500) 

P < 0.001 
C-53 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Endometritis, N (%) 

G1: 7 (1.8) 

G2: 13 (4.1) 

RR = 0.45 (0.18-1.11) 

P = 0.07 

UTI, N (%) 

G1: 20 (5.2) 

G2: 40 (12.5) 

RR = 0.42 (0.25-0.70) 

P < 0.001 

Pulmonary infection, N (%) 

G1: 3 (0.8) 

G2: 1 (0.3) 

RR = 2.49 (0.26-23.86) 

P = 0.63 

Surgical complications, N (%) 

G1: 3 (0.8) 

G2: 1 (0.3) 

RR = 2.49 (0.26-23.86) 

P = 0.63 

Hysterectomy for hemorrhage, N 

(%) 

G1: 0 

G2: 1 (0.3) 

RR = 0 

P = 0.45 

Anaemia, N (%) 

G1: 35 (9.1) 

G2: 31 (9.7) 

RR = 0.94 (0.59-1.49) 

P = 0.79 

Pulmonary embolism, N (%) 

G1: 0 

G2: 1 (0.3) 

RR = NR 

P = 0.45 

Cardiorespiratory arrest, N (%) 

G1: 0 

G2: 2 (0.6) 

RR = NR 

P = 0.21 

Total maternal morbidity, N (%) 

G1: 68 (17.7) 

G2: 90 (28.1) 

RR = 0.063 (0.48-0.83) 

P = 0.001 

NR Relevance 

Low 

Quality Rating 

Not rated 
C-54 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Koroukian 2004 

Setting 

US, population-based 

Study design 

Retrospective cohort 

Inclusion criteria 

• Participaition in the Ohio 

Medicaid fee-for-servuce 

system 

• Continuous eligibility for 

Medicaid for 60 days PP 

Exclusion criteria 

• Multiple births 

• Women with disabling 

conditions identified through 

eligibility for the Medicaid blind 

and disabled program 

Groups 

G1: Vaginal delivery 

G1a: Spontaneous vaginal 

delivery 

• G1a*: Uncomplicated vaginal 

delivery (appears to be a 

subset of G1a) 

• G1b: Assisted vaginal delivery 

G2: C/d 

• G2a: Nonelective c/d 

• G2b: Elective c/d 

N 

G1a: 120,107 

G1b: 17,595 

G1a*: 60,765 

G2a: 25,641 

G2b: 5,393 

Objective of the study 

To estimate the relative risk of 

postpartum complications by type of 

delivery among Ohio Medicaid 

beneficiaries 

Definition of elective cesarean 

Performed between 37 and 42 wks 

GA, birthweight between 2500-4000 

gms, in the absence of any 

documented maternal medical risk 

factors, or labor and delivery events 

in the birth certificate 

Probably includes some women in 

labor 

Modes of delivery other than elective 

c/d include 

• Febrile condition 

• Meconium 

• PROM 

• Placenta previa 

• Abruptio placenta 

• Other excessive bleeding 

• Seizures during labor 

• Precipitous labor 

• Prolonged labor 

• Dysfunctional labor 

• Breech malpresentation 

• Cephalopelvic disproportion 

• Cord prolapse 

• Anesthetic complications 

• Fetal distress 

• Other labor and delivery events 

Maternal age, N ≥ 35 yrs (%) 

G1: 4067 (2.95) 

G2: 1416 (4.56) 

Maternal BMI 

NR 

Parity 

NR 

N of previous cesareans 

NR 

Diabetes, N (%) 

G1: 2512 (1.82) 

G2: 1319 (4.25) 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 
C-55 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Major puerperal infection 

(incidence/100) 

G1a: 0.90 

G1a*: 0.83 

G1b: 1.11 

G2a: 4.28 

G2b: 2.87 

RR for G2 vs G1: 4.07 (3.71-4.46) 

RR for G2b vs G1a*: 3.75 (3.12-4.51) 

Thromboembolic events 

(incidence/100) 

G1a: 0.07 

G1a*: 0.06 

G1b: 0.11 

G2a: 0.45 

G2b: 0.19 

RR for G2 vs G1: 4.07 (3.02-5.48) 

RR for G2b vs G1a*: 3.45 (1.70-7.00) 

Anesthetic complications 

(incidence/100) 

G1a: 0.09 

G1a*: 0.09 

G1b: 0.16 

G2a: 0.36 

G2b: 0.39 

RR for G2 vs G1: 3.64 (2.79-4.76) 

RR for G2b vs G1a*: 4.43 (2.68-7.34) 

Postpartum hemorrhage 

(incidence/100) 

G1a: 3.00 

G1a*: 2.42 

G1b: 3.13 

G2a: 2.22 

G2b: 1.74 

RR for G2 vs G1: 0.51 (0.46-0.56) 

RR for G2b vs G1a*: 0.60 (0.48-0.76) 

NR Relevance 

Low 

Quality Rating 

Not rated 
C-56 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Koroukian 2004 

(continued) 
C-57 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Transfusion (incidence/100) 

G1a: 0.11 

G1a*: 0.06 

G1b: 0.12 

G2a: 0.37 

G2b: 0.07 

RR for G2 vs G1: 1.86 (1.38-2.52) 

RR for G2b vs G1a*: 1.16 (0.41-3.25) 

Obstetric trauma (incidence/100) 

G1a: 7.35 

G1a*: 6.94 

G1b: 7.05 

G2a: 0.57 

G2b: 1.09 

RR for G2 vs G1: 0.09 (0.07-0.11) 

RR for G2b vs G1a*: 0.16 (0.16-0.20) 

Obstetric surgical wound 

complication (incidence/100) 

G1a: 0.25 

G1a*: 0.25 

G1b: 0.49 

G2a: 3.61 

G2b: 3.00 

RR for G2 vs G1: 12.10 (10.69-

13.69) 

RR for G2b vs G1a*: 12.50 (10.00-

15.63) 
C-58 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics

Author 

Krebs and Langhoff-Roos, 2003 

Setting 

Denmark, population-based 

Study design 

Retrospective cohort 

Inclusion criteria 

• Singleton 

• Term 

• Breech 

• Delivery in Denmark 

• 1982-1995 

Exclusion criteria 

• NR 

Groups 

G1: Elective c/d 

G2: Vaginal 

G3: Emergency c/d 

N 

G1: 7,503 

G2: 2,363 

G3: 5,575 

Follow-up 

5-18 years after first delivery 

Objective of the study 

To compare the maternal complications 

of elective c/d for breech at term with 

those after vaginal or emergency c/d 

Definition of elective cesarean 

Excludes labor 

Category includes: 

• Hypertension 

• Diabetes 

• Fetal death before onset of labor 

Maternal age, N (%) 

< 20: 

G1: 215 (2.9) 

G2: 96 (4.1) 

G3: 232 (4.2) 

P < .01 for G2 vs G1

P < .001 for G3 vs G1

≥ 35 

G1: 436 (5.8) 

G2: 50 (2.1) 

G3: 217 (3.9) 

P < .001 for G2 vs G1, G3 vs G1

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes, N (%) 

G1: 59 (0.8) 

G2: 7 (0.3) 

G3: 17 (0.3) 

P < .01 for G2 vs G1

P < .001 for G3 vs G1

Gestational age 

All term 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight, N (%) 

< 2500 gms 

G1: 231 (3.1) 

G2: 117 (5.0) 

G3: 307 (5.5) 

P < .001 for G2 vs G1, G3 vs G1

>4000 gms 

G1: 520 (6.9) 

G2: 47 (2.0) 

G3: 334 (6.0) 

P < .001 for G2 vs G1

P < .05 for G3 vs G1
C-59 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Hemorrhage and/or anemia, N (%) 

G1: 430 (5.7) 

G2: 142 (6.0) 

G3: 393 (7.0) 

RR for G1 vs G2: 1.0 (0.94 - 1.03) 

RR for G1 vs G3: 0.91 (0.84-0.97 

Puerperal fever/Pelvic Infection, N 

(%) 

G1: 110 (1.5) 

G2: 12 (0.5) 

G3: 126 (2.3) 

RR for G1 vs G2: 1.2 (1.11-1.25) 

RR for G1 vs G3: 0.81 (0.7-0.92) 

Wound infection, N (%) 

G1: 65 (0.9) 

G2: 16 (0.7) 

G3: 98 (1.8) 

RR for G1 vs G3: 0.69 (0.57-0.83) 

Bladder injury, N (%) 

G1: 5 (0.1) 

G2: 0 

G3: 10 (0.2) 

RR for G1 vs G3: 0.58 (0.23-1.02) 

Thromboembolism, N (%) 

G1: 6 (0.1) 

G2: 0 

G3: 7 (0.1) 

RR for G1 vs G2: 1.31 (0.95-1.32) 

RR for G1 vs G3: 0.80 (0.38-1.26) 

Rupture of the anal sphincter, N 

(%) 

G1: 0 

G2: 41 (1.7) 

G3: 0 

Hospitalization with vaginal 

descensus or urine incontinence, 

N (%) 

G1: 42/7,503 (0.6) 

G2: 13/2363 (0.6) 

G3: 80/5575 (0.5% as reported in 

article, 1.4% as calculated by authors 

of this report) 

NS 

Hospitalization for fistula or anal 

incontinence: 

G1: 0 

G2: 0 

G3: 0 

Notes: All outcomes for second or 

third pregnancy by mode of delivery 

in first pregnancy 

Placenta Previa, N (%) 

G1: 5 (0.1) 

G2: 1 (0.06) 

G3: 3 (0.08) 

RR for G1 vs G2: 1.14 (0.61-1.35) 

RR for G1 vs G3: 1.12 (0.52-1.60) 

Abruptio, N (%) 

G1: 19 (0.4) 

G2: 6 (0.3) 

G3: 25 (0.6) 

RR for G1 vs G2: 1.04 (0.78-1.22) 

RR for G1 vs G3: 0.77 (0.52-1.04) 

Future Ob/Gyn Issues, N (%) 

Subsequent delivery 

G1: 4126 (55.0) 

G2: 1451 (61.4) 

G3: 3270 (58.7) 

RR for G1 vs G2: 0.94 (0.92-0.96) 

RR for G1 vs G3: 0.94 (0.91-0.97) 

Admissions for infertility 

G1: 79 (1.1) 

G2: 23 (1.0) 

G3: 61 (1.1) 

Relevance 

Low 

Quality Rating 

Not rated 
C-60 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions 

Labor and delivery 

characteristics 

Author 

Krebs and Langhoff-Roos, 2003 

(continued) 

Other: 

Medical conditions 

HTN, N (%): 

G1: 293 (3.9) 

G2: 56 (2.4) 

G3: 219 (3.9) 

P < .001 for G2 vs G1, G3 vs G1

NS 

Smoker (%) 

G1: 29.9 

G2: 29.4 

G3: 30.5 

Characteristics of Delivery 

Technique (%) 

G1: NA 

G2: 

• Forceps: 5.1 

• Episiotomy: 47.6 

G3: NR 
C-61 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Ectopic pregnancy 

G1: 184 (2.5) 

G2: 66 (2.8) 

G3: 144 (2.6) 

Hospitalization for miscarriage 

G1: 508 (6.8) 

G2: 167 (7.1) 

G3: 409 (7.3) 

Fecundity (proportion of women 

having a second birth) for low risk 

mothers < 30, without diabetes, 

HTN, or perinatal death at first 

delivery, N (%) 

G1: 3296 (61) 

G2: 1204 (64) 

G3: 2682 (64) 

RR for G1 vs G2: 0.93 (0.91-0.96) 

RR for G1 vs G3: 0.91 (0.88-0.95) 

Preterm delivery < 37 wks 

G1: 177 (3.6) 

G2: 101 (5.6) 

G3: 242 (6.2) 

RR for G1 vs G2: 0.86 (0.78-0.94) 

RR for G1 vs G3: 0.75 (0.66-0.83) 

Fetal death before onset of labor 

G1: 11 (0.2) 

G2: 5 (0.2) 

G3: 11 (0.3) 

RR for G1 vs G2: 0.94 (0.61-1.19) 

RR for G1 vs G3: 0.90 (0.54-1.25) 

Intrapartum death 

G1: 3 (0.06) 

G2: 1 (0.06) 

G3: 4 (0.1) 

RR for G1 vs G2: 1.02 (0.38– 1.34) 

RR for G1 vs G3: 0.77 (0.23-1.38) 
C-62 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions 

Labor and delivery 

characteristics 

Author 

Krebs and Langhoff-Roos, 2003 

(continued) 

 
C-63 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

5-min Apgar < 7 

G1: 58 (1.1) 

G2: 20 (1.1) 

G3: 50 (1.2) 

RR for G1 vs G2: 1.01 (0.87-1.14) 

RR for G1 vs G3: 0.96 (0.79-1.23) 

Early neonatal death 

G1: 19 (0.4) 

G2: 4 (0.2) 

G3: 11 (0.3) 

RR for G1 vs G2: 1.13 (0.87-1.29) 

RR for G1 vs G3: 1.13 (0.82-1.42) 
C-64 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Lal et al., 2003 

Setting 

UK, hospital-based 

Study design 

Prospective cohort 

Inclusion criteria 

• Consecutive primiparas with 

live singleton pregnancies 

between April 1997 and Sept 

1998 

Exclusion criteria 

• Pregnant again 

• Had an operation, severe 

psychiatric or medical 

problem, neurologic problem, 

urinary tract anomaly, or 

diversion, ill infant 

Groups 

G1: Emergency c/d 

G2: Elective c/d 

G3: Vaginal delivery (non 

instrumental) 

N retained 

G1: 104 

G2: 84 

G3: 100 

Objective of the study 

To compare the incidence and 

severity of anal incontinence in 

primiparas after cesarean delivery 

versus spontaneous vaginal delivery 

Definition of elective cesarean 

Planned procedure or immediately 

after the onset of labor in anyone 

due for a planned delivery 

Does not include labored births 

Category includes: 

Fetal distress 

G1: 53 

G2: 0 

G3: NA 

Breech 

G1: 10 

G2: 48 

G3: NA 

Preeclampsia 

G1: 5 

G2: 5 

G3: NA 

Failure to progress 

G1: 27 

G2: 0 

G3: NA 

Cephalopelvic disproportion 

G1: 0 

G2: 12 

G3: NA 

Fetal growth restriction 

G1: 0 

G2: 3 

G3: NA 

Maternal request 

G1: 0 

G2: 3 

G3: NA 

Miscellaneous 

G1: 9 

G2: 9 

G3: NA 

Maternal age median yrs ± SD 

G1: 28.2 ± 5 

G2: 28.8 ± 5 

G3: 27.5 ± 4 

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes 

G1: 0 

G2: 2 

G3: NR 

Gestational age, median wks 

(range) 

G1: 39 (27-41) 

G2: 38 (27-41) 

G3: 39 (32-41) 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight, kg, ± SD 

G1: 3.1 ± 0.7 

G2: 3.1 ± 0.7 

G3: 3.2 ± 0.4 

Urinary incontinence before 

pregnancy, N (%) 

NR 

Maternal race (N) 

White 

G1: 98 

G2: 77 

G3: 96 

Asian 

G1: 3 

G2: 2 

G3: 4 

Afro-Caribbean 

G1: 3 

G2: 1 

G3: 0 
C-65 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

NR New anal incontinence, N (%) 

G1: 6/104 (5.8) 

G2: 3/80 (3.8) 

G3: 8/100 (8) 

Anal incontinence severe enough 

to require pad use, N (%) 

G1: 0 

G2: 2/80 (2.5) 

G3: 1/100 (1) 

Authors also compare c/d not in labor 

(emergency + elective) to vaginal 

delivery and find that the difference is 

not statistically significant 

Relevance 

Moderate 

Quality Rating 

Fair 
C-66 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Lal et al., 2003 

(continued) 

Maternal age 

NR 

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

Induced labor 

G1: NR 

G2: NR 

G3: 16 

Type of anesthesia 

NR 

Fetal weight, mean kg ± SD 

G1: 3.1 ± 0.7 

G2: 3.1 ± 0.7 

G3: 3.2 ± 0.4 

Urinary incontinence before 

pregnancy 

NR 

Maternal medical condition: 

Irritable Bowel Syndrome 

G1: 10 

G2: 4 

G3: 6 

 
C-67 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

 
C-68 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Lal et al., 2003 

(continued) 

Time to delivery 

Not in labor 

G1: 21 

G2: 80 

G3: NA 

Early labor (cervix < 8 cm) 

G1: 63 

G2: 0 

G3: NA 

Late labor (cervix > 8 cm) 

G1: 20 

G2: NA 

G3: NA 

Mean 

Fetal head circumference, mean cm 

± SD 

G1: 34 ± 4 

G2: 35 ± 3 

G3: 34 ± 2 
C-69 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

 
C-70 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Leiberman et al., 1995 

Setting 

Israel hospital (2 Depts of 

Ob/Gyn that differ in their 

management to breech) 

Study design 

Prospective Cohort 

Inclusion criteria 

• Nulliparous 

• Frank breech 

Exclusion criteria 

• Multiparity 

• Preterm 

• Complete or footling breech 

• Multiple gestation 

• Antepartum death 

• Major congenital 

malformations 

Groups 

G1: Planned trial of labor 

G2: Planned c/d 

N at assignment 

G1: 135 

G2: 129 

Objective of the study 

To examine pregnancy outcome in 

nulliparous women with single term 

breech presentation 

Definition of elective cesarean 

Includes labored births, number NR 

Category includes: 

• Placenta previa 

• Fetal anomalous presentation 

Maternal age 

NR 

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 
C-71 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Maternal morbidity (temperature > 

38 at 2 or more days PP, 

endometritis, wound infection, 

UTI, thrombophlebitis 

G1: 24/135 

G2: 40/129 

OR = 0.48 (0.25-0.89) 

P = 0.01 

NR Relevance 

T 

Quality Rating 

Fair 
C-72 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

MacArthur, Bick, and Keighley, 

1997 

Setting 

UK, hospital-based 

Study design 

Case-control 

Inclusion criteria 

• Women who had postpartum 

symptoms (backache, 

headaches, neckache, 

paraesthesias in hands, pain 

legs, visual disturbances, 

dizziness or fainting, stress 

incontinence, fatigue, fecal 

incontinence, sexual problems, 

and depression and randomly 

selected women without 

symptoms 

Exclusion criteria 

• NR 

Groups 

G1a: Primiparous, new 

incontinence 

G1b: Multiparous, new 

incontinence 

G2a: Primiparous, never had 

incontinence 

G2b: Multiparous, never had 

ncontinence 

Each group further divided into 

elective, emergency, forceps, 

vacuum, spontaneous, vaginal 

N 

Contacted for interview at 45 wks 

PP: 1,156 

Interviewed: 906 

Objective of the study 

To measure the prevalence and 

severity of postpartum fecal 

incontinence, especially new 

incontinence and to identify obstetric 

risk factors 

Definition of elective cesarean 

Probably includes labored births, 

number NR. 

Category not specified 

Maternal age, mean yrs ± SD 

G1a: 27.9 yrs ± 5.5 

G1b: 30.9 yrs ± 4.8

G2a: 26.7 ± 5.2 

G2b: 29.6 ± 4.6 

Maternal BMI 

NR 

Gravidity, N (%) 

One 

G1a: NR 

G1b: 10 (65.6)

G2a: NR 

G2b: 305 (61.5) 

Two 

G1a: NR 

G1b: 7 (38.9)

G2a: NR 

G2b:115 (23.2) 

≥ Three 

G1a: NR 

G1b: 1 (5.6)

G2a: NR 

G2b: 76 (15.3) 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor, N (%) 

Induced onset of labor 

G1a: 5 (27.8) 

G1b: 3 (16.7)

G2a: 49 (14.2) 

G2b: 42 (8.5) 

Type of anesthesia 

NR 

Fetal weight, mean gms ± SD 

G1a: 3306 ± 804.7 

G1b: 3444 ± 435.4

G2a: 3318 ±861.3 

G2b: 3432 ± 633.5 
C-73 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

NR Fecal incontinence, N (%) 

Elective 

Total: 0/61 (0) 

Primip: 0/13 (0) 

Multip: 0/48 (0) 

Emergency 

Total: 6/113 (5.3) 

Primp: 5/59 (8.5) 

Multip: 1/54 (1.9) 

Forceps 

Total: 8/110 (7.2) 

Primp: 5/86 (5.8) 

Multip: 3/24 (12.5) 

Vacuum 

Total: 4/18 (22.2) 

Primp: 3/14 (21.4)) 

Multip: 1/4 (25.0) 

Spontaneous vaginal delivery 

Total: 18/568 (3.2) 

Primp: 5/189 (2.6) 

Multip: 13/379 (3.4) 

Relevance 

Low 

Quality Rating 

Not rated 
C-74 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

MacArthur, Bick, and Keighley, 

1997 

(continued) 

N for analysis 

Elective: 61 

Emergency: 113 

Forceps: 110 

Vacuum: 18 

Spontaneous vaginal: 568 

Total: 870 

Fetal head circumference, mean 

cm ± SD 

G1a: 34 ± 2.3 

G1b: 34.6 ± 1.2

G2a: 34.5 ± 2.7 

G2b: 34.7 ± 2.5 

Second or greater perineal tear, N 

(% of new incontinence 

primiparous) 

G1a: 5 (27.8) 

G1b: 5 (27.8)

G2a: 91 (26.4) 

G2b: 113 (22.8) 

First stage of labor ≥ 10 hrs (% of 

new incontinence primiparous) 

G1a: 9 (60.0) 

G1b: 4 (22.2)

G2a: 136 (47.1) 

G2b: 79 (19.8) 

Second stage of labor ≥ 2 hrs (% of 

new incontinence primiparous) 

G1a: 7 (38.9) 

G1b: NR

G2a: 99 (28.5) 

G2b: 24 (4.8) 

Active second stage of labor ≥ 2 

hrs (% of new incontinence 

primiparous) 

G1a: 4 (22.2) 

G1b: NR

G2a: 41 (11.8) 

G2b: 19 (3.8) 
C-75 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 
C-76 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

MacArthur, Glazener, and 

Wilson, 2001 

Setting 

UK, Hospital 

Study design 

Cross Sectional 

Inclusion criteria 

• All women 

Exclusion criteria 

• NR 

Groups 

G1: SVD 

G2: Forceps 

G3: Vacuum 

G4: Breech 

G5: Elective c/d 

G6: Emergency c/d 

N 

G1: 4,963 

G2: 654 

G3: 329 

G4: 65 

G5: 496 

G6: 664 

Objective of the study 

To determine whether obstetric and 

maternal factors relate to fecal 

incontinence at three months PP

Definition of elective cesarean 

NR 

NR 
C-77 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

NR Fecal Incontinence at 3 mos PP, % 

All Women 

G1: 9.6 

G2: 13.6 

G3: 10.3 

G4: 13.8

G5: 7.3

G6: 7.5

Primiparae 

G1: 8.8

G2: 13.9 

G3: 9.3 

G4: 12.0

G5: 5.4

G6: 4.8

Multiparae 

G1: 10.0 

G2: 12.2 

G3: 14.3 

G4: 15.0 

G5: 8.0 

G6: 12.3

Relevance 

Low 

Quality Ratings 

Not rated 
C-78 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Mason et al., 1999 

Setting 

England, hospital-based 

Study design 

Prospective cohort 

Inclusion criteria 

• Consented to participate at 

prenatal visit 

• 34 wks pregnant 

(Questionnaire 1) 

• 8 mos postpartum 

(Questionnaire 2) 

Exclusion criteria 

• If any doubt that still pregnant 

• Miscarriage/stillbirth/ neonatal 

death 

• Birth outcome unknown to 

team 

Groups 

G1: Vaginal delivery 

G2: Planned c/d 

G3: Emergency c/d 

G4: Forceps 

G5: Ventouse 

N at enrollment 

At 34 wks of pregnancy: 

717/918 

Response rate = 78% 

Follow-up at 8-10 wks PP 

G1: 358/571 

G2: 44/571 

G3: 41/571 

G4: 28/571 

G5: 27/571 

Total N at 8 wks PP = 572/894 

Response rate = 64% 

Objective of the study 

To undertake a prospective survey 

of the prevalence of stress 

incontinence during pregnancy and 

following childbirth 

Definition of elective cesarean 

Unspecified 

Maternal age, N (%) 

 < 20: 

34/717 (4.8) 

20-29: 

357/717 (49.8) 

30-39: 

304/717 (42.3) 

≥ 40: 

22/717 (3) 

Maternal BMI 

NR 

Parity, N (%) 

Nullip: 316/717 (44) 

≥ Para 1: 401/717 (56) 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 

Urinary Incontinence, N (%) 

At 34 weeks GA: 419/717 (59) 

At 8 wks PP: 179/572 (31) 

Extent of reported SUI at 34 weeks 

GA, N (%) 

Daily leak of several time/wk: 207/419 

(49.4) 

Pad daily or most days: 46/419 (11) 

Change underwear most or everyday 

(38/419 (9.1) 

Onset of SUI measured at 34 weeks 

GA, N (%) 

Symptoms began before any 

pregnancy: 25/419 (6) 

During this pregnancy: 264/419 (63.0) 

Symptoms began in connection to prior 

pregnancy or delivery: 127/419 (30) 
C-79 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Stress urinary incontinence, N (%) 

G1: 125/358 (34.9) 

G2: 7/44 (15.9) 

G3: 7/41 (17.1) 

G4: 9/28 (32.1) 

G5: 11/27 (40.1) 

G1 vs G4 or G5: NS 

G2 vs G3: NS 

G1 vs G2 and G3 (cesarean):χ2

 = 

10.85, P = 0.0009 

NR Relevance 

Low 

Quality Rating 

Not rated 
C-80 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Nice et al., 1996 

Setting 

UK, community-based hospital 

Study design 

Prospective cohort 

Inclusion criteria 

• All c/d at 5 hospitals in 3 month 

period 

Exclusion criteria 

• NR 

Groups 

G1: Elective c/d 

G2: Emergency c/d 

N at start of study 

G1: NR 

G2: NR 

Follow-up 

10 days for all patients who had 

c/d 

G1: 220 

G2: 408 

Objective of the study 

To determine the cesarean rates, 

wound infection rates, and whether 

any procedures or prophylactic 

antibiotics influenced the outcome 

Definition of elective cesarean 

Planned by obstetrician in antenatal 

clinic and performed at scheduled 

time or sooner if onset of labor 

accelerated time of delivery, as 

compared to emergency c/d which is 

performed for immediate or 

compelling clinical reasons and not 

planned in advance 

Includes labored births, number NR, 

indications for c/d unspecified 

Maternal age 

NR 

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 
C-81 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Wound complications (“infection”) 

G1: 14/220 

G2: 31/408 

P = NS 

NR Relevance 

Moderate 

Quality rating 

Poor 
C-82 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Persson, Wølner-Hanssen, and 

Rhydstroem, 2000 

Setting 

Sweden, population-based 

Study design 

Case-control 

Inclusion criteria 

• Females born 1932 to 1977 in 

Sweden who had surgery for 

stress urinary incontinence 

between 1987 and 1996 

• For women who had more than 

1 operation for stress 

incontinence, only 1st event of 

surgery was included 

Exclusion criteria 

• Women born outside of 

Sweden 

• Women who had first delivery < 

1973 

• Women who had been 

operated on before their 1st 

delivery 

• Women who had unknown or 

absurd birth weight, or 

erroneous yr of delivery 

Groups 

G1: Women who had surgery for 

stress urinary incontinence (1987 

to 1996) 

G2: All women in population who 

met inclusion/exclusion criteria 

N at enrollment 

G1: 1942 

G2: 876,768 

Follow-up 

NR 

Objective of the study 

To evaluate obstetric and maternal 

risk factors for stress urinary 

incontinence 

Definition of elective cesarean 

Undefined, probably includes labored 

births, number NR 

Maternal age (yrs at 1st birth) 

≤ 19 

G1: 146 

G2: 74,459 

20-24 

G1: 598 

G2: 334,156 

25-29 

G1: 755 

G2: 357,123 

30-34 

G1: 329 

G2: 117,206 

35-39 

G1: 107 

G2: 29,430 

40-44 

G1: 7 

G2: 4,273 

≥ 45 

G1: 0 

G2: 121 

Maternal BMI 

NR 

Parity 

1 

G1: 336 

G2: 251,027 

2 

G1: 949 

G2: 412,984 

3 

G1:499 

G2: 164,102 

4 

G1: 113 

G2: 37,639 

≥ 5 

G1: 46 

G2: 11,016 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 
C-83 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

NR Stress Urinary Incontinence 

Surgery 

OR for elective cesarean vs. noninstrumental vaginal singleton births 

among primiparous women: 0.21 

(95% 0.13-0.34) 

OR for any cesarean vs. noninstrumental vaginal delivery: 0.34 

(95% CI 0.23-0.52) 

Relevance 

Low 

Quality rating 

Not rated 
C-84 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Persson, Wølner-Hanssen, and 

Rhydstroem, 2000 

(continued) 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 
C-85 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

 
C-86 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Phipps et al., 2005 

Setting 

US, hospital-based 

Study design 

Case-control 

Inclusion criteria 

• All women who underwent c/d 

at Women and Infant’s 

Hospital during study period 

(1/95 to 12/02) 

Cases 

• Women with bladder injury 

Controls 

• Two random controls per case 

Exclusion criteria 

• NR 

Groups 

G1: Cesarean delivery-elective 

and nonelective, primary and 

repeat with bladder injury 

G2: Cesarean delivery, no 

bladder injury 

Data reported for scheduled, 

urgent, emergency c/d for cases 

and controls 

N 

G1: 42 

G2: 84 

Objective of the study 

To identify risk factors for bladder 

injury during cesarean delivery 

Definition of elective cesarean 

Scheduled surgery 

All groups include: 

• Previous cesarean deliveries 

• Preterm deliveries 

Maternal age, mean yrs ± SD 

G1: 33.6 ± 3.7 

G2: 29.3 ± 6.3 

Maternal BMI ± SD 

G1: 29.9 ± 5.4 

G2: 33.0 ± 6.7 

Parity %, 

Nulliparous 

G1: 21 

G2: 48 

Multiparous (≥1) 

G1: 79 

G2: 52 

N of previous cesareans 

0 

G1: 33 

G2: 68 

1 

G1: 43 

G2: 27 

≥2 

G1: 24 

G2: 5 

Diabetes 

NR 

Gestational age, mean wks ± SD 

G1: 38.5 ± 1.9 

G2: 37.5 ± 3.4 

Type of labor (%) 

Presence of labor 

G1: 83 

G2: 61 

Type of anesthesia 

NR 

Fetal weight 

NR 
C-87 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Bladder injury 

Scheduled c/d 

G1: 14% 

G2: 27% 

Urgent c/d 

G1: 55% 

G2: 62% 

Emergency c/d 

G1: 31% 

G2: 11% 

P = 0.01 

NR Relevance 

Low 

Quality rating 

Not rated 
C-88 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Reichert, Baron, and Fawcett, 

1993 

Setting 

US, hospital-based 

Study design 

Retrospective cohort 

Inclusion criteria 

• Cesarean delivery 

• Married/living with partner 

• Full term deliveries 

• English 

Exclusion criteria 

• NR 

Groups 

G1: Cesarean deliveries, in 1973-

80 

G2: All deliveries, in 1981-82 

G3: All deliveries, in 1989-90 

G3 further subdivided into 

planned and unplanned, 

outcomes listed for G3 alone 

N at enrollment 

G1: 24 

G2: 15 

G3: 173 

Planned: 84 

Unplanned: 89 

Follow-up 

G1: From a few months to 6 

years 

G2: 6 weeks PP 

G3: 6 weeks PP 

Objective of the study 

To compare findings of three studies 

of women’s responses to planned 

and unplanned cesarean birth 

Definition of elective cesarean 

Labored births, number NR 

Groups (each includes both elective 

and emergency cesarean deliveries) 

include: 

G1: 

• Cephalopelvic disproportion (63%) 

• Dystocia (17%) 

• Fetal distress (8%) 

• Placenta previa (4%) 

• Toxemia (4%) 

• Genital herpes (4%) 

G2: 

• Dystocia (40%) 

• Breech presentation (20%) 

• Cephalopelvic (13%) 

• Fetal distress (13%) 

• Purse string suture of the cervix 

(7%) 

• Previous myomectomy (7%) 

G3: 

• Previous c/d (27%) 

• Breech presentation (19%) 

• Cephalopelvic (19%) 

• Combination of factors (15%) 

• Failed induction (2%) 

• Other reasons (failed vaginal birth 

after c/d, failed forceps delivery, 

genital herpes) (3%) 

Maternal age, mean yrs (range) 

G1: 29 (22-39) 

G2: 29.7 (25-37) 

G3: 31.5 (19-44) 

Maternal BMI 

NR 

Primipara 

G1: 17/24 

G2: 15/15 

G3: 93/173 

Planned c/d 

Primiparas 

G1: 4/17 

G2: 6/15 

G3: 12/93 

Multiparas 

G1: 7/7 

G2: NA, no multiparas 

G3: 72/80 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 
C-89 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

NR Physiologic Mode 

Woman’s goals achieved 

Unplanned: 43 

Planned: 49 

Not achieved 

Unplanned: 134 

Planned: 94 

Self concept mode

Woman’s goals achieved 

Unplanned: 145 

Planned: 154 

Not achieved 

Unplanned: 113 

Planned: 94 

Role function mode

Woman’s goals achieved 

Unplanned: 10 

Planned: 4 

Not achieved 

Unplanned: 22 

Planned: 10 

Interdependence mode*

Woman’s goals achieved 

Unplanned: 47 

Planned: 33 

Ineffective mode 

Unplanned: 30 

Planned: 17 

Test of effective vs. iNot achieveds 

by planned vs. unplanned cesarean 

for Group 3: 

Χ2

 = 5.59, P = 0.0173 

Test of effective vs. iNot achieveds 

by planned vs. unplanned for Group 

1 (data NR): 

Χ2

 = 13.12, P = 0.0006 

Test of effective vs. iNot achieveds 

by planned vs. unplanned for Group 

2 (data NR, Χ2

 NR) 

NS 

*See article for description of items 

within each mode; too lengthy to 

include here 

Relevance 

Low 

Quality Rating 

Not rated 
C-90 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions 

Labor and delivery 

characteristics 

Author 

Ryding, Wijma, and Wijma, 1998 

Country, Setting 

Sweden, hospital-based 

Study design 

Prospective cohort 

Inclusion criteria 

• Swedish speaking 

• Women subjected to cesarean 

delivery 

• Instrumental vaginal delivery or 

normal vaginal delivery 

• Delivered live child 

Exclusion criteria 

• Transferred to another hospital 

• Randomly selected for different 

study and excluded from this 

study (n = 53) 

• Artificial rupture of membranes 

• Oxytocin stimulation of 

spontaneous labor 

Groups 

• G1: Emergency cesarean 

• G2: Elective cesarean 

• G3: Instrumental vaginal 

delivery 

• G4: Normal vaginal delivery 

N at few days PP 

G1: 75 

G2: 79 

G3: 104 

G4: 104 

Follow-up 

1 month PP 

• G1: 71 

• G2: 70 

• G3: 96 

• G4: 96 

Objective of the study 

To compare the psychological 

reactions of women after different 

modes of delivery 

Definition of elective cesarean 

Includes women who had had a date 

set for elective delivery but were 

operated on as an emergency 

procedure because of the onset of 

labor

Includes labored births, but number 

NR

Maternal age, mean yrs 

G1: 31 

G2: 30 

G3: 28 

G4: 28 

All groups: 29 

Maternal BMI 

NR 

Primiparous, % 

G1: 34 

G2: 58 

G3: 87 

G4: 52 

All Groups: 58 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 
C-91 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Median post-traumatic stress 

reactions measured by Impact of 

Event Scale (range) 

2 days PP 

G1: 10.8 (4.0-21.8) 

G2: 6.0 (3.0-12.0) 

G3: 13.0 (5.0-18.3) 

G4: 10.0 (4.0-16.8) 

G1 vs G2: P = 0.001 

1 month PP 

G1: 8.0 (3.8-15.0) 

G2: 5.0 (1.0-11.0) 

G3: 9.0 (5.0-18.6) 

G4: 6.0 (3.0-11.0) 

G1 vs G2: P < 0.01 

Median mental distress 

measured by subset of Symptoms 

Check List (range) 

2 days PP 

G1: 19.0 (10.2-30.0) 

G2: 16.0 (10.1-21.5) 

G3: 20.0 (10.0-33.8) 

G4: 11.1 (6.0-17.0) 

G1 vs G2: P < 0.05 on anxiety only 

1 month PP 

G1: 13.0 (7.0-23.0) NS 

G2: 11.0 (6.0-17.0) 

G3: 15.0 (5.8-28.3) NS 

G4: 14.0 (4.5-19.5) NS 

G1 vs G2: P = NS 

Median appraisal of delivery 

measured by Vaginal Delivery 

Expectancy Questionnaire 

2 days PP 

G1: 59.3 (47.8-68.8) 

G2: 41.0 (31.0-51.0)

G3: 52.0 (37.0-64.0) 

G4: 33.9 (28.5-45.0) 

G1 vs G2: P < .0001 

1 month PP 

G1: 52.0 (40.5-64.8)

G2: 32.3 (24.0-42.0)

G3: 44.0 (31.5-53.5) 

G4: 26.0 (19.5-39.5) 

G1 vs G2: P < 0.01 

Change over time by groups were all 

statistically significant 

(P < 0.05 to P < .0001) for each type 

of questionnaire except for G2 for 

post -traumatic stress and G4 for 

mental distress 

NR Relevance 

Low 

Quality Rating 

Not rated 
C-92 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Sanchez-Ramos et al, 2001 

Setting 

US, hospital-based 

Study design 

Retrospective cohort 

Inclusion criteria 

• Singleton 

• Breech 

• Planned c/d offered; offered 

trial of labor if following criteria 

were met: singleton, frank or 

complete breech; EFW 2000 to 

4000 g; adequate pelvis by 

exam or CT; non extended 

fetal head by U/S or CT 

Exclusion criteria 

• NR 

Groups 

G1: Attempted vaginal breech 

G2: Elective c/d 

N 

G1: 272 

G2: 576 

Objective of the study 

To compare maternal and neonatal 

outcomes in elective cesarean vs 

attempted vaginal delivery for breech 

presentation at or near term 

Definition of elective cesarean 

Probably includes labored births, 

number NR 

Category includes: 

• Patient choice (40.8%) 

• Repeat (% NR) 

• Incomplete breech (25.0%) 

• Abnormal pelvimetry (10.1%) 

• Macrosomia (4.9%) 

• Hyperextension (3.3%) 

• Non-reassuring fetal testing (3.8%) 

Maternal age, mean yrs ± SD 

G1: 24.2 ± 5.7 

G2: 24.0 ± 5.9 

P = 0.62 

Maternal BMI 

NR 

Nulliparity, N (%) 

G1: 122 (44.8%) 

G2: 265 (46%) 

P = 0.81 

Previous cesareans, N (%) 

G1: 16 (5.9) 

G2: 92 (16%) 

P = 0.0003 

Diabetes 

NR 

Gestational age, mean wks ± SD 

G1: 38.7 ± 1.9 

G2: 38.3 ± 2.4 

P = 0.03 

Augmentation of labor via 

oxytocin, N (%) 

G1: 106 (39) 

G2: 4 (0.7) 

P = 0.0001 

Type of anesthesia 

NR 

Fetal weight estimated gms ± SD 

G1: 3028 ± 522 

G2: 3096 ± 687 

P = 0.26 
C-93 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Length of stay, median days 

(interquartile range) 

G1: 2 (2, 3) 

G2: 4 (4, 4) 

P = 0.001 

Febrile morbidity, N (%) 

G1: 23/272 (8.4) 

G2: 79/576 (13.7) 

P = 0.03 

Hemorrhage, N (%) 

G1: 3/272 (1.1) 

G2: 7/576 (1.2) 

P = 1.00 

Anesthesia complications, N (%) 

G1: 3/272 (1.1) 

G2: 6/576 (1.0) 

P = 1.00 

No morbidity, N (%) 

G1: 241/272 (88.6) 

G2: 476/576 (82.6) 

P = 0.02 

NR Relevance 

Moderate 

Quality rating 

Poor 
C-94 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Schindl et al., 2003 

Setting 

Austria, hospital-based 

Study design 

Prospective cohort 

Inclusion criteria 

• Gestation week 38 

Exclusion criteria 

• < 19 yrs 

• Inability to complete 

questionnaire 

• Unwillingness to participate 

• Severe internal problems (e.g., 

HELLP syndrome) 

Groups 

G1: Intended vaginal delivery 

G2: Elective c/d 

• G2a: Elective c/d (medical 

reasons) 

• G2b: Elective c/d (“on 

demand”) 

N at enrollment 

G1: 903 

G2: 147 

• G2a: 103 

• G2b: 44 

Follow-up 

3 days PP 

NR 

4 mos PP 

23.9% response rate 

Objective of the study 

To investigate birth experience and 

medical outcome in women with 

elective cesarean delivery compared 

with intended vaginal delivery 

Definition of elective cesarean 

Probably includes labor, number NR 

Elective c/d on demand includes: 

• Anxiety, nulliparae (16/44) 

• Previous traumatic birth (20/44) 

• Other (coordination problems, 

safety considerations) (8/44) 

Elective c/d for medical indications 

includes: 

• Breech (40/103) 

• Twins (7/103) 

• Preeclampsia (6/103) 

• CS interval < 15 mos (19/103) 

• Cephalopelvic disproportion 

(4/103) 

• HIV and hepatitis C (5/103) 

• Neurological problems (e.g., 

epilepsy) (10/103) 

• Internal problems (e.g., heart 

failure) (9/103) 

• Others (e.g., pelvic failure) (3/103) 

Maternal age, mean yrs (range) 

G1: 28 (15-43) 

G2a: 32 (20-44) 

G2b: 30 17-44) 

P < 0.05 

Maternal BMI 

NR 

N of previous births mean (range) 

G1: 0 (0-9) 

G2a: 1 (0-5) 

G2b: 0 (0-3) 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 

Other 

NR 
C-95 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Blood transfusion required, N (%) 

G1: 6/903 (0.6) 

G2: 0 

Sepsis, N (%) 

G1: 1/903 (0.1) 

G2: 0 

Perineal laceration III/IV, N (%) 

G1: 2/903 (0.2) 

G2: 0 

Labial, vaginal, perineal laceration 

I/II, N (%) 

G1: 302/903 (33.4) 

G2: 0 

Complications of peridural 

anesthesia, N (%) 

G1: 18/903 (2.0) 

G2: 6/147 (4.0) 

Pain, VAS scale (results presented 

graphically in article) 

• At birth, significantly higher median 

pain level during birth in the 

vaginal or assisted vaginal delivery 

groups compared to the cesarean 

group (“peridural” anesthesia was 

offered to every woman but only 

chosen in 11% of patients 

• At 3 days PP, pain significantly 

lower among spontaneous vaginal 

group compared to all C/d, no 

difference between c/d groups 

• At 4 mos PP, no difference in 

momentary birth-related pain was 

observed between all groups 

(Kruskal–Wallis test, P = 0.192) 

NR Relevance 

Moderate 

Quality rating 

Fair 
C-96 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Schindl et al., 2003 

(continued) 

 
C-97 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Birth experience, Zerrsen test for 

momentary personal feelings 

(results presented graphically in 

article) 

• Before birth, no differences in 

momentary personal feelings 

before birth 

• At 3 days PP, women in the 

assisted vaginal delivery and 

emergency cesarean delivery 

groups experienced strong 

negative feelings 

• At 4 mos PP, no difference 

between groups 

Birth experience, modified version 

of Salmon and Drew’s birth 

experience questionnaire (results 

presented graphically in article) 

• Before birth, women planning a 

cesarean delivery without medical 

indications had an expectation of a 

more pleasant birth compared to 

women planning a vaginal delivery 

or a cesarean for medical 

indications 

• At 3 days PP, most positive birth 

experiences in descending order: 

elective c/d on demand, elective 

c/d for medical indications, vaginal 

delivery, emergency c/d and 

assisted vaginal delivery 

• At 4 mos PP, most positive birth 

experiences in descending order: 

elective c/d on demand, elective 

c/d for medical indications, vaginal 

delivery, emergency c/d and 

assisted vaginal delivery 

 
C-98 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Schytt, Lindmark, Waldenstrom, 

2004 

Setting 

Western Europe, hospital-based 

Study design 

Cross Sectional at 1yr PP 

Inclusion criteria 

• Attending antenatal clinic 

Exclusion criteria 

• Miscarriages 

• Non-Swedish speaking 

• Twin deliveries 

Groups 

G1: Elective c/d 

G2: Emergency c/d 

G3: Vaginal 

G4: Forceps & vacuum

N at 1 yr PP 

G1: 133 

G2: 185 

G3: 1893 

G4: 172 

Objective of the study 

To describe the prevalence of stress 

incontinence, as described by the 

women themselves, one year after 

childbirth in a national sample of 

Swedish-speaking women, and to 

identify possible predictors 

Definition of elective cesarean 

NR 

Maternal age, mean yrs ± SD 

Overall: 29.5 ± 4.6 

Median: 29.0 

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight, grams 

NR 

Urinary incontinence before 

pregnancy, N (%) 

NR 

Pregravida BMI ≥ 30 

Primaparous: 25% 

RR: 1.5(1.1-2.0) 

Multiparous: 29.3% 

RR: 1.3 (1.0-1.6) 

Parity 

Primiparous: 44% 

Previous cesarean/s 

Multiparous: 13% 

Fetal weight, mean gms 

> 4500 

Primaparous: 17.9% 

RR: 1.0(0.4-2.3) 

Multiparous: 23% 

RR: 1.3 (0.8-2.0) 
C-99 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

NR Stress incontinence at 1 yr PP, %

Primiparas 

G1: 0 

G2: 11.5 

RR: 0.6 (0.3-1.0) 

G3: 19.9 

G4: 21.8 

RR: 1.1 (0.8-1.6) 

Multiparas 

G1: 12.9 

RR: 0.5 (0.3-0.9) 

G2: 12.7 

RR: 0.5 (0.3-1.0) 

G3: 25.4 

G4: 38.5 

RR: 1.5 (1.0-2.3) 

Relevance 

Low 

Quality Ratings 

Not rated 
C-100 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

van Ham, van Dongen, and 

Mulder, 1997 

Setting 

Netherlands, hospital-based 

Study design 

Retrospective cohort 

Inclusion criteria 

• All c/d performed in the Dept of 

Ob/Gyn in University Hospital, 

Netherlands, between 1983 

and 1992 

Exclusion criteria 

• None 

Groups 

G1: Primary elective c/d-planned 

operation, admitted 8 hr before 

c/d w/o symptoms of ruptured 

membranes, contractions, or 

bleeding (i.e., election) 

G2: Primary acute c/d-time 

between decision to deliver 

abdominally and actual 

performance < 8 hr ignoring 

stage of labor, no attempt to 

deliver vaginally (i.e., c/d, unclear 

whether labored or not, 

emergency) 

G3: Secondary acute c/d - c/d 

following failed vaginal delivery 

(i.e., labored emergency c/d) 

N at selection 

G1: 718/2,647 

G2: 859/2,647 

G3: 1,070/2,647 

Follow-up 

NR 

Objective of the study 

To assess intraoperative surgical 

complications and postoperative 

maternal morbidity rate of cesarean 

delivery 

Definition of elective cesarean 

Primary: planned operation, patient 

admitted ≥ 8 hrs before c/d without 

symptoms of ruptured membranes, 

regular uterine contractions or vaginal 

bleeding 

Maternal age, mean (range) 

G1: 30.5 (18-43) 

G2: 28.9 (16-49) 

G3: 29.3 (17-47) 

Maternal BMI 

NR 

Parity, mean (range) 

G1: 1.0 (0-9) 

G2: 0.7 (0-11) 

G3: 0.4 (0-6) 

N of previous cesareans (repeat), 

N (%) 

G1: 64 (8.9) P < 0.001 

G2: 23 (2.5) 

G3: 15 (1.4) 

Diabetes 

NR 

Gestational age, N (%) 

< 28 weeks 

G1: 5 (0.7) 

G2: 51 (5.9) 

G3: 10 (0.9) 

28-37 wks 

G1: 95 (13.2) 

G2: 52 (65.4) 

G3: 115 (10.7) 

> 37 wks 

G1: 618 (86.1) 

G2: 246 (28.7) 

G3: 945 (88.4) 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 
C-101 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Thrombosis, N (%) 

G1: 4 (0.6) 

G2: 9 (1.0) 

G3: 3 (0.3) 

Total 16 (1.5) 

Thrombophlebitis, N (%) 

G1: 8 (1.1) 

G2: 16 (1.8) 

G3: 41 (3.8) 

Total: 65 (2.5) 

Pneumonia, N (%) 

G1: NR 

G2: 5 (0.6) 

G3: 4 (0.4) 

Total: 9 (0.3) 

Fever, N (%) 

G1: 113 (15.7) P < 0.001 

G2: 217 (25.3) 

G3: 322 (30.1) 

Total: 652 (24.6) 

Coagulation disorders, N (%) 

G1: NR 

G2: 1 (0.1) 

G3: NR 

Total: 1 (0.1) 

Ileus, N (%) 

G1: 8 (1.1) 

G2: 18 (1.9) 

G3: 14 (1.2) 

Total: 40 (1.5) 

Other post-op major 

complications, N (%) 

Major 

G1: 1 (0.2) 

G2: 4 (0.5) 

G3: NR 

Total: 5 (0.2) 

Minor 

G1: 14 (1.9) 

G2: 19 (2.2) 

G3: 23 (2.1) 

Total: 56 (2.1) 

Maternal death 

G1: NR 

G2: NR 

G3: NR 

Total: 3/2,647 

Intra-operative complications, N 

(%) 

G1: 65 (9.1) P < 0.001 

G2: 77 (9.0) 

G3: 250 (23.4) P < 0.001 

Total: 392/2,647 (14.8) 

Uterine laceration, N (%) 

G1: 43 (6.0) 

G2: 47 (5.5) 

G3: 176 (6.5) P < 0.001 

Total: 226 (10.1) 

Bladder lesion, N (%) 

G1: 9 (1.3) 

G2: 3 (0.4) 

G3: 10 (0.9) 

Total: 22 (0.8) 

Lesions of uterine arteries/ 

ligamentum latum/bowels, N (%) 

G1: 3 (0.4) 

G2: 5 (0.6) 

G3: 6 (0.6) 

Total: 14 (0.5) 

Cervical vaginal lesions, N (%) 

G1: NR 

G2: 2 (0.2) 

G3: 6 (0.6) 

Total 8 (0.3) 

Bladder paralysis, N (%) 

G1: 8 (1.1) 

G2: 5 (0.6) 

G3: 10 (0.1) 

Total: 23 (0.9) 

Relevance 

Moderate 

Quality rating 

Poor 
C-102 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

van Ham, van Dongen, and 

Mulder, 1997 

(continued) 

Other indications to c/d 

Ruptured Membranes, N (%) 

G1: NR 

G2: 135 (15.7) 

Sig diff at P < 0.00 

G3: 889 (93.0) 

< 12 h 

G1: NR 

G2: 63 (7.3) 

G3: 542 (50.6) 

12 to 24 h 

G1: NR 

G2: 26 (3.0) 

G3: 261 (24.4) 

> 24 h 

G1: NR 

G2: 46 (5.4) 

G3: 86 (8) 

Mode of delivery, N (%) 

G1: 100% 

G2: 100% 

G3: 100% 

Disproportion, N (%) 

G1: 303 (42.2) P < 0.001 

G2: 70 (8.1) 

G3: 200 (18.7) 

Total 573 (21.6) 

Obstructed labor, N (%) 

G1: NR 

G2: NR 

G3: 453 (42.3) 

Total: 453 (17.1) 

Fetal distress, N (%) 

G1: NR 

G2: 260 (30.3) P < 0.001) 

G3: 178 (16.6) 

Total: 438 (16.5) 

Resident, N (%) 

G1: 464 (65) 

G2: 518 (60) 

G3: 654 (61) 

Obstetrician, N (%) 

G1: 254 (35) 

G2: 341 (40) 

G3: 416 (39) 
C-103 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Other intraoperative 

complications, N (%) 

G1: 10 (1.4) 

G2: 18 (2.1) 

G3: 23 (2.2) 

Total: 51 (1.9) 

Post-operative stay in hospital, 

days ± SD 

G1: 7.2 ± 2.1 

G2: 78 ± 3.1 

G3: 7.6 ± 1.9 

Relapocrotomy, N (%) 

G1: 6 (0.8) 

G2: 29 (3.4) 

G3: 8 (0.8) 

Total: 43 (1.6) 

Sepsis, N (%) 

G1: NR 

G2: 5 (0.6) 

G3: 2 (0.2) 

Total: 7 (0.3) 

Wound infection, N (%) 

G1: 7 (1.0) 

G2: 15 (1.7) 

G3: 30 (2.8) 

Total: 52 (2.0) 

Pelvic infection, N (%) 

G1: 4 (0.6) 

G2: 1 (0.1) 

G3: 11 (1.0) 

Total: 16 (1.5) 

Endometritis, N (%) 

G1: 9 (1.3) 

G2: 4 (0.5) 

G3: 17 (1.6) 

Total: 30 (1.1) 

UTI, N (%) 

G1: 18 (2.5) 

G2: 29 (3.4) 

G3: 33 (3.1) 

Total: 80 (3.0) 

Haematoma, N (%) 

G1: 19 (2.6) 

G2: 48 (5.6) 

G3: 26 (2.4) 

Total: 93 (3.5) 

 
C-104 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

van Ham, van Dongen, and 

Mulder, 1997 

(continued) 
C-105 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes 

Relevance and Quality 

Ratingss 

Blood loss, N (%) 

Intraoperative 

G1: 34 (4.7) P < 0.001 

G2: 67 (7.8) 

G3: 93 (8.7) 

Total: 194 (7.3) 

Post-operational 

≥ 1500 ml 

G1: 11 (1.5) 

G2: 25 (2.9) 

G3: 28 (2.6) 

Total: 64 (2.4) 

Post-operational 

1000 to 1500 ml 

G1: 20 (2.8) 

G2: 32 (3.7) 

G3: 53 (4.9) 

Total: 105 (4.0) 

Post-operation complications N 

(%) 

Summary of major/minor G1: 189 

(26.3) P < 0.001 

G2: 311 (36.2) 

G3: 446 (41.7) 

Total: 946 (35.7) 

Major 

G1: 19 (2.6) P < 0.001 vs emergency 

(G2 + G3) 

G2: 55 (6.4) 

G3: 46 (4.3) 

Total: 120 (4.5) 

Minor 

G1: 170 (23.7) P < 0.001 vs 

emergency (G2 + G3) 

G2: 256 (29.8) 

G3: 400 (37.4) 

Total: 826 (31.2) 

 
C-106 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Wilson, Herbison, and Herbison, 

1996 

Setting 

New Zealand, hospital-based 

Study design 

Retrospective cohort 

Inclusion criteria 

• All women 3 months PP 

• Delivered in Queen Mary 

Maternity Centre 

• Resident in Dunedin area 

Exclusion criteria 

• NR 

Groups 

G1: Spontaneous vertex 

G2: Forceps 

G3: Elective c/d 

G4: C/d in 1st stage of labor 

G5: C/d in 2nd stage of labor 

N 

G1: 1104 

G2: 190 

G3: 87 

G4: 94 

G5: 31 

Objective of the study 

To examine the relation between 

obstetric factors and the prevalence 

of urinary incontinence three months 

after delivery 

Definition of elective cesarean 

Unclear whether elective c/d includes 

labored births since referent groups 

include c/d in labor 

All groups include: 

• Repeat 

• Breech 

• Multiple gestation 

Maternal age, mean yrs 

Overall: 27.8 

Maternal BMI, mean 

Overall: 22.7 

Parity for all women, N (%) 

1 

180/607 (29.7) 

2 

188/498 (37.8) 

3 

98/256 (38.3) 

4 

28/80 (35.0) 

≥ 5 

15/31 (48.4) 

N of previous cesareans 

NR 

Diabetes 

NR 

Mean gestational age 

39.6 

Spontaneous onset of labor (%) 

Overall: 79.3 

Type of anesthesia 

NR 

Fetal birthweight, mean gms 

Overall: 3432 
C-107 

Evidence Table 1. Maternal outcomes of cesarean delivery on maternal request (continued) 

Short Term Maternal Outcomes Long term Maternal Outcomes Relevance and Quality Ratings 

Urinary incontinence, all women at 

3 mo PP, N (%) 

G1: 400/1104 (36.2) 

G2: 67/190 (35.3) 

G3: 20/87 (23.0) 

G4: 22/94 (23.4) 

G5: 8/31 (25.8) 

Urinary incontinence, women with 

no previous incontinence, N (%) 

G1: 112/459 (24.4) 

G2: 27/100 (27) 

G3: 4/45 (8.9) 

G4: 6150 (12.0) 

G5: 1/13 (7.7) 

OR for urinary incontinence, all 

women with no previous 

incontinence 

G1: 1.00 

G2: 1.3 (0.8-2.3) 

G3: 0.3 (0.1-0.6) 

G4: NR 

G5: NR 

Urinary incontinence, only 

primiparae, N (%) 

G1: 115/356 (32.3) 

G2: 48/145 (33.1) 

G3: 3/22 (13.6) 

G4: 11/61 (18.0) 

G5: 4/24 (16.7) 

Urinary incontinence, only 

primiparae with no previous 

incontinence, N (%) 

G1: 49/200 (24.5) 

OR: 1.00 

G2: 22/87 (25.2) 

OR: 1.0 (0.5-1.9)

G3: 0/13 (0.0) 

OR: 0.2 (0.0-0.6)

G4: 2/33 (6.1) 

OR: NR

G5: 1/12 (8.3) 

OR: NR 

 

NR Relevance 

Low 

Quality Rating 

Not rated 
C-108 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Badawi et al., 1998 

Setting 

Australia, population-based 

Study design 

Case-control 

Inclusion criteria 

• Term (≥ 37 ws) infants born in 

metro Perth 6/93 to 9/95 

• Cases: moderate/severe 

newborn encephalopathy 

defined by seizures alone OR 

any 2 of the following lasting 

for > 2 hrs: abnormal 

consciousness, difficulty 

maintaining respiration (of 

presumed central origin), 

difficulty feeding (of presumed 

central origin), abnormal tone 

and reflexes within the 1st 

week of life 

• Controls: randomly selected for 

population of term births in 

Perth, same time period 

Exclusion criteria 

• Down’s syndrome 

• Open neural tube defects 

Groups 

G1: Infants of moderate or 

severe newborn encephalopathy 

G2: Randomly selected control 

N at enrollment 

G1: 164 

G2: 400 

Objective of the study 

To identify intrapartum predictors of 

newborn encephalopathy in term 

infants 

Definition of elective cesarean 

“Planned at least 24 hrs before 

procedure,” probably includes 

labored, number NR 

Indications include: 

• Previous cesarean delivery 

• Malpresentation 

• Previous difficult labor 

• Intrauterine growth retardation 

• Placenta previa 

• Other 

Maternal age median yrs 

NR 

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor, N (%) 

Spontaneous 

G1: 90 (54.9) 

G2: 220 (55.0) 

Unadjusted OR: 1 

Adjusted OR: 1 

Induced 

G1: 68 (41.5) 

G2: 122 (30.5) 

Unadjusted OR: 1.36 

Adjusted OR: 0.97 

(0.57-1.68) 

None 

G1: 6 (3.7) 

G2: 58 (14.5) 

Unadjusted OR 0.25 

Adjusted OR: 0.17 

(0.06-0.49) 

Type of anesthesia, N (%) 

General anesthesia 

G1: 18/164 (11.0) 

G2: 11/400 (2.8) 

Unadjusted OR: 4.40 

Adjusted OR: 3.08 

1.16, 8.17) 

Epidural 

G1: 19/164 (11.6) 

G2: 69/400 (17.2) 

Unadjusted OR: 0.64 

Adjusted OR: 0.51 

(0.26, 1.02) 

Fetal weight 

NR 
C-109 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and Quality Ratings 

Newborn encephalopathy, N (%) 

SVD 

G1: 49 (29.9) 

G2: 261 (40.3) 

Unadjusted OR: 1.0 (reference 

category) 

Adjusted OR: 1.0 (reference 

category) 

Induced VD 

G1: 32 (19.5) 

G2: 80 (20) 

Unadjusted OR: 1.31 

Adjusted OR: 1.0 

(0.55, 2.18) 

Instrumental VD 

G1: 42 (25.6) 

G2: 62 (15.5) 

Unadjusted OR: 2.23 

Adjusted OR: 2.34 

(1.16, 4.70) 

Elective c/d 

G1: 4 (2.4) 

G2: 58 (14.5) 

Unadjusted OR: 0.23 

Adjusted OR: 0.17 

(0.05, 0.56) 

Emergency c/d 

G1: 34 (20.7) 

G2: 38 (9.5) 

Unadjusted OR: 2.94 

Adjusted OR: 2.17 

(1.01, 4.64) 

Breech maneuver 

G1: 3 (1.8) 

G2: 1 (0.3) 

Unadjusted OR: 9.86 

Adjusted OR: 1.54 

(0.10, 25.14) 

NR Relevance 

Moderate 

Quality rating 

Fair 
C-110 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Badawi et al., 1998 

(continued) 

Risk factors in newborn 

encephalopathy, N (%) 

Occiptoposterior presentation 

G1: 17/164 (10.4) 

G2: 15/400 (3.8) 

Unadjusted OR: 2.97 

Adjusted OR: 4.29 

(1.74-10.54) 

Membrane rupture to delivery interval 

> 12 hrs 

G1: 32/164 (19.5) 

G2: 53/400 (13.2) 

Unadjusted OR: 1.59 

Adjusted OR: 1.31 

(0.69, 2.47) 

Cord prolapse 

G1: 1/164 (0.6) 

G2: 1/400 (0.2) 

Unadjusted OR: 2.45 

Adjusted OR: 4.71 

(0.21-105.02) 

Maternal pyrexia ≥ 37.5 

G1: 18/164 (11.0) 

G2: 9/400 (2.2) 

Unadjusted OR: 5.34 

Adjusted OR: 3.82 

(1.44, 10.12) 
C-111 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and Quality Ratings 

 
C-112 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Dani et al., 1999 

Setting 

Italy, community-based 

Study design 

Case-control 

Inclusion criteria 

• Infant born between 2/1/95-

1/31/98 in one of 65 hospitals 

included (Italy) (level II or III 

nursery) 

• TT or RDS diagnosed 

Exclusion criteria 

• Total pneumonia or not having 

TT or RDS 

Groups 

G1:Vaginal 

G2: Operative vaginal 

G3: Elective c/d 

G4: Emergent c/d 

N 

G1: 43,941 

G2: 1,621 

G3: 11,021 

G4: 1,351 

Objective of the study 

To investigate maternal and perinatal 

risk factors for RDS and TT in 

newborn infants. 

Definition of elective cesarean 

Includes labored births. 

Category not defined, but may 

include 

• Twins 

• Unspecified “maternal diseases” 

• Gestosis 

• Placenta previa 

• Placental abruption 

• IUGR 

• PROM 

• Preconceptional diabetes 

• Isoimmunization 

Maternal age 

< 32 yrs 

Overall: 40,152 

≥32 yrs 

Overall: 22,556 

Maternal BMI 

NR 

Gravidity 

First 

28,066 

Second 

20,335 

Third 

7,230 

Fourth 

2,395 

Fifth or more 

1,351 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age, mean wks 

< 36 

Overall: 3,407 

36-42 wks 

Overall: 59,990 

> 42 wks 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight, mean gms 

< 1500 

Overall: 1,036 

1500-2499 

Overall: 3,864 

> 2500 

Overall: 58,224 

Maternal disease 

Not abstractable 
C-113 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and Quality Ratings 

RDS 

G1: 215/43,941 

G2: 1/1621 

G3: 158/11,021 

G4: 360/1,351 

OR for G3 vs G1: 1.88 (1.42-2.48) 

P < 0.0001 

OR for G4 vs G1: 3.46 (2.69-4.44) 

P < 0.0001 

TTN 

G1: 226/43,941 

G2: 13/1,621 

G3: 157/11,021 

G4: 198/1,351 

OR for G3 vs G1: 1.86 (1.48-2.33) 

P < 0.0001 

OR for G4 vs G1: 2.86 (2.25-3.63) 

P < 0.0001 

NR Relevance 

Low 

Quality Rating 

Not rated 
C-114 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Dessole et al., 2004 

Setting 

Italy, hospital-based 

Study design 

Retrospective cohort 

Inclusion criteria 

• All c/d at institution from Jan 

1995–Dec 2002 

Exclusion criteria 

• None 

Groups 

G1: Emergency c/d 

G2: Scheduled c/d 

G3: Unscheduled c/d 

N 

G1: 1421 

G2: 1242 

G3: 445 

Objective of the study 

To investigate the incidence, type, 

location, and risk factors of accidental 

fetal lacerations during cesarean 

delivery

Definition of elective cesarean 

Includes labored births, number NR 

Category includes: 

• Repeat, macrosomia, placenta 

previa (32%) 

• Multiple gestation (51%) 

• Fetal anomalous presentation 

(17%) 

Maternal age 

NR 

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age, mean yrs (range) 

Overall: 38.7, 29-42 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight, gms (range) 

Overall: 3033.8, 825-4350 
C-115 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and Quality Ratings 

Mild laceration 

G1: 73/1421 

G2: 13/1242 

G3: 8/445 

Moderate laceration 

G1: 2/1421 

G2: 0/1242 

G3: 0/445 

Severe laceration 

G1: 1/1421 

G2: 0/1242 

G3: 0/445 

Total lacerations 

G1: 76/1421 

OR: 1.7, compared to all fetal 

laceration/all cesarean deliveries 

G2: 13/1242 

OR: 0.34, compared to all fetal 

laceration/all cesarean deliveries 

G3: 8/445 

OR: 0.57, compared to all fetal 

laceration/all cesarean deliveries 

P < 0.001

NR Relevance 

Moderate 

Quality Rating 

Fair 
C-116 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Durik, Hyde, and Clark, 2000 

Setting 

US, hospital-based 

Study design 

Prospective cohort 

Inclusion criteria 

• ≥ 18 yrs 

• Between 12 and 21 wks 

gestation 

• Living with partner although not 

necessarily married 

• Working/having working partner 

• Possessing telephone 

• Able to speak English 

• Literate 

Exclusion criteria 

• Student 

• Unemployed 

Groups 

G1: Vaginal delivery 

G2: Planned cesarean 

G3: Unplanned cesarean 

N at enrollment 

G1: 477 

G2: 37 

G3: 56 

Total: 96.1% 

% enrollment at 4 mos PP: 98.7% 

Objective of the study 

To examine delivery related 

differences in relation to women’s 

appraisal of their birth experience 

Definition of elective cesarean 

Undefined “planned” cesareans 

Maternal age, mean yrs ± SD 

G1: 30.12 ± 4.47 

G2: 30.54 ± 4.16 

G3: 28.63 ± 4.12 

Education (on scale of 1, less than 

high school, to 8, graduate degree) ± 

SD 

G1: 5.8 ± 1.54 

G2: 5.0 ± 1.53 

G3: 5.61 ± 1.03 

Maternal BMI 

NR 

Primiparous (%) 

G1: 35 

G2: 16 

G3: 66 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight, mean gms ± SD 

G1: 3467 ± 465 

G2: 3437 ± 604 

G3: 3783 ± 532 

Self-esteem, Rosenberb’s self-esteem 

scale ± SD 

G1: 34.72 ± 4.86 

G2: 34.81 ± 5.67 

G3: 35.75 ± 3.23 

Depression CES-D Scale ± SD 

G1: 8.46 ± 7.51 

G2: 1.03 ± 7.44 

G3: 6.88 ± 4.60 

Neuroticism measured by Eysende 

Personality Inventory Form A Score, ± 

SD 

G1: 8.69 ± 5.40 

G2: 9.97 ± 5.15 

G3: 8.82 ± 5.12 
C-117 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and Quality Ratings 

NR NR Relevance 

Low 

Quality Rating 

Not rated 
C-118 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Golfier et al., 2001 

Setting 

Western Europe, France 

Hospital-based 

Study design 

Retrospective cohort 

Inclusion criteria 

• 37-42 wks 

• Breech, singleton 

Exclusion criteria 

• Maternal or fetal pathology that 

could have affected the state 

of the mother or child at birth 

Groups 

G1: Planned vaginal 

G2: Elective c/d 

Actual mode of delivery 

G1: 342/414 delivered vaginally 

G2: 695/702 delivered by c/d 

N 

G1: 414 

G2: 702 

Objective of the study 

To compare neonatal and maternal 

morbidity and mortality between 

planned vaginal delivery and elective 

cesarean delivery for term breech 

presentation 

Definition of elective cesarean 

Probably includes labored births, 

number NR 

All groups include: 

• Breech 

Mean maternal age, mean yrs 

Overall: 29 

Maternal BMI 

NR 

Primiparous, % 

G1: 54 

G2: 68 

P = 0.05 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Anesthesia, % 

General 

G1: 5.8 

G2: 23.5 

Regional 

G1: 57.7 

G2: 76.5 

No anesthesia 

G1: 36.5 

G2: 0 

Birth weight, mean gms 

G1: 3164 

G2: 3206 

P > 0.05 

Macrosomia, > 4000 gms 

G1: NR 

G2: NR 

RR = 3.09 (1.46-6.5) 

Higher in elective c/d group 

Episiotomy, % 

G1: 83 

G2: NR 
C-119 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and Quality Ratings 

NA NA Relevance 

Low 

Quality Rating 

Not rated 
C-120 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Groutz et al., 2003 

Country, Setting 

Israel, hospital-based 

Study design 

Prospective cohort 

Inclusion criteria 

• Primiparous 

• Delivery at Lis Maternity 

Hospital 

Exclusion criteria 

• Nonsingleton deliveries 

• Instrumental vaginal delivery 

• Those with SUI before 

pregnancy 

Groups 

G1: Spontaneous vaginal 

delivery 

G2: Obstructed Labor cesarean 

delivery 

G3: Elective cesarean delivery

N at enrollment 

G1: 145 

G2: 100 

G3: 118

Follow-up 

1 year 

G1: 145 

G2: 100 

G3: 118

Objective of the study 

To compare prevalence of stress 

urinary incontinence by mode of 

delivery 

Definition of elective cesarean 

No trial of labor 

Category includes: 

• Breech (70%) 

• Other indications not specified 

Maternal age, mean yrs ± SD 

G1: 28 ± 4 

G2: 32.5 ± 5.3 

G3: 31.7 ± 5.2 

Maternal height, mean cm ± SD 

G1: 164 ± 6.6 

G2: 162 ± 5.6 

G3: 164 ± 6.7 

Maternal weight, mean kg ± SD 

G1: 60 ± 9.0 

G2: 62.5 ± 1.6 

G3: 63 ± 13.0

Parity, % 

Primiparous: 100% 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age, wks ± SD 

G1: 39.7 ± 1.2 

G2: 40.2 ± 1.3 

G3: 38.8 ± 1.5 

Type of labor 

NR 

Type of anesthesia Epidural 

G1: 134/145 

G2: NR 

G3: NR 

Fetal weight, mean ± SD 

G1: 325 ± 400 

G2: 3450 ± 420 

G3: 3260 ± 617 

P < 0.05 

SUI during Pregnancy, N (%) 

G1: 45 (31) 

G2: 25 (25) 

G3: 33 (28) 
C-121 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and Quality Ratings 

Apgar at 1 minute, N ± SD 

G1: 8.9 ± 0.45 

G2: 9.0 ± 0.14 

G3: 9.0 ± 0.06 

Apgar at 5 minutes, N ± SD 

G1: 9.97 ± 0.2 

G2: 9.98 ± 0.14

G3: 10.0 ± 0 

NR Relevance 

Moderate 

Quality rating 

Fair 
C-122 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Levine et al., 2001 

Setting 

US, hospital-based 

Study design 

Retrospective cohort 

Inclusion criteria 

• Consecutive deliveries at the 

Illinois Masonic Medical Center 

between 1/1992 and 12/1999 

• Singleton, live newborns 

Exclusion criteria 

• Pre-term (≤ 35 wks) 

• Congenital heart disease 

• Congenital diaphragmatic 

hernia 

• Meconium aspiration 

Groups 

G1: Vaginal deliveries 

G2: All c/d 

• G2a: Elective c/d 

N at enrollment 

G1: 21,017 

G2: 4,301 

G3: 1889 

Objective of the study 

To determine whether there is an 

increased incidence of persistent 

pulmonary hypertension in neonates 

delivered by cesarean, with or without 

labor, compared with those delivered 

vaginally 

Definition of elective cesarean 

Does not include labored births 

Category includes: 

• Breech 

• Placenta previa 

• Genital herpes 

• Macrosomia 

• Multiple gestation 

• Prior cesareans 

Maternal age 

NR 

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 
C-123 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and Quality Ratings 

Persistent pulmonary 

hypertension, N (%) 

G1: 17 (0.08) 

G2: 17 (0.40) 

P < 0.001 

OR 4.9 (2.2-8.8) 

C/d vs. vaginal 

• G2a: 7 (0.37) 

P < 0.01 

OR 4.6 (1.3-11) 

Elective vs. vaginal 

TTN, N (%) 

G1: 238 (1.1) 

G2: 151 (3.5) 

P < 0.001 

OR 3.3 (2.6-3.9) 

C/d vs. vaginal 

• G2a: 59 (3.1) 

P < 0.001 

OR: 2.8 (2.1-3.8) 

Elective vs. vaginal 

RDS, N (%) 

G1: 33 (0.16) 

G2: 20 (0.47) 

P < 0.001 

OR 3.0 (1.6-5.3) 

C/d vs. vaginal 

G3: 4 (0.2) 

P < 0.18 

OR 1.3 (0.5-3.8) 

Elective vs. vaginal 

NR Relevance 

Moderate 

Quality rating 

Fair 
C-124 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions 

Labor and delivery 

characteristics 

Author 

Morrison, Rennie, and Milton, 1995 

Setting 

UK, hospital-based 

Study design 

Retrospective cohort 

Inclusion criteria 

• Required admission to NICU at gest 

age ≥ 37 wks with RDS or TTN (Avery 

et al, 1966-grunting, nasal flaring, 

retraction, tachypnea, poor air entry, 

radiographic features of either TTN or 

reticulogranular pattern of RDS) 

• Only those planned to be delivered at 

the teaching hosp included 

• Required oxygen 

Exclusion criteria 

• Evidence of infection including 

meconium aspiration or pneumonia 

Groups 

G1: Vaginal 

G2: Prelabor c/d 

G3: C/d in labor 

N 

G1: 28578 

G2: 2341 

G3: 2370 

Objective of the study 

To establish whether the 

timing of delivery between 37 

and 42 weeks gestation 

influences neonatal 

respiratory outcome and thus 

provide information which can 

be used to aid planning of 

elective delivery at term 

Definition of elective 

cesarean 

Does not include ”labored” 

births (defined as regular 

contractions and effacement 

plus dilation ≥ 3cm) 

Category includes: 

• Repeat 

• Breech 

• Uncomplicated previa 

• Other malpresentation 

• Suspected CPD 

• Chorioamnionitis 

• Rhesus sensitization 

• IUGR 

• Preeclampsia 

• Fetal distress 

Maternal age 

NR 

Maternal BMI 

NR 

Gravidity/parity 

NR 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 
C-125 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and Quality Ratings 

TTN 

G1: 118/28578 

G2: 53/2341 

G3: 20/2370 

RDS 

G1: 32/28578 

G2: 30/2341 

G3: 9/2370 

Respiratory morbidity (RDS+TTN), N 

(range) 

G1: 5.3/1000 (4.4-6.2) 

OR: 1.0 

G2: 35.5/1000 (28.4-43.8) 

OR: 6.8 (5.2-8.9) 

G3: 12.2/1000 (8.2-17.5) 

OR: 2.3 (1.6-3.5) 

NR Relevance 

Moderate 

Quality rating 

Fair 
C-126 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Rubaltelli et al., 1998 

Setting 

Italy, population-based 

Study design 

Prospective cohort 

Inclusion criteria 

• All live infants born in selected 

hospitals including neonates 

who died in maternity wards 

before their transfer to a 

neonatal unit, in a 3 month 

survey of 65 hospitals in 17 

regions 

• Births from Feb 1 to April 30, 

1995 

Exclusion criteria 

• None 

Groups 

G1: Vaginal 

• G1a: Forceps 

G2: Elective c/d 

G3: Emergency c/d 

N 

G1: 12,463 

• G1a: NR 

G2: 2,984 

G3: 1,569 

Objective of the study 

To evaluate the incidence of neonatal 

respiratory disorders and their risk 

factors 

Definition of elective cesarean 

Undefined 

Maternal age 

NR 

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 
C-127 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and Quality Ratings 

TTN (%) 

G1: NR 

• G1a: 3.8 

G2: 1.5 (P < 0.0001 compared to 

vaginal) 

G3: 4.2 

NR Relevance 

Low 

Quality Rating 

Not rated 
C-128 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Schindl et al., 2003 

Setting 

Austria, hospital-based 

Study design 

Prospective cohort 

Inclusion criteria 

• Gestation week 38 

Exclusion criteria 

• < 19 yrs 

• Inability to complete 

questionnaire 

• Unwillingness to participate 

• Severe internal problems (e.g., 

HELLP syndrome) 

Groups 

G1: Intended vaginal delivery 

G2: Elective c/d 

• G2a: Elective c/d (medical 

reasons) 

• G2b: Elective c/d (“on 

demand”) 

N at enrollment 

G1: 903 

G2: 147 

• G2a: 103 

• G2b: 44 

Follow-up 

3 days PP 

NR 

4 mos PP 

23.9% response rate 

Objective of the study 

To investigate birth experience and 

medical outcome in women with 

elective cesarean delivery compared 

with intended vaginal delivery 

Definition of elective cesarean 

Probably includes labor, number NR 

Elective c/d on demand includes: 

• Anxiety, nulliparae (16/44) 

• Previous traumatic birth (20/44) 

• Other (coordination problems, 

safety considerations) (8/44) 

Elective c/d for medical indications 

includes: 

• Breech (40/103) 

• Twins (7/103) 

• Preeclampsia (6/103) 

• CS interval < 15 mos (19/103) 

• Cephalopelvic disproportion 

(4/103) 

• HIV and hepatitis C (5/103) 

• Neurological problems (e.g., 

epilepsy) (10/103) 

• Internal problems (e.g., heart 

failure) (9/103) 

• Others (e.g., pelvic failure) (3/103) 

Maternal age, mean yrs (range) 

G1: 28 (15-43) 

G2a: 32 (20-44) 

G2b: 30 17-44) 

P < 0.05 

Maternal BMI 

NR 

N of previous births mean (range) 

G1: 0 (0-9) 

G2a: 1 (0-5) 

G2b: 0 (0-3) 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 

Other 

NR 
C-129 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and Quality Ratings 

Paresis of recurrens nerve, N (%) 

G1: 1/903 (0.1) 

G2: 0 

Respiratory adaptation problems, 

N (%) 

G1: 0 

G2: 1/147 (0.7) 

NR Relevance 

Moderate 

Quality rating 

Fair 
C-130 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Sutton et al., 2001 

Setting 

New South Wales (NSW), 

Australia, population-based study 

Study design 

Case-control 

Inclusion criteria 

Cases 

• Singleton infants ≥ 37 

gestational age born between 

1/1/1996 and 12/31/1996 

• Mothers resident in the area 

• Require mechanical ventilation 

for at least 4 hrs 

• Admitted to tertiary NICU in 

NSW with the first 96 hrs of life 

• Controls 

• Randomly and independently 

selected 

Exclusion criteria 

Cases 

• No major congenital anomaly 

• Controls 

• No mechanical ventilation 

• No admission to tertiary NICU 

Groups 

G1:Neonates requiring 

mechanical ventilation 

G2: Neonates not requiring 

mechanical ventilation 

N 

G1: 99 

G2: 550 

Objective of the study 

To ascertain antenatal and 

intrapartum risk factors for term 

neonates ventilated primarily for 

respiratory problems. And describe 

the neonatal morbidity and mortality 

Definition of elective cesarean 

Does not include labored births, but 

probably include mix of planned and 

unplanned, defined as “cesarean 

delivery before labor has 

commenced” 

Maternal age, ≥ 35 yrs (%) 

G1: 24/99 (24.2) 

G2: 84/550 (15.3) 

Maternal BMI 

NR 

Primagravida, N (%) 

G1: 54/99 (54.6) 

G2: 230/550 (41.8) 

N of previous cesareans 

NR 

Insulin dependent diabetes, N (%) 

G1:2/99 (2.0) 

G2: 0/550 

Gestational diabetes, N (%) 

G1:9/99 (9.1) 

G2: 18/550 (3.3) 

Gestational age, N of those at 37-

38 wks (%) 

G1:38/99 (38.4) 

G2: 123/550 (22.4) 

Type of labor 

NR 

Type of anesthesia 

NR 

Birth weight, N (%) 

< 3rd percentile 

G1: 8/99 (8.1) 

G2: 13/550 (24) 

> 90th percentile 

G1: 20/99 (20.2) 

G2: 64/550 (11.6) 

Maternal pyrexia, N (%) 

G1: 4/99 (4.0) 

G2: 4/550 (0.73) 
C-131 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and Quality Ratings 

Ventilation for mainly respiratory 

causes (controlling for maternal 

age, maternal pyrexia, gestational 

age 37-38 wks, birth weight < 3rd

percentile) 

OR for elective c/d vs. vaginal: 2.64 

(1.42, 4.90) 

OR for emergency c/d vs. vaginal: 

4.07 (2.13, 7.78) 

OR for forceps delivery vs. vaginal: 

4.47 (2.11, 9.44) 

NR Relevance 

Low 

Quality Rating 

Not rated 
C-132 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Towner et al., 1999 

Setting 

US, population based 

Study design 

Cross-deliveryal 

Inclusion criteria 

• All liveborn singleton neonates 

born to nulliparous women 

• Jan 1 1992 to Dec 31 1994 

• Birthweight 2500g to 4000g 

Exclusion criteria 

• Vaginal breech 

Groups 

G1: Spontaneous vaginal 

G2: Vacuum extraction 

G3: Forceps 

G4: Forceps and vacuum 

G5: Cesarean delivery 

• G5a: Labored cesareans 

• G5b: Labored c/d with attempt 

at vacuum or forceps 

• G5c: Labored c/d, no attempt 

at vacuum or forceps 

• G5d: Unlabored cesareans 

N 

G1: 387,799 

G2: 59,354 

G3: 15,945 

G4: 2817 

G5: 117,425 

• G5a: 84,417 

• G5b: 2,343 

• G5c: 82,075 

• G5d: 33,008 

Objective of the study 

To determine the incidence of rare 

neonatal disorders and their 

association with various modes of 

delivery, particularly vacuum 

extraction 

Definition of elective cesarean 

“Cesarean before labor,” probably 

includes a mix of planned and 

unplanned 

Maternal age 

NR 

Maternal BMI 

NR 

Gravidity 

NR 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age 

NR 

Type of labor 

NR 

Type of anesthesia 

NR 

Fetal weight 

NR 
C-133 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes 

Long Term Neonatal 

Outcomes Relevance and Quality Ratings 

Death before discharge (per 1,000 

deliveries) 

G1: 0.2 

G2: 0.3 OR: 1.5 (0.8-2.8) 

G3: 0.5 OR: 1.9 (0.6-5.4) 

G4: 0.6 OR: 2.6 (0.4-5.4) 

G5: 0.8 OR: 3.7 (2.6-5.4) 

• G5a: NR 

• G5b: NR 

• G5c: NR 

• G5d: 0.8, OR NR, but “no difference 

between infants born by cesarean delivery 

during labor and those born by cesarean 

delivery with no labor” 

Subdural or cerebral hemorrhage (per 

10,000 deliveries) 

G1: 2.9 

G2: 8 OR: 2.7 (1.9–3.9) 

G3: 9.8 OR: 3.4 (1.9–5.9) 

G4: 21.3 OR: 7.3 (2.9–17.2) 

G5: 6.7 OR: 2.3 (1.7–3.1) 

• G5a: 7.4 OR: 2.5 (1.8–3.4) 

• G5b: 25.7 OR: 8.8 (3.9–19.9) 

• G5c: 6.8 OR: 2.3 (1.7–3.2) 

• G5d: 4.1 OR: 1.4 (0.8–2.6) 

Intraventricular hemorrhage (per 10,000 

deliveries) 

G1: 1.1 

G2: 1.5 OR: 1.4 (0.7–3.0) 

G3: 2.6 OR: 2.5 (0.9–6.9) 

G4: 3.7 OR: 3.5 (1.5–25.2) 

G5: 2.1 OR: 2 (1.2–3.3) 

• G5a: 2.5 OR: 2.3 (1.4–4.0) 

• G5b: 0 OR: 0 (0.0–1.1) 

• G5c: 2.6 OR: 2.4 (1.4–4.1) 

• G5d: 0.8 OR: 0.6 (0.1–2.5) 

Subarachnoid hemorrhage (per 10,000 

deliveries) 

G1: 1.3 

G2: 2.2 OR: 1.7 (0.9–3.2) 

G3: 3.3 OR: 2.5 (0.9–6.6) 

G4: 10.7 OR: 8.2 (2.1–27.4) 

G5: 0.9 OR: 0.7 (0.4–1.4) 

• G5a: 1.2 OR: 0.9 (0.4–1.9) 

• G5b: 4.3 OR: 3.3 (0.5–23.9) 

• G5c: 1.1 OR: 0.9 (0.4–1.7) 

• G5d: 0 OR: 0 (0.0–19.7) 

NR Relevance 

Low 

Quality Rating 

Not rated 
C-134 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Towner et al., 1999 

(continued) 

 
C-135 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes 

Long Term Neonatal 

Outcomes Relevance and Quality Ratings 

Facial nerve injury (per 10,000 deliveries)

G1: 3.3 

G2: 4.6 OR: 1.7 (0.9–2.1) 

G3: 45.4 OR: 13.6 (10.0–18.4) 

G4: 28.5 OR: 8.5 (3.9–18.0) 

G5: 3.5 OR: 1.1 (0.7–1.5) 

• G5a: 3.1 OR: 0.9 (0.6–1.4) 

• G5b: 12.8 OR: 3.8 (1.2–12.1) 

• G5c: 2.8 OR: 0.8 (0.5–1.3) 

• G5d: 4.9 OR: 1.5 (0.8–2.6) 

Brachial plexus (per 10,000 deliveries) 

G1: 7.7 

G2: 17.6 OR: 2.3 (1.8–2.9) 

G3: 25 OR: 3.2 (2.3–4.6) 

G4: 46.4 OR: 6 (3.3–10.7) 

G5: 3 OR: 0.4 (0.3–0.5) 

• G5a: 1.8 OR: 0.2 (0.1–0.4) 

• G5b: 8.6 OR: 1.1 (0.3–4.4) 

• G5c: 1.6 OR: 0.2 (0.1–0.4) 

• G5d: 4.1 OR: 0.5 (0.3–1.0) 

Convulsions (per 10,000 deliveries) 

G1: 6.4 

G2: 11.7 OR: 1.8 (1.4–2.4) 

G3: 9.8 OR: 1.6 (0.9–2.7) 

G4: 24.9 OR: 3.9 (1.7–8.6) 

G5: 18.7 OR: 2.9 (2.4–3.6) 

• G5a: 21.3 OR: 3.3 (2.8–4.1) 

• G5b: 68.8 OR: 10.8 (6.5–17.8) 

• G5c: 19.9 OR: 3.1 (2.6–3.8) 

• G5d: 8.6 OR: 1.4 (0.9–2.1) 

CNS depression (per 10,000 deliveries) 

G1: 3.1 

G2: 9.2 OR: 2.9 (2.1–4.1) 

G3: 5.2 OR: 1.4 (0.6–2.8) 

G4: 21.3 OR: 6.9 (2.7–16.2) 

G5: 8.9 OR: 2.9 (2.2–3.7) 

• G5a: 9.6 OR: 3.1 (2.3–4.1) 

• G5b: 17.1 OR: 5.5 (1.7–15.5) 

• G5c: 9.4 OR: 3 (2.3–4.0) 

• G5d: 6.7 OR: 2.2 (1.3–3.6) 

 
C-136 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Towner et al., 1999 

(continued) 

 
C-137 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes 

Long Term Neonatal 

Outcomes Relevance and Quality Ratings 

Feeding difficulty (per 10,000 deliveries) 

G1: 68.5 

G2: 72.1 OR: 1.1 (1.0–1.2) 

G3: 74.6 OR: 1.1 (0.9–1.3) 

G4: 60.7 OR: 0.9 (0.5–1.5) 

G5: 114.7 OR: 1.7 (1.6–1.8) 

• G5a: 117.2 OR: 1.7 (1.6–1.8) 

• G5b: 94.8 OR: 1.4 (0.9–2.1) 

• G5c: 117.9 OR: 1.7 (1.6–1.8) 

• G5d: 106.3 OR: 1.6 (1.4–1.8) 

Mechanical ventilation (per 10,000 

deliveries) 

G1: 25.8 

G2: 39.1 OR: 1.5 (1.3–1.8) 

G3: 45.4 OR: 1.8 (1.4–2.3) 

G4: 50 OR: 1.9 (1.1–3.4) 

G5: 96 OR: 3.7 (3.4–4.1) 

• G5a: 103.2 OR: 4 (3.6–4.3) 

• G5b: 156.1 OR: 6 (4.3–8.3) 

• G5c: 101.7 OR: 2.6 (2.2–3.0) 

• G5d: 71.3 OR: 2.8 (2.4–3.3) 

 
C-138 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Zanardo, Simbi, Franzoi, et al., 

2004 

Setting 

Italy, hospital-based 

Study design 

Case control 

Inclusion criteria 

• 37 0/7 to 41 6/7 weeks (LMP ± 

U/S) 

• No conditions that could 

increase neonatal risk 

Exclusion criteria 

• Acute or chronic maternal 

disease: hypertension, renal 

disease, cardiac disease, 

infectious disease, “etc.” 

• Pregnancy induced 

hypertension, hydramnios, 

gestational diabetes, etc. 

• Fetal abnormalities, 

malformations, fetal distress, 

potential fetal asphyxia or fetal 

growth retardation 

Groups 

G1: Elective cesarean delivery 

G2: Vaginal delivery 

N 

G1: 1284/2361 

G2: NR 

Follow-up 

NR 

Objective of the study 

To determine the incidence of RDS 

and TTN in infants electively 

delivered by cesarean delivery at 

term, to correlate their incidence with 

the vaginal or cesarean mode of 

delivery, and to examine the risk 

during each week of gestation 

between 37 + 0 and 41 + 6 weeks 

Definition of elective cesarean 

Excludes labor, defined as regular 

contractions and effacement plus 

dilation≥ 3cm (Zanardo, Simbi, 

Franzoi et al 2004) 

Category includes: 

• Repeat (prior c/d) (51%) 

• Multiple gestation (twins) (8%) 

• Breech (25%) 

• Suspected CPD (5%) 

• Nulliparous and > 35 yrs (2%) 

• Fear of labor (1%) 

• Miscellaneous (other 

malpresentations, uncomplicated 

placenta previa, retinopathy and 

myopathies) (6%) 

Maternal age, mean yrs, mean yrs 

± SD 

G1: 30.9 ± 2.3 

G2: 29.7 ± 2.5 

Maternal BMI 

NR 

Nulliparae (%) 

G1: 42 

G2: 51 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age mean wks ± SD 

G1: 38.8 ± 1.2 

G2: 38.8 ± 1.6 

Type of labor 

NR 

Type of anesthesia 

G1: Spinal for all elective 

G2: NR 

Fetal weight, mean kg ± SD 

G1: 3.16 ± 0.5 

G2: 3.18 ± 0.6 

Fetal sex, male (%) 

G1: 55 

G2: 53 
C-139 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and Quality Ratings 

Neonatal mortality 

G1: 0/1,284

G2: 0/1,284 

Apgar 

≤ 5 at 1 min 

G1: 21/1,284 

G1: 13/1,284 

Respiratory distress syndrome 

G1: 29/1,284 

G2: 5/1,284 

OR = 2.60 (1.35-5.90) 

P < 0.01 

Respiratory complications 

resuscitation-Phase II, N (%) 

G1: 71 (5.5) 

G2: 44 (3.4) 

P < 0.01 

Transient tachypnea of the newborn 

G1: 12/1,284 

G2: 11/1,284 

Pneumonia 

G1: 1/1,284 

G2: 1/1,284 

Length of hospital stay, mean days ± 

SD 

G1: 6 ± 0.9 

G2: 4 ± 1.1 

NICU admission 

G1: 17/1,284 

G2: 8/1,284 

OR = 2.14 (1.91-5.90) 

P < 0.01 

Mortality/Death 

G1: 0 

G2: 0 

NR Relevance 

Moderate 

Quality rating 

Fair 
C-140 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request 

Study characteristics Objective and definitions Labor and delivery characteristics 

Author 

Zanardo, Simbi, Vedovato et al., 

2004 

Setting 

Italy, hospital 

Study design 

Case-control 

Inclusion criteria 

• Term pregnancies (37 to 42 

wks), estimated by last 

menstrual period or sonogram, 

retaining women undergoing 

elective cesareans before 

labor for the elective group 

(i.e., when c/d was performed 

on clear maternal request) and 

matching vaginal deliveries 

Exclusion criteria 

• Excludes women with 

prenatally identified factors: not 

complicated by conditions that 

might increase risk to the 

neonates, including acute and 

chronic maternal illnesses, 

disorders of preg, fetal 

abnormalities, fetal distress, or 

potential fetal asphysia insult, 

and fetal growth retardation 

Groups 

G1: Elective cesarean 

G2: Vaginal delivery 

N 

G1: 1,284 

G2: 1,284 

Objective of the study 

To examine the association between 

timing of delivery between 37 and 42 

weeks and neonatal resuscitation risk 

in elective c/d 

Definition of elective cesarean 

Excludes labor, defined as regular 

contractions and effacement plus 

dilation ≥ 3cm 

Cases includes: 

• Repeat c/d 

• Breech 

• Twin 

• Cephalopelvic disproportion 

• Fear of labor 

• Uncomplicated placenta previa 

• Retinopathy 

• Myopathies 

Maternal age, mean yrs ± SD 

G1: 30.9 ± 2.3 

G2: 29.7 ± 2.5 

Maternal BMI 

NR 

Nulliparae (%) 

G1: 42 

G2: 51 

N of previous cesareans 

NR 

Diabetes 

NR 

Gestational age, mean wks ± SD 

G1: 38.8 ± 1.2 

G2: 38.8 ± 1.6 

Type of labor 

NR 

Type of anesthesia 

G1: Spinal for all elective 

G2: NR 

Fetal weight, mean kg ± SD 

G1: 3.16 ± 0.5 

G2: 3.18 ± 0.6 

Fetal sex, male (%) 

G1: 55 

G2: 53 
C-141 

Evidence Table 2. Neonatal outcomes of cesarean delivery on maternal request (continued) 

Short Term Neonatal Outcomes Long Term Neonatal Outcomes Relevance and QualityRating 

Apgar 

≤ 5 at 1 min 

G1: 21/1,284 

G2: 13/1,284 

≤ at 5 min 

G1: 4/1,284 

G2: 3/1,284 

PPV resuscitation 

G1: 44/1,284 

G2: 18/1,284 

OR = 2.05 (1.25-5.67) 

P < 0.01 

Respiratory distress syndrome 

G1: 29/1,284 

G2: 5/1,284 

OR = 2.60 (1.35-5.90) 

P < 0.01 

Transient tachypnea of the 

newborn 

G1: 12/1,284 

G2: 11/1,284 

Pneumonia 

G1: 1/1,284 

G2: 1/1,284 

Length of hospital stay, mean days 

± SD 

G1: 6 ± 0.9 

G2: 4 ± 1.1 

NICU admission 

G1: 17/1,284 

G2: 8/1,284 

OR = 2.14 (1.91-5.90) 

P < 0.01 

NR Relevance 

Moderate 

Quality Rating 

Fair 
C-142 

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5(6):566-70. 
 Appendix D 

Listing of Excluded Studies
D-1

Listing of Excluded Studies 

Codesheet for Cesarean Reasons for Exclusion

Code Meaning of Code

BKGRD Background 

DA Decision analysis 

FTE3 Not original research

FTE4 Ineligible geographic location 

FTE5 Incorrect population of study participants 

FTE6 Does not address study questions 

FTE7 Ineligible study design 

FTE8 Sample size too small 

FTE9 Unabstractable 

FTE10 Could not acquire 

FTE11 Not relevant to previa update 
D-2 

1. Prevalent urinary incontinence as a correlate of 

pregnancy, vaginal childbirth and obstetric techniques. 

J Wound Ostomy Continence Nurs 1999; 26(3):28A9A. 

Notes: Urinary Incontinence Search; Journal Article 

AI 

FTE6 

2. Rates of cesarean delivery--United States, 1993. 

MMWR Morb Mortal Wkly Rep 1995;44(15):303-7. 

Notes: HAND SEARCH 

AI 

FTE11 

3. Abu-Heija AT, Jallad MF, Abukteish F. Maternal and 

perinatal outcome of pregnancies after the age of 45. J 

Obstet Gynaecol Res 2000; 26(1):27-30. 

Notes: PREVIA UPDATE 

AI 

FTE11 

4. Acien P. Breech presentation in Spain, 1992: a 

collaborative study. Eur J Obstet Gynecol Reprod Biol 

1995; 62(1):19-24. 

Notes: KQ1 Search Journal Article 

AI 

FTE6 

5. Al-Abdulhadi O, Biehl D, Ong B, Boker A. A 

comparison of spinal hyperbaric ropivacaine and 

hyperbaric bupivacaine for elective cesarean section. 

Can J Anesth 2004; 51(Suppl 1):A55. 

Notes: (39) CCT 

(42) Cochrane CCTR Search; 

Label: PBS Record: 10 

AI 

FTE6 

6. Albrechtsen S , Rasmussen S, Reigstad H, Markestad 

T, Irgens LM, Dalaker K. Evaluation of a protocol for 

selecting fetuses in breech presentation for vaginal 

delivery or cesarean section. Am J Obstet Gynecol 

1997; 177(3):586-92. 

Notes: Comparison Studies Journal Article 

AI 

FTE5 

FTE6 

7. Alcalay M, Hourvitz A, Reichman B et al. Prelabour 

rupture of membranes at term: early induction of 

labour versus expectant management. Eur J Obstet 

Gynecol Reprod Biol 1996; 70(2):129-33. 

Notes: Neonate outcome study Clinical Trial 

Journal Article 

Randomized Controlled Trial 

AI 

FTE6 

8. Allen J, Hippisley-Cox J, Pringle M, Groom L. 

Assisted delivery in the teenage population: the effect 

of inter-hospital variation, deprivation, and age. Int J 

Adolesc Med Health 2003; 15(4):341-7. 

Notes: KQ1 Search Journal Article 

AI 

FTE6 

9. Amarin VN, Akasheh HF. Advanced maternal age and 

pregnancy outcome. East Mediterr Health J 2001; 7(4-

5):646-51. 

Notes: PREVIA UPDATE 

AI 

FTE11 

10. Amoa AB, Klufio CA, Wat S, Kariwiga G, Mathias A. 

A retrospective survey of patients with one previous 

caesarean section delivered at the Port Moresby 

General Hospital: a comparative study of those 

delivered vaginally and those delivered by repeat 

caesarean section. P N G Med J 1997; 40(3-4):127-35. 

Notes: Outcomes Studies; Harms Search; KQ1 

Search Journal Article 

AI 

FTE4 

FTE6 

11. Amu O, Rajendran S, Bolaji I. Should doctors perform 

an elective caesarean section on request? Maternal 

choice alone should not determine method of delivery. 

Br Med J 1998; 317(7156):463-5. 

Notes: Harms Search; Journal Article 

AI 

FTE3 

FTE4 

FTE5 

FTE6 

FTE7 

FTE8 

BKGRD 

12. Ananth CV, Demissie K, Smulian JC, Vintzileos AM. 

Placenta previa in singleton and twin births in the 

United States, 1989 through 1998: a comparison of 

risk factor profiles and associated conditions. Am J 

Obstet Gynecol 2003; 188(1):275-81. 

Notes: PREVIA UPDATE 

AI 

FTE11 

13. Ananth CV, Smulian JC, Vintzileos AM. The 

association of placenta previa with history of cesarean 

delivery and abortion: a metaanalysis. Am J Obstet 

Gynecol 1997; 177(5):1071-8. 

Notes: Journal Article 

Meta-Analysis Placenta Previa Search 

AI 

FTE3 

FTE6 

14. Ananth CV, Wilcox AJ, Savitz DA, Bowes WAJr, 

Luther ER. Effect of maternal age and parity on the 

risk of uteroplacental bleeding disorders in pregnancy. 

Obstet Gynecol 1996; 88(4 Pt 1):511-6. 
D-3 

Notes: Journal Article Placenta Previa Search 

AI 

FTE6 

DA 

15. Annibale DJ, Hulsey TC, Wagner CL, Southgate WM. 

Comparative neonatal morbidity of abdominal and 

vaginal deliveries after uncomplicated pregnancies. 

Arch Pediatr Adolesc Med 1995; 149(8):862-7. 

Notes: Harms Search; Journal Article 

AI 

FTE6 

16. Appleby J. Data briefing. Caesarean births. Health 

Serv J 2001; 111(5756): 31. 

Notes: infant and c-section additions 

AI 

FTE9 

17. Armstrong CA , Harding S, Matthews T, Dickinson 

JE. Is placenta accreta catching up with us? Aust N Z J 

Obstet Gynaecol 2004; 44(3):210-3. 

Notes: Journal Article Placenta Previa Search 

AE 

FTE12 

18. Arsiradam N, Maliti Z, Rocke D. Ropivacaine 7.5 

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179. Holubkov R, Holt VL, Connell FA, LoGerfo JP. 

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180. Homer CS, Davis GK, Brodie PM et al. 

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192. Ilnyckyji A , Blanchard JF, Rawsthorne P, 

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Notes: PREVIA UPDATE 

AI 

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409. Yamani Zamzami TY. Indication of emergency 

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Notes: PREVIA UPDATE 

AI 

FTE 

410. Yan JS, Chang YK, Yin CS. Elective cesarean 

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411. Yancey MK, Pierce B, Schweitzer D, Daniels D. 

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Notes: Outcomes Studies; Journal Article 

AI 

FTE6 

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FTE4 

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AI 

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AI 

FTE6 

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AI 

FTE4 

FTE6 
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5. 

Notes: Harms Search; Comment 

Editorial 

AI 

FTE3 

FTE5 

FTE6 

FTE7 

FTE4 

FTE8 

BKGRD 

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AI 

FTE4 

FTE6 

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AI 

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Appendix E 

Acknowledgments 

E-1

Appendix E. Acknowledgments 

This study was supported by Contract 290-02-0016 from the Agency for Healthcare Research 

and Quality (AHRQ), Task No. 5. We acknowledge the continuing support of Kenneth Fink, JD, 

MA, Director of the AHRQ Evidence-Based Practice Center (EPC) Program, and Susan Meikle, 

MD, MSPH, the AHRQ Task Order Officer for this project. We would also like to extend our 

appreciation to Lata S. Nerurkar, Ph.D., Barnett S. Kramer, M.D., M.P.H., and Susan Rossi, 

Ph.D., M.P.H from the Office of Medical Applications of Research. 

The investigators deeply appreciate the considerable support, commitment, and contributions 

of the EPC team staff at RTI International and the University of North Carolina (UNC). From 

UNC, we thank EPC Co-Director, Timothy S. Carey, MD, MPH; EPC Literature Search 

Specialist, Laura Morgan, UNC Research Assistant, B. Lynn Whitener, PhD., and Shauna Hay, 

BS, UNC Research Assistant. We also express our gratitude to Loraine Monroe, EPC word 

processing specialist and Carol Offen, BA, Editor, at RTI International. 

Technical Expert Panel 

We also extend our appreciation to the members of our Technical Expert Panel (TEP), who 

provided advice and input during our research process. The RTI-UNC EPC team solicited the 

views of TEP members from the beginning of the project. TEP members also provided insights 

into and reactions to work in progress and advice on substantive issues or possibly overlooked 

areas of research. TEP members participated in refining the analytic framework and key 

questions and discussing the preliminary assessment of the literature, including 

inclusion/exclusion criteria, and also provided input on the information and categories, including 

evidence tables. The TEP was both a substantive resource and a “sounding board” throughout the 

study. It was also the body from which expertise was formally sought at several junctions. TEP 

members are listed below: 

Leah Albers, CNM, DrPH, FACNM, 

FAAN* 

Professor 

University of New Mexico College of Nursing

Albuquerque, NM 

Jeffrey Ecker, MD* 

Director 

Obstetrical Clinical Research, 

Massachusetts General Hospital 

Boston, MA 

Haywood Brown, MD 

Chair

Department of Obstetrics/Gynecology 

Duke University School of Medicine 

Durham, NC

Valerie J. King, MD, MPH* 

Research Assistant Professor 

Department of Family Medicine 

Oregon Health & Science University 

Portland, OR 

Linda Brubaker, MD* 

Professor of Obstetrics/Gynecology and 

Urology 

Loyola University 

Chicago, IL 

Kenneth J. Leveno, MD 

Gillette Professor, Department of Obstetrics/Gynecology 

Vice-Chair for Maternal-Fetal Medicine 

The University of Texas Southwestern Medical Center 

Dallas, Texas

* Denotes that the TEP member was also a peer reviewer for the report. 
E-2

Mary D’Alton, MD 

Chair

Department of Obstetrics & Gynecology 

Columbia University Medical Center. 

New York, NY

Marie McCormick, MD 

Professor of Pediatrics 

Harvard Medical School 

Cambridge, MA

Peer Reviewers 

We gratefully acknowledge the following individuals who reviewed the initial draft of this 

report and provided us with constructive feedback. External reviewers comprised clinicians, 

researchers, representatives of professional societies, and potential users of the report. We would 

also like to extend our appreciation to David Atkins, MD, and Susan Meikle, MD, MSPH from 

AHRQ for contributing peer review comments. Our peer review panel also includes four 

members of the TEP. Peer review was a separate duty for these individuals and not part of their 

commitment as TEP members. All are active professionals in the field. The peer reviewers were 

asked to provide comments on the content, structure, and format of the evidence report and to 

complete a checklist. The peer reviewers’ comments and suggestions formed the basis of our 

revisions to the evidence report. Acknowledgments are made with the explicit statement that this 

does not constitute endorsement of the report. 

Melissa D. Avery, CNM, PhD, FACNM 

Associate Professor, Director, NurseMidwifery Program 

University of Minnesota, 

School of Nursing 

Deborah Campbell MD, FAAP 

Chairperson, Section on Perinatal 

Pediatrics

American Academy of Pediatrics 

Mark Landon, M.D. 

Professor/ Division Director 

Department of Obstetrics and Gynecology 

Division of Maternal/ Fetal Medicine 

Ohio State University 

Elizabeth Cooper, CNM, EdD, FACNM 

Associate Professor of 

Obstetrics/Gynecology and Nursing 

University of Rochester Medical Center 

Brian Mercer, MD 

Director 

Department of Obstetrics and Gynecology 

MetroHealth Medical Center 

Case Western Reserve University 

William Hueston, MD

Chair, Department of Family Medicine; 

Professor 

Medical University of South Carolina 

Peggy A. Norton, MD 

Associate Professor and Division Chief of 

Urogynecology 

University of Utah Medical Center 

University Of Utah 
E-3

Cheryl Iglesia, MD 

Director of Urogynecology and 

Reconstructive Pelvic Surgery 

Washington Hospital Center