The Journal of Maternal-Fetal and Neonatal Medicine, 2012; 25(11): 21672170

2012 Informa UK, Ltd.

ISSN 1476-7058 print/ISSN 1476-4954 online
DOI: 10.3109/14767058.2012.668978

Risk factors for relaparotomy after cesarean section

Roy Kessous1, Daniela Danor2, Y. Adi Weintraub1, Arnon Wiznitzer1, Ruslan Sergienko3, Iris Ohel1 & Eyal Sheiner1
1Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel,
2Ben Gurion University of the Negev, Beer-Sheva, Israel, and 3Ben-Gurion University of the Negev, Epidemiology and Health Services

Evaluation, Beer-Sheva, Israel

Objective: To investigate risk factors for relaparotomy after

cesarean section (CS). Methods: A retrospective case-control
study comparing all CS that were complicated with relaparotomy to cesarean deliveries without this complication. Results:
Relaparotomy complicated 0.23% (n=80) of CS during the study
period (n=34,389). Independent risk factors for relaparotomy
following CS from a multivariable logistic regression model were
post partum hemorrhage, cervical tears, placenta previa, uterine
rupture, placental abruption, severe preeclampsia and previous
CS. Most women (51.2%) underwent relaparotomy during the
first 24h after CS. The leading causes for relaparotomy was
bleeding (70%) and burst abdomen (8.8%). Hysterectomy was
performed in 31.3% of the patients. Conclusion: Risk factors for
relaparotomy after CS are previous CS, severe preeclampsia,
placenta previa, uterine rupture, placental abruption, cervical
tear and PPH. Experienced obstetricians should be involved in
such cases and the possibility for complications including relaparotomy should be emphasized.
Keywords: Burst abdomen, cesarean section, hysterectomy,
post partum hemorrhage, relaparotomy

Introduction
Cesarean section (CS) is the most common obstetrical surgery.
The rates of CS are increasing worldwide; in the United States,
cesarean delivery rates exceeded 25% of all deliveries and has
increased from 20.7% in 1996 to 31.1% in 2006 with more than
1.3 million CS performed annually [1,2]. In the United Kingdom,
in 1981, CS rate was 9% of all deliveries and exceeded to 21% in
2001 [3,4]. In Israel, rates of CS are 19.7% of all deliveries [5].
Although considered a relatively safe procedure, the incidence
of severe complications from CS is three times greater than that of
vaginal delivery [6]. Short-term complications (between 6 weeks
and 3 months after the CS) include hemorrhage, intra abdominal
and wound infections, bladder and intestinal injury, and anesthesia complications [6,7]. One of the most significant shortterm complications after CS is relaparotomy. Few studies were
published concerning relaparotomy after CS [811], these are
relatively small and clinical implications are somewhat limited.
Relaparotomy following CS complicates 0.120.72% of CS. Three
or more previous CS and placental abruption were found as major
risk factors for relaparotomy [9].
Given the fact that relaparotomy is a major complication with
immense implication on both the patient and the medical team,

the present study was designed to investigate and define risk

factors for relaparotomy after CS.

Materials and methods

Setting
The study was conducted at the Soroka University Medical
Center, the only hospital in the Negev, the southern region of
Israel, serving the entire obstetrical population. Thus, the study
represents nonselective population-based data. The Institutional
Review Board (in accordance with the Helsinki declaration)
approved the study.
Study population
The study population was composed of all patients who underwent cesarean delivery between the years 1989 and 2009. At our
center, of approximately 12,00013,000 deliveries per annum,
1720% are cesarean deliveries.
Study design
A retrospective case-control study was conducted, comparing
all cesarean deliveries that were and were not complicated with
relaparotomy. Data regarding pregnancy complications and
adverse outcomes were available from the perinatal database of
the center. Data were reported by an obstetrician immediately
after delivery. Skilled medical secretaries routinely reviewed
the information prior to entering it into the database. Coding
was performed after assessing the medical prenatal care records
together with the routine hospital documents.
In our institution, all CS deliveries are performed by two
surgeons; at least one of whom is a senior doctor or a trained resident. All relaparotomies are performed by senior surgeons.
The following demographic and clinical characteristics
were evaluated: maternal age, ethnicity (Jewish or Bedouin),
gravidity, parity, obesity, smoking, drug abuse, gestational age at
delivery, birth weight, and fetal gender. Obstetrical risk factors
that were examined included: hypertensive disorders (mild
and severe preeclampsia, eclampsia and chronic hypertension),
diabetes mellitus, previous CS, placenta previa, placenta abruption, placenta accreta, post-partum hemorrhage (PPH), uterine
rupture, prolapse of cord, non reassuring fetal heart rate, tubal
ligation, and cervical tear. The following perinatal outcomes were
assessed: Apgar scores at 1 and 5min < 7 and perinatal mortality.
Indication for relaparotomy, time to relaparotomy, type of intervention, and outcome were also recorded.

Correspondence: Roy Kessous, MD, Department Of Obstetrics and Gynecology, Soroka University Medical Center, POB 151, Beer Sheva 84101, Israel.
E-mail: kessousr@bgu.ac.il

2167

2168 K. Kessous etal.

Table I. Demographic and clinical characteristics of patients and fetuses of
patients with and without relaparotomy after cesarean delivery.
Relaparotomy No relaparotomy
Characteristics
(n=80)
(n=34,389)
p value
Maternal age
31.86.1
6.030.5
0.071
(Years SD)
Ethnicity
Jewish
41.2%
55.7%
0.006
Bedouin
58.8%
44.3%
Gravidity
1
7.5%
20.7%
<0.001
24
33.8%
43.4%
5
58.8%
35.9%
Parity
1
10%
26%
<0.001
24
45%
47.1%
5
45%
27%
Multiple gestation
1.3%
3.6%
0.263
Gestational age
36.73.8
37.83.0
0.001
(weeks SD)
Preterm delivery
40.0%
21.8%
<0.001
<37 weeks
Gestational age at
32>
10%
4.4%
<0.001
delivery
3632
20%
9.9%
36<
70%
85.7%

Statistical analysis
Statistical analysis was performed using the SPSS package 16
edition (SPSS Inc, Chicago, IL). Statistical significance was
calculated using the chi-square test for differences in qualitative
variables and the Students t-test for differences in continuous
variables. A multivariate logistic regression model, with backward
elimination, was constructed to find independent risk factors
associated with relaparotomy. Odds ratio (OR) and their 95%
confidence intervals (CI) were computed. A value of p < 0.05 was
considered statistically significant.

Table II. Characteristics of patients undergoing relaparotomy after

cesarean delivery.
Characteristics
n=80
Most common indication for relaparotomy: Bleeding:
56
Intra abdominal
47
Subcutaneous
8
- PPH
13
Burst abdomen
7
Repair of bladder tear
4
Infection
2
Intestinal injury
2
Abscess drainage
1
Liver injury
1
Unknown
7
Time to relaparotomy(h)
median 18.5h, range 1166
024
41
08 h
23
816 h
7
1624 h
11
>24
22
Unknown
17
Intervention
Bleeding control
36
Hysterectomy
25
Bilateral internal iliac ligation
12
Repair of urethra and bladder
6
De-packing and Bogota bag
6
Abscess drainage
3
Uterine artery bilateral ligation
2
Bilateral ovarian artery ligation
2
Partial colectomy
1

%
70

8.7
5
2.5
2.5
1.2
1.2
8.7

51.25

27.5
21.25
45
31.3
15
7.5
7.5
3.8
2.6
2.6
1.3

In some patients more than one indication or intervention were reported.

Results
During the study period, 246,437 patients delivered at our institution. Of these 34,389 patients delivered by CS (14%), relaparotomy complicated 0.23% (n=80) of deliveries. Demographic
and clinical characteristics of patients and fetuses of patients with
and without relaparotomy are listed in Table I. Patients following
relaparotomy tended to have higher birth order and had higher
rates of preterm deliveries as compared with the comparison
group. No cases of obesity, smoking or drug abuse were noted in
the relaparotomy group.
The surgical characteristics of the 80 patients that underwent relaparotomy are shown in Table II. The leading indication for relaparotomy was intra-abdominal hemorrhage. Most
surgeries were performed during the first 24h post CS. The
most common intervention was bleeding control followed by
hysterectomy in a third of the cases. Most patients underwent
relaparotomy after an emergency CS (75%) compared to 25%
after an elective CS.
Table III compares pregnancy and delivery complications
between patients who underwent relaparotomy after CS and those
who did not. Patients who underwent relaparotomy had higher
rates of previous CS (OR=1.6, 95% CI 12.4), severe preeclampsia (OR=2.7, 95% CI 1.35.4), placenta previa (OR=7.4,
95% CI 4.113.2), placenta accreta (OR=14.4, 95% CI 3.460.5),
placental abruption (OR=4.6, 95% CI 2.58.5), uterine rupture
(OR=22.2, 95% CI 8.856), cervical tear (OR=24.4, 95% CI

8.768.4), and PPH (OR=58.8, 95% CI 31.6109.6) as compared

to patients without relaparotomy.
Neonatal outcomes of patients with and without relaparotomy
are presented in Table IV. Newborns of patients that later underwent a relaparotomy had lower Apgar scores, <7 at 1 and 5min
(OR=1.8, 95% CI 1.12.9 and OR=4.8, 95% CI 2.59.1, respectively) and had significantly higher rates of perinatal mortality
(OR=4.8, 95% CI 2.210.4).
Previous CS, severe preeclampsia, placenta previa, uterine
rupture, placental abruption, cervical tear, and PPH were found
to be independent risk factors for relaparotomy (Table V)
using a multivariable logistic regression model with stepwise
backward elimination. Given our long study period the model
included also the year of delivery, which was not found to
be a significant risk factor (OR=1.016; CI 95% 0.971.06;
p=0.427).

Discussion
Although relatively rare, relaparotomy represents a major complication of CS. The incidence of relaparotomy in our study was
0.23%, this is in accordance with previous published data [811].
Hemorrhage was the leading cause for relaparotomy in our population accounting for 70% of surgeries. This rate is similar to the
rates reported in other studies (0.120.72% [811]).

The Journal of Maternal-Fetal and Neonatal Medicine

Relaparotomy after cesarean section2169

Table III. A comparison of pregnancy and delivery complications between patients who underwent relaparotomy after CD and those who did not.
Characteristics
Relaparotomy (n=80)
No relaparotomy (n=34,389)
OR
95% CI
Mild preeclampsia
2.5%
4.8%
0.5
0.12.1
Severe preeclampsia
11.3%
4.5%
2.7
1.35.4
Hypertensive disorders
13.8%
11.9%
1.2
0.62.2
Thrombocytopnia
1.3%
1.1%
1.1
8.30.2
Diabetes mellitus
13.8%
11.9%
1.2
0.62.2
Previous cesarean delivery
52.5%
41.4%
1.6
1.02.4
Placenta previa
17.5%
2.8%
7.4
4.113.2
Placenta abruption
15%
3.7%
4.6
2.58.5
Placenta accreta
2.5%
0.2%
14.4
3.460.5
Chorioamnionitis
3.8%
2.5%
1.5
4.80.5
Second trimester bleeding
1.3%
0.2%
7
51.10.96
Post partum hemorrhage
16.3%
0.3%
58.8
31.6109.6
Blood transfusions
63.8%
4.3%
39.6
62.625
Uterine rupture
6.3%
0.3%
22.2
8.856.0
Cervical tear
5%
0.2%
24.4
8.768.4
Table IV. Neonatal outcome in the case of relaparotomy after cesarean delivery.
Characteristics
Relaparotomy (n=80)
No relaparotomy (n=34,389)
Birth weight (mean SD)
2802767
3009753
Infant sex
Male
52.5%
53.5%
Female
47.5%
46.5%
Apgar score 1 min<7
30.0%
19.1%
Apgar score 5 min<7
13.8%
3.2%
Perinatal mortality (total)
8.8%
2.0%
Table V. Independent risk factors for relaparotomy after cesarean delivery
(CD): Results from a backward stepwise multivariable logistic regression
model.
Characteristics
OR
95% CI
p value
Post partum hemorrhage
29.9
14.661.0
<0.001
Cervical tear
8.7
2.234.5
0.002
Placenta previa
6.0
3.211.2
<0.001
Uterine rupture
5.2
1.517.9
0.009
Placental abruption
3.5
1.86.8
<0.001
Severe preeclampsia
3.0
1.56.1
0.003
Previous CD
1.8
1.12.8
0.016
The initial model included in addition, non progressive first stage, prolapse of cord,
placenta accrete, diabetes mellitus, maternal age, gestational age and induction of
labor.
Given our long study period the initial model included the year of delivery which was
not found to be a significant factor ( OR=1.016; CI 95% 0.971.06; p=0.427).

In our study, PPH was the strongest independent risk factor for
relaparotomy (with an OR of 29.9). PPH was defined as estimated
bleeding post CS above 1000 cc according to the estimation of the
attending physician. Seffah etal. [8] reported that relaparotomy
was performed in 44 patients of 6120 who underwent a CS (0.7%).
The most common indication was hemorrhage due to uterine
atony [8]. In contrast, in another study, none of the 12 patients
(out of a total of 17) who underwent relaparotomy for hemorrhage were diagnosed with uterine atony [11]. Nevertheless, PPH
following CS should be handled cautiously, with the best surgically
skilled physicians, and careful surveillance after these patients is
needed. Importantly, according to our data the absolute risk for
relaparotomy among CS patients with PPH is about 10%, whereas
the absolute risk of relaparotomy among CS patients with a prior
CS is only 0.3%

2012 Informa UK, Ltd.

p value
0.34
0.003
0.6
0.891
0.6
0.045
<0.001
<0.001
<0.001
0.483
0.025
<0.001
<0.001
<0.001
<0.001

OR

95% CI

p value
0.014
0.861

1.8
4.8
4.8

1.12.9
2.59.1
2.210.4

0.013
<0.001
<0.001

A previous CS was found to be an independent risk factor for

relaparotomy (with an OR of 1.8). This is of major concern as CS
is the most frequently performed major operation in the United
States, and since the worldwide CS birth rate has quadrupled in
less than 2 decades [2]. Although CS may appear to provide a
relatively safe outcome, it should not be regarded as a risk-free
procedure [2,12].
A hysterectomy was performed in 25 (31%) of the patients
which is similar to the rates published by Seffah et al. [8] and
Gedikbasi etal. [9] (38% and 20%; respectively). In their study,
Lurie et al. [11] did not need to perform hysterectomies in the
17 patients who underwent relaparotomy. Recently, Orbach etal.
[13] investigated risk factors for peripartum cesarean hysterectomy which were almost identical to the risk factors found in our
study for relaparotomy. Hence, when combining such data, we
can identify relaparotomy as an important risk factor for cesarean
hysterectomy.
Most patients underwent relaparotomy after an emergency
CS as opposed to an elective one. Given this fact, the proper
setup for discussing this complication with the patient is limited.
Furthermore, medical preparation for this complication is limited
and there for one should always be aware of this possibility.
The relaparotomy was performed during the first 24h following
the CS in 51.2% (median 18.5h) of the patients. Although relaparotomy is a major complication of CS and could be life threatening, in our study, there were no cases of maternal mortality.
This finding correlates with the results of Lurie et al. [11] and
Gedikbasi etal. [9]. This could be attributed to the relatively short
interval from the CS to the detection of a problem necessitating
relaparotomy, improved surgical technique and technology, as
well as the fact that all cases were actually managed in a tertiary
medical center, by a trained multidisciplinary staff.

2170 K. Kessous etal.

The strengths of our study were our large sample size that
allowed us to study a relatively rare diagnosis and its associated
outcomes. Nevertheless, for several factors (such as maternal age)
power analysis revealed that a sample size of over 200 patients in
each group would be required to detect significant differences with
80% power and =0.05. In addition, the comprehensive database
allowed us to access detailed information regarding pregnancy
outcomes as well as data regarding patients medical and obstetrical history. However, our study is not without limitations. One
potential weakness is that of all retrospective cohort studies, the
potential for missing data. However, the data were reported by an
obstetrician directly after the operation and post partum surveillance. Skilled medical secretaries routinely reviewed the information prior to entering it into the database. Coding was done
after assessing the medical prenatal care records together with the
routine hospital documents. This makes this potential source of
selection bias less likely.
In conclusion, independent risk factors for relaparotomy
after cesarean delivery were PPH, cervical tears, placenta previa,
uterine rupture, placental abruption, severe preeclampsia, and
previous CS. Peripartum hysterectomy was performed in third
of the patients that underwent relaparotomy after cesarean
delivery. For this reason, the evaluation of a patient with one of
the above risk factors should involve experienced obstetricians.
Furthermore, upon obtaining an informed consent from these
patients before a CS, detailed explanations about the possibility
of peripartum hysterectomy and its associated morbidities should
be given.
Declaration of Interest: The authors report no conflicts of interest

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