Operative delivery in the second stage of labor and preterm birth in a subsequent pregnancy: a systematic review and meta-analysis

Am J Obstet Gynecol. 2024 Mar;230(3):295-307.e2. doi: 10.1016/j.ajog.2023.08.033. Epub 2023 Sep 4.


Objective: This study aimed to quantify the association between mode of operative delivery in the second stage of labor (cesarean delivery vs operative vaginal delivery) and spontaneous preterm birth in a subsequent pregnancy.

Data sources: MEDLINE, Embase, EmCare, CINAHL, the Cochrane Library, Web of Science: Core Collection, and Scopus were searched from database inception to April 1, 2023.

Study eligibility criteria: All retrospective cohort studies with participants who had a second-stage cesarean delivery (defined as intrapartum cesarean delivery at full cervical dilation) or operative vaginal delivery (including forceps- and/or vacuum-assisted delivery) and that reported the rate of preterm birth (either spontaneous or not specified) in subsequent pregnancy were included.

Methods: Both a descriptive analysis and a meta-analysis were performed. A meta-analysis was performed for dichotomous data using the Mantel-Haenszel random-effects model and used the odds ratio as an effect measure with 95% confidence intervals. The risk of bias was assessed using Cochrane's 2022 Risk Of Bias In Non-randomized Studies of Exposure tool.

Results: After screening 2671 articles from 7 databases, a total of 18 retrospective cohort studies encompassing 605,138 patients were included. The pooled rates of spontaneous preterm birth in a subsequent pregnancy were 6.9% (12 studies) after second-stage cesarean delivery and 2.6% (8 studies) after operative vaginal delivery. A total of 7 studies encompassing 75,460 patients compared the primary outcome of spontaneous preterm birth after second-stage cesarean delivery vs operative vaginal delivery in an index pregnancy with an odds ratio of 2.01 (95% confidence interval, 1.57-2.58) in favor of operative vaginal delivery. However, most studies did not include important confounding factors, did not address exposure misclassification because of failed operative vaginal delivery, and considered operative vaginal delivery as a homogeneous category with no distinction between forceps- and vacuum-assisted deliveries.

Conclusion: Although a synthesis of the existing literature suggests that the risk of spontaneous preterm birth is higher in those with a previous second-stage cesarean delivery than in those with operative vaginal delivery, the risk of bias in these studies is very high. Findings should be interpreted with caution.

Keywords: cesarean delivery; forceps; mode of delivery; operative delivery; operative vaginal delivery; preterm birth; second stage; vacuum; ventouse.

Publication types

  • Meta-Analysis
  • Systematic Review
  • Review

MeSH terms

  • Cohort Studies
  • Delivery, Obstetric
  • Female
  • Humans
  • Infant, Newborn
  • Labor Stage, Second
  • Pregnancy
  • Premature Birth* / epidemiology
  • Retrospective Studies