Overview
Cesarean delivery is one of the most common major surgeries performed in obstetrics. While many patients recover without serious problems, some experience severe perioperative surgical morbidity, meaning major surgical complications that happen during the cesarean hospitalization. These complications can include serious bleeding, infection, injury to surrounding organs, or other events that require additional treatment. A new large population-based study from California examined whether these complications are linked to a higher chance of being readmitted to the hospital after discharge.
The study found that patients who experienced severe perioperative surgical morbidity during cesarean delivery were about twice as likely to be readmitted within 42 days after discharge compared with patients without such complications. This finding highlights the importance of closer follow-up after a complicated cesarean birth, especially during the early postpartum period.
Why This Study Matters
The postpartum period is a vulnerable time for new mothers. In the weeks after delivery, patients may face bleeding, wound problems, pain, blood pressure complications, infection, or other medical concerns. Readmission after childbirth is not common overall, but when it happens, it can signal a serious issue that needs prompt care.
Cesarean delivery itself carries higher surgical risks than vaginal birth because it involves an abdominal and uterine incision. If a patient has a severe complication during the operation or hospital stay, it may affect healing and increase the chance of later problems. Understanding this relationship helps clinicians identify which patients may benefit most from enhanced discharge planning, early outpatient follow-up, and clear return precautions.
How the Study Was Conducted
This was a retrospective cross-sectional study using linked California birth certificate and hospital discharge data. The researchers identified patients who underwent cesarean delivery in any California hospital between October 2015 and October 2021. In total, the study included 703,079 cesarean deliveries.
Severe perioperative surgical morbidity was defined using diagnosis and procedure codes from the International Classification of Diseases, Tenth Revision. These codes were used to identify severe surgical complications occurring during the cesarean hospitalization.
The main outcome was all-cause postpartum readmission within 42 days after discharge. The investigators compared readmission rates among patients with severe perioperative surgical morbidity and those without it. They also used statistical models that adjusted for patient-level and hospital-level factors, so the comparison would be more reliable. In a secondary analysis, they looked separately at cesarean deliveries performed before labor began and those performed during labor.
Key Findings
The overall readmission rate was much higher among patients with severe perioperative surgical morbidity than among those without it.
Among patients with severe perioperative surgical morbidity, the readmission rate was 469.4 per 10,000 deliveries. Among those without severe perioperative surgical morbidity, the rate was 165.3 per 10,000 deliveries.
After adjustment for other factors, severe perioperative surgical morbidity was associated with a more than twofold increase in the risk of postpartum readmission:
The adjusted relative risk was 2.22.
The adjusted risk difference was 2.5 additional readmissions per 100 cesarean deliveries.
In practical terms, this means that patients who experienced severe complications during cesarean delivery had a substantially higher chance of coming back to the hospital within 42 days after discharge.
The most common diagnosis at readmission among these patients was wound infection, with a rate of 77 per 10,000 deliveries. This is clinically important because wound infections are among the most frequent post-cesarean complications and can lead to pain, fever, drainage, delayed healing, or need for antibiotics and sometimes surgery.
Results by Type of Cesarean Delivery
The researchers also examined whether the association differed depending on when the cesarean was performed.
For intrapartum cesarean delivery, meaning cesarean performed after labor had started, severe perioperative surgical morbidity was associated with a similarly increased risk of readmission, with an adjusted relative risk of 2.35.
For prelabor cesarean delivery, meaning cesarean performed before labor began, the adjusted relative risk was 2.03.
This suggests that the increased readmission risk linked to severe perioperative surgical morbidity is present across both types of cesarean delivery, not only when surgery happens after labor has begun.
What Severe Perioperative Surgical Morbidity May Include
Although the study used diagnosis and procedure codes rather than individual chart review, severe perioperative surgical morbidity generally refers to major complications such as:
Significant hemorrhage or blood transfusion
Infection involving the uterus, incision, or deeper tissues
Surgical injury to nearby structures such as the bladder or bowel
Return to the operating room
Other major operative complications requiring additional treatment
These events may prolong the original hospital stay and can make recovery more difficult. They may also increase the chance of later postpartum problems, especially once the patient returns home and normal activity begins.
Clinical Meaning of the Findings
This study provides strong evidence that severe complications during cesarean hospitalization are not isolated events. They can have consequences that extend well into the postpartum period. A twofold increase in readmission risk is meaningful at the individual and health system level.
For patients, this may mean a greater need for:
Early postpartum contact after discharge
Closer monitoring of wound healing and signs of infection
Assessment of pain, fever, bleeding, and urinary symptoms
Blood pressure follow-up if indicated
Clear instructions on when to seek urgent care
For clinicians and hospitals, the findings support risk-based discharge planning. Patients who had a complicated cesarean delivery may benefit from earlier follow-up appointments, phone check-ins, home nursing support when available, and easier access to urgent postpartum evaluation.
Preventing Readmission After Cesarean Delivery
The study does not test specific prevention strategies, but the results point toward several practical steps that may help reduce readmissions after a complicated cesarean birth.
These include:
Careful wound care instructions before discharge
Monitoring for infection, bleeding, or worsening pain
Reviewing medications and pain control plans
Ensuring that patients know how to measure fever and recognize warning signs
Scheduling timely postpartum follow-up, especially after major complications
Addressing barriers to care such as transportation, childcare, or language access
In many cases, early recognition of wound infection or other complications can prevent a small problem from becoming a reason for rehospitalization.
Strengths and Limitations
This study has several strengths. It is very large, includes real-world hospital data from across California, and uses linked birth and discharge records, which improve the completeness of the analysis. The large sample size also makes it possible to examine relatively uncommon outcomes such as postpartum readmission after severe surgical morbidity.
However, there are also limitations. Because the study is observational, it cannot prove that severe perioperative surgical morbidity directly causes readmission, only that the two are strongly associated. Administrative coding may miss some complications or classify them imperfectly. The analysis also may not capture all social, behavioral, or clinical factors that influence readmission, such as access to outpatient care, patient support at home, or details of the surgical repair.
Even with these limitations, the findings are important because they identify a clear high-risk group that may benefit from targeted postpartum support.
Bottom Line
Among more than 700,000 cesarean deliveries in California, patients who experienced severe perioperative surgical morbidity had a markedly higher risk of postpartum readmission within 42 days. Nearly 1 in 20 of these patients was readmitted, and the overall risk was about twice that of patients without severe surgical complications.
Wound infection was the most common reason for readmission, and the elevated risk was seen after both prelabor and intrapartum cesarean delivery. These findings suggest that patients with severe complications during cesarean birth should receive closer follow-up after discharge to help detect problems early and reduce the need for rehospitalization.
Reference
Butwick A, Baer RJ, Farooqi N, Tatsis V, Stephansson O, Ryckman K, Gossett DR, Hernandez S, Brandt J, Jelliffe-Pawlowski L. Association Between Severe Perioperative Surgical Morbidity With Cesarean Delivery and Postpartum Readmission. Obstetrics and gynecology. 2026-05-15. PMID: 42133949. https://pubmed.ncbi.nlm.nih.gov/42133949/
