Relaparotomy after cesarean delivery: Timing, indications, and maternal outcomes in a tertiary referral center

OBJECTIVE: To determine the incidence of relaparotomy after cesarean delivery in a tertiary referral center, and to evaluate its indications, timing, and association with maternal morbidity. METHODS: This retrospective study included women who underwent relaparotomy within 30 days following cesarean delivery between June 2020 and October 2025 in a tertiary center managing high-risk obstetric cases. Baseline maternal, obstetric, and operative characteristics were recorded. Relaparotomy indications were analyzed according to timing and primary cesarean indication. Maternal morbidity, hospital stay, and intensive care unit (ICU) admission were assessed. An exploratory Poisson regression analysis was performed to evaluate potential associations between baseline variables and repeated relaparotomy. Multivariable linear regression was used to analyze factors associated with perioperative hemoglobin change. RESULTS: Among 44 486 cesarean deliveries, 83 women required relaparotomy (0.19%). Uterine atony and hemorrhage were the most common indications for relaparotomy in the early postoperative period, whereas infectious complications became more frequent later. Bladder injury and intra-abdominal abscess were associated with longer hospitalization, while ICU stay did not differ significantly by indication. Repeated relaparotomy occurred in 15.7% of patients; no baseline maternal or operative variables were significantly associated with this outcome in exploratory analysis. Relaparotomies for non-atony bleeding were associated with greater hemoglobin decline, longer operative duration, and increased transfusion requirement. Maternal morbidity occurred in 20.5% of cases, and one maternal death was observed in a patient with placenta accreta spectrum complicated by hemorrhage. CONCLUSION: Relaparotomy after cesarean delivery, although rare, represents a severe postoperative event associated with substantial maternal morbidity. It is not limited to technically complex index procedures and may follow apparently uncomplicated surgeries. The predominance of hemorrhagic causes early and infectious causes later underscores the need for extended postoperative surveillance. Effective hemostatic control, early recognition of infection, and management in experienced tertiary centers are central to improving maternal outcomes.