Relaparotomy after cesarean delivery: risk factors and outcomes—a systematic review and meta-analysis

Abstract Purpose To estimate the incidence of relaparotomy after cesarean delivery (CD) and identify maternal and surgical factors associated with relaparotomy. Methods MEDLINE, EMBASE, Web of Science, the Cochrane Library, and ClinicalTrials.gov were searched from inception through October 2025. Eligible observational studies evaluated postpartum relaparotomy after CD and included a control group without relaparotomy. Abstract-only reports, case reports, reviews, and editorials were excluded. Logit-transformed proportions, crude odds ratios (ORs), mean differences (MDs), and study-reported adjusted ORs (aORs) were pooled using restricted maximum likelihood random effects with modified Hartung–Knapp confidence intervals. Risk of bias was assessed with QUIPS and certainty with GRADE. Results 14 studies were included: 11 primary cohorts and 3 hemorrhage-specific studies. The primary cohorts reported 646 relaparotomies among 181,383 eligible CDs; pooled incidence was 0.400% (95% CI 0.269%–0.593%; I 2 = 92.7%), approximately 1 in 250. Hemorrhage accounted for 307/424 (72.4%) reported indication assignments among 422 classifiable institutional cases. Hysterectomy occurred in 60/407 cases (pooled 16.6%, 95% CI 5.1%–42.3%; k = 7), transfusion in 196/323 (62.1%, 21.8%–90.6%; k = 5), and maternal death in 17/533 (3.2%, 0.8%–12.0%; k = 9). Multiple gestation (aOR 4.37, 95% CI 2.04–9.35; k = 4) and placenta previa (aOR 4.60, 1.01–21.01; k = 3) remained positively associated after study-specific adjustment. Conclusion Relaparotomy following CD is rare but associated with substantial maternal morbidity and affecting about 1 of every 250 CDs. Hemorrhage is the leading indication although indications are clinically heterogeneous.