OBSTETRICS

OBSTETRICS

Multiple Repeat Caesarean Sections:

Complications and Outcomes
Adekunle Sobande, FRCOG, Mamdoh Eskandar, FRCS
Department of Obstetrics and Gynaecology and Reproductive Medicine, College of Medicine, King Khalid University, Abha, Saudi Arabia

Abstract
Objective: To compare the complications and outcomes of
Caesarean section (CS) in women who have had three or more
previous lower segment Caesarean sections with those in women
with one previous CS.
Methods: We performed a retrospective study of 371 patients
undergoing repeat CS. Of these, 115 (31%) had previously had
three or more Caesarean sections (group 1) and 256 (69%) had
previously had one CS (group 2). All 371 patients had the repeat
CS performed at Abha Maternity Hospital, Saudi Arabia between
June 2002 and May 2004. Demographic data, complications, and
outcomes were compared using the Student t and chi-square tests.
Results: There were statistically significant differences between the
two groups with respect to mean maternal age, parity, gestation at
delivery, and experience of the surgeon (P < 0.05). CS was
performed as an emergency in 38 (32.9%) and 186 (72.6%) of
patients in groups 1 and 2 respectively (P < 0.05).
The consultant was involved in the decision to perform CS in
215 (84.6%) of patients with one previous CS. There were
significant differences between the two groups in the type of skin
incision, the presence of dense adhesions during surgery, and
bladder injury (P < 0.05). There were no statistically significant
differences in birth weight, stillbirth rate, low Apgar score, blood
loss during surgery, duration of surgery, or the duration of
postoperative hospital stay.
Conclusion: The prevalence of dense intra-abdominal adhesions and
of bladder injury during CS was higher in women with a history of
three or more previous CS than in women with one previous CS.
Placenta previa and Caesarean hysterectomy occurred with equal
frequency in each group, and wound dehiscence and uterine
rupture were rare.

Rsum
Objectif : Comparer les complications et les issues de la csarienne
(CS) entre les femmes ayant dj subi trois csariennes du
segment infrieur ou plus et les femmes nayant dj subi quune
CS.
Mthodes : Nous avons men une tude rtrospective portant sur
371 patientes qui subissaient une CS de nouveau. De ce groupe,
115 (31 %) avaient dj subi trois CS ou plus (groupe 1) et
256 (69 %) navaient dj subi quune CS (groupe 2). Toutes les

Key Words: Multiple, repeat Caesarean sections, complications,

fetal outcome
Competing Interests: None declared.
Received on September 23, 2005
Accepted on December 20, 2005

371 patientes ont subi leur nouvelle CS au Abha Maternity

Hospital, en Arabie saoudite, entre juin 2002 et mai 2004. Les
donnes dmographiques, les complications et les issues ont t
compares au moyen du test de Student et du test de chi carr.
Rsultats : Nous avons constat des diffrences significatives sur le
plan statistique entre les deux groupes de patientes en ce qui a
trait lge maternel moyen, la parit, la gestation au moment
de laccouchement et lexprience du chirurgien (P < 0,05). La
CS a t effectue durgence chez 38 (32,9 %) et 186 (72,6 %)
des patientes des groupes 1 et 2, respectivement (P < 0,05). Le
consultant a particip la dcision de recourir la CS chez
215 (84,6 %) des patientes ayant dj subi une CS. Nous avons
constat des diffrences notables entre les deux groupes en ce qui
concerne le type dincision cutane, la prsence dadhrences
denses dcele au cours de la chirurgie et les lsions vsicales
(P < 0,05). Nous navons constat aucune diffrence significative
sur le plan statistique en ce qui a trait au poids de naissance, au
taux de mortinaissance, la faiblesse de lindice dApgar, la
perte sanguine au cours de la chirurgie, la dure de la chirurgie
ou la dure de lhospitalisation postopratoire.
Conclusion : La prvalence des adhrences intra-abdominales
denses et des lsions vsicales au cours de la CS tait plus
leve chez les femmes ayant dj subi trois CS ou plus que chez
les femmes nayant dj subi quune CS. Le placenta praevia et
lhystrectomie par csarienne ont prsent une frquence gale
dans les deux groupes; de plus, la dhiscence de la plaie et la
rupture utrine se sont avres rares.
J Obstet Gynaecol Can 2006;28(3):193197

INTRODUCTION

he incidence of lower segment Caesarean section (CS)

has increased worldwide in the last three decades.1-3
Although maternal death as a result of CS is now rare,
reports of the short- and long-term consequences of the rising CS rate on the childbearing population are conflicting.4
At the same time, it is as yet not clear if the increase in CS
rate has resulted in more favourable fetal outcomes. In
developed countries where small family size is the norm,
pregnant women requiring CS will consider having a tubal
ligation after the second or third delivery.

In a country like Saudi Arabia, where having a large family is

encouraged by social and cultural influences, it is not
unusual to see women planning for their sixth or seventh
CS. One major complication of repeat CS is uterine scar
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Table 1. Maternal demographic characteristics and birth weight

Characteristic
Maternal age in years (mean SD)

Group 1
n = 115

Group 2
n = 256

Significance
P

31.8 4.7

30.0 5.6

0.006

Parity (mean SD)

4.3 1.7

3.4 3.0

0.005

Blood loss in mL (mean SD)

436 191

415 229

NS

Gestational age at delivery in weeks (mean SD)

37.3 2.7

38.7 2.4

0.013

104.4 15.7

103.9 14.9

NS

Hospital stay in days (mean SD)

6.8 2.0

6.3 3.2

NS

Birth weight in grams (mean SD)

2972 818

2941 747

NS

Number of abortions (mean SD)

0.9 1.2

0.8 1.2

NS

55.2 15.7

51.7 12.8

NS

Postoperative hemoglobin in g/L (mean SD)

Duration of surgery in minutes (mean SD)

SD: standard deviation; NS: not significant.

rupture with subsequent adverse fetal and maternal consequences.5,6 Because of the paucity of clinical trials, there is
no consensus on the maximum number of Caesarean sections that a woman can undergo with safety.
Some authors have found no increase in maternal morbidity
in women with a history of multiple CS and have therefore
encouraged them to pursue further pregnancies.7,8 At the
same time, anecdotal case reports of women having more
than ten Caesarean sections have been documented.9 With
the improved safety of anaesthesia, the availability of safe
blood transfusion, and the use of prophylactic antibiotics,
many Caesarean sections are performed uneventfully.
This study was conducted to compare the short-term complications and outcomes of CS in women who had a history
of three or more previous Caesarean sections with those
who had a history of one previous lower segment CS.
MATERIALS AND METHODS

We reviewed the hospital records of women who had a CS

performed after three or more previous Caesarean sections
and those who had a CS for the second time at Abha Maternity Hospital from June 2002 to May 2004. The women
who met these criteria were identified from the operating
room logbook. In total, 371 patients were identified, of
whom 115 (31%) had undergone three or more previous
Caesarean sections (group 1) and 256 (69%) had undergone
one previous CS (group 2). Women with a history of classical CS or of inverted T uterine incision were excluded from
the study.
Women with three or more previous Caesarean sections
were admitted for planned elective CS. Women with the
same history who had no plan made for elective CS and
who were admitted in labour had emergency CS performed.
Women with a history of one previous CS performed for a
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non-recurring indication had a trial of vaginal delivery after

proper maternal and fetal assessment. Hospital department
policy dictated that induction of labour was contraindicated
in patients with previous CS. Emergency CS was performed
for fetal distress, or failure to progress in labour, in patients
with previous CS who were admitted in labour.
All patients received prophylactic antibiotic therapy (intravenous cefoxitin 2 g 30 minutes before surgery, followed by
1 g every 4 hours for 24 hours) and a Foley catheter was
inserted in the bladder prior to surgery. The choice of transverse or vertical subumbilical skin incision was made at the
surgeons discretion.
Data extracted from the patients files included maternal
age, parity, number of abortions, booking status (booked
patients had at least two antenatal clinic visits, and
unbooked patients were seen for the first time in the emergency room in labour or at term), antenatal complications,
placental location on ultrasound, gestation at delivery,
duration of surgery, experience of surgeon, type of skin
incision, presence of severe adhesions, intraoperative and
postoperative complications, preoperative and postoperative hemoglobin concentration, fetal outcome, and number
of postoperative days in the hospital. The data were coded,
tabulated, and entered into an IBM compatible computer.
Statistical analyses were carried out using the SPSS Version
9 for Windows (SPSS, Chicago, IL).
Numbers and percentages were calculated for qualitative
variables, and mean and standard deviation were calculated
for quantitative data. Comparisons between mean values of
quantitative variables were calculated using the Student t
test, and chi-square was used for qualitative data. The test of
significance was set at the 0.05 level.

Multiple Repeat Caesarean Sections: Complications and Outcomes

Table 2. Intraoperative and early postoperative complications

Maternal complication

Group 1
n = 115 (%)

Group 2
n = 256 (%)

Significance

Bladder injury

2 (1.7)

0 (0.00)

c2 = 5.16

Bowel injury

1 (0.86)

0 (0.00)

c2 = 2.23

Caesarean hysterectomy

1 (0.86)

1 (0.39)

c2 = 2.23

Wound infection/dehiscence

4 (3.4)

5 (1.9)

c2 = 0.78

Blood transfusion

4 (3.4)

10 (3.9)

c2 = 0.04

Deep vein thrombosis

1 (0.86)

2 (0.78)

c2 = 0.01

Other*

2 (1.7)

2 (2.7)

c2 = 0.033

Scar dehiscence or rupture

0 (0.0)

1 (0.39)

c2 = 0.39

P = 0.023
P = NS
P = NS
P = NS
P = NS
P = NS
P = NS
P = NS
Skin incision
Lower transverse
Vertical midline
Emergency Caesarean section

214 (83.5)

c2 = 40.75

62 (54)

42 (16.5)

P = 0.000

38 (33.0)

186 (72.6)

c2 = 45.7

53 (46.0)

P < 0.001
*Urinary tract infection, chest infection, atelectasis
NS: not significant.

RESULTS

During the study period, there were 11 228 deliveries with

an overall CS rate of 21.1%. The women who constituted
the study population accounted for 15.6% of the total number of Caesarean sections performed during the study
period.
Of group 1 patients, 79 (68.6%) had three previous Caesarean sections, 24 (20.8%) had four, 10 (8.7%) had five, and
two (1.7%) had six previous Caesarean sections. The maternal demographic characteristics and birth weights are
shown in Table 1. There were statistically significant differences between the two groups regarding mean maternal
age, parity, and gestational age at delivery (P < 0.05), but no
difference in the number of abortions, blood loss during
surgery, duration of surgery, and birth weight. The
intraoperative and postoperative complications are shown
in Table 2. Caesarean section was performed as an
emergency in 38 (32.5%) and 186 (72.6%) of group
1 and 2 patients, respectively (P < 0.05). There were no significant differences in the rates of bowel injury and Caesarean hysterectomy, but the rates of bladder injury and

presence of severe adhesions were higher in group 1 than

in group 2 (P < 0.05). No differences were found in other
variables. Other characteristics and fetal outcomes in the
two groups of patients are shown in Table 3. The rates of
placenta previa and placental abruption were similar in the
two groups. Patients in group 1 were significantly more
likely to have a consultant (senior specialist) surgeon than
patients in group 2.
DISCUSSION

It is not uncommon in Saudi Arabia for pregnant women to

have had more than three Caesarean sections. The high
prevalence of grand multiparity in the community may be
related to the cultural views of the community, which
celebrates the male gender and therefore regards a woman
without male offspring as a failure. Paradoxically, the
woman without female offspring feels out of place in the
family.
Abha Maternity Hospital is a secondary referral obstetric
centre that provides care for a population of about two million, and therefore infrequently admits complicated
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Table 3. Antenatal complications, maternal characteristics, and fetal outcome

Characteristic

Group 1
n = 115 (%)

Group 2
n = 256 (%)

Significance

Placenta previa

4 (3.4)

8 (3.1)

c2 = 0.03

Abruptio placenta

0 (0.0)

7 (2.7)

Stillbirth

4 (3.4)

2 (0.78)

Low Apgar score

6 (5.2)

8 (3.1)

c2 = 0.96

19 (16.5)

130 (50.7)

c2 = 38.07

P = NS
c2 = 3.21
P = NS
c2 = 3.63
P = NS
P = NS

(7 at 5 minutes)
Unbooked patients

P < 0.001
Grade of surgeon
Senior specialist

54 (46.9)

54 (21.0)

c2 = 48.5

Specialist

50 (43.4)

139 (54.2)

P < 0.001

Resident

11 (9.7)

62 (24.8)

obstetric cases. The major complications of repeat CS

include rupture of the scarred uterus, placenta accrete, and
intraoperative complications such as bladder or bowel
injury. Unfortunately, there are no guidelines regarding the
maximum number of Caesarean sections a woman may
undergo before she risks having serious complications.
In our study, scar dehiscence (defined as the presence of a
window in part of the uterine scar with intact membranes)
was found incidentally in only one patient (0.26%), who was
undergoing a second elective CS. There were no instances
of symptomatic uterine rupture, nor was there any maternal
mortality in this study. In the review by Kirkinen,10 27% of
patients with three or more previous Caesarean sections
had fenestration of the uterine scar, but recent studies have
described rates ranging from 1% to 10% in women undergoing anywhere from a fifth to a ninth CS.11,12
It is unclear why the incidence of scar dehiscence in our
study was low despite some patients with more than three
previous Caesarean sections being admitted in early labour
for emergency CS. Although the sample size was relatively
small, at least one study has reported a higher incidence of
scar dehiscence in a study population smaller than ours.10
It is notable that risk factors for scar dehiscence such as
multiple pregnancy and polyhydramnios were not present
in our patients, and induction of labour was not carried out
in patients with one previous CS. The risk of uterine rupture
in patients with one previous CS has been shown to
increase with induction of labour, depending on the agent
used for the induction.13
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The incidence of bowel and bladder injury in our series is

consistent with other reports.12 It is difficult to determine
whether the type of skin incision makes bowel or bladder
injury more likely. In the present study, the majority of
patients with a history of three or more Caesarean sections
had a vertical midline skin incision. We have observed that a
bladder that is drawn towards the uterine fundus by scarring
is more likely to be damaged after a suprapubic transverse
incision, but small bowel that is adherent to the parietal
peritoneum is likely to be damaged after a vertical incision.
In general, careful and meticulous entry into the peritoneal
cavity is the key to reducing injury to these organs.
In our study, there were significantly more adhesions in the
patients with three or more Caesarean sections than in
those with one previous CS, as found in other reviews.12
This is not unexpected because repeated surgery may be
associated with postoperative infection and subsequent
adhesion formation. It must be stressed that factors such as
meticulous surgical technique, gentle tissue handling, and
the general health of the patient affect tissue healing and
adhesion formation. We also found no difference in the
incidence of placenta previa and placenta accreta between
two surgical groups. Although Rashid et al.11 found no difference in the incidence of placenta previa and placenta
accreta between higher order (59) repeat CS and lower
order (34) repeat CS, others have demonstrated that the
incidence of placenta previa and placenta accreta increases
with the number of Caesarean sections.12,14 In a recent
review by Makoha et al.,15 the third CS did not define a
threshold for increased maternal risk, but abnormal

Multiple Repeat Caesarean Sections: Complications and Outcomes

placentation on a scarred uterus increased with successive

Caesarean sections.
Our study found no difference in the rates of Caesarean
hysterectomy between the two groups. Both hysterectomies
performed were carried out because of uncontrolled bleeding from a placenta accreta. The timely decision to perform
hysterectomy may have contributed to the favourable
maternal outcome data.
Despite the limitations of our study, we conclude that scar
dehiscence and uterine rupture are not common in women
who have a CS following either one or three or more Caesarean sections. Nonetheless, dense intra-abdominal adhesions and bladder injury occur more commonly in women
who have had three or more previous Caesarean sections.
Larger, prospective trials are required to confirm these
findings.
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