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Year : 2015  |  Volume : 3  |  Issue : 1  |  Page : 44-49

The effects of repeated caesarean sections on maternal and fetal outcomes

1 Department of Obstetrics and Gynecology, Al Qassimi Hospital, Ministry of Health, Sharjah, United Arab Emirates
2 Department of Statistics, American University of Sharjah, Sharjah, United Arab Emirates

Date of Web Publication20-Jan-2015

Correspondence Address:
Ghazala A Choudhary
P.O. Box 29960, Sharjah
United Arab Emirates
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-631X.149676

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Objectives : To determine (i) the effects of repeated caesarean sections on maternal and fetal outcomes (ii) whether these outcomes are affected by the timings of caesarean section (elective/emergency).
Materials and Methods: This is a retrospective observational study conducted at Al Qassimi Hospital, Sharjah UAE from 1st Jan 2007 to 31st Dec 2008. 224 women who underwent caesarean section (CS) for two or more times were studied with respect to timing of current caesarean section, adhesions, condition of bladder and lower uterine segment, dehiscence of previous scar and any visceral injuries. Total blood loss and postoperative complications were also evaluated. Fetal parameters included gestational age at birth, APGAR scores and breathing difficulties if any.
Results: Incidence of dense adhesions increased with increasing number of caesarean sections (22% for prev 2CS, 33% for prev 3 CS, 39% for prev 4 or more CS). Omental adhesions also followed similar pattern. The lower segment was thinned out in 38% of total patients. Scar dehiscence was seen in 50% of previous 4 caesarean section operated in emergency, in comparison to 4% and 6%% in previous 2 and 3 caesarean section. Other complications like bleeding, blood transfusion and postoperative complications were not statistically different in both the groups (elective and emergency).
There was no case of caesarean hysterectomy and maternal death. The fetal outcome was similar in all the groups.
Conclusions: No definitive upper limit of multiple repeat caesarean sections can be fixed for an individual woman based just on the number of previous Caesarean sections.

  Abstract in Arabic 

ملخص البحث:
هدفت هذه الدراسة إلى معرفة تأثير الولادات القيصرية المتكررة على الأم والجنين. وعلى تأثير الولادات القيصرية المتكررة بتوقيت الولادات القيصرية. هذه دراسة استرجاعية على 422 امرأة تم توليدهن بعملية قيصرية. وضحت الدراسة أن حدوث الالتصاقات الكثيفة والالتصاقات الثربية أرتفع بتكرار العمليات القيصرية إضافة إلى مضاعفات أخرى كالنزف ونقل الدم. كما وضحت الدراسة أن تأثير الولادات القيصرية على الجنين كان متشابها في كل مجموعات الدراسة. وخلصت الدراسة إلى أنه لا يمكن القطع بالحد الأقصى لتكرار العمليات القيصرية لأي امرأة بناء على عدد القيصريات السابقة فقط.

Keywords: Caesarean section, multiple, outcomes

How to cite this article:
Choudhary GA, Patell MK, Sulieman HA. The effects of repeated caesarean sections on maternal and fetal outcomes. Saudi J Med Med Sci 2015;3:44-9

How to cite this URL:
Choudhary GA, Patell MK, Sulieman HA. The effects of repeated caesarean sections on maternal and fetal outcomes. Saudi J Med Med Sci [serial online] 2015 [cited 2022 Nov 27];3:44-9. Available from: https://www.sjmms.net/text.asp?2015/3/1/44/149676

  Introduction Top

Repeated cesarean sections (CSs) is a major cause of maternal morbidity and mortality. [1],[9] The incidence of primary CS is increasing all over the world, primarily due to maternal preferences, maternal obesity, extensive fetal monitoring and altered obstetric practices. Other additional factors are improved safety of anesthesia, antibiotics, availability of blood products and pre- and postoperative monitoring. [2] Consequently, there is a rise in multiple repeat CSs with associated complications. Repeated CS is recommended electively for cases of previous three or more CS, [3] though many obstetricians are inclined to do elective repeat CS after only two CS.

The approximate number of deliveries at Al Qassimi Hospital, which is a regional referral hospital for the entire Sharjah Emirate of the UAE is 4000 per year. The CS rate for this hospital was 21.4% in 2007 and 21.9% in 2008.

The CS rate in the Middle East is <15% in the majority of the countries, except Qatar, Bahrain (16%) and Lebanon (18%), although higher rates have been reported in Egypt (26%) and Sudan (20%). [4] The rate of multiple repeat CS is persistently on the rise because of social and cultural demands for large families.

Repeat multiple CS are associated with an increase in the risk of placenta praevia [5],[7],[13] with other operative complications such as abdominal wall adhesions, bladder and bowel adhesions and injuries, ureteric injuries, hemorrhage, uterine dehiscence and rupture of the uterus. [4],[5],[6],[7],[8],[10],[11],[12] Caesarean hysterectomy is one of the major dreaded complications. [5],[7],[12] Postoperative complications are wound infections, thromboembolism, endometritis, urinary tract infection, fever >37.5°C and blood transfusions. [5],[6],[12]

Very few studies have been undertaken that address the maternal and fetal complications in multiple repeat CSs with varying results. [5],[6]

Primarily, we aim at studying the influence of increasing order of CSs on intraperitoneal adhesions, condition of the bladder and lower uterine segment, extension of uterine incisions, placenta praevia, postpartum haemorrhage (PPH), blood transfusion and postoperative morbidity.

An outcome of secondary interest is the influence of timing of the CS (elective or emergency) on maternal outcome as regards the condition of the lower segment, uterine dehiscence and rupture, as well as neonatal complications.

  Material and methods Top

The study was conducted at Al Qassimi Hospital, which is a 350-bed regional tertiary referral hospital in Sharjah, UAE.

The total number of deliveries in 2007 was 3537; 759 (21.4%) of which underwent CSs, but in 2008, the total number of deliveries rose to 4138, 905 (21.9%) of which were CSs.

This is a retrospective observational study of 235 pregnant women who have had CSs for two or more previous CS in the period between January 1, 2007 and December 31, 2008. The approval was obtained by the Research and Ethical Committee of the hospital, 11 patients were excluded from the analysis because of incomplete hospital records. The study group thus comprised 224 patients; 157 of whom have had two previous CSs, 49 had three previous CSs, 16 had 4 and 2 patients had five previous CSs.

The patients were divided into two main groups: Elective caesarean section group (women who were 37 or more weeks pregnant, admitted electively from the antenatal clinic or via the emergency room when referred from the peripheral clinics or hospitals and scheduled for elective CSs) and Emergency caesarean section group (women who presented in labor directly to the delivery room, and women from the elective group who went into labor after admission while awaiting elective CSs). Each group was further subdivided into two, three, four or more previous CSs.

Our hospital policy was to book patients for elective CS at 38 weeks with two previous CSs, at 37 weeks with three previous CSs and at 36 weeks with four or more previous CSs, after giving them antenatal steroids for fetal lung maturity.

In our study, the data of every patient was collected from the operation theatre register and patients' medical records. These dealt with age, nationality, parity, timing of current CS (elective/emergency), the number of previous CSs, gestational age at the time of this CS. This also dealt with indication for emergency CS, type of skin and uterine incision, intraoperative findings with reference to adhesions; conditions of the bladder and of the lower uterine segment and presence of dehiscence of the previous uterine scar were considered. There were data on intraoperative bladder, bowel and ureteric injuries. Intraoperative blood loss was observed and estimated from operative notes by the surgeon and the anaesthetist. Postoperative complications such as wound infections, urinary tract infections, fever >37.5°C, venous thrombo-embolism (VTE) and blood transfusions were also evaluated. Postpartum hemorrhage was studied according to international standards. Incidence and factors associated with caesarean hysterectomy were also looked into. Fetal factors such as gestation at birth, APGAR score at 1, 5 and 10 minutes, breathing difficulties and traumatic delivery were evaluated.

The severity of peritoneal adhesions were subjectively graded by the surgeon according to the American Fertility Society Classification of adnexal adhesions, ranging from flimsy/avascular adhesions (1-25% of area) classified as mild; dense adhesions (26-50% of area) categorized as moderate and cohesive adhesions (>50% area) categorized as severe. Omental adhesions were separately categorized.

The condition of the lower segment (isthmus) of the uterus was visually estimated as:

a. Normal or an almost normal layer of muscular tissue;

b. Thinned out, which is a very thin layer of muscular fiber <2 mm approximately;

c. Dehiscence was defined as disruption of the uterine muscle with an intact serosa;

d. Fenestration: A lacerated thin layer through which fetal membranes could be seen.

To test for significant differences among the CS groups, Chi-square test was used for categorical outcomes and Kruskal-Wallis test was used for continuous outcomes. A P < 5% indicated a significant difference.

  Results Top

In our study of 224 patients, 147 (66%) had elective (El) CS and 77 (34%) underwent CS in emergency (Em) for various reasons. Of the 224 women, 157 had undergone two previous CSs (El: 102, Em: 55), 49 women had three previous CSs (El: 31, Em: 18), 16 with four previous CSs (El: 12, Em: 4), 2 with five previous CSs (El: 2, Em: 0).

Demographic and clinical features of the study groups are presented in [Table 1]. The mean age was same in all groups of CS (P > 5%) but as expected, parity was significantly higher with increasing number of CSs (P < 0.0001). Gestational age was significantly lower with increasing number of CSs (P < 0.0001). The association between the mode of surgery (elective or emergency) and the number of previous CSs was not significant (P ≥ 5%). In the emergency group of 55 cases with two previous CSs, 75% had gone into labor prior to their planned surgery at 38 weeks gestation. Whereas, out of 18 cases with three previous CSs, nine cases (50%), and three cases (75%) out of 4 with four previous CSs developed uterine contractions. The incidence of preterm premature rupture of membranes, antepartum hemorrhage and fetal distress (based on fetal heart rate abnormalities on cardiotocography tracings) were not observed in the subgroup with four previous CSs.
Table 1: Demographic and clinical features

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Intraperitoneal adhesions were the most common complication encountered during surgery. There was an insignificant difference in the incidence of flimsy and dense adhesions across the three CS subgroups. However, plastered abdominal wall was seen with increased frequency with an increasing number of CS.

The urinary bladder was advanced (adherent at a higher level of anterior uterine wall), in 45 (29%) of the patients with two previous CSs, 24 (49%) with three previous CSs, 13 (72%) with four or more previous CSs. The bladder was inadvertently injured in one case of two previous CSs (elective group) and two cases with three previous CSs (elective group). There was only one serosal bowel injury which was repaired by the surgeon in previous two CSs (elective group).

Postpartum hemorrhage was seen in 6%, 22% respectively of patients with two, three, four or more previous CS groups in the elective subgroup. Hemorrhage was controlled successfully and none had caesarean hysterectomy. One patient had relaparotomy for postoperative haemoperitoneum; no active bleeding was found, except oozing from the base of the bladder. Blood transfusion was required in 8%, 6% and 11% in two, three and four or more previous CS groups.

Eight cases in two previous CS group and two in three previous CS group (all electives), had an extension of the uterine angle while the fetus was being extracted and was successfully sutured. There were two cases of placenta praevia, one each in the groups with three previous CSs and four or more previous CS. These were not placenta accreta and had no catastrophic outcomes such as PPH, cesarean hysterectomy or maternal mortality. No case of ruptured uterus was encountered in our study groups.

In [Table 2] we classify the condition of lower uterine segment by the timing of CS. Thinning of lower uterine segment was higher in the emergency group of all subgroups of CS, compared to the elective group; (previous two CS-41% vs. 30%, previous three CS-61% vs. 29% and previous four or more CS-75% vs. 57%).
Table 2: Intraoperative condition of lower uterine segment by the timing of CS

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A comparison of the incidence of dehiscence of the lower uterine segment of the elective against emergency subgroup of CS were as follows: 5% and 4% in previous two CS groups; 3% and 6% in previous three CS groups and 14% and 50% and in previous four or more CS groups.

Only one case of fenestration of lower uterine segment was observed in the two previous CS groups.

A majority of our patients from all three groups did not have any postoperative morbidity (91%, 96% and 94% respectively). Wound infection was seen in 11 (7%) with two previous CS, 2 (4%) with three previous CS and 1 (5%) with four or more previous CS groups. There was one case of VTE and one case of paralytic ileus, both belonging to the emergency group with two previous CSs. Only one patient from the group with two previous CSs had postoperative febrile morbidity due to urinary tract infection. She was successfully treated with antibiotics. Length of postoperative stay was similar in all subgroups (mean: 4.5 days) [Figure 1].
Figure 1: The fetal outcomes classified by the type of lower segment caesarean section.

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The most common adverse fetal outcome noted in our study was prematurity which showed an increasing trend in the emergency CS subgroup with two, three, and four or more previous CSs (18%, 33% and 100%). These were performed on the onset of labor and third trimester hemorrhage, but overall perinatal outcome was satisfactory. There was no neonatal death. One baby had trauma during extraction (cut on the buttock) due to thinness of the lower uterine segment.

  Discussion Top

Cultural expectations for larger families which are high in many parts of the world, especially in the Arab region has led to an increase in the rate of CSs and the consequent multiple repeat CSs with associated complications.

In order to counsel women accurately on the safety of higher order CSs, many studies were conducted to establish the consequences of multiple repeated CSs on future pregnancies have shown mixed results.

The outcomes and complications of two previous studies involving many women with multiple repeated CSs (Makoha et al. and Silver et al.), [10],[7] are comparable to our study. Our data showed that flimsy adhesions did not show any predilection to the number of repeat CSs, but dense adhesions increased with the increasing number of CSs (22%, 33%, 39% for two, three, four or more previous CSs respectively). Similar results have been reported by other investigators. [5],[6],[10],[11] Although Rashid et al.[5] also mentioned a similar increasing trend of the dense adhesions (15% for 3-4 CSs and 54% for 5-9 CSs) when compared to our study, the magnitude of dense adhesions were slightly lower in two and three previous CSs. Dense adhesions which have been reported by these authors not only create difficulties for the surgeon, but also pose an increased risk to the women by prolonging operative time and the risk of injury to adjacent organs. We encountered three cases of bladder injury and one case of bowel injury (total: 1.3% of visceral injuries); all were associated with dense intraperitoneal adhesions. The incidence here is slightly higher than in the study by Phipps et al. (0.28%). [17]

The need for blood transfusion was on an average 7.5% in our study in all CSs, which is slightly higher than what was reported by Rouse et al. [17] and two Danish studies. [15],[16]

Makoha et al.[10] noted that compared with the third CS, the risk for placenta praevia, acrreta and cesarean hysterectomy was significantly increased with the fifth and sixth cesarean delivery; similar results were reported by Silver et al. [7] in large cohort study. They observed that even in the absence of placenta praevia and accreta, the risk of caesarean hysterectomy increased with the increase in multiple repeat CSs. In our study, we found only two cases of placenta praevia (in previous three and four CS group), which were not accreta and did not pose any haemostatic difficulty, though these results are in slight disagreement with the above-mentioned studies. However, our results are consistent with the findings of other authors [6],[10],[14] who also did not find any association between the increase in placenta praevia and accreta with an increase in CSs. Our results could probably be attributed to the smaller size of the study.

The effect of pregnancy and labor on the lower uterine segment could bring catastrophic consequences in the form of uterine rupture or silent asymptomatic dehiscence. 69% of the women who were operated on in the emergency group came with uterine contractions. We found that the incidence of thinning of the lower uterine segment was higher in these women than in the elective group [Table 3]. Prevalence of dehiscence was significantly higher (50%) in the emergency subgroup with 4 or more previous CS groups compared to 4% and 6% in two previous CSs and three previous CS emergency group, probably due to uterine contractions. In contrast, Rashid et al.[5]
reported similar incidence of complete and incomplete dehiscence in all orders of CSs.
Table 3: Intraoperative adhesions and other complications

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There was no major morbidity such as uterine rupture, placenta accreta, caesarean hysterectomy or maternal death in our study, which is in contrast to other studies.­ [5],[6],[10],[11] This can be attributed to such limitations in our study as (i) the relatively small number of higher order CSs (four and more), (ii) retrospective nature of study since it is likely that some data on complications may not have been completely documented, (iii) lack of uniformity in subjective descriptions of the surgeons regarding adhesions, blood loss and conditions of the lower uterine segment.

A total of 16 (7.1%) cases of PPH were observed in our study with no correlation to the increasing order or timing of CS. The rate of postoperative complications (wound infections, VTE, paralytic ileus, pyrexia and endometritis) observed was very low. It did not exhibit any increase with progressive order of CS which is comparable to other studies.

The most common adverse fetal outcome noted in our study was prematurity, the trend of which increased in the emergency CS subgroup with two, three, and four or more previous CSs (18%, 33% and 100%). These were performed on the onset of labor and third trimester hemorrhage. However, overall perinatal outcome was satisfactory. There was no neonatal death.

  Conclusion Top

In multiple repeat CSs, it is possible to achieve a successful pregnancy outcome without jeopardizing maternal and fetal well-being. However, in cases of four and more previous CSs, further evaluation in a larger study is needed to explore the safety, since the number of this order of CSs was too small for us to reach a definitive conclusion.

Provided the intraoperative findings of adhesions, lower uterine segment thickness and bladder anatomy were satisfactory in the last CS, just the number of CSs does not justify a strong recommendation for sterilization. Based on the smallness of the sample of the study, an absolute upper limit of number of CSs cannot be prescribed. The patient should be made aware of the condition of the uterus, adhesions and the prospects of future pregnancies after each CS. The anticipated complications can be minimized by effective patient counseling, adequate spacing, optimal antenatal and postoperative care and meticulous surgical techniques.

  References Top

Office of the National Statistics. Caesarean section deliveries in NHS Hospitals. (2004).  Back to cited text no. 1
Kirkinen P. Multiple caesarean sections: Outcomes and complications: Br J Obstet Gynecol 1988;95:778-782.  Back to cited text no. 2
Birth after previous caesarean birth. Green top guideline N. 45. RCOG Feb 2007.  Back to cited text no. 3
Khawaja M, Choueiry N, and Jurdi R. Hospital-based caesarean section in the Arab region: An overview: East Mediterr Health J. 2009 Mar-Apr; 15:458-469.  Back to cited text no. 4
JuntunenK, Makarainen L, Kirkinen P. Outcome after a high number (4-10) of repeated caesarean sections. Br J Obstet Gynecol 2004;111:561-563.  Back to cited text no. 5
Rashid M, Rashid RS. Higher order repeat caesarean sections: How safe are five or more? Br J Obstet Gynecol 2004;111:1090-1094.  Back to cited text no. 6
Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EM et al. Maternal morbidity associated with multiple repeat caesarean deliveries. Obstet Gynaecol. 2006;107:1226-1232.  Back to cited text no. 7
Pedro P. Rupture of a caesarean scarred uterus: A community hospital experience. JAMA 2000;92:295-300.  Back to cited text no. 8
J Cook, M Dhanjal, S Jarvis et al. Multiple repeat caesarean section. UK Obstetrics Surveillance System 2008.  Back to cited text no. 9
Makoha FW, Felimban HM, Fathuddien MA, Roomi F, Ghabra T et al. Multiple caesarean section morbidity. Int J Gynaecol Obstet. 2004 Dec;87:227-32.  Back to cited text no. 10
Ugyur D, Gun O, Kelecki S, Ozturk A, Ugyur M, Mungan T et al. Multiple repeat caesarean section: Is it safe? Eur J of Obstet Gynecol Reprod Biol 2005;119:171-175.  Back to cited text no. 11
Nisenblat V, Barak S, Griness OB, Degani S, Ohel G, Gonen R. Maternal Complications Associated With Multiple Caesarean Deliveries. Obstet Gynecol 2006;108:21-26.  Back to cited text no. 12
Gilliam M, Rosenberg D, Davis F. The Likelihood of Placenta Previa With Greater Number of Caesarean Deliveries and Higher Parity. Obstet Gynecol. 2002;99:976-980.  Back to cited text no. 13
Grobman WA, Gersnoviez R, Landon MB, Spong CY, Leveno KJ, Rouse DJ et al. Pregnancy Outcomes for Women with Placenta Previa in Relation to the Number of Prior Caesarean Deliveries. Obstet Gynecol. 2007;110:1249-1255.  Back to cited text no. 14
Rochelle ML, Holt VL, Easterling TR, Martin DP. Risk of Uterine Rupture During Labor among Women with a Prior Caesarean Delivery. New England J of Medicine. July 2001; 345: 3-8.  Back to cited text no. 15
Rouse DJ, MacPherson C, Landon MB, Varner MW, Leveno KJ, Moawad AH et al. Blood Transfusion and Caesarean Delivery. Obstet Gynecol. 2006;108:891-897.  Back to cited text no. 16
Phipps MG, Watabe B, Clemons JL, Weitzen S, Myers DL, Risk factors for bladder injury during cesarean delivery. Obstet Gynecol. 2005 Jan;105:156-60.  Back to cited text no. 17


  [Figure 1]

  [Table 1], [Table 2], [Table 3]

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