**5. Risks in higher order multiple cesarean sections**

Cesarean deliveries by women with more than four prior cesarean sections are very rare and are exceptional cases. Usually the third or fourth cesarean section is combined with tubal ligation. However, in some countries or religious groups with large families and by self-determined decision-making, very high order repeat cesarean deliveries can be observed, in particular if contraception is not desired. Therefore it is critical to know how dangerous it is to perform more than four repeat cesarean sections.

There are not many studies describing women undergoing five or higher multiple cesarean sections. One study with 940 cases demonstrated an increase of the risks of all major complications, and dense adhesions were commonly noticed at cesarean delivery, but only eight women had more than four multiple cesarean deliveries [24]. Another study with a total of 318 women investigated especially the risks of higher order (5–9) repeat cesarean sections and identified no difference in maternal and fetal risks between the group of lower (<4) and higher (>4) repeat cesarean section except for an extended operation time and an increased rate of severe adhesions [16].

As shown in Chapter 4 (maternal risks), multiple cesarean deliveries are in general associated with more adhesions and increased blood loss than only one planned cesarean section. It can therefore be concluded that the surgery and management of higher order (>4) repeat cesarean sections are more difficult and require more planning and operation time and skills. One study with a total of 5007 women pointed out that vertical skin incision in these cases is not associated with improved maternal and fetal outcome [9]. Furthermore, the results of another study suggest that the risks of an urgent multiple cesarean section are in the range of elective multiple cesarean section [6, 18]. There were, however, differences for myometrium herniation during this cesarean section, a need for drainage following surgery, and postoperative fever as well as hospitalization (days), which was held due to the urgency.
