**Abstract**

The professionalization of women has shifted family planning to increased maternal ages. This has increased the use of assisted reproduction. Therefore, the tolerance toward suboptimal outcome of pregnancy decreases, and self-determined decision-making is on the rise. Once women have made the decision for elective cesarean section in their first pregnancy, subsequent pregnancies may result in multiple cesarean deliveries. This chapter analyzes the risks associated with higher multiple cesarean deliveries, such as bleeding and transfusion, adhesions, bowel and urinary tract injury, and uterus rupture. It also discussed the risks for vaginal birth following cesarean (VBAC) following multiple cesareans. Also there are neonatal risks involved, and women may require specific obstetric anesthesia. The chapter will analyze the risks for the offspring and the mother depending on the number of previous cesarean sections. This may enable detailed counseling of parents before a higher multiple repeat cesarean section is performed.

**Keywords:** multiple repeat cesarean section, maternal risks, fetal complications, morbidity, outcome

#### **1. Introduction**

Cesarean section is a surgical technique of delivery that frequently saves the life of both the mother and the baby. Although many women especially in the Western world have only one or two children, there are many countries and communities in which the availability of effective contraception is limited and larger families are common. The recent World Health Organization (WHO) data on the frequency of cesarean section show that cesarean section has increased dramatically throughout the world in the past two decades [1]. This rise is independent of the stage of development of a country. In addition, the increase in cesarean section rates shows no signs of slowing down. There are at least two significant reasons for this increase, although the phenomenon has not been yet fully understood: the increasing rate in primary cesarean sections and the rapidly decreasing rate of vaginal birth after cesarean section (VBAC) [2]. An increasing rate of cesarean sections results inevitably in a rise of multiple repeat cesarean deliveries.

It is known that multiple cesarean sections are associated with short- and long-term risks for both the mother and the baby [3–7]. There are several significant maternal complications such as visceral injury, uterine rupture, abnormal placentation, hysterectomy, bleeding and transfusions, severe adhesions, etc., most of which increase with an increasing number of repeated cesarean sections. There are also neonatal risks: babies born via multiple repeat cesarean section are more likely to experience breathing difficulties and to require admission to neonatal intensive care [4, 5, 8, 9].

Although cesarean section is now safer than it has ever been before, there are some knowledge gaps, and there is uncertainty among many obstetricians about the risks involved in multiple cesarean sections, especially when the number exceeds four. Thus, we would like to summarize the results of the most important studies investigating maternal and fetal risks in multiple repeat cesarean sections enabling and facilitating the counseling of parents and the decision-making for delivery.
