**4. Fetal risks**

Multiple cesarean section may have consequences not only for the maternal but also for the neonatal outcome. Unfortunately, most of the analyzed studies about the risks of multiple cesarean sections place the focus on the mother. Data about the fetal outcome depending on an increased number of cesarean sections are limited. **Table 2** shows an overview for some results of fetal risks in multiple repeat cesarean sections.

There are only 4 studies with a total of 2895 babies that could be looked at [4, 5, 8, 9]. Altogether, there are no significant differences in adverse Apgar score, neonatal intensive care admission, and complications in the neonatal outcome between the groups of lower and higher order repeated cesarean sections. It seems that the neonatal outcome is related to the number of repeat cesarean sections; only some nonsignificant trends were found for adverse fetal outcome. Furthermore, there was no difference in the rate of perinatal death in women with prior cesarean section versus vaginal delivery [27]. More detailed results of neonatal characteristics such as asphyxia, pH-values, fetal defects, and short- and long-term neurological outcome investigating the association with the numbers of repeat cesarean sections could not be found.

There are some studies describing that previous cesarean delivery is associated with an increased risk of preterm birth and small-for-gestational-age fetuses relative to women with no previous cesarean [28, 29]. One trial pointed out that neonates of mothers having multiple repeat cesarean sections were significantly more likely to be born prior to 37 weeks of gestation and therefore had higher rates of complications and admissions, especially adverse respiratory outcome (see also 7) [4]. This aspect may be based on a higher risk potential of women with multiple prior cesarean section (e.g., higher mean maternal age, gravidity, and parity of women who had more than one prior cesarean [5]) and therefore the clinical decision for a preterm elective repeat cesarean section. Preterm birth and fetal growth restriction may also be due to an increased risk of abnormal placentation and uteroplacental dysfunction in association with a prior cesarean section [28].

In conclusion, the results suggest that adverse neonatal outcome depends more on the mode and the timing of delivery than on the number of repeat cesarean section.


**43**

*Maternal and Fetal Risks in Higher Multiple Cesarean Deliveries*

**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

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

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

Clinical decision-making for women following multiple prior cesarean deliveries is influenced by limited evidence and the expectations of the mother. Vaginal birth after multiple cesarean deliveries can be an option if women are eligible. In order to provide the currently best available evidence, we extracted and regrouped informa-

A meta-analysis of 20 studies compared the success rate—and the associated adverse maternal and fetal outcomes of vaginal birth—after one and two cesarean sections (VBAC-1/VBAC-2) with a further repeat multiple cesarean section [30]. Women requesting a trial of labor following two cesarean sections should be informed of a success rate for vaginal delivery of 71.7%, a uterine rupture rate of 1.36%, and of a similar maternal morbidity in both groups. Maternal morbidity of VBAC-2 is comparable to that of multiple cesarean sections. The neonatal morbidity

Another trial pointed out that women with three or more prior cesareans who attempt VBAC have similar success rates and maternal morbidity as those with only one prior cesarean, as well as those delivered by elective repeat cesarean [31]. There are also two systematic Cochrane reviews showing no statistically significant differences between a planned repeat cesarean birth and a planned vaginal

*DOI: http://dx.doi.org/10.5772/intechopen.86334*

cesarean sections.

severe adhesions [16].

was held due to the urgency.

tion from four trials (**Table 3**).

**6. VBAC and the number of repeat cesarean section**

data were too limited to draw valid conclusions [30].

birth after a cesarean section [32, 33].

*\*\*Intraventricular hemorrhage, severe jaundice, severe infection, hypoxic ischemic encephalopathy.*

#### **Table 2.**

*Fetal risks associated with an increasing number of repeated cesarean section.*

*Recent Advances in Cesarean Delivery*

Multiple cesarean section may have consequences not only for the maternal but also for the neonatal outcome. Unfortunately, most of the analyzed studies about the risks of multiple cesarean sections place the focus on the mother. Data about the fetal outcome depending on an increased number of cesarean sections are limited. **Table 2** shows an overview for some results of fetal risks in multiple repeat cesarean

There are only 4 studies with a total of 2895 babies that could be looked at [4, 5, 8, 9]. Altogether, there are no significant differences in adverse Apgar score, neonatal intensive care admission, and complications in the neonatal outcome between the groups of lower and higher order repeated cesarean sections. It seems that the neonatal outcome is related to the number of repeat cesarean sections; only some nonsignificant trends were found for adverse fetal outcome. Furthermore, there was no difference in the rate of perinatal death in women with prior cesarean section versus vaginal delivery [27]. More detailed results of neonatal characteristics such as asphyxia, pH-values, fetal defects, and short- and long-term neurological outcome investigating the association with the numbers of repeat cesarean sections

There are some studies describing that previous cesarean delivery is associated with an increased risk of preterm birth and small-for-gestational-age fetuses relative to women with no previous cesarean [28, 29]. One trial pointed out that neonates of mothers having multiple repeat cesarean sections were significantly more likely to be born prior to 37 weeks of gestation and therefore had higher rates of complications and admissions, especially adverse respiratory outcome (see also 7) [4]. This aspect may be based on a higher risk potential of women with multiple prior cesarean section (e.g., higher mean maternal age, gravidity, and parity of women who had more than one prior cesarean [5]) and therefore the clinical decision for a preterm elective repeat cesarean section. Preterm birth and fetal growth restriction may also be due to an increased risk of abnormal placentation and uteroplacental dysfunction in association with a prior

In conclusion, the results suggest that adverse neonatal outcome depends more on the mode and the timing of delivery than on the number of repeat cesarean

**Fetal risks of multiple repeat cesarean section**

n.k. 21.24%

20.31% n = 588/2895 [5, 8, 9]

2.11% n = 61/2895 [5, 8, 9]

n = 816/3841 [5, 8, 10, 11]

n = 58/415 [5, 8]

n = 39/415 [5, 8]

*\*\*Intraventricular hemorrhage, severe jaundice, severe infection, hypoxic ischemic encephalopathy.*

*Fetal risks associated with an increasing number of repeated cesarean section.*

**First CS Second CS Third CS ≥4 CS**

17.70% n = 154/870 [5, 8, 9]

2.18% n = 19/870 [5, 8, 9]

23.07% n = 218/945 [3, 5, 8, 10, 11]

15.81% n = 68/430 [4, 5, 8, 9]

4.49% n = 15/334 [5, 8, 9]

19.56% n = 62/317 [3, 5, 8, 10, 11]

**4. Fetal risks**

sections.

could not be found.

cesarean section [28].

Admission to NICU\* 13.97%

5-min Apgar < 5 9.39%

Complications\*\* in fetal

*Neonatal intensive care unit.*

outcome

section.

**42**

**Table 2.**

*\**
