Fourth caesarean section: what are the risks?


First a caesarean, then another and another. It may happen to arrive like this, from caesarean to caesarean, to the fourth birth, which at this point will also be a caesarean. But can it really be done? Isn't that too dangerous for mom?

Wouldn't it be better to avoid having other children if they've already had three caesareans?

"Sure, there are gods risks that increase progressively with the increase of the interventions undergone and therefore the fourth are higher than the third "says Anna Locatelli, professor at the University of our city Bicocca and director of obstetrics and gynecology of the Carate Brianza Hospital, one of those in which they do fewer caesareans in Del Paese. "But there is no fixed maximum number, an insurmountable limit that must not be exceeded. Personally, I would not say that after three caesareans the risks are so high that I can no longer have children ".

"Obviously, the risks to which she may face must be clearly explained to the woman with three or even more caesareans who is thinking about a new pregnancy, after which the decision is hers and depends a lot on her. motivation towards a new motherhood and the way in which awareness of these risks lives. ”Let's see exactly what it is.

When the placenta implants abnormally

"The most fearful risk that can occur after repeated caesareans is that of a abnormal implantation of the placenta, which does not occur as it should at the level of the endometrium, the inner lining surface of the uterus, but deeper, directly into the uterine musculature. In this case we speak of placenta accreta"explains Locatelli.

"The problem with placenta accreta is that having difficulty detaching itself after the baby is born can lead to major obstetric complications, such as very serious bleeding." Recall that in our country post-partum haemorrhage is the leading cause of maternal death, an event fortunately however very rare.

According to a study conducted a few years ago in the United States by a group of researchers from the University of Utah - the sample was over 30 women who had had at least one cesarean, up to a maximum of six - the risk of placenta accreta increases in progressively and gradually more and more significant with the increase in the number of interventions carried out. At the third caesarean, for example, the risk is 0,6% but it becomes equal to 2% at the fourth caesarean, 2,3% at the fifth and 6,7% at the sixth.

"So, at the fourth caesarean there is a 2% risk of placenta accreta. This does not mean that for these women things will necessarily go wrong, with hemorrhages or other obstetric complications, but that for them there is some more chance that they will go wrong than those who have fewer cesareans in their fourth pregnancy "summarizes Locatelli. . "Is it a risk that the woman is willing to take? Are you and she willing to run it peacefully, or are you anxious throughout your pregnancy because she knows there could be complications? These are aspects on which you must reflect ".

Repeated caesareans also increase the risks of other abnormalities of the placentation, such as placenta previa, which is inserted in the lower part of the uterus, covering all or part of the uterine orifice, but in a much less steep way. However, if the placenta is previa, the risk that it is also accreta increases.

Uterus in danger?

Another important risk associated with repeated caesarean sections is that of hysterectomy, the intervention of uterus removals which may be necessary in case of particular complications, including post-partum haemorrhage. Also in this case, the risk increases progressively with increasing interventions: 0,9% at the third caesarean, 2,4% at the fourth and then 3,5% at the fifth and 9% at the sixth (the data are always of the American study cited above).


Generally speaking, caesareans they do not increase the risk of uterus rupture, which is rather associated with attempting vaginal delivery after a previous caesarean section. "The guidelines of the Higher Institute of Health on caesarean section remind us that it is possible to attempt a trial labor if the previous caesarean sections have been a maximum of three. After three or more surgeries, vaginal delivery is not recommended, because the risk of lacerations of the uterus increases significantly "recalls Locatelli.


Other possible risks

Having already had more caesareans makes the surgical procedure for a new surgery a little more complicated. "This causes the risk of damaging organs near the uterus, like the bladder and the intestine "explains the gynecologist. Much, however, also depends on the results of the previous operations:" It may also happen that there are fourth caesareans less difficult than second caesareans ".


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Procedures and timing of the intervention

By itself, the execution of the caesarean does not change, whether it is the first or subsequent ones. "Of course, if it is a fourth surgery, we generally try to assemble the operating team in a more specific way, but in essence the only thing that really changes - obviously in the absence of complications - is the duration", explains Locatelli. If with the first caesarean the average duration of the operation is 50 minutes (data from the American study), with the fourth it goes to an hour and ten and with the sixth to an hour and twenty.

As for anesthesia, there are no problems choosing an epidural even in the case of repeated caesareans. "Only if there are complications that carry a serious risk of bleeding the anesthetist could make different choices and prefer general anesthesia."

What can happen next

As cesarean sections increase, the risk of getting a can increase chronic pain, which also lasts for several months after surgery. Pain can be caused by various factors: nerve injuries, scar problems, pelvic adhesions.


On the one hand, the available data show that as the number of caesareans increases, the possibility of even serious complications increases. Therefore, a fourth caesarean can tend to be a little more problematic than the previous ones. On the other hand, however, even after three caesareans, the overall risks still appear to be contained. It is especially from the fifth, sixth caesarean that they become more significant. "In the interventions following the fourth, the overall probability of a complication reaches around 14%" Locatelli emphasizes. But even in this case there are no prohibitions. "Again, the woman will need in-depth advice, who will have to compare her maternity deso with the possible risks."

The effects of caesareans on fetal health and fertility

According to some studies, having one or more caesareans could increase the risk, in a new pregnancy, of fetal problems: from growth retardation to preterm birth to stillbirth. The data is still controversial, because it is not confirmed by all investigations, but it could have a plausible explanation in the placentation abnormalities that can occur in a new pregnancy after cesarean. "We are not talking about conditions such as placenta accreta, but about anomalies that would lead to a malfunction of the placenta, in turn linked to anomalies in the growth of the baby" says Anna Locatelli.

Other studies suggest that one or more caesareans might slightly reduce fertility and slightly increase the risk of miscarriage in a later pregnancy. Even these associations, however, are to be definitively confirmed.

Other sources for this article: Long-term maternal morbidity associated with repeat cesarean delivery literature review article, published in the American Journal of Obstetrics and Gynecology.

  • Caesarean section
  • four caesarean deliveries
  • repeated caesareans
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