How Many C-Sections Can You Have?

Mother with c-section scar and her baby lying on the bed
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The latest research shows that the more cesarean surgeries you have, the riskier the subsequent surgeries become for you and your baby. But circumstances vary from person to person and pregnancy to pregnancy and play a role in determining whether the benefits of a repeat C-section outweigh the risks.

Risks of Repeat C-Sections

C-sections can be life-saving surgeries, but like other major surgeries, they also come with risks. When a surgeon cuts through the layers of skin, muscle, and organs, scar tissue is left behind. A cesarean scar can lead to complications in future pregnancies with the uterus, placenta, and abdomen. The more frequently incisions are made, the greater the risk of complications.

Risks During Pregnancy 

After a cesarean, the risk of placenta previa in future pregnancies increases by 1.5 to six times. Placenta previa is a condition where the placenta grows over the cervical opening. The more C-sections you have, the greater the risk of placenta previa in subsequent pregnancies.

Other placenta complications that can result from prior cesareans include placenta accreta, placenta increta, and placenta percreta. All of these complications are collectively referred to as placenta accreta spectrum. They represent a range of adherence of the placenta into the uterine wall.

The incidence of placenta accreta spectrum has increased dramatically since the 1970s when the rate was 1 in 2,500. More recently, a 2016 study found the rate in the U.S. to be 1 in 272. An increase in risk factors—namely, a sharp rise in cesareans over that time period—is a likely reason for the drastic rise in incidence.

The risk of placenta accreta spectrum increases significantly with the number of previous cesareans. The risk ranges from 0.3% after one C-section to 6.74% after five C-sections.

Uterine rupture occurs at a rate of 0.5% in pregnancies with a prior cesarean. The risk of rupture goes up with a classical incision scar, labor induction or augmentation, a larger-than-average fetus, older maternal age, and post-term delivery. The risk of uterine rupture increases with the number of previous cesareans.

Risks During Delivery 

In addition to risks associated with pregnancies following a cesarean birth, the surgery itself carries risks as well. Just as in any surgery, there is a risk with cesarean delivery that the surgeon could accidentally cut and injure surrounding tissues and organs. In particular, there is a risk of bowel and bladder injury. 

Adhesions are another potential complication of C-sections. Adhesions occur when scar tissue connects tissues and organs that are not normally attached. 

Adhesions complicate future surgeries by making it more challenging to open the uterus and increasing operation time. The presence of adhesions is also associated with a greater risk of bladder injury. The incidence of adhesions increases with subsequent C-sections.

Excessive bleeding is also a risk factor for any surgery, including cesarean. Compared to vaginal delivery, birth by cesarean carries the highest risk of postpartum hemorrhage (PPH).

Studies show that general anesthesia increases the PPH risk by three times, but that may be because people with PPH risk factors are more likely to receive general anesthesia. Other risk factors include anemia, placenta previa, multiple gestation, and chorioamnionitis. The risk of heavy bleeding increases with each C-section you have.

Risks After Delivery 

There is a strong association between incisional hernia repair and prior C-section. Hernia repair risk increases with the number of cesareans a person has had. People who have had two or more cesareans have three times the risk as those who have only had one cesarean. After five cesareans, the risk increases by six times.

Scar endometriosis can occur after cesarean sections. Researchers have found that it can occur months or even years following surgery, with the average timeframe of occurrence at 30 months. Incidence is 0.03% to 1.7%. The risk is twice that of those who give birth vaginally. One prospective study did not show evidence that repeat cesareans further increased this risk.

People are five times more likely to develop a dangerous blood clot when they are pregnant. Delivering by C-section doubles that risk.

Surgical site infection is one of the most common complications from cesarean section. The incidence is between 3% and 15%. Wound infection is associated with a maternal mortality of up to 3%. Necrotizing fasciitis is a severe complication involving gangrenous infection. Necrotizing fasciitis is life-threatening with a mortality rate of up to 50%.

How to Lower Risk

Risks are not absolute. When it comes to evaluating risks associated with cesarean surgery, your overall health and pregnancy circumstances need to be considered. If you need a cesarean, there are sometimes ways to mitigate the risks.

Reason for First C-Section 

A primary cesarean has risks on its own, but it also sets the stage for increased risks for future pregnancies and births. If you are planning to have more children, considering the risks of a primary cesarean to future pregnancies is vital. The American College of Obstetrics and Gynecology (ACOG) advises against C-sections without a medical indication.

If you have had a prior C-section, a repeat cesarean is not your only choice. Vaginal birth after cesarean (VBAC) is an option for many people under certain circumstances. 

Timing of Subsequent Pregnancy 

Pregnancies that occur less than six months from the last cesarean are at greater risk of adverse outcomes. In particular, the risk of uterine rupture is greater in those with shorter intervals between pregnancies. On the other end of the spectrum, intervals of greater than 5-10 years are also associated with an increased risk of adverse outcomes.

Using contraception between pregnancies can help mitigate these risks. Talk to your doctor about which birth control options are most ideal for you. 

Timing of Repeat C-Section 

Research has found that when someone has had multiple cesareans, the timing of a repeat cesarean can reduce the risk of morbidity. Specifically, a 2019 study found that maternal and neonatal morbidity occurred less frequently when delivery occurred at 39 weeks. ACOG and the American Academy of Pediatrics (AAP) recommend deferring scheduled C-sections until 39 completed weeks of gestation.

Vaginal Birth After Cesarean (VBAC)

Trial of labor after cesarean (TOLAC) is the attempt to give birth vaginally after a C-section. Vaginal birth after cesarean is the desired outcome of TOLAC. VBACs are an important option for people who underwent prior cesarean surgery, as they are associated with decreased maternal morbidity and decreased complications in future pregnancies.

Uterine rupture is the primary risk factor associated with VBAC. The risk of uterine rupture for people who have had more than one C-section is between 0.9% and 3.7%. It is not known how that compares to those who have only had one C-section.

The good news is that between 60% and 80% of those who attempt VBAC achieve a vaginal birth.

ACOG supports considering those who have had two prior C-sections with low-transverse incisions as candidates for TOLAC.

Frequently Asked Questions

Are people who have multiple C-sections more prone to uterine cancer?

Scar endometriosis is a risk factor for those who have given birth by cesarean. Sometimes those scars can have a malignant transformation. The incidence is unknown, but it is thought to be rare.

Do you have multiple scars when you have multiple C-sections?

Ideally, your doctor will cut through the same scar so that you don’t have multiple scars on your abdomen and uterus. Sometimes scar tissue can be difficult to cut through but your doctor should be able to cut through it. If it is urgent to get your baby out, however, they may choose to make another incision to avoid delays associated with cutting through scar tissue.

A Word From Verywell

If you are contemplating a repeat cesarean, you may be feeling overwhelmed. There is a lot of information to sort through. The good news is that you likely have options. Talk to your doctor about your concerns and ways that you can reduce the risks of multiple C-sections. If you are interested in a VBAC, ask your doctor if you are a good candidate.

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