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Surveillance of multiple repeat caesarean section

Principal investigator
Joanna Cook (St Mary's Hospital, London)
Mandish Dhanjal (Queen Charlotte's and Chelsea Hospital, London), Marian Knight (NPEU)
Severe maternal morbidity and mortality
Royal College of Obstetricians and Gynaecologists
Start year
End year
NPEU Contact
Marian Knight


The incidence of primary caesarean section is rising throughout the world and the UK also demonstrates this trend. After having three lower segment caesareans women are advised to undergo repeated elective caesarean in any subsequent pregnancies, rather than attempt a vaginal delivery. This practice is thought to reduce the risk of uterine rupture which can be life-threatening for both mother and baby. All caesarean procedures however, have associated risks; venous thromboembolism and haemorrhage - which are leading causes of maternal mortality, infection, and damage to the viscera. Repeated caesareans are also associated with placental invasion into the myometrium and peripartum hysterectomy. Babies born via caesarean are more likely to experience breathing difficulties and require admission to a specialist unit. Current knowledge concerning the maternal-fetal outcomes and management of multiple repeat caesarean is limited and mainly derived from hospital-based retrospective case analysis outside of the UK. The aim of this study was to estimate the incidence of multiple repeat caesarean section (MRCS) (five or more) in the UK, and to describe the outcomes for women and their babies relative to women having fewer repeat caesarean sections.

Key findings

  • Ninety-four women undergoing MRCS were identified over one year, giving an estimated UK incidence of 1.2 per 10 000 maternities (95% confidence interval (CI), 0.97-1.47).
  • Women with MRCS had significantly more major obstetric haemorrhages (>1500 ml) (aOR, 18.6; 95% CI, 3.89-88.8), visceral damage (aOR, 17.6; 95% CI, 1.85-167.1) and critical care admissions (aOR, 15.5; 95% CI, 3.16-76.0), than women with lower order repeat caesarean sections.
  • Women with MRCS who also had placenta praevia or accreta were at highest risk of complications.
  • Neonates of mothers having MRCS were significantly more likely to be born prior to 37 weeks of gestation (OR, 6.15; 95% CI, 2.56-15.78) and therefore had higher rates of complications and admissions.
  • This study shows that MRCS is associated with greater maternal and neonatal morbidity than fewer caesarean sections. Importantly, the associated maternal morbidity is largely secondary to placenta praevia and accreta; in women undergoing MRCS who do not have these conditions, risks are lower.


Journal Articles