Intraoperative complications of multiple caesarean sections (literature review).


  • Oleg POTACEVSCHI "Nicolae Testemitanu" State University of Medicine and Pharmacy



cesarean section, multiple cesarean sections, intraoperative complications, intraoperative difficulties


Multiple caesarean sections increase the risk of intraoperative complications: adhesions, damage to the pelvic organs (bladder, ureters, intestines), bleeding with the need for blood transfusion, abnormal placentation, hysterectomy for cae- sarean section, failure of the uterine scar, uterine rupture. The frequency of these complications increases in proportion to the number of previous caesarean sections. Although a causal relationship is often difficult to establish, some of these complications are likely related to surgically induced adhesions.

Repeated cesarean section operations are associated with more complex surgical interventions: difficulties in opening the abdominal cavity, difficult separation of the uterus, bladder and ureters from adhesions, the need for blood transfusion and surgical correction of damage to neighboring organs (bladder, ureters, intestines), the need for additional surgical intervention such as hysterectomy .

Reducing unnecessary primary caesarean sections and repeat caesarean sections, post-caesarean vaginal delivery, and careful surgical technique can significantly reduce intraoperative surgical complications.


Zwergel C., Kaisenberg C. Maternal and Fetal Risks in Higher Multiple Cesarean Deliveries. In: Recent Advances in Cesarean Delivery (ed. Georg Schmolzer). London: IntechOpen, 2020.

Mynbaev O., Babenko T., Ahmadi F., Raimondo I., Kosmas I., Mishutina A. et al. Uterine Morbidity: Cesarean Section Scar Complications. In: Hysteroscopy (eds. Andrea TinelliLuis, Alonso Pacheco, Sergio Haimovich). Springer International Publishing AG, 2018, p. 421-468.

Hesselman S. Caesarean Section. Shortand longterm maternal complications. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1358. Uppsala: Acta Universitatis Upsaliensis, 2017, 61 p.

Visconti F, Quaresima P, Rania E, Palumbo A, Micieli M, Zullo F et al. Difficult caesarean section: A literature review. Eur J Obstet Gynecol Reprod Biol. 2020; 246: 72-78.

Antoine C, Young B. Cesarean section one hundred years 1920-2020: the Good, the Bad and the Ugly. J Perinat Med. 2021; 49(1): 5-16.

Aujang ER. Complications of Cesarean Operation. In: Caesarean Section (ed. Georgios Androutsopoulos). London: IntechOpen, 2018.

Kremer TG, Ghiorzi IB, Dibi RP. Isthmocele: an overview of diagnosis and treatment. Rev Assoc Med Bras (1992). 2019; 65(5): 714-721.

Montoya-Williams D, Lemas D, Spiryda L, Patel K, Neu J, Carson T. What Are Optimal Cesarean Section Rates in the U.S. and How Do We Get There? A Review of Evidence-Based Recommendations and Interventions. J Womens Health (Larchmt). 2017; 26(12): 1285-1291.

Kandil IM, Farhan AM, Shaker MM. The Impact of Repeated Cesarean Sections on Perioperative Maternal Morbidity. Egypt J Hosp Med. 2019; 77(4): 5307-5312.

Gedikbasi A, Akyol A, Bingol B, Cakmak D, Sargin A, Uncu R et al. Multiple repeated cesarean deliveries: operative complications in the fourth and fifth surgeries in urgent and elective cases. Taiwan J Obstet Gynecol. 2010; 49(4): 425-431.

Lyell DJ. Adhesions and perioperative complications of repeat cesarean delivery. Am J Obstet Gynecol. 2011; 205(6 Suppl): S11-18.

Gohil N, Parikh R, Koli D. To study the incidence and type of surgical difficulties encountered in repeat cesarean Section in comparison with the primary cesarean sections. Int J Med Biomed Stud. (IJMBS). 2020; 4(1): 23-26.

Zia S, Rafique M. Intra-operative complications increase with successive number of cesarean sections: Myth or fact? Obstet Gynecol Sci. 2014; 57(3): 187-192.

Nadu T. A study of intra operative complications associated with repeat cesarean sections at tertiary care hospital. Madras Medical College. Chennai, 2020. 136 p.

Singh N, Sreedevi, Lavanya B. Intra-operative difficulties in repeat caesarean sectionin a tertiary care hospital. Int J Reprod Contracept Obstet Gynecol. 2021;10(7): 2596-2605.

Mishra P, Dandotiya R. Perioperative Difficulties in Previous Caesarean Section and Their On Table Management. JMSCR.2019; 7(12): 672-675.

Amale S, Bhirud A, Sarode P. Study of intraoperative complications in lower segment caesarean section at tertiary care hospital. MedPulse Int J Gynaecol. 2021; 19(1): 06-09.

Hesselman S, Högberg U, Råssjö E, Schytt E, Löfgren M, Jonsson M. Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population-based register study. BJOG. 2018; 125(5): 597-603.

Poole JH. Adhesions following cesarean delivery: a review of their occurrence, consequences and preventative management using adhesion barriers. Womens Health (Lond). 2013; 9(5): 467-477.

Mishra A, Gawade S, Chaudhari S. Perioperative complications with recurrent caesarean section. Med Pulse Int J Gynaecol. 2020; 13(2): 53-58.

Sheethal J, Sareena G. A Comparative Study on Intra Operative Problems during Primary versus Repeat Caesarean Sections. J. App. Med. Sci. 2016; 4(2A): 303-310.

Dempsey A., Diamond K., Bonney E., Myers J. Caesarean section: techniques and complications. Obstet Gynaecol Reprod Med. 2017; 27(2): 37-43.

Korniluk A, Kosiński P, Wielgoś M. Intraoperative damage to the urinary bladder during cesarean section literature review. Ginekol Pol. 2017; 88(3): 161-165.

Saaqib S, Iqbal A, Naheed M, Saeed T, Khalid M. A randomized controlled trial of cystoinflation to prevent bladder injury in the adhesive disease of multiple caesarean sections. Sci Rep. 2020; 10(1): 15297.

Bérubé L, Arial M, Gagnon G, Brassard N, Boutin A, Bujold E. Factors associated with lower uterine segment thickness near term in women with previous caesarean section. J Obstet Gynaecol Can. 2011; 33(6): 581-587.

Higgins M, Monteith C, Foley M, O’Herlihy C. Real increasing incidence of hysterectomy for placenta accreta following previous caesarean section. Eur J Obstet Gynecol Reprod Biol. 2013; 171(1): 54-56.

Silver RM, Barbour KD. Placenta accreta spectrum: accreta, increta, and percreta. Obstet Gynecol Clin North Am. 2015; 42(2): 381-402.

Shanmugham D, Jayakumar H, Ramany C, Varghese J. Intraoperative Difficulties Encountered in Women Undergoing Repeat Caesarean Section. East African Scholars J Med Sci. 2018; 1(3): 77-82.

Singh P, Singh S. A study of per operative findings in cases with previous cesarean section. Int J Clin Obstet Gynaec. 2019; 3(1): 66-68.

Ramkrishnarao MA, Popat GU, Eknath BP, Panditrao SA. Intra-operative difficulties in repeat cesarean sections – A study of 287 cases. J Obstet Gynecol India. 2008; 58(6): 507-510.

Nazaneen S, Kumari A, Malhotra J, Rahman Z, Pankaj S, Alam A et al. Study of Intraoperative Complications Associated With Repeat Cesarean Sections At A Tertiary Care Hospital in Eastern India. IOSR J Dent Med Sci. 2017; 16(8): 77-82.

Kumar V, Hinder P. Study of surgical difficulties encountered in repeat cesarean sections in comparison with the primary cesarean sections. IOSR J Dent Med Sci. 2016; 15(1): 88-91.

Sereke D, Hailemelcot H, Gebremeskel O, Andemaraim Z. Emergency Peripartum Hysterectomy In Mendefera Hospital-Case Control Study. 2021.

Rottenstreich M, Sela H, Shen O, Michaelson-Cohen R, Samueloff A, Reichman O. Prolonged operative time of repeat cesarean is a risk marker for post-operative maternal complications. BMC Pregnancy Childbirth. 2018; 18(1): 477.





Overview Article