Maternal and Neonatal Morbidity and Mortality Among Multiple Repeat Caesarean Deliveries

Background: Cesarean delivery rates have increased substantially worldwide, raising concerns regarding the maternal and neonatal risks associated with multiple repeat procedures. This study aimed to quantify the maternal and neonatal morbidity associated with multiple repeat cesarean deliveries (CDs). Methods: In this retrospective cohort study, we included women with 2 or more prior CDs who gave birth at ≥20 weeks’ gestation at King Saud University Medical City between January 2016 and December 2019. Participants were categorized by number of prior cesareans: 2 (n = 967), 3 (n = 708), 4 (n = 297), or 5 or more (n = 129). Maternal and neonatal outcomes were compared across these groups. Adjusted odds ratios (AORs) were calculated using multivariable logistic regression, with 2 prior cesareans as the reference. Results: Among 2101 women with multiple repeat cesareans, a dose-response relationship was observed between the number of prior surgeries and maternal morbidity. For maternal outcomes, the AORs of unplanned hysterectomy increased from 11.1 (95% confidence interval CI: 1.0–123.7) for 3 prior cesareans to 102.7 (95% CI: 15.0–400.0) for 5 or more (p-trend < 0.001). Significant graded increases were also observed for postpartum hemorrhage (PPH; p-trend = 0.02) and placenta previa/accreta. Neonatal morbidity followed a similar pattern. In women with 5 or more prior cesareans, the AORs were 2.0 (95% CI: 1.1–3.5) for a low Apgar score at 5 minutes and 2.2 (95% CI: 1.4–3.2) for neonatal intensive care unit (NICU) admission compared with the reference group (p-trend ≤ 0.003). Conclusions: The findings demonstrate that multiple repeat CDs are associated with a progressive increase in maternal and neonatal morbidity, with a significant escalation in risk observed following the third procedure. These findings highlight the importance of individualized risk counseling and delivery planning for women with multiple prior cesareans.