title: Multiple cesarean section morbidity.
abstract: OBJECTIVE
  To quantify maternal risk associated with multiple cesarean sections (CSs) and determine whether the third CS defines a threshold for increased morbidity.
  
  
  METHODS
  From January 1997 to January 2002, the clinical records of 3191 women who were delivered by CS at our referral maternity center were examined for selected indicators of maternal morbidity. The women were assigned to groups based on number of CSs and the frequency of each indicator was determined. A composite score for each indicator among women grouped by number of consecutive CSs was then derived to compare risk between groups and against the third CS.
  
  
  RESULTS
  By all indicators studied, morbidity increased with successive CSs before and through the third CS. However, compared with the third, the risk of major morbidity was significantly increased with the fifth, and much worse at the sixth CS for placenta previa (odds ratio [OR]=3.8, 95% confidence interval [CI]=1.9-7.4), placenta accreta (OR=6.1, 95% CI=2.0-18.4) and hysterectomy (OR=5.9, 95% CI=1.5-24.4). But the third and fourth CSs had the same risk of major morbidity for placenta previa (OR=1.4, 95% CI=0.8-2.2), placenta accreta (OR=1.0, 95% CI=0.3-2.9) and hysterectomy (OR=0.3, 95% CI=0.0-2.7).
  
  
  CONCLUSIONS
  The third CS does not define a threshold for increased risk to the mother. Instead, overall morbidity rises continually with each successive CS. However, specifically for major morbidity from the triad of placenta previa, placenta accreta and hysterectomy during CS, the fourth CS carries the same risk as the third.
authors.affiliation: Department of Obstetrics and Gynecology, Maternity and Children's Hospital, Jeddah, Saudi Arabia. fmakoha@yahoo.com
authors.forename: F W
authors.initials: FW
authors.lastname: Makoha
authors.forename: H M
authors.initials: HM
authors.lastname: Felimban
authors.forename: M A
authors.initials: MA
authors.lastname: Fathuddien
authors.forename: F
authors.initials: F
authors.lastname: Roomi
authors.forename: T
authors.initials: T
authors.lastname: Ghabra
mesh_terms: D000328:Adult; D016063:Blood Loss, Surgical; D017604:Cesarean Section, Repeat / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000706:statistics & numerical data; D015994:Incidence; D010921:Placenta Accreta / Q000453:epidemiology / Q000601:surgery; D010923:Placenta Previa / Q000453:epidemiology / Q000601:surgery; D011247:Pregnancy; D012306:Risk; D012529:Saudi Arabia / Q000453:epidemiology; D013529:Surgical Wound Dehiscence / Q000453:epidemiology; D000267:Tissue Adhesions / Q000453:epidemiology; D001743:Urinary Bladder / Q000293:injuries; D014591:Uterine Diseases / Q000453:epidemiology; D014597:Uterine Rupture / Q000453:epidemiology