A worldwide increase in CS rate has resulted in a decrease in the proportion of women achieving spontaneous vaginal delivery [
7]. A considerable obstetric hazard of MRCS is previous uterine scar rupture with consequent increase in both maternal and fetal morbidity and mortality. In the present study, incidence of scar dehiscence was found successively increased with increasing number of CS. Although this difference was statistically significant only between group 2 (CS=4) and group 3 (CS≥5) (
Table 2). This finding is in agreement with others [
4,
8] but out of line with some researchers who reported no increase in incidence of uterine scar rupture with increasing number of CS [
1,
2,
9]. Our results are expected and clear but opponents explained their own results unexpected due to unclear reasons [
1,
9]. All cases with the finding of thinning of lower segment of uterus were also from emergency CS group (
Table 3). This establishes the importance of proper counselling and planning of elective CS before starting labour. Different studies showed variable rates of adhesion formation and their consequences. We found that severe adhesions formation increased significantly with successive number of CS, (27%, 49%, and 53% in group 1, 2, and 3, respectively) (
Table 2). It is in line with others [
1,
2,
9,
10]. This is not unexpected because repeated surgeries are associated with subsequent adhesion formation [
5,
11]. Furthermore, it has been described that presence of severe adhesions can adversely affect the course of subsequent abdominal surgery by increasing the time of operation, the need for blood transfusion and the injury to the surrounding structures including bowel and ureters. In the current study, no significant difference was observed in these parameters, in relation to number of CS. Reason may be that MRCS were done by the consultant or experienced specialists only. High attachment of the bladder on abdominal wall has been described frequently in the women with high number of CS and should be taken into consideration while opening the peritoneum. Alternatively, a midline incision should be considered in cases of severe adhesions. This study showed that the rate of midline incision to open the abdominal cavity, significantly increased with successive number of CS (4%, 40%, and 60% in group 1, 2, and 3, respectively) (
Table 1). No bowel injury was observed in this study. Others have also reported a relatively low incidence of bowel injury during repeat CS as utero-intestinal adhesions are less common [
9,
12]. Due to pelvic adhesions, incidence of bladder injury was found to increase with successive number of CS (0.6%, 0.7%, and 5.5% in women of group 1, 2, and 3, respectively) (
Table 2). In general, careful and meticulous entry into peritoneal cavity is the key in reducing injury to the surrounding organs. No significant correlation was observed regarding minor morbidities such as urinary tract infection and chest infection in various groups. In keeping with others [
4,
8,
13,
14] the incidence of post operative hernia and wound infection was found significantly increased with the number of CS (
Table 2). In accordance with other reports [
1,
14] no significant difference was observed in the neonatal Apgar score, neonatal intensive care unit admission and perinatal mortality rate, in high versus low order repeat CS. In contrast Seidman et al. [
15] described significant association between low Apgar scores and high number of previous CS. We found significantly lower rate of emergency CS (22%) than elective ones (78%) in women of high order (4-6) MRCS. This achievement was probably due to close antenatal follow up and early scheduling for CS in women with high order MRCS. Because of awareness of risks associated with MRCS, about one half of group 2 and 2/3rd of group 3 women opted for tubal ligation despite the fact that BTL is generally not accepted by Saudi women [
1]. Unexpectedly, the incidence of severe adhesions, postpartum hemorrhage and postoperative hernia were observed significantly high in women of elective CS group (
Table 3). Cause of increased incidence of severe adhesions may be early scheduling of CS due to past difficult operative history but high incidence of postpartum hemorrhage and hernia were unexplainable in elective CS group. No significant differences were observed regarding morbidity between emergency and elective MRCS groups. This may be due to the reason that women who had emergency CS reached hospital soon, after starting labour pains or prelabour rupture of membranes. On the basis of these results, it cannot be concluded that there is no difference in morbidity of emergency and elective MRCS due to small sample size. However larger scale studies are recommended to verify these findings.
In conclusion, the incidence of scar dehiscence, adhesion formation and bladder injury increases with increasing number of CS. However, there is no remarkable difference in serious morbidity associated with emergency and elective CS cases. Although not life threatening, multiple repeat CS is associated with risks, so awareness should be extended to the women.