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The safety of multiple cesarean deliveries (more commonly known as C-sections) is something doctors and prospective parents weigh heavily as they make decisions about future childbirths.

While not as common as vaginal births, the numbers of C-sections performed each year in the United States might surprise you. The Centers for Disease Control and Prevention reported that 31.9 percent of births were via cesarean delivery in 2018.

If you fall under that statistic, you might be wondering how safe it is to have more than one C-section.

Each pregnancy is different, so it’s difficult to give a standard answer about the number of C-sections you can have safely. And of course, there are some circumstances where having multiple C-sections is medically necessary.

But if there’s a chance you may have more than one cesarean delivery, here’s what you need to know about the safety, risks, and other options available.

No, you don’t have to have a C-section with future pregnancies, as long as your previous cesarean delivery was a low transverse (roughly horizontal) incision on the uterus, says Robert O. Atlas, MD, FACOG, chairperson of the department of obstetrics and gynecology at Mercy Medical Center.

You might be wondering why the location of your incision matters. According to the American College of Obstetricians and Gynecologists (ACOG), the type of uterine incision you had in a previous C-section can determine future births because some uterine scars are more likely to cause a rupture during a vaginal birth after cesarean delivery (VBAC).

A low vertical and high vertical incision both carry a higher risk of rupture compared to a low transverse incision of the uterus.

The ACOG says people with a history of a C-section have two options for future births: scheduled cesarean delivery or VBAC. If your previous C-section was a low transverse incision, your doctor might talk to you about a trial of labor after cesarean delivery (TOLAC), which is the attempt to have a VBAC.

“TOLAC will work more often than not,” says Atlas. The answer, he says, depends on why the first C-section was performed.

“For example, a person undergoing a C-section for breech presentation has an 80 percent chance of success versus a person who got to fully dilated, pushed for 3 hours, and then had a C-section — their chance of success is less than 33 percent,” he says.

So a VBAC isn’t always possible, and yes, sometimes subsequent pregnancies do have to be cesarean deliveries as well. And that possibility is what leads to the question of how many C-sections are considered safe.

When it comes to the number of C-sections you can have safely, Atlas says there’s no real answer for this question.

“There are some people who have had six or seven C-sections without any issues, and others with only one C-section whose next pregnancy is associated with a very difficult problem such as placenta accreta spectrum disorder, or a horrible adhesions (things stuck together),” he says.

But to quantify things somewhat, the Mayo Clinic says TOLAC isn’t recommended after three or more prior C-sections.

According to Atlas, certain complications may occur with repeat cesareans. These include:

  • uterine rupture
  • bladder complications
  • bowel adhesions or lacerations
  • omentum adhesions
  • blood vessel complications
  • excessive bleeding
  • need for blood transfusions
  • hysterectomy

There are also risks to the placenta that increase with multiple C-sections. These include placenta accreta, placenta previa, and placental abruption.

Although death is a risk associated with any surgical procedure, a 2017 study found no remarkable difference in very serious complications associated with repeat C-sections (more than three) when compared to C-sections in general. The most common complication — which was significantly more prominent in those with multiple C-sections — was adhesions.

The length of time you should wait to get pregnant again after a C-section will depend on several factors.

That said, the U.S. Department of Health and Human Services recommends waiting at least 12 months for any type of delivery, and this is the minimum. Any sooner than 1 year and you increase the chance that your new baby will be born too soon.

You may need an even longer period between delivery and the next pregnancy. To give your body adequate time to recover, your doctor may say 18 months is the minimum. But there is no hard number or consensus among doctors.

And a 2018 study found people of all ages have an increased risk for poor pregnancy outcomes with shorter time periods between pregnancies. These shorter time periods were defined as 6 months compared to 18 months. Based on their findings, the researchers suggest a range of 12 to 24 months, with 18 months being the ideal time.

Hopefully, you feel comfortable talking with your doctor about any issues regarding your pregnancy. But even if your exchange has been brief, consider devoting a significant amount of time to discussing cesarean sections, especially if there may be a repeat C-section.

One of the first things you’ll want to bring up if it’s your first pregnancy is your desired family size, because this could influence the decision about cesarean if it’s not medically necessary.

Also, if this isn’t your first pregnancy and you’re interested in a VBAC, it’s important to find out if your doctor is comfortable performing one or if they recommend another C-section. Depending on their answer, you may need to find a doctor who is comfortable with VBACs.

Additionally, consider asking the following questions before you make a decision:

  • Why are you recommending a scheduled C-section (if they’re recommending one)?
  • What percent of the deliveries at the hospital are C-sections?
  • What percent of your deliveries are C-section?
  • What resources does your hospital have in place to address complications?
  • What additional personnel are available to help if the surgery is difficult?
  • Does the hospital have a NICU?
  • What should I expect during and after my C-section?
  • What are the risks to my baby?
  • Is the recovery time different with repeat C-sections?
  • Where will my incision be?

Delivering a baby via cesarean section is generally considered safe, and in some instances is medically necessary and safer than a vaginal birth. But many people do worry about the risks that come with repeat C-sections.

Although each person and each pregnancy is different, your doctor will be able to discuss general risks and safety concerns with you if you’re considering or need to have more than one C-section.

If you’re interested in vaginal delivery after cesarean delivery, make sure to bring this up with your doctor. Although there are risks with this option, your doctor may consider trying a trial of labor after cesarean delivery if you’re a good candidate.