• Prabha Sivaraman

Monica's Question-Can I conceive after three Caesarean Sections?

Updated: Jun 3, 2019

Monica has requested an answer to this question through our Facebook page messenger. I thought this is a good time to talk about pregnancy after caesarean sections. I have also included answers to questions from women in a similar situation, in the hope it will be useful to many of us.

Caesarean sections are the most common major surgical procedure performed worldwide. Majority of these operations are performed in the interest of the baby or the mother, due to a medical need. Indeed, Caesarean Sections have certainly saved many lives, both babies and mothers. A small minority of these operations are performed for maternal choice, after careful consideration of risks and benefits in the individual circumstances.

Caesarean Section
Caesarean Birth

What happens during a caesarean section?

If you have had a caesarean section yourself, you will see the scar on your skin. In almost all cases, this is about 10-12 centimetres long running across your lower abdomen, just above the hairline. Occasionally, there could be a scar running below your belly-button, in the midline. You will notice that the skin often feels slightly numb around the scar. This is normal with the loss of sensation and scarring that happens after an operation.

Similar to the scar on your skin, there is scarring in the tissue underneath, which is not visible externally. This is from the procedure of opening your abdomen and womb to deliver your baby. We also identify and reflect the bladder out of the way before opening the womb. Over time, healing occurs. But a scar is an area of weakness. The skin and tissue under the skin have varying degrees of strength regained over time.

Any future pregnancy causes the maximum strain on the muscle wall of the womb(uterus) itself which, like in any pregnancy, balloons from the size of a large lemon to the size required to hold a full-grown baby.

How many caesarean sections can I have?

There is no specific number. There is no reason why you can’t have as many children as you desire. Except in circumstances where your surgeon specifically warns you not to, after a caesarean section (usually you will be told why you need to avoid future pregnancy), there is no specific contraindication to future pregnancy.

What are the risks of a pregnancy after a caesarean section?

This is where careful consideration is necessary. Each one of us heals differently and repeated scars mean more weakness in the muscle wall of the womb.

Consider for yourself if the healing after your caesarean section had been straightforward. This would be more encouraging. If on the other hand, you recall having a prolonged period of recovery, wound infection, blood loss etc, there is a higher risk of problems with future pregnancy. Rarer but more serious complications include problems with the after birth such as placenta praevia.

We talk often of the risk of uterine rupture during labour after a previous caesarean section. While this is a grave risk for the baby and there is significant risk to the mother if this were to happen, fortunately this is a rare occurrence. This is even more rare if the labour was spontaneous and natural, rather than induced. It is to guard against this risk that any labour after a caesarean section is watched closely for progress.

What is the more common scenario is a planned caesarean section after a previous caesarean. Women often choose to have the more controlled situation of an elective section rather than risk an emergency section in labour. This is, in most cases, a very reasonable choice.

Here, the risks are more to do with the problems of previous surgery causing adhesions and scarring internally. There is a higher risk of injury to the bladder or adjacent organs, bleeding or wound infection compared to the first caesarean section.

Most women gain weight after childbirth and if you are a BMI over 30, your risk of complications is significantly higher. The higher your BMI, the higher the risk. Lifestyle choices such as smoking also alter wound healing abilities.

How can I reduce my risks when planning a pregnancy after a caesarean section?

Lifestyle alterations to achieve a healthy weight, stopping smoking and a balanced diet can all help reduce risk during surgery. This will also improve your pregnancy outcome. The positive actions to reduce risk are- lose weight, stop smoking, stay active, eat well.

What are the advantages/disadvantages of sterilization at the time of caesarean section?

This is another dilemma that women face, more often at the time of a third caesarean section. Sterilization is a very effective method of contraception, non-hormonal, irreversible. Performed at the time of caesarean section, there is no additional surgical risk (unlike if done as a separate procedure, laparoscopically). Studies quote a slightly higher failure rate possibly due to the nature of tissues with pregnancy related changes. If you are certain your family is complete, this could be risk well worth taking, as there is no contraceptive method that has no failure rate. Contraception should always be a carefully considered choice. There are several options available.

Monica Agartha

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