Safia Sultana Munir, Dawood Amin, Misbah Sultana.
Safety of high order caesarean section.
Pak J Med Health Sci Jan ;5(1):55-9.

Background: Increase in caesarean section rate is global phenomena. Repeat elective Caesarean section is a major cause of this rise. Eastern culture encourages large family size. But high order caesareans (4th or above) Puts mother at higher risk of intraoperative and postoperative complications. Objectives: Our objective was investigate whether women under going high order caesaren section (4th or above) are more at risk as compare to those who under go 2nd and 3rd caesarean section. Methods: In a prospective comparative trial, the women who underwent their 4th or above caesarean section were included in study group, while control group comprised of every next woman who was to go through her 2nd or 3rd CS of same category (i.e. elective or emergency caesarean section). Fetomaternal outcomes were compared between two groups. Results: Out of 48 study women 4th caesarean section was done in 43 and 5th caesarean section was performed in 5 cases. Severe intra peritoneal adhesions were significantly higher in study group (P< 0.012). Cranial attachment of bladder and thin membranes lower segment were more frequent in study group. Incidence of placenta previa was significantly higher in cases. Four patients in study group manifested complete placenta accreta ending up into caesarean hysterectomy while none of the controls exhibited complete placenta accreta. Neonatal outcome in both groups was fairly good without any mortality. Discussion: Caesarean section rate should be decreased as most common indication of repeat caesarean section is previous caesarean section. Decision of primary caesarean section is important, trial of scar in singleton pregnancies should be encouraged, labour should be properly supervised and injudicious use of oxytocin should be discouraged. Women should be motivated to reduce family size to 2 or 3 childrens with history of repeat caesarean section and thoroughly educated about increased risk of high order caesareans. Conclusions: Our study has supported the view that maternal risks are increased in higher order CS but successful delivery is possible if women are managed in tertiary care hospital.

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