Intra-Operative Surgical Difficulties in Women with Previous Two or More Cesarean Sections: A Prospective Observational Study from A Tertiary Care Centre

Background: The global rise in cesarean section rates has resulted in an increasing number of women presenting with multiple previous cesarean deliveries. Repeat cesarean sections are associated with progressive anatomical distortion and operative challenges that may significantly increase intra-operative surgical difficulty. Understanding these difficulties is essential for surgical planning, patient counseling, and improving maternal safety. Objective: To evaluate the spectrum and frequency of intra-operative surgical difficulties encountered during cesarean delivery in women with a history of two or more previous cesarean sections. Materials and Methods: This prospective observational study was conducted at a tertiary care teaching hospital over a period of 18 months. Pregnant women with a history of two or more previous cesarean sections undergoing elective or emergency repeat cesarean delivery were included. Detailed intra-operative findings were systematically recorded, including difficulty in abdominal entry, adhesions, bladder dissection, excessive blood loss, extension of uterine incision, and duration of surgery. Data were analyzed using descriptive statistics. Results: A substantial proportion of women exhibited significant intra-operative difficulties. Dense adhesions between the anterior abdominal wall and uterus were commonly encountered, leading to difficult peritoneal entry and prolonged operative time. Bladder adhesions requiring careful dissection were frequent, increasing the technical complexity of surgery. Increased intra-operative blood loss and need for additional hemostatic measures were also observed in a notable subset of cases. The severity of surgical difficulty tended to increase with the number of previous cesarean sections. Conclusion: Women with two or more previous cesarean sections face a high burden of intra-operative surgical challenges, primarily due to adhesions and altered pelvic anatomy. Anticipation of these difficulties, availability of experienced surgeons, and appropriate pre-operative preparation are crucial to minimize operative risks and ensure maternal safety.