What is the current recommendation for women with three prior low‑transverse cesarean sections regarding mode of delivery and future pregnancies?

Recommendations for Women with Three Prior Cesarean Sections

Mode of Delivery for Current Pregnancy

Women with three or more prior cesarean deliveries face substantially elevated surgical risks and may not have the option for trial of labor after cesarean (TOLAC), with scheduled repeat cesarean delivery at 39-40 weeks being the standard recommendation. 1

Key Risk Profile After Three Cesareans

The cumulative surgical burden after three cesarean deliveries creates a dramatically different risk landscape:

• Placenta previa occurs in 30 per 1,000 women (3%) with three or more prior cesareans, compared to 9 per 1,000 with one cesarean 2, 1
• Placenta accreta risk ranges from 0.25-3% after multiple cesareans, with exponentially increasing risk with each additional surgery 1
• Hysterectomy risk increases to 0.5-4% after the second repeat cesarean 1
• Wound and uterine hematoma risk reaches 4-6% 1
• Red cell transfusion requirements increase to 1-4% 1

TOLAC Eligibility After Three Cesareans

The American Academy of Family Physicians explicitly states that women who have had several cesarean deliveries may not have the choice to undergo TOLAC. 2, 1 The French College of Gynecologists and Obstetricians recommends that elective repeat cesarean delivery should be planned from the outset for women with a history of three or more cesareans. 3

This recommendation reflects:

• The cumulative risk of abnormal placentation that makes emergency surgery more hazardous 2
• The increased technical difficulty of repeat surgery through multiple scar layers 1
• The limited evidence base for safety of TOLAC beyond two prior cesareans 3

Timing of Scheduled Cesarean

Schedule the repeat cesarean at 39-40 weeks gestation to minimize neonatal respiratory complications while avoiding spontaneous labor. 1 Do not perform elective cesarean before 39 weeks except for specific obstetric indications, as this significantly increases the risk of transient respiratory distress. 3

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Counseling Regarding Future Pregnancies

Each additional cesarean exponentially increases the risks of life-threatening complications, particularly abnormal placentation, and this must be discussed explicitly when counseling about future childbearing. 2, 1

Specific Risks for a Fourth Cesarean

If this patient were to have a fourth pregnancy:

• Placenta accreta risk would reach 2.17% (217 per 10,000 pregnancies) 1
• Placenta previa incidence would exceed 3% 2, 1
• Hysterectomy risk would continue to escalate beyond the already elevated 0.5-4% range 1

Critical Counseling Points

Women intending repeat cesarean delivery have progressively increasing risk of uterine rupture, abnormal placentation, hysterectomy, and surgical complications with each subsequent pregnancy. 2 This creates a compounding risk profile where:

• Each surgery makes the next surgery more technically challenging 1
• Abnormal placentation (previa, accreta, increta, percreta) becomes increasingly likely and potentially catastrophic 2
• The cumulative maternal morbidity and mortality risk increases substantially 2, 1

Permanent contraception or highly effective long-acting reversible contraception should be discussed if family planning is complete. The option for intraoperative tubal ligation at the time of the third cesarean should be offered if the patient desires no future pregnancies. 1

If Future Pregnancy Occurs

Should a fourth pregnancy occur despite counseling:

• Early ultrasound screening for placental location and attachment is mandatory 1
• Multidisciplinary planning involving maternal-fetal medicine, anesthesia, and blood bank is essential 1
• Delivery should occur at a tertiary care center with immediate access to interventional radiology and surgical subspecialists 1

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Common Pitfalls to Avoid

• Failing to explicitly discuss the exponentially increasing risks of each additional cesarean during prenatal counseling 2, 1
• Offering TOLAC to women with three or more prior cesareans without recognition that guidelines recommend against this 2, 1, 3
• Scheduling elective cesarean before 39 weeks without clear medical indication, which increases neonatal respiratory morbidity 3
• Inadequate preparation for abnormal placentation at the time of the third cesarean, given the 3% placenta previa risk and up to 3% accreta risk 1