Introduction:

The total hospital stay averaged 4.8 days. Most women (42.6%) stayed 4–5 days; 4.6% stayed 8–10 days, and 1.8% stayed more than 10 days.

How the babies fared

The average birth weight was 3,150 g. One in five babies (21%) weighed more than 3,500 g. The average Apgar score at 1 minute was 8.2, and at 5 minutes it was 9.4 – 84.2% of babies scored 9 or above at 5 minutes.

Sadly, there were 14 stillbirths (2.8%). Perinatal complications (breathing trouble, low blood sugar, infection) occurred in 10.4% of newborns, and 12.6% needed admission to the neonatal unit. Breastfeeding was started by 84.2% of mothers.

Does the number of previous caesareans matter?

First look (univariate analysis)

The number of previous caesareans was clearly linked to pelvic adhesions (p = 0.02), uterine scar problems (p = 0.01), bladder or bowel injuries (p = 0.04), and a longer hospital stay (p = 0.02). We did not find a significant link with heavy bleeding during surgery (p = 0.97), hysterectomy (p = 0.27), infections (p = 0.54), or blood transfusion (p = 0.31). Also, emergency caesarean was linked to uterine scar problems (p = 0.035), and higher parity was linked to hysterectomy (p = 0.047).

After adjusting for other factors (multivariate logistic regression)

After adjusting for potential confounders (age, BMI, smoking, medical/surgical history, parity, interpregnancy interval, pregnancy pathologies, gestational age, and emergency caesarean section), the number of previous caesarean sections remained a very strong independent predictor of several major complications. Specifically, each additional previous caesarean section increased the odds of pelvic adhesions by more than sixfold (OR = 6.01, 95% CI: 3.2–11.3, p < 0.001), the odds of uterine dehiscence or rupture by more than fourfold (OR = 4.19, 95% CI: 2.1–8.4, p < 0.001), the odds of bladder or bowel injuries by more than sixfold (OR = 6.55, 95% CI: 2.5–17.2, p < 0.001), and the odds of a prolonged hospital stay (>7 days) by more than two-and-a-half-fold (OR = 2.68, 95% CI: 1.5–4.8, p < 0.001). Emergency caesarean section was also independently associated with uterine dehiscence or rupture (OR = 2.08, 95% CI: 1.1–3.9, p = 0.02). For haemostatic hysterectomy, the independent predictors were pregnancy pathologies (OR = 3.42, 95% CI: 1.2–9.7, p = 0.02) and parity (OR = 1.76 per unit increase, 95% CI: 1.1–2.9, p = 0.03), but not the number of previous caesarean sections. No variable, including the number of previous caesarean sections, was significantly associated with perioperative haemorrhage, postoperative infections, or blood transfusion after adjustment.

Discussion

What we found

Our study from a regional Tunisian maternity hospital shows that women with a scarred uterus face a high risk of complications when they have another caesarean section. And the more previous caesareans they have had, the higher the risk—especially for adhesions, rupture of the scar, and injuries to the bladder or bowel. These findings are in line with international data, but they come from a country where the caesarean rate is far above what the WHO recommends [1,2].

How our results compare with other studies

Pelvic adhesions – We found adhesions in 26.8% of women, and each additional caesarean multiplied the risk by six (OR = 6.01). Tulandi and colleagues reported that the risk of significant adhesions rises from 20% after one caesarean to 40–50% after two or three [3]. Our rate is a bit lower, probably because we missed some mild adhesions in our retrospective records, but the strong link with the number of caesareans is the same.

Uterine rupture – The old scar opened up (dehiscence or complete rupture) in 11.4% of our women. Landon et al. estimated the risk at 0.5–1% after one caesarean and 2–3% after three [4]. Why is our rate so much higher? Because a large proportion of our patients (17.2%) had three or more previous caesareans, and 14.6% had very short gaps between pregnancies (less than 12 months). Bujold et al. showed that an interval of less than 18 months quadruples the rupture risk [5]. In Tunisia, Ben Temime and colleagues reported a rupture rate of 1.2% [6]—similar to our complete rupture rate (1.2%)—but their population was less heavily scarred.

Bladder and bowel injuries – These are rare but serious: bladder injury in 2.2%, bowel injury in 1.0%. The very strong link with the number of caesareans (OR = 6.55) makes sense: adhesions make dissection like walking through a minefield. Silver et al. found bladder injuries in 1.5% after three caesareans [7], close to our figure.

Bleeding and hysterectomy – Unlike some studies [7,8], we did not find a significant link between the number of previous caesareans and heavy bleeding during surgery or the need for hysterectomy. One reason is that we had only 18 hysterectomies—too few to show a clear statistical relationship. Also, bleeding is driven more by placenta accreta (which we saw in 6% of women) than by the number of scars alone. In our multivariate analysis, the real predictors of hysterectomy were pregnancy complications (OR = 3.42) and parity (OR = 1.76).

Infections and transfusion – One in seven women (15%) developed an infection, and 14.8% needed a blood transfusion. These rates did not rise with more caesareans. That may be because of effective routine antibiotic prophylaxis [9] and good blood management protocols. Blood products were available for 92.8% of women, with an average waiting time of 18.4 minutes.

Short interpregnancy interval – We confirmed that a gap of less than 12 months is a major danger, especially for uterine dehiscence (12.3% vs 9.0% overall). Stamilio et al. recommend waiting at least 18–24 months after a caesarean before trying for another baby [8]—advice that we strongly support.

Strengths and weaknesses of our study

Strengths – We had a large sample (500 women), we used a detailed multivariate analysis to sort out the effects of different factors, and we collected a wide range of information from before, during, and after the operation.

Limitations – Because this was a retrospective study, we could only use what was written in the records; some minor complications may have been missed. We did not have a comparison group of women with unscarred uteri. Our findings come from a single hospital in North East Tunisia, so they may not apply to other settings. Also, rare events like complete uterine rupture and bowel injury were too few to allow strong statistical conclusions.

What this means for everyday practice

Stop unnecessary first caesareans. Tunisia’s 44.4% caesarean rate [2] is far above the WHO’s recommended 10–15%. Every first caesarean that could have been avoided prevents a lifetime of potential scar-related problems.

Talk about family planning. Women need to know that after a caesarean, waiting at least 18–24 months before the next pregnancy greatly reduces the risk of rupture.

Extra care during pregnancy. For women with two or more previous caesareans, we should do a detailed ultrasound looking for the “sliding sign” (which tells us about adhesions) and checking the placenta’s position (praevia, accreta). If we suspect accreta, an MRI can help plan the operation.

Schedule, don’t rush. For women with three or more scars, plan the caesarean between 38 and 39 weeks. In our series, 45.2% of operations were emergencies—and emergencies are more dangerous.

Let the most experienced person operate. Adhesions and the risk of cutting into the bladder or bowel mean that a senior surgeon—or a senior resident under close supervision—should be the one doing the operation.

Be ready for bleeding. Any woman with placenta praevia or accreta should have at least four units of blood immediately available, and a large-bore IV line placed before the first cut.

Where do we go from here?

We need larger, multicentre studies that follow women forward in time (prospective) and include a control group. These would help confirm our findings and also measure the economic and psychological costs of repeat caesareans in Tunisia.

Conclusion

Caesarean sections on a scarred uterus come with a real risk of complications—adhesions, uterine rupture, injuries to nearby organs, and longer hospital stays. And the risk climbs with every additional scar. In Tunisia, where the caesarean rate now exceeds 44%, we have to act. That means avoiding caesareans that are not really needed, helping women space their pregnancies, and carefully planning the delivery for those who already have multiple scars.

What is already known on this topic

Repeat caesarean sections increase the risk of pelvic adhesions, placenta accreta, uterine rupture, and injury to nearby organs. After several caesareans, maternal morbidity can reach 15–25%.

International guidelines recommend avoiding unnecessary caesareans and carefully monitoring women with a scarred uterus.

What this study adds

This is the first large-scale study from a Tunisian regional hospital (500 women) to show exactly how much each additional scar raises the risk of specific complications. For example, the odds of pelvic adhesions multiply sixfold and the odds of bladder/bowel injuries more than sixfold per extra caesarean.

It provides local evidence that short interpregnancy intervals and high multiparity make things even worse, and it gives concrete recommendations for Tunisian maternity wards.

Competing interests

The authors declare no competing interests.

Authors' contributions

All authors contributed to the idea, data collection, analysis, writing, and final approval of the manuscript.

Acknowledgements

The authors sincerely thank the medical and nursing teams of the Department of Obstetrics and Gynecology at Mohamed Tlatli Regional Hospital in Nabeul for their assistance throughout the study. They are also grateful to all the women who participated in this research for their trust and cooperation.