Quick Answer
For most women having a third C-section, the surgeon will typically make the incision in the same location as the previous C-section scars. However, in some cases the doctor may make the incision in a slightly different spot if the old scar is too thick or Fibromatous. The goal is to cut through an area with the thinnest scar tissue for the safest entry point to the uterus.
Explaining the C-Section Procedure
A C-section, also known as a cesarean section, is a surgical procedure used to deliver a baby through incisions in the abdomen and uterus. It is usually done when a vaginal delivery would put the baby or mother at risk.
During a C-section, the mother is given anesthesia to prevent her from feeling pain during the surgery. Once the anesthetic has taken effect, the doctor makes an incision through the skin and fatty tissue of the lower abdomen, usually along or just above the pubic hairline. The abdominal muscles are separated to reach the uterus.
An incision is then made in the uterus, either vertically or horizontally. The amniotic sac is opened, and the baby is carefully extracted. The umbilical cord is cut, and the placenta removed. The incisions are closed with sutures or staples.
A thin plastic sheet may be placed over the abdominal incision to reduce scarring. The procedure typically takes around 45 minutes to an hour.
Location of the Incision
For a first-time C-section, the incision is typically made horizontally across the lower abdomen, about an inch or two above the pubic bone. This is known as a “bikini cut” because it can usually be hidden by the underwear line.
If a woman has a second C-section, the incision is often made vertically, from the belly button down to the pubic bone. This is called a “classical incision.” It provides more exposure and heals well.
For a third or fourth C-section, the doctor will generally attempt to make the uterine incision through the old scar line, whether horizontal or vertical. This requires cutting through dense scar tissue which takes more time and skill.
There are several benefits to re-using the prior incision site:
- Less bleeding because blood vessels have been cauterized
- Thinner scar tissue which is easier and safer to cut through
- No need to detach the bladder which may have adhered to the old scar
- Less risk of damaging other organs
However, in some cases, the surgeon may opt to make a completely new incision for a third or fourth C-section. Reasons include:
- The old scar is too thick or fibrotic to safely re-open
- The prior incision was made too low and there is no room to extend it
- There is concern about weakened scar tissue rupturing during labor
- The patient requests a different site to improve cosmetic outcome
If a new site is used, the doctor will pick the thinnest and least vascular area of the lower abdomen. This allows quick entry into the uterus with minimal bleeding.
Risks of Multiple C-Sections
While making the incision through an old scar has advantages, women undergoing multiple cesareans are at increased risk for:
- Scar tissue build up on internal organs (adhesions)
- Excessive bleeding from placental attachment issues
- Damage to the bladder, ureters, bowel or uterus
- Abnormal placenta location in future pregnancies
The more C-sections a woman has, the greater the risks. Studies show that maternal morbidity is lowest with one or two cesareans, but increases substantially after three or more surgeries.
Recovery After Multiple C-Sections
Recovering from major abdominal surgery takes time. Women having their third C-section usually stay in the hospital for 3-4 days on average. The incision is often more painful because of the dense scar tissue. Strong pain medication is typically needed.
Full recovery takes about 6-8 weeks. Early challenges include:
- Incision pain and tenderness
- Fatigue
- Difficulty standing straight
- Limitations on lifting, exercise, driving
- Recovering bladder and bowel function
- Managing lochia bleeding
The more C-sections a woman has undergone, the longer the recovery. Having help at home is important, especially if there are older children to care for. Many women benefit from having a friend or family member stay with them for the first 1-2 weeks postpartum.
Conclusion
For women undergoing a third or fourth cesarean delivery, the surgeon will usually make every effort to cut through the old C-section scar when performing the uterine incision. This reduces risks and improves healing compared to creating a new larger wound. However, if the prior scar is too thick or fibrous, a new incision site may be needed. While re-opening an old scar is preferable, multiple repeat C-sections increase the risks of complications like bleeding, infections and problems with future pregnancies. Women considering a vaginal birth after cesarean (VBAC) should discuss options with their provider.