Early-Onset Labor in Women with Multiple Cesarean Scars Scheduled for Elective Repeat Cesarean Delivery: Incidence and Outcomes from a Retrospective Study in Ethiopia

Early-Onset Labor in Women with Multiple Cesarean Scars Scheduled for Elective Repeat Cesarean Delivery: Incidence and Outcomes from a Retrospective Study in Ethiopia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Early-Onset Labor in Women with Multiple Cesarean Scars Scheduled for Elective Repeat Cesarean Delivery: Incidence and Outcomes from a Retrospective Study in Ethiopia Malede Birara This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8244294/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background: Early-onset labor among women with multiple cesarean scars poses unique maternal and neonatal risks, particularly in resource-limited settings. Despite growing numbers of women with repeat cesarean sections (RCS) in Ethiopia, evidence on outcomes in this high-risk group remains limited. Methods: We conducted a descriptive, retrospective study at Saint Paul’s Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia, from January 2023 to December 2024. All women with ≥2 prior cesarean deliveries who underwent scheduled RCS were included, excluding cases converted to emergency cesarean for non-labor-related indications. Early-onset labor was defined as spontaneous labor or rupture of membranes before 39 weeks’ gestation. Data were analyzed using descriptive statistics. Results: Of 460 women with ≥2 prior cesarean scars, 86 (19.0%) experienced early-onset labor, including 8.6% who delivered preterm (<37 weeks). The mean maternal age was 32 years; 96.5% resided in Addis Ababa. Most women had two prior cesareans (65.1%). Surgical complications included scar dehiscence (10.4%), endometritis (10.4%), wound infection (4.6%), and urologic injury (17.5%). NICU admission occurred in 12.8% of neonates, with neonatal mortality at 25%. Preterm birth strongly correlated with neonatal morbidity and mortality. Conclusion: The study showed that one in five women with multiple cesarean scars scheduled for elective CS at 39 weeks experienced early-onset labor requiring emergency RCS before 39 weeks, resulting in significant maternal and neonatal complications. spontaneous preterm labor is also common. These findings support consideration of scheduling elective RCS before 39 weeks in this population. Pregnant women with multiple scar may benefit from Preventive interventions such as cervical length screening for preterm labor. multiple CS scar early onset labor SPHMMC adverse outcomes Introduction The rising global prevalence of cesarean delivery has led to a growing population of women presenting with multiple cesarean scars in subsequent pregnancies. These women face heightened risks of uterine rupture, abnormal placentation, surgical complications, and adverse perinatal outcomes (1,2). Optimal timing of repeat cesarean section (RCS) remains a clinical challenge, balancing the maternal risks of early-onset labor against the neonatal risks of iatrogenic prematurity (3). In high-income countries, evidence suggests that 12–15% of women with ≥2 cesarean scars enter spontaneous labor before 39 weeks, and 5–8% deliver preterm (<37 weeks) (4,5). Early-onset labor in such populations is associated with increased emergency cesarean rates, greater intraoperative morbidity, and adverse neonatal outcomes (6,7). To mitigate these risks, many guidelines recommend scheduling RCS between 38+0 and 39+0 weeks, though debate persists regarding earlier intervention in women with multiple scars (8,9). In Ethiopia, cesarean delivery rates have increased over the past two decades, particularly in urban centers (10,11). Saint Paul’s Hospital Millennium Medical College (SPHMMC) serves as a national referral and training center for high-risk obstetrics, managing a large proportion of women with multiple cesarean scars. However, data on early-onset labor and outcomes in this population remain sparse, limiting evidence-based guidance for clinical practice. This study aimed to describe the incidence and outcomes of early-onset labor among women with multiple cesarean scars undergoing RCS at SPHMMC. By characterizing maternal and neonatal outcomes, we seek to inform timing of delivery and identify opportunities for preventive strategies in high-risk obstetric care. Methods We conducted a descriptive, retrospective chart review at Saint Paul’s Hospital Millennium Medical College (SPHMMC), a tertiary referral center and designated center of excellence for high-risk obstetrics in Addis Ababa, Ethiopia. The hospital is one of the largest in the country, with an annual delivery load of approximately 10,000 births. The hospital is also a center of excellence for the delivery of women with multiple previous cesarean scars. According to the hospital’s protocol, women with previous cesarean scars are scheduled for elective delivery at 39 completed weeks of gestation, regardless of the number of scars. The study period spanned two years, from January 1, 2023, through December 31, 2024. All women with two or more prior cesarean deliveries who underwent scheduled repeat cesarean section (RCS) during this interval were eligible for inclusion. We excluded those whose scheduled deliveries were converted to emergency cesarean section for obstetric or medical indications other than spontaneous onset of labor or rupture of membranes prior to 39 weeks’ gestation. Using the hospital’s electronic and paper medical record systems, we identified 460 eligible cases and abstracted demographic, obstetric, surgical, and neonatal data onto a standardized data collection form. Demographic variables included maternal age, residence, and parity. Obstetric variables included gestational age at delivery, number of previous cesarean scars, and timing of labor onset or membrane rupture. Early-onset labor was defined as spontaneous labor or premature rupture of membranes (PROM) occurring before 39 0/7 weeks’ gestation. Preterm delivery was defined as birth before 37 0/7 weeks. Surgical outcomes recorded included indication for emergency RCS, duration of surgery, estimated blood loss, transfusion requirements, and intra- and postoperative complications (scar dehiscence, endometritis, wound infection, ). Maternal outcomes included ICU or high-dependency unit admission, need for mechanical ventilation, length of hospital stay, and maternal mortality. Neonatal outcomes included birth weight, 5-minute APGAR score, NICU admission, respiratory distress syndrome, early neonatal sepsis, and neonatal death. Data abstraction was performed by two trained research assistants under the supervision of the principal investigator. Discrepancies were resolved by consensus or by consulting the original charts. Data were collected electronically using the Kobo data collection toolbox and exported to SPSS version 25 for analysis. We generated descriptive statistics, reporting means and standard deviations or medians and interquartile ranges for continuous variables, and frequencies and percentages for categorical variables. Incidence of early-onset labor and its subcategory of preterm delivery were calculated as proportions of the total RCS cohort. Ethical approval for the study was obtained from the SPHMMC Institutional Review Board, and all data were de-identified to protect patient confidentiality. Results Over the two-year period from 2023 to 2024, a total of 460 women with two or more previous cesarean deliveries underwent repeat cesarean section at SPHMMC. Among these, 86 women (19.0 percent) experienced spontaneous onset of labor or rupture of membranes prior to 39 weeks’ gestation and therefore required emergency delivery. Notably, 40 of these 86 women—equivalent to 8.6 percent of the entire cohort delivered preterm before 37 weeks’ gestation. The mean maternal age of the 86 women presenting in early labor was 32 years. Of these, 82.6 percent (n = 71) were younger than 35 years, while 17.4 percent (n = 15) were aged 35 years or older. Nearly all participants (96.5 percent, n = 83) resided in Addis Ababa, with only three women coming from rural areas. Regarding obstetric history, two prior cesarean scars were most common (65.1 percent, n = 56), while 34.9 percent (n = 30) had three or more previous cesarean deliveries. (see Table 1) Spontaneous labor was the indication for emergency cesarean section in 70.9 percent of cases (n = 61), with the remaining cases presenting with pre-labor rupture of membranes. Although these women all presented before 39 weeks, the majority of deliveries clustered between 37 and 38 weeks’ gestation: 38.4 percent (n = 33) delivered at 38 weeks and 15.1 percent (n = 13) at 37 weeks, while the remaining 46.5 percent (n = 40) delivered before 37 weeks. (see Table 1) Despite the high-risk nature of these cases, only 2.3 percent (n = 2) required blood transfusion, with a median postoperative hemoglobin of 9.6 g/dL. Surgical complications included uterine scar dehiscence (10.4 percent, n = 9), endometritis (10.4 percent, n = 9), and wound infection (4.6 percent, n = 4). Postoperative anemia, defined as hemoglobin <10 g/dL, was observed in 20 percent (n = 17). (see Table 2) In this study, overall NICU admission was 12.8 percent. Neonatal outcomes included a 5-minute APGAR score less than 7 in 7 percent of cases. Low birth weight (<2.5 kg) occurred in 10.5 percent of neonates. Respiratory distress syndrome and early neonatal sepsis were documented in 7 percent and 5.8 percent of neonates, respectively. There were no maternal or perinatal deaths in this cohort. ( see table 2) Table 1: Demographic and Obstetric Factors emergency RCS for pregnant mothers with multiple scar (N = 86) Factors n (%) / Mean (Range) Maternal Age < 35 years 71(17%) ≥ 35 years 15(83%) Address Addis Ababa (AA) 83(96%) Regions 3(4%) Timing of repeat Cesearean section S N=460 elective 374 (81) Emergency 86 (19) Indications for emergency CS labour 61(71) PROM 25(19%) Number of Previous CS 2 56(65%) >2 30 (35%) Preterm labour rate 8.6 Percent GA at delivery (n = 86) 38 weeks 33 (38%) 37 weeks 13 (15%) < 37 40( 46 %) Table 2: Maternal and neonatal outcomes (N = 86) Factors n (%) / Mean / Median (Range) Number of patients required Blood transfusion 2 (2.3 %) Post op hemoglobin ,Median ,IQ-IQ2 9.6 (5 -14)gm/dl Scar Dehisence 9 (10.4) Endometritis 9( 10.4) Wound infection 4 (4.6) APGAR score less than 7 6( 7%) Early neonatal sepsis 5(5.8%) LBW <2.5 kg 9 (10.5%) RDS 6(7%) NICU admission 11 (12.8%) Discussion In this two-year prospective cohort of 460 women with two or more previous cesarean sections at SPHMMC, nearly one in five (19.0%) presented with spontaneous labor or rupture of membranes before 39 weeks’ gestation, requiring emergency delivery. This proportion is substantially higher than rates reported in several international datasets. For example, multicenter WHO surveys and other studies involving predominantly low-risk women with prior cesarean delivery documented spontaneous labor before 39 weeks in approximately 8–10%, with the risk increasing among those with two or more scars (4,5). Although reported figures vary, the overall incidence of unplanned or urgent cesarean delivery ranges from 13–16% when elective delivery is scheduled at 38 weeks and 23–51% when planned for 39 weeks—rates that parallel our findings (6). A recent study by Clement Morabu et al. reported a 62% rate of emergency cesarean delivery following early-onset labor among women scheduled for elective cesarean at 39 weeks (15). These data highlight that a considerable proportion of women with prior cesarean scars, particularly those with multiple scars, enter spontaneous labor before 39 weeks. Established predictors of early labor, including previous preterm birth and the presence of multiple uterine scars, significantly increase the likelihood of spontaneous labor before the scheduled surgical date. Some studies report up to a fourfold increase in emergency cesarean delivery among these high-risk groups (6). The consequences of emergency surgery in women with multiple scars are clinically significant. Consistent with reports such as that by Mohamed et al., which demonstrated approximately 16% maternal morbidity, our study found a comparable overall adverse maternal outcome rate of 16% (7). The most common complications included scar dehiscence, postpartum fever, endometritis, postpartum hemorrhage, perinatal complications, and increased use of general anesthesia (6,16). The lower rate of scar dehiscence (10%) and the absence of maternal and perinatal mortality in our study compared with findings from Tanzania may reflect differences in access to timely care; nearly 90% of our participants were from Addis Ababa, where rapid hospital arrival is feasible, unlike many rural settings (15). The optimal timing of elective cesarean delivery in women with multiple uterine scars remains a topic of ongoing debate. While ACOG and NICE recommend scheduling elective cesarean delivery at or beyond 39 weeks in uncomplicated pregnancies (9,10), implementation in real-world settings is challenging. Studies indicate that 20–50% of women enter labor before their scheduled 39-week delivery date, resulting in substantial emergency intrapartum cesareans. Consequently, nearly half of obstetricians continue to schedule elective procedures at 37–38 weeks due to concerns regarding spontaneous labor and associated surgical risks (6). Evidence suggests that elective delivery at 38 weeks for women with two or more scars does not substantially increase neonatal respiratory morbidity, supporting risk-based, individualized scheduling—particularly relevant in low-resource settings where timely emergency intervention may be limited (8,13). Laura Hart et al. concluded that the optimal timing for elective cesarean is 38+0 to 38+6 weeks for women with two scars and 37+0 to 37+6 weeks for those with three or more (14). In our study, the preterm birth rate was 8.6%, supporting the hypothesis that multiple previous cesarean sections significantly increase the risk of preterm labor. Other studies similarly report over a fourfold increased risk of preterm labor among women with more than two cesareans, attributed to cumulative uterine trauma, myometrial scarring, altered uterine compliance, abnormal placentation, and cervical dysfunction (17). Randomized trials have shown that second-trimester cervical length assessment and vaginal progesterone can reduce preterm birth in at-risk women. Applying these strategies to women with multiple scars may reduce spontaneous early labor and emergency surgical intervention. A case–control study by Khalefa Essam et al. identified preterm labor in 26% of women with repeated scars and demonstrated that both mid-trimester cervical length and lower uterine segment thickness are strong predictors of preterm birth; however, further prospective randomized trials are needed to refine risk stratification and targeted prevention (23). Neonatal outcomes in our cohort further demonstrate the burden associated with early labor in highly scarred pregnancies. We observed notable proportions of low Apgar scores, neonatal sepsis (5.8%), low birthweight, and respiratory distress syndrome; overall, 12.8% required NICU admission. These results are consistent with findings from Clemente et al. and others, where nearly one-third of neonates born after emergency cesarean for multiple-scar pregnancies experienced significant morbidity and early neonatal mortality of about 3% (14,18,19). A decision-analysis model by Vanessa Lee et al. also concluded that elective cesarean should be performed before the onset of labor—around 38 weeks—for optimal neonatal outcomes, supporting our results (17). Overall, our findings reinforce that women with multiple cesarean scars face a substantially elevated risk of early labor and emergency cesarean delivery, accompanied by heightened maternal and neonatal morbidity. Several studies advocate scheduling elective delivery between 37 and 38 weeks in this high-risk population to minimize spontaneous labor while avoiding excessive iatrogenic prematurity (13,21). In our cohort, nearly half of spontaneous labor cases occurred between 37 and 38 weeks, supporting consideration of revised timing policies in resource-limited settings such as Ethiopia, where emergency access varies widely. Given the rising cesarean rate in Ethiopia and increasing numbers of women with repeated scars, early scheduling for women with two or more scars warrants serious consideration (12,16,22). Conclusion Routine scheduling of elective cesarean delivery at 39 weeks for women with two or more previous cesarean sections significantly increases the incidence of spontaneous early labor and the associated maternal and neonatal risks. Individualized, risk-based scheduling at 37–38 weeks should be considered for women with multiple scars, particularly in settings where timely emergency obstetric care may be limited. Future multicenter prospective studies with comprehensive assessment of maternal and obstetric risk factors are needed to determine the safest gestational age for elective delivery and to identify the most effective surveillance strategies for this high-risk population. Abbreviations ANC Antenatal Care SPHMMC Saint Paul Hospital Mellinum Medical college CD cesarean section RCS Repeat cesarean section Declarations Acknowledgment I am grateful to SPHMMC, for allowing us to obtain access to the delivery data. We are also highly indebted to the data collectors for their incredible contributions to this study. Author contributions MF was involved in conceptualization, methodology, review, supervision, data analysis and writing of the final manuscript. Funding No funding for this study. Data availability The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Ethical approval Ethical clearance for this study was obtained from the Departmental Research and Ethics Review Committee and the Institutional Review Board (IRB) of Saint Paul’s Hospital Millennium Medical College (SPHMMC). All procedures were conducted in accordance with institutional ethical standards. To ensure confidentiality, patient identifiers were retrieved from the admission register and used solely for the purpose of locating the corresponding medical charts and electronic records from the labor ward and operating theatres. Each record was assigned a unique code number, and the data were extracted using a structured questionnaire. No personal identifiers were entered into the study database. All completed data collection tools were securely stored in locked cabinets and were accessible only to the research team. Declaration of Consent to Participate Because the study relied exclusively on retrospective chart review and did not involve interviews, contact with patients, or the collection of new data directly from individuals, obtaining informed consent from study participants was not applicable. The Institutional Review Board formally waived the need for consent based on the retrospective nature of the study. Consent for publication Not applicable. Competing interests The author declares no competing interests. References Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates. PLoS One . 2016;11(2):e0148343. Clark EA, Silver RM. Long-term maternal morbidity associated with repeat cesarean delivery. Am J Obstet Gynecol . 2011;205(6 Suppl):S2–10. Tita ATN, Landon MB, Spong CY, Lai Y, Leveno KJ, Varner MW, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med . 2009;360(2):111–20. Ganchimeg T, Togoobaatar G, et al. Optimal timing of delivery among low-risk women with prior caesarean section: a secondary analysis of the WHO multicountry survey on maternal and newborn health. PLoS One . 2016;11(2):e0149091. Roberts CL, Henderson J, Algert CS, Morris JM. Rate of spontaneous onset of labour before planned repeat caesarean section at term. BMC Pregnancy Childbirth . 2014;14:125. Ramadan MK, Melamed N, Keidar L, Peled Y, Wiznitzer A, Yogev Y. Timing of an elective repeat cesarean delivery at term: addressing the controversy. J Clin Gynecol Obstet . 2019;8(1):1–8. Melamed N, Hadar E, Keidar L, Peled Y, Wiznitzer A, Yogev Y. Timing of planned repeat cesarean delivery after two or more previous cesarean sections—risk for unplanned cesarean delivery and pregnancy outcome. J Matern Fetal Neonatal Med . 2014;27:431–8. Shinar S, et al. Timing of cesarean delivery in women with ≥2 previous cesarean deliveries. Am J Obstet Gynecol . 2022;226(1):110.e1–110.e8. ACOG Practice Bulletin No. 205. Vaginal birth after cesarean delivery. Obstet Gynecol . 2019;133(2):e110–27. Royal College of Obstetricians and Gynaecologists (RCOG). Birth after previous caesarean birth (Green-top Guideline No. 45). London: RCOG; 2015. Mekonnen ZA, Lerebo WT, Gebrehiwot TG, Abadura SA. Multilevel analysis of individual and community-level factors associated with institutional delivery in Ethiopia. BMC Res Notes . 2015;8:376. Yisma E, Smithers LG, Lynch JW, Mol BW. Cesarean section in Ethiopia: prevalence and sociodemographic characteristics. J Matern Fetal Neonatal Med . 2019;32(7):1130–5. Leybovitz-Haleluya N, et al. Timing of planned cesarean delivery among patients with two previous cesarean sections. Arch Gynecol Obstet . 2024;310(3):1483–9. Hart L, Refuerzo J, Sibai B, Blackwell S. Should the “39-week rule” apply to women with multiple prior cesarean deliveries? Am J Obstet Gynecol . 2014;210(1 Suppl):S27. Morabu C, Matovelo D, Massinde A, Kihunrwa A, Kidenya B. Factors associated with women with multiple caesarean deliveries presenting in labour and their fetomaternal outcomes in Mwanza Region, Tanzania. Tanzan J Health Res . 2022;23(2):1–4. Danieli-Gruber S, Shalev-Rosenthal Y, Matot R, Brzezinski-Sinai N, Zeevi G, Pardo A, et al. Risks of urgent cesarean delivery preceding the planned schedule: a retrospective cohort study. PLoS One . 2023;18(8):e0289655. Khan S, Bibi H, Jehangir A, Khan M, Bangash H. The number of C-sections as a risk factor for preterm labour: a case control study. Insights J Health Rehabil . 2025;3(3):272–8. Wood SL, Chen S, Ross S, Sauve R. The risk of neonatal death in relation to cesarean delivery at term: a population-based study. Am J Obstet Gynecol . 2018;219(1):88.e1–88.e9. Lau TK, Rogers MS, Sahota DS, Chang AMZ. Timing of elective cesarean delivery at term and neonatal outcomes: a population-based study. Arch Gynecol Obstet . 2019;299(3):629–35. Lee V, Dorius A, Niu B, Griffin E, Kaimal A, Caughey A. Timing of delivery in women with two prior cesareans: a decision analysis. Am J Obstet Gynecol . 2015;212(1 Suppl):S132. Mekonnen T, Bekele A, Tilahun T, Kebede B, Yismaw AE. Neonatal morbidity and mortality in public hospitals of Addis Ababa, Ethiopia: a cross-sectional study. BMC Pediatr . 2021;21:507. Debelew GT, Afework MF, Yalew AW. Determinants and causes of neonatal mortality in Ethiopia: a cohort study in Northwest Ethiopia. BMC Public Health . 2014;14:129. Khalefa E, Abdelbasset A, Hussein RS, Farghaly T, Ali MK, Mohamed AA. Cervical length and thickness of cesarean section scar are predictors for preterm labor in women with previous cesarean section. Fertil Steril . 2023;120(4):e238. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8244294","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":554388080,"identity":"b23ccd6a-d5d4-40f2-a992-eb91c15f1f60","order_by":0,"name":"Malede Birara","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYBACgwPMDQw8DAd4wLwPDAwJcBlcWiwPMCK0MM4gRos9VAuYw8xDjBaz4wcbH7ypuCNj3n724WfbNrs8fvYGxg8fGA4b49RyJrHZcM6ZZzwyZ9KNpXPbkoslew4wS85gOGyGU8uBxDZp3rbDPBIMaQxALcyJG24ksAFdeNgGlxaD8w/bf/P+A2rhf8b827KtnggtNxLbmHkbgFok0tikGdsOw7XgdJjBjYfNknOOPQNqecZm2XPueOLMnoPNkjMM0nF63+B88sEPb2ru2EvwpzHf+FFWndjP3nzww4cKa8MGXHpQACMbmGzAEysY4A/RKkfBKBgFo2AEAQDSBVxN2bMoTQAAAABJRU5ErkJggg==","orcid":"","institution":"St Paul’s Hospital Millennium Medical College Addis Ababa","correspondingAuthor":true,"prefix":"","firstName":"Malede","middleName":"","lastName":"Birara","suffix":""}],"badges":[],"createdAt":"2025-11-30 20:23:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8244294/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8244294/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97420990,"identity":"5d8693d5-6dd8-432a-86e4-09968cd02b87","added_by":"auto","created_at":"2025-12-04 08:30:13","extension":"doc","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":112640,"visible":true,"origin":"","legend":"","description":"","filename":"manuscriptonincidneceofearlyonsetlabourandoutcomesamongwomenwithprevioustwoormoreCSscarscheduledforelectivedeliveryat39weeksinEthiopia..doc","url":"https://assets-eu.researchsquare.com/files/rs-8244294/v1/574aba854e392fc76c855291.doc"},{"id":97420991,"identity":"c74d37df-f56f-4452-a459-59e2dc258996","added_by":"auto","created_at":"2025-12-04 08:30:13","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":3956,"visible":true,"origin":"","legend":"","description":"","filename":"7e842168b7ab405f88b62ecd8bcc93b3.json","url":"https://assets-eu.researchsquare.com/files/rs-8244294/v1/3ec2e740fdadb5e2d633ad94.json"},{"id":97420994,"identity":"987fb419-5e85-4ab9-b175-4a71276adbf7","added_by":"auto","created_at":"2025-12-04 08:30:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":647552,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8244294/v1/f1dbb63e-cf11-49eb-98d4-5ad96626211c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Early-Onset Labor in Women with Multiple Cesarean Scars Scheduled for Elective Repeat Cesarean Delivery: Incidence and Outcomes from a Retrospective Study in Ethiopia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe rising global prevalence of cesarean delivery has led to a growing population of women presenting with multiple cesarean scars in subsequent pregnancies. These women face heightened risks of uterine rupture, abnormal placentation, surgical complications, and adverse perinatal outcomes (1,2). Optimal timing of repeat cesarean section (RCS) remains a clinical challenge, balancing the maternal risks of early-onset labor against the neonatal risks of iatrogenic prematurity (3).\u003c/p\u003e\n\u003cp\u003eIn high-income countries, evidence suggests that 12\u0026ndash;15% of women with \u0026ge;2 cesarean scars enter spontaneous labor before 39 weeks, and 5\u0026ndash;8% deliver preterm (\u0026lt;37 weeks) (4,5). Early-onset labor in such populations is associated with increased emergency cesarean rates, greater intraoperative morbidity, and adverse neonatal outcomes (6,7). To mitigate these risks, many guidelines recommend scheduling RCS between 38+0 and 39+0 weeks, though debate persists regarding earlier intervention in women with multiple scars (8,9).\u003c/p\u003e\n\u003cp\u003eIn Ethiopia, cesarean delivery rates have increased over the past two decades, particularly in urban centers (10,11). Saint Paul\u0026rsquo;s Hospital Millennium Medical College (SPHMMC) serves as a national referral and training center for high-risk obstetrics, managing a large proportion of women with multiple cesarean scars. However, data on early-onset labor and outcomes in this population remain sparse, limiting evidence-based guidance for clinical practice.\u003c/p\u003e\n\u003cp\u003eThis study aimed to describe the incidence and outcomes of early-onset labor among women with multiple cesarean scars undergoing RCS at SPHMMC. By characterizing maternal and neonatal outcomes, we seek to inform timing of delivery and identify opportunities for preventive strategies in high-risk obstetric care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a descriptive, retrospective chart review at Saint Paul\u0026rsquo;s Hospital Millennium Medical College (SPHMMC), a tertiary referral center and designated center of excellence for high-risk obstetrics in Addis Ababa, Ethiopia. The hospital is one of the largest in the country, with an annual delivery load of approximately 10,000 births. The hospital is also a center of excellence for the delivery of women with multiple previous cesarean scars. According to the hospital\u0026rsquo;s protocol, women with previous cesarean scars are scheduled for elective delivery at 39 completed weeks of gestation, regardless of the number of scars.\u003c/p\u003e\n\u003cp\u003eThe study period spanned two years, from January 1, 2023, through December 31, 2024. All women with two or more prior cesarean deliveries who underwent scheduled repeat cesarean section (RCS) during this interval were eligible for inclusion. We excluded those whose scheduled deliveries were converted to emergency cesarean section for obstetric or medical indications other than spontaneous onset of labor or rupture of membranes prior to 39 weeks\u0026rsquo; gestation.\u003c/p\u003e\n\u003cp\u003eUsing the hospital\u0026rsquo;s electronic and paper medical record systems, we identified 460 eligible cases and abstracted demographic, obstetric, surgical, and neonatal data onto a standardized data collection form. Demographic variables included maternal age, residence, and parity. Obstetric variables included gestational age at delivery, number of previous cesarean scars, and timing of labor onset or membrane rupture. Early-onset labor was defined as spontaneous labor or premature rupture of membranes (PROM) occurring before 39 0/7 weeks\u0026rsquo; gestation. Preterm delivery was defined as birth before 37 0/7 weeks. Surgical outcomes recorded included indication for emergency RCS, duration of surgery, estimated blood loss, transfusion requirements, and intra- and postoperative complications (scar dehiscence, endometritis, wound infection, ). Maternal outcomes included ICU or high-dependency unit admission, need for mechanical ventilation, length of hospital stay, and maternal mortality. Neonatal outcomes included birth weight, 5-minute APGAR score, NICU admission, respiratory distress syndrome, early neonatal sepsis, and neonatal death.\u003c/p\u003e\n\u003cp\u003eData abstraction was performed by two trained research assistants under the supervision of the principal investigator. Discrepancies were resolved by consensus or by consulting the original charts. Data were collected electronically using the Kobo data collection toolbox and exported to SPSS version 25 for analysis. We generated descriptive statistics, reporting means and standard deviations or medians and interquartile ranges for continuous variables, and frequencies and percentages for categorical variables. Incidence of early-onset labor and its subcategory of preterm delivery were calculated as proportions of the total RCS cohort. Ethical approval for the study was obtained from the SPHMMC Institutional Review Board, and all data were de-identified to protect patient confidentiality.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOver the two-year period from 2023 to 2024, a total of 460 women with two or more previous cesarean deliveries underwent repeat cesarean section at SPHMMC. Among these, 86 women (19.0 percent) experienced spontaneous onset of labor or rupture of membranes prior to 39 weeks\u0026rsquo; gestation and therefore required emergency delivery. Notably, 40 of these 86 women\u0026mdash;equivalent to 8.6 percent of the entire cohort delivered preterm before 37 weeks\u0026rsquo; gestation.\u003c/p\u003e\n\u003cp\u003eThe mean maternal age of the 86 women presenting in early labor was 32 years. Of these, 82.6 percent (n = 71) were younger than 35 years, while 17.4 percent (n = 15) were aged 35 years or older. Nearly all participants (96.5 percent, n = 83) resided in Addis Ababa, with only three women coming from rural areas. Regarding obstetric history, two prior cesarean scars were most common (65.1 percent, n = 56), while 34.9 percent (n = 30) had three or more previous cesarean deliveries. \u003cstrong\u003e(see Table 1)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpontaneous labor was the indication for emergency cesarean section in 70.9 percent of cases (n = 61), with the remaining cases presenting with pre-labor rupture of membranes. Although these women all presented before 39 weeks, the majority of deliveries clustered between 37 and 38 weeks\u0026rsquo; gestation: 38.4 percent (n = 33) delivered at 38 weeks and 15.1 percent (n = 13) at 37 weeks, while the remaining 46.5 percent (n = 40) delivered before 37 weeks. \u003cstrong\u003e(see Table 1)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite the high-risk nature of these cases, only 2.3 percent (n = 2) required blood transfusion, with a median postoperative hemoglobin of 9.6 g/dL. Surgical complications included uterine scar dehiscence (10.4 percent, n = 9), endometritis (10.4 percent, n = 9), and wound infection (4.6 percent, n = 4). Postoperative anemia, defined as hemoglobin \u0026lt;10 g/dL, was observed in 20 percent (n = 17). \u003cstrong\u003e(see Table 2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, overall NICU admission was 12.8 percent. Neonatal outcomes included a 5-minute APGAR score less than 7 in 7 percent of cases. Low birth weight (\u0026lt;2.5 kg) occurred in 10.5 percent of neonates. Respiratory distress syndrome and early neonatal sepsis were documented in 7 percent and 5.8 percent of neonates, respectively. There were no maternal or perinatal deaths in this cohort. \u003cstrong\u003e( see table 2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Demographic and Obstetric Factors emergency RCS for pregnant mothers with multiple scar (N = 86)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFactors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;n (%) / Mean (Range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal Age\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026lt; 35 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71(17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026ge; 35 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15(83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAddress \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Addis Ababa (AA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e83(96%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Regions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3(4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTiming of repeat Cesearean section S N=460\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;elective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e374 (81)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Emergency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e86 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eIndications for emergency CS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; labour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61(71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; PROM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;25(19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Previous CS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56(65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026gt;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreterm labour rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.6 Percent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eGA at \u0026nbsp; delivery (n = 86)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;38 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;37 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026lt; 37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40( 46 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Maternal and neonatal outcomes \u0026nbsp; (N = 86)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFactors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003en (%) / Mean / Median (Range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of patients required Blood transfusion\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;2 (2.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePost op hemoglobin ,Median ,IQ-IQ2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;9.6 \u0026nbsp;(5 -14)gm/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eScar Dehisence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;9 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEndometritis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 9( 10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eWound infection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 4 (4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAPGAR score less than 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 6( 7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEarly neonatal sepsis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5(5.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLBW \u0026lt;2.5 kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (10.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6(7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNICU admission\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (12.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this two-year prospective cohort of 460 women with two or more previous cesarean sections at SPHMMC, nearly one in five (19.0%) presented with spontaneous labor or rupture of membranes before 39 weeks\u0026rsquo; gestation, requiring emergency delivery. This proportion is substantially higher than rates reported in several international datasets. For example, multicenter WHO surveys and other studies involving predominantly low-risk women with prior cesarean delivery documented spontaneous labor before 39 weeks in approximately 8\u0026ndash;10%, with the risk increasing among those with two or more scars (4,5). Although reported figures vary, the overall incidence of unplanned or urgent cesarean delivery ranges from 13\u0026ndash;16% when elective delivery is scheduled at 38 weeks and 23\u0026ndash;51% when planned for 39 weeks\u0026mdash;rates that parallel our findings (6). A recent study by Clement Morabu et al. reported a 62% rate of emergency cesarean delivery following early-onset labor among women scheduled for elective cesarean at 39 weeks (15). These data highlight that a considerable proportion of women with prior cesarean scars, particularly those with multiple scars, enter spontaneous labor before 39 weeks.\u003c/p\u003e\n\u003cp\u003eEstablished predictors of early labor, including previous preterm birth and the presence of multiple uterine scars, significantly increase the likelihood of spontaneous labor before the scheduled surgical date. Some studies report up to a fourfold increase in emergency cesarean delivery among these high-risk groups (6). The consequences of emergency surgery in women with multiple scars are clinically significant. Consistent with reports such as that by Mohamed et al., which demonstrated approximately 16% maternal morbidity, our study found a comparable overall adverse maternal outcome rate of 16% (7). The most common complications included scar dehiscence, postpartum fever, endometritis, postpartum hemorrhage, perinatal complications, and increased use of general anesthesia (6,16). The lower rate of scar dehiscence (10%) and the absence of maternal and perinatal mortality in our study compared with findings from Tanzania may reflect differences in access to timely care; nearly 90% of our participants were from Addis Ababa, where rapid hospital arrival is feasible, unlike many rural settings (15).\u003c/p\u003e\n\u003cp\u003eThe optimal timing of elective cesarean delivery in women with multiple uterine scars remains a topic of ongoing debate. While ACOG and NICE recommend scheduling elective cesarean delivery at or beyond 39 weeks in uncomplicated pregnancies (9,10), implementation in real-world settings is challenging. Studies indicate that 20\u0026ndash;50% of women enter labor before their scheduled 39-week delivery date, resulting in substantial emergency intrapartum cesareans. Consequently, nearly half of obstetricians continue to schedule elective procedures at 37\u0026ndash;38 weeks due to concerns regarding spontaneous labor and associated surgical risks (6). Evidence suggests that elective delivery at 38 weeks for women with two or more scars does not substantially increase neonatal respiratory morbidity, supporting risk-based, individualized scheduling\u0026mdash;particularly relevant in low-resource settings where timely emergency intervention may be limited (8,13). Laura Hart et al. concluded that the optimal timing for elective cesarean is 38+0 to 38+6 weeks for women with two scars and 37+0 to 37+6 weeks for those with three or more (14).\u003c/p\u003e\n\u003cp\u003eIn our study, the preterm birth rate was 8.6%, supporting the hypothesis that multiple previous cesarean sections significantly increase the risk of preterm labor. Other studies similarly report over a fourfold increased risk of preterm labor among women with more than two cesareans, attributed to cumulative uterine trauma, myometrial scarring, altered uterine compliance, abnormal placentation, and cervical dysfunction (17). Randomized trials have shown that second-trimester cervical length assessment and vaginal progesterone can reduce preterm birth in at-risk women. Applying these strategies to women with multiple scars may reduce spontaneous early labor and emergency surgical intervention. A case\u0026ndash;control study by Khalefa Essam et al. identified preterm labor in 26% of women with repeated scars and demonstrated that both mid-trimester cervical length and lower uterine segment thickness are strong predictors of preterm birth; however, further prospective randomized trials are needed to refine risk stratification and targeted prevention (23).\u003c/p\u003e\n\u003cp\u003eNeonatal outcomes in our cohort further demonstrate the burden associated with early labor in highly scarred pregnancies. We observed notable proportions of low Apgar scores, neonatal sepsis (5.8%), low birthweight, and respiratory distress syndrome; overall, 12.8% required NICU admission. These results are consistent with findings from Clemente et al. and others, where nearly one-third of neonates born after emergency cesarean for multiple-scar pregnancies experienced significant morbidity and early neonatal mortality of about 3% (14,18,19). A decision-analysis model by Vanessa Lee et al. also concluded that elective cesarean should be performed before the onset of labor\u0026mdash;around 38 weeks\u0026mdash;for optimal neonatal outcomes, supporting our results (17).\u003c/p\u003e\n\u003cp\u003eOverall, our findings reinforce that women with multiple cesarean scars face a substantially elevated risk of early labor and emergency cesarean delivery, accompanied by heightened maternal and neonatal morbidity. Several studies advocate scheduling elective delivery between 37 and 38 weeks in this high-risk population to minimize spontaneous labor while avoiding excessive iatrogenic prematurity (13,21). In our cohort, nearly half of spontaneous labor cases occurred between 37 and 38 weeks, supporting consideration of revised timing policies in resource-limited settings such as Ethiopia, where emergency access varies widely. Given the rising cesarean rate in Ethiopia and increasing numbers of women with repeated scars, early scheduling for women with two or more scars warrants serious consideration (12,16,22).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRoutine scheduling of elective cesarean delivery at 39 weeks for women with two or more previous cesarean sections significantly increases the incidence of spontaneous early labor and the associated maternal and neonatal risks. Individualized, risk-based scheduling at 37\u0026ndash;38 weeks should be considered for women with multiple scars, particularly in settings where timely emergency obstetric care may be limited. Future multicenter prospective studies with comprehensive assessment of maternal and obstetric risk factors are needed to determine the safest gestational age for elective delivery and to identify the most effective surveillance strategies for this high-risk population.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eANC Antenatal Care\u003c/p\u003e\n\u003cp\u003eSPHMMC Saint Paul Hospital Mellinum Medical college\u003c/p\u003e\n\u003cp\u003eCD cesarean section\u003c/p\u003e\n\u003cp\u003eRCS Repeat cesarean section \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI am grateful to SPHMMC, for allowing us to obtain access to the delivery data. We are also highly indebted to the data collectors for their incredible contributions to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMF was involved in conceptualization, methodology, review, supervision, data analysis and writing of the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance for this study was obtained from the Departmental Research and Ethics Review Committee and the Institutional Review Board (IRB) of Saint Paul\u0026rsquo;s Hospital Millennium Medical College (SPHMMC). All procedures were conducted in accordance with institutional ethical standards. To ensure confidentiality, patient identifiers were retrieved from the admission register and used solely for the purpose of locating the corresponding medical charts and electronic records from the labor ward and operating theatres. Each record was assigned a unique code number, and the data were extracted using a structured questionnaire. No personal identifiers were entered into the study database. All completed data collection tools were securely stored in locked cabinets and were accessible only to the research team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBecause the study relied exclusively on retrospective chart review and did not involve interviews, contact with patients, or the collection of new data directly from individuals, obtaining informed consent from study participants was not applicable. The Institutional Review Board formally waived the need for consent based on the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBetr\u0026aacute;n AP, Ye J, Moller AB, Zhang J, G\u0026uuml;lmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates. \u003cem\u003ePLoS One\u003c/em\u003e. 2016;11(2):e0148343.\u003c/li\u003e\n \u003cli\u003eClark EA, Silver RM. Long-term maternal morbidity associated with repeat cesarean delivery. \u003cem\u003eAm J Obstet Gynecol\u003c/em\u003e. 2011;205(6 Suppl):S2\u0026ndash;10.\u003c/li\u003e\n \u003cli\u003eTita ATN, Landon MB, Spong CY, Lai Y, Leveno KJ, Varner MW, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. \u003cem\u003eN Engl J Med\u003c/em\u003e. 2009;360(2):111\u0026ndash;20.\u003c/li\u003e\n \u003cli\u003eGanchimeg T, Togoobaatar G, et al. Optimal timing of delivery among low-risk women with prior caesarean section: a secondary analysis of the WHO multicountry survey on maternal and newborn health. \u003cem\u003ePLoS One\u003c/em\u003e. 2016;11(2):e0149091.\u003c/li\u003e\n \u003cli\u003eRoberts CL, Henderson J, Algert CS, Morris JM. Rate of spontaneous onset of labour before planned repeat caesarean section at term. \u003cem\u003eBMC Pregnancy Childbirth\u003c/em\u003e. 2014;14:125.\u003c/li\u003e\n \u003cli\u003eRamadan MK, Melamed N, Keidar L, Peled Y, Wiznitzer A, Yogev Y. Timing of an elective repeat cesarean delivery at term: addressing the controversy. \u003cem\u003eJ Clin Gynecol Obstet\u003c/em\u003e. 2019;8(1):1\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eMelamed N, Hadar E, Keidar L, Peled Y, Wiznitzer A, Yogev Y. Timing of planned repeat cesarean delivery after two or more previous cesarean sections\u0026mdash;risk for unplanned cesarean delivery and pregnancy outcome. \u003cem\u003eJ Matern Fetal Neonatal Med\u003c/em\u003e. 2014;27:431\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eShinar S, et al. Timing of cesarean delivery in women with \u0026ge;2 previous cesarean deliveries. \u003cem\u003eAm J Obstet Gynecol\u003c/em\u003e. 2022;226(1):110.e1\u0026ndash;110.e8.\u003c/li\u003e\n \u003cli\u003eACOG Practice Bulletin No. 205. Vaginal birth after cesarean delivery. \u003cem\u003eObstet Gynecol\u003c/em\u003e. 2019;133(2):e110\u0026ndash;27.\u003c/li\u003e\n \u003cli\u003eRoyal College of Obstetricians and Gynaecologists (RCOG). \u003cem\u003eBirth after previous caesarean birth\u003c/em\u003e (Green-top Guideline No. 45). London: RCOG; 2015.\u003c/li\u003e\n \u003cli\u003eMekonnen ZA, Lerebo WT, Gebrehiwot TG, Abadura SA. Multilevel analysis of individual and community-level factors associated with institutional delivery in Ethiopia. \u003cem\u003eBMC Res Notes\u003c/em\u003e. 2015;8:376.\u003c/li\u003e\n \u003cli\u003eYisma E, Smithers LG, Lynch JW, Mol BW. Cesarean section in Ethiopia: prevalence and sociodemographic characteristics. \u003cem\u003eJ Matern Fetal Neonatal Med\u003c/em\u003e. 2019;32(7):1130\u0026ndash;5.\u003c/li\u003e\n \u003cli\u003eLeybovitz-Haleluya N, et al. Timing of planned cesarean delivery among patients with two previous cesarean sections. \u003cem\u003eArch Gynecol Obstet\u003c/em\u003e. 2024;310(3):1483\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eHart L, Refuerzo J, Sibai B, Blackwell S. Should the \u0026ldquo;39-week rule\u0026rdquo; apply to women with multiple prior cesarean deliveries? \u003cem\u003eAm J Obstet Gynecol\u003c/em\u003e. 2014;210(1 Suppl):S27.\u003c/li\u003e\n \u003cli\u003eMorabu C, Matovelo D, Massinde A, Kihunrwa A, Kidenya B. Factors associated with women with multiple caesarean deliveries presenting in labour and their fetomaternal outcomes in Mwanza Region, Tanzania. \u003cem\u003eTanzan J Health Res\u003c/em\u003e. 2022;23(2):1\u0026ndash;4.\u003c/li\u003e\n \u003cli\u003eDanieli-Gruber S, Shalev-Rosenthal Y, Matot R, Brzezinski-Sinai N, Zeevi G, Pardo A, et al. Risks of urgent cesarean delivery preceding the planned schedule: a retrospective cohort study. \u003cem\u003ePLoS One\u003c/em\u003e. 2023;18(8):e0289655.\u003c/li\u003e\n \u003cli\u003eKhan S, Bibi H, Jehangir A, Khan M, Bangash H. The number of C-sections as a risk factor for preterm labour: a case control study. \u003cem\u003eInsights J Health Rehabil\u003c/em\u003e. 2025;3(3):272\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eWood SL, Chen S, Ross S, Sauve R. The risk of neonatal death in relation to cesarean delivery at term: a population-based study. \u003cem\u003eAm J Obstet Gynecol\u003c/em\u003e. 2018;219(1):88.e1\u0026ndash;88.e9.\u003c/li\u003e\n \u003cli\u003eLau TK, Rogers MS, Sahota DS, Chang AMZ. Timing of elective cesarean delivery at term and neonatal outcomes: a population-based study. \u003cem\u003eArch Gynecol Obstet\u003c/em\u003e. 2019;299(3):629\u0026ndash;35.\u003c/li\u003e\n \u003cli\u003eLee V, Dorius A, Niu B, Griffin E, Kaimal A, Caughey A. Timing of delivery in women with two prior cesareans: a decision analysis. \u003cem\u003eAm J Obstet Gynecol\u003c/em\u003e. 2015;212(1 Suppl):S132.\u003c/li\u003e\n \u003cli\u003eMekonnen T, Bekele A, Tilahun T, Kebede B, Yismaw AE. Neonatal morbidity and mortality in public hospitals of Addis Ababa, Ethiopia: a cross-sectional study. \u003cem\u003eBMC Pediatr\u003c/em\u003e. 2021;21:507.\u003c/li\u003e\n \u003cli\u003eDebelew GT, Afework MF, Yalew AW. Determinants and causes of neonatal mortality in Ethiopia: a cohort study in Northwest Ethiopia. \u003cem\u003eBMC Public Health\u003c/em\u003e. 2014;14:129.\u003c/li\u003e\n \u003cli\u003eKhalefa E, Abdelbasset A, Hussein RS, Farghaly T, Ali MK, Mohamed AA. Cervical length and thickness of cesarean section scar are predictors for preterm labor in women with previous cesarean section. \u003cem\u003eFertil Steril\u003c/em\u003e. 2023;120(4):e238.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"multiple CS scar, early onset labor, SPHMMC, adverse outcomes","lastPublishedDoi":"10.21203/rs.3.rs-8244294/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8244294/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Early-onset labor among women with multiple cesarean scars poses unique maternal and neonatal risks, particularly in resource-limited settings. Despite growing numbers of women with repeat cesarean sections (RCS) in Ethiopia, evidence on outcomes in this high-risk group remains limited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We conducted a descriptive, retrospective study at Saint Paul’s Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia, from January 2023 to December 2024. All women with ≥2 prior cesarean deliveries who underwent scheduled RCS were included, excluding cases converted to emergency cesarean for non-labor-related indications. Early-onset labor was defined as spontaneous labor or rupture of membranes before 39 weeks’ gestation. Data were analyzed using descriptive statistics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Of 460 women with ≥2 prior cesarean scars, 86 (19.0%) experienced early-onset labor, including 8.6% who delivered preterm (\u0026lt;37 weeks). The mean maternal age was 32 years; 96.5% resided in Addis Ababa. Most women had two prior cesareans (65.1%). Surgical complications included scar dehiscence (10.4%), endometritis (10.4%), wound infection (4.6%), and urologic injury (17.5%). NICU admission occurred in 12.8% of neonates, with neonatal mortality at 25%. Preterm birth strongly correlated with neonatal morbidity and mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The study showed that one in five women with multiple cesarean scars scheduled for elective CS at 39 weeks experienced early-onset labor requiring emergency RCS before 39 weeks, resulting in significant maternal and neonatal complications. spontaneous preterm labor is also common. These findings support consideration of scheduling elective RCS before 39 weeks in this population. Pregnant women with multiple scar may benefit from Preventive interventions such as cervical length screening for preterm labor.\u003c/p\u003e","manuscriptTitle":"Early-Onset Labor in Women with Multiple Cesarean Scars Scheduled for Elective Repeat Cesarean Delivery: Incidence and Outcomes from a Retrospective Study in Ethiopia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-04 08:30:08","doi":"10.21203/rs.3.rs-8244294/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"247576204747720617845174791928548702274","date":"2026-01-09T14:04:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-30T16:56:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-05T09:15:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-03T03:20:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-03T03:19:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-11-30T20:11:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"232ee0d5-5658-4721-b94b-410ead0ad26a","owner":[],"postedDate":"December 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-30T17:08:37+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-04 08:30:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8244294","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8244294","identity":"rs-8244294","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}