European Journal of Cardiovascular Medicine

Caesarean section can be a lifesaving procedure for both the mother and baby, particularly in cases where vaginal delivery is complicated by factors such as malpresentations, fetal distress, or cephalopelvic disproportion, provided it is performed based on appropriate medical indications. [1] However, the increasing rates of caesarean sections without clear medical necessity have led to a lack of awareness regarding the associated maternal and fetal risks. The decline in vaginal birth after caesarean (VBAC) rates and the rise in primary caesarean section rates can be attributed to three key factors. [2]. The predictive accuracy of scar tenderness for assessing intraoperative scar integrity varies widely. While some research suggests a strong association between scar tenderness and adverse intraoperative findings, others report no significant correlation. [3]. Intraoperative findings offer critical insights into uterine scar conditions, with factors such as scar thickness, adhesions, vascularity, and dehiscence influencing fetomaternal outcomes. A compromised scar can lead to serious complications, including hemorrhage, uterine rupture, and, in severe cases, hysterectomy. [4,5] From a fetal perspective, pregnancies complicated by scar dehiscence or rupture are associated with risks such as preterm birth, fetal distress, and NICU admissions.  [6]

Advancements in ultrasound imaging have also been explored as a tool for assessing uterine scar integrity in women with a previous LSCS. Some studies suggest that ultrasound markers provide a more objective assessment of scar strength compared to clinical evaluation alone. However, integrating radiological findings with clinical assessment remains an area of ongoing research. [7]. This study aims to evaluate intraoperative uterine scar conditions and their impact on fetomaternal outcomes in women with previous LSCS presenting with scar tenderness. By analyzing intraoperative findings, maternal complications, and neonatal outcomes, this research seeks to clarify the significance of scar tenderness and contribute to evidence-based obstetric decision-making to enhance maternal and neonatal safety.

Aims and Objectives

1. To assess the condition of uterine scars intraoperatively in terms of intact scars, thinnedout scars, scar dehiscence, or rupture in patients with previous LSCS presenting with
2. scar tenderness.
3. To analyze the associated maternal and fetal outcomes in these cases.

The present study was a prospective observational study conducted at Kempegowda Institute of Medical Sciences, Bangalore, over duration of 12 months (November 2023 to October 2024). Among the 284 women undergoing repeat emergency lower segment cesarean section (LSCS) for various indications with a gestational age of more than 28 weeks, 46 women who presented with previous LSCS and scar tenderness were included in the study. Women undergoing elective LSCS, those with uterine anomalies, and those with other causes of abdominal pain, including gynecological, surgical, and obstetrical conditions, were excluded from the study.

Clinically, scar tenderness is assessed by palpating the abdomen in the suprapubic region from one iliac fossa to the other using the palmar aspect of the dominant hand while engaging the woman in conversation and observing for a visible wince on her face. If the woman is in labor, tenderness is elicited between contractions when the uterus is relaxed. Intraoperatively, the scar is assessed and categorized as intact, thinned-out, dehiscent, or ruptured, and the fetomaternal outcome is correlated accordingly

Table 1: Patient Demographics

The majority of women in the study (65.2%) were aged between 26 and 35 years, indicating that this age group had the highest prevalence of repeat emergency LSCS with scar tenderness. Women aged 21 to 25 years accounted for 21.7% of cases, while those aged 36 to 40 years represented the smallest proportion (13.1%). This distribution suggests that repeat emergency LSCS with scar tenderness is more commonly observed in women in their late twenties and early thirties.

Table 2: Delivery

In this study, the majority of women (76.08%) underwent repeat emergency LSCS at term (gestational age ≥37 weeks), while 23.9% had preterm deliveries (gestational age <37 weeks). This indicates that most cases of scar tenderness occurred in term pregnancies, though a significant proportion also presented in preterm gestations.

Table 3: Intraoperative uterine Scar Condition

The study analyzed scar conditions in women with a history of one or two previous LSCS. Among the 28 women with a single previous LSCS, 82.1% had an intact scar, while 17.9% had a thinned-out scar. No cases of dehiscence or rupture were observed in this group. 

Among the 18 women with two previous LSCS, 50% had an intact scar, 44.4% had a thinned-out scar, and 5.6% had dehiscence. No cases of rupture were noted in either group. These findings suggest that the likelihood of scar thinning and dehiscence increases with multiple prior cesarean deliveries.

Table 4: Maternal Outcomes

The study assessed maternal outcomes in women with one or two previous LSCS. Among the 28 women with a single prior LSCS, urinary complications were observed in 14.3%, wound infections in 7.1%, and none required a blood transfusion. 

In contrast, among the 18 women with two previous LSCS, the incidence of complications was higher. Urinary complications were seen in 38.9%, wound infections in 27.8%, and 16.7% required a blood transfusion. These findings indicate that maternal morbidity, particularly urinary complications and wound infections, increases with the number of prior cesarean deliveries.

Table 5: Fetal Outcomes

The study evaluated fetal outcomes in women undergoing repeat emergency LSCS. Meconium-stained amniotic fluid was observed in 19.5% of cases, while 6.5% of newborns had an APGAR score of less than 7 at birth. Additionally, 30.4% of neonates required immediate NICU admission, highlighting the potential risks associated with repeat cesarean deliveries.

In this study a total of 46 women with previous LSCS and scar tenderness were assesed. The highest prevalence of repeat emergency LSCS with scar tenderness was observed in women aged 26–35 years (65.2%), followed by 21–25 years (21.7%) and 36–40 years (13.1%). This suggests that scar tenderness is more common in women in their late twenties and early thirties. Similar results were noted by the Gupta N et al.[7] (2017), in their study total of 120 patients were included for evaluation. Around 72% patients belong to the age group of 21-30 years.

The scar integrity declines with an increasing number of previous LSCS. While 82.1% of patients with one prior LSCS had an intact scar, this dropped to 50% in those with two LSCS, with higher rates of thinning and dehiscence.The majority of deliveries (76.08%) occurred at term, while 23.9% were preterm. This indicates a notable occurrence of preterm births, highlighting the need for careful monitoring in pregnancies with previous LSCS to reduce the risk of early delivery. The study by Adu‐Bredu et al.[8] (2025) indicates that higher parity (≥2) is more common (64.0%), but scar-related complications are distributed across both groups, with 54.5% occurring in multiparous women and 45.5% in primiparous women. This suggests that while higher parity is prevalent, the risk of scar complications remains significant regardless of parity.

Misra M et al. [9](2019) found a strong association between scar tenderness and sonographic scar thinning with scar complications. In their study, 46% (23 out of 50) of patients with these risk factors experienced complications, compared to only 10.6% (5 out of 47) among those without, highlighting the importance of close monitoring and timely intervention.

In this study, Patients with two previous LSCS had a higher incidence of complications compared to those with one previous LSCS. Urinary complications (15.2% vs. 8.69%), wound infections (10.8% vs. 4.34%), and blood transfusion requirements (6.5% vs. 0%) were more frequent in the two previous LSCS group. This indicates that increasing the number of prior cesarean deliveries is associated with a higher risk of post-operative complications.

In this study, 19.5% of cases had meconium-stained fluid, 6.5% of newborns had an APGAR score <7, and 30.4% required immediate NICU admission. These findings highlight the risk of fetal distress and neonatal complications in pregnancies with previous LSCS. Similarly, Kandregula MS et al. [10] (2024) reported that adverse foeto-maternal outcomes were common, with NICU admissions (16.6%), preterm births (25%), and low birth weight (33.3%) being notable concerns. Additionally, 16.6% of newborns had an APGAR score <7 at 5 minutes, indicating potential neonatal distress. These findings highlight a significant risk of neonatal complications, particularly in preterm deliveries.

The present study indicates that postoperative complications were more frequent in patients with two previous LSCS compared to those with one. Urinary complications (15.2% vs. 8.69%), wound infections (10.8% vs. 4.34%), and the need for blood transfusion (6.5% vs. 0%) were all higher in the two LSCS group. This suggests that increasing the number of prior cesarean sections is associated with a higher risk of postoperative morbidity, emphasizing the need for careful perioperative management in these patients.

Scar tenderness serves as a valuable predictor of complications in women with a previous LSCS. In this study, intact scars were the most common finding among women with one or two prior LSCS, suggesting that a trial of labor can be considered when there is no recurrent indication for repeat LSCS. Conversely, thinned-out scars were significantly associated with adverse maternal and fetal outcomes, including higher NICU admissions and urinary injuries, highlighting the need for close monitoring and elective cesarean delivery in high-risk cases. Further studies with larger cohorts are necessary to validate these findings and establish their clinical significance.

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