In short
- An adhesion is an abnormal sticking together of tissues that ought to slide over one another. After a caesarean they can form between the abdominal wall, the womb, the bladder and the bowel.
- ⚠️ How often they really occur is not settled: between 24.4% and 46% at the second caesarean, depending on which series you read.
- What every series does agree on is the trend: they increase with each caesarean, up to 42.8-75% from the third onwards.
- 🔑 In first caesareans no adhesions were found. What appears at the second was left by the first.
- The technique used for the caesarean matters: closing the peritoneum was associated with fewer adhesions in a meta-analysis of 33 studies.
- They are felt as tightness, as a scar that “does not move”, or as discomfort on stretching, and they do not always cause symptoms.
- ⚠️ Having adhesions does not mean having to be operated on. Many are discovered on opening for another reason and never caused any trouble.
How many women have adhesions after a caesarean has no single answer, and that is worth knowing before reading any figure. Two series published in the same journal give, for the same thing, 24.4% and 46%: almost twice as much in one as in the other. It is not that one is wrong; it is that there is no shared criterion for what counts as an adhesion.
With that caveat stated up front, a good deal can still be said: what they are, why they form, how they are felt, what makes them more likely and what can be done about them. That is what this page sets out.
This page expands one of the sections of the after-effects of a caesarean, which brings together the rest of the picture.
What an adhesion actually is
Inside the abdomen, surfaces slide over one another: the bowel over the peritoneum, the womb over the bladder, the wall over what lies beneath it. An adhesion is a band of scar tissue that joins two of those surfaces and stops them sliding.
They form as part of normal healing, not through any error. When a surface is injured — and a caesarean injures them — the body repairs it by laying down fibrin; if that fibrin is not fully reabsorbed, it organises into a permanent bridge.
After a caesarean the most frequent are those joining the abdominal wall to the womb, and those joining the bladder to the lower segment of the womb. The first are the ones that produce the symptoms that bring women to the clinic; the second matter mainly if there is another caesarean ahead.
How they are felt
There is no symptom exclusive to them, and that is the first difficulty. What the women who have them describe:
- Tightness in the area of the scar, above all on stretching, on arching the back or on getting up from bed.
- The sensation that the scar “does not move”: on trying to shift the skin over the deep planes, it does not give as it does in the rest of the abdomen.
- Discomfort with certain movements or at the end of the day.
- A sensation of being pulled inwards when the abdomen is tensed.
⚠️ And something worth saying plainly: many adhesions cause no symptoms at all. They are found on opening again for another reason, in women who never noticed anything. That they exist and that they cause trouble are two different things, and only the second is a reason for treatment.
There is no imaging test that diagnoses them reliably. Examination gives an indication — how the skin slides over the planes is assessed, whether the scar is tethered, whether there is a point that reproduces the discomfort — and direct confirmation comes only from looking, that is, at another operation.
How often they occur: two answers, and both published
Here is the figure most people are looking for, and it deserves to be given in full.
Adhesions are measured by seeing them, so almost all the information comes from women who went on to have a second caesarean. In other words: the figure that exists is what the surgeon found on opening again.
| Series | After one previous caesarean | After three | Population |
|---|---|---|---|
| Tulandi, 2009 | 24.4% | 42.8% | 1,283 repeat caesareans and 203 first caesareans |
| Morales, 2007 | 46% (100 of 217) | 75% (48 of 64) | 542 women |
The difference between the two is almost twofold, and it is not resolved by picking whichever you prefer. The most likely explanation is methodological: there is no standardised definition of what counts as an adhesion, nor any single scale for scoring them, so two teams looking at the same abdomen may record different things. The series use their own scoring systems, and that feeds through into the prevalence.
The honest thing is to publish the range: between one in four and almost half.
Where they do agree
On two things, and both matter more than the exact figure:
- The frequency rises with each caesarean. From the second to the third, the jump is large in both series.
- 🔑 In first caesareans, Tulandi found no adhesions. That is the finding that allows what is seen at the next caesarean to be attributed to the previous one, rather than to pregnancy or to labour.
There is also a finding with practical consequences for obstetrics: in Morales’s series, the time from incision to delivery lengthened progressively with each caesarean — from 10.7 minutes at the first to 16.3 at the second and 19.2 at the third — which is exactly the problem adhesions pose in an emergency caesarean.
What makes them more likely
The technique used to close the previous caesarean. A meta-analysis of 33 studies and 4,423 women compared three ways of performing a caesarean and found that closing the peritoneum was associated with fewer adhesions — with an odds ratio of 0.28 on direct comparison — (Shi, 2011).
🔑 It is the same pattern that explains the caesarean shelf from another plane. What is decided to be closed in the delivery theatre shapes what will be found later: the peritoneum, for adhesions; Scarpa’s fascia, for the shelf or “apron”. Two independent papers, from 2011 and 2026, pointing to the same thing from different layers.
⚠️ This is not written to reproach anybody. The technique of a caesarean is chosen on grounds of maternal and fetal safety in a context that is often urgent, and preventing adhesions is one factor among several, not the main one. What it makes sense to raise — and in what words — is on the page about closing the caesarean.
What can be done
Where what predominates is a tethered scar, massage can free it and release it, and improve the discomfort. It is a reasonable first-line treatment, non-invasive and with no need for theatre.
🚨 And here is the limit to know about before starting: where the bulge is mechanical — fat herniated through an open fascia — massage does not resolve it. It can improve how the scar feels, but it does not put the fat back in its plane or remove skin. Telling the two cases apart is the first thing assessed, and it is what prevents months of treatment with the wrong expectation. The page on the conservative route sets it out.
Where surgery is ahead, the adhesion is released during the operation itself: in scar revision, in a mini tummy tuck and in a full tummy tuck, the old scar is excised and the plane released as part of the procedure. It is not charged separately because it is not an extra. The full ladder is in how surgery is decided on.
And the appearance of the scar — which is a different matter from its tethering — is dealt with by the clinic’s scar protocol.
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Frequently asked questions
How do I know if I have adhesions?
By what you feel rather than by a test: tightness, a sensation that the scar does not move, discomfort on stretching. At the examination, how the skin slides over the deep planes is assessed, and whether there is a point that reproduces the discomfort. There is no imaging test that diagnoses them reliably.
Can adhesions be seen on an ultrasound or an MRI scan?
Not reliably. Indirect signs can be inferred, but neither ultrasound nor MRI is a diagnostic test for this. Direct confirmation comes only from looking inside, that is, at an operation carried out for another reason.
Are they dangerous?
In most cases they cause no problem at all. What they do is lengthen and complicate later surgery in the same area, including another caesarean, and that is why they appear in the obstetric series. Where they cause persistent pain or interfere with how the bowel works, they are assessed separately.
Can they be removed without an operation?
A tethered scar can improve with massage, which can free it and release it. What massage does not do is correct a bulge that comes from herniated fat, because there is nothing stuck there to release. Telling one case from the other is the first part of the assessment.
If I become pregnant again, are adhesions a problem?
That is the setting in which they have been studied most. They lengthen the operation and can complicate it, which matters particularly if the caesarean is an emergency. It is information your obstetric team should know about, not a reason not to have more children.
Why do some women get adhesions and others do not?
It depends on the technique used for the caesarean — closing the peritoneum is associated with fewer adhesions — on the number of previous caesareans, and on individual healing factors that cannot be anticipated. It does not depend on anything done or not done after the birth.
I have tightness but also a bulge over the scar — is it the same thing?
They are probably two things at once, and that is the most usual picture. The tightness points to an adhesion; the bulge with a groove across it, to the caesarean shelf. They are treated differently, and that is why it is worth examining them together.
Sources
- Tulandi T, Agdi M, Zarei A, Miner L, Sikirica V. Adhesion development and morbidity after repeat cesarean delivery. American Journal of Obstetrics and Gynecology. 2009;201(1):56.e1-6. PMID 19576375 — A review of 1,283 women having a repeat caesarean and 203 having a first caesarean. Adhesions in 24.4% at the second caesarean and 42.8% after three. No adhesions were found in first caesareans, which is the finding that allows what appears at the second to be attributed to the first. Checked on 29 August 2026.
- Morales KJ, Gordon MC, Bates GW Jr. Postcesarean delivery adhesions associated with delayed delivery of infant. American Journal of Obstetrics and Gynecology. 2007;196(5):461.e1-6. PMID 17466702 — A cohort of 542 women (265 first, 277 repeat). Adhesions in 46% (100/217) after one previous caesarean, 75% (48/64) after three and 83% (5/6) after four. It also documents the progressive lengthening of the time to delivery: 10.7 minutes at the first caesarean, 16.3 at the second and 19.2 at the third. Checked on 29 August 2026.
- Shi Z, Ma L, Yang Y, et al. Adhesion formation after previous caesarean section — a meta-analysis and systematic review. BJOG. 2011;118(4):410-422. PMID 21176087 — A meta-analysis of 33 studies and 4,423 women comparing the Stark technique, the modified Stark technique and the classic lower segment technique. Closing the peritoneum was associated with fewer adhesions (OR 0.28; 95% CI 0.10-0.82 on direct comparison). Checked on 29 August 2026.
- Pelosi MA 2nd, Pelosi MA 3rd, Romero R. The cesarean apron: description, proposed pathophysiology, classification, and prevention through Scarpa fascia closure at cesarean delivery. American Journal of Obstetrics and Gynecology. 2026;233(6S):S118-S128. PMID 41485815 — Cited here to separate the adhesion from the shelf: it describes the mechanism by which deep fat herniates through an unclosed Scarpa’s fascia, which is a different problem from planes sticking together and does not respond to the same treatment. Checked on 29 August 2026.
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If your scar is tethered and pulls, what makes clear what can be done is an examination: it is checked whether the skin slides over the planes, whether what is there is adhesion or volume, and whether massage makes sense in your case or will fall short. It is a short assessment and it produces a concrete recommendation.
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Last reviewed: 6 September 2026. This content is for information only and does not replace an individual assessment by a healthcare professional.
