Objective: To determine if the midline subumbilical incision reduces the risk of trauma to bladder and bowel in women undergoing multiple cesarean sections. Study design: Retrospective analysis of hospital histories of 3164 women who had repeat cesarean sections at a referral maternity hospital. Methods: The clinical records of women who had between one and eight cesarean sections over a 4-year period to October 2002 were examined for entries on injury to bladder and bowel. The frequency of these injuries in relation to abdominal incision used was determined. Multiple logistic regression analysis was performed to assess the influence of cesarean number, abdominal incision, intraperitoneal adhesions, operator experience, and anterior placenta previa on risk of bladder injury. Main outcome measure: Frequency of trauma to bladder and bowel associated with either Pfannenstiel or midline incision. Results: There were 3164 women who met the inclusion criteria to the study. The midline incision was associated with significantly higher risk than Pfannenstiel for injury to the bladder (P < 0.0001, OR 6.7, 95% CI 2.6- 16.5). For both incisions, injury to the bladder increased with rising cesarean number. In addition, for a given cesarean other than primary, bladder trauma was more likely with the midline incision. The risk of injury to bowel was higher with the midline incision (RR 5.5), but there were too few events to permit Chi square analysis. Conclusion: In repeat cesarean section, the midline incision is associated with a higher risk of bladder and bowel injury than Pfannenstiel. Objective: To determine if the midline subumbilical incision reduces the risk of trauma to bladder and bowel in women undergoing multiple cesarean sections. Study design: Retrospective analysis of hospital histories of 3164 women who had repeat cesarean sections at a referral maternity hospital. Methods: The clinical records of women who had between one and eight cesarean sections over a 4-year period to October 2002 were examined for entries on injury to bladder and bowel. The frequency of these injuries in relation to abdominal incision used was determined. Multiple logistic regression analysis was performed to assess the influence of cesarean number, abdominal incision, intraperitoneal adhesions, operator experience, and anterior placenta previa on risk of bladder injury. Main outcome measure: Frequency of trauma to bladder and bowel associated with either Pfannenstiel or midline incision. Results: There were 3164 women who met the inclusion criteria to the study. The midline incisi On both associated with significantly higher risk than Pfannenstiel for injury to the bladder (P <0.0001, OR 6.7, 95% CI 2.6- 16.5). For both incisions, injury to the bladder increased with rising cesarean number. cesarean other than primary, bladder trauma was more likely with the midline incision. The risk of injury to bowel was higher with the midline incision (RR 5.5), but there were too few events to permit Chi square analysis. Conclusion: In repeat cesarean section , the midline incision is associated with a higher risk of bladder and bowel injury than Pfannenstiel.