Between 1994 and 1999, of the 44 357 mothers delivered at the Riyadh Armed Forces Hospital (RAFH), 255 patients had four or more previous caesarean sections (CS). This comprised 0.5% of the obstetric population. One hundred and eighty-nine (74%) had four, 52 (20%) five, 12 (5%) six and two (0.4%) patients had seven CSs. Adhesions were severe in 128 (50%), moderate in 18 (7%), mild in 81 (32%) and no adhesions in 28 (11%) cases. The incidence of placenta praevia was five times that of the overall obstetric population (2.4% vs. 0.5%). One case of uterine rupture occurred, an incidence of 4/1000 cases. The incidence of placenta praevia rises with rising CS rate. Patients with multiple CS and placenta praevia should be counselled regarding the possibility of caesarean hysterectomy. Repeat CS is safe and tubal ligation should be advised, but not forced as it is not an absolute indication for sterilisation.