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The sliding sign (the relative motion between the abdominal and uterine wall as assessed by ultrasonography) may help identify severe intra-abdominal adhesions before repeat cesarean delivery.We conducted a prospective observational study of scheduled repeat cesarean deliveries. Using transabdominal ultrasonography, while the parturient breathed deeply, the ultrasonographer recorded a video clip in a sagittal plane lateral to the umbilicus. These clips were assessed for the presence (sliding-positive) or absence (sliding-negative) of relative movement between the maternal abdominal and uterine wall. Surgeons blinded to ultrasonography results graded the severity of intraperitoneal adhesions intraoperatively. Study outcomes were the accuracy of the preoperative sliding sign for prediction of severe adhesions and its association with surgical times and bleeding.We recruited 370 women. A negative sliding sign was associated with severe adhesions (sensitivity 56%, 95% CI 35–76; specificity 95%, 95% CI 93–97). A similar accuracy (sensitivity 64%, 95% CI 43–82; specificity 94%, 95% CI 92–97) was achieved by combining the sliding sign with a history of adhesions in the previous surgery. In multivariable models, a negative sliding sign was significantly correlated with a longer interval from skin incision to delivery and increased risk for bleeding.A negative sliding sign predicts severe intra-abdominal adhesions encountered during repeat cesarean delivery, longer time to delivery, and a higher chance of bleeding.