Objective Prior cesarean delivery is a well-known risk factor for placenta accreta spectrum disorders. While primary cesarean section is unavoidable in some patients, in others it may not be clearly indicated. The aim of the study is to determine the proportion of patients with placenta accreta spectrum who had a potentially preventable primary cesarean section and to identify factors associated with preventable placenta accreta spectrum. Study Design This was a single-center retrospective cohort study of women with pathology-confirmed placenta accreta spectrum from 2007 to 2019. Primary cesarean sections were categorized as potentially preventable or unpreventable based on practice consistent with the American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine “Safe Prevention of the Primary Cesarean Delivery” recommendations. Fisher's exact test and Mann-Whitney U-test were used for comparison with p <0.05 considered statistically significant. Results Seventy-two patients had pathology-confirmed placenta accreta spectrum over the course of the study period, 15 (20.8%) of whom required a cesarean hysterectomy at the time of primary cesarean section. Fifty-seven patients had placenta accreta spectrum in a pregnancy following their primary cesarean section. Of these, 29 (50.9%) were considered potentially preventable. Most were performed without clear medical indication (37.9%) or for fetal malpresentation without attempted external cephalic version (37.9%). The remainder were due to arrest of labor not meeting criteria (17.2%) and abnormal or indeterminate fetal heart patterns with documented recovery (6.9%). Of the 11 patients without clear medical indication for primary cesarean section, eight (72.7%) were patient-choice cesarean sections and three (27.3%) were for suspected fetal macrosomia with estimated fetal weights not meeting criteria for cesarean delivery. There was no difference in the incidence of potentially preventable primary cesarean sections before and after the ACOG-SMFM “Safe Prevention of the Primary Cesarean Delivery” publication (48.8 vs. 57.1%, p = 0.59). Privately insured patients were more likely to have a potentially preventable primary cesarean section than those with Medicaid (62.5 vs. 23.5%, p = 0.008) and were more likely to have a primary cesarean section without clear medical indication (81.8 vs. 18.2%, p = 0.004). Conclusion Many patients with placenta accreta spectrum had a potentially preventable primary cesarean section. Most were performed without clear medical indication or for malpresentation without attempted external cephalic version, suggesting that at least a subset of placenta accreta spectrum cases may be preventable. This was particularly true for privately insured patients. These findings call for continued investigation of potentially preventable primary cesarean sections with initiatives to address concerns at the patient, provider, and hospital level. Key Points