Know the risks and benefits of a Cesarean section (C-section)

By: Jeffrey Johnson, M.D., Wayne Health Department of Obstetrics and Gynecology

Cesarean sections are the most commonly performed surgical procedures in the world, with almost 1.2 million C-sections performed in the United States in 2019. The rate of C-section varies among countries and health care systems. The U.S. has one of the highest rates of C-sections, at about 33% of all deliveries each year.

There are two types of C-section:

• a low transverse C-section (performed in the vast majority of cases) with a scar in the uterus down low, near the level of the bladder and cervix
• a classical C-section (not widely performed) used only in very specific circumstances, such as for very premature babies (generally less than 28 weeks gestation) and very premature babies who are breech (bottom first).

The high rate of C-sections is driven by a medical legal climate that promotes this method of delivery as ‘safer’ than vaginal delivery. Unfortunately, this is not true in most cases.  C-section rates are lower in other industrialized nations with similar long-term child health outcomes. There was a long-held misconception that C-section combined with external fetal monitoring would result in near-eradication of cerebral palsy and other types of birth injuries. This has not been the case and rates of cerebral palsy are unchanged. But the risks to mothers have increased exponentially over the past 40-50 years, with significantly more complications, due to the number of C-section deliveries.

There are certainly many circumstances that make delivery by C-section the preferred method of having your baby. These include babies who are not head down during labor, certain twin pregnancies, and deliveries where there are abnormalities of the baby or mother. In the U.S. and many other countries, if there are concerns with the baby’s heart rate on the fetal monitor during labor, many doctors will resort to delivery by C-section. But in many cases, delivery by C-section does not result in better outcomes for babies, and puts mothers at unnecessary risk from having surgery. There are ways to get the baby to recover on the monitor during labor, so that a vaginal delivery with good outcomes for both mom and her baby can take place.

There are risks to the mother having a baby by C-section. Some are risks associated with anesthesia. Others include an increased risk of significant bleeding, infection, and damage to other organs surrounding the uterus during the surgery.

Delivery by C-section is not safer for the baby either. The baby can have more difficulty transitioning between their life in the womb and the outside world and have more difficulty breathing in the immediate newborn period. Birth by C-section is not any less traumatic than vaginal delivery for the baby. Mother Nature designed us to be born vaginally.

There are also risks to having multiple C-sections, all to the mother. We form scar tissue inside our belly after surgery, just like having a scar on your skin. After multiple surgeries, the scar tissue becomes denser, making surgery more complicated, with longer operating times, more difficulty getting to the uterus to deliver the baby, and more risk of accidental injury to surrounding organs.

Also, women who have multiple C-sections are at risk of having abnormal attachment of the placenta at the time of conception. The placenta becomes more likely to grow through the prior scar on the uterus itself, and can invade the bladder or surrounding intestines, making the surgery incredibly difficult. There is also a higher risk of a condition called placenta previa, where the placenta implants over the cervix instead of the wall of the uterus. These are very dangerous conditions that can result in significant bleeding during pregnancy, very complicated C-section deliveries and a higher rate of hysterectomy at the time of delivery.

We advise women who deliver by C-section to limit family size to avoid the risks associated with multiple C-sections. There is also an approach called “Trial of Labor After C-section” (TOLAC), which we advocate for in certain patients. This is where a woman will try to labor and have a baby vaginally after one, or sometimes two, prior C-sections. The risks of TOLAC are primarily scar separation during labor, which happens in less than 1% of women with a low transverse C-section scar. We do not allow TOLAC in women who have a classical (vertical) C-section scar, or who have had three or more prior C-sections, due to a much higher risk of scar separation during labor.

The success rates of TOLAC vary widely, and depend upon the prior indications for a C-section. Generally speaking, a TOLAC is more likely to be successful if the prior C-section was done for circumstances such as fetal compromise during labor in the last pregnancy, or for babies who were not head first during labor. C-sections that were previously done for failure to dilate, or babies not descending into the vagina during labor, are less likely to be successful. Your obstetrician can advise you whether you are a candidate for TOLAC and on your specific chances of success.

Although C-section is safe and performed many times a day across the country, it is still major surgery with a longer recovery and more complications than vaginal delivery. So, a woman needs to know the reasons why a C-section is being performed and understand her risks. The ultimate goal for families and their caregivers is a happy and healthy baby, with high quality, safe care for mothers. C-section can be an appropriate method to achieve these outcomes.

Wayne Health’s Obstetrics and Gynecology team serves as your partners in care, working hard to meet each woman’s unique needs and expectations. We offer an inter-disciplinary approach, coordinating care with Wayne Health specialists in Maternal-Fetal Medicine, Reproductive Endocrinology and Infertility, Gynecologic Oncology and Nurse Midwifery .

To set up an appointment with a Wayne Health physician or provider, visit our website OR call 877-929-6342