Why Should You Care Whether You Have a Cesarean?

by | May 15, 2024 | Cesarean Surgery

Birth [that is powered by the innate human capacity of the woman and fetus] is more likely to be safe and healthy because there is no unnecessary intervention that disrupts normal physiologic processes. Some women and/or fetuses will develop complications that warrant medical attention to assure safe and healthy outcome. However supporting the normal physiologic processes of labor and birth, even in the presence of such complications, has the potential to enhance best outcomes for the mother and infant.


— American College of Nurse-Midwives, Midwives Alliance of North America, National Association of Certified Professional Midwives4

After posting a graphic on social media stating that half of cesareans could safely be prevented, a commenter wrote: “Why do we want to prevent them?” “Good question,” I thought. “I think I’ll answer it in my next blog post.” I’ve actually done that in general terms in the quote that opens this post, but I expect she was interested in specifics, which may also be true for some of you. So, for her and any of you out there who have the same question, this blog post is for you.

Here’s our roadmap: I’ll start with complications inherent to having a baby via major surgery, follow that with the probabilities of you or your baby experiencing specific complications according to whether you have a cesarean delivery or a vaginal birth, and follow that with the probabilities of your experiencing future reproductive complications according to whether you have had a prior cesarean compared or only vaginal births. Finally, as usual, I’ll finish up with “Your Takeaway,” which for this post will be links to a couple of other posts containing tips and strategies for preventing a preventable cesarean.

And, just to be clear, while I’m going to argue that cesarean delivery is the riskier proposition, I am not saying we shouldn’t be doing them. Appropriate, timely cesarean delivery clearly has the potential to save lives and prevent permanent harm to mothers and babies. However, the sweet spot for the cesarean rate is between 10 and 15 percent, and the U.S. cesarean rate has hovered at 33 percent since 2009,41 which means we’re doing way too many cesareans in this country, and as the rest of this blog post will attest, those avoidable cesareans are doing a tremendous amount of harm.

Complications Inherent to Delivering Via Major Surgery

To begin with, inherent to surgical delivery compared with vaginal birth is:

  • More intense and longer-lasting pain.22, 44, 97
  • More difficult and lengthy recovery,55, 73, 115 which includes limitations on driving and lifting.97
  • The potential for chronic pelvic pain from the formation of internal scar tissue (adhesions) or from cesarean-scar endometriosis,6, 8, 15, 47, 62, 65, 79, 84, 112, 119 which happens when cells that make up the uterine lining seed into the abdominal, uterine, or skin wound at the time of the surgery; grow there; and cause cyclic pain.

Moreover, the issues of pain and recovery are magnified after a cesarean because, unlike recovery from other surgeries, you are also caring for a newborn while you deal with them.

In addition, having an unplanned cesarean increases the probability of viewing the birth negatively20, 73, 91—no surprise there—but also of more severe distress, including full-blown post-traumatic stress disorder.5, 14, 87, 91, 98 The research is inconclusive on whether unplanned cesarean increases likelihood of postpartum depression, but some studies find that it does.13, 73, 98

Excess Complication Rates with First Cesarean Versus First Vaginal Birth

This brings us to our comparison list of specific complications with having a first cesarean. As I said, I’ve divided my list into two subsections: first, the consequences of having a first cesarean compared with a first vaginal birth, which I’ll cover here, and second, the effects of having had a cesarean on future reproductive complications, which I’ll cover next.

Before we get to that, though, I need to explain what I mean by “excess complication rates.”

Let’s suppose I have a study that reports an incidence of 6 per 1,000 for a particular complication with cesarean delivery versus 2 per 1,000 with vaginal birth. That would make the excess with cesarean 6 per 1,000 minus 2 per 1,000, or 4 more occurrences of that complication per 1,000 cesarean deliveries. Now suppose I have a second study reporting on the incidence of the same complication that reports an incidence of 3 per 1,000 with cesarean delivery versus 1 per 1,000 with vaginal birth. The excess difference in this study would be 3 minus 1, or 2 per 1,000 cesarean deliveries. Finally, suppose I have a third study reporting an incidence of 7 per 1,000 for that complication with cesarean delivery versus 5 per 1,000 with vaginal birth, which would also be an excess of 2 per 1,000 cesarean deliveries. Taking the three studies together, the excess differences would range from 2 to 4 per 1,000 cesarean deliveries. To give you a sense of the likelihood of experiencing these complications as a result of having a cesarean, I’m going to group excess occurrence rates according to 1 to 9 more excess occurrences per 100, 1,000, 10,000, and 100,000 cesarean deliveries. Also, some complications are unique to having surgery. I’ve highlighted these by noting that the incidence with vaginal birth is zero.

Maternal complications: 
  • Excess maternal complications with cesarean falling in the range of 1 to 9 more per 100 include:
    • surgical incision complications or infection27, 51, 63 (incidence with vaginal birth = 0)
    • readmission to the hospital after discharge68, 72, 105
  • Excess maternal complications with cesarean falling in the range of 1 to 9 more per 1,000 include:
    • surgical wound hematomas (blood-filled swelling)69 (incidence with vaginal birth = 0)
    • major infection (not defined)69
    • anesthetic complications (not defined)69
    • re-operation70 (incidence with vaginal birth = 0)
    • urinary tract infection51, 63
  • Excess maternal complications with cesarean falling in the range of 1 to 9 more per 10,000 include:
    • cardiac arrest69
    • hysterectomy69
    • wound disruption69
    • thromboembolism (deep venous clots)69
    • septicemia (bloodstream infection)1
  • Excess maternal complications with cesarean falling in the range of 1 to 9 more per 100,000 include:
    • amniotic fluid embolism (a rare condition in which amniotic fluid or fetal cells enter the maternal bloodstream and trigger an overwhelming, sometimes fatal, allergic reaction)66
    • death24, 45
Newborn complications:
    • Excess newborn complications with cesarean falling in the range of 1 to 9 more per 100 include:
      • surgical cuts3, 25, 39, 100, 111 (vaginal birth rate = 0)
      • not breastfeeding or failure of breastfeeding21
    • Excess newborn complications with cesarean falling in the range of 1 to 9 more per 1,000 include:
      • breathing complications, especially with delivery at term (i.e., after 36 weeks) but before 39 weeks.26, 31, 42, 43, 60, 67, 77, 93, 95, 117
    • Excess newborn complications with cesarean falling in the range of 1 to 9 more per 10,000 include:
      • death: The study that found this used U.S. national statistics to compare newborn deaths in women at low risk for complications having elective cesareans, meaning no medical indication, with women planning vaginal birth.75

    Cesarean delivery also has long-term potential consequences for babies. Children delivered by cesarean are slightly more likely to develop asthma54, 85 or an autoimmune disease, including type 1 diabetes, inflammatory bowel disease, and juvenile arthritis,12, 54, 56, 93, 94 and they are more likely to be overweight in childhood.54, 93, 103

    As for why these associations, one explanation for the association between cesarean and autoimmune disease is differences with cesarean in the baby’s intestinal microbiome, that is, the organisms that colonize the baby’s intestines.93 This is because the baby doesn’t pass through the vagina, which is where it would pick up these organisms. Also, it is usual to give antibiotics prior to cesarean surgery to reduce the risk of infection, and the antibiotic crosses into the fetal circulation.93 (Note: ongoing breastfeeding can help remedy this because it transfers beneficial organisms to the baby that help build a healthy intestinal microbiome.10)

    The association with childhood overweight may also be explained by differences in the baby’s intestinal microbiome.93 Other explanations include less likelihood of breastfeeding with cesarean delivery,64 which increases probability of being overweight in childhood, as well as other effects of mode of delivery on inflammation, immune, or endocrine function independent of intestinal colonization.50, 93

    As for asthma, it, too, is an immune system disorder—in this case a dysfunctional reaction to certain triggers—so the effects of cesarean delivery on the microbiome could also apply.104 Another theory is that cesarean-born newborns are more likely to have breathing difficulties, and this is associated with increased risk of asthma.7

Excess Reproductive Complication Rates Consequent to Having a Prior Cesarean

The increased probability of complications with cesarean delivery doesn’t end with healing from the surgery. Cesareans have a long tail that extends throughout reproductive life. I’ve combined maternal and newborn complications in this section because unlike the initial cesarean, where complications arise at the birth and can be divided into those affecting the mother and those affecting the baby, having had a prior cesarean causes maternal complications that affect future pregnancies from conception through birth, and almost all of them necessarily pose risks to the baby as well.

Reproductive complications:
  • Reproductive complications:
    • Excess reproductive complications of one prior cesarean falling in the range of 10 or more per 100:
      • dense adhesions (internal scar tissue) (range in incidence 12 to 50 percent) (incidence with vaginal birth = 0)40, 74, 76, 81-83
    • Excess reproductive complications of one prior cesarean falling in the range of 1 to 9 more per 100:
      • less likely to have a second child, sometimes by choice but also because of inability to conceive 36, 38, 57, 58
      • miscarriage54
      • probably preterm birth at second birth with first birth cesarean versus first birth vaginal (9 out of 12 studies)9, 29, 34, 46, 49, 102, 108-110, 113, 114, 118
      • maternal blood transfusion30
      • maternal intensive care admission30
      • newborn need for breathing assistance30
      • newborn hospital stay longer than 7 days30
    • Excess reproductive complications at second delivery with first delivery cesarean versus first vaginal birth falling in the range of 1 to 9 more per 1,000:
      • placental abruption (the placenta detaches partially or completely before birth)9, 17, 52, 71, 116
      • placenta previa (the placenta overlays the cervix)9, 17, 37, 71, 116
      • placenta accreta (the placenta grows into the uterine muscle or even through it)19
      • stillbirth2, 9, 80, 86
      • newborn possibly small-for-gestational-age (weights in the 10th percentile or lower for gestational age) (3 of 6 studies)9, 17, 46, 49, 99, 102
      • the uterine incision scar gives way during labor35 (incidence with vaginal birth = 0)
      • hysterectomy52
      • maternal hospital readmission30
    • Excess reproductive complications of prior cesarean falling in the range of a 1 to 9 more per 10,000:
      • cesarean-scar ectopic pregnancy (the embryo implants inside the uterine scar) or early placenta accreta (the placenta develops within the cesarean scar, causing symptoms early in pregnancy)90, 92, 107 (incidence with vaginal birth = 0)
      • pregnancy loss due to cesarean-scar ectopic pregnancy or early placenta accreta90, 92, 107 (incidence with vaginal birth = 0)
      • the uterine incision scar gives way during pregnancy23, 35 (incidence with vaginal birth = 0)

    Abnormal placental attachment, cesarean scar ectopic pregnancy, and the uterine scar giving way increase the likelihood of severe hemorrhage, hysterectomy, injury to other organs or blood vessels during urgent cesarean surgery, abnormal clotting, a clot in the deep leg veins, and fluid in the lungs, as well as preterm birth and therefore its consequences, all of which increase the likelihood of death in baby and mother.28, 32, 33, 35, 59, 71, 76, 78, 88, 89, 101, 106 Dense adhesions make future cesareans, and, in fact, any future pelvic surgery more complicated and difficult and more likely to result in operative injury to internal organs or blood vessels.11, 18 And, as I said, any pregnancy or labor complication carrying severe consequences for the mother can also have severe potential consequences for the baby.

    Finally, as the number of repeat cesareans goes up, so does the incidence of abnormal placental attachment35 This in turn increases the probability of severe hemorrhage and hysterectomy,35, 61 preterm delivery and its consequences,16 and maternal and perinatal death in subsequent pregnancies and births. Placenta accreta, for example, the most dangerous of the placental attachment abnormalities, and fortunately the rarest, is associated with a 52 percent hysterectomy rate and a maternal mortality rate of 50 per 100,000.53 (For comparison’s sake, the US national maternal mortality rate the year before the COVID-19 pandemic was 20 per 100,000.48) The probability of dense adhesions goes up as well,35 resulting in increased risk of operative injury to bladder and bowel.16, 76, 83, 96

Your Takeaway

As I promised in my intro, here are a couple of blog posts with practical tips and ideas on how you can avoid an avoidable cesarean, “How Can You Avoid an Avoidable First Cesarean?” and “Policies and Practices that Avoid an Avoidable Cesarean.”


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