We all know the primary risk of VBAC – uterine rupture. And when your typical VBACing mom meets with an OB, she must sign a “VBAC consent form” acknowledging that she understands this risk. However, I find it ironic that women signing up for a repeat cesarean are not required by their OB to sign a “Repeat Cesarean Section consent form” as a matter of course during prenatal exams since there are risks associated with cesarean section. But since this does not happen, and most OBs breeze over the risks if they even bother to mention them, expectant moms are lead to believe that VBACs are risky and cesareans are not.
What most moms signing up for cesareans don’t know, is that this decision not only introduces risks that can impact them or their baby immediately, but this decision also impacts their future fertility as well as future cesarean deliveries and babies. And some of these complications increase with each surgery.
The Risks of Cesarean Section
A Coalition for Improving Maternity Services Fact Sheet
Cesarean section is the most common major surgical procedure performed in the United States. The Coalition for Improving Maternity Services (CIMS) is concerned about the dramatic increase and ongoing overuse of cesarean section. The surgical procedure poses short- and long-term health risks to mothers and infants, and a scarred uterus poses risks to all future pregnancies and deliveries. For these reasons, CIMS recommends that cesarean surgery be reserved for situations when potential benefits clearly outweigh potential harms. The cesarean rate can safely be less than 15 percent84 and 11 percent or less in low-risk women giving birth for the first time,28 yet, in 2007 the U.S. cesarean rate was 32 percent.30 When cesarean surgery rates rise above 15 percent health outcomes for mothers and babies worsen,5 and increasing numbers of scheduled cesareans are contributing to the rising number of late-preterm births.2,6
Cesarean rates have been rising for all women in the United States regardless of medical condition, age, race, or gestational age,52 and while the number of first cesareans performed without medical indication is increasing, no evidence supports the beliefs that these elective cesareans represent maternal request cesareans or that the rise in elective first cesareans has contributed significantly to the overall increase in cesarean rates.52 Elective first cesarean at physician request may, however, play a significant role,39 and the rise in elective repeat surgeries, which has climbed by more than 40 percent in the last ten years, certainly does.64 Although 70 percent of women or more who plan a vaginal birth after cesarean (VBAC) can birth vaginally and avoid the complications of repeat cesarean surgeries,28 almost all women today have a repeat operation because most doctors and many hospitals refuse to allow VBAC.20,35,54
A cesarean can be a life-saving operation, and some babies would not be born vaginally under any circumstances; however, it is still major surgery. Women have a legal right to know the risks associated with their treatment and the right to accept or refuse it.14 CIMS encourages childbearing women to take advantage of their rights and to find out more about the risks of cesarean section so they can make informed decisions about how they want to give birth.
What are the potential harms of cesarean surgery compared with vaginal birth?
Health outcomes after a cesarean may be worse because medical problems may lead to surgery. This fact sheet, however, is based on research that determined excess harms arising from the surgery itself. In other words, women with a healthy pregnancy who have a cesarean rather than a vaginal birth are at increased risk for the following complications as are their babies:
Potential Harms to the Mother
Compared with vaginal birth, women who have a cesarean are more likely to experience:
• Accidental surgical cuts to internal organs.53,60,72
• Major infection.43,48
• Emergency hysterectomy (because of uncontrollable bleeding).38,48,83
• Complications from anesthesia.28
• Deep venous clots that can travel to the lungs (pulmonary embolism) and brain (stroke).28,48
• Admission to intensive care.58
• Readmission to the hospital for complications related to the surgery.18,28
• Pain that may last six months or longer after the delivery.19 More women report problems with pain from the cesarean incision than report pain in the genital area after vaginal birth.19
• Adhesions, thick internal scar tissue that may cause future chronic pain, in rare cases a twisted bowel, and can complicate future abdominal or pelvic surgeries.19
• Endometriosis (cells from the uterine lining that grow outside of the womb) causing pain, bleeding, or both severe enough to require major surgery to remove the abnormal cells.27
• Appendicitis, stroke, or gallstones in the ensuing year.18,46,47,50 Gall bladder problems and stroke may be because high-weight women and women with high blood pressure are more likely to have cesareans.
• Negative psychological consequences with unplanned cesarean. These include:
o Poor birth experience, overall impaired mental health, and/or self-esteem.12
o Feelings of being overwhelmed, frightened, or helpless during the birth.20
o A sense of loss, grief, personal failure , acute trauma symptoms, posttraumatic stress, and clinical depression.37
Potential Harms to the Baby
Compared with vaginal birth, babies born by cesarean section are more likely to experience:
• Accidental surgical cuts, sometimes severe enough to require suturing.1,28
• Being born late-preterm (34 to 36 weeks of pregnancy) as a result of scheduled surgery.6
• Complications from prematurity, including difficulties with respiration, digestion, liver function, jaundice, dehydration, infection, feeding, and regulating blood sugar levels and body temperature.25,26 Late-preterm babies also have more immature brains,63 and they are more likely to have learning and behavior problems at school age.25,26
• Respiratory complications, sometimes severe enough to require admission to a special care nursery, even in infants born at early term (37 to 39 weeks of pregnancy).28 Scheduling surgery after 39 completed weeks minimizes, but does not eliminate, the risk.31,32
• Readmission to the hospital.25
• Childhood development of asthma,3,78 sensitivity to allergens,61 or Type 1 diabetes.11
• Death in the first 28 days after birth.51
Potential Harms to Maternal Attachment and Breastfeeding
Failure to breastfeed has adverse health consequences for mothers and babies. Breastfeeding helps protect mothers against postpartum depression, Type 2 diabetes, high blood pressure, heart disease, ovarian and pre-menopausal breast cancer, and osteoporosis later in life.36,71 Breastfeeding helps protect babies against ear infections, stomach infections, severe respiratory infections, allergies, asthma, obesity, Type 1 and Type 2 diabetes, childhood leukemia, sudden infant death syndrome (SIDS), and necrotizing enterocolitis (a severe, life-threatening intestinal infection).15,36
• Women who have unplanned cesareans are more likely to have difficulties forming an attachment to their babies.23
• Women who have cesareans are less likely to have their infants with them skin-to-skin (cradled naked against their bare chest) after the delivery.20 Babies who have skin-to-skin contact interact more with their mothers, stay warmer, and cry less. When skin-to-skin, babies are more likely to be breastfed early and well, and to be breastfed for longer. They may also be more likely to have a good early relationship with their mothers, but the evidence for this is not as strong.16,57
• Women are less likely to breastfeed.21,44
Potential Harms to Future Pregnancies
With prior cesarean, women and their babies are more likely to experience serious complications during subsequent pregnancy and birth regardless of whether they plan repeat cesarean or vaginal birth. The likelihood of serious complications increases with each additional operation.28
Compared with prior vaginal birth, prior cesarean puts women at increased risk of:
• Uterine scar rupture. Planning repeat cesarean reduces the excess risk, but it is not completely protective.8,49,55,75
• Infertility, either voluntary (doesn’t want more children) or involuntary (can’t have more children).7,12,56,70,74,79,80
• Cesarean scar ectopic pregnancy (implantation within the cesarean scar), a condition that is life-threatening to the mother and always fatal for the embryo.67
• Placenta previa (placenta covers the cervix, the opening to the womb), placental abruption (placenta detaches partially or completely before the birth), and placenta accreta, (placenta grows into the uterine muscle and sometimes through the uterus, invading other organs), all of which increase the risk for severe hemorrhage and are potentially life-threatening complications for mother and baby.17,28,85
• Emergency hysterectomy.42,53
• Preterm birth and low birth weight.6,40,65,73,76
• A baby with congenital malformation or central nervous system injury12 due to a poorly functioning placenta.
Cesarean Surgery and Pelvic Floor Dysfunction
Cesarean proponents claim that cesarean surgery will prevent pelvic floor dysfunction, but it offers little or no protection once healing is complete and no protection in later life.12 Moreover, risk-free measures such as engaging in exercises to strengthen the pelvic floor or losing weight can often improve or relieve stress urinary incontinence (loss of urine with pressure on the pelvic floor such as with exercise, laughing, sneezing, or coughing).9,12
• Cesarean surgery does not protect against sexual problems,4,33,41 gas or stool incontinence,10,59 or urge urinary incontinence (loss of urine after sudden need to void).10,13,24,62,82
• Cesarean surgery does not protect against severe stress urinary incontinence.62,82 As many as one more woman in six having vaginal birth may experience stress urinary incontinence of some degree, mostly minor, at six months or more after birth.10,13,24,62,82
• Perhaps one more woman in twenty having vaginal birth will experience symptomatic pelvic floor prolapse (muscle weakness causes the internal organs to sag downwards).45,66,77,81 With three or more vaginal births, this number may be as high as one more woman in ten.66 However, many other factors, including smoking, hysterectomy, hormone replacement therapy, constipation, irritable bowel syndrome, and urinary tract infections are also associated with pelvic floor prolapse.
Cesarean Section, Care Providers and Place of Birth
To reduce the risk of cesarean surgery, CIMS encourages women to seek providers and hospitals with low cesarean rates (15% or less) and those that support VBAC. Women can access this data from their state health departments. They can also access hospital-specific cesarean rates and rates for other birth interventions for several states at www.thebirthsurvey.com and a listing of hospitals that do or do not support VBAC from the International Cesarean Network at http://ican-online.org/vac-ban-info.
Healthy women at low risk for complications should also know that choosing midwifery care or giving birth in a birth center or at home can lower their risk for cesarean section.68,69 Having a doula reduces the likelihood of a cesarean as well.34
This fact sheet was co-authored by Henci Goer, BA and Nicette Jukelevics, MA, ICCE.
This fact sheet is endorsed by the following organizations (as of Feb. 2010). Academy of Certified Birth Educators, Birth Matters Virginia, BirthNet of Albany NY, BirthNetwork National, Birth Network of Santa Cruz, Birth Works International, Childbirth Connection, Choices in Childbirth, Citizens for Midwifery, DONA International, International Childbirth Education Association, Lamaze International, The Lawton and Rhea Chiles Center for Healthy Mothers and Babies, Midwives Alliance of North America, National Association of Certified Professional Midwives, North American Registry of Midwives, Perinatal Education Associates, Reading Birth and Women’s Center, The Tatia Oden-French Memorial Foundation, toLabor: The Organization of Labor Assistants for Birth Options and Resources.
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