If you are pregnant or are hoping to become pregnant soon, you may be thinking about whether you will need a cesarean section, or C-section.
You’re not alone: C-section rates have gone up worldwide over the past few decades. In some Latin American countries, C-section rates are approaching 60 %. In some Northern European countries such as Iceland, Sweden and Norway, rates are significantly lower, closer to 15% to 17%. The United States is in the middle of these extremes: Approximately 1 in 3 pregnant women deliver via C-section.
We know that cultural and societal differences play a role in C-section rates. In the United States, some of the increase in cesarean rates is thought to be due to women having babies at older ages; advanced maternal age (35 years old or older) is a risk factor for needing a cesarean section.
Also, obesity and diabetes in pregnancy have increased in the United States and these are also risk factors for needing a cesarean section.
In general, we can group the reasons behind C-sections into three categories:
1. Scheduled C-sections due to certain medical or pregnancy-related conditions
2. Unplanned C-sections due to challenges during labor and delivery
3. Elective C-sections (patient choice without a medical indication)
Scheduled C-Sections Due to Certain Medical Conditions
When I have a patient with certain medical conditions or risk factors, I may recommend a C-section to ensure the health of mom and baby.
- Placenta previa: The placenta covers the cervix in such a way that a vaginal birth would be dangerous. Normally, the placenta attaches to the inner wall of the uterus, away from the uterine opening. Placenta previa occurs when the placenta attaches so low that it blocks the opening.
- History of previous surgery on the uterus, including certain fibroid surgeries
- Being pregnant with twins if the first baby is not head-down. We usually can safely deliver twins with vaginal delivery if both are head-down and, in some cases, where at least the first twin is head-down.
- Being pregnant with three or more babies. For triplets or higher, C-section is usually the best approach.
- Breech babies. A baby positioned in the uterus in a bottom-first/feetfirst position is a breech baby. Sometimes we can turn the baby, but for patients who don’t want to try that procedure, of if that procedure is unsuccessful, a C-section is the way to go.
- Expecting a very large baby, with an estimated weight more than 5000 grams (or about 11 pounds) in a mom without diabetes, and 4500 grams (or about 9.9 pounds) in a mom with diabetes. Large babies delivered vaginally are at higher risk for shoulder dystocia, a condition in which the baby’s shoulder gets stuck during delivery. A C-section in these cases can reduce the risk of birth injuries.
- People who had a prior cesarean delivery. If you previously had a C-section and are interested in delivering your next baby vaginally, that may be possible. A VBAC – vaginal birth after cesarean – is successful for many patients. Your doctor can help you determine whether you would be a good candidate for a VBAC, taking into account your age, body mass index (BMI), how many prior C-sections you had and why you had them. The biggest risk of VBAC is a 1% chance that the scar on your uterus from the prior C-section could open (uterine rupture). That is a medical emergency and why I recommend patients who are trying a VBAC do so in a hospital with the ability to do an emergency cesarean section in case it is needed.
Unplanned C-Sections
Sometimes, people intend to have a vaginal delivery but something unexpected happens during labor. This can lead to an unscheduled C-section.
One of the main reasons women would need to have a C-section in the middle of labor is a situation called arrest of labor, or failure to progress in labor. In this situation, labor lasts for many hours with little to no progress. Either the cervix stops dilating despite having adequate contractions, or the baby is not descending into the pelvis. This is usually not an emergency situation and one that your doctor will discuss with you along the way.
Abnormal fetal heart rate patterns (also referred to as fetal distress or fetal intolerance of labor) are another key reason behind unscheduled cesarean sections. For a variety of reasons, some babies are not able to tolerate the stress of labor, and a C-section would be the best, safest approach.
What if the baby’s umbilical cord is wrapped around the head? Most of the time, people are still able to have a vaginal delivery! A C-section may be needed if the cord is wound very tightly around the baby’s body or neck and is causing decreased blood flow during contractions or descent in the birth canal
Elective C-Sections
If a patient who otherwise is a candidate for vaginal birth chooses to have a C-section, that is considered an elective procedure. Some women choose to have a C-section because they want to have everything scheduled and planned. They fear going into labor at work or in the middle of the night or at another unexpected time or they fear the pain and unpredictable nature of labor itself. Having a planned surgery eases their concerns.
Some women also want to avoid vaginal delivery because they are concerned about future pelvic floor problems, such as incontinence or pelvic prolapse. I remind patients that even a C-section can be a risk factor for these conditions, so choosing a caesarean section is no guarantee.
C-Section Risks
For most women who do not have a medical situation in which a C-section is recommended, vaginal delivery is strongly encouraged. There are risks associated with C-sections, including risk of infection, bleeding that could require blood transfusion and, in extreme cases, a need for a hysterectomy. With a C-section, there is risk of damage to other organs, such as the bladder and ureter. Recovery from a C-section is generally longer than recovery from a vaginal birth. And for women who are planning more than one pregnancy, we strongly encourage a vaginal birth for the first child because the more C-sections someone has, the greater the risk of complications with future pregnancies.
Having a baby can be a truly exciting time, and your medical team wants to help ensure a healthy mom and a healthy baby. Talking to your doctor about your own unique situation can give you peace of mind that you are taking the right approach for you and your family.
Amy Banulis, MD, is a board-certified ob-gyn with the Mid-Atlantic Permanente Medical Group. She sees patients at the Kaiser Permanente Falls Church Medical Center.
Liam McCrickard holds a B.A. in creative and professional writing from Goucher College. He is former assistant editor at Washington Parent. He works as a freelance designer, writer and editor of tabletop role-playing games.
Amy Banulis, MD, is a board-certified ob-gyn with the Mid-Atlantic Permanente Medical Group. She sees patients at the Kaiser Permanente Falls Church Medical Center.
