Best Evidence: C-Section

• physical effects of cesareans on mothers around the time of birth
• psychological effects of cesareans on mothers around the time of birth
• ongoing effects of cesareans on mothers
• effects of cesareans on babies
• effects of cesareans on mothers in future pregnancies and births
• effects of cesareans on future babies (when a baby grows in a uterus with a cesarean scar)
• effects of vaginal birth on mothers
• effects of vaginal birth on babies

What are some concerns about physical effects of cesareans on mothers around the time of birth?

• maternal death: some studies found that cesarean surgery itself, not any problems that led to surgery, appeared to cause additional maternal deaths compared with vaginal birth.
  Added likelihood for a woman with a cesarean: LOW to VERY LOW for maternal death
• emergency hysterectomy: a woman with a cesarean is more likely than a woman with vaginal birth to have emergency surgery to remove her uterus (hysterectomy) in the early weeks after birth.
  Added likelihood for a woman with a cesarean: MODERATE for emergency hysterectomy
• blood clots and stroke: a woman with a cesarean appears to be more likely than a woman with vaginal birth to have blood clots, including clots blocking blood vessels in the lungs (pulmonary embolism) and blocking blood flow to the brain (stroke).
  Added likelihood for a woman with a cesarean: LOW for blood clots and stroke
• injuries from surgery: all women who have a cesarean have a wound; a woman with a cesarean may also be injured from accidental cuts to nearby organs such as the bladder or bowel or ureter (the tube that carries urine from the kidney to the bladder), especially if the surgery is done in haste.
  Added likelihood for a woman with a cesarean: VERY HIGH for abdominal wound
  Added likelihood of accidental cuts from surgery cannot be determined from studies examined
• longer time in hospital: a woman who has a cesarean usually stays in the hospital a day or two longer than a woman who has a vaginal birth for post-operative monitoring and care, and this stay may be extended if she has complications.
  Added likelihood for a woman with a cesarean: VERY HIGH for a longer time in the hospital
• going back into the hospital: a woman who has a cesarean is more likely than a woman with vaginal birth to be readmitted to the hospital in the weeks after birth.
  Added likelihood for a woman with a cesarean: MODERATE for going back to the hospital
• infection: a woman with a cesarean is at risk for wound infection and may be much more likely than a woman with vaginal birth to have an infected uterus; women with a cesarean generally receive routine antibiotics to try to prevent infection.
  Added likelihood for a woman with a cesarean: HIGH for infection
• pain: in the first days and weeks after birth, a woman who has had a cesarean is likely to have more intense and longer-lasting pain than a woman with vaginal birth; most women with a cesarean use pain medication after birth and consider pain at the cesarean wound to be a problem.
  Added likelihood for a woman with a cesarean: VERY HIGH for more severe and longer-lasting pain

What are some concerns about psychological effects of cesareans on mothers around the time of birth?

• poor birth experience: a woman with a cesarean tends to give lower ratings to her birth experience than a woman with a vaginal birth, both early on and over time; she may be less likely to have her partner or other support people present; and to feel that she had control.
  Added likelihood for a woman with a cesarean: VERY HIGH to HIGH for poor birth experience (unplanned cesarean is worse than planned cesarean, vaginal birth with vacuum extraction or forceps is worse than vaginal birth without these procedures)
• less early contact with her baby: a woman with a cesarean is less likely to see and hold her baby soon after birth than a woman with vaginal birth.
  Added likelihood for a woman with a cesarean: VERY HIGH for seeing and holding the baby later
• unfavorable early reaction to her baby: early on, a woman with a cesarean is more likely to have negative feelings about her baby and to evaluate her baby less favorably than a woman with vaginal birth.
  Added likelihood for unfavorable early reaction to babies cannot be determined from studies examined
• depression: a woman who has had a cesarean may be at higher risk for depression than a woman with vaginal birth.
  Current evidence is mixed on whether cesarean increases likelihood of depression
• psychological trauma: a woman who has an unplanned cesarean during labor is at higher risk than other mothers for having traumatic symptoms (such as fear and anxiety) and for meeting criteria of Post-Traumatic Stress Disorder (PTSD).
  Added likelihood for a woman with an unplanned cesarean: HIGHfor having traumatic symptoms and for meeting criteria of PTSD (unplanned cesarean or vaginal birth with vacuum extraction or forceps pose HIGH extra risk in comparison with planned cesarean or vaginal birth with no vacuum/forceps)
• poor overall mental health and self-esteem: a woman who has a cesarean section may be at greater risk for poorer overall mental health and lower self-esteem than a woman with vaginal birth.
  Added likelihood for poor overall mental health and self-esteem cannot be determined from studies examined
• poor overall functioning: a woman who has a cesarean section may face greater challenges than a woman with vaginal birth for physical and social functioning and carrying out daily activities in the early weeks after birth.
  Added likelihood for poor overall functioning cannot be determined from studies examined

What are some concerns about ongoing effects of cesareans on mothers?

• ongoing pelvic pain: a woman who has had a cesarean may have ongoing pelvic pain, possibly due to scarring and the growth of adhesion tissue.
  Added likelihood for ongoing pelvic pain cannot be determined from studies examined
• bowel obstruction: a woman who has had a cesarean may develop twisted and blocked intestines in the years after surgery as a result of scarring and adhesion tissue in the abdomen.
  Added likelihood for a woman with a cesarean: MODERATE for bowel obstruction

What are some concerns about effects of cesareans on babies?

• surgical cuts: a baby born by cesarean section may be accidentally cut (usually minor) during the surgery.
  Added likelihood for a baby born by cesarean: HIGH for accidental surgical cuts
• respiratory problems: a baby born by a planned cesarean before the 39th week of pregnancy is at higher risk for mild to serious lung and breathing problems than other babies born at the same time.
  Added likelihood for a baby born by cesarean: HIGH to MODERATE for respiratory problems with a planned cesarean before 39 weeks
• not breastfeeding: a mother who has had a cesarean faces extra challenges in getting breastfeeding under way, and her baby is less likely to be breastfed than a baby born vaginally.
  Added likelihood for a baby born by cesarean: VERY HIGH to HIGH for not breastfeeding
• asthma: a person who is born by cesarean section appears to be at higher risk than a person born vaginally for asthma, both in childhood and in adulthood.
  Added likelihood for a person born by cesarean: HIGH for greater risk for asthma

What are some concerns about effects of cesareans on mothers in future pregnancies and births?

• infertility: a woman who has had a cesarean is more likely than a woman with a previous vaginal birth to have difficulty conceiving another baby and is less likely to ever have another baby.
  Added likelihood for a woman with a previous cesarean: VERY HIGH to HIGH for infertility (not by choice)
• reduced fertility: a woman who has had a cesarean is more likely than a woman with a previous vaginal birth to have negative feelings and attitudes about childbirth, to decide not to have additional children, and to point to these feelings and attitudes as the reason for this decision.
  Added likelihood for a woman with a previous cesarean: HIGH for reduced fertility by choice
• maternal death: in future pregnancies and births, a woman whose uterus has a cesarean scar is more likely than a woman with a previous vaginal birth to have life-threatening problems with the placenta and the scar (see next points).
  Added likelihood for a woman with a previous cesarean: has not been measured well, may be VERY LOW for maternal death related to scar
• ectopic pregnancy: a woman whose uterus has a cesarean scar is more likely than a woman with an unscarred uterus to have an embryo grow outside her uterus, including a cesarean scar pregnancy; in such cases, the pregnancy must be ended to save her life, and she may have severe bleeding, emergency surgery, which may include emergency removal of her uterus (hysterectomy), and other complications.
  Added likelihood for a woman with a previous cesarean: MODERATE for ectopic pregnancy
• placenta previa: a woman whose uterus has a cesarean scar is more likely than a woman with an unscarred uterus to have a future placenta attach near or over the opening to her cervix; this increases her risk for serious bleeding, shock, blood transfusion, blood clots, planned or emergency delivery, emergency removal of her uterus (hysterectomy), placenta accreta (see next), and other complications.
  Added likelihood for a woman with a previous cesarean: MODERATE for placenta previa in a future pregnancy after having one cesarean; HIGH for placenta previa in a future pregnancy after having more than one cesarean
• placenta accreta: a woman whose uterus has a cesarean scar is more likely than a woman with an unscarred uterus to have a future placenta grow through the uterine lining and into or through the muscle of the uterus; this increases her risk for a ruptured uterus (see below), serious bleeding, shock, blood transfusion, emergency surgery, emergency removal of her uterus (hysterectomy), and other complications.
  Added likelihood for a woman with at least one previous cesarean: MODERATE for placenta accreta in a future pregnancy
• placental abruption: a woman whose uterus has a cesarean scar is more likely than a woman with an unscarred uterus to have a future placenta detach from her uterus before the baby is born; this increases her risk for severe bleeding, shock, blood transfusion, blood clots, planned or emergency cesarean delivery, and other complications, and it may reduce oxygen and nutrients to her baby
  Added likelihood for a woman with a previous cesarean: MODERATE for placental abruption
• rupture of the uterus: a woman whose uterus has a cesarean scar is more likely than a woman with an unscarred uterus to have the wall of the uterus give way in a future pregnancy or labor, especially at the site of the scar; this increases her risk for severe bleeding, shock, blood transfusion, blood clots, planned or emergency cesarean delivery, emergency removal of the uterus (hysterectomy), and other complications; whether a woman plans a repeat cesarean or a VBAC (vaginal birth after cesarean), she is at greater risk for a ruptured uterus than a woman with no previous cesarean.
  Added likelihood for a woman with a previous cesarean: MODERATE for rupture of the uterus

What are some concerns about effects of cesareans on future babies (when a baby grows in a uterus with a cesarean scar)?

• death: a baby who develops in a uterus with a cesarean scar appears to have an increased risk of dying before (stillbirth) or shortly after birth compared with a baby who develops in an unscarred uterus.
  Added likelihood for a baby who grows in a uterus with a cesarean scar: MODERATE for death of the baby
• low birthweight and preterm birth: a baby who develops in a uterus with a cesarean scar may be at higher risk for being born too small (low birthweight) and for being born too soon (preterm birth) than a baby who develops in an unscarred uterus.
  Added likelihood for low birthweight and preterm birth cannot be determined from studies examined
• malformation: a baby who develops in a uterus with a cesarean scar may be at higher risk for having a physical malformation that develops before birth than a baby who develops in an unscarred uterus.
  Added likelihood for malformation cannot be determined from studies examined
• central nervous system injury: a baby who develops in a uterus with a cesarean scar may be at higher risk for having a brain or spinal cord injury than a baby who develops in an unscarred uterus.
  Added likelihood for central nervous system injury cannot be determined from studies examined

What is a concern about effects of vaginal birth on mothers?

• painful vaginal area: a woman who has a vaginal birth is more likely than a woman who has a cesarean to have a painful vaginal area in the weeks and months after birth.
  Added likelihood for a woman with vaginal birth: VERY HIGH for a painful perineum in the weeks and months after birth
• urinary incontinence: a woman who has a vaginal birth is more likely than a woman who has a cesarean to leak urine.
  Added likelihood for a woman with vaginal birth: depends on how this is defined, time elapsed since the birth, and procedures and practices used during vaginal birth. (How can I prevent pelvic floor problems when giving birth? is a full Maternity Topic on this website.)
• bowel incontinence: a woman who has a vaginal birth is more likely than a woman who has a cesarean to have leakage of gas or, more rarely, of feces.
  Added likelihood for a woman with vaginal birth: depends on how this is defined, time elapsed since the birth, and procedures and practices used during vaginal birth. (How can I prevent pelvic floor problems when giving birth? is a full Maternity Topic on this website.)

What is a concern about effects of vaginal birth on babies?

• birth injury: in comparison with cesarean birth, a baby born by vaginal birth may be at higher risk for nerve injury affecting the shoulder, arm or hand (brachial plexus injury); although most of these injuries are temporary, some are permanent. Added likelihood for a baby born with vaginal birth: LOW for brachial plexus injury.

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