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C-sections: Why and How to Avoid Having One

You probably know lots of women who have given birth by c-section. So why is it so often talked about like a bad thing? Well, it’s more complicated than “good” and “bad, ” but there are reasons you want to avoid a c-section. This is your guide to understanding the risks of c-sections and how to decrease your chances of having one.

woman after a c-section

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Did you know that nearly 1 in 3 babies born in the US today are born by c-section? That’s about 33%.

For comparison, in 1997, the c-section rate in America was just over 20% (1 in 5). And in 1970, it was just 5.5% (about 1 in 20). That means that in just my lifetime, the rate has increased by 60%. And in just my parents’ lifetime it’s increased by 500%.

The Problem With C-sections

So what’s the big deal? Why are c-sections so “bad”?

Well, first of all, they aren’t inherently bad. Sometimes a c-section is the only way to save the life of a baby or a mom. It’s a good thing we have doctors who know how to safely perform a c-section.

But the problem with c-sections is that far more are being performed than are truly necessary and that means too many women and babies are being exposed to unnecessary risk.

In 2015, a group of researchers found that c-section rates higher than 19% do not improve outcomes for mothers or babies. At the same time, the WHO maintains that the rate shouldn’t be higher than 10%.

Either way, the point is still the same: one third of births should not be happening by c-section.

Three Big Risks

There are three main risks that c-sections pose:

  1. A cesarean section is major abdominal surgery.
  2. Vaginal births provide benefits to babies that c-sections don’t.
  3. One c-section has implications for all successive births.

Let’s dive into each one to understand more.

A c-section is major abdominal surgery.

First, a c-section is a surgical procedure. Obstetricians are surgeons and this is their specialty.

In order to get the baby out, an obstetrician has to go through 7 layers: skin, fat, fascia, muscle, peritoneum, uterus, and amniotic sac. (The abdominal muscles are the only layer that is not cut; they are simply pushed out of the way to either side.)

The uterus is near the bladder, which is pulled out of the way during the procedure, so there is a risk of damaging the bladder.

After the baby is out, the incisions are stitched up. Some women (somewhere between 3% and 15%) develop an infection around the incision while it’s healing. C-sections also increase your risk of hemorrhaging and of needing a blood transfusion.

In addition to that, like any surgery, recovery takes time. Recovering from a c-section is usually longer and harder than recovering from a vaginal birth.

Finally, the risk of dying is slightly increased if you have a c-section compared to if you gave birth vaginally.

While the likelihood is small (roughly 10 in every 100,000), it is possible. Many of the factors above could potentially be fatal, including infection, damage to other organs, and serious blood loss.

Vaginal births provide benefits to babies that c-sections don’t.

Second, babies born by c-section miss out on some benefits that babies born vaginally receive. 

As babies move through their mother’s vagina, they are exposed to the natural bacteria there. This exposure has lots of health benefits. It boosts their immune system, improves their gut health, and lowers their risk of asthma, allergies, and other health conditions.

None of that happens if a baby is born by c-section. (Some degree of healthy bacteria is transferred to baby if mom labors for a little while before having a c-section, though.)

Babies born vaginally also experience what is called the “fetal heimlich maneuver.” That’s just a fancy way to say that the pressure of being pushed out through their mom’s vaginal opening expels amniotic fluid from a baby’s lungs and airways.

The fetal heimlich maneuver is far more effective than suctioning out a baby’s nose and mouth with a device. This is significant because it contributes to the fact that babies born by c-section have more breathing problems than babies born vaginally do. 

Hormones also come into play here. Both mom and baby get a surge of hormones right before birth. That surge is far less pronounced in moms and babies who experience a c-section.

The purpose of that surge is manifold, but one purpose is to provide the baby with a final boost to prepare it for the world it is about to enter.

Babies who don’t experience that surge are more likely to have respiratory issues (compounding the issue of the fetal heimlich maneuver). That surge also plays a role in the baby’s ability to regulate his or her body temperature right after birth.

Additional Risks to Baby

In addition to the problems directly related to not being born vaginally, babies are exposed to a few other risks when born by c-section.

Occasionally, as the doctor makes the incision in a mother’s abdomen and uterus, the baby will get cut. This “fetal laceration” happens about 0.7 – 3% of the time. Most often it isn’t serious and the baby will heal just fine. Rarely, the cut is serious.

Another risk is the possibility of accidental prematurity. Due dates are usually inaccurate, so even if you are close to your due date, you baby may not be ready for life outside the womb.

If your baby is not as developed as you think, a scheduled c-section may cause them to be accidentally premature. They might need to stay in the NICU and may have other complications.

It’s also been found that mother and baby pairs who experience a c-section are less likely to breastfeed exclusively or to breastfeed as long. 

One c-section has implications for any successive births.

Finally, a c-section is risky because once a woman has one c-section, all her future births are potentially impacted. There are two aspects of this.

First, for a woman who has had a c-section before, there’s an almost 90% chance that her next birth will also be a c-section.

Though many women could safely try for a VBAC – a vaginal birth after cesarean – many doctors recommend a repeat c-section. The reasons for that recommendation are varied, both in motivation and validity, but that’s a topic for another day.

Risks of Repeat C-sections

All the same risks apply to that second (or third or fourth) c-section, but now there’s a few more potential complications.

Obviously, you’ll have a scar where the incision was made during the previous birth. Scar tissue – and similar tissue called adhesions – can build up both externally and internally.

That scar tissue makes it more dangerous to make another incision because of potential injury to nearby organs.

The risk of hernia along the incision site also increases with each successive c-section.

Problems with the placenta – like placenta accreta and placenta previa – increase with each one, too.

Finally, though still rare, maternal mortality – the number of mothers that die – related to elective repeat c-sections (choosing to have a c-section before labor begins), is significantly higher than those who try for a VBAC.

The mortality rate increases by more than 250% – from 3.8 out of 100,000 births (trying for VBAC) to 13.4 out of 100,000 births (elective repeat c-section).

Risks of VBACs

The other way c-sections affect all future births is that now having a vaginal birth might be a little more risky.

When a woman tries for a VBAC (remember, that’s a vaginal birth after cesarean), she’ll go through labor like normal. This is called a trial of labor after cesarean, or TOLAC.

Somewhere around 70% of TOLACs do end in a vaginal birth.

The rest end in another c-section, for various reasons.

Most doctors believe VBACs need to happen in hospitals, where the operating room is readily available. While that may be important for some women, many women have had a successful VBAC at home or in a birth center. You always have choices.

The main risk of a TOLAC is what is called uterine rupture. It is rare – happening in only about 0.07% of pregnancies (70 out of every 100,000) – but it is dangerous.

A uterine rupture is when the uterus tears open spontaneously. Most often, it happens along the line of a previous c-section incision. Uterine rupture can be fatal, but if quick action is taken, both the mother and the baby can be saved most of the time. 

Now, of course none of these things – with a repeat c-section or a VBAC – are guaranteed to happen. You may experience none of them, even if you have 2 or 3 or more cesareans. But your risk does increase so I think it’s important for everyone to know what the dangers are.

“Success Rate” of VBAC (A Statistic You Need to See)

I want to share one thing before we move on. That 70% “success rate” number of TOLACs is the hospital statistic. I know that because nearly 99% of women in the US give birth in the hospital.

But that isn’t necessarily an accurate number. Why? Because there’s proof it can be better.

Over a span of 40 years, midwives at The Farm Midwifery Center cared for 127 mothers trying for a VBAC. Only 4 of those ended in a c-section. That’s a 96.8% success rate.

I’m just saying…it’s possible.

READ MORE >> Midwife or OBGYN: Which is Right For Me? (15 Questions to Help You Decide)

Things That Increase the Likelihood of a C-section

So are there things that increase your likelihood of a c-section? Yes. They include:

  • Where you give birth
  • Medications and other interventions used during labor
  • Carrying multiples (twins or more)
  • Unideal positioning of the baby
  • Dehydration
  • Maternal age
  • Being overweight
  • Pre-existing conditions, like heart disease

Let’s look at each one in a little more detail.

Where You Give Birth

It may be obvious to you that being at home will change how likely a c-section is compared to a hospital. Your care provider is a midwife and the operating room isn’t just a few rooms away.

But more than that, which hospital you go to can increase your chance of a c-section by more than nine times.

C-section rates vary from hospital to hospital and doctor to doctor because of hospital policies and the different ways doctors practice. The doctor is the main determining factor in whether a c-section happens or not and they don’t always make perfect judgment calls.

It would be easy for a doctor to see something on the fetal monitoring systems and worry that something is wrong when really everything is fine. It’s also possible that a doctor chooses to recommend a c-section for other reasons – time or money or legal reasons. 

The moral of the story is to have a clear conversation with your doctor about their c-section rate, and if it’s not satisfactory, find a different doctor! (Or just hire a midwife instead.)

Medical Intervention

Sometimes using one medicine or intervention during labor (like getting induced or using continuous fetal monitoring) leads to more and more intervention until, eventually, a mother has a c-section.

Not every woman will experience this “cascade of interventions,” but too many do.

Multiples (Twins or More) and Positioning of Baby

OBGYNs will perform a c-section for twins most of the time. For a doctor trained to see birth as a medical event, having two babies must seem like twice the risk. (That’s usually not the case.)

Another reason twins are often born by c-section is that it’s common for one of the babies to be breech. Breech is when the baby’s butt or feet are down instead of their head. OBGYNs aren’t trained to help breech babies be born, so a c-section is often automatically recommended to a mother with a breech baby.

Dehydration

Though most hospitals require IVs during labor, studies have found that a typical amount of fluids given through an IV (125 mL/hr) is insufficient to keep a woman hydrated. The same studies found that women who were dehydrated were up to 30% more likely to have a c-section.

Maternal Age and Being Overweight

A mother’s age and weight are tricky subjects when it comes to the possibility of increasing risk. Though older women and women who are overweight do tend to have more c-sections, it may not be true to say that these factors always increase your risk.

A 37-year-old woman may be in far better shape – and therefore much more prepared for a vaginal birth – than a 20-year-old woman. 

And a mother who has an average weight may have other complications that make it more likely that she’ll have a c-section than a mother with an otherwise healthy pregnancy who is overweight.

So while it’s a good idea to be aware of age and weight as factors in the likelihood of a c-section, know that there are likely things that have a far greater effect on your outcomes.

Pre-existing Conditions

Certain medical conditions that existed before pregnancy may make it unsafe to go through labor or birth a baby vaginally. In other words, some (relatively rare) conditions may make a c-section the best option. This list is shorter than many people believe, though.

If you have an active HIV or herpes infection in your vagina, giving birth vaginally will likely pass that on to your baby. That is usually a good reason for a c-section.

Heart conditions may also make it unsafe for you to get pregnant and give birth. (Even then, though, many times vaginal birth can still be safely attempted.)

Circumstances like having diabetes or uterine fibroids can increase your need for a c-section but don’t necessarily require one.

Things That Decrease the Likelihood of a C-section

Now let’s talk about some things that decrease your likelihood of a c-section. These are more fun to talk about because most of them are things you can do long before labor starts to prepare for a good experience.

To decrease your chance of having a c-section you can…

  • Eat well during pregnancy
  • Exercise regularly during pregnancy
  • Choose a labor support person who can be with you through all of labor
  • Stay home until active labor begins
  • Work through your fears about birth
  • Ask questions when your doctor recommends anything

Let’s learn a little more about each.

Eat well during pregnancy.

First and foremost, if you want to avoid a c-section, eat well. Good nutrition during pregnancy is important for lots of reasons. One of those is that a nutrient-dense diet supplies your muscles and tissues with the things they need to be healthy, flexible, and ready to give birth to a baby.

And the more ready your body is, the better labor will be able to proceed like it’s meant to and the less likely intervention and injury are.

I recommend The Brewer Diet. You can learn all about it in The Brewer Diet: What, Why, and How (+ free checklist).

Exercise regularly throughout pregnancy.

Like eating well, exercising during pregnancy helps your body be ready for the intense physical demands of labor. Specific labor prep exercises can target the muscles that will be called upon during labor.

Exercising can also reduce your risk of developing fibroids. Fibroids are non-cancerous growths in the uterus. They can cause problems during labor and are a risk factor for hysterectomy so you want to avoid them if you can. (And, as I alluded to above, some doctors will want to perform a c-section if you have fibroids.)

RELATED >> The Best At-Home Pregnancy Workouts

Choose a labor support person who can be with you through all of labor.

Having a familiar, trusted person with you continually during labor has lots of benefits, including a better chance of a vaginal birth and less likelihood of a c-section.

A doula is likely going to help you achieve the best outcomes, but anyone – your husband, your best friend, your mom – can be your support person.

Stay home until active labor begins.

Even if you plan to give birth in the hospital, labor at home as long as you can. Learn the signs of the different stages of labor so you know when you are in active labor and so you can avoid going to the hospital too soon.

Home is the ideal place for early labor because at home you are more relaxed, you can move around more, and you can eat and drink whatever you want. Each of those things will help you to labor more effectively and more comfortably.

Plus, the longer you stay home, the shorter amount of time you’ll be in a situation where interventions and medications are common (both of which can negatively affect your labor and make a c-section more likely).

Work through your fears about birth.

In 1933, Dr. Grantly Dick-Read, an obstetrician and natural birth advocate, introduced a concept that we now call the “fear-tension-pain cycle.” In short, his belief was that a woman who was afraid to give birth would hold that fear as tension in her body.

That tension would prevent her from relaxing and therefore make contractions more painful. The more pain the woman experienced, the more scared she would get and the cycle would continue.

That cycle is the driving idea behind the many childbirth methods that emphasize relaxation, hypnosis, and breathing techniques. Beyond relaxation, though, if a woman can address her fears before going into labor, she has a much higher chance of a successful, comfortable vaginal birth.

Why? Because emotions affect our body. If we are scared, we naturally hold back or tense up and that makes labor harder and more painful and it makes injury and intervention (like a c-section) more likely.

Ask questions when your doctor recommends anything.

As much as I wish I could teach you everything you need to know to have a wonderful birth experience, I don’t know your care provider and I won’t know every situation you’ll be in. That’s why it’s so important for you to ask questions any time your care provider recommends something.

When it comes to labor and birth, small things can have big consequences. Even something as seemingly simple as being hooked up to fetal monitoring can contribute to an eventual c-section. So do everything you can to make sure you’re getting all the information. 

To make sure you’re truly informed, you can use the acronym BRAIN.

Using BRAIN to Get Informed

B is for benefits. Anytime a procedure or intervention is suggested, ask what the benefits are to you and your baby.

R is for risks. You also want to make sure to ask what any and all risks are that are associated with whatever your care provider is recommending. Make sure to ask about risks to both you and your baby, short-term and long-term.

A is for alternatives. After understanding the pros and cons, ask what possible alternatives exist. Try asking, “What could I do instead of (thing they just recommended)?”

I is for intuition. Once you have all the information, trust your intuition. Some people call it a gut feeling. Some people call it inspiration from God. Whatever it is to you, trust that.

N is for nothing (or for “natural” or “normal”). Your care provider may make lots of suggestions, but that doesn’t mean you have to do any of it. Birth is a normal, natural process that usually proceeds without complications. Remember that doing none of what is recommended is an option, too.

When a C-section is Necessary

Now that we’ve covered all the reasons and ways to avoid an unnecessary c-section, let me explain when a c-section may be necessary. It’s really fairly infrequent.

Baby’s Position

Like I mentioned, a baby who is in a breech position doesn’t necessarily require a c-section. However, if the baby is sideways in the uterus (called “transverse”) that will almost always require a c-section. 

Still, it is possible to turn a baby before they are born, so even if your baby is transverse at some point during pregnancy, that doesn’t necessarily mean they will be the day they are ready to be born.

A Truly Big Baby

It is common for doctors to see an ultrasound or to observe a long labor and conclude that a baby is too big and a mother’s pelvis too small. If that were true, it would require a c-section.

But, again, most often it is not the case and the problem lies elsewhere, whether that be in a shoulder dystocia or an emotional holdup or something else.

I plan to write a full blog post about truly big babies and the problem with the “big baby, small pelvis” reasoning soon, so stay tuned!

Placenta Problems

Sometimes even first-time mothers have placenta problems, like placenta previa (where the placenta covers the cervix). If that is the case, and the placenta does not move on its own, a c-section will be necessary.

Health Conditions, Weight Gain

Other conditions such as diabetes or heart conditions may necessitate a c-section.

Excessive weight gain during pregnancy may also require a c-section, likely because of its correlation with other risk factors such as preeclampsia.

Birth Defects

Finally, if a baby has birth defects, such as spina bifida, a c-section may be the safest way to birth that baby. If fetal surgery is performed to help with conditions like spina bifida, all future births will likely be c-sections because of the wound and scar left by the surgery. 

If You’ve Already Had a C-section

Now, some of you reading this might have already had a c-section with a previous birth. If that’s you, this article isn’t meant to discourage you. I still think it’s important that you have the information. 

More than information, though, I’m guessing what you want is encouragement and compassion.

Straight from the mouth of a family member of mine who had a traumatic c-section with her first baby, here’s what I want you to hear:

“You are not a bad mom. You didn’t take the easy way out. Your birth story is still valid. You are still a mom – a good mom. There is value in every story and every experience. Healing IS possible and available. You’ve got this!”

Conclusion and Summary

To summarize, getting a c-section is not without risk and there are many reasons you want to avoid one if you can. It’s a major surgery, your baby misses out on benefits gained only from a vaginal birth, and it leads to higher risk during each successive birth.

Whether you’ve already had a c-section or not, there are things you can do to lower your likelihood of having a c-section this time around. Keep your body healthy, avoid medications and interventions, and choose your birth place and care provider carefully. 

If you do end up needing a c-section, don’t get discouraged. Sometimes a c-section is a good thing if that is what you and your baby need. 

Ultimately, you do what feels right for you and this pregnancy and have compassion for yourself, whatever happens.

Until next time,

Allison

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