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  • Ashley Robertson

Risks of Cesareans vs. Vaginal Births

Updated: Nov 14, 2019

I’d like to start this piece by first saying, cesarean sections absolutely have their place and have saved lives of both mothers and infants. The problem lies in the blatant overuse of this major, invasive surgery. In addition, for mothers who have chosen an elective surgery, this is absolutely not meant to be a judgement, so long as they have done the research and are educated in their decision. Two of the main reasons the cesarean rate is so incredibly high in the U.S. are avoiding liability and simplifying doctors’ schedules. In fact, in 21 studies, clinicians’ fear of litigation was the most common factor in deciding to perform a cesarean (Panda, Begley, and Daly 2018). As cesareans have become so commonplace, it is important to remind women and their partners that it is a huge surgery. There are a whole host of risks, which is why it should more often than not, be used only for emergencies.

“Obstetric interventions such as caesarean section sometimes save lives and sometimes kills - maternal mortality even for elective (non-emergency) caesarean section is 2.84 fold or nearly three times higher than for vaginal birth.” (Marsden 2001). The World Health Organization has said time and time again that the goal rate for cesareans should be between 10-15%, but the U.S. has an average rate of 32% (Centers for Disease Control and Prevention 2017). Google the cesarean rate for the hospitals nearest you and you will likely find at least one with a rate higher than this. On a personal note, the three hospitals closest to me have rates of 27%, 38% and 45%. There are even websites dedicated to listing doctors with their individual cesarean rate, so women know their chances beforehand and can choose different doctors. As Dr. Wagner said, “we are now at the point in maternity care in industrialized countries where the positive effects of development and technology are approaching the maximum and the negative effects are surfacing. This helps to explain why advances in technology and in development cannot lead to improvements in health unless the technology is in harmony with natural biological processes and is accompanied by humanized health care. Here is a simple example. If an elective caesarean section is done after labour has started, it may in some cases facilitate natural processes. But waiting until labour starts means doctors lose the possibility of scheduling the procedure at their convenience. But if, as is almost always the case today, the doctor tries to circumvent natural processes by performing elective caesarean section before labour starts, there is a greater risk of respiratory distress syndrome and prematurity, both leading killers of newborn infants.” (Marsden 2001)

In first time mothers, the most common reason for a cesarean is not an emergency – it is a labor that progresses “too slowly”. This means different things in different settings. For example, in a home birth, as long as there is progress at any rate and the baby seems to be doing well, the mother is seen as doing great. However, in a hospital, it is common knowledge that there is a 24 hour time limit, and if the mother reaches that limit, she is almost guaranteed to be wheeled into the OR. The irony of this is that all the interventions leading up to this point, have they been used (such as an epidural, use of Pitocin, lack of movement of the mother, continuous fetal monitoring) have been shown to prolong labor even individually, as they interfere with the mother’s natural hormonal process (Howland 2018). A study published in Obstetrics & Gynecology in 2014 showed that an epidural alone prolongs labor by 2-3 hours. The back and forth between an epidural and Pitocin to augment labor results time and time again in babies in “distress,” leading almost immediately to a cesarean.

The risks of cesareans are sometimes obvious, such as laceration of the infant, infection in both the newborn and mother, aspiration (extremely rare) during surgery, impaired physical health of the mother for a minimum of two months following birth (Van der Woude, 2015), and extreme difficulty with breastfeeding, but are sometimes not as obvious because they are not as widely talked about. Risks to the mother can also include emergency hysterectomies (De La Cruz, Thompson, O’Rourke, Nembhard, 2015), difficulty becoming pregnant and maintaining pregnancy (Gurol-Urganci, 2013), cesarean ectopic pregnancy, and placenta accreta (Lyell, Caughey, & Daniels, 2005). Risks to the newborn tend to be lifelong and include a failure to establish breastfeeding (which leads to a host of issues in and of itself), increased risk of asthma (Bager, Wohlfahrt, & Westergaard, 2008), childhood onset diabetes (Cardwell, et al, 2008) childhood obesity (Kuhle, Tong, & Woolcott, 2015), autism spectrum disorder or attention deficit disorder (Curran, et al 2014), chronic inflammatory bowel disease (Li et al, 2014), hay fever (Bager, Wohlfahrt, & Westergaard, 2008), and food sensitivities and allergies (Koplin, et al, 2008). Interestingly, almost all these associated diseases have to do the microbiota of the newborn, as they do not pass through the vaginal canal, therefore missing out on the host of beneficial bacteria from the birthing mother. There is a procedure to attempt to give baby this “splash” of mom’s microbes called seeding, which involves placing a piece of sterile gauze within the mother’s vagina and swabbing it inside the newborn’s mouth, on baby’s skin, and on mom’s nipples so baby gets more of the microbes while breastfeeding (Finley & Arrieta 2016). Seeding is especially important in the very likely event that the cesarean is performed in conjunction with antibiotics, as the nature of antibiotics is to clear the gut of any bacteria, with no distinguishing between good or bad (Finley & Arrieta 2016).

Having covered the risks of cesareans, let’s go over the risks of vaginal births. In the U.S., about 78% of women deliver vaginally. Although labor and delivery is hard work, generally speaking vaginal birth is easier on a woman’s body. Recovery is almost always shorter and less painful, especially if it was a natural unmedicated birth, and allows for “better” bonding. Complications that are specific to vaginal birth include genital trauma, perineal tears, umbilical cord prolapse, instrument assisted deliveries, and shoulder dystocia. Prolapsed cords can lead to cutting of the umbilical cord prematurely in the case that it is pinched, cutting off oxygen to the newborn, but it is still almost always recommended to continue with a vaginal birth, as it is most likely the fastest delivery option (Ahmed & Hamdy, 2018). Shoulder dystocia can also be serious and is considered one of the most litigated causes in obstetrics, but there are clear risk factors that come into play in predicting the rare event, such as mothers with diabetes, high BMIs, advanced maternal age, induction of labor, and instrument assisted deliveries.

*Bager, P., Wohlfahrt, J., & Westergaard, T. (2008). Caesarean delivery and risk of atopy and allergic disease: Meta-analyses. Clinical & Experimental Allergy, 38(4), 634-642; Thavagnanam, S., Fleming, J., Bromley, A., Shields, M., & Cardwell, C. (2008). A meta-analysis of the association between Caesarean section and childhood asthma. Clinical & Experimental Allergy, 38, 629-633.

*Curran, E., O'Neill, S., Cryan, J., Kenny, L., Dinan, T., Khashan, A., & Kearney, P. (2014). Research Review: Birth by caesarean section and development of autism spectrum disorder and attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. Journal of Child Psychology and Psychiatry, 56, 500-508.

*Darmasseelane, K., Hyde, M., Santhakumaran, S., Gale, C., & Modi, N. (2014). Mode of Delivery and Offspring Body Mass Index, Overweight and Obesity in Adult Life: A Systematic Review and Meta-Analysis. PLoS One, 9, e97827.

*De la Cruz, C., Thompson, E., O’Rourke, K., & Nembhard, W. (2015). Cesarean section and the risk of emergency peripartum hysterectomy in high-income countries: A systematic review. Archives of Gynecology and Obstetrics, 292(6), 1201-15; Rossi, A., Lee, R., & Chmait, R. (2010). Emergency Postpartum Hysterectomy for Uncontrolled Postpartum Bleeding: A Systematic Review. Obstetrics & Gynecology, 115(3), 1453-1454.

*Finlay, B. Brett, and Marie-Claire Arrieta. Let Them Eat Dirt: How Microbes Can Make Your Child Healthier. Algonquin Books of Chapel Hill, 2017.

*Gurol-Urganci, I., Bou-Antoun, S., Lim, C., Cromwell, D., Mahmood, T., Templeton, A., & Meulen, J. (2013). Impact of Caesarean section on subsequent fertility: A systematic review and meta-analysis. Human Reproduction, 28(7), 1943-1952.

*Gurol-Urganci, I., Cromwell, D., Edozien, L., Smith, G., Onwere, C., Mahmood, T., & Meulen, J. (2011). Risk of placenta previa in second birth after first birth cesarean section: A population-based study and meta-analysis. BMC Pregnancy and Childbirth, 11, 95; Klar, M., Michels, K.B. (2014). Cesarean section and placental disorders in subsequent pregnancies: A meta-analysis. Journal of Perinatal Medicine, 42(5), 871-883.

*Hansen, A.K., Wisborg, K., Uldjerg, N., & Henriksen, T.B. (2007). Elective caesarean section and respiratory morbidity in the term and near-term neonate. Acta Obstetrica et Gynecologica Scandanavia, 86, 389-94.

*Hawkins, J L, et al. “Anesthesia-Related Deaths during Obstetric Delivery in the United States, 1979-1990.” Anesthesiology, U.S. National Library of Medicine, Feb. 1997, www.ncbi.nlm.nih.gov/pmc/articles/PMC3279180/

*Hofmeyr, G.J., Say, L., & Gülmezoglu, A.M. (2005). WHO systematic Review of maternal mortality and morbidity: The prevalence of uterine rupture. BJOG: An International Journal of Obstetrics & Gynaecology, 112(9), 1221-1228.

*Howland, Genevieve. The Mama Natural Week-by-Week Guide to Pregnancy & Childbirth. Gallery Books, 2018.

*Klar, M., Michels, K.B. (2014). Cesarean section and placental disorders in subsequent pregnancies: A meta-analysis. Journal of Perinatal Medicine, 42(5), 871-883.

*Koplin, J., Allen, K., Gurrin, L., Osborne, N., Tang, M., & Dharmage, S. (2008). Is caesarean delivery associated with sensitization to food allergens and IgE-mediated food allergy: A systematic review. Pediatric Allergy and Immunology, 19, 682-687.

*Kuhle, S., Tong, O., & Woolcott, C. (2015). Association between caesarean section and childhood obesity: A systematic review and meta-analysis. Obesity Reviews, 16, 295-303.

*Li, H., Zhou, Y., & Liu, J. (2013). The Impact of Cesarean Section on Offspring Overweight and Obesity. Obstetrical & Gynecological Survey, 37, 9-11.

*Li, Y., Tian, Y., Zhu, W., Gong, J., Gu, L., Zhang, & W, Li, J. (2014). Cesarean delivery and risk of inflammatory bowel disease: A systematic review and meta-analysis. Scandinavian Journal of Gastroenterology, 49(7), 834-844.

*Lyell, D.J., Caughey, A.B., Hu, E., & Daniels, K. (2005). Peritoneal closure at primary cesarean delivery and adhesions. Obstetrics & Gynecology, 106(2), 275-280.

*Martin, Joyce, et al. “FastStats - Births - Method of Delivery.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 7 Nov. 2018, www.cdc.gov/nchs/fastats/delivery.htm.

*Moraitis, A.A., Oliver-Williams, C., Wood, A.M., Fleming, M., Pell, J.P., & Smith, G.C.S. (2015). Previous caesarean delivery and the risk of unexplained stillbirth: retrospective cohort study and meta-analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 122(11), 1467-1474; O’Neill, S., Kearney, P., Kenny, L., Khashan, A., Henriksen, T., Lutomski, J., & Greene, R. (2013). Caesarean Delivery and Subsequent Stillbirth or Miscarriage: Systematic Review and Meta-Analysis. PLoS One, 8(1), e54588..

*Politi, Salvatore, et al. “Shoulder Dystocia: an Evidence-Based Approach.” Journal of Prenatal Medicine, CIC Edizioni Internazionali, July 2010, www.ncbi.nlm.nih.gov/pmc/articles/PMC3279180/.

*Prior, E., Santhakumaran, S., Gale, C., Philipps, L.H., Modi, N., & Hyde, M.J. (2012). Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature. American Journal of Clinical Nutrition, 95, 1113-35.

*Sayed Ahmed, Waleed Ali, and Mostafa Ahmed Hamdy. “Optimal Management of Umbilical Cord Prolapse.” International Journal of Women's Health, Dove Medical Press, 21 Aug. 2018, www.ncbi.nlm.nih.gov/pmc/articles/PMC6109652/.

*Van der Woude, D.A., Pijnenborg, J.M., & de Vries, J. (2015). Health status and quality of life in postpartum women: A systematic review of associated factors. European Journal of Obstetrics & Gynecology and Reproductive Biology, 185, 45-52.

*Wagner, Marsden. “Fish Can't See Water: The Need to Humanize Birth.” The Need to Humanize Birth... By Marsden Wagner., Journal of Gynecology and Obstetrics, 2001, www.wonderfulbirth.com/Services/ViewServices.asp?Ref=2312.