You’re likely here to find out “is a c section safe”, so let’s jump right into what we are seeing in America with our climbing cesarean section rates. Furthermore, I’ll explain cesarean section history, risks with a c section, cesarean section indications, and the procedure for cesarean section.
Cesarean Section History
“Birth by cesarean section was rare in the United States in 1960, representing fewer than 4 percent of births overall [1].” And at this time, the dictum was “once a cesarean, always a cesarean.”
Then between 1965 and 1987, the cesarean section rate in the United States rose 455% from 4.5 percent to 25 percent [1].
In 2010, cesarean section became the country’s most commonly performed surgical procedure. And today our cesarean rate in America is 32% and rising [2].
Cesarean Section Indications:
- Umbilical cord prolapse with a cephalic (head down) baby
- Placenta previa
- Placental abruption
- Persistent transverse lie of the fetus
- Obstruction (a large uterine fibroid, a pelvic fracture)
- Genital herpes at time of birth
However, each of these conditions occurs in considerably fewer than 1% of births.
In contrast the two most common reasons for cesarean section in America today are fetal distress and “failure to progress”. Failure to progress is a myth and has already been proven to simply be “failure to wait.”
And regarding fetal distress, the vast majority of these occurances are iatrogenic: meaning, the issue was caused by medical treatment.
Things like epidurals, lack of movement, continuous fetal monitoring, induction and augmentation of labor with Pitocin, and opioid medications that cross the placenta are causes of fetal distress.
The Science of Natural Birth and Optimal Cesarean Rates
However, naturally, there’s an abundance of reasons a birth is likely to go well: 99% of the time there is only one fetus in the womb, 97% of infants are born head first, and 97% of fetuses have no major structural or genetic abnormalities.
For years the WHO has been stating that the optimal cesarean rate is between 10-15%. There is nothing wrong with medically indicated cesareans. The issue is all the cesareans that are not medically indicated. Even worse, the number of cesareans that mothers are led to believe were necessary is astronomically high.
Furthermore, WHO states from medical records across time, on average, only about 5% of human births run into trouble when labor begins spontaneously (meaning naturally and not induced). And they recommend that countries not exceed 10-15% for optimal maternal and neonatal outcomes [9]. WHO even states, “When the rate goes above 10%, there is no evidence that mortality rates improve” [9].
J. Whitridge Williams, head of the Department of Obstetrics at John Hopkins University, admonished his students in 1926: “any one with two hands and a few instruments can do a cesarean section, but… it frequently requires great intelligence not to do it.” [3]
Yet, today conservative obstetricians do the opposite. They perform a cesarean in the face of even niggling doubt about a birth’s outcome. While doctors once viewed cesarean section as the riskiest of obstetric procedures, today vaginal birth represents the risk.
Nevertheless, there is one type of cesarean section that most surgeons in the U.S. dread and fear: and that is the cesarean section for placenta accreta.
Is a C Section Safe?
Placenta accreta is a condition in which the placenta grows into the uterine wall and will not release after birth, often because it has grown into the scar from a previous cesarean.
In the 1950s, accretas occurred in fewer than 1 in 30,000 births; by 1980 the rates was 1 in 2,500. Today, 1 in 533 births sees an accreta – a 55-fold increase in 60 years [1].
Furthermore, a study published in 2022 found, “according to current estimation, the incidence rate of placenta accreta spectrum may increase to 1 in 200 women undergoing cesarean delivery by 2025 [4]”.
Worse, the maternal mortality rate in the face of accreta is as high as 7 percent. One obstetrician, in connecting a cesarean section today “the complications [of] tomorrow,” decribed a mother who had given birth at his hospital and died shortly after due to postpartum hemorrhge caused by placenta accreta: “72 units of blood, the entire hospital stopped [5].”
So, when you hear about postpartum hemorrhage being the leading cause of maternal death, many American OBs convey this as if it is vaginal birth causing this, and that vaginal birth is the risk. But we have such high rates of postpartum hemorrhage that has increased because of their medicalization of birth regarding cesarean sections, inductions and augmentations of labor with Pitocin, and continuous electronic fetal monitoring.
Continuous Electronic Fetal Monitoring (CEFM)
CEFM was never tested before its use began and was intended only for high-risk women because some experts thought it might decrease the rates of cerebral palsy.
5 decades later, despite evidence showing “it is ineffectual, prone to interpretive errors, has a 99% false-positive prediction of fetal distress, has increased the incidence of cesarean delivery, has not reduced the rate of cerebral palsy (CP), and has not produced better perinatal outcomes. With CEFM, OBs and labor and delivery nurses can simultaneously sit and watch multiple monitors. CEFM doesn’t seem to be going anywhere anytime soon in American hospitals [6]”.
Additionally, CEFM is not supported for high-risk women either. These machines cannot be used without a proper understanding of physiologic birth. Heart decels from baby can be a health adaptation to a situation in birth.
Even experts saw different meanings in identical patterns on the EFM machine. These specialists were able to agree on the implication of a pattern only 68% of the time [1]. And in a 2008 study, four obstetricians could agree on the meaning of 50 fetal heart tracings in only 22% of cases [10].
The De-Skilling of Obstetricians and Hopsital Midwives
Unfortunately, too many American hospital obstetricians and midwives are becoming more and more deskilled in everything except for cesareans and administering medications that are often unnecessary or are only needed because of other routine interventions they do to mothers without asking or providing information for the mother to provide true informed consent. These American health professionals are becoming deskilled in intermittent auscultation, Leopold’s maneuver to feel what position the baby is in (instead, they always use ultrasound), and vaginal breech birth.
One may argue the increase in cesareans in the U.S. is due to a rise in maternal obesity, multiples due to fertility treatments, and a higher incidence of mothers giving birth over 30. However, these incidences only account for a small portion of the rise. Wolf, Ph.D. argues, “the increase has been driven less by medical need and more by a change in American society and American medical culture in the last quarter of the twentieth century, changes that created the perception that vaginal birth is risky and that cesarean section serves as its infallible guardrail [1].”
More Risks with a C Section
Did you know that a cesarean is the only surgery in America that you can receive upon request (aka elective surgery)? You cannot go to the doctors and have them give you an appendectomy as a preventative measure in case you get appendicitis one day, as this surgery is generally viewed as too risky to do unless it is medically required. But instead, when it comes to our maternal health care in the U.S., many hospital-based OBs and even some Midwives (I call med-wives if they are like this), view vaginal birth as more dangerous than a cesarean.
For infants, even full-term ones delivered by cesarean section, have a death rate almost three times higher than their vaginal counterparts. With higher morbidity rates too. Babies born by cesareans have an immediate disadvantage. Vaginal birth benefits the baby by squeezing amniotic fluid from its lungs. While children born by c section are born with lungs full of amniotic fluid in which wet lung at birth can have a lifelong effect, including higher rates of asthma and allergies. Infants born by cesarean section are also deprived of the mom’s vaginal flora, which in a vaginal birth colonizes the neonatal gut, and persists for up to six months; researchers have connected the lack of exposure to the mother’s vaginal microbiome to a higher incidence of allergic disorders throughout life.
Additionally, cesarean sections have economic risks, and a cesarean section with no complications costs twice as much as a vaginal birth. [1]. And the mother’s health is also affected detrimentally. Learn more about the risks of elective cesarean for mothers and babies in: The Truth About Elective Cesarean Birth Safety.
Is a C Section a Major Surgery?
The procedure for cesarean section includes cutting through seven layers. These layers include:
- Skin
- Fat
- Fascia (which is rough and fibrous, and in this case, known as the rectus sheath – the coating outside of the abdominal muscle)
- Abdominal muscle
- Peritoneum (a thin, transparent layer that is cut through vertically)
- Uterus (after moving down the bladder)
- Amniotic sac
A cesarean is a major surgery that should have standard physical therapy during recovery, just like any other major surgery, as it cuts through the abdominal muscles.
What is the Procedure for Cesarean Section?
How long does a cesarean take?
In emergency situations, a cesarean section baby can be born in a few minutes, and with closing up the layers, the procedure for cesarean section can be done in 15-30 minutes.
However, a cesarean section generally takes about 45 minutes from start to finish.
Before a planned c section, the following procedures will be followed:
- Sign consent forms for the cesarean section
- Next, the anesthesiologist will discuss options for anesthesia. Most often, a spinal block is used (this is different than an epidural), which numbs you from your breasts down to your feet for 1-2 hours.
- Then, your pubic hair in the areas around the incision site will be shaved, and your abdomen will be cleaned with an antiseptic.
- A catheter will be inserted to keep your bladder empty
- You will have heart and blood pressure monitors applied
- You will get an IV in your hand or arm to give you medication and fluids
- You’ll discuss the procedure and what to expect with your OB (if you haven’t already)
- Next, your provider places a sterile drape around the incision site and over your legs and chest, then raises the curtain between your head and body
- Finally, the procedure for cesarean section begins.
The Recovery for Cesarean Section
The risk of postpartum infection after a cesarean is nearly five-fold that of vaginal birth. Even when all goes well, births by c section result in longer recovery times and greater and lengthier postpartum discomfort.
A 2019 study found that women’s priorities around cesarean section recovery centered on pain, mobility, and the ability to resume everyday activities, including caregiving.
“Those undergoing a CS for the first time reported not feeling confident in their ability to identify signs of infection and sought to visit health professionals’ expertise and reassurance. Women were unable to recall whether they had received information regarding infection prevention and felt that they had not received sufficient advice. Some reported receiving general information regarding CS recovery, which ranged in quality… the majority of women were not aware that womb (as opposed to wound) infection was a post-CS risk [7].”
Furthermore, a study from 2010 interviewed 32 women who, between them, had 68 births; 7 of them had experienced both cesarean and vaginal births.
“Thirty of the 32 women described difficulties following the postoperative advice they received prior to hospital discharge, and their physical recovery after caesarean was hindered by a range of health issues, including pain and reduced mobility, abdominal wound problems, infection, vaginal bleeding and urinary incontinence. These problems were experienced across the three zones of clinical practice, regardless of the reasons women gave for their caesarean [8].”
“The women in this study reported a range of unanticipated and unwanted negative physical health outcomes following caesarean birth. This qualitative study adds to the existing epidemiological evidence of significant maternal morbidity after caesarean section and underlines the need for caesarean section to be reserved for circumstances where the benefit is known to outweigh the harms [8].”
Sources:
[1] Cesarean Section by Jacqueline H. Wolf
[2] https://www.cdc.gov/nchs/fastats/delivery.htm
[3] J. Whitridge Williams, “Cesarean Section at the Johns Hopkins Hospital,” Northwest Medicine 25 (October 1926): 519-526, quote on 526.) Yet, today conservative obstetricians do the opposite. They perform a cesarean in the face of even niggling doubt about a birth’s outcome. While doctors once viewed cesarean section as the riskiest of obstetric procedures, today vaginal birth represents the risk. Nevertheless, there is one type of cesarean section that most surgeons in the US dread and fear: and that is the cesarean section for placenta accreta. (if they dread it so much, they’re going to have to start getting their c sections rates under control
[4] Han X, Guo Z, Yang X, Yang H, Ma J. Association of Placenta Previa With Severe Maternal Morbidity Among Patients With Placenta Accreta Spectrum Disorder. JAMA Netw Open. 2022;5(8):e2228002. doi:10.1001/jamanetworkopen.2022.28002
[5] “Management of Placenta Accreta”; interview of retired obstetrician by author, Chicago physician interview 8, October 5, 2012, Chicago IL, transcribed from digital recording.
[6] Sartwelle TP. Electronic Fetal Monitoring: A Defense Lawyer’s View. Rev Obstet Gynecol. 2012;5(3-4):e121-5. PMID: 23483132; PMCID: PMC3594858.)
[7] Weckesser, A., Farmer, N., Dam, R., Wilson, A., Morton, V. H., & Morris, R. K. (2018). Women’s perspectives on caesarean section recovery, infection and the PREPS trial: a qualitative pilot study. BMC Pregnancy and Childbirth, 19. https://doi.org/10.1186/s12884-019-2402-8
[8] Kealy, M. A., Small, R. E., & Liamputtong, P. (2009). Recovery after caesarean birth: a qualitative study of women’s accounts in Victoria, Australia. BMC Pregnancy and Childbirth, 10, 47. https://doi.org/10.1186/1471-2393-10-47
[9] https://www.who.int/publications/i/item/WHO-RHR-15.02
[10] “The 2008 National Institute”; Brody, “Updating a Standard.”
DISCLAIMER: This post is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding you or your baby’s health. Please read my Medical Disclaimer for more info
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