In this post, we only focus on elective cesarean birth, if it’s the safest way for babies to be born from mothers who have LOW-RISK pregnancies, and the gentle cesarean birth plan. Therefore, this post is not talking about medically indicated cesareans, although we will go over the importance of their differences regarding the number of deaths in babies.
Why Are We Talking About Elective Cesarean Birth?
This feels like a heavier blog post compared to many others of mine; however, I felt the need to collect the data and make this because I’ve been seeing some posts on social media (specifically, from a labor and delivery nurse) who is not giving out comprehensive education when talking about some topics, including this one.
When she made a list of the risks and benefits of cesareans, she missed a lot of facts and had a completely incorrect statement saying cesareans are the “Safest way for your baby to enter this world. And what could be a greater benefit than that?”.
Additionally, with rising elective cesarean rates, I know most hospital-based obstetricians and midwives only have 5-15 minutes for each mother I worry that mothers may have a similar experience to mine, where I asked questions about a major intervention but was not given a comprehensive risks and benefits conversation by my very kind obstetrician.
Side note: With a homebirth midwife, appointments are typically 45-60 minutes long and full of preparation, education, and getting to know each other!
This is a difficult topic to go over because I don’t want to instill fear or regret in anybody. However, I want everyone to have the access to this information to make educated decisions because it’s impossible to make informed decisions without having all the information.
So, Are Elective Cesarean Births Safer for Baby?
Elective cesarean birth is not safer than vaginal birth. Even if your favorite nurse, “medwife” (Nurse-Midwife or Certified Midwife in the U.S. who practices more under the medical model of care versus the midwifery model of care), or an obstetrician says it is, they’re going against the research.
When looking at medically necessary cesareans, neonatal mortality rates decrease. However, when looking at elective cesareans that were not medically needed, research shows that neonatal mortality rates increase [1].
Recent Studies Looking at Cesarean Rates:
The most recent research study related to this topic is from 2015. This study looked at 194 WHO member states around the world to analyze if the WHO recommendation that population-level cesarean delivery rates should not exceed 10-15% is accurate.
Several studies show that lower cesarean rates are optimal for maternal (2, 3, 4) and neonatal mortality [2] were correct in the wealthier first-world countries where these studies took place. However, this doesn’t show to apply when looking worldwide. Regarding improving maternal and neonatal mortality, there’s a sweet spot we must try our best to reach for the benefits of maternal and neonatal mortality rates where we avoid unnecessary cesareans and still provide access to cesarean births when needed [5].
In conclusion, we need to support the medically indicated use of cesarean births to reduce maternal and neonatal mortality without causing overuse of procedures [5].
Benefits of Elective Cesarean Birth for Mother and Baby:
- Reduced risk of urinary incontinence
- Some believe there are minimized pelvic floor risks, however, sometimes pelvic floor problems may be worse after a cesarean than in some vaginal births as the abdominal muscles are cut through during a cesarean, and these muscles are attached to your pelvic floor muscles.
- No tearing because no vaginal birth
- Cesareans can be scheduled
- Lower risk of birth injuries such as fractures and shoulder dystocia
Risks of Cesarean Birth:
The risks of cesarean birth can affect you, your baby, and future pregnancies.
For the Mother:
Increased risks of:
- Postpartum hemorrhage [6, 7]
- Maternal death [8]
- Blood transfusion (280.4/100,000) [9].
- Increased risk of hysterectomy (0.3-5.0 per 1000 births) [10, 11, 12]
- Increased risk for blood clots due to bed rest after major surgery
- Although rare, the risk of damaging/cutting surrounding organs [13]
- Perinatal mood disorders, such as postpartum depression, which can be partially from lower rates of breastfeeding after a cesarean birth [19] or birth trauma.
Additional risks for mothers having a cesarean include:
- Higher cost of hospitalization [18]
- Longer and more difficult recovery
For Baby:
- Increased risk for respiratory problems because they are not squeezed through the vagina which helps get the amniotic fluid out of their lungs to help them breathe effectively and transition better after birth [20].
- Additionally, without experiencing the “vaginal squeeze” from a vaginal birth, pediatric occupational therapists who came on the Down to Birth podcast [21] (not my podcast), talked about how these infants’ Moro or “startle” reflex may become over-reactive leading to more fussy babies and slower development.
- Increased neonatal morbidity and mortality risks in second pregnancy (seizure, respiratory issues, low APGARs, asphyxia-related death) [20].
- Although rare, small cuts to the baby’s skin from the physician cutting open the uterus.
- Babies born via cesarean have different gut bacteria compared to those born vaginally. Babies passing through the vaginal canal make contact with the vaginal microbiome, which helps them establish and develop a healthy gut microbiome [31, 32]. To help combat this, vaginal seeding should be an option for mothers who do not have GBS, herpes complex, nor an STI.
Vaginal seeding is the practice of using a cotton gauze or something similar to transfer the vaginal flora (the good bacteria) to the baby’s mouth, nose, and skin [33], and this may help in improving cesarean baby’s microbiomes at birth which should give them benefits lasting the rest of their lives!
Read The Truth About Our Climbing Cesarean Rates here and how the number of unnecessary c sections is putting more and more mothers’ lives at risk and worsening the overall health of babies who didn’t need a cesarean birth.
For Another Pregnancy and Birth After a Cesarean:
Getting pregnant after having a cesarean increases risks for the mother and baby, whether she is having a VBAC (vaginal birth after cesarean) or an elective cesarean. VBAC or another cesarean is associated with higher risks of:
- A placenta that embedds too deeply into the uterine wall (placenta accreta) potentially leading to an increased risk of needing a hysterectomy [14], postpartum hemorrhage, and more [15].
- Uterine rupture [17, 23]. However, the risk is still small, with rates of uterine rupture falling around 0.22-0.5% in some developed countries [24, 25, 26, 27], and for women who are at high-risk for a cesarean, this rate can increase to 9.1 per 1,000 cesarean births [28].
- Sepsis. There is a 12% rate of sepsis after TOLAC (trial of labor after cesarean) which is attempting a vaginal birth after cesarean, compared to 2% after a successful VBAC [23, 29].
- Postpartum hemorrhage and the need for blood transfusion [7, 23].
- Maternal mortality and morbidity with each cesarean section compared with vaginal birth [30].
What About Elective Cesarean Births for Preterm Labor?
This study found no improvement for babies who were born cesarean due to preterm labor. However, they found increased maternal complications in the cesarean group compared to the group who went into preterm labor and had a vaginal birth [34]. However, in this study, there was no difference found in cesarean mothers having an increased risk of postpartum hemorrhage.
The author’s conclusions on this study stated, “Given that very few women have been recruited to trials of planned immediate caesarean section versus planned vaginal delivery for preterm birth, and that the quality of the trials conducted is generally unclear, we recommend that firm conclusions regarding the relative merits of planned immediate caesarean section versus planned vaginal delivery should not be drawn from this evidence to guide practice for preterm births.”
Although, I feel like this meta-analysis (an evaluation of multiple studies) has brought some evidence to the table which can help mothers make informed decisions for themselves and their babies.
Should You Be Worried?
Despite what some labor and delivery nurses or whoever else may say on social media or in an appointment room, the evidence does not support elective cesarean births being safer for the birth of babies nor birthing mothers.
The things that are at increased risk are still on the lower side, for sure, however, when we look at these risks in large numbers of women and babies, we can see the effect, and this is why the majority of people are aware of this research would not particularly encourage elective cesareans.
Furthermore, there are so many evidence-based ways to decrease cesarean rates without labor induction. If more women, families, and health professionals can become aware of the evidence out there and some work harder for the job they chose while at work for these mothers and families, we can make a huge difference in cesarean rates, and I believe improve mothers’ satisfaction with birth.
Gentle Cesarean Birth Plan
I know there are mothers out there who simply don’t want a vaginal birth ever, and this is completely fine! I only want you to know the honest and comprehensive evidence because if you still want a cesarean, I know having this education may help you investigate ways how to decrease risks or adverse effects that are a higher possibility with this choice. And to me, that is a huge reason I love my work: you being empowered and making informed decisions for you and your baby’s birth and life experience!
For example, Skin to skin after a cesarean birth during the “closing” may increase breastfeeding initiation, reduce formula supplementation in the hospital, and help your baby maintain a healthy body temperature [35].
If you’d like this birth plan template, fill out the pop-up on my website! The Birthing Balance Birth Plan will show you all the options you can learn about in The Balanced Birth Course (Coming soon!), then the last page of the birth plan provides a template to write out your wishes in a list format so that there’s nothing written on your birth plan that you do not want!
Learn more about why I highly recommend writing a birth plan in: Why You Should Make a Birth Plan Template
You are encouraged, educated, and empowered here at Birthing Balance. Thank you so much for being here, and don’t forget I have online consultations available for your pregnancy, birth, postpartum, and breastfeeding questions and/or support here.
Talk soon, mama!
Sources:
[1] Article Source: Associations between cesarean delivery and child mortality: A national record linkage longitudinal study of 17.8 million births in Brazil
Paixao ES, Bottomley C, Pescarini JM, Wong KLM, Cardim LL, et al. (2021) Associations between cesarean delivery and child mortality: A national record linkage longitudinal study of 17.8 million births in Brazil. PLOS Medicine 18(10): e1003791. https://doi.org/10.1371/journal.pmed.1003791
[2] Ye J, Betrán AP, Guerrero Vela M, Souza JP, Zhang J. Searching for the optimal rate of medically necessary cesarean delivery. Birth. 2014;41(3):237-244.
[3] Volpe FM. Correlation of Cesarean rates to maternal and infant mortality rates: an ecologic study of official international data. Rev Panam Salud Publica. 2011;29(5):303-308.
[4] Betrán AP, Merialdi M, Lauer JA, et al. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol. 2007;21(2):98-113.
[5] Molina G, Weiser TG, Lipsitz SR, et al. Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality. JAMA. 2015;314(21):2263–2270. doi:10.1001/jama.2015.15553
[6] Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case control study. BMJ. 2001;322:1089-94.
[7] Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B. Prevalence and risk factors of severe obstetric haemorrhage. BJOG. 2008;115:1265-72.
[8] Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ. 2007;176(4):455-60.
[9] Curtin SC, Gregory KD, Korst LM, and Uddin SFG. Maternal Morbidity for Vaginal and Cesarean Deliveries, According to Previous Cesarean History: New Data From the Birth Certificate, 2013. National Vital Statistics Reports. 2015; Volume 64, Number 4. https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_04.pdf
[10] Stivanello E, Knight M, Dallolio L, Frammartino B, Rizzo N, Fantini MP. Peripartum hysterectomy and cesarean delivery: a population-based study. Acta Obstet Gynecol Scand. 2010;89:321-27.
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[11] Knight M, Kurinczuk J, Spark P, Brocklehurst P. Cesarean delivery and peripartum hysterectomy; United Kingdom Obstetric Surveillance System Steering Committee. Obstet Gynecol. 2008;111(1):97-105.
[12] O Brien D, Babiker E, O’Sullivan O, Conroy R, McAuliffe F, Geary M, et al. Prediction of peripartum hysterectomy and end organ dysfunction in major obstetric haemorrhage. Eur J Obstet Reprod Biol. 2010;153(2):165-69.
[13] Häger RM, Daltveit AK, Hofoss D, Nilsen ST, Kolaas T, Øian P, et al. Complications of cesarean deliveries: Rates and risk factors. Am J Obstet Gynecol. 2004;190(2):428-34.
[14] Roethlisberger M, Womastek I, Posch M, Husslein P, Pateisky N, Lehner R. Early postpartum hysterectomy: incidence and risk factors. Acta Obst Gyn Scand
[15] https://www.mayoclinic.org/diseases-conditions/placenta-accreta/symptoms-causes/syc-20376431
[16] Fitzpatrick KE, Kurinczuk JJ, Bhattacharya S, Quigley MA (2019) Planned mode of delivery after previous cesarean section and short-term maternal and perinatal outcomes: A population-based record linkage cohort study in Scotland. PLOS Medicine 16(9): e1002913. https://doi.org/10.1371/journal.pmed.1002913
[17] Fitzpatrick KE, Sellers S, Spark P, Kurinczuk JJ, Brocklehurst P, Knight M. Incidence and risk factors for placenta accrete/increta/percreta in the UK: A national case-control study. PLOS One. 2012;7(12):e52893.
[18] Negrini, R., da Silva Ferreira, R.D. & Guimarães, D.Z. Value-based care in obstetrics: comparison between vaginal birth and caesarean section. BMC Pregnancy Childbirth 21, 333 (2021). https://doi.org/10.1186/s12884-021-03798-2
[19] Rivi V, Petrilli G, Blom JMC. Mind the Mother When Considering Breastfeeding. Front Glob Womens Health. 2020;1:3. Published 2020 Sep 15. doi:10.3389/fgwh.2020.00003
[20] Huang X, Lei J, Tan H, Walker M, Zhou J, Wen SW. Cesarean delivery for first pregnancy and neonatal morbidity and mortality in second pregnancy. Eur J Obstet Gynecol Reprod Biol. 2011 Oct;158(2):204-8. doi: 10.1016/j.ejogrb.2011.05.006. PMID: 21641102.
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[21] https://downtobirthshow.com/152-the-impact-of-birth-stress-on-infant-development-with-ontrack-baby/
[23] Fitzpatrick KE, Kurinczuk JJ, Bhattacharya S, Quigley MA (2019) Planned mode of delivery after previous cesarean section and short-term maternal and perinatal outcomes: A population-based record linkage cohort study in Scotland. PLOS Medicine 16(9): e1002913. https://doi.org/10.1371/journal.pmed.1002913
[24] Kennare R., Tucker G., Heard A. & Chan A.Risks of adverse outcomes in the next birth after a first cesarean delivery. Obstet. Gynecol. 109, 270–276, doi: 10.1097/01.AOG.0000250469.23047.73 (2007).
[25] Lydon-Rochelle M., Holt V. L., Easterling T. R. & Martin D. P. Risk of uterine rupture during labor among women with a prior cesarean delivery. N. Engl. J. Med. 345, 3–8, doi: 10.1056/nejm200107053450101 (2001).
[26] Spong C. Y. et al.. Risk of uterine rupture and adverse perinatal outcome at term after cesarean delivery. Obstet. Gynecol. 110, 801–807, doi: 10.1097/01.AOG.0000284622.71222.b2 (2007).
[27] Al-Zirqi I., Stray-Pedersen B., Forsen L. & Vangen S. Uterine rupture after previous caesarean section. BJOG. 117, 809–820, doi: 10.1111/j.1471-0528.2010.02533.x (2010).
[28] Smith GC, White IR, Pell JP, Dobbie R. Predicting cesarean section and uterine rupture among women attempting vaginal birth after prior cesarean section. PLoS Med. 2005 Sep;2(9):e252. doi: 10.1371/journal.pmed.0020252. Epub 2005 Sep 13. PMID: 16146414; PMCID: PMC1201366.
[29] Patel RM, Jain L. Delivery after previous cesarean: short-term perinatal outcomes. Semin Perinatol. 2010;34(4):272-280. doi:10.1053/j.semperi.2010.03.007
[30] Zandvakili F, Rezaie M, Shahoei R, Roshani D. Maternal Outcomes Associated with Caesarean versus Vaginal Delivery. J Clin Diagn Res. 2017;11(7):QC01-QC04. doi:10.7860/JCDR/2017/24891.10239
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[31] Shao, Y., Forster, S.C., Tsaliki, E. et al. Stunted microbiota and opportunistic pathogen colonization in caesarean-section birth. Nature 574, 117–121 (2019). https://doi.org/10.1038/s41586-019-1560-1
[32] Dominguez-Bello MG, De Jesus-Laboy KM, Shen N, Cox LM, Amir A, Gonzalez A, Bokulich NA, Song SJ, Hoashi M, Rivera-Vinas JI, Mendez K, Knight R, Clemente JC. Partial restoration of the microbiota of cesarean-born infants via vaginal microbial transfer. Nat Med. 2016 Mar;22(3):250-3. doi: 10.1038/nm.4039. Epub 2016 Feb 1. PMID: 26828196; PMCID: PMC5062956.
[33] https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/11/vaginal-seeding
[34] Alfirevic Z, Milan SJ, Livio S. Caesarean section versus vaginal delivery for preterm birth in singletons. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD000078. DOI: 10.1002/14651858.CD000078.pub3. Accessed 14 April 2022.
[35] Stevens J, Schmied V, Burns E, Dahlen H. Immediate or early skin-to-skin contact after a Caesarean section: a review of the literature. Matern Child Nutr. 2014 Oct;10(4):456-73. doi: 10.1111/mcn.12128. Epub 2014 Apr 10. PMID: 24720501; PMCID: PMC6860199.
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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