Overview

A cesarean section, also known as a C-section, is a surgical procedure to deliver a baby through incisions in the mother’s abdomen and uterus. You and your doctor may plan a cesarean birth if you have a complication that would make a vaginal delivery difficult. Every expecting mother should be knowledgeable about cesarean birth, even if that is not your primary birth plan. In the United States, one in three babies is born via cesarean. Often, unplanned circumstances in labor lead to a cesarean birth. Labor is an intense experience, and a lot can happen that puts you in a position where you or your care provider has to make quick decisions and may not have time to explain your options at length. Knowing what to expect in a cesarean birth will better prepare you for labor and give you confidence to navigate any scenario.

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Cesarean Section

A cesarean section, also known as a C-section, is a surgical procedure to deliver a baby through incisions in the mother’s abdomen and uterus. You and your doctor may plan a cesarean birth if you have a complication that would make a vaginal delivery difficult. Often, unplanned circumstances in labor lead to a cesarean birth.

The Ideal Cesarean Rate

Since 1985, the international healthcare community has considered the ideal rate for cesarean births 10-15%. The World Health Organization’s official statement is that cesarean sections are effective in saving maternal and infant lives, but only when they are required for medically indicated reasons. The World Health Organization states that cesarean-section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates. Cesarean sections can cause significant and sometimes permanent complications, disability, or death, particularly in settings that lack the facilities and/or capacity to properly conduct safe surgery and treat surgical complications. Cesarean sections should ideally only be undertaken when medically necessary. The effects of cesarean section rates on other outcomes, such as maternal and perinatal morbidity, pediatric outcomes, and psychological or social well-being, are still unclear.

A cesarean birth can be a lifesaving procedure for a mother or baby. However, like any intervention, there are risks associated with the procedure. In a perfect world, cesareans are only used when needed to avoid exposing mothers and babies to unnecessary risks. Some research shows the optimal cesarean birth rate should be closer to 19%. Actual cesarean birth rates are much higher.

The Actual Cesarean Birth Rate

Worldwide, 21.1% of women give birth via cesarean section. This is from data from 154 countries covering 94.5% of world live births. Averages range from 5% in sub-Saharan Africa to 42.8% in Latin America and the Caribbean. Projections show that by 2030, 28.5% of women worldwide will give birth by cesarean section. That amounts to around 38 million cesarean sections every year. Cesarean rates vary by country: Canada 29.8%, United Kingdom 31.3%, and Australia 37%. Rates are very high in Mexico, 52.6%, and Korea, 53.8%.

Nearly one in three babies in the United States is born via cesarean section. In 2022, the overall cesarean birth rate was 32.2%. If you single out low-risk pregnancies, the rate is just over one in four births at 26.3% in 2022. A low-risk pregnancy is defined as a a baby at 37 weeks or more, singleton (not twins or multiples), the baby is vertex (head down), and it is the mother’s first pregnancy. Every expecting mother should be knowledgeable about cesarean birth, even if that is not your primary birth plan. Labor is an intense experience. A lot can happen that puts you in a position where you or your care provider has to make quick decisions and may not have time to explain your options at length.

Benefits and Risks

Cesarean sections are the most common surgery performed in the United States. Any obstetrician performing this surgery should be very skilled and experienced. Like any other major surgery, cesarean sections carry risks, which is why organizations like the World Health Organization seek to limit their use. Let’s briefly run through some of the risks of a cesarean section.

• Endometritis is inflammation and infection of the membrane lining the uterus.
• Excessive bleeding
• Blood clots
• Infection of the incision
• Although it is rare, the possibility of injury to nearby organs during the surgery, which would require additional surgery to repair the injury, exists.
• There is an increased risk in subsequent pregnancies of complications like a uterine rupture.
• Maternal death occurs in about 2.2 per 100,000 cesarean deliveries. Although it is a rare complication, this rate is higher than for vaginal birth, which is approximately 0.2 per 100,000.

There are also some risks to your baby from a cesarean birth. The risk of fetal trauma is 1%. This includes skin laceration, fractures, nerve damage, and cephalohematoma, an accumulation of blood under the scalp. It should be noted that these risks are higher in a vaginal delivery. Cesareans carry higher risks of respiratory complications, asthma, and allergy.

Being pregnant inherently carries risks. The point of reviewing these risks is not to scare you. The goal is to give you all of the information so you can make informed decisions.

Planned Cesarean Births

A cesarean section can be a lifesaving procedure for a mother or baby. There are many reasons you and your doctor could plan a cesarean birth.

• In cases of some maternal health conditions a doctor may suggest a cesarean. This includes heart disease, diabetes, high blood pressure, or kidney disease. A vaginal birth could also be more stressful for a baby with some illnesses or congenital conditions. An example is neural tube defects.
• If there is the possibility of a mother passing on an infection, like herpes or HIV, to a baby during a vaginal birth, a cesarean could prevent the baby from becoming infected.
• High-risk pregnancies with complications like preeclampsia or eclampsia may require a c-section.
• A mechanical obstruction like a large fibroid obstructing the birth canal, a severely displaced pelvic fracture, or a baby has severe hydrocephalus, which is a condition that can cause the head to be unusually large.
• Care providers can be concerned that a large baby will not be able to travel through the birth canal safely. A cesarean birth may be planned if your baby is unusually large and has a condition called macrosomia.
• Ideally, your baby is in a vertex head-down position before birth. About 3-4% of babies are not head down at term. Few doctors and midwives have training and experience in vaginal breech birth. As a result, most mothers with a breech baby will require a cesarean delivery. See this episode for more information on your baby’s position. See this episode for the evidence on methods to turn a breech baby.
• Placental abnormalities could require a cesarean birth. An example is when a mother has placenta previa, where the placenta covers the opening of the cervix.
• A doctor might recommend a cesarean if a mother had a previous invasive uterine surgery. An example would be a myomectomy, which is the surgical removal of fibroids.
• A cesarean can be planned for a mother who had a previous cesarean and is not planning a VBAC (vaginal birth after cesarean).
• Obesity significantly increases your chance of needing a cesarean. This is partially due to other risk factors that often accompany obesity and partially because obese mothers tend to have longer labors, which can increase the risk of cesarean.
• The last reason you may have a planned cesarean birth is because that is how you want to have your baby, and an elective cesarean birth is an option. The American College of Obstetricians and Gynecologists supports a cesarean delivery on maternal request after 39 weeks. If you are considering this, please discuss it at length with your care provider.

Unplanned and Emergency Cesarean Birth

Recall that the rate of cesareans for mothers who are considered low-risk is 26.3%. A low-risk pregnancy is defined as a baby at 37 weeks or more, singleton (not twins), vertex (head down), and it is the mother’s first pregnancy. Many of these mothers went into labor planning a vaginal birth.

The two most common reasons for an unplanned cesarean are that labor is not progressing or a non-reassuring fetal heart rate. In one study of over 38,000 women, 35.4% of cesareans were due to labor that was not progressing. Your care provider measures progress by changes in your cervix assessed with a vaginal exam or by contractions measured with an electronic fetal monitor. A fetal monitor also tracks your baby’s heart rate. 27.3% of cesareans in this study were for non-reassuring fetal heart rate tracing. In both of these cases, your doctor will apply less invasive interventions before resorting to a cesarean. See this episode for an overview of birth interventions.

There are a couple of other emergency scenarios that can compromise your baby’s oxygen supply and could require a cesarean. One is a prolapsed umbilical cord when the umbilical cord slips through the cervix ahead of the baby. If the uterus compresses the cord during contractions or as the baby comes through, it can cut off the oxygen supply to the baby. Another is a placental abruption when the placenta starts to separate from the uterine wall.

An Overview of the Procedure

You can see that some things can be out of your control and create the need for a cesarean birth. Every expecting mother should have a basic understanding of cesarean birth. There is always the possibility you could have a cesarean. Even if you are planning the most unmedicated, low-intervention birth possible. If circumstances change in labor and a cesarean is suggested, you will have a better idea of what is involved and what your options are if you have a basic understanding of the procedure.

Before the Surgery

If you have a non-emergency planned cesarean birth to take place before 39 weeks, your doctor may test your baby’s lung maturity. This test is an amniocentesis, which uses a needle to take a sample of amniotic fluid from the uterus.

The majority of cesarean births utilize an epidural that numbs the lower part of your body. Medications in an epidural are extremely effective, and you will not feel any pain during the procedure. You will remain awake and may feel some pressure or a tugging sensation during the surgery. Doctrors may use general anesthesia in an emergency scenario. In this case, you could not see, feel, or hear anything during the birth. General anesthesia is not routine, and most cesareans are performed with an epidural.

Before the surgery, a catheter will placed into your urethra to your bladder to collect urine. You will have an IV in your hand or arm to provide IV fluids and antibiotics. Antibiotics will help prevent infection after the operation. A review of 95 studies involving over 15,000 women found that routine use of antibiotics at cesarean section reduced the risk of infections in mothers as well as the risk of serious complications of infections by 60% to 70%. The review notes that none of the studies looked properly at possible adverse effects on the baby. So, although there are benefits for the mother, there is some uncertainty about whether there are any important effects on the baby. If you receive antibiotics before the umbilical cord is clamped, they will also go to your baby.

If you have concerns about how antibiotics could affect your baby, talk to your care provider. You can ask whether it is their practice to administer antibiotics before or after clamping the umbilical cord.

Cesarean Surgery

Let’s run through what a cesarean birth is like and what you can expect. The process of a cesarean birth can vary depending on your circumstances, but overall, the procedure is going to take about 45 minutes to an hour. Your baby is usually born in the first 5-15 minutes, and the remainder is closing the incision. This procedure takes place in an operating room by an OBGYN. The OB part of this designation stands for obstetrician, a doctor qualified to perform a cesarean surgery.

Operating rooms are sterile environments. They are cold and brightly lit, and you may smell cleaning products. You can expect around 6-12 doctors, nurses, and medical staff to be present. You will lie down on your back on an operating table with your arms out to your sides. Nurses will begin to cover you in sterile sheets. Next, they will place a wedge under one of your hips or tilt the table to one side. This positioning will relieve pressure on your vena cava, the main vein that goes to your lower body, and will help maintain good circulation for your baby.

There will be a sterile cloth at your chest to block your view so you cannot watch the surgery. Everything on the other side of the screen is a sterile field. Most of the nurses and doctors will be on the sterile side of the cloth, except for the anesthesiologist, who will be next to your head.

Your partner or another support person is brought in just a few minutes before your baby is born and will be seated by your head. Having your partner or another support person by your side can make a big difference in the room’s energy and give you comfort in an environment that could be intimidating.

The procedure starts with cleaning your abdomen and your doctor making an incision through your abdominal wall. The most common is a bikini incision horizontally near the pubic hairline. If the circumstances require a very quick delivery, your OB may use a vertical incision from just below your navel to just above the pubic bone. Surgeons make incisions layer by layer. These will go through your fatty and connective tissue and separate the abdominal muscle to access your abdominal cavity.

Next, the OB makes an incision to the uterus. This incision could be horizontal or vertical, and it does not have to be the same type of incision in your abdomen. The most commonly used uterine incision is a low transverse incision, similar to the bikini incision. This has fewer risks and complications than the other types of incisions, and it may allow you to attempt a VBAC (vaginal birth after cesarean) in a subsequent pregnancy with little risk of uterine rupture. Another option for the type of incision is a vertical classical incision. Doctors usually reserve a classical incision for complicated situations such as placenta previa, extreme emergencies, or babies with abnormalities.

Meeting Your Baby

Once the OB makes all of the incisions, your baby is ready to make their big entrance into the world. If you want to see the moment your baby comes out, you can request that your doctor or a nurse lower the screen slightly so you can see your baby. They probably will not remove the screen entirely, but they should be able to lower it a bit. As your baby is born, you may feel tugging or pressure. Once their head is out, your doctor will clear your baby’s mouth and nose of fluids. Since they are not going through the vaginal canal, which naturally squeezes fluids out of their lungs, they may need some assistance getting fluids out. Then, once their whole body is born, your doctor should hold your beautiful baby up so you can see them.

It is possible to delay clamping of the umbilical cord in a cesarean birth. The American College of Obstetricians and Gynecologists recommends a delay in umbilical cord clamping for at least 30–60 seconds after birth. Benefits of delayed cord clamping include increased blood volume, reduced need for blood transfusion, decreased incidence of intracranial hemorrhage in preterm infants, and decreased frequency of iron deficiency anemia. In addition, a longer duration of placental transfusion after birth may be beneficial because this blood is enriched with immunoglobulins and stem cells, which provide the potential for improved organ repair and rebuilding after injury from disorders caused by preterm birth.

An in-depth episode examines the research and offers many more details on delayed cord clamping. If you are considering cord blood banking, it may be challenging to both delay cord clamping and bank cord blood. This episode is a must-listen if you consider banking your baby’s cord blood.

Generally, many care providers will first pass your baby to the nurse for a quick evaluation. If your baby is adjusting well, then you should be able to get skin-to-skin contact right away. You and your baby will be monitored closely for complications after the surgery and during your recovery. Skin-to-skin contact tis critical, especially for a baby born via a cesarean. Skin-to-skin stabilizes your baby’s heart rate, breathing, and temperature and reduces stress in both you and your baby. It also increases your interactions with your baby and the likelihood and length of breastfeeding. You can talk to your doctor about how soon you can hold your baby after they are born and let them know if that is a priority for you.

You may notice a white substance on your baby’s skin. During the second trimester, your baby’s skin becomes covered with vernix caseosa. Vernix is the Latin word for varnish; caseosa is the word for cheese. Vernix is greasy and cheese-like and protects your baby’s delicate skin from abrasions and hardening from exposure to the amniotic fluid. The vernix sheds as delivery approaches. At birth, vernix may cover the entire surface of your baby’s skin, or you may only find it in the folds of their skin. Babies born via a cesarean birth tend to have more vernix because it doesn’t get wiped off in the vaginal canal.

Vernix serves many different functions in the womb and after birth. It keeps your baby’s skin hydrated, prevents water loss, helps with temperature regulation, and contains antimicrobial polypeptides and proteins that defend your baby against bacteria. Vernix also includes antioxidants and immune proteins. Hospitals have long practiced wiping vernix off newborns. You also have the option to leave it on. If vernix is left alone, most of it will be absorbed within the first 24 hours and should be fully absorbed by day 5 or 6. You can check out this episode to learn more about vernix and your baby’s first bath.

Recovery After a Cesarean

Immediately following the surgery, you may experience nausea and trembling. Several things, including the anesthesia, your uterus contracting, or a letdown of adrenaline, could cause this. Nausea and trembling should pass quickly, and you may be drowsy afterward. As you are recovering from surgery, you will receive pain medication through an IV. Soon after the birth, your doctor will encourage you to get up and walk around. This can help prevent things like constipation and blood clots, which can be dangerous.

A hospital stay following a cesarean birth is longer than for a vaginal birth. You can expect to be in the hospital for two to three days. You will have doctors, nurses, and specialists monitoring you and your baby to ensure there are no complications. They will check the incision for signs of infection and monitor your movement, fluid intake, and bladder and bowel functioning.

Take advantage of available doctors and nurses to ask questions about your recovery, how your baby is adjusting, and anything else that comes to mind. The hospital should have a lactation consultant on staff. Breastfeeding can be more challenging with a baby born via cesarean, so it’s a good idea to request a consultation with a lactation consultant while you have easy access to them in the hospital.

Before you leave the hospital, your doctor or a nurse will review things to keep an eye out for as you recover. You need to contact your care provider if you have any signs of an infection; this could show up as a fever, severe pain in your abdomen, or redness, swelling, and discharge where your incision is. If you have any breast pain accompanied by redness or fever, if your vaginal discharge is foul-smelling, or if you feel pain when you urinate, you should contact your doctor. If anything comes up that you are concerned about, do not hesitate to call your doctor.

Recovery at Home

Once you are home from the hospital, you should focus on resting and taking it easy. One way you can do this is to plan ahead and have some meals in your freezer. Take up friends and family on their offers to come by and help. You should avoid lifting from a squatting position or lifting anything heavier than your baby. This is also a great time to lean on your partner. Your job is to be with your baby and rest. Check out this episode on planning for postpartum.

Your Birth Plan

Every expecting mother should be knowledgeable about cesarean birth, even if that is not your primary birth plan. Labor is an intense experience, and a lot can happen that puts you in a position where you or your care provider has to make quick decisions and may not have time to explain your options at length. If you know you are having a cesarean, you can build your birth plan around your preferences for that. If you are planning a vaginal birth, I recommend creating a backup birth plan in the event you need a cesarean section. Remember that one in three babies is born via cesarean. Creating a backup birth plan will help alleviate some fears and give you more confidence in the event things do not go as planned.

The Pregnancy Podcast has several resources to help you create your birth plan: 

• Guide to Creating Your Birth Plan
• Why You Need a Backup Plan
• Get a copy of Vanessa’s birth plan 
• Your Birth Plan book (FREE for Premium Members) 

More Options for a Cesarean Birth

As with anything during your pregnancy and birth, you have a lot of options for a cesarean if you know what those options are. Stay tuned for an episode next week that dives into more of your options and examines a family-centered cesarean, vaginal seeding, and more.

Thank you to the amazing companies that have supported this episode.