Options: C-Section

What situations can lead to cesarean section?

What can affect whether I have a cesarean section or a vaginal birth?

Why is the c-section rate so high?

How does my right to "informed consent" or "informed refusal" relate to these matters?

How can I learn more about my specific situation?

What are some non-medical (elective) reasons for cesarean section?

What are some situations where some caregivers may recommend a cesarean section?

How does planned cesarean compare with unplanned cesarean?

How does planned cesarean compare with vaginal birth?

What is the relationship between care during birth and pelvic floor problems?

What is it like to have a c-section?

If you’re expecting a baby, there’s a good chance you’ve wondered if you’ll have a vaginal birth or a c-section. Maybe you talked about your chance of having a c-section with your doctor or midwife. You might even wonder if a c-section is easier or safer than vaginal birth. It’s important to get the facts and understand your options, so you can be prepared to make the best decisions for you and your baby.

What situations can lead to cesarean section?

The reasons for having a cesarean section fall into three general categories:
  • Non-urgent health problems: If your doctor or midwife suggests a c-section, chances are you have plenty of time to ask questions and find the information you need to make the decision that is right for you. Even if you are in labor, most situations are not urgent. However, it is important to learn as much as you can before labor so that you are fully prepared in case you do have to make the decision quickly. The most common non-urgent reasons why a cesarean is proposed are discussed below.
  • Urgent health problems: Much less commonly, situations may arise that pose an urgent threat to the health or life of the mother or baby. For example, if the mother is bleeding heavily (hemorrhage) or the baby isn't getting enough oxygen, a cesarean is needed. Such urgent situations can occur in pregnancy or while giving birth. This Pregnancy Topic doesn't cover the small proportion of situations when just about everyone would agree that a cesarean section is necessary.
  • Non-medical situations: In some cases, your caregiver may propose, or you may be considering, a cesarean section for reasons that have nothing to do with your health or your baby's health in the present pregnancy. In this case, it is important to make an informed decision with full understanding of the risks and benefits involved.

What can affect whether I have a cesarean section or a vaginal birth?

The health needs of you and your baby can certainly influence whether you have a cesarean section or vaginal birth, but some other key factors include
  • your choice of caregiver and birth setting
  • your access to supportive care during labor, and
  • the medical interventions you experience while giving birth.

Cesarean rates in the U.S. can range from under 10% for some caregivers and birth settings to over 60% for others. This variation occurs for many reasons. One is that caregivers differ in the ways that they support women who are giving birth and in their judgment about when to recommend surgical birth ("practice style"). C-section rates also vary from one birth setting to another due to differences in policies and practices. Because of this variation, your choice of caregiver and choice of birth setting can have a major impact on the type of birth that you will have.

Why is the c-section rate so high?

Many medical, legal, social and financial factors influence the cesarean rate. These include:
  • under-use of care that can enhance the natural progress of labor and birth, for example less emphasis on:
    • providing continuous labor support (by a trained or experienced companion)
    • encouraging women to be upright and moving during labor (not on their backs, a position that can slow down labor)
    • ensuring that women are well-rested and well-nourished while giving birth
  • side effects of widely used medical interventions: the likelihood of c-section goes up, for example, when:
    • caregivers try to cause labor to start (labor induction)
    • caregivers use continuous electronic fetal monitoring (EFM) to check the baby's heart beats
  • the willingness of some caregivers to move to cesarean section before trying measures that may avoid the surgery, for example by:
    • failing to attempt to turn babies in a breech position (buttocks- or feet-first) to a head-first position in late pregnancy with hands-on-belly movements (external version)
    • failing to allow more time for a vaginal birth to occur due to pressures in understaffed hospitals and on busy caregivers
  • pressures on caregivers today to practice "defensive medicine," for example:
    • caregivers may feel that performing a cesarean section reduces their risk of being sued or of losing a lawsuit should complications occur
  • failure to offer women with a previous cesarean section a choice between VBAC (vaginal birth after cesarean) and repeat c-section:
    • more and more hospitals and caregivers are adopting a 'no-VBAC' policy, and a woman who wants a VBAC may be unable to have one due to these restrictions
  • loss of skills or unwillingness to offer vaginal birth to women in some situations, for example:
    • a woman who makes an informed choice to have a vaginal birth with a baby in breech position may have trouble finding a caregiver who is experienced and willing to attend such a birth
    • a woman who is expecting twins may have trouble finding a caregiver who is experienced and willing to attend the vaginal birth of twins
  • the perception that a cesarean section, and especially a planned (elective) c-section, is "safe":
    • although cesareans are safer now than before, the surgery still carries a broad range of short- and longer-term risks for mothers and babies
    • although planned cesareans offer some advantages in comparison with unplanned cesareans, the fact remains that surgery - planned or unplanned - poses a series of risks in comparison with vaginal birth.

These factors can increase your chances for having a cesarean. But, the section Tips & Tools: C-Section, offers many ideas for reducing the likelihood that they will come into play in your situation.

How does my right to "informed consent" or "informed refusal" relate to these matters?

Informed consent is a process to help you decide what will and will not be done to you and your body. In the case of maternity care, informed consent also gives you the authority to decide about care that affects your baby. The purpose of informed consent is to respect your right to self-determination. It empowers you with the authority to decide what options are in the best interest of you and your baby. Your rights to autonomy, to the truth (as best as it can be known at the time), and to keep yourself and your children safe and free of harm are basic human rights. As the person receiving care and mother of your baby, you are in the best position to decide what risks are important to you. (Learn more about informed consent.)

Whether you wish to plan a vaginal birth or a cesarean section, it is important to make this decision on the basis of complete, accurate, unbiased information.

How can I learn more about my specific situation?

Below you will find a brief discussion of the more common reasons why your doctor or midwife may recommend a non-urgent cesarean. Less common reasons are not discussed. If your doctor or midwife suggests a c-section and it is not an urgent situation, here are some questions to ask:

Questions to Ask
  • What is the benefit of a c-section for me or my baby?
  • What problems might happen if I continue with my plan for a vaginal birth?
  • How likely are those problems if I plan for a vaginal birth?
  • Could they still happen if I have a c-section?
  • What are the possible harms of a c-section?
  • How likely are these possible harms?

If you need more information or want to double check what you learn, you can find a comprehensive list of possible benefits and harms of c-section, along with information about how likely they are, in
Best Evidence: C-Section. Your caregiver can help answer questions about this information.

Once you have answers to your questions, think about what is most important to you and discuss these goals and preferences with your care provider. With these in mind, weigh the possible benefits of a c-section against the risks and make the decision that feels right for you and your baby.

What are some non-medical (elective) reasons for cesarean section?

Concerns about pelvic floor disorders: You may be hearing that an elective cesarean section will prevent later-life problems with leaking urine (urinary incontinence) or leaking feces or gas (bowel incontinence). The research does not support this claim.

Current research suggests that pregnancy and some commonly used maternity practices (such as routine episiotomy, a surgical cut made just before birth to widen the opening of the vagina) can contribute to incontinence in the period after the birth. While research supports avoiding whenever possible maternity practices that can harm the pelvic floor, it does not support avoiding vaginal birth itself. In addition, studies find that birthing practices have their strongest effects in the recovery period in the first weeks and months after birth. These effects fall off quickly for nearly all women and disappear for nearly all by about age 50. Incontinence in later life seems to be related to other health and lifestyle factors such as excess weight and smoking.

You can find out more about problems with the belief that cesarean section protects the pelvic floor in Best Evidence: Pelvic Floor Dysfunction. You can learn more about how to prevent and relieve such problems in Tips & Tools: Pelvic Floor Dysfunction.

Profound fear of childbirth: A small proportion of women, both first-time and experienced mothers, have an extreme fear of childbirth. Certainly, almost every expectant mother experiences some degree of fear or apprehension, but here we are talking about something altogether different.

A series of counseling or psychotherapy sessions during pregnancy can help many women overcome their deep fears and give birth vaginally. Continuous support during labor by a trained labor support companion (doula) may be of special value to a woman in this situation. (Options: Labor Support will give you information on doulas.) If you decide to seek counseling, be sure to get help from a trained individual who has both good counseling skills and an understanding of maternity issues.

If you still have deep fears of childbirth despite counseling, you may decide to have a cesarean birth. Be sure to talk this over with your caregiver as early as possible in your pregnancy, and work together to help ensure the safest possible and most satisfying birth.

Other rationales for "cesarean by choice": As attitudes toward cesareans become more casual, and as they are performed more "routinely," you may have thought about planning a cesarean for reasons of convenience. For example, you may wish to schedule your baby's birth date. Or you may think of a cesarean as a pain-free way to give birth. Or perhaps, if labor does not go as smoothly or as quickly as you would like, the idea of a cesarean may appeal to you or your caregiver even if there is no clear medical reason. Before going down this path, it is important to investigate whether this choice truly offers you what you believe it will (such as greater convenience or less pain). And it is also important for you to make an informed decision with full understanding of the trade-offs that are involved.

What are some situations where some caregivers may recommend a cesarean section?

Previous cesarean section: Caregivers disagree about how a woman should give birth if she had a cesarean in the past. Some recommend planning a VBAC ("vee-back," vaginal birth after cesarean), while others recommend scheduling a repeat cesarean. The concern is with the fact that the woman's uterus has a scar, which can give way (rupture) in a future pregnancy or labor. On the one hand, having a repeat cesarean lowers the likelihood that a scar will open and create problems. A recent U.S. government evidence report estimates that for every 10,000 women who plan a VBAC, 1.4 babies will die due to scar problems during labor. On the other hand, a surgical delivery poses its own set of risks for mothers and babies, some of them also quite serious. As the number of previous cesareans goes up, some of the serious risks for any future pregnancies increase sharply.

If you've had a previous cesarean, you would do best to learn all you can about these and other trade-offs involved with this decision and discuss these matters thoroughly with your caregiver before making your decision. Be sure that your caregiver and any others who may be attending your birth agree with your decision.

Unfortunately, it's becoming harder to find a hospital and caregiver who will leave the choice in your hands. If you want to have a VBAC, you may need to search for a caregiver and hospital that will offer you this. In some communities, this may not be available.

To help pregnant women with a previous cesarean understand these matters and make their birth plans, this website has a complete Pregnancy Topic called VBAC or Repeat C-Section.

Prolonged labor or failure to progress: The length of labor varies from woman to woman. Your labor may be short, long, or somewhere in the middle. If your labor is taking longer than average, you may be told that you have prolonged labor.

Caregivers vary in how they might prevent or respond to a slow labor and in their degree of patience with a long labor. For example, some will try to rest the uterus or stimulate stronger contractions with drugs before turning to a cesarean. They may try such things as ensuring that the mother is getting enough fluids or encouraging her to change positions or walk around rather than lying flat on her back. Others will be quicker to turn to a cesarean. As long as you and your baby are doing well, there is no medical reason to decide on a cesarean. It's a good idea to talk with your caregiver, well before labor begins, about how he or she handles a long labor. Then you can think about what you might do if you are faced with this situation.

Taking a long time to get to the point when your cervix is open (dilated) to 4 centimeters or so says nothing about your ability to birth your baby vaginally. Slow or stalled labors after that (in active labor) are more concerning, but even in these cases, most women can have vaginal births.

Having continuous supportive care from a woman trained to help women in labor (doula), or a female friend or family member who is experienced with labor, can help you get through a long and challenging labor. This kind of support can also help meet your partner's needs and help your partner support you.

Baby in breech position: Nearly all babies will take up a head-first position by the end of pregnancy. When the baby is in a buttocks- or feet-first (breech) position, labor poses some increased risks for both mother and baby. Because a cesarean poses its own set of risks, you may want to find a caregiver who has hands-to-belly skills to turn the baby to a head-first position (external version) in the last weeks of pregnancy. Sometimes it is not possible to turn a baby with this technique, and sometimes a turned baby will flip back to a breech position. However, most women who try this technique will go into labor with the baby in a head-first position.

Should your baby continue in the breech position, most caregivers will recommend a cesarean. There are important advantages to cesarean in this situation in comparison with typical hospital ways of handling vaginal breech births, especially lower likelihood of death or serious problems for your baby. On the other hand, vaginal birth avoids risks of surgery for mothers and babies in the present pregnancy and has many advantages for mothers and babies in future pregnancies. (You can learn more about possible problems resulting from cesarean surgery in Best Evidence: C-Section.)

If you find yourself in this situation, you will want to discuss this matter with your caregiver and to learn all you can about these and other specific trade-offs involved with this decision. Be sure that you and your caregiver agree ahead of time about your birth plan. If you decide to plan a vaginal breech birth, it is important that your caregiver and any others who may be attending your birth have skills and experience with this type of birth.

Changes in the fetal heart rate: Certain changes in the fetal heart rate may signal a problem for the baby. When the fetal heart rate is very fast, very slow, or irregular, your caregivers may be concerned about the baby's condition. In some situations, these changes are easy to correct. For example, a doctor or midwife can ask a mother who is lying on her back to move to another position, give her oxygen or fluids, or lower a high dose of synthetic oxytocin (a hormone to strengthen contractions, also called Pitocin). If this cannot be corrected and the baby is not about to be born, a cesarean may be recommended. However, electronic fetal monitors (EFM machines) often suggest that the baby is in trouble when this is not the case. Further testing can help identify which babies may need help.

Multiple births: Giving birth to more than one baby poses unique challenges. However, no well-done research currently supports routine delivery of twins by cesarean section. Most caregivers will recommend a cesarean when there are three or more babies. As always, it's important to learn as much as you can about the expected benefits and risks of cesarean compared with vaginal birth and discuss your individual situation with your caregiver before making your decision. If you are having twins and want to have a vaginal birth, you may need to seek out a caregiver who will support this.

How does planned cesarean compare with unplanned cesarean?

A planned cesarean offers some advantages over an unplanned cesarean (a cesarean that occurs after labor is under way). For example, there may be fewer surgical injuries and fewer infections. The emotional impact of a cesarean that is planned in advance appears to be similar to or somewhat worse than a vaginal birth. By contrast, unplanned cesareans can take a greater emotional toll.

How does planned cesarean compare with vaginal birth?

A planned cesarean still involves the risks associated with major surgery. And both planned and unplanned cesareans result in a uterine scar and internal scarring and adhesions. This means women with planned and unplanned cesareans face similar risks in future pregnancies and for problems related to scarring and adhesions at any time

What is the relationship between care during birth and pelvic floor problems? 

More and more research finds that some practices used at the time of pushing increase the likelihood of pelvic floor injury. Many women experience one or more of these during vaginal birth. You can lower your risk by choosing a caregiver and birth setting with low rates of intervention. These practices include:

  • cutting an episiotomy
  • using vacuum extraction or forceps to help bring the baby out
  • having women give birth while lying on their backs
  • using caregiver-directed pushing, which is often more forceful than having the woman and her own reflexes guide pushing
  • pressing on the woman's abdomen to help move the baby out

Preventing Pelvic Floor Dysfunction
is a full Pregnancy Topic on this important issue.

What is it like to have a c-section?

A c-section might happen during labor or before labor starts (scheduled c-section). Unless there is a special situation, the woman will be awake during the surgery. Before the surgery starts, there are many preparations:

  • An intravenous (IV) line will be put in the woman’s arm or hand. The IV will be used to deliver fluids as well as medicines to prevent infection and bleeding problems.
  • An anesthesiologist will give an injection into her back to deliver spinal or epidural anesthesia, which numbs her belly and legs.
  • She will be positioned under the operating light on a firm, narrow bed that is slightly tilted to prevent her from lying flat on her back. Straps that are similar to seat belts will secure her on the bed.
  • A catheter will be inserted into her urethra to remove urine. The catheter will stay in place for about one day, and will be removed when the woman can walk on her own to the bathroom.
  • Oxygen will be given through a tube that fits into or over the nose.
  • Her belly and thighs will be shaved and cleaned with a special soap to reduce infection
  • Her belly, legs, and chest will be covered with sterile cloths and a curtain will be raised between her head and her lower body.
  • Machines will check her blood pressure and oxygen levels.
  • Before the surgery starts, staff will count all of the tools (clamps, scissors, etc.) and other supplies and may introduce themselves and double check the woman’s name and the reason for the surgery. These are safety checks to help prevent errors in the operating room.

During the surgery, the woman will have a support person (usually her partner or other family member) next to her on the same side of the curtain. The anesthesiologist will also be on that side of the curtain. After making sure the belly is numb, a doctor and a surgical assistant will begin the surgery. The woman may feel tugging and pulling sensations, especially right before the birth of the baby, but should feel absolutely nothing sharp. (If there is pain or a sharp sensation, the surgery should be stopped immediately so more anesthesia can be given.) It usually takes about 15 minutes from when the surgery begins to when the baby is born. Just before the baby is born, the curtain may be lowered to allow the woman and her support person to watch the baby come out. A nurse will dry and place the baby on a warming table to do a quick check on the baby’s breathing, color, and heart rate.

Once the baby is stable, the baby may be wrapped and brought to the woman to cuddle cheek-to-cheek. Some hospitals will place the baby skin-to-skin on the woman’s chest because early skin-to-skin contact after birth is healthy for babies and women. After the baby is born, the doctors will deliver the placenta, give medications to control bleeding, and stitch the uterus and other muscle and tissue layers. The skin may be closed with stitches or staples. Stitches will dissolve on their own after a couple of weeks. Staples are removed with a special tool either just before the woman goes home from the hospital or at an office visit about 1 week after the birth.

After the surgery is done, the woman is moved to a recovery room for an hour or so to be closely checked for bleeding and other problems. The baby is usually in the recovery room with the mother. This is a good time to have the baby skin-to-skin and begin breastfeeding. After the recovery room, the woman will be moved to a regular postpartum room in the hospital. The spinal anesthesia wears off around this time, and pain medications are then given by IV. The woman cannot eat or drink at first, but will soon be able to have clear liquids like juice or popsicles, then regular food. At this point the IV will be removed and the woman will take pain medication by mouth. Most women stay in the hospital about 3-4 days after a c-section.

Next >
Best Evidence: C-Section

Most recent page update: 12/11/2012

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