April 03, 2023Pregnancy

Q&A with a Midwife: C-Section Awareness Month

April is c-section awareness month, so we have spoke to mother of two and practicing NHS midwife of 10 years, Angie (@theecomidwife) who has provided us with all the information on how a c-section works, when it is commonly advised and what the risks are so that you can make an informed choice on the type of birth best suited to you and your baby.

What is a caesarean section (c-section)?

A caesarean is an operation to birth a baby abdominally. It is a surgical incision usually made above the bikini line in the lower abdomen (but sometimes it can be a mid line down the middle of the abdomen in extreme premature or special circumstances).

Why are c-sections typically carried out?

Most commonly they are carried out where there are risks to either mum or baby. The two most common reasons in the UK are labour not progressing quickly enough or fetal distress. Other reasons include previous traumatic birth, maternal choice, tokophobia (fear of childbirth), declining an induction of labour, diabetes, pre eclampsia, breech, unstable lie, polyhydramnios, previous third or fourth degree tear, previous shoulder dystocia, previous caesarean birth, twins or obstetric emergencies like placental abruption, cord prolapse or uterine rupture.

Can I choose whether I have a c-section or a vaginal delivery?

Yes in the UK the NICE guidelines state it is a woman’s right to choose. If an obstetrician is unwilling to perform a caesarean birth then they must refer the woman to another obstetrician who will perform the caesarean birth. Often there is a team or service for any psychological support too if it is relating to a fear of childbirth or previous birth trauma that is also recommended alongside. If you do have any concerns in getting a trust to agree to your caesarean birth (less of an issue in 2023) then contacting birth rights is the next step alongside your maternity voices partnership volunteers.

However there is a caveat: One of the chances of a planned caesarean birth is some women will enter labour before the planned caesarean date. If this were to happen you would be counselled regarding the risks and benefits of an unplanned caesarean vs a vaginal birth – this is the degree where sometimes very rarely women end up having a vaginal birth because it has been too quick even though they had planned a caesarean birth – the majority of women wanting a caesarean have their caesarean but I have known a few women having a rapid vaginal birth before a caesarean has been able to be performed.

What advice would you give to an expecting parent deciding on their chosen birth method?

Check out my article on Bloss on both vaginal birth risks and benefits and caesarean birth risks and benefits. Talk to other parents, read positive birth stories for both births. Explore all the options with both births. Undertake an antenatal course which gives you the options you will have in both scenarios because caesarean or vaginal birth you have choices and options. I teach antenatal courses that cover all births and options.

I am not planning to have c-section, but should I still be aware of how it works?

Yes absolutely as 25-40% of all births are caesareans in the UK. Around 15% are planned which mean the other 10-25% is unplanned and women who entered labour. If you know your choices and options, understand advocating for yourself, what the process is and your choices then you are more likely to have a positive birth IF a caesarean becomes the safest option for you or your baby.

What benefits are there with a caesarean birth?

Caesarean birth can be the safest way for a baby to be born with certain medical or pregnancy complexities. There is no perineal tearing or vaginal tearing, postpartum bleeding is shorter in length, no labour and you can choose the date and time too. For some women it can be a healing experience particularly those with previous trauma and there is a lower chance of incontinence (13% vs 21%) and a slightly lower chance of pelvic organ prolape (5.6 vs 6% vaginal birth).

What are the risks of caesarean birth?

There are many risks to a caesarean birth as there is with any surgery, and why informed consent should take place before the caesarean birth happening. The full list of risks is on the RCOG caesarean birth site. I have written articles which are on my website on both the risks and benefits of a vaginal birth and also a caesarean birth. Here are the most common risks:

25% of women will have another caesarean in future pregnancies
10% of women will have a wound infection. Antibiotics are always given in theatre to reduce this risk, instruments are always sterile and good wound care postnatally can help prevent infection. Women with a BMI over 35 are now recommended to have a special type of dressing as the risks are greater for women with a BMI over 35.
For women planning a caesarean, 10% will go into labour before the planned caesarean date (increasing the risks of a caesarean to the mother as labour has already began). Planned caesareans without labour before 39 weeks increases the chances of a baby going to the neonatal unit with breathing concerns.
10-15% of women will develop a paralytic ileus (where the bowel stops working). This is often managed by laxatives and diet but in serious but rare cases leads to severe pain, NG tube feeding, hospitalisation and antibiotics to prevent bowel damage or perforation. There is no data for absolute risk at the severe end of the scale.
9% of women will have continued abdominal pain in the first few months after birth.
5% of women will have a postpartum haemorrhage – excessive bleeding over 500mls (higher in an unplanned caesarean at around 20-22%, variable depending on when the caesarean birth was done, length of labour, whether oxytocin was used, medical and obstetric and pregnancy history).
5% will be readmitted to hospital (with pain, infection or other complications)
0.5% chance of uterine rupture in future pregnancies (This can vary by pregnancy interval, incision type, medical factors and number of caesareans)
Longer recovery time compared to spontaneous vaginal birth
Unable to drive until 6 weeks postpartum or signed off by GP
4-5% chance (4-5:100) of a baby being admitted to the neonatal unit with breathing difficulties – called respiratory distress or tachyapneoa of the newborn. The average time spent in a neonatal unit is 1-5 days for breathing support.
Increased chance of asthma, allergies and eczema. Breastmilk is a protective factor against these
Increased chance of obesity for babies born by caesarean birth

Less common risks include:

0.07% chance of an emergency hysterectomy, (more likely in unplanned caesareans or women who have had multiple caesarean births)
0.09 % chance of being admitted to ICU.
0.04-0.016% chance of blood clots (those women at high risk will be advised to wear TED stockings and self administer blood thinning injections for ten days, alongside mobilising and hydration which significantly lowers the risks. Not smoking also lowers the risk further).
0.05% of women will require further surgery.
0.01% chance of bladder damage (less common in women which have had less than 3 caesareans – but greater risks after 3+ caesarean births)
Increased chance around 0.35 of placenta previa in future pregnancies (where the placenta covers the cervix and can cause miscarriage, stillbirth and be life threatening for the woman, usually requiring long term hospital admission in pregnancy) in a future pregnancy – this risk becomes higher with every caesarean birth a woman has.
NIHR report around a 1:69 chance of miscarriage in future pregnancies, but further data is needed to confirm.
Small increased stillbirth chance in future pregnancies. One study found a 0.01% chance in women with a previous caesarean birth having an unexplained stillbirth in a future pregnancy compared to 0.005 per 1000 women who had a previous vaginal birth from 34 weeks. Stillbirth risks vary by study, and because there are other known factors (like smoking, medication/drug use, placental abruption, pre eclampsia, uncontrolled diabetes, gestation) without a randomised trial only correlation looking at population groups can be found rather than cause and effect. The risks of placenta previa and uterine rupture can also lead to a stillbirth if they aren't recognised and responded to quickly which is another factor when exploring increased stillbirth chance after a previous caesarean birth. Bjellemo et al (2020) found the chance of pre term birth, stillbirth, cerebral palsy, small for gestational age baby, pre eclampsia, postpartum heamorrhage and placental concerns all increased after one previous caesarean birth compared to previous vaginal birth. There were limitations of this study but it was a large study. Taylor, 2005 found the same chances increasing after one previous caesarean birth compared to vaginal birth as a first birth mode.
Increased placenta accreta in future pregnancies (where the placenta vessels embed through the uterus and into the abdominal cavity or other organs). There is no absolute risk, but there is an small observed upward trend on the MBRRACE UK of placenta accreta data as caesarean births increase, placenta accreta is rising too. These can be more common with diagnosed placenta previa.
Increased chance of endometriosis (some studies report around 1-2% increase compared to vaginal births).
Increased chance of difficulty in trying to conceive (Kjurlff, 2020) the difficulties in research available is that it is limited, and difficult to know if fewer women decide to have future children after one caesarean birth (as family dynamics vary), whether implantation is as easy with previous uterine surgery, whether there were reasons in the first place with having a caesarean birth which impacts fertility or whether birth trauma also inhibits women in having more babies. There is no absolute risk in this area due to limited research currently. Secondary infertility can happen to anyone, however in the limited evidence available currently it appears that a caesarean birth may be linked to conception difficulties. More research is needed in this area, with much larger scale population studies. Recognition of secondary infertility also needs to be explored further too.

What is the typical recovery of a c-section like compared to vaginal delivery?

Typically much longer with the average recovery time of 6-8 weeks. Some women will recover quicker and others take longer sometimes many months. Some women will find the scar heals quickly, others find the numbness and desensitisation can last for a few months. Exercising during pregnancy and gentle postpartum exercise when you have reached 6-8 weeks tailored to post caesarean birth recovery can help with recovery as does good support around you and a good diet.

If you have a c-section for your first child, do you have to deliver any future children in the same way?

Not necessarily, it will depend on firstly your preferences, what the incision made was, any complications from your previous caesarean birth, how many you have had, the reason(s) for these, how your pregnancy has been and any additional medical or obstetric factors which arise.