Understand the Risks of a Cesarean Delivery

Nearly one-third of babies today are born by Cesarean delivery, where the doctor delivers the baby through an incision in the abdomen and uterus. Reasons for a Cesarean include: repeat Cesareans for women with one or more prior Cesareans; breech or transverse presentation of your baby; arrested labor or cephalopelvic disproportion, where either the baby is too big or the maternal pelvis is too small for safe delivery to occur; fetal distress, where the baby will not tolerate normal labor safely; and other less common reasons. Sometimes, Cesareans are planned and occur on a scheduled basis before labor has started; but sometimes Cesareans are emergent and occur after labor has started. In general, planned Cesareans are safer for the mother and baby than emergent Cesareans. There are, of course, unique risks to Cesarean delivery, which are discussed below.

Bleeding. There will almost always be more bleeding at the time of a Cesarean delivery than with a vaginal delivery. A blood transfusion is needed about 1 in 80 times, and this can be associated with an allergic reaction or about a 1 in 2,000,000 chance of serious infections such as Hepatitis C or HIV. You need to tell your doctor if you are unwilling to accept a blood transfusion in order to save your life. In about 1 in 700 births, it is necessary to perform a hysterectomy (removal of the uterus). This is often done as a life-saving measure because of otherwise uncontrollable bleeding, and would mean that you could not become pregnant again. The risk of hysterectomy for bleeding increases with the risk of something we call placenta accreta spectrum disorders, the risk of which increases with the number of repeat Cesarean deliveries.

Infection. Infection in your uterus, abdomen, or wound can follow a Cesarean delivery. Usually, infections in the uterus can be treated easily with antibiotics. Antibiotics which are given at the time of your Cesarean don’t guarantee that you won’t get an infection. Occasionally, an infection in your wound will require it to be opened up and it may take some time for the wound to heal. Very rarely, an infection in your abdomen, called an abscess, will require additional surgery.

Damage to other organs. During less than 1% of Cesareans, the organs around the uterus may be damaged. This includes the bladder, bowel, ovaries, fallopian tubes, and the ureters (the tubes running from the kidneys to the bladder). Most of the time, these injuries are found at the time of surgery. If this happens, your doctor will do whatever is necessary at the time to repair the injury. These types of injuries are more common in women who have had previous Cesareans or previous surgery in their abdomen or pelvis.

Blood clots. About 1 in 300 women will have a blood clot in her legs following a Cesarean that requires treatment with blood thinners, and sometimes this blood clot can move to the lungs, which can be fatal. Blood clots are more common following a Cesarean than a vaginal delivery. Your doctor will ask you to walk soon and often following your delivery to try to prevent blood clots from forming.

Injury to the baby. Less than 1% of the time, the baby can be injured during your Cesarean. Usually, these injuries are very minor – often a small, shallow cut. Occasionally, the baby might have a broken arm or collarbone, although this is more likely to happen with a vaginal delivery.

Ileus. Occasionally, following a Cesarean, bowel function is slow to return. This usually only lasts two to three days.

Anesthesia. Most women (about 95%) have either a spinal or epidural for anesthesia, allowing the mother to remain awake during her surgery. Sometimes, circumstances require general anesthesia, where the mother is put to sleep. Your nurse anesthetist and/or anesthesiologist will discuss the risks and benefits of these types of anesthesia with you in detail.

Risks in future pregnancies. Some risks of Cesarean delivery are not realized until later pregnancies. One is the risk of the scar on the uterus rupturing. This risk is generally less than 1%, depending on how many Cesareans you have had. This risk may be even higher if you have what is called a “classical Cesarean delivery,” where a vertical incision is made on the uterus (rather than a horizontal or transverse incision that is usually used). This may be necessary if your baby is very small or if it turns in a way that makes it difficult to deliver. Another is the risk of the placenta becoming abnormally attached to the uterus (placenta accreta). This risk increases with each Cesarean you have.

Death. Although pregnancy and childbirth are very safe compared to most medical conditions, it unfortunately can still lead to maternal death about one time in every 10,000 births. Causes for this include severe bleeding, blood clots in the lungs, hypertension, and other medical problems the mother may have. Also, some babies do not survive birth or have significant problems after birth, particularly if they are born very early or are very small. About six to seven babies out of 1,000 die late in pregnancy either before birth or shortly afterward due to a variety of problems with the baby or mother. Many of these deaths cannot be predicted or prevented, but if you or your baby are at a higher risk for problems, your doctor will work closely with you to provide extra surveillance and testing for you and your baby.