Caveat Emptor: The Real Risks of Cesarean Section

Today's post is written by Pamela Candelaria who writes over at Natural Birth for Normal Women. 

Over 1.3 million babies in the US were born by c-section in 2008, accounting for 32.3% of all births. The most common reason for cesarean delivery is having had one before, but the reasons for a cesarean can vary widely. Sometimes there are medical reasons for planning a c-section prior to labor, and emergencies during labor make other c-sections truly lifesaving. For a huge number of women, though, the picture is less clear. They are told they have small pelvises, or big babies, or their labors aren’t progressing fast enough. Many women are told cesareans are a safe way to avoid the risks of vaginal birth, and an increasing number of mothers are choosing c-sections with no medical indication at all. Whatever the reason for the c-section, though, one thing they almost always have in common is a lack of truly informed consent. Let’s look at the risks listed on a fairly typical consent form—what isn’t on the form may be surprising:

The consent form says:
Infection in the skin incision, usually this is controlled with antibiotics. Sometimes it can require you to be re-admitted to the hospital, but in most cases antibiotics are taken as an out-patient.
In reality, you are twice as likely to be re-hospitalized following a c-section, infection is almost five times more likely to occur, and infection can extend to the uterine incision. Taking antibiotics while breastfeeding contributes to thrush, adding another challenge when breastfeeding is already less likely to succeed following a cesarean. 

The consent form says:
Development of heavy bleeding at the time of surgery with the possibility of hemorrhage which could require a blood transfusion.
Transfusion is required in up to 6% of cesarean sections. If your c-section goes perfectly, you’ll lose over twice as much blood as you would during a normal vaginal birth- and even that number may be grossly underestimated. It is interesting to note that “normal” blood loss during a c-section would be considered a hemorrhage during a vaginal birth.  

The consent form says:
Injury to the bladder and/or bowel which could require surgical repair (this occurs in less than 1% of all Cesarean sections)
True- but mild bowel paralysis occurs following up to 20% of cesareans, and some women have bladder injuries that don’t require surgical correction but do require use of a catheter for weeks following delivery. Even if only 1% of women require further surgery to correct these injuries, that is almost 14,000 additional- and largely preventable- surgeries per year being performed on mothers who should be happily caring for their newborns.

The consent form says:
Injury to the ureter (a small tube which passes urine from the kidney to the bladder)
While this injury is unusual, occurring in just 0.1% to 0.25% of cesareans, it often goes undiagnosed until the mother returns to her doctor with symptoms including pain and fever. Another surgery is then required. 

The consent form says:
Developing a blood clot in the leg veins after delivery
This occurs in ½% to 2% of c-sections- somewhere between 6,900 and 27,000 women- and can be fatal; yet many women are never told what symptoms to look for or how to reduce their risk.  

The consent form says:
Risks for subsequent pregnancies include: placenta previa (where the placenta lies wholly or partly in the lower part of the uterus)
Shockingly, this consent form fails to list any other risks for future pregnancies. Reproductive consequences of a primary cesarean include a risk of uterine rupture that is 12 times higher than it would be with an unscarred uterus, even if a repeat cesarean is scheduled. A woman also faces increased risk of placenta previa, more severe placenta problems like abruption and accreta, miscarriage and unexplained stillbirth, unexplained secondary infertility, and dramatically increased risk of surgical complications in future c-sections. If that is not enough, the scar tissue and adhesions left by cesarean surgery can cause chronic pelvic pain and sexual dysfunction, and in rare cases can cause intestinal blockage that can be fatal.

The consent form says:
Cutting the baby during the incision into the uterus (this occurs rarely).
About 1-2% of babies are cut during c-sections- that could mean over 25,000 babies, every year, receiving anything from a nick to a severe laceration at the hands of the delivering OB. While the consent form ends here, a slippery scalpel is not the only risk babies face when delivered by cesarean. Babies born by elective cesarean are up to seven times more likely to have respiratory problems at birth, and are up to three times as likely to die in their first month of life.  C-section babies have lower APGAR scores, higher NICU admission rates, and they are more likely to have ongoing health problems like asthma. It’s important to note, these are low-risk babies, not babies who are delivered by emergency cesarean who may have been affected by complications of labor. No, these babies experience these issues as a direct result of the way they were born. 

I’ve talked with hundreds of women about their cesarean births, both online and in real life. There is a pervasive belief that c-sections transfer the inherent risks of birth to the mother, providing babies a safer and lower-risk entrance into the world than they’d have with a vaginal birth. Many OBs perpetuate this myth, but it’s clear they aren’t telling us the whole story. I don’t think I’ve met one woman- not one single mother- who was told up front that in some respects her c-section put her baby at greater risk than vaginal birth would have. Even though many women seem comfortable with the increased maternal risks of c-sections, few are truly aware of exactly what those risks are, how much they are increased, or how they can be reduced. OBs are selling c-sections as a safe and easy way to deliver a baby- and women are buying. 

Buyer beware.

Pam is a mother of 4 who found a passion for birth through her cesarean and 3 VBAC journeys. She believes the best way to improve maternity care is to empower all women to make fully informed decisions, regardless of what type of birth they choose. She resides in Denver, Colorado. 


2008 Birth Data

Cesarean Section Consent Form

Risk of selected postpartum infections after cesarean section compared with vaginal birth: A five-year cohort study of 32,468 women

Cesarean Fact Sheet

Neonatal Morbidity and Mortality After Elective Cesarean Delivery
Caroline Signore, MD, MPHa and Mark Klebanoff, MD, MPHb

Thrush in Breastfeeding Moms

Cesarean Childbirth

Estimates of cesarean-related blood loss shown to be too low

Urologic Injury at the Time of Cesarean Delivery

Uterine Rupture in Pregnancy
Deadly Delivery Summary

Fetal Injury Associated with Cesarean Delivery


Stassja said...

Great piece Pam! Thanks for hosting it Andrea. :D

I have nooooo clue what was on my consent form, honestly. I was so weak at that point I could hardly scribble a letter or two for my name. Nobody bothered to read it to me either.

Andrea said...

I have no idea what was on mine either. I don't even remember signing anything! And, when I had my VBAC, and got the epidural, I could barely scribble my name on that either. I asked my husband to sign it for me!! It's amazing what we will do when faced with a situation where we are not in our right minds.
That's why I think this post is so important. To really know what we're getting into.

TBM said...

I've had two Crash sections. First time was because I had a 31 week footling and had gone from 2cm to delivering the first foot in an hour, within 20 minutes of finding said foot I was under GA and my baby on her way to NNU.

They didn't give enough space to get her out (she was a big baby!) and had to cut upwards leaving me with an inverse T shaped scar. They told me I'd never be able to VBAC because of it. I looked into the risks and it was one point something %. I would have fought it but I didn't have the support from my family or partner and was still suffering Birth Trauma from the first time.

Reading through that list it makes me angry how many risks are 1-2% and considered low. I wanted to shout at the anaesthetist who told me the risk of headache was 1-2% so very rare!!!

I hate the overuse of Cesarean, I don't understand why people think that cutting into their body is normal?! Let's look at it for what it is, cutting into your abdomen for major abdominal surgery. Slicing through your flesh, exposing your insides to the air. All surgery has risk and is only done when necessary!

Yes Cesareans have a place, just like appendectomy but you don't cut a healthy appendix out either!

Pam C. said...

@TBM- I know! When I was writing this I was surprised how many risks were in the 1-2% range but still classified as "rare" in the context of cesarean safety. Talk about a 1% risk of uterine rupture for VBAC and you'd think everyone who has a trial of labor is signing up for the worst possible outcome.

@Stassja & Andrea, I do remember talking about risks with my OB prior to my c-section, but the only specific thing I remember her saying was something along the lines of "that almost never happens." I don't feel like I was misled or anything, and I can't really imagine being in a situation where a c-section is immediately necessary and having to think about all these risks. Why make a scary time even scarier if it's clear that the c-section IS the safer option? (not saying anything against informed consent,but I wouldn't see the point in telling a mom with a foot coming out her vagina "Hey, you do realize they might nick your ureter, right? Are you REALLY SURE YOU UNDERSTAND THAT?!?")

What really got me about the consent form I used in the post is that it seemed to be for a woman who was planning a c-section in advance. She should have the luxury of time to make a truly informed decision about whether the risks of a c-section are appropriate. Unfortunately there is no balance of information, just discussion about the "small" risks of c-sections, which sometimes seems to imply that the risks of vaginal birth are "not small." It's time for our cultural discussion about birth to stop occurring in a vacuum. A c-section can be the right choice, but even when it is, it will permanently alter the course of a woman's reproductive life.

Ashley said...

yeah I have noticed many women have a c-section. I go to a teen mothers support group on mondays and out of the 30 girls that go, only 3 (including me) have had a baby natural.

Erin said...

Great job Pam! Its amazing to see all of that statistics written down. Maybe you should come up with a "new" c-section consent and see if ACOG will pick it up! lol.

You ladies rock and i feel privileged to "know" both of you!

PreemieMommie said...

I too has an emergency c-section when I delivered my premature son. During this time I didn't even care what was on the consent form. However, you write about empowering the women in making her own decisions in health care, your "empowering" article is very biased. You cite many scientific statistic that are correct, yet you fail to mention any point that doesn't show sections in a bad light. Yes it is a major, life changing event, but childbirth is. How dare hospitals be vague and leave out details (which I agree is wrong), but you do not mention how there is no consent to have a vaginal birth in the hospital either, should we go through all the things that can go wrong with those? Yes 1-2% of this large number is a large number, but the percentage of c-section complications has dropped quicker than the amount of patients having them has grown. Your article has valid points, and true facts, yet it is skewed in such a way the whole picture is not presented. Empower women with complete information, not just tidbits that reinforce your soapbox.

Andrea said...

@PreemieMommie- Thanks for visiting and leaving your point of view. Yes, this article is biased and I asked Pam to write it that way, as she wanted to. In my humble opinion (and according to the World Health Organization) the cesarean section rate is entirely too high, "unnecesareans" are being performed all across the country. This post wasn't meant to scare women, but to have them open their eyes and learn things they didn't know before, so maybe a pregnant mom won't be so quick to chose a c-section after knowing the risks. Many women think c-section is "the easy way" and that breaks my heart. I'm sure the birth of your son was very scary for you, and a necessary cesarean and I hope that he is well.
I believe I do empower women- to make decisions for themselves, to trust their instincts and research for themselves.
I would also be interested in the research you mentioned.

Pam C. said...

@PreemieMommy- Thanks for your comment! I do know my post is one-sided, and I never intended this to be complete information for someone to make a birth decision. In my own experience, and in the experience of many many other women I know, the risks of cesareans are often understated or completely overlooked. When I was discussing the informed consent sheet for my first VBAC, my OB told me a repeat cesarean was "just like a zipper" they could open and close to get the baby out. Even at the time I wondered how that was supposed to help me make an informed decision. Hmmmmm, uterine rupture, your baby might die, you might hemorrhage, OR just a zipper, opened and closed. Seriously?

As the cesarean rate continues to climb in the US, c-sections gain greater visibility and social acceptance. More and more I see the sentiment that a c-section is no big deal, it's low-risk, and you get to avoid all the unknowns of vaginal delivery. Talking about a 1% risk may seem like I'm trying to make c-sections sound more dangerous than they are, but in reality I think it's important to talk about the fact that there ARE risks to c-sections, and what those actual risks are. When I found the information about how "hemorrhage" is defined differently for c-section and vaginal birth, it was a huge "AHA" moment for me! How in the world can we even begin to make an informed choice when the very definition of "risk" is different depending on how you deliver?

Again, my article is clearly not intended to provide full information for a woman who is making critical decisions about her birth. My intent was to illustrate how even "informed consent" can be inadequate.

One last thing- I *did* have to sign a general consent form for vaginal delivery at my OB's office. It listed all the common complications that can occur in any vaginal delivery (not vbac-related). That may not be standard, but I did think it was interesting, especially in light of the "zipper" comment.