When is a C-section an option?

A C-section is a procedure performed on the abdomen (belly) to take the baby directly out of the womb. To do so, an incision of about 8 to 12 centimeters is made across the mother’s lower abdomen, just above the pubic bone. The other layers of tissue are usually stretched open carefully with the fingers.

The procedure is usually carried out using local anesthesia, and in rare cases general anesthesia may be used. When a local anesthetic is used, the you remain fully conscious but don’t feel any pain.

Complications can occur during pregnancy or childbirth that make vaginal birth too risky or even impossible. The baby can then be delivered safely by C-section.

Situations that make a C-section necessary include:

• The baby is in a position that makes vaginal birth risky or impossible (such as the baby being sideways).
• The placenta is in front of the cervix, blocking the birth canal.
• The umbilical cord is between the child and the birth canal (umbilical cord prolapse).
• The uterine wall is at risk of tearing.
• The placenta is detaching from the uterine wall too early.
• The baby’s heart rate is constantly much too slow.
• The baby is not getting enough oxygen.

In Germany, fewer than 10 out of 100 C-sections are performed for necessary reasons like these.

Sometimes there are increased risks associated with a regular birth, but a C-section is not absolutely necessary. You can then discuss which type of birth is best for you and your baby with your doctor and midwife. C-sections also have certain risks.

Those situations include:

• A previous C-section delivery: About 1 in 4 C-sections are carried out because the woman has already had at least one C-section in the past. The C-section scar increases the risk of a ruptured uterus during vaginal birth. But vaginal birth is mostly possible and safe enough after a past C-section. Doctors can scan for any special risks like the placenta being in the wrong position.
• Breech presentation: By the 37^th week of pregnancy, most babies have turned into the optimum birth position with their head pointing downwards. Weak contractions or oxygen deficiency affecting the baby is more likely if the baby has their bottom or feet pointing downwards during birth. It is possible to try to turn the baby around into a cephalic position with their head pointing downwards (known as external cephalic version, or ECV) four weeks before the due date at the earliest. That works about half of the time. But the external cephalic version can also trigger contractions. If it is not successful or the baby goes back into breech position again, experienced clinics often offer vaginal birth in breech presentation.
• Delayed growth of the baby: Ultrasound scans detect that the baby is smaller than expected because the placenta is not supplying enough nutrients and oxygen. The question is then whether vaginal birth would be too stressful for the baby. A decision for or against a C-section will depend on many factors, including how concerning the ultrasound findings are and how advanced the pregnancy is.
• Multiple birth: Over half of all twins are delivered via C-section. The decision depends on things like whether there were complications during pregnancy, such as the placenta no longer being able to supply the babies properly, and how the babies are positioned in the womb. The procedure aims to prevent deficiencies in the babies. A C-section is nearly always recommended for pregnancies with more than two babies.
• Preterm birth: If contractions start too early or your water breaks prematurely, the baby is at more risk because it is still not mature. Whether a C-section is then safer than vaginal birth depends on a number of factors that the birth team will discuss with the expectant parents.
• Transmissible diseases: Mothers can pass on certain diseases to their baby during birth. Vaginal birth is possible in case of HIV if the mother takes medication against the virus and the viral load in the body is then very low. Otherwise, a C-section is recommended. A C-section is also advised in case of a vaginal herpes infection. But there is no proof that a C-section reduces the risk of transmitting of hepatitis B or C. C-sections aren’t recommended for HPV infections, either.
• Obstructed labor: The cervix doesn’t open widely enough and the baby cannot keep moving forwards or even slides backwards. It is possible to wait at first and try to make the birth progress through movement and different positions. If the birthing process doesn’t move forward for a longer time, you are very exhausted or other complications are developing, there is an increased risk that the baby will not get enough oxygen or nutrients or that you may be harmed during the birth. A C-section is then usually performed.

About 90 out of 100 C-sections are performed for non-essential reasons like these. The associated risks for you and your child are usually only slightly increased, though.

Whether a C-section is recommended or not can also depend on the hospital where you give birth: Some hospitals recommend C-sections more readily than others. That can be due to things such as the staffing situation or the obstetricians’ experience.

It is also easier to schedule C-sections and they are usually quicker than normal births. That might have an influence on the advice given in some hospitals. For example, it has been observed that C-sections are more common in smaller departments. C-sections are also more common in some parts of Germany than they are in others, without any medical reasons for that. You can ask about the rate of C-sections in a hospital at an information event for pregnant women or when registering with the hospital. C-section rates in German hospitals can also be searched on the Mother Hood e.V. association’s website.

Some women might want to give birth to their baby via C-section even if there are no medical reasons. They might be apprehensive about vaginal birth, perhaps because they have had bad experiences in the past. Others worry about longer-term drawbacks like damage to the pelvic floor, perineal tears or sexual impairments.

Women with concerns like that can seek advice, either from their treating physicians or midwife, or from specialist psychologists. Together, they can discuss the exact reasons for wanting a C-section and whether vaginal birth might be an option after all. It is also important to talk about the pros and cons of a C-section in general and in their personal situation. The costs for a C-section for no medical reason are not covered by health insurers in Germany.

Bad experiences from previous births might be a source of fear. But other difficult experiences, traumas or anxiety disorders can also play a role.

One first step might be to try to work through the bad experiences and find the exact causes. For example: What exactly was difficult or distressing during previous births? What am I especially scared of? Women can also contact the previous maternity clinic, request the birth report, and ask to talk to a physician about it.

A second step might be to think about: What do I need for a successful vaginal birth? What support do I need to feel safe? How can I deal with the challenges during labor? The answers to these questions also help when choosing where to give birth and who you want to have with you.

Midwives, physicians and psychology experts can help with all of these questions and considerations. Pregnancy advice centers offer consultations free of charge.

Sometimes, it is already clear during antenatal care that a C-section will be necessary or at least an option. An appointment (scheduled C-section) is then usually arranged for after the 40^th week of pregnancy. That is one week before the due date.

Problems sometimes occur during vaginal birth, such as if the birth is not progressing or the baby’s heartbeat gets worse. A C-section can then help to quickly move along the birth (unscheduled C-section). There is normally enough time to make that decision together with the physicians during labor.

Emergency situations during labor in which the mother or baby is in acute danger and fast action is needed are rare. The baby is then usually delivered by C-section within 20 minutes (emergency C-section).

The advantages of a C-section in emergency situations or in case of high risks of vaginal birth are obvious: It is then necessary to protect the health or life of the baby or mother.

Certain follow-up effects of birth are less common with a C-section than with vaginal birth. Women who give birth via C-section

• have less pain in the vaginal-perineal area,
• do not suffer any vaginal or perineal ruptures,
• experience urinary or fecal incontinence less often in the year after birth, and
• are less likely to experience vaginal or uterine prolapse than women who have vaginal birth.

The risk of these effects following vaginal birth depends on your individual situation, though, including factors like age, the size of the baby, and whether you have already given birth.

They can also vary in their intensity: Problems like urinary or fecal incontinence can sometimes go away again a few weeks after birth. But some women are affected by them for longer. What's more, the risk of incontinence or of vaginal or uterine prolapse already increases because of the pregnancy itself and only has partly to do with whether the baby was delivered by C-section or naturally.

Like with any operation, complications can occur during C-section, too. These include

• The usual risks of using an anesthetic, although there are usually no complications. The possible side effects of the anesthetic are nausea and headache.
• Hysterectomy (removal of the uterus) due to injury: That occurs in about 2 out of 1,000 C-sections.
• Damage to neighboring organs (bladder, urethra, bowel)
• Heavy blood loss
• Pain, infections or healing problems on the surgical wound

The C-section itself is actually linked to less pain than giving birth naturally. But the surgical wound means that the pain is more severe afterwards. Women stay in hospital for about 1 to 2 days longer and often need more rest and help taking care of the child in the first days and weeks after birth.

Most women can get pregnant again after a C-section, and also have a child by vaginal birth. Studies do in fact show that after a C-section, women are a little less likely to become pregnant. But it’s not clear whether that is because of impaired fertility or other reasons.

There is an increased risk of the following complications if the next child is born by vaginal birth after a C-section:

• The placenta is growing into the uterine wall (Placenta accreta). That can cause heavy bleeding when it is released. That happens in around 1 out of 1,000 women during vaginal birth following a C-section.
• The uterine wall ruptures in about 10 out of 1,000 women, usually during contractions. That is because the uterus is less stable because of the C-section scar. That kind of rupture is life-threatening for both the mother and child.

That’s why another C-section is often recommended if you’ve already had one.

C-sections can have three different kinds of health-related effects:

• Direct effects (during or immediately after birth)
• Effects on later pregnancies
• Effects on the pelvic floor

The following three tables show the differences between C-section and vaginal birth.

In the event of urinary and fecal incontinence, note that the pregnancy itself puts stress on the pelvic floor. That's why good pelvic floor training before and after pregnancy is important, regardless of the type of birth. Incontinence often goes away again within a few months.

C-sections are usually unproblematic for the baby. Around 2 out of 100 children are actually injured during C-section, but they are usually just small cuts that heal quickly again. The baby can also be injured during vaginal birth, but that is usually unproblematic as well.

It generally doesn’t make any difference for the child’s health and development whether it is born by C-section or vaginal birth. Studies do suggest that certain problems occur a little more often after a C-section, including asthma and obesity. But the risk only increases a little. The reasons for this are not clear. Experts suspect, amongst other things, that children born by C-section have a weaker immune system because they haven't come into contact with the germs in the birth canal, which is the case in vaginal birth.

It is not clear whether a C-section slightly increases a child’s risk of later psychological diseases such as attention deficit hyperactivity disorder (ADHD) or autism. Some studies did find a slightly higher risk, but it’s unclear whether that was due to the C-section itself or if there were other reasons. So, there is no proof of a link.

Expectant parents can discuss the pros and cons of C-section with their doctors. Midwives can also offer advice.

Specialist clinics provide information in case of particular birth risks like breech presentation.

You can talk about the personal and emotional aspects of the decision in particular in a pregnancy advice center. This advice is free of charge and can be anonymous upon request. The Federal Centre for Health Education (BZgA) offers further information about where to find advice.