This post is not about the indications for a c-section nor about the ever increasing number of c-sections. This post is about the actual risks of a c-section, which I find glossed over by some and exaggerated by others.

A great study was published last year by researchers in Finland (Pallasmaa et al. Acta Obstetricia et Gynecologica 2010). They prospectively looked at the complication rate among almost 2,500 women having a c-section during a 6 month time frame. It’s a well done study and it provides good solid data.

The c-section rate was 16.6% and ranged from 12.4% to 24.1%, so in some hospitals the c-section rate is on par with the US, an interesting aside. The most common reason for a c-section was failure of labor to progress (28.6%) and the second most common was fetal distress (21.7%). Again, fairly similar to our population.

While many different complications were recorded, serious complications were defined as the following: more than 1,500 ml of blood loss, need for blood transfusion, hysterectomy, needing another surgery, septicemia (a serious infection), blood clots, pulmonary edema, and pneumonia.

The rate of serious complications for all c-sections was 10.4%. When the groups were stratified, women who were having an elective c-section had the lowest rate of serious complications: 7.1%. As expected emergency c-sections and crash c-sections (ultra emergent) had far higher serious complications rates: 11.7% and 25% respectively.

Elective c-sections by far have the lowest complication rates, because membranes are typically not ruptured lowering the infection risk. Also, some of the serious problems that lead to an emergency c-section, such as severe bleeding or fetal distress related to infection, will by their very nature increase the risk of surgical complications.

Other factors that increased the complication rate in the study were obesity (BMI > 30), pre-eclampsia, and prematurity. Obesity makes surgery more challenging, increasing blood loss and the infection rate. Obese women are 50% more likely to have a c-section complication compared to those women who are not. Pre-eclampsia increased the complication rate by 60%, which makes sense because these women have vascular problems. Being less than 30 weeks pregnant doubled the risk of serious complications. In fact, complications were highest for women with pre-eclampsia and prematurity less than 30 weeks. Many premature deliveries are related to infection, so this association also makes sense. Operating on uterus that is infected is far more likely to result in bleeding, blood clots, or a serious infection after the procedure is over.

So c-sections are not benign. Overall, 27% of all c-sections will have some kind of complication and 10.4% of women will have a serious complication. An elective c-section (typically meaning a healthy mom in a controlled situation) has the lowest risk of complications, but that risk is still 7.1%. That is higher than a vaginal delivery.

This information is important when counseling women about c-sections as well as part of our discussion about the high c-section rate. If you have an infection or an abruption as an indication for your c-section, the serious complication rate of 11.7% for an emergency c-section may actually be low, because the outcome for both you and your baby could be much worse without intervention. However, for the woman requesting a c-section because she is afraid of labor, discussing these complications is important part of discussing the real risks of both vaginal delivery and c-section.

I had an indicated c-section for chorioamnionitis at 26 weeks. Less than 24 hours later I was septic. If I had waited and done a trial of labor, my boys would most likely have done far worse as the infection in my blood stream would have reached them. For me, the risk of a serious complication was a fair trade off (if I had been in that study, I would have been in the serious complication rate as I was septic post delivery). But to do everything for my boys was my only option. When a c-section is needed, it is needed.

The c-section conversation is emotionally charged for many, many reasons. And all are valid. However, these kinds of studies help us really know what we are talking about when we are discussing risk, and are invaluable in counseling patients as well as an important contributor in the discussion about our c-section rate in the United States.

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  1. Great post.
    The only thing I would add however is that a large proportion of the planned cesareans in this study will be surgeries for medical or obstetrical reasons, which also have inherently higher risks than a planned cesarean at 39+ weeks’ in a healthy pregnancy.
    Also, women can only ‘plan’ a vaginal birth, and therefore although a healthy, spontaneous vaginal delivery birth outcome may be desirable, women should still be informed (as I’m sure you agree) of the potential risks associated with assisted vaginal delivery and/or an emergency cesarean.
    When all outcomes of each birth plan type (cesarean versus vaginal) are compared, the truth (albeit an uncomfortable truth for some) is that a planned cesarean compares very favourably with Mother Nature’s route.

    1. Actually, a planned c-section in this study has a 7% risk of serious complications, far higher than a spontaneous vaginal delivery. That is well supported my a multitude of excellent data.

      1. Jen,

        Further to your valid response to ‘’, may i add a useful reference to a Danish study published 2012.

        Full Study: Holm C, Langhoff-Roos J, Petersen KB, Norgaard A, Diness BR. Severe postpartum haemorrhage and mode of delivery: a retrospective cohort study. BJOG 2012; DOI: 10.1111/j.1471-0528.2011.03267.x.

        Professor Philip Steer, Editor of BJOG added:

        “This study looks at intended mode of delivery rather than actual delivery. This is important because emergency caesarean sections need to be seen as a complication of intended vaginal birth, rather than being included in the same group as elective caesareans.

        “While women achieving a vaginal birth usually have the best outcomes, those whose labours end with an emergency caesarean face much higher risks than those having an elective caesarean. It is the fear of an unexpected emergency that drives some women to request elective caesareans when there is no obvious medical indication.”

    2. C-section planned b/c of a medical problem such as pre-eclampsia should be able to be teased out. There are different ICD-9 codes for cesarean section with or without medical indication, and the secondary code will often be what the complication was. Although the study probably isn’t specific about those methods, I would assume the researchers took that into account.

      In the absence of medical indication a planned cesarean absolutely is not safer than a vaginal birth. I have researched this area extensively for graduate school, wrote my thesis on VBAC guidelines, and am writing my dissertation on pregnancies complicated by diabetes. I have never seen one study that would indicate what you claim. The only study that would even comes close is that absolute breech babies do better with a cesarean section. However the risks to the mother are still the same. The most common of which are blood loss, nicked bowel. and maternal fever. People also rarely talk about the risks in future pregnancies which include infertility, and placenta previa. Placenta previa increases exponentially with each pregnancy, and can be life threatening to the mother & baby. Note that this study was looking at maternal not fetal risks. For the baby, in the absence of medical indications, a planned cesarean is the worst method of delivery in terms of outcomes. They have up to 4 times the rate of respiratory distress and NICU admission compared to emergency cesareans. Their lungs never receive hormones to prepare them to breathe, and they don’t get the fluid pushed out in the birth canal. In an emergency cesarean, the baby at least gets the hormones to prepare the lungs. I have had two cesareans (one failed TOL), and I would never plan one. If I need another, I will go into labor & then have the cesarean. Unless there is a medical risk to the baby, they absolutely have better outcomes when mom labors first.

      I do, however, agree with you that doctors need to prepare women for the risks with a vaginal birth. No method of birth is devoid of risk, it is an inherently risky situation. However, in the absence of medical indication, a vaginal birth is absolutely the least risky choice for both mother and child. This also includes VBACs where the only reason for the repeat cesarean would be the fact that the mother already had one.

  2. “When a c-section is needed, it is needed.” Exactly, simply well-put. I imagine few moms want to be sliced open, but to save their baby most will go through Hell and back. I’d rather go through Hell and have my baby live, then try to avoid a section and lose him/her.

    For the record, I had an emergency c-section at 27 weeks. My water broke, my daughter was in distress, and that c-section saved her life. Turns out my womb was infected with GBS; daughter was also infected, but luckily her spinal tap came back negative *phew* Also lucky in that I had no post-section complications myself (in contrast to the vaginal delivery of my son at 18 weeks under the same circumstances, I had horrid fever/ infection after that).

  3. Can you do a comparison of long term issues from VB vs CS? I think you are one of the only doc bloggers I trust to actually consider vaginal or sexual issues as well, most don’t seem to think these things even matter. As if not wanting to be torn up is something I want for just my husband….. Also, there seems to be a lot about VB that is totally glossed over or ignored. I can think of so many things that no one bothered to tell me until *after* my (failed) TOL. I heard all about the dangers of CS though. Repeatedly.

    (Personally, I will take my chances with the Cs. I had one, for “stuck baby” and do not want to VBAC at all.)

    1. I heard an interesting discussion of this recently on Doctor Radio. The author of When Sex Hurts (, Dr. Deborah Coady, actually went into detail about post cesarean sexual dysfunction. I have rarely heard that discussed, but I have definitely heard of post vaginal delivery sexual dysfunction, especially post episiotomy. She didn’t mention sexual dysfunction after vaginal delivery at all. Of course, this is commonly brought up elsewhere.

      Also, being “torn up” should not happen in most spontaneous vaginal deliveries. Most doctors should know by now to avoid episiotomies unless all else fails, and forceps deliveries are diminishingly rare. Pelvic floor damage is probably as difficult to predict as nerve damage from cesarean would be.

      I am sorry about your “stuck baby”, and I hope any subsequent births are easier on you.

    2. Stacey: I don’t think doctors can give good information on this topic, because I don’t think they have it. I will say that I’ve only had c-sections (not happily), but have had awful sexual complications. Yes – my vagina is *intact*, but my sexuality isn’t all in my vagina. For about a year after my third c-section, I had *no* sensation in my clitoris, most of my pelvis (and abdomen – both worse on the left side than the right), or the vaginal walls on the left side. That c-section was seven years ago, and I’ve never regained full sensation in those areas. My last section was almost three years ago, and the surgeries *still* affect my sex life.

      There are dangers in both, of course. I don’t think any rational human being can deny that. But, having surgery isn’t a guarantee of a good sex life.

  4. When considering that the risk of a rupture actually being catastrophic is only 6%, it seems much more likely that the outcomes from a vaginal birth would be better than from a cesarean, even a scheduled one. I know there are more risks than just rupture that women who have had a cesarean need to worry about, but that is the one that doctors love to scare women with.

    To Stacey – I’m very sorry about your stuck baby. 😦 It is very scary, but also unlikely to happen again in another birth.

  5. Pingback: ELCS?!
  6. Hi please help me. I’m 11 weeks pregnant and I got a trans abdominal stitch done 3 months before getting pregnant. I got a abdominal stitch as I lost 2 boys different times at 19 weeks. Now already at 11 weeks the ultrasound said that the water sac membranes is already past the stitch I got and paid a lot of money for. They said it is too lose. Please help I’m scared. If my water broke at say 16 weeks I need a c-section because u got that stitch in now so can vaginal deliver. But if I have a c-section early don’t that mean I can’t have anymore pregnancies.??? Please info be great thanks my mobile is 0422-965-305 or email is please help

  7. What about comparing the chances of serious complications of c-section of di/di twins @38wks because Baby A hasn’t decided on breech vs transverse vs cephalic compared to trial of labor? The chances of cord prolapse seems to be much lower than chances of serious complications of planned c-section. Am I correct in this?

  8. I do 60 c/s a year and can’t remember the last time I had a complication. Certainly not within the last 5 years. I wonder about the research. Sometimes I think evidence free medicine is the best.

    1. The complication rate is pretty well documented. Many women who develop pain after delivery don’t get taken seriously or they think it’s normal so unless you followed them and prospectively collected data you wouldn’t likely know

      1. You said serious complications not to belittle ongoing pain but I know that happens after vaginal birth as well. Dyspareunia prolapse incontinence
        As you said vaginal birth is safer than c/s but planned vaginal birth is not same as vaginal birth. If mom is planning only 2 babies a booked c/s may be better. I expect disagreement but look at Mary Hannah breech trial risks of planned c/s.

    2. Doug Hepburn: I’ve had five c-sections, and my doctors don’t know about any of my complications (including extensive loss of feeling in my pelvis and lower abdomen), because they blew me off the few times I tried to talk to them. You honestly don’t even know if your patients have had complications.

      I sincerely hope you’re joking about evidence free medicine.

    3. A breech trial isn’t really relevant to most vaginal vs cesarean birth, which are more than 90% cephalic presentation. It’s strange that this one unrelated trial is an acceptable addition to your 30 years of clinical experience, but the volume of evidence in the original post isn’t.

      Major surgery should be justified. I find it hard to believe that your patients never have any sequelae from cesarean sections. No adhesions and pelvic pain later in life? No placenta accreta?

  9. The article or comments do not mention anywhere what is the rate of complications in vaginal birth. Only with that number available can one compare the c-sec risks.

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