Considering a caesarean birth

The majority of women in the UK give birth vaginally, recover well and have healthy babies.

Most women who have a planned caesarean birth will also recover well and have healthy babies. However, there are risks for both you and your baby if you have a planned caesarean birth and it may take longer to recover after your baby is born. Having a caesarean birth is a major operation with risks that should be compared with your risks of a planned vaginal birth.

Your healthcare professional will not usually recommend a caesarean birth unless there are specific issues complicating your pregnancy. However, there are many factors that can influence how you feel about the way you give birth. The risks of caesarean and vaginal births will also depend on your individual circumstances. Your personal feelings, concerns, interpretation of risks and opinions are all important and will be respected when you speak with your healthcare professional about your birth plan.

You should tell your healthcare professional you are considering a caesarean birth as early as possible in your pregnancy.

Your healthcare professional will need to discuss this with you, including the reasons for your choice. They do this to ensure that you have accurate information, and to offer further support or options that you may find helpful. Some maternity units may offer peer support, group information sessions, or appointments with specific healthcare professionals (e.g. anaesthetists, mental health professionals, specialist midwives) who can offer you information to prepare for birth.

It is important to consider the benefits and risks carefully. People view risk differently and how you view risk depends to a large extent on your own preferences and experience. You can find out more information on risk from the RCOG patient information Understanding how risk is discussed in healthcare.

If your healthcare team are not able to offer you a planned caesarean birth they should refer you to a different team who can offer this choice to you.

Women consider a caesarean birth for many reasons. Your thoughts and feelings about giving birth will be influenced by the culture you grew up in, your previous experiences, and the experiences of the people around you. 

• You may have had a difficult vaginal birth in the past.
• You may have concerns about damage to your pelvic floor during a vaginal birth.
• You may think that a planned caesarean birth is safer for your baby.
• You may have anxieties about having a vaginal birth for the first time, including about how you might react to vaginal examinations and labour pain.
• You may want to avoid the chance of needing an emergency caesarean or an assisted vaginal birth.
• You may want to avoid having an induction of labour.
• You may feel that a planned caesarean birth gives you a better sense of control.
• You may have had a previous traumatic experience or sexual abuse.
• You may be concerned as many of your family members have required emergency caesarean births.
• You have considered the benefits and risks and have decided you would prefer a caesarean birth.

Your healthcare professional may offer you support from specialists with experience supporting women with anxieties and other mental health issues in pregnancy. If you had a difficult vaginal birth previously, discussing your birth with a healthcare professional to understand what happened may help. Many complications that happen during one birth do not, or are unlikely to, happen again. Even if you had a complicated assisted vaginal birth in your first pregnancy, your chance of having a vaginal birth with no assistance is more than 4 in 5 (80%) in your next birth.

Discussing your options for pain relief might be helpful. Safe and effective options for pain relief including epidural analgesia are available. For more information about pain relief during labour see the Labour Pains website labourpains.org from the Obstetric Anaesthetists’ Association. You may wish to talk about your options with an anaesthetist.

Your maternity unit may also be able to offer you care from a small group of midwives that will look after you throughout your pregnancy, during labour, and visit you at home after birth. Building a relationship with the same midwives who will look after you in labour may give you more confidence. Some maternity units can offer a birth planning appointment with a senior midwife to explore and discuss other aspects of birth in more detail. Ask your healthcare professional for more information if any of these options seem attractive to you.

If you are anxious about the need for vaginal examination or about any other aspect of birth, your healthcare professional may offer ways of caring for you in labour that may be more acceptable to you, and offer referral to a specialist to explore the underlying reasons for your anxiety. There are tools available to help you feel more in control when you are in stressful situations (during birth and beyond). There is a chance that vaginal examinations may be needed even after a caesarean birth (for example if you have heavy bleeding afterwards).

If you are concerned about the timing of labour and its unpredictability (for example, if your planned birth partner is going to be away for work or if you need childcare for an older child), you can ask to have your labour started in a controlled way. This process is called an ‘induction of labour’. If you would like to discuss this option alongside the option of a planned caesarean birth, let your healthcare professional know. For more information on induced labour, see NHS information on Inducing labour:
https://www.nhs.uk/pregnancy/labour-and-birth/signs-of-labour/inducing-labour/

Giving birth in the UK is extremely safe whichever way your baby is born. The safest way for your baby to be born will depend on your own individual circumstances and you should discuss this during your pregnancy with your healthcare professional. From the research evaluated in Appendix A of the NICE guideline on Caesarean birth [NG192]:

Babies born by caesarean and babies born vaginally have similar risks of:

• Needing admission to a neonatal unit
• Being born with a severe infection
• Having long term problems with speech

There is currently not enough evidence to be able to say for certain if either a caesarean or a vaginal birth is more associated with babies developing:

• Breathing problems after birth
• Cerebral palsy
• Autism
• Type 1 diabetes.

There is a very small increased chance of babies born by caesarean:

• Developing asthma later on in life (1 in 55 compared with 1 in 67 after a vaginal birth).
• Becoming obese as a child (1 in 22 compared to 1 in 25 after a vaginal birth).
• Dying in the first 28 days of birth (1 in 2000 compared to around 1 in 3300 after vaginal birth).

If you have specific concerns about your baby needing to be born with the help of ventouse or forceps, you can find out more from the RCOG patient information Assisted vaginal birth (ventouse or forceps). Forceps may also be used during a caesarean birth.

There is a chance of your baby being cut during a caesarean birth. This happens in 1–2 out of every 100 babies born by caesarean, but usually heals without any long term problems.

The benefits of having a planned caesarean birth include:

• Minimising the chance of needing an assisted vaginal birth or an emergency caesarean birth.
  • The chance of you needing an assisted vaginal birth if you are a first time mum is between 1 in 2 and 1 in 3 in the UK (1 in 8 including women who have given birth before).
  • The chance of you needing an emergency caesarean birth is 1 in 3 if you are a first time mum in the UK (1 in 5 including women who have given birth before).
• Avoiding the chance of tears to your vagina or perineum. Perineal tearing is very common during a vaginal birth. The chance of long term complications following a tear is small. Further information, including how to reduce your chance of tearing, can be found on the RCOG hub for Perineal tears and episiotomies in childbirth and patient information poster Perineal tears during childbirth.
• Reducing the chance of you having urinary incontinence (leaking urine). Up to 1 in 4 (28%) women who have a baby born by caesarean experience urinary incontinence compared to up to 1 in 2 (49%) women who give birth vaginally. The chance of longer term urinary incontinence is lower whichever way you give birth and pelvic floor exercises can help.
• Having a planned date for the birth and reducing the uncertainties of going into labour naturally.

The risks of having a planned caesarean birth include:

• Although you should not feel any pain during the caesarean (because you will have an anaesthetic), the wound will be painful while you recover. You will be given pain relief in hospital and to take home. One in 10 women will experience discomfort for the first few months. The recovery period after a caesarean birth is usually about 6 weeks, but this can vary.
• Infection – this can be of your wound or your uterus (womb). It is common (2–7 in 100 women) and can take several weeks to heal. You will be offered antibiotics through a drip at the start of your caesarean to reduce this risk.
• Developing scar tissue (adhesions) internally when you heal from the operation. This can cause pain and can make any operations you might need later in life more difficult.

Serious complications are more common if you have had previous operations to your abdomen such as previous caesarean births. Serious complications are not common if you are having your first caesarean birth, if it is planned in advance and if you are fit, healthy and not overweight.

Serious complications include:

• The chance of needing to undergo a hysterectomy (removal of your uterus) because of heavy bleeding at the time of your caesarean birth increases with each operation, but overall this risk is low (about 1 in 670 women after caesarean birth compared with 1 in 1250 after vaginal birth).
• Maternal death – 1 in 4200 women after caesarean birth compared with 1 in 25 000 women after vaginal birth.
• Rarely there is the chance of injuring your bladder or other abdominal organs during a planned caesarean. This may require further operations to repair any injury. Your healthcare team will discuss with you the chance of this happening as it will depend on your individual circumstances.

You can choose to breast feed your baby after having a caesarean birth and are no more likely to experience difficulties with this than if you have had a vaginal birth. You can have skin-to-skin contact with your baby during a caesarean birth. 

The risks associated with surgery increase with the number of caesarean births you have. Once you have had a caesarean birth:

• You have a higher chance of a serious complication called placenta accreta in any future pregnancy (1 in 1000 women compared with 1 in 2500 women who have had vaginal births). Placenta accreta is where the placenta does not come away as it should when your baby is born. If this happens, you may lose a lot of blood and need a blood transfusion, and you are likely to need a hysterectomy. The chance of placenta accreta increases with every caesarean birth. See RCOG patient information Placenta praevia, placenta accreta and vasa praevia.
• If you have a vaginal birth with your next pregnancy, there is a higher chance of having a uterine rupture (1 in 98 women after a previous caesarean compared with 1 in 2500 with no previous caesarean). This usually only happens if you go into labour, and is less likely to happen if you plan another caesarean birth. It is an uncommon but serious complication that can lead to very heavy bleeding.

If you have a vaginal birth, you will usually have:

• A shorter stay in hospital after your baby is born (on average 1 and a half days shorter than women having a caesarean birth). Women having straightforward vaginal births can often be discharged the same day. Women having straightforward caesarean births are usually discharged after an overnight stay (24–36 hours).
• A faster recovery. You should be able to get back to everyday activities more quickly and you should be able to drive sooner. Standard advice for women having a caesarean birth is to allow 6 weeks for physical recovery and not to plan to drive during this time.
• A much shorter labour in the future, with a low chance of harm to you and your baby.

It is common for the area between your vagina and anus (perineum) to feel sore and uncomfortable for a while after you have given birth. This is because this area will have stretched as your baby is born and you may have stitches.

Complications can also happen during a vaginal birth, especially with first births. These may include:

• The need for forceps or ventouse to help your baby to be born. For more information, see RCOG patient information Assisted vaginal birth (ventouse or forceps).
• Vaginal or perineal tears. See the RCOG hub for Perineal tears and episiotomies in childbirth for more information, including how you can reduce the chance of having a serious tear during birth.
• Needing an emergency caesarean birth.

Whether you have a caesarean birth or a vaginal birth, there is no significant difference in the chance of developing:

• Blood clots in your legs or lungs.
• Excessive bleeding during birth.
• Postnatal depression.

Some women find it useful to see this information in a comparative side-by-side table:

* Numbers for planned and unplanned caesarean births

If you have been offered an induction of labour for a specific reason, but you do not want this, you can choose to wait for natural labour or plan a caesarean birth instead. Speak with your healthcare professional as early as possible to discuss your options.

There are two types of anaesthetic. You can be either awake (with a regional anaesthetic) or asleep (with a general anaesthetic). The majority of women having a planned caesarean birth will have a regional anaesthetic (a spinal anaesthetic or an epidural, or a combination of the two). You will not feel pain although you may feel nausea, experience vomiting, and have a pulling sensation or pressure in your lower body. There are medicines that your anaesthetist can give you to help with discomfort or nausea during the procedure. A regional anaesthetic is usually safer for you and your baby than a general anaesthetic and allows you and your partner to experience the birth together. Your partner will not be able to be with you in the operating theatre if you have a general anaesthetic.

You will have an opportunity to discuss your anaesthetic with an anaesthetist. For more information on the different types of anaesthetic and risks of each, see www.labourpains.org.

You will usually be offered a date at or soon after 39 weeks of pregnancy. Babies born by caesarean earlier than this are more likely to need admission to the neonatal unit for help with their breathing (1 in 24 babies at 38 weeks compared to 1 in 56 babies after 39 weeks). Even a short stay in the neonatal unit can be very stressful for new parents, and rarely babies can be affected in the longer term as well. This is why your healthcare professional will recommend planning for your caesarean to take place after 39 weeks, unless there are other reasons why your baby may need to be born earlier.

The planned date of your caesarean may change because of emergency situations on the day of your operation. It is uncommon for this to happen, but if it does your healthcare team will arrange a new date with you as soon as possible.

If you are certain that you do not want to plan for a vaginal birth and understand the risks of a caesarean birth you can choose this option for the birth of your baby. Your healthcare team will make arrangements for this to happen and will give you the information you need to prepare for your caesarean birth.

There is a chance that you may go into labour before the date of your planned caesarean (1–2 in 100 women). It is important to discuss your preferences should this happen. Complication rates for caesarean birth are higher when they are performed during labour (about 1 in 4 women experience complications) compared with during a planned procedure (about 1 in 6 women experience complications). Complication rates are higher when a woman is in the active stage of labour where contractions are regular and the cervix is dilated (1 in 3 women may have complications) compared with when she is in early labour and the cervix has not dilated much (1 in 6 women may have complications). If you do go into labour before the date of your planned caesarean you will be offered a choice of continuing with labour or of having a caesarean birth as planned. Uncommonly, labour may be so advanced that it is not safe for you or your baby to have a caesarean, but your healthcare team will discuss your options depending on your individual situation.