Natural Childbirth VII: C-Section Risks and Complications | Chris Kresser
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Natural Childbirth VII: C-Section Risks and Complications

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This is the final article in the Natural Childbirth series. If you’ve missed the other articles, make sure to check them out here.

There’s absolutely no question that cesarean surgery (c-section) can save both mothers’ and babies’ lives when performed appropriately. The purpose of this article is not to question the use of c-section in those circumstances.

Instead, my goal is to challenge the idea – now prevalent in the Western world – that elective c-section is a safe way of delivering our babies, and perhaps even safer than vaginal birth. This is simply not true.

The risks and complications can be broken into two categories: problems experienced by the mother, and problems experienced by the baby. The most significant risk for mothers is an increased risk of death, and the most significant risk for babies includes a variety of changes – such as the composition of the gut microbiota – that have lifelong effects.

Cesarean risks for mothers

Cesarean involves major abdominal surgery and increases the risk of maternal death by about four times in emergency situations and about three times during elective surgery on a healthy mother and baby.(1,2) The major causes of death in these cases are infection, blood clots and anesthetic accidents.(3)

Post-cesarean infections are also common. One study showed that 20 to 40 percent of women have post-cesarean complications, including infections of the uterus, wound, or urinary tract.(4) Cesarean mothers are twice as likely to have severe complications and five times more likely to require antibiotics after birth, compared to women giving birth vaginally.(5) Another study found a three times higher risk for serious complications such as major infection, hysterectomy or cardiac arrest.(6)

There are also psychosocial risks above and beyond the physical risks. For example, when compared with women who give birth vaginally, women who receive cesarean:

  • are less satisfied with their birth experience;
  • more likely to be re-hospitalized;
  • less confident with their babies;
  • less likely to breastfeed; and,
  • more fatigued, even up to four years later. (7,8,9,10)

Although cesareans are often portrayed as being less likely to produce pelvic floor dysfunction than vaginal birth, large population studies have demonstrated that this is not the case over the long term.(11)

Finally, mothers will continue to experience the effects of cesareans throughout her childbearing years. Studies show reduced fertility following a cesarean and greater levels of fear about giving birth five years later.(12,13) A previous cesarean may double the risk of a breech baby in subsequent pregnancies and increase the risk of uterine rupture.(14)

Cesarean risks for babies

The complications associated with cesarean for even low-risk, healthy babies are numerous. They include 1:

  • Increased risk of respiratory compromise, low blood sugar and poor temperature regulation.
  • Slower neurological adaptation after birth.
  • Differences in levels of hormones regulating calcium metabolism, renin-angiotensin, progesterone, creatine kinase, dopamine, nitric oxide synthesis, thyroid hormones and liver enzymes.
  • Depressed immune function, including poor function of neutrophils, natural killer cells and lymphocytes (all cells that fight infection).
  • Increased risk of oxidative stress.
But perhaps one of the most significant and lasting risks for babies delivered via cesarean is the alteration of the of gut flora.

Studies have consistently shown that cesarean babies have altered fecal microbiota compared with vaginally born babies, which can persist for at least six months and quite possibly for life.(16)

As I’ve explained elsewhere, the gut flora plays a crucial role in health. From that article:

Among other things, the gut flora promotes normal gastrointestinal function, provides protection from infection, regulates metabolism and comprises more than 75% of our immune system. Dysregulated gut flora has been linked to diseases ranging from autism and depression to autoimmune conditions like Hashimoto’s, inflammatory bowel disease and type 1 diabetes.

This probably explains why babies born via cesarean may have increased susceptibility to gut infections, asthma and allergies later in life.(17,18,19)

The marked changes in gut flora in cesarean babies are not greatly affected by the method of feeding (i.e. breastfeeding vs. formula) afterwards.(20) This means that breastfeeding after cesarean section can’t compensate for the alterations in gut flora experienced with that type of delivery.

If you did have a cesarean for any reason, I recommend using a high-quality infant probiotic to help populate your baby’s gut with beneficial flora. The brand I use in my practice is called Therbiotic Infant, from Klaire labs. (Important note: although they recommend starting with 1/4 tsp., that is far too high of a dose. I suggest lightly dusting the nipple with the powder once or twice a day before feedings. If you notice diarrhea, especially with green flecks or tint, decrease the dose.)

Articles in this series:

  1. Buckley, Sarah J. Gentle Birth, Gentle Mothering: A Doctor’s Guide to Natural Childbirth and Gentle Early Parenting Choices. Celestial Arts, 2009. pp. 120
  1. Great article! C-sections are certainly saving lives of moms and babies everyday but they are completely overused as is every medical intervention at Drs., midwives, and hospitals disposal these days – to our collective health’s detriment as well as our national and personal healthcare pocketbook. And for the record, I naturally (unmedicated) birthed, in a hospital with a midwife, a 41+3 week, posterior (known to be for weeks and he did not turn) 8lb 13oz healthy baby boy. It can be done.

    • Sure it can be done. It can also NOT be done (i.e. many women in your situation would have ended up with a dead or injured baby and/or severe tearing, or would have gotten a c-section to prevent those horrific results). You gambled on it working and it did. But what if you had gambled and lost?

      I would never presume to write an article or post saying you shouldn’t have had a vaginal birth without meds, since it’s your body, your baby and your right to choose. And I would hope that you would also not judge other women for their decision to have a c-section, or pain relief (epidural) during a vaginal birth–for the exact same reason: it’s their body, their baby, their right. Your decision to gamble that it would work should be respected just as much as other women’s decision not to take that gamble.

  2. Claire, I’ve had three children via c-section, and they are the healthiest babies I know — never an ear infection, I finally had to use a thermometer last year because I thought one was warm, only two colds amongst all three in 5 years. I breastfed exclusively for six months (and I had never used birth control pills, so my gut flora was really good). Just breastfeed, breastfeed, breastfeed!

    • Sure it can be done. It can also NOT be done (i.e. many women in your situation would have ended up with a dead or injured baby and/or severe tearing, or would have gotten a c-section to prevent those horrific results). You gambled on it working and it did. But what if you had gambled and lost?

      I would never presume to write an article or post saying you shouldn’t have had a vaginal birth without meds, since it’s your body, your baby and your right to choose. And I would hope that you would also not judge other women for their decision to have a c-section, or pain relief (epidural) during a vaginal birth–for the exact same reason: it’s their body, their baby, their right. Your decision to gamble that it would work should be respected just as much as other women’s decision not to take that gamble.

  3. I’ve just left my midwife appointment. I ‘might’ be breach, I will have a scan to check. If this is the case then I have to have a c section – my hospital won’t deliver breach babies naturally. I’m so upset because I had my heart set on a home/ natural birth. Can anyone recommend some reads on getting my babies health back after a c- section? All being well i’ll be breast feeding. Thanks

  4. Thank you Elizabeth for sharing your stories. It is hard for a Mum to know when a ceserean is needed. Sara R. I did read the disclaimer at the top but how can anyone know what an ideal cesarean rate should be? Babies can be born vaginally but yet have handicaps as a result of being born too late, etc. So techinically yes, great, the baby was born vaginally, but the price?
    I didn’t think a Dr could tell whether a baby is posterior until the Mum had dialated enough for them to be able to tell? I had assumed that to be the case. When I went in to the hospital I was 1cm dialated and the Dr didn’t know the baby was posterior. I was already three days in with a lot of pain and no sleep. The baby was wedged in and my water had broke, making her even more wedged on bone and even more pain for me. Even if the baby had turned, which I don’t think was possible at that point, I certainly did not have the energy to push!
    The Dr told me that 8 of every 10 babies that are posterior turn during labour. How the heck is anyone to know whether they have a baby that is one of the eight? It’s dangerous to get Mums to second guess their Drs and have doubts about cesareans. I didn’t want one and my husband had to convince me to. THANK GOD he did because I dread to think what could have happened to my baby girl if I had foolishly let me own agenda of a natural, vaginal birth get in the way. Mums aren’t in a position to play Dr, especially when in labour.
    If cesarean rates are too high, then the Drs have to make the change. It can’t be a change fueled by Mums taking risks without being properly informed.

  5. I had a baby via c-section last April. I started to have contractions every 20 minutes on Tuesday, painful contractions every 7 minutes on Wednesday, then on Thursday evening, my waterbroke and the contractions increased to every four minutes. I was in agony for 48 hours. When I arrived at the hospital that Thursday evening I could barely walk and talk I was so exhausted. I hadn’t slept in three days. I was 1cm dialated. My daughter was wedged in tight, sunny side up, my cervix was swollen. The more contractions I had, the more swollen I became, the more cone shaped her head became. I “elected” to have a cesarean because her heart had decels. (Not before I had morphine to get me to sleep, which got me to 6cm dialated. Anyway, Friday at 5pm I had the cesarean. There wasn’t a chance I could have PUSHED her out even if I had fully dialated. Even with meds and extra 24 hours, could only get to 6cm. I am sick of hearing all this crap about how bad cesareans are. If I had waited until it became an emergency, my Dr said my daughter may well have had cerebral palsy. STOP DEMONIZING THESE LIFE SAVING SURGERIES and scaring Mums into being hell-bent on vaginal deliveries to the point of jeopardising their own safety or the safety of their babies.

    • Good for you for speaking out. I agree with you that given certain circumstances c-sections are for the best. My grandmother should have had a c-section for her 5th — instead she wound up holding a dead baby because the doctor or she couldn’t get him out in time. My aunt should have had a c-section, instead she cared for her severely disabled son until he died in his late 30s. My cousin’s wife should have had a repeat c-section; instead she tried for a VBAC resulting in her uterus rupturing, her baby dying, and she wound up in a coma for 15 days, awakening to learn her baby had died.

    • Did you miss the misclaimer in the beginning of the article? Sometimes women need c-sections, but it’s almost certainly not 30%. or 50%, or whatever. And it’s possible that you could have birthed your baby vaginally had she turned. There are techniques to encourage babies to turn, but most care providers are unaware of this. I have several friends who have had c-sections for babies who were posterior but they were not told this, instead, “their pelvis was too small”. Then again I know a few other friends who had skilled, experience care providers who supported them and their babies turned and were born vaginally. I personally kept a close eye on the position of my babies during pregnancy so that I could take action if they were not in an optimal position for birth. Not ALL babies will turn (or have to, for that matter), but many will, if the mother is well-supported.

  6. My two children were born via c-section. Ultimately, I wanted them to be born without problems to them or to me. I believe the c-sections were the right thing to do given my circumstances. That said, I am shocked to hear that even though my babies were exclusively breastfed for the first six months of life, that they have gut flora that will lead to problems. How well did that study include breast-fed c-section babies and the gut flora of their mothers? My children have NEVER had an ear infection, I’ve NEVER recorded a fever on them, and they are always healthy (except for one very light cold once a year, which has been over a year now). In contrast, I know so many people (my brother, for instance) born vaginally and have health issue after health issue, etc. I’m just very curious about that study and how reliable it is about breastfeeding not mattering.

    • Hi Elizabeth, don’t believe the scare tactics. The gut flora studies are MINUSCULE–the main researchers looking at this are in Scandinavia and they seriously publish articles after only looking at 30 kids born by c-section and 34 born vaginally:
      http://www.ncbi.nlm.nih.gov/pubmed/9890463

      The only other time I’ve ever heard of such tiny studies is with studies of incredibly rare diseases/conditions. I can’t imagine why they would go to press with articles about such small numbers of children that the results could be down to chance.

      And even that minuscule study didn’t find permanent differences or health effects. Instead it just found that the colonization of the intestinal tract in c-section babies “was delayed”–and not even by very long: “Bifidobacterium-like bacteria and Lactobacillus-like bacteria colonization rates reached the rates of vaginally delivered infants at 1 month and 10 days, respectively.” Also, it specifically said there were no additional gastrointestinal problems in babies born by c-section: “The occurrence of gastrointestinal signs did not differ between the study groups.”

      And here’s another study that looked at the issue and found NO DIFFERENCE in food allergies between babies born the two ways: http://www.ncbi.nlm.nih.gov/pubmed/18976354
      Same result in another study: http://www.ncbi.nlm.nih.gov/pubmed/23078601

      And here’s a study that looked at oral microflora (like gut bacteria but in the mouth), and actually found that babies born vaginally were actually MORE likely to have cavity-causing bacteria in their mouths:
      http://www.ncbi.nlm.nih.gov/pubmed/21702851

      Long story short, the evidence on this issue is weak and inconclusive. And if you think about it, even if it does end up turning out that getting mom’s vaginal flora in your mouth while being born matters to your health, the solution is simple: swab mom’s vagina and put that swab into the baby’s mouth. Problem (if there even is a problem) solved.

  7. I am 37 weeks pregnant and tested positive for Group D Strep, therefore I will be on antibiotics during labor and delivery. I know that you recommend Klaire Labs infant probiotic, but I live in Thailand and it is impossible to get that here. What other options do I have to help establish good gut flora in my newborn. Can I use adult probiotics? Are there specific bacteria strains that the baby should not be given as a newborn? Thanks for your help.

    • The author of the Body Ecology Diet, in a YouTube video with Natasha Cambell-McBride, recommends coconut water kefir on the nipple at every feeding. As I recall that is a recommendation for all babies, not just those with known complications in gut flora, but it’s a good start – and should be reasonably doable for you, right?

      • If I can find some kefir grains we do have an abundance of coconut water out here. Thanks for your suggestion.

  8. I empathize with Peggy the Primal Parent. I was also born vaginally (despite being a breech baby, and my mom being in 48 hours of labor with me – probably something a modern hospital would never allow to happen) and was also breastfed, and I struggle with obesity (though have lost 127 pounds), gluten intolerance, diabetes type 2, Hasimoto’s. My two bottle-fed sisters are both slender and in much better health!

    My own son was born vaginally and breastfed for a year, and he struggles with obesity too. One of my sisters had her first child vaginally and the second via emergency C-section. She said the C-section was such a wonderful experience compared to a vaginal birth that she would have demanded a C-section for her first child too if she had only known! 🙂

  9. Great article Chris! I have to say, the thought of cutting someone open and surgically removing a child has always unsettled me, especially as an elective procedure. However, at the end of the day, the woman is in charge of her own body, and if it is a choice she wants to make, than so be it. It’s just important that people know exactly what risks they are putting themselves and their babies in by doing so, so cheers to ya for the post!

  10. Great, concise article on this topic. Two years ago I had a really difficult decision to make: I intended to have my baby girl at home until at 36 weeks we suspected she was breech. I did massive research and decided to continue with the home birth, but hired an extra midwife with scores of breech baby deliveries under her belt. It turned out to be a good choice and my girl was born butt first, quickly and easily, but I totally understand why this is not a choice most people would make. Not to be morbid, but I felt like in the end I was the one who needed to be the most safe as I am already alive and have a family that loves and needs me, while if anything should happen to the baby, well, I could always have another baby…maybe not if a c-section went terribly wrong though…
    Dr.’s are not trained to deliver breech babies and I found a MW who was very skilled, so I actually felt safer staying out of the hospital and avoiding c-section.

  11. Chris, thank you for this post! What is your opinion on VBACs? I had twins a couple years ago. My OB told me early on to pretty much expect a c-section. I ended up with gestational hypertension and was on at-home bed rest for the last month of my pregnancy (up to then I was perfectly healthy). Because of this complication, my doc didn’t want me to go past 38 weeks which meant I had to have a c-section. My recovery from the c-section was pretty difficult, especially while trying to breastfeed two babies.

    So, because I had a c-section for my first two, if I were to have another I am guaranteed to have another one since most doctors are unwilling to do VBACs. However, I’ve heard that VBACs aren’t as risky as previously thought. Have you found anything about this?

    Thanks again for all of the information you put out there!!

    • Yes, the risk has been overstated. According to most studies, 75% of VBACs are successful, with excellent outcomes for mothers and babies.

      • But, Chris, that means that 25% of all VBACs are UNsuccessful. My cousins’s wife is one of those. She tried for a VBAC, her uterus ruptured, her full-term baby died, she wound up in a coma for two weeks, she lost her uterus, and when she woke up, instead of holding her baby, she had to go visit him at the cemetery.

        • Please keep in mind that VBACs termed “unsuccessful” can be due to any number of different reasons – it doesn’t mean that all 25% or even a small percentage ended in someone’s death. As a pregnant mom I bought everything Ina May Gaskin ever published http://www.inamay.com/ – she has an enormous amount of experience on the subject & has a ton of references for free on her website. I would recommend her as an essential read to any new mom – she will relieve your anxiety & empower you to do exactly what your body is designed to do.

        • Hi, Beverly. NO, I do not know what kind of stitching my cousin had. It’s very sad. My grandmother is someone else that should have had a c-section; instead, they tried for natural childbirth, and her baby (who would have been my uncle) was stillborn. There are so many sad stories out there.

    • I had twins by c-section as well. All my other babies were born vaginally in the hospital. In order to have vbac for my baby after the twins, the best route for me was to have a homebirth with a midwife. This decision wasafe after talking to many, many doctors about vbac and the various parameters that govern that in the hospital. It would have been a sure c-section again with their rules. Anyways, we don’t regret fighting for our vbac, but it was not easy!

  12. It’s not just the Western World that believe C sections are perfectly safe and possibly preferable. The Chinese deliver a huge percentage of babies via c-section, a touch less than 50% which is way above the US rate. The reasons are partially economic- hospitals can charge more and partially practical- you can schedule the birth and know about how long the process will take. Neither of these are good reasons of course but that’s how it is.

    My wife had her first baby by c- section and hospitals here won’t even consider the possibility of a natural birth for the second.

  13. Tyler,

    I think there are only two options. One is the you mentioned and the other, probably more important, is the vaginal route itself that provides first bacterial exposure to the child.

    Which brings to mind… if uteral/cervical and vaginal excretions are the main reason for the benefits of natural childbirth, why bothering with any supplementsl magic, at all. Some stupid christian beliew surely must keep people from seeing the plain truth wide open… (keyword: vaginal microbiota, the first exposure to evil world)

    Also, the birth trauma itself may have some recuperative effects in itself.

    Oh and I was born via cesarean. Got 13 allergies and Crohn’s disease, thank you very much!

  14. Thank you, thank you, thank you. This neatly encapsulates the issue and will be my send-to article in the future when someone asks why I’m so vehemently anti-CS.
    Tyler, we evolved by, with, and because of birth. It is triggered by a signal in the baby’s brain when the child is done gestating; it forcefully massages the airways, removing fluids, and the spine; and it generally takes longer than surgery, and the child’s body needs that transition time to adapt to the biggest change of its life. So you are right with the “too early” hypothesis, but it’s not just when, but HOW.
    Fast food makes sick bodies, and “fast birth” makes sick babies.

    • I’m glad to see some pro c section people. I don’t think mothers should be able to choose a c section over vaginal birth if vaginal birth is possible. I was two weeks late with my daughter and was induced unfortunatley i was in labor for around 50 hrs and after every attempt was made including cervadil, potocin, and breaking my water I could not give birth to my daughter. I received an emergency c section and she is a perfect. I’m 30 weeks pregnant now and will be delivering via c section in 9weeks 🙂

  15. Chris, what is the reasoning behind the risks of a child born during a c-section? Is it because they’re coming out earlier than meant to be?

  16. I’m one of the women who tried to give birth at home and ended up at the hospital with a doctor shouting to my husband “Dead wife or dead baby” when I insisted I just wanted pain relief (after baby flipping backwards during labor and a swollen cervix) and the doctor insisted upon a c-section. The doctor won and due to that, I could not physically give birth to my second baby. My uterus was scarred. I had adhesions. This second time my wonderful MW recognized the problems and insisted upon taking me to the hospital where even she said that a c-section was inevitable given my symptoms. Giving birth naturally is no longer an option for me despite being a good healer, eating well, and having great pregnancies.

    The medical industry has so many problems and giving women support for natural birth is just one. Beyond the obvious problems with c-sections, women are not counseled on the post birth complications such as gut flora for the babies. Both of my children spent their infancy reacting severely to proteins in my breastmilk and have dealt with severe food intolerances. Then you have the arduous recovery from surgery while trying to care for a newborn.

    So thank you for writing about the problems for mothers and babies. Getting this information into the hands of pregnant women and especially the medical profession is a must. I know that the surgeons operating on me thought I was an idiot for attempting a home and then a birth center birth and verbally told me so during the operation. These abuses need to be addressed and the medical profession needs to be educated appropriately. I just don’t know how this can be done.

    • Shazer, So sorry you were verbally and emotionally abused by the surgeon. Yes, he was inappropriate.

  17. Chris, what is your stance on things like Rhogam during pregnancy rather than waiting until after birth? Or treating newborns with antibacterial eyedrops and vit k shots? All these treatment are to prevent diseases that are rare, but then you are the dummy if it happens to you. Do you feel the side effects are bad enough to avoid these preventative treatments?

  18. I don’t understand why anyone would elect to have their baby pulled out of a huge incision when we are perfectly well equipped to push babies out through an elastic birth canal. I had an “emergency” c-section in a hospital and wish I had experienced natural child birth. Hospitals are much to hasty in their decision to do c-sections and allowing women to elect a c-section is just crazy (or money driven).

    I healed amazingly well and quickly and my daughter has no signs of any of the problems you speak of after 6 years, but we also ate a Paleo diet the whole time which includes plenty of naturally fermented foods. I’m sure we would have been better off with natural childbirth, but with a meticulously healthy diet, we turned out ok.

    • Hi Peggy

      Interesting comment. I also had an emergency C section (the doc who performed the surgery said afterwards that I am probably one of those women who in ‘the olden days’ would have either died, or the baby died, or both, due to a bunch of different reasons.) Preferring not to have just one child, I will now be considering electing for a C section for #2. There’s one reason for you!

      But in doing a LOT of research regarding C sections vs VBAC (which thankfully the hospital is supportive of), I’ve noticed a recurring theme of legality, especially here in Australia. You see, there has never been a lawsuit regarding a C section here raised against the ob, whereas with a vaginal birth there have been several (Ie damage to baby from forceps, extreme tearing etc). When you elect/consent to a C section you acknowledge the risks involved and sign something saying that the hospital won’t be held liable. You don’t sign anything like this for a vaginal birth. You do sign it for a VBAC. Also, the public hospital is funded $5000 (approx) for each C Section performed, whereas a vaginal birth is only funded $3000. I think this is why they tend towards a C section – much safer for them!

      My daughter also experienced no signs or negative responses to the C Section mentioned in the article and (despite our SAD and lack of fermented food) we have also turned out ok.

    • How dare you judge. I went through a 30 od hour intense labour and was still only 2-3 cen dilated. I had walked miles and trief everything. My son was 2 weeks late and I ended with a raised temp due to infection and he had a raised heartbeat. So yes after 30+ hours I adked for a c sect as was told I would he another 24 hours! How dare you judge others. Have my labour then comment.

      • hi there I no its a little late but I totally agree with you, ive had 2 vaginal births now and both were horrific! my 2nd ending me in hospital for 8 days with a catheter in for 5 days couldn’t walk for 5 days or lift the baby ended up delivering baby by having a episiotomy and getting her out with forceps! after over 20 hours of labour! im now pregnant and have opted for a c section, surley this is the way the to go after my experiences

      • You are absolutely right – I am the product of a c-section after 27 hours of labor (my mother’s birth canal was too small and I was almost 9 lbs.), and my youngest son was born by c-section because his heart rate was dropping and it was likely that he would die if left inside full-term.