Pregnant women in high-income countries, such as the United States and Australia, give birth via c-section at more than double the rate the World Health Organization recommends.
Neonatal and maternal outcomes improve as countries’ rates of c-section top 10%, but once a country’s rate exceeds 15 %, the risk factors outweigh the benefits.
There is no doubt that, when medically necessary, c-sections save the lives of women and babies.
In certain situations, a medical complication means a c-section will be scheduled before a woman’s due date. This is called a planned or elective c-section.
There could be a number of reasons why an elective c-section is required, and it can be a daunting decision to make.
However, we now know that a c-section birth can cause problems for both mother and baby — problems which are uncommon in spontaneous labors.
When planning an elective c-section, it’s a great idea to look into the benefits of allowing labor to begin spontaneously before having surgery. This could be a viable option for you and your baby – especially when maternal and neonatal morbidity are a risk.
Where possible, allowing labor to begin before surgery will produce better neonatal outcomes. Labor can also have positive benefits for your baby, such as the following:
#1: Fewer respiratory problems
When babies are born via cesarean delivery there’s a significant difference between those who have gone through labor and those who haven’t. The respiratory morbidity of babies who haven’t experienced labor is higher. During labor, babies get ready for life outside their mother’s womb. Labor allows the last necessary changes to the baby’s lungs, once the umbilical cord stops providing oxygen and the baby’s respiratory system takes over.
Babies who don’t go through labor are more likely to develop transient tachypnea, which is also known as ‘wet lung’.
While in utero, babies’ lungs are filled with fluid. In the weeks leading up to the birth, this fluid is slowly expelled. During labor, the squeezing action of the contractions pushes even more of the fluid out, preparing the baby to breathe.
Babies who are born via c-section, without labor, tend to have fluid in their lungs. They often need help (i.e. with a suction device) and sometimes require oxygen immediately after birth. In the following days, wet lung can develop. This is characterized by fast, labored breathing, which might need oxygen treatment, IV fluids for hydration, and possibly, antibiotics.
In most cases, babies will spend a few days in the special care nursery; this adds extra stress and can interfere with mother and baby bonding.
#2: Reduced risk of premature birth
Each woman is different. Each baby is different. Each pregnancy is different. These three factors determine why a baby chooses a specific time to be born (gestational age). Why are some babies born after 37 weeks of pregnancy and others several weeks after the estimated due date? No relevant relationship has been found between being born at term and neonatal outcomes.
It’s quite clear now that it’s the baby who initiates spontaneous labor. In low risk women with no pregnancy complications, this means that the baby starts labor when she’s ready to be born. There is a decreased risk of adverse outcomes, for both mother and baby, when baby is born after labor has commenced.
When spontaneous onset of labor occurs it means that baby is prepared or making the last preparations to be born. Regardless of how she’s finally born, she is ready. How she copes outside might differ significantly from the way she might cope after just being pulled out without warning or preparation.
Baby is well prepared to start a separate life from her mother; therefore, even when she’s born by cesarean section, the neonatal outcome tends to be better because the baby is ready for life outside the comfy maternal womb.
Unless there is a medical urgency, guidelines recommend elective c-sections should not be performed before 39 weeks. This allows for due dates being incorrect, given that most estimates are based on ultrasounds and last menstrual period dates, which can be up to two weeks inaccurate either way.
A study of almost 13,500 elective repeat c-sections, shows almost 36% of the babies were less than 39 weeks gestation. These babies are more likely to experience a host of health problems which are less likely to occur in healthy babies born vaginally.
Neonates who are born before they are fully developed, can have a range of difficulties: respiratory distress syndrome (difficulty in breathing unassisted); difficulty maintaining body temperature; low blood sugar (because breastfeeding is trickier); and being prone to infections. They can even develop more serious conditions, such as hypoxic ischemic encephalopathy (related to brain damage due to lack of oxygen when the baby is born immature), and might require extended stays in a neonatal intensive care unit.
Babies are usually able to leave the hospital when these problems are resolved but many preterm newborns end up back in hospital due to jaundice and ongoing feeding problems, which lead to weight loss and dehydration.
#3: Breastfeeding success
It might seem a stretch to think that a c-section can affect breastfeeding success. However, a large meta-analysis looked at breastfeeding rates after c-section in over 550,000 women with very different maternal characteristics (such as maternal age, gestational age…) and found early rates of breastfeeding were affected.
Rates of breastfeeding were low after c-section compared with after vaginal birth. When the researchers looked further into the data, the women who had surgery after labor had begun had higher rates of breastfeeding than those women who had elective c-sections.
Recovery after the surgery can limit movement, and you might also be feeling sore. Your baby could be in the NICU, due to prematurity or breathing difficulties. This can affect nursing, as babies often tire easily and struggle to latch and nurse effectively.
Different studies looked at weight loss in exclusively breastfed babies born via c-section. The research found that babies born before labor began had a significantly higher percentage of weight loss from their original birth weight than those who were delivered after labor had begun. This is because those births might have taken place several weeks before the babies were ready to be born. An adverse neonatal outcome that is a result of being born without any warning plus being born when still immature can really mess up the first encounter between mother and baby that is necessary for a good start to breastfeeding.
Weight loss in newborns often prompts care providers to suggest supplementary feeding in place of or alongside breastfeeding. Supplementation is associated with a shortened duration of breastfeeding and increases the likelihood that babies are not fed breast milk exclusively for the first 6 months.
#4: Improved general public health
Being born at the right time matters greatly to each individual family but also in the general sense. When a secondary analysis is performed in general birth outcomes, the statistical significance is extremely relevant for health care providers to change protocols and guidelines. Most planned cesarean sections shouldn’t have a scheduled date and even if it’s clear that that baby will be born by cesarean delivery, such as in cases of a placenta previa, active genital herpes, or a fetal presentation that doesn’t allow a vaginal birth, doing it only when the baby is ready is the right way to proceed. This is an urgent change in practice for maternal fetal medicine teams around the world.
If only healthcare providers waited for spontaneous onset of labor before performing an elective cesarean section the neonatal outcomes, the maternal perioperative outcomes, adverse maternal morbidity, and other secondary outcomes would significantly improve.
Having scheduled c-sections certainly makes healthcare providers’ lives much easier but let’s not forget what is really important. Maternal and child health should always take priority over the comfort of planned schedules.
The obstetric maternity unit is an emergency service, which means it is open 24/7. Doctors and other healthcare providers should be ready to care for pregnant women effectively whenever they go into spontaneous labor.
Another problem with planned cesarean sections is that mothers and babies are not given enough time to ‘correct’ the problem that’s causing the c-section to be performed.
Many obstetric units around the world, for example, plan c-sections for babies who are not head down. Many of those babies would turn before the spontaneous onset of labor, if given the chance.
Some obstetric units perform a cesarean section when the woman has a multiple gestation (twins or triplets). If they waited for labor to commence spontaneously those babies would have a much easier start to life.
Some protocols are really obsolete and not evidence-based. Investments should be made in training doctors and midwives in breech vaginal births or multiple births – especially as there is robust evidence in favor of allowing these births to happen vaginally if the staff is properly trained.
For every cesarean section avoided, complications for mother and baby are avoided in that moment. Further, there is a huge positive impact on the woman’s future health and pregnancies. This is because so many complications can arise when a woman has had a previous cesarean section. If the first c-section isn’t performed, there’ll be no chance of a planned repeat cesarean delivery afterwards, and that will have a direct positive impact on every woman who avoids that first major abdominal surgery.
Let’s keep low-risk women low risk, as much as possible.
Benefits for the mother
Not only are there positive neonatal outcomes when labor happens before a cesarean birth but there are also better perinatal outcomes for mothers who experience spontaneous labor before c-section.
Here are some of the benefits:
- The uterus, especially its lower segment, changes its shape and qualities as labor develops. Performing the cesarean section after the uterus has experienced labor contractions lowers the risk of several adverse maternal outcomes, such as heavy blood loss, postpartum hemorrhage, the need for a blood transfusion, and damage to the uterus and other organs
- When spontaneous labor is experienced before a cesarean section, the operation for the mother is usually easier and recovery tends to be faster than after a planned cesarean section. When the recovery time is shorter, the chances of complications, such as venous thromboembolism, are also reduced
- When the uterus has gone through the changes that happen during labor, the muscle walls become thinner, and maternal morbidity decreases as there are likely to be fewer adhesions if subsequent pregnancies take place. There is an increased risk of placenta previa in future pregnancies when a c-section has been done on a thick uterine wall
- Pain management tends to be better, as labor hormones have done their work to manage labor pain
- In this retrospective cohort study, research shows there’s a decreased risk of uterine rupture in future labors.
Is it better to go into labor before a c-section?
You might wish to consider labor before a primary cesarean delivery in most situations, even if you’ve decided that your baby will be born by cesarean section.
Allowing spontaneous onset of labor is perfectly safe in the following situations:
- Your baby is breech or bottom down
- You’re having more than one baby and the first baby isn’t in a head-down (vertex) position
- Your baby is in a sideways or transverse position: although your baby cannot be born in these positions, your baby might turn into a favorable position. Even if your baby doesn’t turn, waiting for the spontaneous onset of labor will have many benefits for her health
- You have pre-eclampsia that’s monitored and remaining stable.
Most women want to avoid a c-section, and the prospect of requiring one for the safe birth of their baby can bring a sense of disappointment. It’s worth discussing with your care provider the option of performing a c-section once labor has begun. This will classify your c-section as an ‘emergency’ which defines it as having occurred after labor has started.
If you and your baby are both well enough to experience labor for a certain amount of time before your scheduled cesarean delivery, it can provide you with a sense of control and satisfaction, as well as offer a host of benefits to your baby.
Talk to your doctor to find out more about your particular situation and whether allowing labor to begin is a safe option for you.