When women become pregnant, do they ever assume they will end up delivering via cesarean section (c-section) ? Probably not. I would bet the average parent-to-be’s mindset defaults to a stable vaginal delivery, with the slight knowledge of a possible c-section in the way back of their mind. This is one reason I feel it is essential to spread more knowledge about c-sections. Prevalence, indications, preparation, and recovery tips. So, keep reading: educate yourself!

Prevalence

The rate of cesarean section has risen globally, with the most recent statistic being 21.1% of all births world-wide in 2021. That statistic actually only accounts for the primary c-section rate, meaning first time c-section. When including all c-sections, repeat c-section being a common practice for women who have already given birth once or more via cesarean, that overall percentage increases to 32.1%. 

For comparison purpose, note that the OVERALL c-sections rate in 1996 was 20.7% world-wide. According to the World Health Organization (WHO), the trends and data suggest that by 2030, the primary c-sections rate could increase by 20%, predicting nearly one third of all (primary) births. 

Cesarean sections are not all bad. A medically necessary c-section can be a life saving procedure, for both moms and babies. The advances in medicine and monitoring can account for some of the rise in statistics. The problems really is when people are having c-sections that are NOT medically necessary. 

Cesarean section rates by region: What accounts for the large discrepancy?

Africa: 9%

Australia/New Zealand: 21.4%

Asia: 23.1%

Europe 25.7 %

The Americas (north, central, and south): 39.3%

What accounts for these staggering differences in rates? We have a range of reasons. From access to high-quality care and access to cesarean section as an option in a medically necessary birth situation to cultural norms, rates of pre-term birth, and quality of healthcare. The United States has one of the higher primary cesarean rates. Which then increases the repeat cesarean rate, yet we have the highest rate of maternal mortality and morbidity when compared to other industrialized nations. Rather than being life saving, could our high c-section rate be contributing to maternal mortality?

So what can we do?

Rather than focusing on a number or universal target goal, the WHO puts emphasis on each population and women’s specific needs to their pregnancy and childbirth. It is so important that all women have access to a quality healthcare provider. And receiving guiding information, including risks and benefits or their birthing options, education and emotional support during this time of bringing life into the world. 

Here are some non-clinical actions the WHO recommends to help decrease the rate of non-medically necessary c-sections, in the setting of quality and respectful healthcare: 

• Birth education! Knowledge is power. Having access to birth preparation courses, relaxation techniques, psycho-social support to address fears and anxieties can be an important step before the patient is even in the hospital or birthing center
• Practicing with evidence based guidelines, performing audits of c-section practices in healthcare facilities, and giving timely feedback on those practices, especially in facilities with the highest rates of primary cesarean births
• Team approach to birth. That can be second medical opinion before performing a c-section if that is available. Or a collaborative care model with midwives taking primary care and obstetricians always available when necessary, and trust in labor nursing staff. 

Birth education should include c-sections

Most of the time, when patients come to the hospital in labor or for labor induction, c-section is not even something that has crossed their mind as a possibility for their birth outcome. I’ve seen and heard of some birth education classes including segments about c-section. But I find most focus on labor support, pain management options, and baby care. And as the statistics show, birth via c-section is a highly possible outcome. So here I am to save the world!

Indications

So, with all these statistics, why would someone need to give birth via cesarean section? As someone who has had a c-section myself, I understand, both professionally and personally, their are many reasons someone would need to, and sometimes choose to, give birth via a c-section.

Here are some “indications” I’ve seen in my 14 years as a labor & delivery nurse for some not-so-necessary c-sections…

• Providers or hospitals not allowing attempts at VBAC’s (vaginal birth after cesarean). Labor if you’ve had a cesarean section has its risks. It can only be done if your previous c-section incision was a low transverse incision. But believe it or not, in the right candidate, those risks can actually be lower than the risks that come with a c-section **
• Lack of experience and/or education of the labor and delivery staff. Getting your patient an epidural at 2 cm dilated and leaving them in low semi-fowlers position for the duration of the labor is not going to lend itself to a vaginal delivery. With the use of the peanut ball, spinning baby position changes, and quick interventions for category II fetal heart rate tracings, the nurse or other labor support staff can make a huge difference in the patients birth outcome.
• Providers being too quick to “call a c-section”. If you’re a nurse reading this then I know you are familiar with c-section because it’s 5 o’clock and the doctor wants to get home for dinner. Or if the patient is “stuck” at 4 centimeters for longer than desired, and the provider loses patience.
• Elective primary cesarean sections. There is an increase in patients choosing to schedule a c-section for their birth for many reasons. Those reasons can be cosmetic, fear of the pain of labor, assuming that if their mom and/or sister needed a c-section then they will too, etc etc. That said, there are some very reasonable indications a person might elect for a scheduled c-section. Everyone should have choice over their own body. It is also the responsibility of the healthcare providers to present the education, alternatives and address the patients fears or concerns specifically and directly. And I am talking legit education: review what the patient saw on TikTok that maybe influences their decision making

** Side Note

Would anyone want more in-depth information about a trial of labor after a cesarean section and VBACs?

For more information with reference to cesarean sections in regards to postpartum care, CLICK HERE!

We aren’t in the business of birth shaming over here

and when I say we, it’s just me. Not cool or popular enough to have a team. It is not my goal to shame anyone that elects for a scheduled cesarean section for their birth. Especially, since I myself had a c-section. And if I were ever able to get pregnant again, I would elect to have a repeat c-section rather than attempting a VBAC.

I have seen a few situations in my labor and delivery practice when it was certainly appropriate for the patient to elect for a primary c-section. An example being when a patient’s previous birth was vaginal but resulted in a shoulder dystocia. To describe it simply, a shoulder dystocia is when the infants head delivers but the shoulders and rest of the body doesn’t. Or doesn’t with typical birth maneuvers. It is an obstetric emergency. This can result in injury and insult not only to the baby, but also mom. Such as greater degrees of lacerations to the patients perineum/vagina, and trauma from an unexpected emergency. A patient may not want to risk their next baby being born with a shoulder dystocia, because it is an increased risk. Once you have had one, you are at risk for it happening again.

Another super sensitive example is of a 13 year old patient whose pregnancy was a result from sexual abuse. It is often difficult for adults to relax their legs and pelvis during a cervical exam or to cope with the pain of contractions. So imagine that experience as an early teenager. I can’t imagine a more vulnerable birth experience. So to avoid continued trauma, her mother and healthcare provider helped her elect for a scheduled surgery instead.

Examples of medically necessary cesarean sections:

• Malpresentation: This means when the presenting part (the part to come out of the vagina first lol) is not the fetal head. The head is designed to move and mold to facilitate delivery; the butt or an elbow, not so much. If you have heard the term breech, that means the presenting part is the baby’s butt or feet.
• Labor dystocia: That’s a fancier term for a stalled labor (not reaching 10 cm dilated) or a “failed induction”. I think we should take the word failed out of a lot of our medically terminology. That increases the pressure to achieve a vaginal delivery and feeling like a failure if they do not. True labor dystocia does not mean the patient has been 4 cm for 4 hours. And not given more time and alternatives (if allowable by the fetal heart rate and other maternal or fetal factors)
• Fetal heart rate patterns: Sometimes continuing the labor or even attempting to start labor is not safe if the fetal heart rate is showing signs of distress and decreased oxygenation. This requires the healthcare providers to continue training in fetal monitoring. Education on what patterns, or “abnormalities” can be tolerated and when is it unsafe to continue labor.  
• Maternal medical conditions: certain medical conditions are contraindications for labor and vaginal birth. Some examples include high viral load of maternal HIV, current herpes outbreak, maternal cardiac or neurologic (heart and brain) conditions where pushing can be unsafe. Or something specific to the pregnancy like placenta previa (when the placenta in positioned over the cervix).

Preparation

Now, let us get into the real reason anyone might be interested in reading this article. What can healthcare providers and patients with their family do to prepare for a possible c-section birth?

Research & Education

What can a pregnant person and their support partner do to prepare for the possibility of a c-section delivery? Research and education. This can be as simple as talking with friends and family who have had a c-section. Or could be as in-depth as finding a reputable online educator and/or taking a birth class that includes comprehensive teaching on c-sections. Knowledge is power. And education for labor and birth should include the knowledge of possible interventions and indications to transition from a planned vaginal birth to cesarean. This gives you power to question plans being made for you and turn them into plans being made WITH you. 

Now, this is important. Read closely. Birth education does NOT mean doing what you saw on an Instagram reel or what someone on TikTok said you should do. I know I am getting old, but I get it. Social media is a way to get information quickly. And there is great content out there. But please consider your sources. Many content creators talk a lot about what happened to them from their perspective, but they might not have the full story or true understanding of why something happened, which is kinda sad. Every situation is completely different. I have a lot of patients come in absolutely terrified of aspects of the labor process because of what they have seen on social media. I am not about scaring people into doing what I think should happen.

Basics to know about the Cesarean Section process and how it differs from a vaginal delivery: 

1. Your delivery will be in the operating room. It is bright in there. You will only be allowed one support person in the OR with you. And, usually they can’t come in until the doctors are ready to start the actual surgery. There are a few different methods of anesthesia. Most likely a spinal (similar to an epidural). But a spinal should make you much more numb. General anesthesia is a possibility, which is when you are put fully to sleep with a breathing tube. Usually in that case, no support person is allowed with you. But usually they can get them in somewhere to be with the baby
2. While with a spinal you are mostly numb, you will still feel touch and pressure. You should not feel any sharpness of the surgery, but you are awake and having major surgery. So, you will feel uncomfortable pressure especially in the moment they pull the baby out
3. The brings me to my next point: C-section is a MAJOR surgery. It is often downplayed because it is such a common surgery and not necessarily the result of disease or injury. But a c-section is a surgery when someone is cut through SEVEN layer of their body, yet women are expected to bounce back and not only take care of themselves but a brand new human. Don’t get me started on a rant.
4. Your birth experience may not be what you hoped, but many facilities try to accommodate your birth preferences. Our unit has a double drape, one blue, one clear. That’s what is blocking you and your support person from seeing everything and maintaining a sterile field. When the baby is delivered, we give the option of dropping the blue drape so you can see your new baby right away. We attempt to do skin to skin in the OR if that’s what the patient wishes. It is a bit difficult with the patient so flat and not having much real estate to choose from, but it’s usually possible. It’s just fine to do skin to skin the recovery room if you are in pain or nauseated.
5. You will have pain afterwards. That’s just a fact. Between anesthesia, long acting morphine placed in your spinal, PCA pumps (a self pressed button system to give small amounts of pain medicine through your IV) we try our best to keep your pain manageable and tolerable. But you cannot expect to have a constant pain level of 0/10 after such a major surgery
6. You will likely stay in the hospital a night or two longer than if you had a vaginal delivery. It takes time before you can walk on your own, pee on your own, eat normally. And having at least some capability to care for a brand new human. (see #3)
7. If you have an indication to schedule your surgery, it’s not 100% that your birth will happen on that day. Still prepare for the unexpected. For example, you’re baby is in the breech position and you have a c-section scheduled Tuesday. But it’s 2 am on Saturday, and your water just broke. That baby is coming Saturday.
8. I like to warn people that day 2 is often more painful than day 1 (or day of surgery). The day or night of your surgery, you usually have some numbness for a few hours afterwards from the anesthesia, many hospitals use a long acting morphine that help the pain for 18-24 hours, and you remain in the bed with a catheter so you don’t have to get up to use the bathroom. Oh yea, you will have a catheter in your bladder during the surgery and at least 6 hours after. Ideally, it doesn’t get placed until after your spinal, so try not to worry too much about it. On day 2, the catheter comes out and the anesthesia has warn off and you’re like “wait, what? You want me to get up and walk around?” But getting up and moving will help you recover. I’ll chat about some specific tips of on modifications that will help accommodate your recovery
9. There are also differences in a scheduled or “add-on” c-section versus a STAT c-section. How fast the providers are moving around you and talking to you is worrisome. It’s like a NASCAR pitstop. If you’re on a good unit, it may look chaotic but it’s usually controlled chaos. We do STAT c-section drills at least yearly. There isn’t as much time for questions and understanding, unfortunately. If you have been through an experience like that, then coming in for a scheduled repeat c-section 2 years later can be anxiety inducing. But it should be a much more calm and smooth experience I hope.
10. It may be a while before you can eat again. In the case of a scheduled c-section, you will be asked not to eat or drink anything for at least 8 hours before. For example, nothing after midnight for an 8 am surgery time. After surgery, especially abdominal surgery, it is normal for your digestion system to slow down. And anything you eat that cannot digest and move OUT, it will likely come UP or even get stuck. Once the gurgles in the tummy come back, and ideally if you pass gas, you know things are moving down there. You should be fine to eat if you are not feeling nauseas. Generally, you will start with ice chips, progress to water, then clear liquids*, then food as tolerated 

Disclaimer: every hospital or birth facility is different

Different protocols and practices. This is just a generalized guide.

• Also a separate FYI: Clear liquids are something that are liquid at room temperate and you could see through looking through a glass. That is why we consider popsicles as clear liquid but ice cream or smoothies are not. This is a common diet orders for patients in labor. Not gonna lie though, I do really stretch that definition and count applesauce as a clear liquid for some of my patients… 

Recovery

Recovering from labor, delivery, and birth can be difficult in any situation. Physical and mental recovery. But the recovery process post cesarean section is quite different than after a vaginal delivery. I think this is a huge knowledge gap for birthing persons. Again, I believe since it is such a common procedure, and the patient is often awake, that it gets downplayed.

When I have patients starting to lose it in labor, saying they can’t do it anymore and want a c-section, I have to school them. I know this labor has been hard. Painful, tiring, long. Whatever it is that’s discouraging them. But at least, after the baby is born, it’s essentially over. You may not feel 100%, but the contractions are done, food and naps are in sight, and hopefully you’ll start feeling back to normal soon. But if you are feeling bad now and THEN have a c-section, the recovery pain is just beginning. Plus, this major surgery is not without its risks. Again, 7 layers of your body. Increased blood loss, risks to the other organs that are right by the uterus (bladder, bowels). So if you can avoid this, its a good idea to try.

Tips for your recovery period post cesarean section

• You never realize how much you use your abs until you can’t anymore. It is not going to feel good when you sit up from a laying position or stand from sitting. You should use a small pillow or rolled blanket and press that against your abdomen. Sounds crazy to push something against your incision site, but this helps keeps everything supported and not stretching out
• Another way to save your abs, is instead of lifting yourself up with your abs, consciously push yourself up with your thigh muscles
• You are not going to be able to, or should not, use stairs often when you first get home. This also related to the abs and healing incision. Hopefully you have support and people to help you take care of yourself and the baby when you get home and can take those trips up and down the stairs for you. But I sure know that is not always the case. So it takes planning. Unfortunately, my c-section came with quite a few complications, so even when some time had passed when my daughter was able to come home from the NICU, I still wasn’t very far into healing. I would plan my day to be downstairs for most of it, because that’s where more of the stuff and the food lol. I would try to make only 1 or 2 trips to get the baby, my rock-n-play (since recalled), phone charger, etc all downstairs and just lay on the couch and hopefully not have to go back up the stairs until nighttime. 
• As a general rule, when you leave the hospital you should not lift anything heavier than the baby. And that includes the baby in the carseat. Those things are cumbersome and heavy. Take it easy as long as you can
• You should not drive until directed by your provider. There are a few reasons for this: you may still be taking medications that could make you dizzy or drowsy. Even if you are no longer taking strong pain medicine, your abdomen and incision may not be able to withstand the impact of an airbag deploy. 
• You might be constipated. And that shit sucks. (ba dum tss) This is due to the anesthesia and a common side effect of opioid pain medication. Trying to walk and drink water as much as you will be helpful. Definitely take stool softeners, like Colace or Miralax.
• It is still normal to have vaginal bleeding after a c-section, even if you did not labor. Some people transition to spotting by the time they are discharged from the hospital and that may come and go for 6 weeks. It’s also normal to have bleeding like a period for 6-8 weeks. That said, I had very heavy bleeding for 10 weeks, but I was not normal 
• Be kind to yourself. I have no clue why women still think that because they needed a c-section their failed. Whether it was because you couldn’t get to 10 cm dilated or your baby was breech, you are not a failure. You are a bad ass mom who got their baby cut out of her and most likely have to get back to business pretty quickly. Also, you can use your c-section scar as a reminder to your kid what you went through to bring them into the world and that is why they have to do what you say. Or is it just me that still does that?

For the Healthcare Providers

So what can healthcare providers do to prepare a patient for a possible c-section delivery? Anticipatory guidance. That is when you have open and honest conversation and provide education BEFORE it’s necessary. While it may seem common to us, the fast paced controlled chaos can be very scary to a patient and their family. And that moment does not lend itself to questions and education.

If a patient comes in for a labor induction, take the time in the beginning to get to know the patients: their wishes and fears. Help them get to know you. That helps establish trust in the care and guidance you are giving them. Review possibilities of fetal heart rate distress and interventions that might need to be done quickly. Try to get to know what their current understanding or thoughts are on c-sections. Giving information and guidance when the climate is calm will help facilitate the patient actually absorbing and understanding of the information and giving time to ask questions. 

Language Barrier?

This anticipatory guidance may be even more important if you and your patient have a language barrier. I cannot imagine having a baby, especially via surgery, in a place where I don’t understand the people taking care of me. And I am supposed to trust them. And we all know talking through an interpreter takes AT LEAST twice as long. Depending on the urgency of the c-section, time is precious.

Whether in the case of a language barrier or not, in the case of urgent intervention or a plan changes to a c-section, reference your earlier conversation. Reminding the patient that this is what you you were talking about earlier, and saying out loud what you said would happen as it happens can really instill trust from your patient. And I can imagine that trust in your healthcare team really eases some stress and anxiety an unfamiliar situation.

Anticipatory Guidance

Here are some suggestions to include in your education to your patients AND their family members or other support people at the bedside. These are things that seem common sense or basic to us, we do it everyday. But there is so much misunderstood about the birth process, cesarean section, and even the female body/anatomy.

If your patient is at an increased risk of c-section, be open and honest. You don’t want to scare or worry them unnecessarily, of course. I understand each patient has individual needs, so take their lead. But for example, if the patient is attempting to VBAC, and they maybe are not the most ideal candidate, tell them in advance what the process would be in the event the plan changes to deliver via cesarean. Another example might be the case that your fetal heart rate pattern is not optimal or Category I, but you are attempting to induce or augment labor.

Sample Script

Here is an example of what I may say to my patient in that situation. “We have your baby on an external heart rate monitor to both assess that and your contraction pattern. Right now the baby is not showing signs of distress, but it isn’t A+ perfect. Which is ok, but I just want to watch it really closely, so these monitors will stay on through the course of your labor. We use Pitocin to (start, strengthen) the contractions and sometimes the baby shows us signs through the heart rate pattern that she is not tolerating that strong or frequent of contractions. We have many interventions that can help the signs of distress, but there are times when I might turn off the Pitocin. And if the heart rate pattern is showing signs that oxygenation is compromised, we may have to transition to a c-section”.

Assume your patient knows nothing. I still get surprised at what patients are completely unfamiliar with that I think should be common knowledge.

You Learn Something New Everyday

Hopefully you know more now than you did before. That’s always a victory. I could go on and on about pregnancy, labor, delivery, cesarean sections, and postpartum forever. That’s one of the many amazing aspects I love about medicine and healthcare: its always evolving and striving for better. How can pregnancy not fascinate anybody and everybody? The human body is amazing. How can a tiny speck released from an ovary and 1 single sperm out of millions, combine and grow to a full functioning human?! Amazing.

Cesarean sections are not usually the preferred method for birthing a baby. It’s a major surgery, it’s painful, but it’s also life saving. And whether you are a mom-to-be and you wanted your birth research to include what you need to know about c-sections, or you’re a nurse, med student interested in OB, or a doula who wants to be prepared to support your client through any avenue, I hope this article was helpful. And I hope the knowledge gives more of an understanding that leads to alleviation of some nerves. Share with your friends and family to spread the wealth of knowledge!

Let me know if you are interested in a deeper dive into VBAC’s (vaginal birth after cesarean) or any other questions related to my three tenants: Mental Health, Motherhood, & Registered Nurse!

Ashley, RN

Mental Mommy Nurse