Cesarean Section Risks and Complications

Cesarean section, more commonly known as “c-section”, rates vary across the United States. According to the most recent birth statistics from the Centers for Disease Control and Prevention’s National Center for Health Statistics, the rates of c-sections have increased substantially from 5% in 1970 to 32.1% in 2022 (Centers for Disease Control and Prevention [CDC], 2024; Sung & Mahdy, 2023). In the United States, the c-section is the most common surgery, with over one million c-sections performed each year (Sung & Mahdy, 2023). There are risks and benefits to both vaginal birth and c-sections. There are certain circumstances in which a c-section is the safest delivery route for the mother and/or the fetus, even with the increased risks of surgery (Sung & Mahdy, 2023).

A c-section can save the life of a mother or fetus. The reasons for performing a c-section can be classified into:

1. Maternal indications
2. Uterine or anatomic indications
3. Fetal indications

The cesarean section mortality rate in the United States is 2.2 per 100,000 c-sections (Sung & Mahdy, 2023). The mortality rate for vaginal deliveries is only 0.2 per 100,000 (Sung & Mahdy, 2023).

Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity in the United States (Sung & Mahdy, 2023). C-sections are one major factor that can increase the risk of hemorrhage.

Image 2:
Postpartum Hemorrhage

C-sections put the patient at risk of having abnormal placentation, uterine rupture, and adhesions in future pregnancies, which further increases the risk of PPH (Burke & Allen, 2020). PPH is complex, but can lead to transfusion, need for intensive care, and unplanned hysterectomy (Burke & Allen, 2020).

Other intraoperative complications that could occur during a c-section can include:

• Surgical injury to the mother, such as a bladder injury
• Surgical injury to the fetus, such as a facial laceration
• Bowel obstruction
• Incisional hernia

Following c-section delivery, there is generally more intense pain associated with a c-section recovery versus an uncomplicated vaginal birth (Larsson et al., 2021). Because of this, a woman may have more difficulty moving and caring for her newborn.

Endometritis, infections, and wound complications all can occur with a c-section. Surgical site infections (SSI) affect between 3% to 18% of all patients who have a c-section (Erritty et al., 2023). SSI’s can be superficial or deep, which can result in an abscess, which can lead the wound to dehisce (open). Endometritis can occur when the infection involves the decidual layer of the uterus (Larsson et al., 2021).

A thrombotic event such as ischemic stroke, acute myocardial infarction, or venous thromboembolism (VTE) during the first 6 weeks postpartum occurs significantly more often after a c-section birth than vaginal birth because these patients have a higher coagulopathy activation, making them four times more at risk of developing a VTE than a patient who had a vaginal delivery (Burke & Allen, 2020).

Image 3:
Venous Thromboembolism (VTE)

Approximately 80% of VTEs are deep vein thrombosis (DVT) and 20% are pulmonary embolism (PE). PEs are less common but may account for up to 10% of maternal deaths (Burke & Allen, 2020).

C-section surgery anesthesia-related complications are possible. A woman undergoing a c-section could react to the given anesthesia. Neuraxial anesthesia is often used with few complications and is the gold standard for c-sections, but general anesthesia may be used in an emergency case (Ring et al., 2021). Failed intubation is a complication of general anesthesia that is more common in pregnant women (Ring et al., 2021). In addition, changes in a pregnant patient’s respiratory system can put them at risk for rapid onset profound hypoxemia (Ring et al., 2021). Aspiration is rare, but serious and can also occur with general anesthesia as can malignant hyperthermia. General anesthesia can also lead to poor neonatal outcomes, such as lower neonatal APGAR scores, more assisted ventilation and more admissions to the neonatal intensive care unit (NICU) (Ring, et al., 2021).

Many of the associated complications we have reviewed can be prevented. Hemorrhage cannot always be prevented, but recognition and treatment can help to reduce morbidity and mortality (Wormer et al., 2023). Patients need to have their hemodynamic status monitored and treat blood loss quickly. Every labor unit should use hemorrhage protocols and have supplies readily accessible. A multidisciplinary team who is educated and performs drills can help to manage these patients best (Burke & Allen, 2020).

Infections can be prevented by using a strict sterile technique, providing intravenous (IV) antibiotics within 60 minutes before incision, and using a chlorhexidine-alcohol or betadine scrub before the surgery (Burke & Allen, 2020).A vaginal cleanse should also be performed if the woman has labored before the c-section. It is also important to warm the patient, using active and passive measures (such as warmed air, warm blankets, and warmed IV fluids). Preventing hypothermia can also help to prevent infection (Burke & Allen, 2020).

If hair removal is needed, this should be done by clipping, not shaving. For all women undergoing cesarean delivery, mechanical thromboprophylaxis (with pneumatic compression devices) is recommended. For women with a high risk of venous thromboembolism (VTE), mechanical thromboprophylaxis and pharmacologic thromboprophylaxis (Lovenox, Heparin) is recommended. Mechanical and pharmacologic prophylaxis should be continued until the woman is fully ambulating (Burke & Allen, 2020).

Multimodal pain relief options should help the woman move easier and care for her baby while preventing the overuse of narcotics. Early ambulation and oral intake have been shown to promote recovery.

Long-term risks from a c-section can be serious. A cesarean delivery significantly increases the risk of abnormal placentation in future pregnancies, often due to scarring from the c-section itself (Mayo Clinic, 2022b). This risk increases with each subsequent c-section.

Placenta previa can occur when the placenta implants and covers part or all of the woman’s cervix, making vaginal delivery impossible (Mayo Clinic, 2022c).

Image 4:
Types of Placental Previa

This can cause bleeding throughout pregnancy or significant hemorrhage. The severity of bleeding will determine the delivery timing and may lead to preterm delivery (Mayo Clinic, 2022c).

The placenta accreta spectrum refers to the range of adherence of the placenta, including placenta accreta, placenta increta, and placenta percreta (Cleveland Clinic, 2022).

Image 5:
Types of Placenta Accreta

The placenta accreta spectrum is the invasion of part or all of the placenta into the myometrium of the uterine wall. As pictured above, the three types of placenta accreta can include (Cleveland Clinic, 2022):

1. Placenta accreta: Attachment to the wall of the uterus, but it does not pass through the wall and impact the uterine muscle.
2. Placenta increta: Deeply embedded in the wall of the uterus, still not passing through the uterine wall, but securely attached to the uterine muscle.
3. Placenta percreta: Placental development through the wall of the uterus and potentially impacting other organs, such as the bladder or intestines.

Placenta accreta is serious and requires extensive surgery (Cleveland Clinic, 2022). The woman may require a hysterectomy to prevent death from hemorrhage. A surgical team must plan blood product replacements and hemodynamic monitoring for the woman (Rathbun & Hildebrand, 2022).

Women with c-sections are also at risk for uterine rupture in future pregnancies. This risk increases with a trial of labor after a cesarean, although this risk is low and does not always prevent a vaginal delivery after cesarean (ACOG, 2019).

A c-section can have short- and long-term psychological effects for the woman. Women may be more likely to experience postpartum depression. A c-section may lead to Post-traumatic Stress Disorder (PTSD) for a woman who required an emergency c-section, with some reporting an intense fear of death or injury for themselves or their babies during delivery (Benton et al., 2019). These women may complain of poorer physical functioning, as well as issues with maternal-infant bonding as well.

It is important to remember that many women who deliver via c-section may feel a loss of perceived control of their birth experience, as well as helplessness, and disappointment at the birth experience that they had (Benton et al., 2019). Women who are having these feelings may need extra support and resources.

Cecilia comes to your labor and delivery unit. She wants to have a trial of labor after cesarean (TOLAC). Her first c-section was for a non-reassuring fetal heart rate. That baby was born with an umbilical cord around the neck but was fine after delivery.

Cecilia is 6cm dilated and contracting every 2 minutes. Her vital signs are normal.

Is Cecilia a candidate for a TOLAC?

Yes, Cecilia is a candidate for TOLAC. She had her first c-section due to fetal distress. She is a candidate as long as she did not have a vertical uterine incision with her first baby.

What is the biggest risk for Cecilia during labor, given that the pregnancy has been normal until labor?

The biggest risk for Cecilia with a TOLAC is that of a uterine rupture because having had a c-section, she has scarring on her uterus.

Cesarean sections are necessary to prevent maternal or fetal risks or death in certain circumstances. A c-section is not the appropriate method of delivery for every woman. There are risks to both the mom and fetus. The benefits and risks must be weighed before a c-section delivery should take place.

• American College of Obstetricians and Gynecologists. (ACOG). (2019). ACOG Practice Bulletin No. 205: Vaginal birth after cesarean delivery. Obstetrics and gynecology, 133(2), e110–e127. Visit Source.
• Benton, M., Salter, A., Tape, N., Wilkinson, C., & Turnbull, D. (2019). Women's psychosocial outcomes following an emergency cesarean section: A systematic literature review. BMC pregnancy and childbirth, 19(1), 535. Visit Source.
• Bjorklund, J., Wiberg-Itzel, E., & Wallstrom, T. (2022). Is there an increased risk of cesarean section in obese women after induction of labor? A retrospective cohort study. PLoS ONE, 17(2). Visit Source.
• Burke, C., & Allen, R. (2020). Complications of cesarean birth: Clinical recommendations for prevention and management. MCN. The American Journal of Maternal/Child Nursing, 45(2), 92–99. Visit Source.
• Centers for Disease Control and Prevention. (CDC). (2024). Births: Method of delivery. Centers for Disease Control and Prevention (CDC) National Center for Health Statistics. Visit Source.
• Cleveland Clinic. (2022). Placental accreta. Cleveland Clinic. Visit Source.
• Erritty, M., Hale, J., Thomas, J., Thompson, A., Wright, R., Low, A., Carr, M., George, R., Williams, L., Dumitrescu, A., Rees, J., Irukulla, S., Fry, C. H., Fluck, D., & Han, T. S. (2023). Reduction of adverse outcomes from cesarean section by surgical-site infection prevention care bundles in maternity. International Journal of Gynecology & Obstetrics, 161(3), 963-968. Visit Source.
• Kauffmann, T., & Silberman, M. (2023). Fetal monitoring. In StatPearls. StatPearls Publishing. Visit Source.
• Larsson, C., Djuvfelt, E., Lindam, A., Tunón, K., & Nordin, P. (2021). Surgical complications after caesarean section: A population-based cohort study. PloS One, 16(10), e0258222. Visit Source.
• Mayo Clinic. (2022a). Gestational diabetes. Mayo Clinic. Visit Source.
• Mayo Clinic. (2022b). Placenta accreta. Mayo Clinic. Visit Source.
• Mayo Clinic. (2022c). Placenta previa. Mayo Clinic. Visit Source.
• MedlinePlus. (2022). C-section-Procedure, Part 3. MedlinePlus.gov. Visit Source.
• Njogu, P. K., Makunyi, E. G., & Musau, J. (2022). Risk factors for caesarean delivery and fetal macrosomia among women with gestational diabetes in Nyeri County, Kenya: A cross-section study. The Pan African Medical Journal, 41. Visit Source.
• Rathbun, K. M., & Hildebrand, J. P. (2022). Placenta abnormalities. In StatPearls. StatPearls Publishing. Visit Source.
• Ring, L., Landau, R., & Delgado, C. (2021). The current role of general anesthesia for cesarean delivery. Current Anesthesiology Reports, 11(1), 18–27. Visit Source.
• Rydahl, E., Declercq, E., Juhl, M., & Maimburg, R. D. (2019). Cesarean section on a rise—Does advanced maternal age explain the increase? A population register-based study. PLoS ONE, 14(1). Visit Source.
• Sung, S., & Mahdy, H. (2023). Cesarean section. In StatPearls. StatPearls Publishing. Visit Source.
• Wormer, K. C., Jamil, R. T., & Bryant, S. B. (2023). Acute postpartum hemorrhage. In StatPearls. StatPearls Publishing. Visit Source.