To C or not to C? That Is the Question

By Elaine Stillerman , LMT

To C or not to C? That Is the Question

By Elaine Stillerman , LMT

Part of the work of a prenatal massage practitioner is to support your clients' decisions about their pregnancies and birthing preferences in a nonjudgmental environment. Hopefully, we also can educate them about the ramifications, benefits and potential risks associated with their decisions. In other words, make sure they are making informed decisions based on all the facts (without imposing our own will on them.)

However, I find it rather upsetting to watch the elective C-section rate escalate (it's up 36 percent in the past five years),1 simply because women don't want to go through labor. When asked if they are aware of the risk factors involved in major abdominal surgery, the reply often is, "What risks? My doctor never said anything about risks."

There are a number of medical situations and emergencies that account for approximately 70 percent of all Cesareans. They might include failure of labor to progress, questionable fetal health, prior Cesarean, and fetal malpresentation or breech presentation. In other and less frequent instances, abnormal placentation, obstruction of the birth canal, maternal illnesses and infections and cervical cancer might be indicators of a surgical delivery.23,4

However, even in some of these medical cases, the diagnosis of a C-section might be based on false or incorrect interpretations of instrumentation, and many surgeries are performed when there is little or no risk to the fetus or laboring woman.

There is no question about the safety and benefits of a Cesarean section when the medical need is compelling. However, as with any surgery, a Cesarean section is not without its risks. Whether it is performed out of medical necessity or as an elective decision, women need to be informed about the potential dangers. Dr. Peter Bernstein, MD, the author of "Complications of Cesarean Deliveries," divides the risk of surgical deliveries into three categories: short term, longer term, and those that present risks to future pregnancies. He also recognizes that risk factors are heightened when the surgery is not planned or in an emergency, compared to when it is a planned surgical delivery. Dr. Bernstein's article features the work and research of the Maternity Center Association, New York City.

Some of the short-term risk factors involving a C-section include maternal death (although low),5,6,7 thromboembolism and stroke (deep-vein thrombosis resulting in pulmonary embolism is one of the leading causes of maternal mortality after a C-section),8 excessive bleeding and hemorrhage,9,10 infection,11,12,13 rare accidental surgical injuries, particularly bladder or to a lesser degree, intestinal injuries,14 longer hospitalization,1516 pain,17 and an unhappy birth experience with a longer period of time needed to bond with the baby.18 In the long run, complications from a Cesarean might include additional hospitalization or readmission after discharge,19 incision pain,20 scar and adhesion formation,2122 emergency hysterectomy, or difficulty conceiving another pregnancy.

Although most surgical deliveries are safe for the newborn, there still are some risks that must be explored. C-section newborns are four times as likely to die than vaginally delivered babies,23 experience a higher incidence of asthma and respiratory problems,24,25 the birth is more traumatic,26 and these babies often fail to breastfeed.27 In addition, future pregnancies might be affected, with such complications as uterine rupture at the site of the initial incision,28 abnormal attachment of the placenta,29 and the need for a hysterectomy.30

While it's true that modern sanitary conditions and surgical competence reduce the chances of many of these complications, clients should be advised about the risk factors when electing to have a Cesarean. While we can't make up their minds, we can offer documentation to give them a clear picture of what their choice could mean.


  1. Eyewitness News, WABC-TV, Dec. 26, 2005.
  2. Bernstein, Peters S, MD, MPH. "Complications of Cesarean Deliveries." Medscape, Sept.15, 2005.
  3. Nelson KB, Dambrosia JM, Ting TY, Grether JK. Uncertain value of electronic fetal monitoring in predicting cerebral palsy. N Engl J Med 1996:334:613-618.
  4. Jibodu, OA, Arulkumaran S. Intrapartum fetal surveillance. Curr Opin Obstet Gynecol 2000;12:123-127.
  5. Wen SW, Rusen ID, Walker M, et al. Maternal Health Study Group, Canadian Perinatal Surveillance System. Comparison of maternal mortality and morbidity between trial of labor and election Cesarean section among primiparas in Washington State. Am J Obstet Gynecol 2004;191:1263-1269.
  6. Schuitemaker N, van Roosman J, Dekker G, et al. Maternal mortality after Cesarean section in the Netherlands. Acta Obstet Gynecol Scand 1997;76:332-334.
  7. Harper MA, Bington RP, Espeland MA, et al. Pregnancy-related death and health care services. Obstet Gynecol 2003;102:273-278.
  8. Ros HS, Lichtenstein P, Belloco R, Petersson G, Cnattingiuis S. Pulmonary embolism and stroke in relation to pregnancy: how can high risk women be identified? Am J Obstet Gynecol 2002;186:198-203.
  9. Hebert PR, Reed G, Entman SS, Mitchel EF Jr., Berg C, Griffin MR. Serious maternal morbidity after childbirth: prolonged hospital stays and readmissions. Obstet Gynecol 1999;94:942-947.
  10. Sherman SJ, Greenspoon JS, Nelson JM, Paul RH, Obstetric hemorrhage and blood utililzation. J Reprod Med 1993;38:929-934.
  11. Allen, VM, O'Connell CM, Liston RM, Baskett TF. Maternal morbidity associated with cesarean delivery without labor compared with spontaneous onset of labor at term. Obstet Gynecol 2003;102:477-482.
  12. Chaim W, Bashiri A, Bar-David J, Shoham-Vardi I, Mazor M. Prevalence and clinical significance of postpartum endometritis and wound infection. Infect Dis Obstet Gynecol 2000;8:77-82.
  13. Fisher J, Astbury J, Smith A. Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study. Aust NZ J Psychiatry 1997;31:728-738.
  14. Phipps MG, Watabe B, Clemons JL, et al. Risk factors for bladder injury during Cesarean delivery. Obstet Gynecol 2005;105:156.
  15. Thompson JF, Roberts, CL, Currie M, Ellwood DA. Prevalence and persistence of health problems after childbirth: associations with parity and method of birth. Birth 2002;29:83-94.
  16. Kacmar J, Bhimani L, Boyd M. et al. Route of delivery as a risk factor for emergent peripartum hysterectomy: a case-control study. Arch Gynecol Obstet 2005;271:154-9.
  17. Almeida EC, Nogueira AA, Candido dos Reis FJ, Rosa e Silva JC. Cesarean section as a cause of chronic pelvic pain. Int J Gynaecol Obstet 2002;79:101-104.
  18. Di Matteo MR, Morton SC, Lepper HS, et al. Cesarean childbirth and psychological outcomes: a meta-analysis. Health Psychol 1966;15:303-314.
  19. Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. JAMA 2000;283:2411-2416.
  20. Declerq ER, Sakala C, Corry MP, Applebaum S, et al. Listening to Mothers: Report of the First National U.S. Survey of Women's Childbearing Experiences. New York: Maternity Center Association, Oct. 2002.
  21. Al-Took S, Platt R, Tulandi T. Adhesion-related small-bowel obstruction.