NPWF President: "Robust interventions to address the substantial racial inequities in maternal health in the United States are long overdue and require immediate action." WASHINGTON, D.C. – September 19, 2023 – Today, the National Partnership for Women...
NOTE: For guiding care, Childbirth Connection gives priority to systematic reviews. These rigorous summaries of best available evidence are the most trustworthy way to know the benefits and harms of specific practices.
There are many drug and drug-free ways to help you cope with labor pain. The benefits of some methods are better understood than others. Many women want to know about the effectiveness and downsides of specific methods of pain relief; researchers have given more attention to effectiveness and less to possible downsides.
In this section, we summarize labor pain relief options based on systematic reviews published since 2005. Some pain relief strategies (e.g., showers, warm packs, music, visualization) are not covered below because we did not find systematic reviews about their effects.
Despite the challenges of conducting research on labor pain relief and limitations within the best available research, the following conclusions seem clear:
- A woman’s labor pain relief options depend in large measure on where and with whom she chooses to give birth.
- Receiving continuous support during labor decreases the probability of using pain medication and increases the likelihood of satisfaction.
What is a C-section?
A vaginal birth is when a baby is born by coming through the mother’s vagina or “birth canal.” By contrast, a cesarean birth is when a baby is born by coming through surgical cuts (“incisions”) in her belly – through her skin, fat, muscle and uterus.
What affects whether I have a C-section or a vaginal birth?
Your health needs and those of your baby affect whether you will have a C-section or vaginal birth, but other things can affect it too, such as:
- Your choice of care provider and birth setting. C-section rates in the United States vary from less than 10 percent for some care providers and birth settings to more than 60 percent for others. This variation occurs for many reasons, including that providers differ in how they support women in labor, in their judgment about when to recommend surgical birth and in their comfort level with this procedure (we also call this “practice style”). C-section rates vary from one birth setting to another due to differences in policies and practices.
- Your access to supportive care during labor.
- The medical interventions you experience while giving birth.
What are some non-medical (elective) reasons for C-section?
Some women choose, or elect, to have a C-section for non-medical reasons, including:
- Profound fear of childbirth: A small number of women have an extreme fear of childbirth. While almost all pregnant women are anxious or scared about giving birth, this level of fear is much greater. Often, counseling or therapy can help women overcome deep fears and give birth vaginally. Continuous support during labor by a trained labor support companion (doula) may be especially helpful for these women. If you seek counseling, look for a therapist who has both strong counseling skills and an understanding of maternity issues. If you still have deep fears of childbirth despite counseling, you may decide to have a C-section. Be sure to talk this over with your care provider as early as possible in your pregnancy, and work together to help ensure the safest and most satisfying birth possible.
- Convenience/Speed: Very rarely, women want a C-section because they like the idea of scheduling the baby’s birth date. Or you may think of a C-section as a pain-free way to give birth. In some cases, a C-section might sound appealing if labor does not go as smoothly or as quickly as you would like. Before making that choice, it is important to investigate whether it truly offers what you think it will (greater convenience or less pain) and to understand the risks and benefits.
Why might my doctor or midwife recommend a C-section?
Your care provider might tell you a C-section is a good option for you for a few reasons:
You have had a C-section before. Care providers disagree about how a woman should give birth if she had a C-section in the past. Some recommend planning a VBAC (“vee-back” or vaginal birth after cesarean), while others recommend scheduling another C-section. The concern is that the woman’s uterus has a scar that could give way (rupture) during labor. On the one hand, having another C-section lowers the likelihood that the scar will open and create problems. On the other hand, a C-section poses quite a few risks for mothers and babies, over the short, moderate and longer terms. As the number of previous C-sections goes up, some of the serious risks for future pregnancies increase sharply.
If you’ve had a C-section in the past, it’s a good idea to learn as much as you can about VBAC, which is covered separately and in-depth here and talk through your preference with your care provider. Keep in mind that it is a challenge in some areas to find a provider willing to support a VBAC, so you will need to ask when you are choosing a care provider.
Your labor is taking a long time.How long labor takes is different for each woman. Your labor may be short, long or somewhere in the middle. If your labor is taking longer than average, you may be told that you have “prolonged labor” or “failure to progress.”
Care providers vary in how they might try to prevent or respond to a slow labor, and in their patience with a long labor. For example, some will try to rest the uterus or stimulate stronger contractions with drugs before recommending a C-section. Others will be quicker to turn to a C-section. As long as you and your baby are doing well, there is no medical reason to get a C-section and recent professional recommendations call for much more patience than has been the norm in the past. So it’s very important that you talk to your provider well before labor begins about what she or he will want to do if your labor is taking a long time. Then you can discuss your options.
If it takes a long time for your cervix to open (dilate) to 6 centimeters, that doesn’t mean you can’t give birth vaginally. Even if your labor is slow after that point (during what is called “active labor”), it’s still likely you will be able to have a vaginal birth.
Having a doula can help you get through a long and challenging labor. This person can also support your spouse or partner and help them help you. Such care lowers the likelihood that you will have a cesarean birth.
The baby is in breech position. Nearly all babies will be in a head-first position by the end of pregnancy. But if the baby is in a buttocks- or feet-first (breech) position, there can be increased risks during labor for both mother and baby, and many maternity care providers lack the skills and knowledge needed to safely attend vaginal breech births. Because a C-section has its own risks, you may want to find a care provider who has the skills to use his or her hands on your belly (called external version) to turn the baby to a head-first position in the last weeks of pregnancy. Sometimes it is not possible to turn a baby with this technique, and sometimes a turned baby will flip back to a breech position, but this technique usually works and trying it lowers your likelihood of having a cesarean birth.de Hundt, M., Velzel, J., de Groot, C.J., Mol, B.W., & Kok, M. (2014). Mode of delivery after successful external cephalic version: a systematic review and meta-analysis. Obstetrics & Gynecology, 123(6), 1327-34; Grootscholten, K., Kok, M., Oei, S.G., Mol, B.W., & van der Post, J.A. (2008). External cephalic version-related risks: a meta-analysis. Obstetrics & Gynecology, 112(5), 1143-51; Hofmeyr, G.J., Kulier, R., & West, H.M. (2015). External cephalic version for breech presentation at term. Cochrane Database of Systematic Reviews, 4, CD000083
If your baby is still in breech position when it’s time to give birth, your provider will probably recommend a C-section. In this situation, vaginal birth has been found to increase the likelihood of death or serious problems for the baby and reduce likelihood of problems for the mother in the short term. However, when followed for two years, research showed that breech babies after planned cesarean had more medical problems compared with breech babies delivered vaginally. There was no difference between the two groups (breech babies with planned vaginal birth and those delivered via planned C-section) with respect to developmental delays and/or death. At two years, there were also no differences in maternal health outcomes. The best available studies did not measure established advantages of vaginal birth for mothers and babies in future pregnancies. If you find yourself in this situation, talk to your provider to learn all you can about the risks and benefits of each option. Be sure that you and your provider agree ahead of time about your birth plan. If you decide you want to have a vaginal breech birth, you may need to search for a care team with skills and experience with vaginal breech birth.
There are changes in the fetal heart rate. When the fetal heart rate is very fast, very slow or irregular, your care provider may be concerned about the baby’s condition. In some situations, the heart rate can be improved by no longer lying on your back but rather moving to another position or by giving drugs to stop contractions. If those strategies don’t work and the baby is not about to be born, a C-section may be recommended. However, electronic fetal monitoring (EFM) can falsely suggest that the baby is in trouble, so further testing can help show if your baby needs help.
You are giving birth to more than one baby. This has unique challenges, but right now, the research doesn’t support routine delivery of twins by C-section. Most providers will recommend a C-section if you are having three or more babies. As always, it’s important to learn as much as you can about the benefits and risks of C-section compared with vaginal birth and discuss your individual situation with your care provider before making your decision. If you are having twins and want to have a vaginal birth, you may need to seek out a care provider who is experienced with vaginal twin birth and will support this.
What is it like to have a C-section?
A C-section might happen during labor or before labor starts (scheduled C-section). Unless there is a special situation, you will use “regional” rather than “general” analgesia and will be awake during the surgery. Here are the steps involved in a C-section.
- An intravenous (IV) line will be put in your arm or hand. The IV will be used to deliver fluids as well as medicines to prevent infection and bleeding problems.
- An anesthesiologist will deliver spinal or epidural anesthesia through a needle in your back, which numbs your belly and legs.
- You will be positioned under the operating light on a firm, narrow bed that is slightly tilted to prevent you from lying flat. Straps that are similar to seat belts will secure you to the bed.
- A catheter will be inserted into your urethra to remove urine. The catheter will stay in place for about one day, and will be removed when you can walk to the bathroom on your own.
- Oxygen will be given through a tube that fits into or over your nose.
- Your belly and thighs will be cleaned to reduce infection risk.
- Your belly, legs and chest will be covered with sterile cloths and a curtain will be raised between your head and your lower body.
- Machines will check your blood pressure and oxygen levels.
- Before the surgery starts, staff will count all of the tools (clamps, scissors, etc.) and other supplies, may introduce themselves, and will double-check your name and the reason for the surgery. These are safety checks to help prevent errors in the operating room.
- During the surgery, your spouse, partner or other support person will be next to you on the same side of the curtain. The anesthesiologist will also be on that side of the curtain.
- After making sure the belly is numb, a doctor and a surgical assistant will begin the surgery.
- You may feel tugging and pulling sensations, especially right before the birth of the baby, but should feel absolutely nothing sharp. (If there is pain or a sharp sensation, the surgery should be stopped immediately so that more anesthesia can be given.)
- It usually takes about 15 minutes from when the surgery begins to when the baby is born.
- Just before the baby is born, the curtain may be lowered so you and your partner can watch the baby come out.
- A nurse may dry and place the baby on a warming table to do a quick check on the baby’s breathing, color and heart rate.
- Increasingly, hospital policies call for placing the baby skin-to-skin on your chest because early skin-to-skin contact after birth is healthy for babies and women. You can ask to have this done. Some hospitals still wrap the baby and bring him or her to you to cuddle cheek-to-cheek, or hand the baby to your partner.
- After the baby is born, the doctors will deliver the placenta, give medications to control bleeding, and stitch the uterus and other muscle and tissue layers. The skin may be closed with stitches or staples. Stitches will dissolve on their own after a couple of weeks. Staples are removed with a special tool either just before you go home from the hospital or at an office visit about one week after the birth.
- After surgery you will be moved to a recovery room for an hour or so to be closely checked for bleeding and other problems.
- The baby is usually in the recovery room with you. This is a good time to have the baby skin-to-skin and to begin breastfeeding.
- After the recovery room, you will be moved to a regular postpartum room in the hospital. The spinal anesthesia wears off around this time, and pain medications are then given by IV.
- You won’t be able to eat or drink at first, but will soon be able to have clear liquids like juice or an ice pop and then regular food.
- At this point, the IV will be removed and you will take pain medication by mouth.
- Most women stay in the hospital about 3-4 days after a C-section.
Why is the C-section rate in the United States so high?
Today, nearly 1 in 3 women in the United States have their babies via C-section. You can view charts here that show how C-section rates have changed over time. (There is also a fact sheet with more details on this issue, available here.) There are a number of reasons for this trend, including:
- Care providers aren’t focused enough on care that supports the natural progress of labor and birth, like providing continuous labor support (by a trained or experienced companion); encouraging women to be upright and moving during labor (not on their backs, a position that can slow down labor); and ensuring that women are well-rested and well-nourished while giving birth.
- It can be a side effect of other procedures used during childbirth, such as labor induction (in first-time mothers and when the cervix is not soft and ready to open) and continuous electronic fetal monitoring (EFM) to check the baby’s heartbeats.
- Some care providers move to C-section without being patient and letting labor take its course or before trying to avoid surgery, for example, by trying to turn a baby in breech position around with hands-on-belly movements or allowing more time for a vaginal birth to occur.
- Women aren’t offered VBAC (vaginal birth after cesarean). More and more hospitals and caregivers are adopting a “no-VBAC” policy or discouraging VBAC, making it hard for women who want a VBAC to have one.
- Care providers are without the skills or willingness to offer vaginal birth to women in certain situations, like when a baby is in breech (feet or buttocks first) position or when the mother is having twins.
- People believe that C-section is safe. Although C-section births are safer now than before, the surgery still carries a broad range of short- and longer-term risks for mothers and babies.
These factors can increase your chance of having a C-section. Read the Planning Ahead section for more information on how you can avoid having an unnecessary C-section.
Is C-section a special concern for certain women?
Because C-section has become so common, all pregnant women should learn about it. However, knowing the facts is especially important when:
- You are expecting your first baby. As a first-time expectant mother, you have the greatest freedom to determine the kind of birth you will have and the choices you make for this first baby are likely to determine your options for any future babies. If you have a C-section for this birth, you probably will have a C-section for any future babies because it is becoming more difficult to find care providers and hospitals that support vaginal birth after cesarean (VBAC). This means that you and your babies will probably face the extra risks of repeated C-sections. However, if your first birth is a vaginal birth, you will almost certainly go on having vaginal births in the future.
- You might have more than two babies. The likelihood of certain life-threatening complications that could affect you and your future babies goes up as the number of C-sections you have rises. Avoiding unneeded cesareans is very important for women who want large families.
- You are expecting your first baby in your 30s or beyond. Older women are at increased risk of cesarean for both medical reasons and because of non-medical factors such as the false belief that a planned C-section is safer for babies. Women who are 35 or older also face a higher risk of certain complications with C-sections, such as excessive bleeding or blood clots.
- You are overweight or obese. This can increase the likelihood of having a C-section. High weight also increases the risk of certain complications with C-sections, especially infections and blood clots. Patience and a confident, supportive care provider can make a big difference for women who weigh more.
- You have had abdominal or pelvic surgery before. Every operation increases the amount of internal scar tissue (adhesions) and the problems scar tissue can cause, including chronic pain and a twisted and blocked bowel. Later surgery is harder when there is scar tissue, so it’s more likely to result in injuries to organs or blood vessels.
Will how I give birth to this baby affect my next pregnancy and baby?
Most likely, yes. The way you give birth can affect your next pregnancy in two ways: your choices and your safety.
- Choices: Even though research shows that most women can safely have a vaginal birth after a cesarean (VBAC), some hospitals and health care providers will only offer or will strongly encourage a repeat cesarean. As a result, in recent years about 9 in 10 women with past cesarean birth have been having cesareans in future births. If you plan a VBAC, you may have fewer choices in terms of where you can have your baby, who will attend your birth, or which tests and procedures you will have.
- Safety: Whether you have a C-section or plan a vaginal birth for any future babies, your pregnancy will be considered high-risk if you’ve had a C-section before. That’s because the C-section scar can come apart in pregnancy or during labor or can cause problems with the new placenta. These are serious problems for both a woman and her baby. The more C-sections a woman has, the more likely these problems are. These risks are discussed in more detail on the Cesarean and VBAC Research and Evidence pages.
On the other hand, if your first birth is vaginal, your future births are highly likely to be vaginal as well.