How will I know if I need a C-section?

If your doctor or midwife suggests a C-section, chances are you have plenty of time to ask questions and find the information you need to make the decision that is right for you. Even if you are in labor, most situations are not urgent. However, it is important to learn as much as you can before labor so that you are fully prepared in case you do have to make the decision quickly. If your doctor or midwife suggests a C-section and it is not an urgent situation, here are some questions to ask:

• What is the possible benefit of a C-section for me or my baby?
• What problems might happen if I continue with my plan for a vaginal birth?
• How likely are those problems if I plan for a vaginal birth?
• Could they still happen if I have a C-section?
• What are the possible harms of a C-section for me or my baby?
• How likely are these possible harms for me or my baby?
• What are the possible benefits of a vaginal birth for me or my baby?

Once you have answers to your questions, think about what is most important to you and discuss these goals and preferences with your care provider. With these in mind, weigh the possible benefits of a C-section against the risks and make the decision that feels right for you and your baby.

What can I do during pregnancy to reduce the likelihood of a C-section?

You can reduce the likelihood of an unneeded cesarean by choosing a maternity care provider and place of birth with lower-than-average C-section rates. Some variation in this rate is because of differences in the needs of women receiving care. There are also big differences in the practice style of providers and facilities and how readily they move to C-section during labor. There are online sources where you can look up the C-section rates of hospitals in your area; click here for some. Be aware that there may be differences in how C-section rates are measured; for example, some report total C-section rates, others report “primary” or first-time rates and others report C-section rates in low-risk women.)

While C-section rates of individual maternity care providers vary widely, a systematic review found that women in the care of certified nurse-midwives were less likely to have C-sections than similar women in the care of physicians.Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Women’s Health Issues, 22, e73-81.

If you had one or more C-sections in the past, finding a care provider and hospital that support and have a good track record with vaginal birth after cesarean (VBAC) can help you avoid an unneeded repeat cesarean. The Resources page for this section includes a source for hospital-level VBAC rates in many states; you can also learn more about VBAC here.

Systematic reviews have found that the following pregnancy practices are associated with reduced likelihood of having a C-section:

• Regular low to moderate physical activity, especially in the second and third trimestersPoyatos-León, R., García-Hermoso, A., Sanabria-Martínez, G., Álvarez-Bueno, C., Sánchez-López, M., & Martínez-Vizcaíno, V. (2015). Effects of exercise during pregnancy on mode of delivery: A meta-analysis. Acta Obstetricia Et Gynecologica Scandinavica, 94, 1039-1047. and participation in exercise programs during pregnancy.Domenjoz, I., Kayser, B., & Boulvain, M. (2014). Effect of physical activity during pregnancy on mode of delivery. American Journal of Obstetrics and Gynecology, 211(4), 401.e1-11.
• Arranging for a doula to provide continuous support during labor.Hodnett, E.D., Gates, S., Hofmeyr, G.J., & Sakala, C. (2013). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 10,CD003766.
• If your baby is in a breech position (buttocks- or feet-first rather than headfirst), a care provider’s hands-to-belly movements at the end of pregnancy (external version) helps turn the baby to a headfirst position and increases the likelihood of a vaginal birth.Hutton, E.K., Hofmeyr, G.J., & Dowswell, T. (2015). External cephalic version for breech presentation at term. Cochrane Database of Systematic Reviews, 7, CD00008.

You can also take steps that may reduce your risk of C-section before you become pregnant. Systematic reviews have found that being overweight or obese is associated with increased likelihood of cesarean rather than vaginal birth.Dean, S., Lassi, Z., Imam, A., & Bhutta, Z. (2014). Preconception care: Nutritional risks and interventions. Reproductive Health, 11; Marchi, J., Berg, M., Dencker, A., Olander, E., & Begley, C. (2015). Risks associated with obesity in pregnancy, for the mother and baby: A systematic review of reviews. Obesity Reviews, 8, 621-638. Attaining a healthy weight before pregnancy could reduce your likelihood of C-section.

How can I reduce the likelihood of having a C-section around the time of birth?

Systematic reviews have found that the following practices around the time of birth reduce the likelihood of having a C-section:

• Receiving continuous support during labor from a doula who is there solely to support you.Hodnett, E.D., Gates, S., Hofmeyr, G.J., & Sakala, C. (2013). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 10, CD003766.
• Staying upright and moving about rather than lying down in bed.Lawrence, A., Lewis, L., Hofmeyr, G., & Styles, C. (2013). Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews, 10.
• Monitoring your baby’s heart rate periodically with a handheld device (such as a Doppler) rather than being attached to continuous electronic fetal monitoring (EFM).Alfirevic Z., Devane, D., & Gyte, G.M. (2013). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, 5, CD006066.

Although there is not a systematic review on this topic, waiting to go to the hospital until “active labor” begins is consistently associated with a lower likelihood of C-section, as compared to going to the hospital earlier in labor.Caughey, A.B., Sundaram, V., Kaimal, A.J., Cheng, Y., Gienger, A., Little, S., Lee, J., Wong, L., Shaffer, B., Tran, S., Padula, A., McDonald, K., Long, E., Owens, D., & Bravata, D. (2009). Maternal and Neonatal Outcomes of Elective Induction of Labor. Evidence Report/Technology Assessment No. 176. (Prepared by the Stanford University-UCSF Evidenced-based Practice Center under contract No. 290-02-0017.) AHRQ Publication No. 09-E005. Rockville, MD.: Agency for Healthcare Research and Quality; Kauffman, E., Souter, V.L., Katon, J.G., & Sitcov, K. (2016). Cervical Dilation on Admission in Term Spontaneous Labor and Maternal and Newborn Outcomes. Obstetrics & Gynecology, 127(3), 481-488; Tilden, E.L., Lee, V.R., Allen, A.J., Griffin, E.E., & Caughey, A.B. (2015). Cost-Effectiveness Analysis of Latent versus Active Labor Hospital Admission for Medically Low-Risk, Term Women. Birth, 42(3), 219-26. You can be in touch with a nurse or other health professional by phone to help you stay in the comfort of your home in early labor until your contraction pattern suggests that you are reaching active labor. Talk to your care provider about the right interval and duration of contractions for you).

High-quality studies have found that the following practices around the time of birth may increase the likelihood of having a C-section:

• The use of epidural analgesia increases the likelihood of a C-section due to fetal distress.Anim-Somuah, M., Smyth, R.M., & Jones, L. (2011). Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews, 12, CD000331. This is because epidurals slow labor and women who get them usually also get synthetic oxytocin (also called “Pitocin”) to speed labor. C-sections are also more likely when epidurals are used with a low dose of synthetic oxytocin, which is common in North America.Kotaska, A.J., Klein, M.C., & Liston, R.M. (2006). Epidural analgesia associated with low-dose oxytocin augmentation increases cesarean births: a critical look at the external validity of randomized trials. American Journal of Obstetrics and Gynecology, 194(3), 809-14.
• Routine “breaking of waters” (rupturing membranes) in labor has no known benefits and may increase the likelihood of cesarean birth.Smyth, R.M., Markham, C., Dowswell, T. (2013). Amniotomy for shortening spontaneous labour. Cochrane Database of Systematic Reviews, 6, CD006167.

Read our summary of obstetrical society recommendations for more information on safely preventing C-section. This includes new guidance about being patient for your labor to unfold in its own time when you and your fetus are doing well.

Is labor induction a good way to reduce the likelihood of having a C-section?

No. In fact, labor induction has been associated with an increased likelihood of having a C-section for some groups of women, including first-time mothers and women whose cervix is not soft and ready to open (“ripe”).Caughey, A.B., Sundaram, V., Kaimal, A.J., Cheng, Y., Gienger, A., Little, S., Lee, J., Wong, L., Shaffer, B., Tran, S., Padula, A., McDonald, K., Long, E., Owens, D., & Bravata, D. (2009). Maternal and Neonatal Outcomes of Elective Induction of Labor. Evidence Report/Technology Assessment No. 176. (Prepared by the Stanford University-UCSF Evidenced-based Practice Center under contract No. 290-02-0017.) AHRQ Publication No. 09-E005. Rockville, MD.: Agency for Healthcare Research and Quality; Grobman, W. (2007). Elective Induction: When? Ever? Clinical Obstetrics & Gynecology, 50(2), 537-546. For other women or for women overall at full term, systematic reviews have concluded that labor induction either doesn’t impact the likelihood of C-sectionSaccone, G., & Berghella, V. (2015). Induction of labor at full term in uncomplicated singleton gestations: A systematic review and metaanalysis of randomized controlled trials. American Journal of Obstetrics and Gynecology, 15, 00356-7. or is associated with reduced likelihood of C-section.Mishanina, E., Rogozinska, E., Thatthi, T., Uddin-Khan, R., Khan, K., & Meads, C. (2014). Use of labour induction and risk of cesarean delivery: A systematic review and meta-analysis. Canadian Medical Association Journal, 186, 665-673; Nicholson, J., Kellar, L., Henning, G., Waheed, A., Colon-Gonzalez, M., & Ural, S. (2015). The association between the regular use of preventive labour induction and improved term birth outcomes: Findings of a systematic review and meta-analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 122, 773-784. This is confusing to pregnant women and to others!

Some experts are beginning to talk about inducing labor when there is no medical reason as a way to reduce the C-section rate. Childbirth Connection does not support induction without a clear medical reason for the following reasons:

• Labor induction is a major intervention that cuts short the important preparations for labor and beyond that take place in the body of a woman and her fetus up to the time when labor starts on its own.
• The procedure exposes both woman and fetus to the drugs and other practices used to start labor. We do not at present understand well the possible harms of making pregnancy shorter and using the various methods for starting labor. These may have an adverse effect on important outcomes such as severe bleeding after birth (postpartum hemorrhage), getting breastfeeding started, maternal mood, maternal behavior and mother-baby attachment.

You can stay on the safe side by avoiding labor induction when there is no clear need. And, as discussed in this section, there are many other safer ways to reduce the likelihood of having a C-section.

If I do have a C-section, how can I make it safer and more satisfying?

There are many ways to increase the safety of C-section, if you do have one. While this website does cover technical details about the surgery, here are a few tips to keep in mind:

• As with any surgery, infection is a concern. Systematic reviews clarify that antibiotics given before the incision reduce your likelihood of infection compared with antibiotics given later or not at all.Baaqeel, H., & Baaqeel, R. (2013). Timing of administration of prophylactic antibiotics for caesarean section: A systematic review and meta-analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 120(6), 661-669; Costantine, M., Rahman, M., Ghulmiyah, L., Byers, B., Longo, M., Wen, T., . . . Saade, G. (2008). Timing of perioperative antibiotics for cesarean delivery: A metaanalysis. American Journal of Obstetrics and Gynecology, 199(3), 301; Smaill, F., & Gyte, G. (2014). Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database of Systematic Reviews, 10; Tita, A.T., Rouse, D.J., Blackwell, S., Saade, G.R., Spong, C.Y., & Andrews, W.W. (2009). Emerging concepts in antibiotic prophylaxis for cesarean delivery: a systematic review. Obstetrics and Gynecology, 113, 675-82. Don’t hesitate to speak up to be sure that this is a part of your care!
• A systematic review found that chewing gum after cesarean birth can help get your digestive system going again. Hochner, H., Tenfelde, S., Ahmad, W., & Liebergall-Wischnitzer, M. (2015). Gum chewing and gastrointestinal function following caesarean delivery: A systematic review and meta-analysis. Journal of Clinical Nursing, 24(13-14), 1795-1804.
• Although you have had major surgery, you and your baby will benefit from two important practices very shortly after birth: being together skin-to-skin Moore, E.R., Anderson, G.C., Bergman, N., & Dowswell, T. (2012). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews, 5, CD003519; Renfrew, M.J., Craig, D., Dyson, L., McCormick, F., Rice, S., King, S.E., Misso, K., Stenhouse, E., & Williams, A.F. (2009). Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis. Health Technology Assessment, 13(40),1-146. and getting breastfeeding underway. Khan, J., Vesel, L., Bahl, R., & Martines, J.C. (2015). Timing of breastfeeding initiation and exclusivity of breastfeeding during the first month of life: effects on neonatal mortality and morbidity—a systematic review and meta-analysis. Maternal and Child Health Journal, 19(3), 468-79; Renfrew, M.J., Craig, D., Dyson, L., McCormick, F., Rice, S., King, S.E., Misso, K., Stenhouse, E., & Williams, A.F. (2009). Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis. Health Technology Assessment, 13(40),1-146. Although these are often challenging after surgery, you can let your care team know that these are priorities for you.

If you and your care provider agree that you should have a C-section, there are steps you can take to help make sure you and your baby are safe, your recovery is easier and your experience is as satisfying as possible. Discuss these options with your care provider even if you plan vaginal birth, just in case there are unexpected problems at the end of your pregnancy or during labor. It’s best to be prepared.

• Participate fully in decisions about the birth. Women are most likely to feel satisfied with their births when they feel a sense of accomplishment and personal control and when they have a good relationship with care providers. A good relationship includes being treated with kindness and respect, getting good information and having the opportunity to participate in decisions about your care. Hodnett, E.D. (2002). Pain and women’s satisfaction with the experience of childbirth: a systematic review. American Journal of Obstetrics and Gynecology, 186(5), S160-172.
• If you are having a scheduled C-section, wait until at least 39 weeks unless there is a medical reason to have your baby sooner. The last days and weeks of pregnancy are important for the baby’s lungs, brain and other organs to develop. Babies born before 39 weeks may need special care and have continuing problems if they are born before they are ready.
• Consider waiting to have the cesarean until after labor has begun. It is more convenient for care providers and hospitals to schedule planned cesareans. However, healthy changes for women and babies take place until shortly before women go into labor. Labor beginning on its own is an excellent sign that you are ready to give birth and your baby is ready to be born.
• Ask for antibiotics at the time of the C-section. Antibiotics reduce the high chance of infection that comes with surgery. You do not need them afterward unless you develop an infection.
• Ask for care to lower your chance of getting blood clots after surgery, like wearing inflatable devices on your legs, taking medication or both. It is important to get up and walk soon after the operation.
• Talk to your care provider about what is important to you in giving birth – for instance, if you want to take pictures or videos, to have the doctor or nurse explain what is happening during surgery, or to discover your baby’s sex on your own. This way, the staff can plan ahead and be prepared to best support you and your loved ones.
• Hold your baby skin-to-skin on your chest right after the birth. This has many benefits for both of you, and more and more hospitals are making sure that this happens after both vaginal and cesarean births. Moore, E.R., Anderson, G.C., Bergman, N., & Dowswell, T. (2012). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews, 5, CD003519.
• Have your baby and your labor companions with you in the recovery area. Holding and breastfeeding your baby soon after the birth helps both you and your baby get started on the right foot and may avoid problems with breastfeeding.
• If your baby goes to the nursery, make sure your spouse or partner or another labor companion can be there with him or her. This includes the newborn intensive care nursery. If your baby must be separated from you because of concerns about the baby’s health, it will help to know that someone close to you can be there for your baby and tell you how she or he is doing.
• Ask for extra help with breastfeeding. After a cesarean, and especially a planned cesarean, it can be hard to get breastfeeding off to a good start. Good support can help. You can find lactation consultants – trained professionals who can offer support – here. Research also suggests that peer breastfeeding support helps with breastfeeding. Renfrew, M.J., McCormick, F.M., Wade, A., Quinn, B., & Dowswell, T. (2012). Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews, 5, CD001141.
• Plan for extra help at home. When you go home, you are still recovering from surgery. It may be difficult or painful for you to walk for long periods, and your care provider will probably tell you not to drive or lift anything except your baby. Ask for help from family, friends or neighbors and keep a list of things they can do around the house. If possible, have a family member stay with you for a while after you get home. Stay focused on your needs and those of your baby. Whenever possible, line up help for the rest.

How does planned C-section compare with unplanned C-section?

A planned C-section offers some advantages over an unplanned C-section (a cesarean that occurs after labor is under way). For example, there may be fewer surgical injuries and fewer infections. The emotional impact of a planned C-section appears to be similar to, or somewhat worse than, a vaginal birth. By contrast, unplanned C-sections can take a greater emotional toll.

Planned C-sections that take place before labor starts on its own shorten pregnancy and happen before important late pregnancy bodily processes to prepare for birth and beyond take place. That may explain, for example, why breastfeeding is less successful after planned C-sections than after C-sections that occur during labor.Prior, E., Santhakumaran, S., Gale, C., Philipps, L.H., Modi, N., & Hyde M,J. (2012). Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature. American Journal of Clinical Nutrition, 95(5), 1113-35

Since both types of C-section will result in a uterine scar and internal scarring and adhesions, women with planned or unplanned C-sections face similar risks in future pregnancies and for problems related to scarring and adhesions at any time.

What if I have already had a C-section?

We recommend you read Vaginal Birth After Cesarean (VBAC) section. If this is your situation, you will want a complete picture of the trade-offs between VBAC and a repeat C-section before making this crucial decision.