Risks of Caesarean Sections

  • General
  • Wound infections etc.
  • Links to other sources of information

General Risks of Caesareans

Other things being equal, is a caeserean section always more hazardous to the mother’s health than vaginal birth?


A quick summary by Olubusola Amu, Sasha Rajendran and Ibrahim I Bolaji,
BMJ 1998;317:462-465 ( 15 August )
http://www.bmj.com/cgi/content/full/317/7156/462

“Caesarean sections are not without complications and consequences. Maternal risks in the short term include haemorrhage, infection, ileus, pulmonary embolism, and Mendelson’s syndrome. The prevalence of hysterectomy due to haemorrhage after caesarean section is 10 times that after vaginal delivery, and the risk of maternal death is increased up to 16-fold.

Long term morbidity including formation of adhesions, intestinal obstruction, bladder injury, and uterine rupture is often underestimated during subsequent pregnancy. There is evidence suggesting decreased fecundity, increased risk of ectopic pregnancy, placenta praevia, and worse infant outcome in subsequent pregnancies, although the effect on non-reproductive health is unclear and contradictory. Feelings of inadequacy, guilt, and failure in not completing a natural process may affect bonding between mother and infant, particularly if the operation was conducted under general anaesthetic”

Caesareans and Obstetric Hysterectomy

Anna’s Story – a mother expecting her first child was scared out of booking a home birth because she was expecting a large baby and was told that she risked shoulder dystocia. Because this can (rarely) be fatal in hospital or at home, she chose an elective caesarean instead – supposedly the ‘safe’ option.


After Anna’s story about her hysterectomy after an elective caesarean, I’ve been looking for stats on the frequency of this. It varies a lot between countries, but here are some examples:

– One emergency hysterectomy required after every 110 caesareans, compared to one after every 824 deliveries overall (vaginal or caesarean) [1, USA 1975-1981]

– Caesarean hysterectomy was performed in 0.17% (1 in 588) of caesarean sections and a hysterectomy was done in 0.02% (1 in 5,000) of cases following a vaginal delivery.[2, Singapore, 1998]

– hysterectomy rate during or after cesarean section was 0.44% (1 in 227) and after vaginal delivery was 0.02% (1 in 5,000) [3, Italy, 1991]

– From 1978 to 1982, 70 cases of emergency hysterectomy for obstetric hemorrhage were performed at Los Angeles County/University of Southern California Women’s Hospital. Sixty hysterectomies followed cesarean section, and ten were performed for hemorrhage after vaginal delivery [4, 1984]

– The incidence of obstetric hysterectomy was 1 in 1420 deliveries. Overall, 0.32% (1 in 313) of caesarean sections and 0.02% (1 in 5,000) of vaginal deliveries were complicated by emergency obstetric hysterectomy. [5, Hong Kong, 1997]

– a recent study from St George’s Hospital in London [7] found that women with a previous c/s are up to 27 times more likely to need obstetric hysterectomy in subsequent births, than those who have only had vaginal births.

This is just one example of a very serious health consequence for the mother, but of course there are others, eg greatly increased risk of severe blood loss and increased need for transfusion.

Although fear of damage to the bladder and pelvic floor are often cited as reasons for elective c/s, apparently many women suffer bladder damage as a result of c/s anyway. A friend has had stress incontinence since her last caesarean three years ago, for example, having previously got through two vaginal births and another c/s with no problems. She feels as though ‘it was all sewn up too tightly’ and has felt constant pressure on her bladder. It was suggested to me recently that sometimes nerves can be severed or damaged during a c/s which can affect bladder function and sometimes sexual enjoyment, although I’ve not seen any research on this.

Bear in mind too that these stats only refer to one birth, and they ignore the long-term consequences for the mother’s whole childbearing life – eg future risks of placenta praevia, placenta accreta, uterine rupture etc.. all increase, and in subsequent pregnancies these all pose life-threatening risks to mother and baby even if she plans elective repeat caesareans. I think it was our own Margaret Jowitt who said that a woman with a past caesarean has already had intervention in all her future births.

It has also been said that caesareans shift some of the risks of one birth, to all of the mother’s future pregnancies and births. As Chung et al say in medicalese,
Obstetricians should be ready to face the late sequelae of today’s decision for cesarean section.” [6].

Any assessment of the costs and benefits of caesareans really needs to look at the mother’s whole childbearing career, not just this one birth. And that obviously needs to include the tragic cases where the operation itself leads to a hysterectomy – who can put a price on such a loss when the mother wanted more children?

Angela Horn
Homebirth Reference Site

www.homebirth.org.uk

REFS

[1] TITLE: Cesarean hysterectomy at Louisiana State University, 1975 through 1981.
AUTHORS: Plauche WC; Wycheck JG; Iannessa MJ; Rousset KM; Mickal A
SOURCE: South Med J 1983 Oct;76(10):1261-3
CITATION IDS: PMID: 6623139 UI: 84017742

[2] TITLE: Caesarean and postpartum hysterectomy.
AUTHORS: Chew S; Biswas A
AUTHOR AFFILIATION: Department of Obstetrics and Gynaecology, National University Hospital, Singapore.
SOURCE: Singapore Med J 1998 Jan;39(1):9-13
CITATION IDS: PMID: 9557096 UI: 98217844

[3] TITLE: [Ablative cesarean section and post-partum hysterectomy: review of 11 years of obstetric practice] VERNACULAR TITLE: Taglio cesareo demolitore ed isterectomia post-partum: rassegna di 11 anni di attivita ostetrica.
AUTHORS: Dindelli M; Ferrari S; Potenza MT; Ferrari D; Ferrari A
AUTHOR AFFILIATION: Clinica Ostetrico-Ginecologica L. Mangiagalli, Universita degli Studi di Milano.
SOURCE: Ann Ostet Ginecol Med Perinat 1991 May-Jun;112(3):179-87
CITATION IDS: PMID: 1812802 UI: 92255178

[4] TITLE: Emergency hysterectomy for obstetric hemorrhage.
AUTHORS: Clark SL; Yeh SY; Phelan JP; Bruce S; Paul RH
SOURCE: Obstet Gynecol 1984 Sep;64(3):376-80
CITATION IDS: PMID: 6462567 UI: 84271569

[5] TITLE: Ten years experience of caesarean and postpartum hysterectomy in a teaching hospital in Hong Kong.
AUTHORS: Lau WC; Fung HY; Rogers MS
AUTHOR AFFILIATION: Department of Obstetrics and Gynaecology, Chinese University of Hong Kong, Shatin NT, Hong Kong.
SOURCE: Eur J Obstet Gynecol Reprod Biol 1997 Aug;74(2):133-7
CITATION IDS: PMID: 9306105 UI: 97451129

[6] TITLE: Obstetrical hysterectomy and placenta previa/accreta: three bladder injury case reports.
AUTHORS: Chung CL; Cheng PJ; Liang CC; Chang FH; Lee JD; Soong YK
AUTHOR AFFILIATION: Department of Obstetrics & Gynecology, Chang Gung Memorial Hospital, Taipei, Taiwan, R.O.C.
SOURCE: Chang Keng I Hsueh 1997 Mar;20(1):44-51
CITATION IDS: PMID: 9178593 UI: 97321901

[7] Gould, D et al, ’emergency obstetric hysterectomy – an increasing incidence’,
Journ. Obset. Gynaecol. 1999 vol 19 p580-583


Wound problems

A friend of mine had a c/s for alleged iugr (intra-uterine growth retardation). She didn’t want one and was deeply distressed by the whole experience. She developed an infection which never really went away and she died, five months later, from septicaemia.

It was about ten years ago that it happened, but even now I feel some of the fury at the waste and the fact that there was nothing I could do, and she lost her uterus that day when they operated because they couldn’t stop the bleeding or fix the infection and she never woke up to say goodbye to her babies who were only 2 and 5 months or her husband who just couldn’t comprehend why she’d only had a bit of a pain…………

Lesley


I know of 2 people who have had infected scars more than 9 months after their CS operations – there is probably a great deal of information that is being lost.

Maria


A friend had her last child by c/s 4 years ago. She is still in and out of hospital with scar infections. She is seriously overweight, which apparently exacerbates the problem as it’s hard for air to get to the wound inside skin folds. But then, maybe that’s a reason for obstetricians to try extra hard to avoid c/s in large women, rather than using the woman’s size as an excuse…

My mother’s last c/s was in February 1997. She is slim. She still has problems with the scar – feels she has a pouch of fluid on her tummy after nasty infections earlier on, and has had bladder weakness ever since the op. None of this will be documented in her medical records as, like so many other women, she just puts up with it and wants to stay as far away from hospitals as possible.

Angela H.


Links to other sources of information:

On this site:

On Other Sites:

Cesareans: Are they really a safe option? by Henci Goer

Caesarean pages on US Midwife Archives
http://www.gentlebirth.org/archives/icanvbac.html


AH updated 6 August 2000

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