The Most Common Reasons You Might Have A C-Section

If you’ve delivered by cesarean before, you are more likely to have a C-section the second time around, though it’s by no means guaranteed; plenty of women now have a vaginal birth after cesarean (VBAC). “After one C-section, on average, 30% of women will have another C-section,” says Dr. Clarel Antoine, MD, an associate professor in the Department of Obstetrics & Gynecology at NYU Langone Health. “Nowadays, the old dictum ‘Once a section, always a section’ applies mostly to women who have had a classical C-section.”

The tissue up where the higher classical incision is performed is very muscular, making those incisions more likely to reopen in a subsequent labor, Antoine says, but the horizontal incision is performed lower, where the tissue naturally stretches during labor and is very unlikely to rupture during a VBAC. “The risk of rupture is too dangerous for women with a classical cut to attempt VBAC,” he says.

Another reason for repeat C-sections is a recurrent issue that prevents vaginal birth. For example, “If the uterus is heart shaped, such that the baby will never really be in a head-down position, that’s somebody who would need to have a repeat C-section,” Sharma says.

Almost everyone else who has had one C-section and wants to have a VBAC is free to attempt it, and for people who have only had one cesarean in the past, the VBAC works out 60 to 80% of the time, according to Antoine. After two C-sections, you may be able to try, but the success rate goes down to 50%. “It is not recommended to attempt VBAC after three or more C-sections,” he says.

If you want to try for a VBAC, you’re more likely to be successful if you go into labor on your own, rather than being induced. “I think that always gives [the patient] a better chance,” Sharma says. Pitocin, the synthetic hormone used to induce or augment labor, can cause very strong contractions. “With that, there’s an increased risk of a scar opening up.” There’s also the chance that your body just won’t respond to the induction. “Sometimes we just can’t get the labor to take off when there’s a prior C-section and you’re inducing their labor,” Sharma says.

Depending on the positioning of the babies and how early you go into labor, pregnant people carrying multiples often end up having C-sections.

In the case of twins, the rule is that if both babies are breech or transverse (sideways), you will need to have a C-section. In 40% of twin pregnancies, however, both babies are head down. “When they’re both head down, a trial of labor should be considered. It’s perfectly reasonable to be talking about the possibility,” Sharma says.

Things get more complicated in the rest of cases, where only one baby is head down. “If one is head down and the second one is breech or transverse, some [obstetricians] will feel pretty comfortable delivering the second baby as a breech delivery or trying to turn that second baby head down when [the first] baby is coming out,” Sharma says. Other doctors may recommend a C-section to play it safe.

“With twins, you always have to think about the context of what’s going on, like the difference between the sizes of the twins. If the second baby is much bigger, then it may not be the safest thing to try to deliver [that] baby breech,” Sharma says. “Twins have an increased risk of other complications — diabetes, high blood pressure issues, so you have to look at the overall safety of the situation for the mode of delivery.”

If you are carrying more than two babies, they were bound for a C-section at conception. “Triplets or a greater number of multiple pregnancies are delivered via C-section,” Antoine says. Period.

If your baby is in any position other than head down, your doctor will likely recommend a C-section, Sharma says. Most hospitals discourage vaginal breech deliveries due to an influential study published in 2000 that showed higher rates of survival for breech babies born via C-section. Especially if you have never delivered vaginally before, your doctor has no way of knowing if your pelvis will accommodate a breech delivery, and the risks are significant. In addition, many obstetricians aren’t trained in breech births. “For a first-time mom, it’s really out of the question,” Sharma says.

When a baby is breech and the pregnant person prefers a vaginal birth, doctors may offer to try to turn the baby in a procedure known as an external cephalic version or “version” for short. According to Sharma, versions are successful around 50% of the time, and 40% of those successful versions will still result in a C-section.

Along with the well-being of your baby, your doctor will factor your health into the decision of how you will deliver. “Women with certain health conditions like heart disease, high blood pressure, diabetes, or seizures may do better with a planned cesarean delivery,” Antoine says. Sharma adds that if a patient’s diabetes or epilepsy is well-controlled, it is possible to try for a vaginal birth.

A C-section might also be advised if you have an infection like HIV or genital herpes that can be passed to your baby during a vaginal delivery and you have a detectable viral load, in the case of HIV, or a flare-up of herpes when you go into labor. (Otherwise, they do not require a C-section.)

If you know from prenatal testing that your baby has certain genetic or anatomical issues, your doctor may recommend a C-section. A baby with “certain birth defects like congenital heart diseases or excessive fluid in the brain, may do better if delivered via cesarean,” Antoine says.

Labor doesn’t always go according to plan, and if your labor stalls or “fails to progress,” your doctor will likely recommend a C-section. “During labor with regular contractions, if the baby’s head stops descending in the pelvis and there is arrest of cervical opening and thinning, a cesarean section is often indicated,” Antoine says. Stalled labor can be a result of a number of factors, he notes, including “the baby’s size, position, and the shape and dimensions of the mother’s pelvis.”

In recent years, OB-GYNs have made an effort to give early labor as much time as needed to progress, but they also have a responsibility to keep your safety and your baby’s top of mind. “It’s not that we put a stopwatch next to the labor bed,” Sharma says. What they are trying to avoid is a situation where your baby is stuck and begins to experience distress, which could result in an emergency situation, instead of a simply unplanned one. “You want to make sure that if you’re doing a C-section, you’re doing it as safely as possible,” Sharma says.

The circumstances mentioned above that can stall labor usually won’t be known until you are close to your delivery date or in the process of labor. That’s all the more reason to talk to your doctor ahead of time about what could go down and how they would handle it.

If your placenta is in a problematic position in your uterus or it malfunctions, you will likely have a C-section. Most of the time, the placenta is in one of three positions: fundal (at the top of the uterus), posterior (toward the mother’s spine), or anterior (on the front wall of the uterus toward the mother’s belly button). If it’s lower down in the uterus, it can cause problems for the pregnancy, sometimes automatically requiring a C-section. In the case of placenta previa, the placenta grows over the opening in the uterus, blocking the baby’s access to the birth canal.

The placenta can also behave in unusual ways that significantly complicate pregnancy and delivery. Placenta accreta refers to a dangerous situation in which the placenta grows into the wall of the uterus and must be surgically detached after birth. Placental abruption happens when the placenta detaches from the wall of the uterus before birth, which can mean the baby stops getting nutrients and can cause major bleeding for the pregnant person. “Mothers with placenta previa, placenta accreta, … and some cases of placental abruption must be delivered by cesarean,” Antoine says.

The most obvious and common indicator of a complication is when your baby’s heart rate drops and doesn’t rebound, especially when there are also signs that your labor has stalled. The first response when this happens is for your OB to ask you to change position and/or to increase your IV fluids, both of which can make your baby more comfortable. After making those adjustments, “if we have any signs that the fetus is not tolerating the labor process, then a C-section would be recommended,” Sharma says. “You don’t want to wait too long.”

If you’ve had surgery inside your uterus that didn’t involve cutting through the uterine wall, such as a surgical abortion (cutterage) or polyp removal, there’s no reason you can’t deliver vaginally, Antoine says.

However, if you have had invasive surgery on your uterus, your doctor may plan a C-section to avoid the possibility of labor rupturing the previous incision. The key determinant is whether that pre-pregnancy surgery cut through the wall of the uterus.

Take fibroid removal, for example. “The indications for a C-section depend on the number of fibroids removed and, most importantly, on whether the uterine cavity was entered or not during the removal,” Antoine says, adding that having fibroids doesn’t necessarily mean you will deliver via C-section. “Women who have fibroids and are currently pregnant may attempt to deliver [vaginally] as long as the fibroids are not interfering with the normal progression of labor.”

Experts:

Dr. Geeta Sharma, M.D., a high-risk OBGYN at Carnegie Hill OBGYN in New York City

Dr. Clarel Antoine, MD, an associate professor in the Department of Obstetrics & Gynecology at NYU Langone Health