Everything to Know About Having a C-Section Versus Vaginal Birth

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Collage: Stevie Remsberg

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Larisa Courtien really didn’t want a cesarean, but she’d been in labor for three days. “I told my doctor at my last check-in I wanted to do everything I possibly could to avoid a C-section,” says Courtien, a blogger and entrepreneur. “But then I wouldn’t dilate. I was in the hospital for three days and we tried three different drugs four different times. My cervix just wouldn’t open.”

Courtien had also developed cholestasis, a liver condition associated with late pregnancy. “It wasn’t that dangerous for me,” she says, “but it could’ve been life threatening to the baby.” So, Courtien was wheeled into the operating room and her daughter, Ivy, was delivered via C-section.

“The doctor said she was sunny-side-up and her head was in the 90th percentile,” Courtien says. “He said, verbatim, ‘You would have been ripped apart.’ One of the nurses was like, ‘This baby was never coming out of you, honey.’” Courtien ended up with a C-section despite planning for a vaginal delivery. Every year millions of women have the same experience; then again, millions of others have the opposite: They plan a C-section and end up doing things the old-fashioned way.

Neither method of giving birth is objectively “better” than the other, and both have short- and long-term risks and complications; plus they both give rise to misconceptions and fears. To set the record straight and put some of those fears to rest, we asked OB/GYNs and maternal-fetal experts to answer the questions you have about getting a baby born safely.

So what happens during a C-section?

In a routine C-section, you’ll be brought into the operating room, and drapes will be put up just above your belly. (You probably don’t want to watch yourself have major abdominal surgery.) The surgeon will make a horizontal incision between four and six inches long, just above where your pubic hair starts. Then, once the uterus is exposed, they’ll make another horizontal incision in the lower half of the uterus. The baby gets pulled out, briefly examined and cleaned up. Meanwhile, the surgeon will remove the remaining umbilical cord and placenta, and stitch your uterus and abdomen closed. The procedure is very common: about 32 percent of babies in the United States are born via C-section.

Does it hurt?

Not exactly. “It is technically major surgery, so of course a woman receives anesthesia,” says Victoria Handa, a professor of gynecology and obstetrics at Johns Hopkins School of Medicine. “It’s typically an epidural, so she’s numb, but awake.”

And while the epidural should keep you from feeling pain, that doesn’t mean you won’t feel anything at all. “It varies quite a bit, but women can feel pressure or other sensations during the procedure,” Handa says.

And what happens during a vaginal birth?

At the risk of giving you high-school health-class flashbacks: During a routine delivery, the muscles of the uterus contract to push the baby headfirst down the “birth canal,” which starts between the pelvic bone and the tail bone, at the top of the cervix. During labor, your cervix dilates, opening enough to accommodate the baby’s head and shoulders. Then, the baby’s head stretches the perineum — the area of skin between the vagina and the anus — until the baby can move out of the vagina.

Does it hurt?

“Physiologically, a bowling ball is coming through the perineum,” says Clark Johnson, a Johns Hopkins maternal-fetal specialist — in other words, yes, although an epidural should dull the pain.

The direction the baby is facing inside the birth canal plays a role, too. In a textbook scenario, they’ll be face-down, but if they’re face-up, it can cause what’s commonly called “back labor,” or intense pain in the lower back during and between contractions. It can also mean pushing harder, for longer.

What’s the difference in recovery time?

Assuming there are no major complications, recovering from a vaginal delivery is significantly easier and quicker than recovering from a C-section. “One’s an invasive procedure with a much longer recuperation,” Wendy Martinez, CEO of Advocare the Women’s Group for OB/GYN in New Jersey, explains. “With vaginal delivery you’re up and running the next day. If you have a C-section, you’re not running for a while.”

Courtien’s recovery was difficult, to say the least. “I haven’t romanticized it in my head at all,” she says. “I still really hate it. I look back on it and I’m grateful Ivy came out okay, but I was sore so deep inside myself that it was excruciating. You just feel really beyond weak. You’re recovering from major abdominal surgery and trying to care for an infant.”

The most difficult part for Courtien was being unable to perform basic tasks on her own for the first two weeks as her incision healed.

“You need your core to do everything,” she says. “I couldn’t sit down and stand up by myself. I couldn’t even vacuum my floors because pushing and pulling the vacuum requires abs. I felt like half a person because I physically couldn’t move. It was like a special kind of hell.”

What kind of complications could I have?

You lose a lot more blood during a C-section than during a vaginal delivery, so the chances of hemorrhage are higher. And as with any surgery, there’s a risk of infection and blood clots. “The risk of throwing a clot is increased with C-section,” Martinez says, “because it’s an invasive procedure and you’re not moving around for a while.”

There are also plenty of complications that can arise when you’re pushing a watermelon-sized baby out of your vagina. “You can have something called shoulder dystocia,” Martinez says. “If the baby gets stuck coming out, you have to get them out fast. Sometimes you have to break the clavicle to get them out. It happens more often than you’d like to think.”

Obstetricians use other tools to get stubborn babies out, too. A vacuum extraction involves placing a vacuum cup on the baby’s head and using suction to pull the baby out. Johnson says he prefers forceps — a large pair of pincers that have been used in childbirth since the 19th century or earlier.

“It’s basically a pair of metal spatulas,” he says. “Today about 2.5 percent of U.S. births use vacuum extraction, and another 0.5 percent use forceps. Those tools are used with someone who gets to full dilation, so you can see the baby without pushing, and it’s low enough that you can reach in and pull it out. You can move quicker with a vacuum or forceps than with a C-section in that situation, and a C-section when the baby is that low is very complicated.”

A very common, but typically minor, complication of vaginal delivery is tearing; as the baby’s head passes through the perineum, the skin can stretch to its limit and tear. To avoid this, Martinez uses an old-school aid: olive oil. “We use it to help the baby’s head slide, and the perineum stretch,” she says. “I had three births yesterday and I went through two or three bottles. I think it’s one of the best things we use in the delivery room — it often helps us to avoid an episiotomy.”

But sometimes an episiotomy — a small cut made with a scalpel, to widen the vaginal opening and avoid significant tearing — is necessary. “You won’t know until the very last minute,” Martinez says. “If it looks like it’s going to tear all over, you want to make a tiny one inch cut that opens it enough so the baby comes out. In the old days, everyone used to do it. Almost everyone got an episiotomy. Nowadays, it’s almost considered a trauma. We’re trying not to do them as much as possible.”

With a couple of stitches and a little time, episiotomies generally heal well, and having had an episiotomy doesn’t typically affect mobility. But long-term complications can develop as a result of vaginal delivery, too. Handa’s research focuses on bladder control issues and pelvic organ prolapse, which disproportionately affect women who’ve had babies. “Bladder control problems affect up to a third of women — maybe more,” Handa says. Prolapse, a condition where the vaginal walls and uterus sag, sometimes so much they begin to protrude from the vagina, is a bit less common, but, she says, “we know that one in five women will undergo surgery in her lifetime for one of these disorders.”

Handa says her research, which involved 1,500 women, found that prolapse was much more likely to happen later in life to women who’ve delivered vaginally. And while an equal number of C-section havers and vaginal deliverers develop bladder control problems after age 65, those who developed them earlier tended to be women who delivered vaginally.

Handa’s research also dispelled a few myths about C-sections. “People believe C-sections make you fatter: that’s not true,” she says. “They say it makes breastfeeding more difficult — nope. It also doesn’t make it harder to get pregnant down the line.”

Which one’s better for my baby?

Barring complications, neither is better. Studies have shown that babies born via C-section have lower lung function immediately after birth, but things even out within a few days. There’s also been some research that indicates “those babies may also have more problems later in life,” Handa says. “There’s some concern about allergies and asthma.”

Scientists think this has to do with microbes: a baby acquires them from its mother on its way through the birth canal. Martinez says there are other ways to acquire these immune-building microbes, though.

“With a vaginal delivery, we do skin-to-skin right away,” she says. “We try to do the same with our C-sections. The baby is brought right over to mom and we lay the baby right on her chest. That baby is getting all the microbiota it needs from mom’s skin.”

I’ve heard of “vaginal seeding” — what the heck is it?

A 2016 study involved placing gauze in the vagina during a C-section, presumably to soak up all the microbe-heavy fluid. Immediately after delivery, the baby’s eyes, mouth, and mucus membranes were wiped with the gauze. The researchers found that microbiota were at least partially restored, but the study only involved four babies, and there wasn’t any long term follow-up. A planned follow-up study will look at the impact on 800 babies over three years.

But you might not need “seeding” to ensure the health of your child. “The other thing to look at here is that a lot of the benefits they were touting from vaginal seeding, you also get from breast feeding,” Martinez says. “We know that breastfeeding immediately decreases your child’s risk of eczema, allergies, hay fever, and builds their immune system.”

Can I choose which kind of birth I want?

That depends. “A lot of younger people nowadays are electing to have a C-section because they don’t want urinary continence, they don’t want their vaginal supports coming down, fecal incontinence; those are things you can see with vaginal births and not cesareans,” Martinez says. And if there aren’t any big risk factors, you may be able to work with your doctor to schedule an elective C-section.

In some cases, a C-section is unavoidable, or at the very least, it’s the least risky option. “It’s not recommended that they have a vaginal delivery if the baby’s not head-down,” Johnson says. “25 or 30 years ago we used to do vaginal breech delivery, but we don’t do that anymore. Most often they’re delivered by C-section.”

And about one percent of all deliveries are twins, some of whom can’t be delivered vaginally. “If they’re dichorionic/diamniotic twins [who each have a placenta and amniotic sac], we would like them to come out vaginally, Johnson continues. “But monoamniotic twins [who share an amniotic sac] need to be delivered by C-section because they can be twisted up with each other.”

If I have a C-section, can I have a vaginal delivery next time?

“The old adage was ‘once a C-section, always a C-section,” Martinez says. “But you can also do a VBAC (vaginal birth after cesarean). You could even possibly do it after two C-sections.” Martinez says the VBAC success rate is high — between 60 and 80 percent — but there are certain criteria. A typical C-section involves a horizontal cut near the bottom of the uterus, where there isn’t much uterine muscle. The chance of that incision rupturing during a subsequent vaginal delivery is between 0.2 and 1.5 percent.

The chances of rupture greatly increase, though, if the C-section incision was made vertically, as is sometimes necessary if the baby is lying a certain direction in the uterus, or is too large to remove through the horizontal incision. “When you cut vertically, you’re cutting through thick muscle at the top section of the uterus,” Johnson says. “In the future when the uterus contracts, it has a defect that makes it more likely to open up.”

And because a uterine rupture is critically dangerous for both mom and baby, Martinez says a VBAC should never be attempted outside a hospital. “The baby could die,” she says. “Mom could hemorrhage, lose her uterus, or die. If that uterus ruptures, the baby needs to come out quickly. I can get a baby out in three minutes — just hand me a scalpel — but you need to be in a hospital.”

Ultimately, Courtien says, the path to motherhood matters less than taking home a healthy baby. “At the end of the day it doesn’t matter how your baby gets here,” she says, “as long as everybody is safe and healthy. My delivery wasn’t a fairy-tale, but I’m a fully recovered, fully functioning person, and my daughter is safe and healthy.”

Everything to Know About C-Sections Versus Vaginal Births