Overall, a cesarean section is an extremely safe operation. Most of the serious complications associated with cesarean sections are not due to the operation itself. Instead, the complications come from the reason for the cesarean section. For example, a woman whose placenta separates too early (placental abruption) may require an emergency cesarean section. In this case, problems arise primarily from the placental abruption—not the actual surgery.
In other situations during labor and delivery, an emergency requiring a cesarean section may arise. There may not be time to get an epidural or spinal anesthetic (because these forms of anesthesia are complicated to get), and general anesthesia may be required. In these cases, complications may arise from the general anesthesia. Complications of general anesthesia are considerably greater than those seen with spinal or epidural anesthesia.
Many complications of cesarean section delivery are unpredictable and very rare, but there are some things that make women more likely to have complications. These risk factors include:
- large infant size
- emergency complications that necessitate a C-section
- long labor or surgery
- having more than one baby
- allergies to anesthetics, drugs, or latex
- maternal inactivity
- low maternal blood cell count
- use of an epidural
- premature labor
Some possible complications of cesarean deliveries are as follows (Mayo Clinic, 2012):
- post-surgery infection or fever
- too much blood loss
- injury to organs
- emergency hysterectomy
- blood clot
- reaction to medication or anesthesia
- emotional difficulties
- scar tissue and difficulty with future deliveries
- death of the mother
- harm to the baby
Fortunately, serious complications from C-sections are rare. In developed countries, maternal death is very rare. Death of the mother is higher for women who have a C-section than for women who have a vaginal birth, but this may be related to complications with the pregnancy that make a C-section essential. Each of the main complications of a C-section is described in more detail below.
After the membranes have ruptured, the uterus is especially susceptible to infection—the bacteria that normally inhabit the vagina (which are generally harmless) can easily spread to the uterus. If bacteria are in the uterus, a cesarean section incision may result in endometritis (infection of the uterus).
Depending on the population studied, endometritis may occur in anywhere between 5 and 75 percent of women who have a cesarean section. In the U.S., 2–15 percent of C-sections result in endometritis (ACOG, 2010). Fortunately, almost all cases of endometritis can be treated with antibiotics, and this type of infection doesn’t seem to keep women from having safe pregnancies in the future. In very rare cases, the infection may be serious and require a hysterectomy. In extremely rare cases, the infection may result in death.
It is important to know that these complications are so rare that during their entire careers, most obstetricians will not see a single case of hysterectomy or death due to infection. Serious infections are rare in women who have planned C-sections before labor and before the membranes are ruptured. Problems like this are more common after long labors, when the membranes have been ruptured for a long time before the surgery begins.
Post-Cesarean Wound Infection
Some women develop an infection at the site of the incision on the outer skin layers, instead of in the uterus. This is often called post-cesarean wound infection. Infections of the wound are often associated with fever and abdominal pain. Infection of the skin or any layer of tissue that was cut can normally be treated with antibiotics. These infections can also cause abscesses that fill with pus. If an abscess exists, a doctor may have to re-open the wound to drain and clean the infected area.
Sometimes, the infection can spread to other organs or the type of bacteria that infects the wound can be very aggressive. These dangerous infections are rare. With proper treatment, such as antibiotics and hospitalization, even the most serious infections can be cured.
Puerperal or Postpartum Fever and Sepsis
Up to 8 percent of women who have a C-section delivery develop a bacterial infection called puerperal fever or postpartum fever (Barrett, 2002). This infection often starts in the uterus or vagina. If it spreads throughout the body, it is called sepsis. Most of the time, the infection is caught early. It can usually be cured with antibiotics. If the infection is untreated and sepsis occurs, it is harder to treat. In rare cases, sepsis can be deadly. A fever in the first 10 days after the C-section is a warning sign for puerperal fever. Infections like urinary tract infections or mastitis (infections in the breasts) can be a sign of this complication. They should be treated quickly to avoid the spread of the infection.
While the average blood loss for a vaginal birth is about 500 cc (about two cups), the average blood loss with cesarean section is twice that much: about four cups or one quart (Miller, 2002). This is because the pregnant uterus has one of the greatest blood supplies of any organ in the body. In every cesarean section, large blood vessels are cut as the surgeon opens the wall of the uterus to gain access to the baby. Most healthy pregnant women can tolerate this much blood loss without any difficulty. Occasionally, however, blood loss can be greater than this and cause (or arise from) complications.
The following forms of dangerous blood loss can happen during or after a cesarean section: postpartum hemorrhaging, atony, lacerations, and placental accreta.
It is normal to lose a lot of blood during a C-section. When you bleed too much, this may be called a postpartum hemorrhage. This can happen when an organ is cut, the blood vessels are not stitched up completely, or there is an emergency problem during labor. They can also be caused by a tear in the vagina or nearby tissue, a large episiotomy, or a ruptured uterus. Some women have problems clotting blood, which makes it hard to stop bleeding after any type of cut, tear, or bruise. About 6 percent of deliveries result in postpartum hemorrhaging.
In some cases, blood loss is not a problem. Pregnant women have about 50 percent more blood than when they are not pregnant. Hemorrhages are emergencies, though, and should be treated immediately by a doctor. If you continue bleeding heavily after you are sent home from the hospital, call a health professional immediately for advice. When they receive treatment, most women make a full recovery in a few weeks. In some cases, women are given a blood transfusion during or after the C-section to replace lost blood. Medicine, IV fluids, iron supplements, and nutritious foods or vitamins are recommended to help you regain your strength and blood supply after hemorrhaging.
After the baby and the placenta are delivered, the uterus must contract to close the blood vessels that supplied the placenta during pregnancy. Uterine atony is when the uterus remains relaxed, without tone or tension. This can happen after a long labor or the birth of a big baby or twins. When the uterus has atony, bleeding may be very fast. Fortunately, a number of very effective medications have been developed to treat uterine atony. Most of these drugs are variations of natural substances in the body called prostaglandins. With the use of prostaglandins, long-term complications from uterine atony are extremely rare.
Sometimes the cesarean section incision is not wide enough for the baby to pass through, especially when the baby is very large. As the baby is delivered through the incision, the incision may tear into areas not intended by the surgeon. The areas to the right and left of the uterus have big arteries and veins that can be torn accidentally. Often, there is nothing the surgeon can do to avoid such tears; every obstetrician will see this problem many times. If the doctor notices a tear quickly, it can be safely repaired before too much blood loss occurs.
Sometimes, these tears affect blood vessels near the uterus. Other times, the surgeon may accidentally cut into arteries or nearby organs during the operation. For instance, the knife sometimes hits the bladder during a C-section because it is so close to the uterus. These lacerations can cause heavy bleeding. They also might require extra stiches and repairs. In rare cases, damage to other organs requires a second surgery to fix.
When the tiny embryo travels into the uterus, the cells that will form the placenta begin to collect on the walls of the uterus. These cells are called trophoblasts. Trophoblasts generally grow through the walls of the uterus and into the blood vessels of the mother. These cells play an important role in moving oxygen and nutrients from mother to fetus. They also move waste products from fetus to mother. As the fetus and placenta grow, the trophoblasts keep seeking blood vessels to support the growing fetus. A fibrous layer (called Nitabuch's membrane) limits how deep the villi are able to reach into the wall of the uterus.
When the uterus has been damaged (for instance, from a previous cesarean section) the fibrous layer may not stop the trophoblasts from growing deep into the mother's uterus. They may even spread into other organs, such as the bladder. This condition is called placenta accreta. Placenta accreta is especially common in women who have had a C-section in the past and whose embryo, during a later pregnancy, implants in the area of the C-section scar. Although this complication is rare, doctors are now seeing it more often because of the large number of cesarean deliveries that have been performed in the last 10 years.
The good news is that doctors are now able to recognize women at risk for this condition and are usually ready to deal with it. The bad news is that almost all cases require a hysterectomy to save the life of the mother. Since the chances of this happening tend to increase with each C-section a woman has, some women try vaginal birth after a previous cesarean section to reduce their risk of placenta accreta or a hysterectomy.
Cesarean hysterectomy is the removal of the uterus right after a cesarean section. Certain complications of cesarean section (usually connected to severe bleeding) may require the doctor to remove the uterus to save the mother's life. Even though the risk of a hysterectomy is higher after a C-section, bleeding requiring a hysterectomy may happen even after a seemingly normal vaginal birth. As with all of the complications listed above, cesarean hysterectomy is very rare. Most obstetricians will probably need to do an emergency hysterectomy only a few times in their careers.
Women who have had a hysterectomy cannot have more children, but there are usually no extra side effects from this operation. Obviously, this is a terrible situation, and physicians try their best to avoid it. There is no question that cesarean hysterectomies save lives, though, especially when bleeding cannot be controlled by simpler measures.
Planned Cesarean Hysterectomy
Although hysterectomy following cesarean section is probably easier than performing one later, blood loss is greater. For this reason, most surgeons do not plan cesarean hysterectomies—even when a woman has other conditions that might require a hysterectomy.
Under certain circumstances, however, a cesarean hysterectomy may be planned. This is only done when there is a serious need to do the hysterectomy for reasons unrelated to pregnancy. The mother's health must also be good and her blood count high. Otherwise, cesarean hysterectomies are done only in the case of emergency, as in the cases above.
Probably the most feared complication of C-section deliveries is the formation of blood clots in the mother's legs or pelvic area. These blood clots can break off and travel to the lungs. If this happens, it is called a pulmonary embolism. This complication is the leading cause of death among pregnant women in most developed countries. Fortunately, the clots usually cause swelling and pain in the legs, and most women bring this to their doctor's attention before the clots travel to the lung. If a blood clot is found early, it can be treated with use of a blood thinner (e.g., Coumadin or Warfarin).
Occasionally, there are no warning signs until after the clots have broken off and reached the lungs. Most women recover with treatment, but sometimes the clot can be so large that the mother dies. Unfortunately, there does not appear to be a reliable way of avoiding or detecting this condition.
Blood clots are more common in the following situations:
- The mother is overweight.
- The operation was long or complicated.
- The mother has had a long period of bed rest after the operation.
Blood clots were much more common in the past, when women were commonly told to remain in bed for weeks after giving birth. Fortunately, they are less common today.
Blood clots are more common when a woman is pregnant than when she is not for two reasons. First, estrogen is produced in large amounts by the placenta. This increases the body's production of clotting proteins. It is important that blood forms clots quickly after delivery to avoid the bleeding complications above. Second, as the baby grows, the uterus puts pressure on the veins that bring blood back from the mother's legs. This slows blood flow during pregnancy. The combination of slow blood flow and increased ability to clot leads to a higher risk of clotting complications during pregnancy.
In addition to problems caused by the actual surgery, some women experience complications related to medication, latex, or anesthesia. Bad reactions to these items can range from very mild (like a headache or dry mouth) to very serious (like death from anaphylactic shock). Problems with drugs, latex products, and anesthesia are more common with emergency C-sections. This is because there is sometimes not enough time to double check for all possible drug interactions or allergies, find latex substitutes, or provide localized (instead of general) anesthesia.
Some women have severe allergies to medications or products used in a C-section operation. If the doctor does not know about these allergies, it may be impossible to avoid a bad reaction. In addition, general anesthesia is risker than localized anesthesia. Sometimes general anesthesia must be used because there is not enough time to use local anesthetics before the first cut must be made. General anesthesia can cause problems for the mother and also cause the baby to be drowsy when he or she is born. When a cesarean delivery is planned ahead of time, the medical workers have the chance to ask about allergies and plan the anesthesia.
Although these problems are less likely to happen in planned surgeries, they can still happen. Sometimes, the mother does not know she has an allergy to medications or anesthesia. Severe reactions are very rare. Rare but serious problems from medication, latex, or anesthesia reactions include (Mayo Clinic, 2012; Mayo Clinic, 2012):
- severe headache
- blurry vision
- vomiting or nausea
- stomach, back, or leg pain
- swelling of the throat
- lasting weakness
- pale or yellowed skin
- hives, swelling, or blotchy skin
- dizziness or fainting
- difficulty breathing
- weak, fast pulse
Most of these reactions happen soon after the drug or item is used. Serious reactions can be deadly, but most are treatable with other drugs and rest. Women having a bad reaction need immediate medical help. Although they may need a longer hospital stay and may not be able to benefit from certain drugs during their surgery, most women do not have lasting problems from bad reactions to medication, latex, or anesthesia.
Many women experiencing cesarean section deliveries struggle with emotional issues after the baby is born. Some women express dissatisfaction with the delivery experience or process and mourn the loss of the opportunity to deliver vaginally. Other women initially experience difficulty bonding with the baby. Many women overcome these emotional difficulties by spending time in direct skin contact with the baby, joining a postnatal C-section support group, or discussing their concerns in talk therapy (APA, 2007).
In addition to these emotions, women who have experienced other C-section complications (such as an emergency hysterectomy) may have emotional difficulty adjusting to infertility or inability to deliver vaginally in the future. Women experiencing these losses should discuss their feelings and seek treatment from a mental health professional or specialty support group if necessary.
Some C-section complications—like a hysterectomy—make it impossible for a woman to have another baby. However, even if the surgery goes well and the mother heals, she may have difficulties with pregnancy in the future. This can happen because of scar tissue at the site of the C-section. In some cases, C-section scarring can connect the uterus to the bladder (Harms, 2012). When they are connected, future C-sections are more likely to damage the bladder. Future pregnancies may also implant in dangerous areas, like the C-section scar.
The surgery may also leave the wall of the uterus weak, making a future vaginal birth difficult or even dangerous. Many women can have a successful vaginal birth after a prior cesarean delivery. In some cases, however, the uterus will tear open at the site of the old cut. If this happens, another C-section is needed to protect the mother and the baby.
Although very rare, some women die from complications with a C-section delivery. Death is almost always caused from one or more of the complications listed above, like uncontrolled infection or a blood clot in the lung. Death may result from too much blood loss or untreated C-section complications. Although many of the complications above can happen after vaginal births as well, the maternal death rate after C-sections is three to four times higher (Deneux-Tharaux, Carmona, Bouvier-Colle, & Breart, 2006; Liu, et al., 2007). Even though this difference seems very large, maternal death after C-sections is still very rare.
Out of pregnancy-related deaths, up to 55 percent are caused by the problems described above (CDC, 2012). The rest are caused by other problems, like heart trouble or high blood pressure. Death from C-section complications or any pregnancy-related cause is very rare in the U.S. and other developed countries.
Women are not the only ones who can have complications from a C-section delivery. Sometimes, the baby may also have problems. The following complications may affect the baby (APA, 2007):
- cuts or nicks from the surgery tools
- breathing problems
- low Apgar scores
- premature birth from an incorrect gestational age
Just as the mother’s skin, blood vessels, and organs can be injured by the surgery, the baby can also be accidentally cut during a C-section. This is rare (1–2 percent of cesarean deliveries); any cuts are usually very small and heal quickly. More often, babies have some problems breathing when they are born via C-section. He or she may need extra care to breathe or thrive right after birth.
Babies born via cesarean delivery are also 50 percent more likely than babies born vaginally to have low Apgar scores (APA, 2007). Apgar scores measure how healthy your baby seems shortly after birth. Many babies are born via C-section because of other problems (like a slow heartbeat, fetal distress, or a long labor). The problems that lead to a cesarean delivery—and the anesthesia from the surgery itself—can cause some temporary problems that show up as a low Apgar score.
Finally, some babies born via C-section have problems because they are preterm. This often happens when a woman goes into labor early because of a problem with the pregnancy. It also happens when the gestational age of the baby is calculated incorrectly. Sometimes, a C-section is planned for a time when the baby is thought to be near or at term, but after the operation it is clear the age was wrong and the baby was delivered too early. Babies born too early can have problems with growth and development.
When the baby is full term and the C-section is planned, complications for the baby are rare and usually temporary. There is no research that shows a permanent difference between babies born vaginally and babies born in a cesarean delivery.