What is the most common complication for the newborn in a cesarean birth?

A caesarean section is a major surgical operation in which your baby is born through a cut in your abdomen and uterus. It is usually performed under a spinal or epidural anaesthesia. In some cases it is necessary to use a general anaesthetic so that you are asleep throughout.  

Some caesarean births are planned in advance (elective caesarean) because of existing problems with your pregnancy. In other cases, the decision to perform a caesarean is made during the course of labour. This is called an emergency caesarean.

An emergency caesarean is recommended for the following reasons:

• concern for your baby’s wellbeing  
• your labour is not progressing
• there are maternal complications, such as severe bleeding or severe pre-eclampsia
• there is a life-threatening emergency for you or your baby.

What to expect if you need an emergency caesarean

• You may be in the operating theatre for an hour or more. 
• Unless you are having a general anaesthetic, in most cases, your partner can be with you in the operating theatre.
• Most hospitals will have a midwife stay and look after you and your baby in the theatre and the recovery area.
• Unless you have had a general anaesthetic, skin-to-skin contact with your baby will be encouraged immediately after the birth, otherwise you are likely to have skin-to-skin as soon as you are able.
• The midwife will help you with breastfeeding.
• If your baby is unwell or needs to be monitored they may need to go to special or intensive care. In some cases they may need to go to a different hospital, which has a higher level of care for babies who are very sick.
• After surgery you will be offered a number of different pain-relieving medications as you need them.
• You will be encouraged to express breast milk if your baby is unable to feed from the breast. This will start as soon as possible after the birth and you will need to express about 8 to 10 times every 24 hours.

Risks with a caesarean birth:

• Side effects and complications from anaesthesia including, nausea, drowsiness, dizziness, short-term memory loss and, in rare circumstances, an allergic reaction.
• Pain is very common after surgery. There are several layers of body tissue that are cut and then repaired during a caesarean, so post-surgical pain is to be expected. This can usually be managed well with medications.
• Infection of the wound and bladder will affect a small number of women. This can be treated with antibiotics.
• You may have fever, which will usually be due to an infection.
• Blood clots can form after surgery. If it is in the lung (pulmonary embolus) it can be very serious.
• You may not be able to hold or feed your baby immediately after the birth, which may have implications for breastfeeding. This is only likely to be a problem if you have had a general anaesthetic. However, you should be able to hold and feed your baby as soon as you are more alert.
• Adhesions or scar tissue can form in your abdomen, which can cause ongoing pain and have implications for future abdominal surgery.
• Hysterectomy is a possible complication with any birth option.

After you have had one caesarean section the risk of complications increases with each caesarean after that. For example, there is an increased chance of the placenta implanting into or over the scar in future pregnancies.

This condition is referred to as placenta praevia or placenta accreta.

Vaginal birth after a previous caesarean

If you have had a caesarean section it may affect your future pregnancies and births. For future births, you will need to make a choice about whether to have another caesarean section or attempt a vaginal birth. This is called a Vaginal Birth After Caesarean Section (VBAC). Both options carry a level of risk. Having another caesarean carries all of the risks of a normal caesarean section. The main risk for VBAC is that the scar on the uterus will rupture, which can be very painful and, in some cases, life threatening. Between one and two in 200 women who attempt a VBAC will suffer a ruptured scar.

Most women who attempt a vaginal birth after a caesarean will succeed (70 per cent). Thirty per cent of women who attempt a vaginal birth will, for any number of reasons, end up having an emergency caesarean.

Many women who have had a previous caesarean section find the prospect of a vaginal birth healing, particularly if the first caesarean was unplanned or traumatic. Unless there are particular health reasons why you would be advised to have another ceasarean, the decision is ultimately yours. Your midwife or doctor will usually discuss this with when you are around 26 weeks pregnant. It’s a good idea to ask about the specific risks and benefits for you. 

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For the first time in more than a decade the U.S. cesarean birth rate decreased, if only by .1%.  The rate decreased from 32.9% to 32.8% in 2010. But still, one in three mothers gives birth by cesarean and scheduled cesareans for non-medical reasons have been rising. Surgical birth without labor impacts the health of newborns.

Birth by cesarean poses several challenges for a baby. Compared to babies born vaginally, babies born by cesarean are at risk for health complications they are less likely to face with a normal birth. Especially if the mother did not labor, babies are more likely to have difficulty breathing on their own. With a scheduled cesarean, babies are more likely to be born preterm, before the lungs have fully developed. Respiratory complications can be serious enough to require admission to a special care nursery.

With a cesarean,  mothers and babies are less likely to have skin-to-skin contact immediately after birth.

Planned Cesareans and Late Pre-Term Birth

Many cesareans that are scheduled before labor put newborns at risk. Often, the birth takes place a few weeks before the due date and babies are born late-preterm. Late  preterm birth is defined as a live birth before 37 completed weeks gestation. A baby born between the 34th and 36th week of pregnancy is considered  late-preterm . When cesarean sections are scheduled there is a margin of error in pinpointing fetal maturity. Being born only one week earlier can make a difference in terms of complications babies are likely to suffer. The March of Dimes (MOD) is concerned that increasing inductions and planned cesareans may be contributing to the rising number of babies born preterm.  Late- preterm births account for 70% of all premature births in the United States and are the fastest growing subgroup of premature babies. Low-birthweight infants (less than 5 pounds, 8 ounces)  are at higher risk of death or long-term illness and disability than are infants of normal birthweight.

Breathing Difficulties and Admission to Intensive Care

Birth by cesarean increases the risk for breathing problems. Infant respiratory distress syndrome, a complication related to scheduled cesareans, was the most expensive condition of all hospital stays in 2005. The cost for each stay with this diagnosis was $114,200. Newborns with this condition were hospitalized for about 25.7 days. Cost and length of hospital stay surpassed those for spinal cord injury, heart valve disorders, and leukemia.

Contractions of labor help to prepare the baby’s lungs for respiration at birth. In her article on the role of stress, pain, and catecholamines (produced by the body in response to stress), Penny Simkin explains that during each contraction of labor there is temporary reduction in the amount of oxygen that is available to the fetus. Contractions reduce the amount of oxygenated blood that is passed through to the placenta. This causes the baby’s heart rate to slow down.

To adapt to this level of stress the baby increases her production of catecholamines which shunts the blood going to her vital organs and preserves her energy stores. This adaptive response allows the baby to receive the same amount of oxygen as before labor contractions. This increased surge of catecholamines accumulated during labor also helps to prepare the baby’s lungs to breath on their own at birth by absorbing the liquid in her lungs. Babies born by a scheduled cesarean have lower levels of catecholamines than babies born vaginally. A scheduled cesarean (without labor) is more likely to make it more difficult for the baby to initially breathe on her own.

Babies born before term  have a higher risk of persistent pulmonary hypertension, a potentially life-threatening condition. To facilitate the transition from the uterine environment to the outside world, the blood vessels in the baby’s lungs relax and allow blood to flow through them with the first breaths after birth. This function allows the blood to exchange carbon dioxide for oxygen. When this adaptation fails the blood vessels do not relax and pulmonary high blood pressure (hypertension) prevails. Newborns who experience persistent pulmonary hypertension and low blood oxygen levels can suffer from damage to vital organs and the brain. Persistent pulmonary hypertension is four times higher for babies born by elective cesarean than for babies born vaginally.

Increased Risk for Asthma

Some reports have suggested a link between cesarean birth and later development of asthma. Recent studies conducted in the Netherlands and in Norway  found  that children delivered by cesarean  are at an increased risk of developing  asthma later in life.   Babies were more likely to have a certain kind of bacteria in their intestines if they were born  by cesarean. Babies with these intestinal bacteria have a greater risk for developing allergies or asthma later on.

Mother-Infant Attachment is More Likely to Be Delayed

Holding, touching and caring for healthy, sick, premature infants or infants with congenital problems enhances attachment between mothers and babies. Minimizing or avoiding separating babies from their mothers after birth reduces stress in healthy newborns and mothers. The World Health Organization and the American Academy of Pediatrics encourage skin-to-skin contact between mother and baby as soon as possible after the birth for at least one hour and until the newborn has successfully completed the first breastfeed.

Placing a newborn belly-down directly on her mother’s chest has several important health benefits. Skin-to-skin contact calms the mother and her baby and helps to stabilize the baby’s heartbeat and breathing. The mother’s body heat keeps the baby warm, reduces the newborn’s crying, stress and energy use. Skin-to-skin contact helps with the baby’s metabolic adaptation and stabilizes its blood glucose level. If the mother is the first person to hold the baby rather than a staff person, it helps to colonize the baby’s gut with her mother’s normal body bacteria gut.

The Lamaze Institute for Normal Birth recommends no separation of mother and baby after birth with unlimited opportunity for breastfeeding.  “Nature prepares a mother and her baby to need each other from the moment of birth. Oxytocin, the hormone that causes a woman’s uterus to contract, also causes the temperature of her breasts to rise and helps her feel calm and responsive. This hormone stimulates “mothering” feelings as the woman touches, gazes at, and breastfeeds her baby. More oxytocin is released as she holds her baby skin-to-skin. Endorphins, narcotic-like hormones, are also released and enhance mothering feelings. High levels of adrenaline, which are normal in babies at birth, make the baby alert and prepare him to look for his mother, find his way to her breast, and breastfeed.”

The Listening to Mothers II U.S. national survey of women’s childbearing experiences revealed that only 14% of mothers who gave birth by cesarean had their baby in their arms immediately after birth compared to 43% of the mothers who had a vaginal delivery.  With a cesarean delivery babies are more likely to be taken to the nursery for observation and monitoring for potential problems during the first hour of life. They are also more likely to spend time in a newborn nursery than rooming in with their mothers. The separation seems to have an impact on the mother’s initial ability to respond to and care for her infant. When mothers and babies stay together, babies cry less, it improves the mother’s perception of her infant, and enhances her confidence in her mothering skills.Babies are more likely to be breastfed and for a longer period of time if they have early skin-to-skin contact.

When the mother is not able to receive her infant immediately after a cesarean birth, a Swedish study found that the baby’s father can provide skin-to-skin contact with his newborn and offer the same calming and comforting benefits as the baby’s mother. This skin-to-skin contact between the father and his baby also facilitates the newborn’s pre-breastfeeding behavior. A calm newborn is better prepared for breastfeeding when mother and baby are able to be together. The researchers of this study recommend that the fathers should be the primary caregivers for their newborns when mothers and babies are separated.

A cesarean birth makes it more difficult for mothers to initiate and establish breastfeeding.  The Centers for Disease Control established that hospital birth practices have a significant impact on the initiation and continuation of breastfeeding. The use of medications during labor and cesarean birth have a negative effect on breastfeeding, so does the separation of mother and baby after birth and during the hospital stay. The maternity care experience exerts a unique influence on both breastfeeding initiation and later infant feeding behavior. Although  the hospital stay is typically very short, events during this time have a long and lasting impact.

Medications and procedures administered to the mother during labor affect her  infant’s behavior at the time of birth, which in turn affects her  infant’s ability to suckle in an organized and effective manner at the breast.  If hospitals provide  mothers with  the support, guidance, and education  from  a lactation specialist mothers are more likely to initiate and continue breastfeeding. Encouraging more mothers to breastfeed is a national priority.

Planned Cesareans and Risk of Neonatal Death

Increasingly in many countries around the world women are having a planned cesarean without a medical indication. These are considered low-risk cesareans. In the United States the number of healthy women who have a primary cesarean (first cesarean delivery) at term (37-41 weeks and a singleton pregnancy) without any medical indication. These are cesarean deliveries for which no medical diagnosis were reported on the birth certificates.

How do these planned cesareans affect neonatal (the first 28 days of life) and infant (less than 1 year of life) health? In 2006 researchers examined live births between 1999 and 2001. They reported that newborns of mothers who had a planned cesarean were more likely to die in the first four weeks of life (1.77 per 1,000 births) than newborns of mothers who had a vaginal birth (0.62 per 1,000 births). Almost three times the risk. The infant mortality rate for first time mothers with a planned cesarean was 2.85 per 1,000 compared to 1.83 for mothers who had a vaginal birth.  A 56 percent  higher rate. For  mothers who had one or more children before their planned cesarean  the infant mortality rate was 4.51 per 1,000 compared to 2.18 for a similar group of women who had a vaginal birth. More than twice the increase.

Especially for Mothers

Birth by cesarean affects you as well as your baby. A long labor preceding a cesarean, pain from the surgery, complications such as developing a fever, your reaction to medications, or developing an infection may make it difficult for you to be with your baby right after birth. Holding, feeding, and soothing your baby may be more painful than you anticipated. You and your baby will benefit from skin-to-skin contact and rooming in (having the baby in your room as opposed to the nursery) as soon as possible. But, you should  take the time you need to feel ready to have your baby.

Should you have a cesarean delivery, the following suggestions can help you and your baby get off to a more healthy and satisfying start together.

1. In the operating room, after your baby has been born if you are feeling well, ask that one of your arms be released and your baby be placed belly-down on your chest as soon as it is safe. You can also ask that the baby be placed skin-to-skin with your partner as soon as it is safe. Your baby will be less fussy and more ready to breastfeed.
2. Ask that a lactation specialist help you to recognize your baby’s hunger signs, to position your baby to latch on correctly at your breast, to support you to continue to breastfeed while in the hospital, and to provide you with a list of community resources that you can access once you are home.
3. Your health insurance may reimburse you for the services of a lactation consultant once you’re home and for the rental of a breast pump if you need one.
4. You may want to draft a birth plan to communicate your needs and wishes for staff support with breastfeeding.
5. You will be in pain after the initial anesthetic wears off. Ask about the safest pain medication available for breastfeeding.
6. Ask for your partner, friend, or doula to stay with you in the room to help you lift your baby, change positions in bed, change the baby’s diapers, and help you get out of bed.

Resources

Deciding if VBAC is Right for You: A Parent’s Guide

California Maternal Quality Care Collaborative, White Paper: Cesarean Deliveries

Childbirth Connection, Cesarean Section

Childbirth Connection, Pathway to a Healthy Birth

Northern New England Perinatal Quality Improvement Network, Risk Consequences of a Near Term Birth,  a video

Coalition for Improving Maternity Services, Breastfeeding Is Priceless

Association for Women’s Health, Obstetrics and Neonatal Nurses, What Parents of Late-Preterm (Near-Term) Infants Need to Know

Updated April 18, 2016.