Is an elective cesarean section (C-section) better than vaginal delivery?

Vaginal Delivery is Generally Safer Than Elective Cesarean Section for Most Women

Vaginal delivery is preferred over elective cesarean section for most women due to lower maternal morbidity and mortality rates, faster recovery times, and fewer postpartum complications. 1, 2

Maternal Risks and Benefits

Vaginal Delivery Benefits

• Lower risk of postpartum infections compared to cesarean section (5-7 times fewer infections) 3
• Faster and healthier recovery period after delivery 4
• Reduced risk of venous thromboembolism compared to cesarean section (2.6 per 1000 CS births) 1
• Lower risk of complications in future pregnancies, including placenta previa and accreta 1, 5
• Reduced risk of secondary infertility (reported in up to 43% of women after cesarean section) 1

Cesarean Section Risks

• Higher rates of postpartum fever (6.7% with cesarean vs 1.1% with vaginal delivery) 3
• Increased risk of endometritis, wound infection, and pneumonia 3
• Higher relative risk of any postpartum complication (1.85 for elective cesarean and 4.17 for emergency cesarean compared to vaginal delivery) 3
• Chronic wound pain (15.4% at 3-6 months postpartum) 5
• Risk of uterine rupture in subsequent pregnancies (22 per 10,000 births) 5

Specific Medical Conditions Where Cesarean May Be Preferred

Cesarean section is recommended in specific circumstances:

• Women with HIV-1 RNA >1,000 copies/mL near delivery time, regardless of antiretroviral therapy 3, 6
• Severe cardiac conditions including:
  • Severe pulmonary hypertension 3, 6
  • Significant aortopathy (aortic diameter >45 mm in Marfan syndrome) 3
  • Acute heart failure 3, 6
• Women on oral anticoagulants in preterm labor 3
• Acute fatty liver of pregnancy 6
• Fetal distress with irreversible causes (major placental abruption, fetal hemorrhage) 6, 5

Decision-Making Algorithm

1. Assess for absolute indications for cesarean section:

   • HIV-1 RNA >1,000 copies/mL 3
   • Severe cardiac conditions (pulmonary hypertension, aortic diameter >45 mm, acute heart failure) 3, 6
   • Maternal anticoagulation therapy 3
   • Fetal distress with irreversible causes 6

2. If no absolute indications exist, vaginal delivery should be the default plan due to:

   • Lower maternal morbidity and mortality 7
   • Faster recovery 4
   • Reduced risk of complications in future pregnancies 1, 5

3. For women with previous cesarean section:

   • Trial of labor after cesarean (TOLAC) should be considered when appropriate 8
   • Success rates of vaginal birth after cesarean are approximately 35% 8
   • Factors favoring successful VBAC include maternal age 21-30 years, prior vaginal birth, non-recurring indication for previous cesarean, and favorable cervical conditions 8

Common Pitfalls to Avoid

• Performing unnecessary cesarean sections increases maternal risks without providing additional benefits 3, 7
• Inadequate preparation for potential complications during either delivery method 5
• Overlooking the impact of delivery method on future pregnancies 1, 5
• Failing to consider the woman's preferences and psychological factors that may influence her choice 4
• Declining skill in operative vaginal delivery techniques (forceps, vacuum) that could safely prevent some cesarean sections 9

Special Considerations

• Cesarean section rates exceeding 42% in some regions are significantly higher than the rates recommended by WHO 7
• Higher educational status, pregnancy after infertility treatment, and previous cesarean section are factors that may influence women to choose cesarean section even when not medically indicated 4
• Operative vaginal delivery (forceps or vacuum) may be a safe alternative to cesarean section in appropriate cases 9

Vaginal delivery remains the safest option for most women and should be encouraged when no contraindications exist, with cesarean section reserved for specific medical indications.