Vaginal Delivery vs Cesarean Section

Maternal Risks and Benefits

Women who undergo vaginal delivery have a lower risk of postpartum infections compared to cesarean section (5-7 times fewer infections) 1
Cesarean section is associated with higher rates of postpartum fever (6.7% with cesarean vs 1.1% with vaginal delivery) 2
Cesarean section increases the risk of endometritis, wound infection, and pneumonia 1
The relative risk of any postpartum complication is higher for elective cesarean (1.85) and emergency cesarean (4.17) compared to vaginal delivery 1

The American College of Obstetricians and Gynecologists recommends cesarean section for women with HIV-1 RNA >1,000 copies/mL near delivery time, regardless of antiretroviral therapy 2
The European Society of Cardiology recommends cesarean section for women with severe cardiac conditions, including severe pulmonary hypertension, significant aortopathy (aortic diameter >45 mm in Marfan syndrome), and acute heart failure 3
Women on oral anticoagulants in preterm labor should undergo cesarean section, as recommended by the European Society of Cardiology 3

The American College of Obstetricians and Gynecologists recommends assessing for absolute indications for cesarean section, including HIV-1 RNA >1,000 copies/mL and severe cardiac conditions, before deciding on the mode of delivery 2
The European Society of Cardiology recommends that vaginal delivery should be the default plan when no absolute indications for cesarean section exist, due to lower maternal morbidity and mortality 3

Performing unnecessary cesarean sections increases maternal risks without providing additional benefits, as stated by the Centers for Disease Control and Prevention 1

Vaginal delivery is preferred where possible, even in high-risk cases, with cesarean section reserved for obstetric indications, as recommended by the European Society of Cardiology 4
In women with certain cardiac conditions, individualized delivery plans should be made with support from a multidisciplinary team, but gestational age alone does not dictate cesarean section, according to the European Heart Journal 4
For women with vascular liver disease, delivery should be performed for obstetric indications, not based on gestational age alone, as suggested by the European Association for the Study of the Liver 5

Cesarean section carries risks including chronic wound pain (15.4% at 3-6 months postpartum), increased risk of placenta previa and accreta in subsequent pregnancies, uterine rupture in subsequent pregnancies (22 per 10,000 births in women with previous CS), venous thromboembolism (2.6 per 1000 CS births), and secondary infertility (reported in up to 43% of women), as reported by The Lancet Global Health 6

The American College of Obstetricians and Gynecologists suggests that vaginal delivery has the lowest risk of postpartum morbidity among HIV-infected women, with elective cesarean being intermediate and nonelective cesarean having the highest complication rates, in a population with unique considerations, but the pattern of lower morbidity with vaginal delivery holds across populations 7, 8, 9

The American College of Obstetricians and Gynecologists recommends avoiding iatrogenic prematurity that can occur with scheduled cesarean delivery, particularly when performed at 38 weeks without documentation of fetal lung maturity, as neonatal outcomes are generally comparable between planned vaginal delivery and cesarean section when delivery occurs at term 7, 8
Active genital herpes lesions at labor onset and transverse fetal lie are considered absolute contraindications to vaginal delivery, according to the American Journal of Obstetrics and Gynecology 10
The American College of Obstetricians and Gynecologists advises against scheduling elective cesarean before 39 weeks unless there is a clear medical indication, as this increases the risk of neonatal respiratory complications 7
Allowing adequate time for labor progression, up to 4 hours of arrest in the active phase with oxytocin augmentation when appropriate, can prevent unnecessary cesarean delivery, as recommended by the American Journal of Obstetrics and Gynecology 10

The American Stroke Association guidelines recommend vaginal delivery for pregnant women with known unruptured cerebral aneurysms, as it does not carry a higher risk for hemorrhage than cesarean section, and is associated with lower maternal morbidity 11, 12
Vaginal delivery does not increase the risk of aneurysm rupture during delivery, and the available data demonstrate that increased venous pressure during Valsalva maneuver is not directly transmitted to the draining veins of cerebral aneurysms 11, 12
The already low incidence of aneurysm-related complications during delivery is not reduced by cesarean section, and vaginal delivery is the preferred mode of delivery for pregnant women with known unruptured cerebral aneurysms 11, 12

The European Society of Cardiology guidelines emphasize that vaginal delivery should be the default approach for high-risk maternal conditions, as it is associated with less blood loss, lower infection risk, and reduced risk of venous thromboembolism compared to cesarean delivery 13, 14

Plan for vaginal delivery with epidural analgesia to reduce pain-related sympathetic activity and the urge to push, and use assisted delivery to shorten the second stage and minimize prolonged Valsalva maneuvers 13, 14
Avoid elective cesarean section unless obstetric indications exist, as the presence of an unruptured cerebral aneurysm alone is not an indication for cesarean delivery 11, 12, 13, 14

Cesarean section should be reserved for obstetric indications only, such as fetal distress, malpresentation, or placental complications 13, 14
The rebleeding rate during pregnancy after initial hemorrhage may be as high as 26%, supporting early definitive aneurysm treatment, and prioritizing neurosurgical treatment of the ruptured aneurysm first, followed by delivery planning based on gestational age and maternal neurological status 11, 12