cesarean section

cesarean section

[si-zair-ee-uhn]
cesarean section, delivery of an infant by surgical removal from the uterus through an abdominal incision. The operation is of ancient origin: indeed, the name derives from the legend that Julius Caesar was born in this fashion. Until advancements in the late 19th cent., the mother generally died in surgery. The procedure was also aided by antisepsis, anesthetics, and other developments that made surgery as a whole more successful. Cesarean section is performed nowadays when factors exist that make natural childbirth hazardous, such as an abnormally narrow pelvis, pelvic tumors, hemorrhage, active infection with herpes simplex, multiple births, or an abnormal position of the fetus within the uterus. Subsequent deliveries are largely also by cesarean section. In the last few decades there has been a significant increase in the number of cesarean sections performed-a response both to the increase in malpractice litigation arising from problems attendant to vaginal deliveries and to the information provided by the many new devices that monitor the well-being of the fetus in the uterus.
or C-section

Surgical removal of a fetus from the uterus through an abdominal incision at or before full term. It is usually performed when vaginal delivery would endanger the life or health of the mother or the child. Vaginal delivery is often possible in subsequent pregnancies. Cesarean section carries the usual risks of major surgery. Once overused, largely for fear of malpractice suits, its use has been greatly reduced by the natural childbirth movement.

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A Caesarean section (or Cesarean section in American English), also known as C-section, is a form of childbirth in which a surgical incision is made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies. It is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk, although in recent times it has been also performed upon request for births that would otherwise have been natural.

Etymology

There are three theories about the origin of the name:

  1. In the English language, the name for the procedure is said to derive from a Roman legal code called "Lex Caesarea", which allegedly contained a law prescribing that the baby be cut out of its mother's womb in the case that she dies before giving birth. (The Merriam-Webster dictionary is unable to trace any such law; but "Lex Caesarea" might mean simply "imperial law" rather than a specific statute of Julius Caesar.)
  2. The derivation of the name is also often attributed to an ancient story, told in the first century A.D. by Pliny the Elder, which claims that Caesar's ancestor was delivered in this manner.
  3. An alternative etymology suggests that the procedure's name derives from the Latin verb caedere (supine stem caesum), "to cut," in which case the term "Caesarean section" is redundant. Proponents of this view consider the traditional derivation to be a false etymology, though the supposed link with Julius Caesar has clearly influenced the spelling. (A corollary suggesting that Julius Caesar himself derived his name from the operation is refuted by the fact that the cognomen "Caesar" had been used in the Julii family for centuries before his birth, and the Historia Augusta cites three possible sources for the name Caesar, none of which have to do with Caesarean sections or the root word caedere.)

The link with the Roman dictator Julius Caesar, or with Roman Emperors generally, exists in other languages as well. For example, the modern German, Danish, and Dutch terms are respectively Kaiserschnitt, kejsersnit, and keizersnede (literally: "Emperor's section"). The German term has also been imported into Japanese (帝王切開) and Korean (제왕 절개), both literally meaning "emperor incision." The South Slavic term is carski rez, which literally means imperial cut.

History

Pliny the Elder theorized that Julius Caesar's namesake came from an ancestor who was born by Caesarean section, but the truth of this is debated (see here). The Ancient Roman Caesarean section was first performed to remove a baby from the womb of a mother who died during childbirth. Caesar's mother, Aurelia, lived through childbirth and successfully gave birth to her son, ruling out the possibility that the Roman Dictator and General born by Caesarean section. (In fact, she died 45 years later.) The Catalan saint, Raymond Nonnatus (1204-1240), received his surname — from the Latin non natus ("not born") — because he was born by Caesarean section. His mother died while giving birth to him.

In 1316 the future Robert II of Scotland was delivered by Caesarean section — his mother, Marjorie Bruce, died. This may have been the inspiration for Macduff in Shakespeare's play ''Macbeth". (see below).

Caesarean section usually resulted in the death of the mother; the first recorded incidence of a woman surviving a Caesarean section was in 1500, in Siegershausen, Switzerland: Jakob Nufer, a pig gelder, is supposed to have performed the operation on his wife after a prolonged labour. For most of the time since the sixteenth century, the procedure had a high mortality. In Great Britain and Ireland the mortality rate in 1865 was 85%. Key steps in reducing mortality were:

European travelers in the Great Lakes region of Africa during the 19th century observed Caeserean sections being performed on a regular basis. The expectant mother was normally anesthetized with alcohol, and herbal mixtures were used to encourage healing. From the well-developed nature of the procedures employed, European observers concluded that they had been employed for some time.

On March 5, 2000, Inés Ramírez performed a caesarean section on herself and survived, as did her son, Orlando Ruiz Ramírez. She is believed to be the only woman to have performed a successful Caesarean section on herself.

Types

There are several types of Caesarean sections (CS). The differences between them primarily lie in the deep incision made on the uterus, below the skin and subcutaneous tissue, and should be differentiated from the skin incision, such as a Pfannenstiel incision.

  • The classical Caesarean section involves a midline longitudinal incision which allows a larger space to deliver the baby. However, it is rarely performed today as it is more prone to complications.
  • The lower uterine segment section is the procedure most commonly used today; it involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair.
  • An emergency Caesarean section is a Caesarean performed once labour has commenced.
  • A crash Caesarean section is a Caesarean performed in an obstetric emergency, where complications of pregnancy onset suddenly during the process of labour, and swift action is required to prevent the deaths of mother, child(ren) or both.
  • A Caesarean hysterectomy consists of a Caesarean section followed by the removal of the uterus. This may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus.
  • Traditionally other forms of Caesarean section have been used, such as extraperitoneal Caesarean section or Porro Caesarean section.
  • a repeat Caesarean section is done when a patient had a previous Caesarean section. Typically it is performed through the old scar.

In many hospitals, especially in Argentina, the United States, United Kingdom, Canada, Norway, Australia, and New Zealand the mother's birth partner is encouraged to attend the surgery to support the mother and share the experience. The anaesthetist will usually lower the drape temporarily as the child is delivered so the parents can see their newborn.

Indications

Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. Reasons for caesarean delivery include:

  • precious (High Risk) Fetus
  • prolonged labour or a failure to progress (dystocia)
  • apparent fetal distress
  • apparent maternal distress
  • complications (pre-eclampsia, active herpes)
  • catastrophes such as cord prolapse or uterine rupture
  • multiple births
  • abnormal presentation (breech or transverse positions)
  • failed induction of labour
  • failed instrumental delivery (by forceps or ventouse. Sometimes a 'trial of forceps/ventouse' is tried out - This means a forceps/ventouse delivery is attempted, and if the forceps/ventouse delivery is unsuccessful, it will be switched to a caesarean section. This takes place in the operating theatre.
  • the baby is too large (macrosomia)
  • placental problems (placenta praevia, placental abruption or placenta accreta)
  • umbilical cord abnormalities (vasa previa, multi-lobate including bi-lobate and succenturiate-lobed placentas, velamentous insertion)
  • contracted pelvis
  • Sexually transmitted infections such as genital herpes (which can be passed on to the baby if the baby is born vaginally, but can usually be treated in with medication and do not require a Caesarean section)
  • previous Caesarean section (though this is controversial – see discussion below)
  • prior problems with the healing of the perineum (from previous childbirth or Crohn's Disease)

However, different providers may disagree about when a Caesarean is required. For example, while one obstetrician may feel that a woman is too small to deliver her baby, another might well disagree. Similarly, some care providers may be much quicker to cite "failure to progress" than others. Disagreements like this help to explain why Caesarean rates for some physicians and hospitals are much higher than are those for others. The medico-legal restrictions on vaginal birth after Caesarean (VBAC), have also increased the Caesarean rate.

For religious, personal or other reasons, a mother may refuse to undergo Caesarean section. In the United Kingdom, the law states that a woman in labour has the absolute right to refuse any medical treatment including Caesarean section "for any reason or none", even if that decision may cause her own death, or that of her baby. Other countries have different laws.

During the past couple decades, there has been a movement to perform Caesarean delivery on maternal request (CDMR), though the 2006 NIH Consensus and State of the Science has admitted that there is little research supporting or refuting the safety of such elective Caesarean sections. There is also a consumer-driven movement to support VBAC as an alternative for repeat Caesareans in the face of increased medico-legal restrictions on vaginal birth.

Risks

Statistics from the 1990s suggest that less than one woman in 2,500 who has a Caesarean section will die, compared to a rate of one in 10,000 for a vaginal delivery. However the mortality rate for both continues to drop steadily. The UK National Health Service gives the risk of death for the mother as three times that of a vaginal birth. However, it is misleading to directly compare the mortality rates of vaginal and caesarean deliveries. Women with severe medical disease often require a caesarean section which can distort the mortality figures.

A study published in the 13 February 2007 issue of the Canadian Medical Association Journal found that women that have planned Caesareans had an overall rate of severe morbidity of 27.3 per 1000 deliveries compared to an overall rate of severe morbidity of 9.0 per 1000 planned vaginal deliveries. The planned Caesarean group had increased risks of cardiac arrest, wound haematoma, hysterectomy (alt PPH - Post Pregnancy Hysterectomy), major puerperal infection, anaesthetic complications, venous thromboembolism, and haemorrhage requiring hysterectomy over those suffered by the planned vaginal delivery group. Again, these figures can be significantly distorted given that women with severe health conditions are more likely to preschedule births by caesarean.

A study published in the February 2007 issue of the journal Obstetrics and Gynecology found that women who had just one previous caesarean section were more likely to have problems with their second birth. Women who delivered their first child by Caesarean delivery had increased risks for malpresentation, placenta previa, antepartum hemorrhage, placenta accreta, prolonged labor, uterine rupture, preterm birth, low birth weight, and stillbirth in their second delivery.

A study published in the June 2006 issue of the journal Obstetrics and Gynecology found that women who had multiple Caesarean sections were more likely to have problems with later pregnancies, and recommended that women who want larger families should not seek Caesarean section as an elective. The risk of placenta accreta, a potentially life-threatening condition, is only 0.13% after two Caesarean sections but increases to 2.13% after four and then to 6.74% after six or more surgeries. Along with this is a similar rise in the risk of emergency hysterectomies at delivery. The findings were based on outcomes from 30,132 caesarean deliveries. (see also review by WebMD.com)

The risk to the baby of contracting diabetes is increased significantly by being delivered by Caesarean section. The risk of developing diabetes is 20% greater for children born by Caesarean section compared to those born naturally.

A Caesarean section is a major operation, with all that it entails, including the risk of post-operative adhesions. Pain at the incision can be intense, and full recovery of mobility can take several weeks or more. A prior Caesarean section increases the risk of uterine rupture during subsequent labour.

If a Caesarean is performed under emergency situations, the risk of the surgery may be increased due to a number of factors. The patient's stomach may not be empty, increasing the anaesthesia risk.

Incidence

The World Health Organization estimates the rate of Caesarean sections at between 10% and 15% of all births in developed countries. In 2004, the Caesarean rate was about 20% in the United Kingdom, while the Canadian rate was 22.5% in 2001-2002.

In the United States the Caesarean rate has risen 46% since 1996, reaching a level of 30.2% in 2005. A 2008 report found that fully one-third of babies born in Massachusetts in 2006 were delivered by Caesarean section. In response, the state's Secretary of Health and Human Services, Dr. Judy Ann Bigby, announced the formation of a panel to investigate the reasons for the increase and the implications for public policy.

Among developing countries, Brazil has one of the highest rates of caesarean sections in the world. In the public health network, the rate reaches 35%, while in private hospitals the rate approaches 80%.

Studies have shown that continuity of care with a known carer may significantly decrease the rate of Caesarean delivery but that there is also research that appears to show that there is no significant difference in caesarean rates when comparing midwife continuity care to conventional fragmented care.

Elective Caesarean sections

Caesarean sections are in some cases performed for reasons other than medical necessity. Reasons for elective caesareans vary, with a key distinction being between hospital or doctor-centric reasons and mother-centric reasons. Critics of doctor-ordered Caesareans worry that Caesareans are in some cases performed because they are profitable for the hospital, because a quick caesarean is more convenient for an obstetrician than a lengthy vaginal birth, or because it is easier to perform surgery at a scheduled time than to respond to nature's schedule and deliver a baby at an hour that is not predetermined. Another contributing factor for doctor-ordered procedures may be fear of medical malpractice lawsuits. For example, the failure to perform a Caesarean section has been a central point in numerous lawsuits against obstetricians over incidents of cerebral palsy.

Studies of US women have indicated that married white women giving birth in private hospitals are more likely to have a Caesarean section than poorer women even though they are less likely to have complications that may lead to a Caesarean section being required. The women in these studies have indicated that their preference for Caesarean section is more likely to be partly due to considerations of pain and vaginal tone. in contrast to this, a recent study in the British Medical Journal retrospectively analysed a large number of caesarean sections in England and stratified them by social class. Their finding was that Caesarean sections are not more likely in women of higher social class than in women in other classes. While such mother-elected Caesareans do occur, the prevalence of them does not appear to be statistically significant, while a much larger number of women wanting to have a vaginal birth find that the lack of support and medico-legal restrictions led to their Caesarean.

Anaesthesia

Both general and regional anaesthesia (spinal, epidural or combined spinal and epidural anaesthesia) are acceptable for use during caesarean section; however, regional anaesthesia is preferred as it allows the mother to be awake and react immediately with her baby. Regional anaesthesia is used in 95% of deliveries, with spinal and combined spinal and epidural anaesthesia being the most commonly used regional techniques in scheduled caesarean section. Regional anaesthesia during caesarean section is different to the analgesia (pain relief) used in labor and vaginal delivery. The pain that is experienced because of surgery is greater than that of labor and therefore requires a more intense nerve block. The dermatomal level of anesthesia required for cesarean delivery is also higher than that required for labor analgesia.

However, in caesarean sections which are considered to be emergencies (such as cases with heavy, rapid bleeding or other haemodynamic compromise) or when caesarean section is carried out and deemed to be urgent, regional anaesthesia may not be appropriate due to the compromise of the mother and general anaesthesia is considered. However, general anaesthesia provides the downside of an unconscious mother who is unable to interact with her baby immediately after delivery. Oesophageal intubation and pulmonary aspiration of gastric contents are both undesired complications that can occur under general anaesthesia.

Vaginal birth after caesarean

Vaginal birth after caesarean (VBAC) is not uncommon today. The medical practice until the late 1970s was "once a caesarean, always a caesarean" but a consumer-driven movement supporting VBAC changed the medical practice. Rates of VBAC in the 80s and early 90s soared, but more recently the rates of VBAC have dramatically dropped owing to medico-legal restrictions.

In the past, caesarean sections used a vertical incision which cut the uterine muscle fibres in an up and down direction (a classical caesarean). Modern caesareans typically involve a horizontal incision along the muscle fibres in the lower portion of the uterus (hence the term lower uterine segment caesarean section, LUSCS/LSCS). The uterus then better maintains its integrity and can tolerate the strong contractions of future childbirth. Cosmetically the scar for modern caesareans is below the "bikini line."

Obstetricians and other caregivers differ on the relative merits of vaginal and caesarean section following a caesarean delivery; some still recommend a caesarean routinely, others do not. What should be emphasised in modern obstetric care is that the decision should be a mutual decision between the obstetrician and the mother/birth partner after assessing the risks and benefits of each type of delivery. As is the case for all surgical procedures a patient signed form relating to informed consent must be obtained prior to surgery attesting the completeness of patient information because of reasonable and viable alternatives to maternal choice CS.

Twenty years of medical research on VBAC support a woman's choice to have a vaginal birth after caesarean. Because the consequences of caesareans include a higher chance of re-hospitalization after birth, infertility, and uterine rupture in the next birth, preventing the first caesarean remains the priority. For women with one or more previous caesareans, as an alternative to major abdominal surgery, some claim that VBAC remains a safer option.

In the United States, the American College of Obstetricians and Gynecologists (ACOG) modified the guidelines on vaginal birth after previous cesarean delivery in 1999 and again in 2004. This modification to the guideline including the addition of following recommendation:

Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.
This recommendation has, in some cases, had a major impact on the availability of VBACs to birthing mothers in the United States. For example, a study of the change in frequency of VBAC deliveries in California after the change in guidelines, published in 2006, found that the VBAC rate fell to 13.5% after the change, compared with 24% VBAC rate before the change. The new recommendation has been interpreted by many hospitals as indicating that a full surgical team must be standing by to perform a caesarean section for the full duration of a VBAC woman's labor. Hospitals that prohibit VBACs entirely are said to have a 'VBAC ban'. In these situations, birthing mothers are forced to choose between having a repeat caesarean section, finding an alternate hospital in which to deliver their baby or attempting delivery outside the hospital setting.

Caesareans in fiction

The first caesarean section according to mythology was performed by Apollo on his lover Coronis when he delivered Asklepios, after she had been murdered.

In Persian mythology, Rudaba's labour of Rostam was prolonged due to the extraordinary size of her baby. Zal, her lover and husband, was certain that his wife would die in labour. Rudaba was near death when Zal decided to summon the Simurgh. The Simurgh appeared and instructed him upon how to perform a caesarean section, thus saving Rudaba and the child, who later on became one of the greatest Persian heroes.

A caesarean section appears in Shakespeare's play Macbeth. Macbeth hears a prophecy that "none of woman born shall harm Macbeth," an impossibility, but later finds out that Macduff was "from his mother's womb untimely ripp'd," the product of a caesarean section birth (not unlike Robert II of Scotland).

The stillborn child of character Katherine Barkley is delivered by caesarean section in the Hemingway novel A Farewell to Arms.

In the video game Metal Gear Solid 3: Snake Eater, a main character called 'The Boss' exposes a c-section scar to Naked Snake (The player's character). The scar is from a botched procedure made during the middle of a battle and runs from the abdomen to the breasts, and is in the shape of a snake. The character of 'Ocelot' is the child born from the c-section.

In Alexandra Ripley's "Scarlett", the main character, Scarlett O'Hara, has a caesarean section performed by a so-called "medicine woman". She almost miraculously recovers after giving birth to a girl.

In the novel, Midwives, by Chris Bohjalian, midwife Sybil Danforth, stranded with a labouring mother in a storm, performs a caesarean section when the mother dies in order to save the child. The story revolves around the court case that ensues when doubts are raised as to whether the mother was in fact dead at the time of the surgery or the midwife made a mistake.

In the novel Restoration set in Britain of the 1660s the surgeon protagonist delivers his own daughter by caesarean, but the mother dies shortly thereafter.

On the TV show EastEnders, in the Summer of 2007, Dr May Wright kidnapped a pregnant Dawn Swann (who was carrying May's Husband's child) in order to get her baby. She threatened that if Dawn failed to cooperate with May then May would give Dawn a caesarean against her will to remove the baby early.

On the TV show Desperate Housewives the character Edie Britt says she has a C-section scar when she tries to seduce Carlos Solis.

In the novel A Thousand Splendid Suns by Khaled Hosseini, which is set in Afghanistan, the character Laila undergoes a Caesarean section without anaesthesia while giving birth to her son, Zalmai. The doctor explains that as the baby is breech, they must perform a Caesarean section or the baby will die. However, as a result of difficulties on the part of the Taliban, the hospital is desperately lacking in basic supplies, and therefore, they have no anaesthesia to give Laila for the procedure. Laila nonetheless agrees to go through with it.

In the novel Breaking Dawn, the fourth book in the Twilight Saga by Stephenie Meyer, Edward Cullen performs a C-section on Bella when she is birthing their child, Renesmee. This leaves Bella with a C-section scar which vanishes when she is turned into a vampire.

References

External links

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