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A team of obstetricians performing a Caesarean section in a modern hospital.
A team of obstetricians performing a Caesarean section in a modern hospital.
A Caesarean section (often C-section, also other spellings) is a surgical procedure in which one or more incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies, or, rarely, to remove a dead fetus. A late-term abortion using Caesarean section procedures is termed a hysterotomy abortion and is very rarely performed. The first modern Caesarean section was performed by German gynecologist Ferdinand Adolf Kehrer in 1881.
C-sections result in a small overall increase in bad outcomes in low risk pregnancies (8.6% of vaginal deliveries and 9.2% of C-sections). The bad outcomes that occur with C-section differ from those that occur with vaginal delivery. Professional societies have established guidelines for non-medically indicated cesarean before 39 weeks.
The rate has risen to 46% in China and to levels of 25% and above in many Asian, European and Latin American countries. The rate has increased in the United States, to 33% of all births in 2012, up from 21% in 1996. Across Europe, there are differences between countries: in Italy the Caesarean section rate is 40%, while in the Nordic countries it is 14%.
Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. C-sections are also carried out for personal preference but this is not recommended. Planned caesarean sections also known as elective caesarean sections should not be scheduled before 39 weeks gestational age unless there is a medical reason to do so.
A planned or elective caesarean section is an elective surgery, meaning that it is scheduled in advance rather than performed because of an unscheduled emergency. Elective caesarean sections may be performed on the basis of an obstetrical or medical indication, or because of a non-indicated maternal request. Among women in the United Kingdom, Sweden and Australian about 7% preferred C-section as a method of delivery. In cases without medical indications the American College of Obstetricians and Gynecologists recommend a planned vaginal delivery. The National Institute for Health and Care Excellence recommends that if after a women has been provided information on the risk of a planned C-section and she still insists on the procedure it should be provided. If provided this should be done 39 weeks of gestation or later.
Some medical indications are below. Not all of the listed conditions represent a mandatory indication, and in many cases the obstetrician must use discretion to decide whether a Caesarean is necessary.
Complications of labor and factors impeding vaginal delivery, such as:
Other complications of pregnancy, pre-existing conditions and concomitant disease, such as:
For otherwise healthy twin pregnancies where both twins are head down a trial of vaginal delivery is recommended at between 37 and 38 weeks. Vaginal delivery in this case does not worsen the outcome for the infant as compared with C-section. There is controversy on the best method of delivery where the first twin is head first and the second is not. When the first twin is not head down a C-section is often recommended. While the second twin does has a higher rate of problems it is not know if a planned C-section changes this. It is estimated that 75% of twin pregnancies in the United States were delivered by Cesarean section in 2008.
Adverse outcomes in low risk pregnancies occur in 8.6% of vaginal deliveries and 9.2% of C-section deliveries.
In those who are low risk the risk of death for Caesarian sections is 13 per 100,000 and for vaginal birth 3.5 per 100,000 in the developed world. The UK National Health Service gives the risk of death for the mother as three times that of a vaginal birth.
In Canada the difference in bad outcome in the mother (e.g. cardiac arrest, wound hematoma, or hysterectomy) was 1.8 additional cases per 100 or three times the risk.
As with all types of abdominal surgeries, a Caesarean section is associated with risks of postoperative adhesions, incisional hernias (which may require surgical correction) and wound infections. 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. Other risks include severe blood loss (which may require a blood transfusion) and postdural-puncture spinal headaches.
Women who had Caesarean sections were more likely to have problems with later pregnancies, and it is recommended that women who want larger families should not seek an elective Caesarean. The risk of placenta accreta, a potentially life-threatening condition, is 0.13% after two Caesarean sections, but increases to 2.13% after four and then to 6.74% after six or more. Along with this is a similar rise in the risk of emergency hysterectomies at delivery.
Women who had just one previous Caesarean section are 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 deliveries. However, some risks may be due to confounding factors related to the indication for the first Caesarean, rather than due to the procedure itself.
Mothers can experience increased incidence of postnatal depression, and can experience significant psychological birth trauma and ongoing birth-related post-traumatic stress disorder after obstetric intervention during the birthing process. Factors like pain in first stage of labor, feelings of powerlessness, intrusive emergency obstetric intervention are important in the development of birth trauma.
Non-medically indicated (elective) childbirth before 39 weeks gestation "carry significant risks for the baby with no known benefit to the mother." Complications from elective cesarean before 39 weeks include: newborn mortality at 37 weeks may be 2.5 times the number at 40 weeks, and was elevated compared to 38 weeks of gestation. These “early term” births were also associated with increased death during infancy, compared to those occurring at 39 to 41 weeks ("full term"). Researchers in one study and another review found many benefits to going full term, but “no adverse effects” in the health of the mothers or babies.
The American College of Obstetricians and Gynecologists and medical policy makers review research studies and find increased incidence of suspected or proven sepsis, RDS, Hypoglycemia, need for respiratory support, need for NICU admission, and need for hospitalization > 4–5 days. In the case of cesarean sections, rates of respiratory death were 14 times higher in pre-labor at 37 compared with 40 weeks gestation, and 8.2 times higher for pre-labor cesarean at 38 weeks. In this review, no studies found decreased neonatal morbidity due to non-medically indicated (elective) delivery prior to 39 weeks.
In contrast with singleton pregnancies, the medical literature recommends delivery of dichorionic twins at 38 weeks, and monochorionic twins (identical twins sharing a placenta) by 37 weeks due to the increased risk of stillbirth in monochorionic twins who remain in utero after 37 weeks. The consensus is that late preterm delivery of monochorionic twins is justified because the risk of stillbirth for post-37 week delivery is significantly higher than the risks posed by delivering monochorionic twins near term (i.e., 36–37 weeks).
The consensus concerning monoamniotic twins (identical twins sharing an amniotic sac), the highest risk type of twins, is that they should be delivered by caesarean section at or shortly after 32 weeks.
In a research study widely publicized, singleton children born earlier than 39 weeks may have developmental problems, including slower learning in reading and math.
Other risks include:
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There are several types of Caesarean section (CS). An important distinction lies in the type of incision (longitudinal or latitudinal) made on the uterus, apart from the incision on the skin.
In many hospitals, especially in Argentina, the United States, United Kingdom, Canada, Norway, Sweden, Finland, 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.
Cesarean section can be performed with single or double layer suturing of the uterine incision. A Cochrane review came to the result that single layer closure compared with double layer closure was associated with a statistically significant reduction in mean blood loss.
A modified cesarean section which has been used nearly all over the world in the last 20 years. It was described by Michael Stark, the president of the New European Surgical Academy, at the time he was the director of the Misgav Ladach general hospital in Jerusalem. The method was presented during a FIGO conference in Montréal in 1994 and then distributed by the University of Uppsala, Sweden, in more than 100 countries. This method is based on minimalistic principles. He examined all steps in cesarean sections in use, analyzed them for their necessity and, if found necessary, for their optimal way of performance. For the abdominal incision he used the modified Joel Cohen incision and compared the longitudinal abdominal structures to strings on musical instruments. As blood vessels and muscles have lateral sway, it is possible to stretch rather than cut them. The peritoneum is opened by repeat stretching, no abdominal swabs are used, the uterus is closed in one layer with a big needle to reduce the amount of foreign body as much as possible, the peritoneal layers remain unsutured and the abdomen is closed with two layers only. Women undergoing this operation recover quickly and can look after the newborns soon after surgery. There are many publications showing the advantages over traditional cesarean section methods.
Both general and regional anaesthesia(spinal, epidural or combined spinal and epidural anaesthesia) are acceptable for use during Caesarean section. Regional anaesthesia is preferred as it allows the mother to be awake and interact immediately with her baby. Other advantages of regional anesthesia include the absence of typical risks of general anesthesia: pulmonary aspiration (which has a relatively high incidence in patients undergoing anesthesia in late pregnancy) of gastric contents and Oesophageal intubation.
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 from 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 Caesarean delivery is also higher than that required for labor analgesia.
General anesthesia may be necessary because of specific risks to mother or child. Patients with heavy, uncontrolled bleeding may not tolerate the hemodynamic effects of regional anesthesia. General anesthesia is also preferred in very urgent cases, such as severe fetal distress, when there is no time to perform a regional anesthesia.
Typically, the recovery time depends on the patient and her pain tolerance and inflammation levels. Doctors do recommend abstention from strenuous work (e.g., lifting objects over 10 lbs (4.5 kg)., running, walking up stairs, or athletics) for up to six weeks[medical citation needed] , and a waiting period of ~18 months before attempting to conceive another child.[medical citation needed]
Postpartum infection is one of the main causes of morbidity and mortality around childbirth, accounting for around 10% of maternal deaths globally. Cesarean section greatly increases the risk of infection and associated morbidity (estimated to be between 5 and 20 times as high). Infection can occur in around 8% of women who have cesareans, largely endometritis, urinary tract infections and wound infections.
Antibiotic prophylaxis is particularly effective for endometritis, preventing as many as 3 out of 4 cases. Taking antibiotics before skin incision further reduces the risk for the mother, without increasing adverse effects for the baby.
It is generally agreed that the prevalence of C-section is higher than needed in many countries and physicians are encouraged to actively lower the rate. Some of these efforts include: emphasizing that a long latent phase of labor is not abnormal and thus not a justification for C-section; changing the start of active labor from a cervical dilation of 4 cm to a dilation of 6 cm; and allowing at least 2 hours of pushing for women who have previously given birth and 3 hours of pushing for women who have not previously given birth before labor arrest is considered.
In the United Kingdom, in 2008, the Caesarean section rate was 24%. In Ireland the rate was 26.1% in 2009. The Canadian rate was 26% in 2005–2006. Australia has a high Caesarean section rate, at 31% in 2007. In the United States the rate of C-section is around 33% and varies from 23% to 40% depending on the state in question.
In Italy the incidence of Caesarean sections is particularly high, although it varies from region to region. In Campania, 60% of 2008 births reportedly occurred via Caesarean sections. In the Rome region, the mean incidence is around 44%, but can reach as high as 85% in some private clinics.
With nearly 1.3 million stays, Cesarean section was one of the most common procedures performed in U.S. hospitals in 2011. It was the second-most common procedure performed for people ages 18 to 44 years old. Caesarean rates in the U.S. have risen considerably since 1996. The procedure increased 60% from 1996 to 2009. In 2010, the Cesarean delivery rate was 32.8% of all births (a slight decrease from 2009's high of 32.9% of all births). A study found that in 2011, women covered by private insurance were 11% more likely to have a caesarean section delivery those covered by Medicaid.
China has been cited as having the highest rates of C-sections in the world at 46% as of 2008.
Studies have shown that continuity of care with a known carer may significantly decrease the rate of Caesarean delivery but 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.
More emergency Caesareans—about 66%—are performed during the day rather than during the night.
In the United States C-section rates have increased from just over 20% in 1996 to 33% in 2011. This increase has not resulted in improved outcomes resulting in the position that C-sections may be done too frequently.
The World Health Organization officially withdrew its previous recommendation of a 15% C-section rates in June 2010. Their official statement read, "There is no empirical evidence for an optimum percentage. What matters most is that all women who need caesarean sections receive them."
The US National Institutes of Health says rises in rates of Caesarean sections are not, in isolation, a cause for concern, but may reflect changing reproductive patterns: "The World Health Organization has determined an “ideal rate” of all cesarean deliveries (such as 15 percent) for a population. One surgeon's opinion[who?] is that there is no consistency in this ideal rate, and artificial declarations of an ideal rate should be discouraged. Goals for achieving an optimal cesarean delivery rate should be based on maximizing the best possible maternal and neonatal outcomes, taking into account available medical and health resources and maternal preferences. This opinion is based on the idea that if left unchallenged, optimal cesarean delivery rates will vary over time and across different populations according to individual and societal circumstances."
The number of C-sections performed has grown, for example, a fourfold increase from 1971 to 1991 (from 4.2 per 100 births). This may be accredited to the improved technology in detecting prebirth distress. Malpractice has been looked into because of the rapid increase. Some argue the higher costs of C-section births compared to regular births make physicians quicker to recommend surgery. Usually, if a doctor makes a recommendation, people are quick to take it to heart and act upon it. The effect of relative C-section price on C-section usage should be examined.
Some have speculated that cesarean section rates have increased due to a relationship between birth weight and maternal pelvis size, positing on the basis of Darwinian-inspired logic that since the advent of successful Caesarean birth over the last 150 years, more mothers with small pelvises and babies with large birth weights have survived and contributed to these traits. However, this idea fails to take into account that historically disproportion in childbirth was caused by maternal malnutrition in childhood, in particular malformed pelvic bones due to childhood rickets. Improved maternal nutrition should have led to increased ease in vaginal birth, not an increase in cesarean sections.
The mother of Bindusara (born c. 320 BCE, ruled 298 – c.272 BCE), the second Mauryan Samrat (emperor) of India, accidentally consumed poison and died when she was close to delivering him. Chanakya, the Chandragupta's teacher and adviser, made up his mind that the baby should survive. He cut open the belly of the queen and took out the baby, thus saving the baby's life.
According to the ancient Chinese Records of the Grand Historian, Luzhong, a sixth-generation descendant of the Yellow Emperor, had six sons, all born by "cutting open the body". The sixth son Jilian founded the House of Mi that ruled the State of Chu (c. 1030–223 BCE).
Pliny the Elder theorized that Julius Caesar's name came from an ancestor who was born by Caesarean section, but the truth of this is debated (see the article on the Etymology of the name of Julius Caesar). 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 the Roman ruler and general was born by Caesarean section. His first wife however died in childbirth, giving birth to a stilborn son who might have lived had a caesarean taken place.
An early account of Caesarean section in Iran is mentioned in the book of Shahnameh, written around 1000 AD, and relates to the birth of Rostam, the national legendary hero of Iran. According to the Shahnameh, the Simurgh instructed Zal upon how to perform a Caesarean section, thus saving Rudaba and the child Rostam.
Caesarean section usually resulted in the death of the mother; the first recorded incidence of a woman surviving a Caesarean section was in the 1580s, in Siegershausen, Switzerland: Jakob Nufer, a pig gelder, is supposed to have performed the operation on his wife after a prolonged labour. However, there is some basis for supposing that women regularly survived the operation in Roman times. For most of the time since the 16th century, the procedure had a high mortality rate. However, it was long considered an extreme measure, performed only when the mother was already dead or considered to be beyond help. 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 Caesarean 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 they had been employed for some time. Dr. James Barry carried out the first successful Caesarean by a European doctor in Africa in Cape Town, while posted there between 1817 and 1828.
The first successful Caesarean section to be performed in America took place in what was formerly Mason County, Virginia (now Mason County, West Virginia), in 1794. The procedure was performed by Dr. Jesse Bennett on his wife Elizabeth.
On March 5, 2000, in Mexico, 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.
The Roman Lex Regia (royal law), later the Lex Caesarea (imperial law), of Numa Pompilius (715–673 BCE), required the child of a mother dead in childbirth to be cut from her womb. This seems to have begun as a religious requirement that mothers not be buried pregnant, and to have evolved into a way of saving the fetus, with Roman practice requiring a living mother to be in her tenth month of pregnancy before resorting to the procedure, reflecting the knowledge that she could not survive the delivery. Speculation that the Roman dictator Julius Caesar was born by the method now known as C-section is apparently false. Although Caesarean sections were performed in Roman times, no classical source records a mother surviving such a delivery – the earliest recorded survival dates to the 12th century scholar and physician Maimonides (see Commentary to Mishnah Bekhorot 8:2). The term has also been explained as deriving from the verb caedere, "to cut", with children delivered this way referred to as caesones. Pliny the Elder refers to a certain Julius Caesar (an ancestor of the famous Roman statesman) as ab utero caeso, "cut from the womb" giving this as an explanation for the cognomen "Caesar" which was then carried by his descendents. Nonetheless, even if the etymological hypothesis linking the cesarean section to Julius Caesar is a false etymology, it has been widely believed. For example, the Oxford English Dictionary defines Caesarean birth as "the delivery of a child by cutting through the walls of the abdomen when delivery cannot take place in the natural way, as was done in the case of Julius Caesar". Merriam-Webster's Collegiate Dictionary (11th edition) leaves room for etymological uncertainty with the phrase, "from the legendary association of such a delivery with the Roman cognomen Caesar"
Some link with Julius Caesar or with Roman emperors exists in other languages as well. For example, the modern German, Norwegian, Danish, Dutch, Swedish, Turkish and Hungarian terms are respectively Kaiserschnitt, keisersnitt, kejsersnit,keizersnede, kejsarsnitt, sezeryan, and császármetszés (literally: "Emperor's cut"). The German term has also been imported into Japanese (帝王切開 teiōsekkai) and Korean (제왕 절개 jewang jeolgae), both literally meaning "emperor incision". Similar in western Slavic (Polish) cięcie cesarskie, (Czech)císařský řez and (Slovak) cisársky rez (literally "imperial cut"), whereas the south Slavic term is Serbian царски рез and Slovenian cárski réz, which literally means "tzar" cut. The Russian term kesarevo secheniye (Кесарево сечение késarevo sečénije) literally means Caesar's section. The Arabic term (ولادة قيصرية wilaada qaySaríyya) also means "Caesarean birth." The Hebrew term ניתוח קיסרי (nitúakh Keisári) translates literally as Caesarean surgery. In Romania and Portugal, it is usually called cesariana, meaning from (or related to) Caesar.
According to Shahnameh ancient Persian book, the hero Rostam was the first person who was born with this method and term رستمينه (rostamineh) is corresponded to Caesarean. Also, Hindu mythical monkey god Hanuman was born through a similar procedure on her mother Anjani.
Finally, the Roman praenomen (given name) Caeso was said to be given to children who were born via C-section. While this was probably just folk etymology made popular by Pliny the Elder, it was well known by the time the term came into common use.
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While vaginal births after Caesarean (VBAC) are not uncommon today, the rate of VBAC has declined to include less than 10% of births after previous Cesarean. Although Caesarean deliveries made up only 5% of births overall in the USA until the mid-1970s, it was commonly believed that for women with previous Caesarean sections, "Once a Caesarean, always a Caesarean". A consumer-driven movement supporting VBAC changed medical practice and led to soaring rates of VBAC in the 1980s and early 1990s, but rates of VBAC dramatically dropped after the publication of a highly publicized scientific study showing worse outcomes for VBACs as compared to repeat Caesarean and the resulting medicolegal changes within obstetrics. In 2010, the National Institutes of Health, U.S. Department of Health and Human Services, and American College of Obstetrics and Gynecology all released statements in support of increasing VBAC access and rates.
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). 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, while others do not. In the US, the American College of Obstetricians and Gynecologists (ACOG) modified the guidelines on vaginal birth after previous Caesarean delivery in 1999, 2004, and again in 2010. In 2004, this modification to the guideline included the addition of the 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.
In 2010, ACOG modified these guidelines again to express more encouragement of VBAC, but maintained it should still be undertaken at facilities capable of emergency care, though patient autonomy in assuming increased levels of risk should be respected (ACOG Practice Bulletin Number 115, August 2010).
The recommendation for access to emergency care during trial of labor has, in some cases, had a major impact on the availability of VBACs to birthing mothers in the US. For example, a study of the change in frequency of VBAC deliveries in California after the change in guidelines, published in 2006, found 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 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 babies or attempting delivery outside the hospital setting.
Most recently, enhanced access to VBAC has been recommended based on updated scientific data on the safety of VBAC as compared to repeat Caesarean section, including the following recommendation emerging from the NIH VBAC conference panel in March 2010, "We recommend that hospitals, maternity care providers, health care and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor." The U.S Department of Health and Human Services' Healthy People 2020 initiative includes objectives to reduce the primary cesarean rate and to increase the VBAC rate by at least 10% each.
There is a dispute among the poskim (Rabbinic authorities) as to whether a first-born son from a Caesarean section has the laws of a bechor. Traditionally, a male child delivered by Caesarean is not eligible for the Pidyon HaBen dedication ritual.
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