Caesarean section

A team of obstetricians perform a caesarean section in a modern hosptial. The image shows the very first moment the mother glimpses her new-born child.

Caesarean section
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List of terms related to Caesarean section

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

A caesarean section (AE cesarean section), or 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 normal.

Etymology

The earliest attested usages of the made up language in an obstetric context date from the first century. 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 case 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 thus. Whether or not the story is true, it may have been widely enough believed to give its name to the operation. (The reverse view, that the name "Caesar" was derived from the operation, is clearly indefensible, see below.)
3. An alternative etymology has been proposed, suggesting that the procedure's name derives from the Latin verb caedere (supine stem caesum), "to cut," in which case the term "Caesarean section" is a tautology. 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. The merits of this view must be considered separately from the corollary believed by some, that Caesar himself derived his name from the operation. This is certainly false: the cognomen "Caesar" had been used in the Julii family for centuries before Julius Caesar's birth[2], 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 Julius Caesar, or with Roman emperors generally, exists in other languages as well. For example, the modern German & Dutch terms are respectively Kaiserschnitt & 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."

History

Successful caesarean section performed by indigenous healers in Kahura, Uganda. As observed by R. W. Felkin in 1879.

Pliny the Elder theorized that Julius Caesar's namesake came from an ancestor who was born by Caesarian section, but the truth of this is debated. The Ancient Roman c-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 was a c-section baby. (In fact, she died 45 years later.) It should be noted that Maimonides, the famous rabbi, philosopher, and doctor, says that it was known in ancient Rome how to perform a c-section without killing the mother, but that the medical knowledge of his day was lacking and it was not performed. Thus it would seem that, according to what Maimonides knew, c-sections were not performed solely on dying women, but also on mothers who would live after the birth of their child.

The Catalan saint, Raymond Nonnatus (1204-1240), received his surname — from the Latin non natus ("not born") — because he was born by C-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).

Caesarian 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:

• Adherence to principles of asepsis.
• The introduction of uterine suturing by Max Sänger in 1882.
• Extraperitoneal CS and then moving to low transverse incision (Krönig, 1912).
• Anesthesia advances.
• Blood transfusion.
• Antibiotics.

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

A caesarean section in progress.

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 obstetrical emergency, where complications of pregnancy onset suddenly during the process of labor, 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 CS have been used, such as extraperitoneal CS or Porro CS.
• a repeat caesarean section is done when a patient had a previous section. Typically it is performed through the old scar.

In many hospitals, especially in 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 c-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.

As scheduled caesarean sections have become a rather safe operation (but see section on Risks), there has been a movement to perform caesarean delivery on maternal request (CDMR). 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, major puerperal infection, anaesthetic complications, venous thromboembolism, and haemorrhage requiring hysterectomy over those suffered by the planned vaginal delivery group.

A study published in the February 2007 issue of the journal Obstetrics and Gynecology found that women who had just one previous ceasarian section were more likely to have problems with their second birth. Women who delivered their first child by cesarean delivery had increased risks for malpresentation, placenta previa, antepartum hemorrhage, placenta accreta, prolonged labor, emergency cesarean, uterine rupture, preterm birth, low birth weight, small for gestational age 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 caesarian sections were more likely to have problems with later pregnancies, and recommended that women who want larger families should not seek caesarian section as an elective. The risk of placenta accreta, a potentially life-threatening condition, is 0.13% after two c-sections, and 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)

Babies born by caesarean sometimes have some initial trouble breathing. In addition, because the baby may be drowsy from the pain medication administered to the mother, and because the mother's mobility is reduced, breastfeeding may be difficult.

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 CS 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 anesthesia risk.

Incidence

The World Health Organisation 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. In 2005 the caesarean rate was 30.2% in the United States. During 2001–2002, the Canadian caesarean section rate was 22.5%. In the United States the caesarean rate has risen 46% since 1996.

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

Main article: Elective caesarean section

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 3 a.m: for unknown reasons, naturally-occurring labour seems to occur most often between midnight and dawn. 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. A recent study in the British Medical Journal retrospectively analysed a large number of caesarean sections 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

The mother has the option of receiving regional anaesthesia (spinal or epidural) or general anaesthesia for caesarean section. Regional anaesthesia has the advantage of allowing her to remain awake for the delivery and avoids sedation of the newborn. Pain relief after the caesarean is also improved.

General anaesthesia for caesarean section is becoming less common as scientific research has now clearly established the benefits of regional anaesthesia for both the mother and baby. General anaesthesia tends to be reserved for emergencies where the mother or baby's life is immediately threatened or other high-risk cases. The risks of general anaesthesia for mother and baby are still extremely small overall.

If the mother already has an epidural in, this epidural can often be used for the caesarean section. Multiple recent studies have now shown that epidurals in labour do not increase the caesarean section rate (Meta analysis 2005 Anim-Somuah, Cochrane Review) but they may increase the risk of a forceps or instrumental delivery. Epidurals placed after 5cms dilation is achieved do not affect chance of c-section. Epidurals traditionally have been known to slow down the progress of labour, but recent work has shown that they may actually speed up the labour process (COMET Study, Lancet 2001).

Vaginal birth after caesarean

Main article: 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 due 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.

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.

Contraindicated medications

Previous caesarean section is considered a relative contraindication to the use of the following medications:

• Oxytocin

Caesareans in fiction

The first caesarean section according to mythology was performed by Apollo on his lover Coronis when he delivered Asklepios.

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 possibly from a blundered procedure and runs from the abdomen to the breasts, and is in the shape of a snake.

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 caesarian 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 1660's the surgeon protagonist delivers his own daughter by caesarean, but the mother dies shortly thereafter.

References

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