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Caesarean section
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A Caesarean section (or Cesarean section in American English), also known as C-section or Caesar, is a surgical procedure in which incisions are 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 childbirths that could otherwise have been natural.
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A Caesarean section (or Cesarean section in American English), also known as C-section or Caesar, is a surgical procedure in which incisions are 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 childbirths that could otherwise have been natural. The World Health Organization (WHO) recommends that the rate of Caesarean sections should not exceed 15% in any country. In 2006, the rate of U.S. births by C-section was 31.1%.
Etymology
There are three theories about the origin of the name:
- 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.)
- 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 an ancestor of Caesar was delivered in this manner.
- An alternative etymology suggests that the procedure's name derives from the Latin verb (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 and Korean (?? ??, ?? ??), both literally meaning "emperor incision." The South Slavic term is carski rez, which literally means caesarean cut. The Arabic term (????????) also means pertaining to Caesar or literally Caesarean.
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 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 that the Roman Dictator and General was born by Caesarean section.
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. 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 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 section (CS). The differences between them lie primarily in the deep incision made on the uterus, apart from the type of laparotomy used to access the uterus.
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.
Complications
Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. Not all of the listed conditions represent a mandatory indication, and in many cases the obstetrician must make use of his discretion to decide whether a caesarean is necessary. Some indications for caesarean delivery are:
Complications of labor and factors impeding vaginal delivery such as
Other complications of preganancy, preexisting conditions and concomitant disease such as
- pre-eclampsia
- hypertension
- multiple births
- precious (High Risk) Fetus
- HIV infection of the mother
- 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)
Other
- Lack of Obstetric Skill (Obstetricians not being skilled in performing breech births, multiple births, etc. [In most situations women can birth under these circumstances naturally. However, obstetricians are not always trained in proper procedures])
- Improper Use of Technology (Electric Fetal Monitoring [EFM])
Risks
Risks for the mother
The mortality rate for both caesarian sections and vaginal birth, in the Western world, continues to drop steadily. In 2000, the mortality rate for caesareans in the United States were 20 per 1,000,000. 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 conditions, or higher-risk pregnancies, 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 the absolute differences in severe maternal morbity and mortality was small, but that the additional risk over vaginal delivery should be considered by women contemplating an elective cesarean delivery and by their physicians.
As with all types of abdominal surgery, a Caesarean section is associated with risks of post-operative 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 post spinal headaches.
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.
It is difficult to study the effects of caesarean sections because it can be difficult to separate out issues caused by the procedure itself versus issues caused by the conditions that require it. For example, 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. However, the authors conclude that some risks may be due to confounding factors related to the indication for the first cesarean, rather than due to the procedure itself.
Risks for the child
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.
For the baby, complications can also include neonatal depression due to anesthesia and fetal injury due to the uterine incision and extraction.
One study found an increased risk of complications if a repeat elective Caesarean section is performed even a few days before the recommended 39 weeks.
Risks for both mother and child
Due to extended hospital stays, both the mother and child are at risk for developing a hospital-borne infection.
Studies have shown that mothers who have their babies by caesarean take longer to first interact with their child when compared with mothers who had their babies vaginally.
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 Italy the incidence of Caesarian sections is particularly high, albeit it varies from Region to Region. In Campania reportedly 90% of 2008 birth occurred via Ceasarian sections. In Rome, the incidence is around 80%, varying slightly according to the clinics.
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.
Analyzing the rise in caesarean section rates
The US National Institutes of Health says that rises in rates of caesarean sections are not, in isolation, a cause for concern, but may reflect changing reproductive patterns:
Some authors have proposed an “ideal rate” of all cesarean deliveries (such as 15 percent) for a population. There is no consistency in this ideal rate, and arti?cial 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. Thus, optimal cesarean delivery rates will vary over time and across different populations according to individual and societal circumstances.
Nonetheless, some commentators are concerned by the rise and have tried to generate theories to explain it. Louise Silverton, deputy general-secretary of the Royal College of Midwives, says that not only has society’s tolerance for pain and illness been “significantly reduced”, but also that women are scared of pain and think that if they have a caesarean there will be less, if any, pain. It is the opinion of Silverton and the Royal College of Midwives that “women have lost their confidence in their ability to give birth."
Silverton's analysis is controversial. Dr Maggie Blott, a consultant obstetrician at University College Hospital, London and a Royal College of Obstetricians and Gynaecologists spokeswoman on caesareans, responds: 'There isn't any evidence to support Louise Silverton's view that increasingly pain-averse women are pushing up the caesarean rate. There's an undercurrent that caesarean sections are a bad thing, but they can be life-saving.'
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. Italian gynaecologyst Enrico Zupi, whose clinic in Rome Mater Dai was under media attention for carrying a record of caesarian sections (90% over total birth), explained: “We shouldn't be blamed. Our approach must be understood. We doctors are often sued for events and complications that cannot be classified as malpractice. So we turn to defensive medicine. We will keep acting this way as long as medical mistakes are not depenalized. We are not martyrs. So if a pregnant woman is facing an even minimum risk, we suggest her to [get a c-section]”
Studies of United States 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.
Some 42% of obstetricians blame expectant mothers (among other sources) for the rising caesarean section rates. Studies from Sweden also confirm this..
Anaesthesia
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 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.
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.
Vaginal birth after caesarean
While Vaginal birth after caesarean (VBAC) are not uncommon today, their numbers are shrinking. 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.
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.
In Shakespeare's play Macbeth, 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 Catherine Barkley is delivered by Caesarean section in the Hemingway novel A Farewell to Arms.
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.
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.
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