Caesarean section

A Caesarean section (or Cesarean section in American English), also known as C-section, 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 would otherwise have been natural. ^[1][2][3]The World Health Organization (WHO) recommends that caesarean sections rates should not go above 15% in any country. However, rates between 5% to 10% are best. ^[4]

Etymology

There are three theories about the origin of the name:

1. 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.^[5] (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 an ancestor of Caesar was delivered in this manner.^[6]
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,^[7] 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").^[8] The German term has also been imported into Japanese (帝王切開) and Korean (제왕 절개, 帝王 切開), both literally meaning "emperor incision." The South Slavic term is carski rez, which literally means imperial cut.

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 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.^[9]

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:

• 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.

Incision for lower uterine segment section after stapling has been completed.

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.

• 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

A 7 week old Caesarean section scar and linea nigra visible on a 31 year old female; this Caesarean section was performed due to dystocia.

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)
• Loss 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])^[10]
• Improper Use of Technology (Electric Fetal Monitoring [EFM])^{[10] [11]}
• hypertension^[12]

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 for the Mother

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.^[13] However the mortality rate for both continues to drop steadily. In 2000, the mortality rate for caesareans in the United States were 20 per 1,000,000.^[14] The UK National Health Service gives the risk of death for the mother as three times that of a vaginal birth.^[15] 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. ^[16] Again, these figures can be significantly distorted given that women with severe health conditions are more likely to preschedule births by caesarean.

A Caesarean section is a major operation, with all that it entails, including the risk of post-operative adhesions. Incisional hernias (which may require surgical correction) and wound infections can occur.^[14] 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.^[17] Other risks include severe blood loss (which may require a blood transfusion) and post spinal headaches.^[14]

Even long after the caesarean has happened, there are still risks that need to be considered. These can include ongoing pelvic pain, bowel blockage, and future infertility.^[18] Pain at the incision can be intense, interfering with functioning, and may require more visits to the hospital., and full recovery of mobility can take several weeks or more.^[18] A prior Caesarean section increases the risk of uterine rupture during subsequent labour.

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.^[19] (see also review by WebMD.com)

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.^[20]

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. ^[21]

Babies born by caesarean are more likely to have breathing problems. ^[18] Recent studies have shown that babies born by caesarean section have a 50% increased risk of developing asthma later in life when compared to babies born vaginally.^[22]

For the baby, complications can also include neonatal depression due to anesthesia and fetal injury due to the uterine incision and extraction. ^[14]

Babies born by caesarean section are more likely to have difficulty beginning breast feeding. ^[18] Not only do babies born by caesarean take long to begin breast feeding, but they also are less likely to be exclusively breast fed. ^[14]

Risks for Both Mother and Child

Due to extended hospital stays, both the mother and child are at risk for developing a hospital born infection.^[14]

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. ^[14]

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.^[23]

In the United States the Caesarean rate has risen 46% since 1996,^[24] reaching a level of 30.2% in 2005.^[24] 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.^[25]

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^[26] 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.^[27]

Reasons for a Rise in Caesarean Section Rates

Low Priority of Enhancing Women's Own Abilities to Give Birth^[18]: 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."^[28]

Side Effects of Common Labor Interventions: Research has shown that inducing first-time mothers appears to increase the likelihood of a caesarean. This may be due to the fact that the cervix may not be ready for birth (soft and open).^[18] Improper use of electro fetal monitoring is also cited as a labor intervention that is increasing caesarean section rates. For women who are experiencing a low risk pregnancy and birth, electro fetal monitoring is not recommended. It has often produced false alarms. Because of these false alarms providers often jump to a caesarean.^{[10] [11]}

Refusal to Offer the Informed Choice of Vaginal Birth^[18]: Women are not being presented with enough information to make informed decisions when it comes to childbirth. Rather, the decision is often made for them. Due to medicolegal restrictions on VBACS, women are not allowed to birth in the method they chose. Many hospitals do not allow women to even attempt VBACS and individual providers as well.^[29] Women whose fetuses are in the breech position are also not often offered the choice of birthing vaginally.^[18]

Limited Awareness of Risks and Harms that are the Result of Caesareans^[18]: A Caesarean is major surgery. As a result, there are many long and short term risks and side effects for both the mother and child when it comes to caesarean sections. Many women are finding themselves unaware of the risks and side effects when the option of a caesarean is presented to them or the decision made for them.^[18]

Providers' Fear of Medical Malpractice Suits^[18]: Many obstetricians may perform caesareans out of fear that they will be sued (despite the fact that this has proven to be a flawed way of thinking^{[30] [31]}). Instead of using methods such as allowing a woman to walk (in order to encourage a breech baby to turn) or waiting for labor to progress (when the cervix does not appear to be dialated) providers are jumping straight to caesareans. ^[18]

Incentives to Practice in a Manner that is Efficient for Providers/Insurance Companies: Providers are paid more by insurance companies to perform a caesarean than they are for a vaginal birth. Also, hospitals profit more from caesareans than a vaginal birth. Many health care professionals (obstetricians included) are forced to practice in a health care system that demands they see as many patients as possible in the shortest amount of time. Planning caesareans is an efficient way for hospitals to organize themselves. ^[18]

Loss of Obstetric Skill: While women are finding is hard to obtain an obstetrician who is willing to perform a breech delivery, VBAC, or multiple birth vaginally, a whole generation of doctors are being deprived of the opportunity to learn how to deliver babies in this way.^[10] Providers who are not skilled in overseeing breeches, VBACS, or vaginal multiple births are putting themselves at risk for malpractice suit and their patients at risk for morbidity and mortality.

Medicalization of Childbirth: . In an age where naturally occurring events like menopause and menstruation are treated as medical conditions with hormone replacement therapy and ibuprofen/Midol, it is no surprise that childbirth has become medicalized as well. Medicalization comes in the form of improper use of electro fetal monitoring, a technology that is not recommended for use with women who have had an uncomplicated, low risk, pregnancy/birth.^{[10] [11]} Birth is now treated as a a medical problem rather than a naturally occurring event in a women's life. Women are moving to hospitals to birth their babies from the homes in which they used to birth.

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 an hour that is not predetermined. ^[32] 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. Despite the fact that many doctors are performing caesareans out of fear of a malpractice lawsuit, they are actually putting themselves more at risk as research shows that as the rates of caesareans rise, so do the number of medical malpractice suits. ^[33]

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.^[34] 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.^[35] 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.

While 42% of obstetricians blame expectant mothers (among other sources) for the rising caesarean section rates^[36], the actual number of women asking for unnecessary caesareans (without a medical reason) is actually somewhere around 2% ^[29]. Studies from Sweden also confirm this fact ^[37]. This absolves women of the idea that they are the sole reason for the rise of caesareans in this country. However, their reputation precedes them despite extensive literature showing that women are not asking for caesareans without medical necessity.

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.^[38] 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.^[39] 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.^[40]

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.^[40]

Vaginal birth after caesarean

Main article: Vaginal birth after caesarean

While Vaginal birth after caesarean (VBAC) are not uncommon today, their numbers are shrinking^[41]. 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.^[42]

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^[43]. 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.^[44]

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^[45]. 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^[46].

Financial Costs

Caesareans are far more expensive than vaginal births. As women of all social classes and levels of income give birth with and without insurance, this has severe economic repercussions. In Massachusetts, a caesarean without complications costs $11,500 when compared with a vaginal delivery with no complications at $6,200. A caesarean is even more than a vaginal delivery with complications costing $8,200. A caesarean with complications costs $15,500.^[47] Nationally, the figures are similar with vaginal births at a birthing center being the least expensive at $1,624; a vaginal birth at a hospital with no complications averages at $6,973; with complications at a hospital rises to an average of $8,963; a caesarean without complications averages at $12,544; while a caesarean with complications averages at $15,960.^[48] Women (and their families) pay between $0 and the costs of the delivery itself depending on what type of insurance they have, if they have it all. This effects women of a lower socioeconomic status more as they are less likely to have the means to pay for these higher costs. Also, the time needed to recover from a caesarean is greater than it is for a vaginal birth. Women of a lower socioeconomic status may be in greater danger of losing their jobs if they are not lucky enough to have a decent maternity leave package. This would result in even greater financial troubles for them and their family.

How to Safely Lower Caesarean Section Rates

Education of Women: Extensive literature has shown that women are not being told what their bodies are capable of doing and have been doing for thousands of years. Women need to know their options. While many hospitals and providers do not allow their patients to attempt a VBAC, a breech birth, or multiples, women need to know that birthing in these situations vaginally is still an option. It can be done safely. Because it has been shown that women are "less prepared" to give birth than women in generations past, education needs to be done in order to give women confidence in their bodies. Louise Silverton of the Royal College of Midwives cites a decline in antenatal classes as a reason for the rise in caesareans. Classes that bring pregnant women together to discuss the issues with an informed, unbiased instructor would have a positive influence not just on the women in the classes, but on the caesarean section rates as a whole.^[49]

Education of Doctors:It has been found that, despite doctors performing caesareans as a result of their fear of malpractice suits, as caesarean section rates rise, medical malpractice suits rise as well. Doctors need to be made aware of this correlation as it appears to be a myth in the world of medicine that performing caesareans will prevent one from being sued.^{[50] [51]} Also, by training student doctors in breech, VBAC, and multiple births, they can become better providers, making safer choices for themselves and their patients.^[10]

Incentives at the Local Level: Incentives at the local level can include rewards and/or recognition for individual doctors, obstetrics/gynecology floors, or whole hospitals with the lowest caesarean section rates.^[52]

Improvement of Labor and Delivery Management: In England one in five women are left alone during childbirth.^[53] Not caring for birthing women correctly is having a massive impact on caesareans. in a very negative way. W. Savage asks in the 2007 paper, "Could it be that the way labour is conducted-in large, hashley lit, noisy, impersonal labour wards with gangs of doctors coming round at intervals and constantly changing staff- affects the way women labour?".^[10] This is a a bold but true analysis on how women are cared for during childbirth. Electro fetal monitoring is not needed for women experiencing a low risk pregnancy. It has been shown that electro fetal monitoring often produces false alarms, prompting unnecessary caesareans. Women who have had an uncomplicated/unremarkable pregnancy and are not at risk for any complications do not need to have electro fetal monitoring as a part of their child's birth.^{[10] [11]}

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 Catherine 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

Caesarean section at the Open Directory Project