| Caesarean section | |
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| Intervention | |
A team of obstetricians performing a Caesarean section in a modern hospital. |
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| ICD-9-CM | 74 |
| MeSH | D002585 |
A Caesarean section, (also C-section, Caesarian section, Cesarean section, Caesar, etc.) 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.
A Caesarean section 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.[1][2][3] In recent years the rate has risen to a record level of 46% in China and to levels of 25% and above in many Asian and European countries, Latin America, and the United States.[4]
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The Roman Lex Regia, (later the Lex Caesarea) of Numa Pompilius (715–673 BC), required that the child of a mother dead in childbirth be cut from her womb. [5] This seems to have begun as a religious requirement that mothers not be buried pregnant, [6] and to have evolved into a way of saving the fetus, with Roman practice requiring a living mother be in her 10th month of pregnancy before the procedure was resorted to, reflecting the knowledge that she could not survive the delivery. [7] 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,[5][8] – the earliest recorded survival dates to 1500 AD[9] – and Caesar's mother Aurelia Cotta lived to serve him as an advisor in his adulthood.[7]
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 (not the dictator, but a remote ancestor) as ab utero caeso, "cut from the womb", a godly attribute comparable to rumours about the birth of Alexander the Great. [10] This and Caesar's name may have led to a false etymological connection with the ancient monarch. It should be noted that the Oxford English Dictionary does not credit a derivation from "caedere", and 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 Cæsar".
Some link with Julius Caesar, or with Roman Dictators generally, exists in other languages as well. For example, the modern German, Danish, Dutch and Hungarian terms are respectively Kaiserschnitt, kejsersnit, keizersnede, and császármetszés (literally: "Emperor's cut").[11] 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 pertaining to Caesar or literally Caesarean. 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.
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.
Bindusara (born c. 320 BC, ruled 298 – c.272 BC), the second Mauryan Samrat (emperor) of India, is said to be the first child born by surgery.[13] His mother, wife of Chandragupta Maurya, accidentally consumed poison and died when she was close to delivering him. Chanakya, the Chandragupta's teacher and advisor, 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.[14][15]
According to the Shahnameh, the Simurgh instructed Zal upon how to perform a Caesarean section, thus saving Rudaba and the child Rostam.[16]
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 was the ancestor of the royal house of the State of Chu (c. 1030–223 BC).[17]
In the Irish mythological text the Ulster Cycle, the character Furbaide Ferbend is said to have been born by posthumous Caesarean section, after his mother was murdered by his evil aunt Medb.
The Babylonian Talmud, an ancient Jewish religious text, mentions a procedure similar to the Caesarian section. The procedure is termed "yotzei dofen".[15]
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 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.[18]
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".).
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.[19] However, there is some basis for supposing that women regularly survived the operation in Roman times.[20] For most of the time since the sixteenth 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.[21] 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.[21]
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.[22]
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.
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.[23][24]
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.
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 use 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 pregnancy, preexisting conditions and concomitant disease such as
Other
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.[28] The UK National Health Service gives the risk of death for the mother as three times that of a vaginal birth.[29] 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 morbidity and mortality was small, but that the additional risk over vaginal delivery should be considered by women contemplating an elective Caesarean delivery and by their physicians.[30]
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.[28] 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.[31] Other risks include severe blood loss (which may require a blood transfusion) and post spinal headaches.[28]
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.[32]
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 Caesarean, rather than due to the procedure itself.[33]
This list is currently incomplete and should not be taken as comprehensive or reflective of current research. It covers some of the most commonly discussed risks to the child posed by the procedure itself rather than the medical indications that may call for it. Some risks are rare, and as with most medical procedures the likelihood of any risk is highly dependent on individual factors such as whether other pregnancy complications exist, whether the operation is planned or done as an emergency measure, and how and where it is performed.
In 2004, the Caesarean rate was about 20% in the United Kingdom, while the Canadian rate was 22.5% in 2001–2002.[37]
In Italy the incidence of Caesarean sections is particularly high, although it varies from region to region.[38] In Campania, 60% of 2008 births reportedly occurred via Caesarean sections.[39] In the Rome region, the mean incidence is around 44%, but can reach as high as 85% in some private clinics.[40][41]
In the United States the Caesarean rate has risen 48% since 1996,[42] reaching a level of 31.8% in 2007.[42] 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.[43]
In Brazil's public health network, the rate reaches 35%, while in private hospitals the rate approaches 80%.
China has been cited as having the highest rates of C-sections in the world at 46% as of 2008[44]
Studies have shown that continuity of care with a known carer may significantly decrease the rate of Caesarean delivery[45] 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.[46]
More emergency Caesareans—about 66%—are performed during the day rather than during the night.[47]
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." [48]
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:
The World Health Organization has determined an “ideal rate” of all cesarean deliveries (such as 15 percent) for a population. One surgeon's opinion 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.[49]
There has been a rapid growth in the number of c-sections performed. For example, there has been a fourfold increase from 1971 to 1991. (From 4.2 c-sections per 100 births). This may be accredited to the improved technology in detecting pre-birth distress. Malpractice has been looked into because of the rapid increase in c-sections. Some argue that the higher costs of c-section births compared to regular births make physicians quicker to recommend a c-section. 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.
However, some commentators are concerned by the rise and have noted several evidence-based studies. 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."[50]
Silverton's analysis is controversial among some surgeons. Dr Maggie Blott, a consultant obstetrician at University College Hospital, London and then a Royal College of Obstetricians and Gynaecologists (RCOG) spokeswoman on Caesareans (and Vice President of the RCOG), responded: '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.'[50]
A previously unexplored hypothesis for the increasing section rate is the evolution of birth weight and maternal pelvis size. It is proposed that since the advent of successful Caesarean birth over the last 150 years, mothers with a small pelvis and babies with a large birth weight have survived and contributed to these traits increasing in the population. Such a hypothesis is based upon the idea that even without fears of malpractice, without maternal obesity and diabetes, and without other widely quoted factors, the C-section rate would continue to rise simply due to slow changes in population genetics.[51]
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.[52] Another reason for doctors to recommend C-section is money. In China, doctors are compensated based on the monetary value of medical treatments offered. As a result, doctors have an incentive to persuade mothers to choosing the more expensive C-section.
In this context, it is worth remembering that many studies have shown that operations performed out-of-hours tend to have more complications (both surgical and anaesthetic).[53] For this reason if a Caesarean is anticipated to be likely to be needed for a woman, it may be preferable to perform this electively (or pre-emptively) during daylight operating hours, rather than wait for it to become an emergency with the increased risk of surgical and anaesthetic complications that can follow from emergency surgery.
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 she gets a C-section "[38]
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.[54] 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.[55] Some have suggested that due to the comparative risks of Caesarean section with an uncomplicated vaginal delivery, patients should be discouraged or forbidden from choosing it.[56]
Some 42% of obstetricians believe the media and women are responsible for the rising Caesarean section rates.[57] Some studies, however, conclude that relatively few women wish to be delivered by Caesarean section.[58]
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.[59] 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.[60]
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.[61] 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 Caesarean delivery is also higher than that required for labor analgesia.[60]
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.
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.[62] [63] Although cesarean deliveries made up only 5% of births overall in the USA until the mid-1970s, it was commonly believed that for women with previous cesarean 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 80s and early 90s, but rates of VBAC dramatically dropped after the publication of a highly publicized scientific study showing worse outcomes for VBAC as compared to repeat cesarean and the resulting medico-legal changes within obstetrics.[64] 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.[65][66][67][68]
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, 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.[69] 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.[70]
In 2010, ACOG modified these guidelines again to express more encouragement of VBAC but maintained that it should still be undertaken at facilities capable of emergency care, even 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 that the VBAC rate fell to 13.5% after the change, compared with 24% VBAC rate before the change.[71] 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.[72]
Most recently, enhanced access to VBAC has been recommended based on updated scientific data on the safety of VBAC as compared to repeat cesarean 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."[65] 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.[68]
Typically the recovery time depends on the patient and her pain/inflammation levels. Doctors do recommend no strenuous work (i.e., lifting objects over 10 lbs., running, walking up stairs, or athletics) for up to six weeks.
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.[73] Traditionally, a male child delivered by Cesarean is not eligible for the Pidyon HaBen dedication ritual.[74][75]
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