C-Section Risks and Uses

17/3/2015
CaesareansectionWikipedia,thefreeencyclopedia
Caesareansection
FromWikipedia,thefreeencyclopedia
ACaesareansection(oftenCsection,alsootherspellings)isa
surgicalprocedureinwhichoneormoreincisionsaremadethrougha
mother'sabdomen(laparotomy)anduterus(hysterotomy)todeliver
oneormorebabies.ThefirstmodernCaesareansectionwasperformed
byGermangynecologistFerdinandAdolfKehrerin1881.
Caesareansection
Intervention
ACaesareansectionisoftenperformedwhenavaginaldeliverywould
putthebaby'sormother'slifeorhealthatrisk.Somearealso
performeduponrequestwithoutamedicalreasontodoso,whichisa
practicehealthauthoritieswouldliketoreduce.[1][2][3]
Csectionsresultinasmalloverallincreaseinbadoutcomesinlow
riskpregnancies.[4]ThebadoutcomesthatoccurwithCsectiondiffer
fromthosethatoccurwithvaginaldelivery.Establishedguidelines
recommendthatcaesareansectionsnotbeusedbefore39weeks
withoutamedicalindicationtoperformthesurgery.[5]
Inmanycountries,caesareansectionproceduresareusedmore
frequentlythanisnecessary,andconsequentlygovernmentsandhealth
organizationspromoteprogramstoreducetheuseofcaesareansection
infavorofusingvaginaldelivery.Thecountrieswhichreportoveruse
ofthisprocedurearenotfindingwaystodecreaseuseoftheprocedure
asmuchastheywouldlike.
AteamofobstetriciansperformingaCaesareansectioninamodern
hospital.
ICD10
PCS
10D00Z0
ICD9CM
74(http://icd9cm.chrisendres.com/index.php?
srchtype=procs&srchtext=74&Submit=Search&action=search)
1.1Medicaluses
MeSH
D002585
1.2Prevention
MedlinePlus 002911
Contents
1Uses
http://en.wikipedia.org/wiki/Caesarean_section
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2Risks
2.1Riskstothemother
2.2Riskstothechild
3Classification
3.1Byurgency
3.2Bycharacteristicsofthemother
3.3Otherways,includingbysurgerytechnique
4Technique
4.1Anaesthesia
4.2Preventionofcomplications
5Recoveryperiod
6Usage
6.1Increasinguse
7History
8Societyandculture
8.1Etymology
8.2Orthography
9Specialpopulations
10References
Uses
Caesareansectionisrecommendedwhenvaginaldeliverymightposearisktothemotherorbaby.Csectionsarealsocarriedoutforpersonal
preferencebutthisisnotrecommended.Plannedcaesareansectionsalsoknownaselectivecaesareansectionsshouldnotbescheduledbefore
39weeksgestationalageunlessthereisamedicalreasontodoso.
Medicaluses
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Somemedicalindicationsarebelow.Notallofthelistedconditionsrepresentamandatoryindication,andinmanycasestheobstetricianmust
usediscretiontodecidewhetheraCaesareanisnecessary.
Complicationsoflaborandfactorsimpedingvaginaldelivery,suchas:
abnormalpresentation(breechortransversepositions)
prolongedlabourorafailuretoprogress(dystocia)
fetaldistress
cordprolapse
uterineruptureoranelevatedriskthereof
increasedbloodpressure(hypertension)inthemotherorbabyafteramnioticrupture
increasedheartrate(tachycardia)inthemotherorbabyafteramnioticrupture
placentalproblems(placentapraevia,placentalabruptionorplacentaaccreta)
failedlabourinduction
failedinstrumentaldelivery(byforcepsorventouse(Sometimesatrialofforceps/ventouse
deliveryisattempted,andifunsuccessful,itwillbeswitchedtoaCaesareansection.)
largebabyweighing>4000g(macrosomia)
umbilicalcordabnormalities(vasaprevia,multilobateincludingbilobateandsuccenturiatelobed
placentas,velamentousinsertion)
Othercomplicationsofpregnancy,preexistingconditionsandconcomitantdisease,suchas:
A7weekoldCaesareansectionscar
andlineanigravisibleona31year
oldmother.
preeclampsia[6]
previous(highrisk)fetus
HIVinfectionofthemother
Sexuallytransmitteddiseases,suchasgenitalherpes(whichcanbefataltothebabyifthebabyisbornvaginally)
previousclassical(longitudinal)Caesareansection
previousuterinerupture
priorproblemswiththehealingoftheperineum(frompreviouschildbirthorCrohn'sdisease)
Bicornuateuterus
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Rarecasesofposthumousbirthafterthedeathofthemother
Other
Lackofobstetricskillobstetriciansnotbeingskilledinperformingbreechbirths,multiplebirths,etc.(Inmostsituationswomencan
birthvaginallyunderthesecircumstances,althoughplannedCsectionhasalowerriskofinfantdeathforbreechbirthsthanvaginal
delivery.[7]Obstetriciansarenotalwaystrainedinproperproceduresforsuchdeliveries,increasingtheriskstillfurther.)[8]
ImproperUseofTechnology(ElectricFetalMonitoring[EFM])[8][9]
Prevention
ItisgenerallyagreedthattheprevalenceofCsectionishigherthanneededinmanycountriesandphysiciansareencouragedtoactivelylower
therate.Someoftheseeffortsinclude:emphasizingthatalonglatentphaseoflaborisnotabnormalandthusnotajustificationforCsection
changingthestartofactivelaborfromacervicaldilationof4cmtoadilationof6cmandallowingatleast2hoursofpushingforwomen
whohavepreviouslygivenbirthand3hoursofpushingforwomenwhohavenotpreviouslygivenbirthbeforelaborarrestisconsidered.[4]
Physicalexerciseduringpregnancyalsodecreasestherisk.[10]
Risks
Adverseoutcomesinlowriskpregnanciesoccurin8.6%ofvaginaldeliveriesand9.2%ofCsectiondeliveries.[4]
Riskstothemother
InthosewhoarelowrisktheriskofdeathforCaesariansectionsis13per100,000andforvaginalbirth3.5per100,000inthedeveloped
world.[4]TheUKNationalHealthServicegivestheriskofdeathforthemotherasthreetimesthatofavaginalbirth.[11]
InCanadathedifferenceinbadoutcomeinthemother(e.g.cardiacarrest,woundhematoma,orhysterectomy)was1.8additionalcasesper
100orthreetimestherisk.[12]
Aswithalltypesofabdominalsurgeries,aCaesareansectionisassociatedwithrisksofpostoperativeadhesions,incisionalhernias(which
mayrequiresurgicalcorrection)andwoundinfections.[13]IfaCaesareanisperformedunderemergencysituations,theriskofthesurgerymay
beincreasedduetoanumberoffactors.Thepatient'sstomachmaynotbeempty,increasingtheanaesthesiarisk.[14]Otherrisksincludesevere
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bloodloss(whichmayrequireabloodtransfusion)andpostduralpuncturespinalheadaches.[13]
WomenwhohadCaesareansectionsweremorelikelytohaveproblemswithlaterpregnancies,anditisrecommendedthatwomenwhowant
largerfamiliesshouldnotseekanelectiveCaesarean.Theriskofplacentaaccreta,apotentiallylifethreateningcondition,is0.13%aftertwo
Caesareansections,butincreasesto2.13%afterfourandthento6.74%aftersixormore.Alongwith
thisisasimilarriseintheriskofemergencyhysterectomiesatdelivery.[15]
Motherscanexperienceincreasedincidenceofpostnataldepression,andcanexperiencesignificant
psychologicalbirthtraumaandongoingbirthrelatedposttraumaticstressdisorderafterobstetric
interventionduringthebirthingprocess.[16]Factorslikepaininfirststageoflabor,feelingsof
powerlessness,intrusiveemergencyobstetricinterventionareimportantinthedevelopmentofbirth
trauma.[16]
Subsequentpregnancies
Transvaginalultrasonographyofa
uterusyearsafteraCaesareansection,
showingthecharacteristicscar
formationinitsanteriorpart.
WomenwhohavehadaCaesareanforanyreasonaresomewhatlesslikelytobecomepregnantorgive
birthagainascomparedtowomenwhohavepreviouslyonlydeliveredvaginally.[17]
WomenwhohadjustonepreviousCaesareansectionaremorelikelytohaveproblemswiththeirsecondbirth.[4]Deliveryafterprevious
Caesareansectionisbyeitheroftwomainoptions:
VaginalbirthafterCaesareansection(VBAC)
ElectiverepeatCaesareansection(ERCS)
BothhavehigherrisksthanavaginalbirthwithnopreviousCaesareansection.CriteriaformakingVBACincludethatthepreviousCaesarean
sectionshouldbealowtransverseone.VBAC(comparedtoERCS)confersahigherriskformainlyuterineruptureandperinataldeathofthe
child.[18]Furthermore,optingforVBACresultsin2040%oftimesinthatCaesareansectionisperformedeventuallyanyway,withgreater
risksofcomplicationsinanemergentrepeatCaesareansectionthaninanERCS.[19][20]Ontheotherhand,VBACconferslessmaternal
morbidityandadecreasedriskofcomplicationsinfuturepregnanciesthanERCS.[21]
Adhesions
Therearenumberofstepsthatcanbetakenduringabdominalorpelvicsurgerytominimizepostoperativecomplications,suchasthe
formationofadhesions.Suchtechniquesandprinciplesmayinclude:
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Handlingalltissuewithabsolutecare
Usingpowderfreesurgicalgloves
Controllingbleeding
Choosingsuturesandimplantscarefully
Keepingtissuemoist
Preventinginfection
However,despitetheseproactivemeasures,abdominalorpelvicsurgerycanresultintraumathatcan
leadtoadhesions.Inordertopreventadhesionsfromformingfollowingapelvic(gynecologic)surgery,
suchashysterectomy,myomectomyorcaesareansection,adhesionbarriercanbeplacedduring
surgerytominimizetheriskofadhesionsbetweentheuterusandovaries,thesmallbowel,andalmost
anytissueintheabdomenorpelvis.
Suturingoftheuterusafter
extraction.
Adhesionscancausecomplications,suchas:
Infertility,whichmayresultwhenadhesionstwistthetissuesoftheovariesandtubes,blocking
thenormalpassageoftheegg(ovum)fromtheovarytotheuterus.Oneinfiveinfertilitycasesis
estimatedtobeadhesionrelated(stoval)
Chronicpelvicpain,whichmayresultwhenadhesionsarepresentinthepelvis.Almost50
percentofchronicpelvicpaincasesareestimatedtobeadhesionrelated(stoval)
Smallbowelobstructionthedisruptionofnormalbowelflow,whichcanresultwhen
ClosedIncisionforlowtransverse
abdominalincisionafterstaplinghas
beencompleted.
adhesionstwistorpullthesmallbowel.
Riskstothechild
Nonmedicallyindicated(elective)childbirthbefore39weeksgestation"carrysignificantrisksforthebabywithnoknownbenefittothe
mother."Complicationsfromelectivecaesareanbefore39weeksinclude:newbornmortalityat37weeksmaybeupto3timesthenumberat
40weeks,andwaselevatedcomparedto38weeksofgestation.Theseearlytermbirthswerealsoassociatedwithincreaseddeathduring
infancy,comparedtothoseoccurringat39to41weeks("fullterm").[22]Researchersinonestudyandanotherreviewfoundmanybenefitsto
goingfullterm,butnoadverseeffectsinthehealthofthemothersorbabies.[22][23]
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TheAmericanCongressofObstetriciansandGynecologistsandmedicalpolicymakersreviewresearchstudiesandfindincreasedincidenceof
suspectedorprovensepsis,RDS,hypoglycemia,needforrespiratorysupport,needforNICUadmission,andneedforhospitalization>45
days.Inthecaseofcaesareansections,ratesofrespiratorydeathwere14timeshigherinprelaborat37comparedwith40weeksgestation,
and8.2timeshigherforprelaborcaesareanat38weeks.Inthisreview,nostudiesfounddecreasedneonatalmorbidityduetononmedically
indicated(elective)deliverypriorto39weeks.[22]
Forotherwisehealthytwinpregnancieswherebothtwinsareheaddownatrialofvaginaldeliveryisrecommendedatbetween37and38
weeks.[24][25]VaginaldeliveryinthiscasedoesnotworsentheoutcomefortheinfantascomparedwithCaesareansection.[24]Thereis
controversyonthebestmethodofdeliverywerethefirsttwinisheadfirstandthesecondisnot.[24]WhenthefirsttwinisnotheaddownaC
sectionisoftenrecommended.[24]Regardlessofbirthbysectionorvaginally,themedicalliteraturerecommendsdeliveryofdichorionictwins
at38weeks,andmonochorionictwins(identicaltwinssharingaplacenta)by37weeksduetotheincreasedriskofstillbirthinmonochorionic
twinswhoremaininuteroafter37weeks.[26][27]Theconsensusisthatlatepretermdeliveryofmonochorionictwinsisjustifiedbecausethe
riskofstillbirthforpost37weekdeliveryissignificantlyhigherthantherisksposedbydeliveringmonochorionictwinsnearterm(i.e.,3637
weeks).[28]
Theconsensusconcerningmonoamniotictwins(identicaltwinssharinganamnioticsac),thehighestrisktypeoftwins,isthattheyshouldbe
deliveredbycaesareansectionatorshortlyafter32weeks.[29][30][31]
Inaresearchstudywidelypublicized,singletonchildrenbornearlierthan39weeksmayhavedevelopmentalproblems,includingslower
learninginreadingandmath.[32]
Otherrisksinclude:
Wetlung:Retentionoffluidinthelungscanoccurifnotexpelledbythepressureofcontractionsduringlabor.[33]
Potentialforearlydeliveryandcomplications:Pretermdeliveryispossibleifduedatecalculationisinaccurate.Onestudyfoundan
increasedcomplicationriskifarepeatelectiveCaesareansectionisperformedevenafewdaysbeforetherecommended39weeks.[34]
Higherinfantmortalityrisk:InCsectionsperformedwithnoindicatedrisk(singletonatfullterminaheaddownposition),theriskof
deathinthefirst28daysoflifehasbeencitedas1.77per1,000livebirthsamongwomenwhohadCsections,comparedto0.62per
1,000forwomenwhodeliveredvaginally.[35]
Classification
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Caesareansectionshavebeenclassifiedinvariouswaysbydifferentperspectives.[36]Onewaytodiscussallclassificationsystemsistogroup
thembytheirfocuseitherontheurgencyoftheprocedure,characteristicsofthemother,orasagroupbasedonother,lesscommonly
discussedfactors.[36]
Itismostcommontoclassifycsectionsbytheurgencyofperformingthem.[36]Whenthereissomethingunusualaboutthemotherorthe
pregnancy,thenitbecomescommontoclassifythatcsectionbywhateverunusualcharacteristicsareseen.[36]Whendiscussingtheactual
techniqueorsurgicalconditions,thencsectionsareclassifiedbythosetechniques.[36]
Byurgency
Conventionally,caesareansectionsareclassifiedasbeingeitheranelectivesurgeryoranemergencysurgery.[37]Classificationisusedtonote
astrategyforusinganesthesia,asinemergenciesgeneralanesthesiamustbeusedbutwhentimeisavailable,itispreferabletouseregional
anesthesia.[37]
Aplannedcaesarean(orelective/scheduledcaesarean),arrangedaheadoftime,ismostcommonlyarrangedformedicalreasonsandideallyas
closetotheduedateaspossible.Acrash/emergent/emergencyCaesareansectionisperformedinanobstetricemergency,wherecomplications
ofpregnancyonsetsuddenlyduringtheprocessoflabour,andswiftactionisrequiredtopreventthedeathsofmother,child(ren)orboth.
Aplannedorelectivecaesareansectionisanelectivesurgery,meaningthatitisscheduledinadvanceratherthanperformedbecauseofan
unscheduledemergency.Thisconferstheabilitytoperformthedeliveryatatimewhenhospitalresourcesareoptimal,suchasatdaytime
ratherthanwhatmightotherwiseturnouttobeatnight.Thecosttothepatientandthebabyforunnecessarysurgerymaybesubstantial.
Criticsalsoarguethatbecausephysiciansandinstitutionsmaybenefitbyreducingnighttimeandweekendwork,thataninappropriate
incentiveexiststosuggestelectivesurgery.[38]
Electivecaesareansectionsmaybeperformedonthebasisofanobstetricalormedicalindication,orbecauseofanonindicatedmaternal
request.[25]AmongwomenintheUnitedKingdom,SwedenandAustralianabout7%preferredCsectionasamethodofdelivery.[25]Incases
withoutmedicalindicationstheAmericanCongressofObstetriciansandGynecologistsrecommendaplannedvaginaldelivery.[39]The
NationalInstituteforHealthandCareExcellencerecommendsthatifafterawomenhasbeenprovidedinformationontheriskofaplannedC
sectionandshestillinsistsontheprocedureitshouldbeprovided.[25]Ifprovidedthisshouldbedone39weeksofgestationorlater.[39]
Bycharacteristicsofthemother
Caesareandeliveryonmaternalrequest
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Caesareandeliveryonmaternalrequest(CDMR)isamedicallyunnecessarycaesareansection,wheretheconductofachildbirthviaa
caesareansectionisrequestedbythepregnantpatienteventhoughthereisnotamedicalindicationtohavethesurgery.[40]
AfterpreviousCaesarean
Motherswhohavepreviouslyhadacaesareansectionaremorelikelytohaveacsectionforfuturepregnanciesthanmotherswhohavenever
hadacsection.Thereisdiscussionaboutthecircumstancesunderwhichwomenshouldhaveavaginalbirthafterapreviouscaesarean.
Vaginalbirthaftercaesarean(VBAC)isthepracticeofbirthingababyvaginallyafterapreviousbabyhasbeendeliveredthroughcaesarean
section(surgically).[41]AccordingtoTheAmericanCongressofObstetriciansandGynecologists(ACOG),VBACisassociatedwith
decreasedmaternalmorbidityandadecreasedriskofcomplicationsinfuturepregnancies.[42]AccordingtotheAmericanPregnancy
Association,90%ofwomenwhohaveundergonecaesareandeliveriesarecandidatesforVBAC.[19]Approximately6080%ofwomenopting
forVBACwillsuccessfullygivebirthvaginally,whichiscomparabletotheoverallvaginaldeliveryrateintheUnitedStatesin2010.[19][20][43]
Twins
Forotherwisehealthytwinpregnancieswherebothtwinsareheaddownatrialofvaginaldeliveryisrecommendedatbetween37and38
weeks.[24][25]VaginaldeliveryinthiscasedoesnotworsentheoutcomefortheinfantascomparedwithCsection.[24]Thereiscontroversyon
thebestmethodofdeliverywherethefirsttwinisheadfirstandthesecondisnot.[24]Whenthefirsttwinisnotheaddown,aCsectionisoften
recommended.[24]Althoughthesecondtwintypicallyhasahigherfrequencyofproblems,itisnotknownifaplannedCsectionaffects
this.[25]Itisestimatedthat75%oftwinpregnanciesintheUnitedStatesweredeliveredbyCaesareansectionin2008.[44]
Breechbirth
Abreechbirthisthebirthofababyfromabreechpresentation,inwhichthebabyexitsthepelviswiththebuttocksorfeetfirstasopposedto
thenormalheadfirstpresentation.Inbreechpresentation,fetalheartsoundsareheardjustabovetheumbilicus.
Thebottomdownpositionpresentssomehazardstothebabyduringtheprocessofbirth,andthemodeofdelivery(vaginalversusCaesarean)
iscontroversialinthefieldsofobstetricsandmidwifery.
Thoughvaginalbirthispossibleforthebreechbaby,certainfetalandmaternalfactorsinfluencethesafetyofvaginalbreechbirth.The
majorityofbreechbabiesbornintheUnitedStatesaredeliveredbyCaesareansectionasstudieshaveshownincreasedrisksofmorbidityand
mortalityforvaginalbreechdelivery,andmosthospitalpoliciesdonotpermitvaginalbreechbirthforthisreason.Asaresultofreduced
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numbersofvaginalbreechdeliveries,mostobstetriciansdonotreceivetrainingintheskillsetrequiredforsafevaginalbreechdelivery
anymore.
Otherways,includingbysurgerytechnique
ThereareseveraltypesofCaesareansection(CS).Animportantdistinctionliesinthetypeofincision(longitudinalorlatitudinal)madeonthe
uterus,apartfromtheincisionontheskin.
TheclassicalCaesareansectioninvolvesamidlinelongitudinalincisionwhichallowsalargerspacetodeliverthebaby.However,itis
rarelyperformedtoday,asitismorepronetocomplications.
Theloweruterinesegmentsectionistheproceduremostcommonlyusedtodayitinvolvesatransversecutjustabovetheedgeofthe
bladderandresultsinlessbloodlossandiseasiertorepair.
AnunplannedCaesareansectionisperformedoncelabourhascommencedduetounexpectedlaborcomplications.
ACaesareanhysterectomyconsistsofaCaesareansectionfollowedbytheremovaloftheuterus.Thismaybedoneincasesof
intractablebleedingorwhentheplacentacannotbeseparatedfromtheuterus.
Traditionally,otherformsofCaesareansectionhavebeenused,suchasextraperitonealCaesareansectionorPorroCaesareansection.
ArepeatCaesareansectionisonethatisdonewhenapatienthadapreviousCaesareansection.Typicallyitisperformedthroughtheold
scar.
TheEXITprocedureisaspecializedsurgicaldeliveryprocedureusedtodeliverbabieswhohaveairwaycompression.
TheMisgavLadachmethodisamodifiedcaesareansectionwhichhasbeenusednearlyallovertheworldsincethe1990s.Itwasdescribedby
MichaelStark,thepresidentoftheNewEuropeanSurgicalAcademy,atthetimehewasthedirectorofMisgavLadach,ageneralhospitalin
Jerusalem.ThemethodwaspresentedduringaFIGOconferenceinMontralin1994[45]andthendistributedbytheUniversityofUppsala,
Sweden,inmorethan100countries.Thismethodisbasedonminimalisticprinciples.Heexaminedallstepsincaesareansectionsinuse,
analyzedthemfortheirnecessityand,iffoundnecessary,fortheiroptimalwayofperformance.Fortheabdominalincisionheusedthe
modifiedJoelCohenincisionandcomparedthelongitudinalabdominalstructurestostringsonmusicalinstruments.Asbloodvesselsand
muscleshavelateralsway,itispossibletostretchratherthancutthem.Theperitoneumisopenedbyrepeatstretching,noabdominalswabsare
used,theuterusisclosedinonelayerwithabigneedletoreducetheamountofforeignbodyasmuchaspossible,theperitoneallayersremain
unsuturedandtheabdomenisclosedwithtwolayersonly.Womenundergoingthisoperationrecoverquicklyandcanlookafterthenewborns
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soonaftersurgery.Therearemanypublicationsshowingtheadvantagesovertraditionalcaesareansectionmethods.However,thereisan
increasedriskofabruptioplacentaanduterineruptureinsubsequentpregnanciesforwomenwhounderwentthismethodinprior
deliveries.[46][47]
Technique
Antibioticprophylaxisisusedbeforeanincision.[48]Theuterusisincised,andthisincisionisextended
withbluntpressurealongacephaladcaudadaxis.[48]Theinfantisdelivered,andtheplacentaisthen
removed.[48]Thesurgeonthenmakesadecisionaboututerineexteriorization.[48]Singlelayeruterine
closureisusedwhenthemotherdoesnotwantafuturepregnancy.[48]Whensubcutaneoustissueis
2cmthickormore,surgicalsutureisused.[48]Discouragedpracticesincludemanualcervicaldilation,
anysubcutaneousdrain,orsupplementaloxygentherapywithintenttopreventinfection.[48]
Caesareansectioncanbeperformedwithsingleordoublelayersuturingoftheuterineincision.[49]A
Cochranereviewcametotheresultthatsinglelayerclosurecomparedwithdoublelayerclosurewas
associatedwithastatisticallyreductioninmeanbloodloss.[50]Suturingclosedtheperitoneumalso
doesnotappeartoberequired.[51]
Pullingoutthebaby
Inmanyhospitals,especiallyinArgentina,theUnitedStates,UnitedKingdom,Canada,Norway,
Sweden,Finland,Australia,andNewZealand,themother'spartnerisencouragedtoattendthesurgery
tosupportthemotherandsharetheexperience.Theanaesthetistwillusuallylowerthedrape
temporarilyasthechildisdeliveredsotheparentscanseetheirnewborn.
Anaesthesia
Bothgeneralandregionalanaesthesia(spinal,epiduralorcombinedspinalandepiduralanaesthesia)
IllustrationdepictingCaesarean
areacceptableforuseduringCaesareansection.Regionalanaesthesiaispreferredasitallowsthe
section.
mothertobeawakeandinteractimmediatelywithherbaby.[52]Otheradvantagesofregionalanesthesia
includetheabsenceoftypicalrisksofgeneralanesthesia:pulmonaryaspiration(whichhasarelatively
highincidenceinpatientsundergoinganesthesiainlatepregnancy)ofgastriccontentsandOesophagealintubation.[53]
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Regionalanaesthesiaisusedin95%ofdeliveries,withspinalandcombinedspinalandepiduralanaesthesiabeingthemostcommonlyused
regionaltechniquesinscheduledCaesareansection.[54]RegionalanaesthesiaduringCaesareansectionisdifferentfromtheanalgesia(pain
relief)usedinlaborandvaginaldelivery.Thepainthatisexperiencedbecauseofsurgeryisgreaterthanthatoflaborandthereforerequiresa
moreintensenerveblock.ThedermatomallevelofanesthesiarequiredforCaesareandeliveryisalsohigherthanthatrequiredforlabor
analgesia.[53]
Generalanesthesiamaybenecessarybecauseofspecificriskstomotherorchild.Patientswithheavy,uncontrolledbleedingmaynottolerate
thehemodynamiceffectsofregionalanesthesia.Generalanesthesiaisalsopreferredinveryurgentcases,suchasseverefetaldistress,when
thereisnotimetoperformaregionalanesthesia.
Preventionofcomplications
Postpartuminfectionisoneofthemaincausesofbadoutcomes[55][56]anddeatharoundchildbirth,accountingforaround10%ofmaternal
deathsglobally.[57]Caesareansectiongreatlyincreasestheriskofinfectionandassociatedmorbidity(estimatedtobebetween5and20times
ashigh).[55]Infectioncanoccurinaround8%ofwomenwhohavecaesareans,[56]largelyendometritis,urinarytractinfectionsandwound
infections.
Antibioticprophylaxisiseffectiveforendometritis,preventingasmanyas3outof4cases.[55][56]Takingantibioticsbeforeskinincisionrather
thanaftercordclampingreducestheriskforthemother,withoutincreasingadverseeffectsforthebaby.[56][58]Whetheraparticulartypeof
skincleanerimprovesoutcomesinunclear.[59]
Somedoctorsbelievethatduringacaesareansection,mechanicalcervicaldilationwithafingerorforcepswillpreventtheobstructionof
bloodandlochiadrainage,andtherebybenefitthemotherbyreducingriskofdeath.[60]Theavailableclinicalevidenceisnotsufficienttodraw
aconclusionontheeffectofthispractice.[60]
Recoveryperiod
Typically,therecoverytimedependsonthepatientandherpaintoleranceandinflammationlevels.Doctorsdorecommendabstentionfrom
strenuouswork(e.g.,liftingobjectsover10lbs(4.5kg).,running,walkingupstairs,orathletics)foruptosixteenweeks,andawaitingperiod
of~18monthsbeforeattemptingtoconceiveanotherchild.
Usage
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IntheUnitedKingdom,in2008,theCaesareansectionratewas24%.[61]InIrelandtheratewas26.1%in2009.[62]TheCanadianratewas
26%in20052006.[63]AustraliahasahighCaesareansectionrate,at31%in2007.[64]IntheUnitedStatestherateofCsectionisaround33%
andvariesfrom23%to40%dependingonthestateinquestion.[4]
InItalytheincidenceofCaesareansectionsisparticularlyhigh,althoughitvariesfromregiontoregion.[65]InCampania,60%of2008births
reportedlyoccurredviaCaesareansections.[66]IntheRomeregion,themeanincidenceisaround44%,butcanreachashighas85%insome
privateclinics.[67][68]
Withnearly1.3millionstays,CaesareansectionwasoneofthemostcommonproceduresperformedinU.S.hospitalsin2011.Itwasthe
secondmostcommonprocedureperformedforpeopleages18to44yearsold.[69]CaesareanratesintheU.S.haverisenconsiderablysince
1996.[70]Theprocedureincreased60%from1996to2009.In2010,theCaesareandeliveryratewas32.8%ofallbirths(aslightdecreasefrom
2009'shighof32.9%ofallbirths).[71]Astudyfoundthatin2011,womencoveredbyprivateinsurancewere11%morelikelytohavea
caesareansectiondeliverythanthosecoveredbyMedicaid.[72]
ChinahasbeencitedashavingthehighestratesofCsectionsintheworldat46%asof2008.[73]
StudieshaveshownthatcontinuityofcarewithaknowncarermaysignificantlydecreasetherateofCaesareandelivery[74]butthereisalso
researchthatappearstoshowthatthereisnosignificantdifferenceinCaesareanrateswhencomparingmidwifecontinuitycareto
conventionalfragmentedcare.[75]
MoreemergencyCaesareansabout66%areperformedduringthedayratherthanduringthenight.[76]
Theratehasrisento46%inChinaandtolevelsof25%andaboveinmanyAsian,EuropeanandLatinAmericancountries.[77]Theratehas
increasedintheUnitedStates,to33%ofallbirthsin2012,upfrom21%in1996.[4]AcrossEurope,therearedifferencesbetweencountries:in
ItalytheCaesareansectionrateis40%,whileintheNordiccountriesitis14%.[78]
Increasinguse
IntheUnitedStatesCsectionrateshaveincreasedfromjustover20%in1996to33%in2011.[4]Thisincreasehasnotresultedinimproved
outcomesresultinginthepositionthatCsectionsmaybedonetoofrequently.[4]
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TheWorldHealthOrganizationofficiallywithdrewitspreviousrecommendationofa15%CsectionratesinJune2010.Theirofficial
statementread,"Thereisnoempiricalevidenceforanoptimumpercentage.Whatmattersmostisthatallwomenwhoneedcaesareansections
receivethem."[79]
TheUSNationalInstitutesofHealthsaysrisesinratesofCaesareansectionsarenot,inisolation,acauseforconcern,butmayreflect
changingreproductivepatterns:"TheWorldHealthOrganizationhasdeterminedanidealrateofallcaesareandeliveries(suchas15percent)
forapopulation.Onesurgeon'sopinionisthatthereisnoconsistencyinthisidealrate,andartificialdeclarationsofanidealrateshouldbe
discouraged.Goalsforachievinganoptimalcaesareandeliveryrateshouldbebasedonmaximizingthebestpossiblematernalandneonatal
outcomes,takingintoaccountavailablemedicalandhealthresourcesandmaternalpreferences.Thisopinionisbasedontheideathatifleft
unchallenged,optimalcaesareandeliveryrateswillvaryovertimeandacrossdifferentpopulationsaccordingtoindividualandsocietal
circumstances."[40]
Somehavespeculatedthatcaesareansectionrateshaveincreasedduetoarelationshipbetweenbirthweightandmaternalpelvissize,positing
onthebasisofDarwinianinspiredlogicthatsincetheadventofsuccessfulCaesareanbirthoverthelast150years,moremotherswithsmall
pelvisesandbabieswithlargebirthweightshavesurvivedandcontributedtothesetraits.However,thisideafailstotakeintoaccountthat
historicallydisproportioninchildbirthwascausedbymaternalmalnutritioninchildhood,inparticularmalformedpelvicbonesdueto
childhoodrickets.Improvedmaternalnutritionshouldhaveledtoincreasedeaseinvaginalbirth,notanincreaseincaesareansections.[80]
History
ThemotherofBindusara(bornc.320BCE,ruled298c.272BCE),thesecondMauryan
Samrat(emperor)ofIndia,accidentallyconsumedpoisonanddiedwhenshewascloseto
deliveringhim.Chanakya,theChandragupta'steacherandadviser,madeuphismindthat
thebabyshouldsurvive.Hecutopenthebellyofthequeenandtookoutthebaby,thus
savingthebaby'slife.[81][82]
AccordingtotheancientChineseRecordsoftheGrandHistorian,Luzhong,asixth
generationdescendantoftheYellowEmperor,hadsixsons,allbornby"cuttingopenthe
body".ThesixthsonJilianfoundedtheHouseofMithatruledtheStateofChu(c.1030
223BCE).[83]
IntheIrishmythologicaltexttheUlsterCycle,thecharacterFurbaideFerbendissaidto
havebeenbornbyposthumouscaesareansection,afterhismotherwasmurderedbyhis
evilauntMedb.
SuccessfulCaesareansectionperformedby
indigenoushealersinKahura,Uganda.Asobserved
byR.W.Felkinin1879.
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TheBabylonianTalmud,anancientJewishreligioustext,mentionsaproceduresimilartothecaesareansection.Theprocedureistermed
yotzeidofen.[82]
PlinytheEldertheorizedthatJuliusCaesar'snamecamefromanancestorwhowasbornbycaesareansection,butthetruthofthisisdebated
(seethearticleontheEtymologyofthenameofJuliusCaesar).TheAncientRomancaesareansectionwasfirstperformedtoremoveababy
fromthewombofamotherwhodiedduringchildbirth.Caesar'smother,Aurelia,livedthroughchildbirthandsuccessfullygavebirthtoher
son,rulingoutthepossibilitytheRomanrulerandgeneralwasbornbycaesareansection.Hisfirstwifehoweverdiedinchildbirth,giving
birthtoastilbornsonwhomighthavelivedhadacaesareantakenplace.
TheCatalansaintRaymondNonnatus(12041240),receivedhissurnamefromtheLatinnonnatus("notborn")becausehewasbornby
caesareansection.Hismotherdiedwhilegivingbirthtohim.[84]
AnearlyaccountofcaesareansectioninIranismentionedinthebookofShahnameh,writtenaround1000AD,andrelatestothebirthof
Rostam,thenationallegendaryheroofIran.[85][86]AccordingtotheShahnameh,theSimurghinstructedZaluponhowtoperformaCaesarean
section,thussavingRudabaandthechildRostam.[87]
Caesareansectionusuallyresultedinthedeathofthemotherthefirstrecordedincidenceofawomansurvivingacaesareansectionwasinthe
1580s,inSiegershausen,Switzerland:JakobNufer,apiggelder,issupposedtohaveperformedtheoperationonhiswifeafteraprolonged
labour.[88]However,thereissomebasisforsupposingthatwomenregularlysurvivedtheoperationinRomantimes.[89]Formostofthetime
sincethe16thcentury,theprocedurehadahighmortalityrate.However,itwaslongconsideredanextrememeasure,performedonlywhenthe
motherwasalreadydeadorconsideredtobebeyondhelp.InGreatBritainandIreland,themortalityratein1865was85%.Keystepsin
reducingmortalitywere:
IntroductionofthetransverseincisiontechniquetominimizebleedingbyFerdinandAdolfKehrerin1881isthoughttobefirstmodern
CSperformed.
TheintroductionofuterinesuturingbyMaxSngerin1882
ModificationbyHermannJohannesPfannenstielin1900,seePfannenstielincision
ExtraperitonealCSandthenmovingtolowtransverseincision(Krnig,1912)
Adherencetoprinciplesofasepsis
Anesthesiaadvances
Bloodtransfusion
Antibiotics
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EuropeantravelersintheGreatLakesregionofAfricaduringthe19thcenturyobservedCaesareansectionsbeingperformedonaregular
basis.[90]Theexpectantmotherwasnormallyanesthetizedwithalcohol,andherbalmixtureswereusedtoencouragehealing.Fromthewell
developednatureoftheproceduresemployed,Europeanobserversconcludedtheyhadbeenemployedforsometime.[90]Dr.JamesBarry
carriedoutthefirstsuccessfulCaesareanbyaEuropeandoctorinAfricainCapeTown,whilepostedtherebetween1817and1828.[91]
ThefirstsuccessfulCaesareansectiontobeperformedinAmericatookplaceinwhatwasformerlyMasonCounty,Virginia(nowMason
County,WestVirginia),in1794.TheprocedurewasperformedbyDr.JesseBennettonhiswifeElizabeth.[92]
OnMarch5,2000,inMexico,InsRamrezperformedaCaesareansectiononherselfandsurvived,asdidherson,OrlandoRuizRamrez.[93]
SheisbelievedtobetheonlywomantohaveperformedasuccessfulCaesareansectiononherself.
Societyandculture
Etymology
TheRomanLexRegia(royallaw),latertheLexCaesarea(imperiallaw),ofNumaPompilius(715673BCE),[94]requiredthechildofa
motherdeadinchildbirthtobecutfromherwomb.[95]Thisseemstohavebegunasareligiousrequirementthatmothersnotbeburied
pregnant,[96]andtohaveevolvedintoawayofsavingthefetus,withRomanpracticerequiringalivingmothertobeinhertenthmonthof
pregnancybeforeresortingtotheprocedure,reflectingtheknowledgethatshecouldnotsurvivethedelivery.[97]SpeculationthattheRoman
dictatorJuliusCaesarwasbornbythemethodnowknownasCsectionisapparentlyfalse.[98]AlthoughCaesareansectionswereperformedin
Romantimes,noclassicalsourcerecordsamothersurvivingsuchadelivery[95][99]theearliestrecordedsurvivaldatestothe12thcentury
scholarandphysicianMaimonides(seeCommentarytoMishnahBekhorot8:2).Thetermhasalsobeenexplainedasderivingfromtheverb
caedere,"tocut",withchildrendeliveredthiswayreferredtoascaesones.PlinytheElderreferstoacertainJuliusCaesar(anancestorofthe
famousRomanstatesman)asabuterocaeso,"cutfromthewomb"givingthisasanexplanationforthecognomen"Caesar"whichwasthen
carriedbyhisdescendents.[95]Nonetheless,eveniftheetymologicalhypothesislinkingthecaesareansectiontoJuliusCaesarisafalse
etymology,ithasbeenwidelybelieved.Forexample,theOxfordEnglishDictionarydefinesCaesareanbirthas"thedeliveryofachildby
cuttingthroughthewallsoftheabdomenwhendeliverycannottakeplaceinthenaturalway,aswasdoneinthecaseofJuliusCaesar".[100]
MerriamWebster'sCollegiateDictionary(11thedition)leavesroomforetymologicaluncertaintywiththephrase,"fromthelegendary
associationofsuchadeliverywiththeRomancognomenCaesar"[101]
SomelinkwithJuliusCaesarorwithRomanemperorsexistsinotherlanguagesaswell.Forexample,themodernGerman,Norwegian,
Danish,Dutch,Swedish,TurkishandHungariantermsarerespectivelyKaiserschnitt,keisersnitt,kejsersnit,keizersnede,kejsarsnitt,sezaryen,
andcsszrmetszs(literally:"Emperor'scut").[102]TheGermantermhasalsobeenimportedintoJapanese(teisekkai)andKorean
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(jewangjeolgae),bothliterallymeaning"emperorincision".SimilarinwesternSlavic(Polish)ciciecesarskie,(Czech)csaskez
and(Slovak)cisrskyrez(literally"imperialcut"),whereasthesouthSlavictermisSerbianandSloveniancrskirz,which
literallymeans"tzar"cut.TheRussiantermkesarevosecheniye(ksarevosenije)literallymeansCaesar'ssection.The
Arabicterm(wilaadaqaySaryya)alsomeans"Caesareanbirth."TheHebrewterm(nitakhKeisri)translatesliterally
asCaesareansurgery.InRomaniaandPortugal,[103]itisusuallycalledcesariana,meaningfrom(orrelatedto)Caesar.
AccordingtoShahnamehancientPersianbook,theheroRostamwasthefirstpersonwhowasbornwiththismethodandterm
(rostamineh)iscorrespondedtoCaesarean.Also,HindumythicalmonkeygodHanumanwasbornthroughasimilarprocedureonhermother
Anjani.
Finally,theRomanpraenomen(givenname)CaesowassaidtobegiventochildrenwhowerebornviaCsection.Whilethiswasprobablyjust
folketymologymadepopularbyPlinytheElder,itwaswellknownbythetimethetermcameintocommonuse.[104]
Orthography
Theterm"Caesareansection"isspelledinmanydifferentways.
Onevariationisthee/ae/variationwhichreflectsAmericanandBritishEnglishspellingdifferences.Becausesomesourcessaytheprocedure
isnamedafterJuliusCaesar,theprocedure'snameissometimescapitalized.Thecapitalversuslowercasevariationreflectsastyleof
lowercasingsomeeponymousterms(e.g.,caesarean,eustachian,fallopian,mendelian,parkinsonian,parkinsonism).[105]Capitaland
lowercasestylingscoexistinprevalentusage.
Becauseof(1)theevsaedigraphvariation,(2)therelatedaevstypographicligaturevariation,(3)thecapitalvslowercasevariation
(whichisbasedontheideaofeponymousorigin,whetherthatishistoricallyaccurateornotseeeponym>orthographicconventions),and(4)
theeanvsiansuffixvariation,thesefactorscrossmultipliedinatablecausethiswordtobeoneoftheveryfewwordsinpresentday
Englishorthographytohavemanydifferentnormativespellingsororthographicstylings,whichamountto12fromthepointofviewof
characterencoding(thatis,thereare12differentcharacterstringsthatareallacceptedasnormativeorthographicrepresentationsofthisone
word):
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Multiplicationtable
C+e
c+e
C+ae
c+ae
C+
c+
ean Cesarean cesarean Caesarean caesarean Csarean csarean
ian Cesarian
cesarian
Caesarian
caesarian
Csarian
csarian
Specialpopulations
InJudaismthereisadisputeamongtheposkim(Rabbinicauthorities)astowhetherafirstbornsonfromaCaesareansectionhasthelawsofa
bechor.[106]Traditionally,amalechilddeliveredbyCaesareanisnoteligibleforthePidyonHaBendedicationritual.[107][108]
Inrarecases,caesareansectionscanbeusedtoremoveadeadfetus.AlatetermabortionusingCaesareansectionproceduresistermeda
hysterotomyabortionandisveryrarelyperformed.
Selfinflictedcaesareansectionistheconceptofamotheraloneperformingherowncaesareansection.Therehaveapparentlybeenafew
successfulcases,notablyInsRamrezPrezofMexicowhoinMarch2000,performedasuccessfulCaesareansectiononherself.[109][110]
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