Caesarean Section

Researched by Anthony
A caesarean section (AE cesarean section), or c-section, is a form of childbirth in which a surgical incision is made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies. It is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk, although in recent times it has been also performed upon request for births that would otherwise have been normal.

See Video of an actual CS Procedure

History

Although most believe that Caesar himself was born by c-section, this may not be the case. The Ancient Roman c-section was first performed to remove a baby from the womb of a mother who died during childbirth. Caesar's mother, Aurelia, lived through childbirth and successfully gave birth to her son, ruling out the possibility that the Roman Dictator and General was a c-section baby. (In fact, she died 45 years later.) It should be noted that Maimonides, the famous rabbi, philosopher, and doctor, says that it was known in ancient Rome how to perform a c-section without killing the mother, but that the medical knowledge of his day was lacking and it was not performed. Thus it would seem that, according to what Maimonides knew, c-sections were not performed solely on dying women, but also on mothers who would live after the birth of their child.

The Catalan saint, Raymond Nonnatus (1204-1240), received his surname — from the Latin non natus ("not born") — because he was born by C-section. His mother died while giving birth to him.

In 1316 the future Robert II of Scotland was delivered by caesarean section — his mother, Marjorie Bruce, died. This may have been the inspiration for Macduff in Shakespeare's play Macbeth".

Caesarian section sacrificed the mother for the sake of the child; 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 labor. 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

There are several types of caesarean sections (CS). The differences between them primarily lie in the deep incision made on the uterus, below the skin and subcutaneous tissue, and should be differentiated from the skin incision, such as a Pfannenstiel incision.

The classical caesarean section involves a midline longitudinal incision which allows a larger space to deliver the baby. However, it is rarely performed today as it is more prone to complications.

The lower uterine segment section is the procedure most commonly used today; it involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair.

An emergency caesarean section is a caesarean performed once labor has commenced.

A crash caesarean section is a caesarean performed in an obstetrical emergency, where complications of pregnancy onset suddenly during the process of labor, and swift action is required to prevent the deaths of mother, child(ren) or both.

A caesarean hysterectomy consists of a caesarean section followed by the removal of the uterus. This may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus.

Traditionally other forms of CS have been used, such as extraperitoneal CS or Porro CS.

A repeat caesarean section is done when a patient had a previous section. Typically it is performed through the old scar.

In many hospitals, especially in the United States, United Kingdom, Canada, Australia, and New Zealand the mother's birth partner is encouraged to attend the surgery to support the mother and share the experience. The anesthetist will usually lower the drape temporarily as the child is delivered so the parents can see their newborn.

Indications

Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. Reasons for caesarean delivery include:

* prolonged labor 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 labor
* 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 theater.
* the baby is too large (macrosomia)
* placental problems (placenta previa, placental abruption or placenta accreta)
* contracted pelvis
* Sexually transmitted infections such as genital herpes (which can be passed on to the baby, if the baby is born vaginally)
* previous caesarean section (though this is controversial)
* prior problems with the healing of the perineum (from previous childbirth or Crohn's Disease)

However, different providers may disagree about when a caesarean is required. For example, while one obstetrician may feel that a woman is too small to deliver her baby, another might well disagree. Similarly, some care providers may be much quicker to cite "failure to progress" than others. Disagreements like this help to explain why caesarean rates for some physicians and hospitals are much higher than are those for others. The medico-legal restrictions on vaginal birth after caesarean (VBAC), have also increased the caesarean rate.

For religious, personal or other reasons, a mother may refuse to undergo caesarean section. In the United Kingdom, the law states that a woman in labor has the absolute right to refuse any medical treatment including caesarean section "for any reason or none", even if that decision may cause her own death, or that of her baby. Other countries have different laws.

As scheduled caesarean sections have become a rather safe operation although there are some risks involved, there has been a movement to perform caesarean delivery on maternal request (CDMR). There is also a consumer-driven movement to support VBAC as an alternative for repeat caesareans in the face of increased medico-legal restrictions on vaginal birth.

Risks

Statistics from the 1990s suggest that less than one woman in 2,500 who has a caesarean section will die, compared to a rate of one in 10,000 for a vaginal delivery. However the mortality rate for both continues to drop steadily. The UK National Health Service gives the risk of death for the mother as three times that of a vaginal birth. However, it is misleading to directly compare the mortality rates of vaginal and caesarean deliveries. Women with severe medical disease often require a caesarean section which can distort the mortality figures.

A study published in the 13 February 2007 issue of the Canadian Medical Association Journal found that women that have planned caesareans had an overall rate of severe morbidity of 27.3 per 1000 deliveries compared to an overall rate of severe morbidity of 9.0 per 1000 planned vaginal deliveries. The planned caesarean group had increased risks of cardiac arrest, wound hematoma, hysterectomy, major puerperal infection, anesthetic complications, venous thromboembolism, and hemorrhage requiring hysterectomy over those suffered by the planned vaginal delivery group.

A study published in the February 2007 issue of the journal Obstetrics and Gynecology found that women who had just one previous 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, emergency cesarean, uterine rupture, preterm birth, low birth weight, small for gestational age and stillbirth in their second delivery.

A study published in the June 2006 issue of the journal Obstetrics and Gynecology found that women who had multiple 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 0.13% after two c-sections, and increases to 2.13% after four and then to 6.74% after six or more surgeries. Along with this is a similar rise in the risk of emergency hysterectomies at delivery. The findings were based on outcomes from 30,132 caesarean deliveries. (see also review by WebMD.com)

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

A caesarean section is a major operation, with all that it entails, including the risk of post-operative adhesions. Pain at the incision can be intense, and full recovery of mobility can take several weeks or more. A prior caesarean section increases the risk of uterine rupture during subsequent labor.

If a CS is performed under emergency situations, the risk of the surgery may be increased due to a number of factors. The patient's stomach may not be empty, increasing the anesthesia risk.

Anesthesia

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

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

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

Vaginal Births after Caesarean

Vaginal birth after caesarean (VBAC) is not uncommon today. The medical practice until the late 1970s was "once a caesarean, always a caesarean" but a consumer-driven movement supporting VBAC changed the medical practice. Rates of VBAC in the 80s and early 90s soared, but more recently the rates of VBAC have dramatically dropped due to medico-legal restrictions.

In the past, caesarean sections used a vertical incision which cut the uterine muscle fibers in an up and down direction (a classical caesarean). Modern caesareans typically involve a horizontal incision along the muscle fibers 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 emphasized in modern obstetric care is that the decision should be a mutual decision between the obstetrician and the mother/birth partner after assessing the risks and benefits of each type of delivery.

Twenty years of medical research on VBAC support a woman's choice to have a vaginal birth after caesarean. Because the consequences of caesareans include a higher chance of re-hospitalization after birth, infertility, and uterine rupture in the next birth, preventing the first caesarean remains the priority. For women with one or more previous caesareans, as an alternative to major abdominal surgery, some claim that VBAC remains a safer option.

References:

http://www.wikipedia.org
Source for information regarding CS.

http://www.webmd.com
Served as additional reference.

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