Caesarean section

A caesarean section (cesarean section AE), 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 fetuses. It is usually performed when a vaginal delivery would lead to medical complications.

Etymology

There are several elements which contribute to a linguistic explanation of the word caesarean.

• The term may be simply derived from the Latin verb caedere (supine stem caesum), 'to cut'. The term caesarean section then would be a tautology.
• The caesarean is possibly named after the Roman dictator Julius Caesar who allegedly was so delivered. Historically, this is impossible as his mother was alive after he reached adulthood, but the legend is at least as old as the 2nd century AD.
• Roman law prescribed that the procedure was to be performed at the end of a pregnancy on a dying woman in order to save the life of the baby. This was called the lex caesarea. Thus the Roman law may be the origin of the term.

Most likely is a combination of these. The beginning of the story is certainly the verb caedo: the phrase a matre caesus ('cut out of his mother') was used in Roman times to describe the operation. The real etymology of the name Caesar (a much older family name) is completely unrelated, but a very early folk etymology invented the story of Julius Caesar's birth by section in order to suggest that his name is derived from this verb. The title of the Roman law must be influenced by this legend, since the form caesareus cannot be derived directly from caesus without some interference of Caesar. The form of the modern English word caesarean may come either from the law or from the name Caesar, but the modern German Kaiserschnitt (literally: 'Emperor's section') obviously comes directly from the legend of Julius Caesar's birth.

Types

There are several types of caesarean sections (CS):

• The classical section involves a midline longitudinal incision which allows a larger space to deliver the baby. However, it is rarely performed today as it more prone to potential complications.
• The lower 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.
• A Caesarian hysterectomy consists of a caesarian section first followed by 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 had been used, i.e. extraperitoneal CS or Porro CS.

In modern practice the father is usually encouraged to attend the caesarian section to support and share the experience with his partner. The anaesthetist will usually lower the drape temporarily as the child is delivered so the parents can see their newborn. This is the view that the father can expect of their newborn child. The mother's view is similar but from a lower angle.

Indications

Obstetricians or other care-providers recommend caesarean section when vaginal delivery might pose a risk to the mother or baby. Possible reasons for Caesarean delivery include:

• prolonged labour (or failure to progress) (dystocia)
• apparent fetal distress
• apparent maternal distress or complications such as pre-eclampsia, eclampsia
• multiple births
• abnormal presentation, i.e.breech presentation
• failed induction of labour
• failed instrumental delivery
• the baby is too large (macrosomia)
• the mother has a low-lying placenta or placenta praevia
• contracted pelvis
• evidence of intrauterine infection
• previous caesarean section (though this is controversial – see discussion below)
• prior problems with healing of the perineum, such as from childbirth or Crohn's Disease

Note, however, that different providers may disagree about when a caesarean is required. For example, 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 doctors and hospitals are much higher than are those for others.

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.[1] (http://www.childbirth.org/section/risks.html). 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. [2] (http://www.nhsdirect.nhs.uk/en.asp?TopicID=85&AreaID=4414&LinkID=3489) However, it is not possible to directly compare the mortality rates of vaginal and caesarean deliveries as women having the surgery are often those who were at a higher risk anyway.

Babies born by Caesarian often have some initial trouble breathing. In addition, because the baby will be drowsy from the pain medication administered to the mother, and because the mother's mobility is reduced, breast-feeding may be difficult.

A Caesarean section is a major operation, with all that that entails. Pain at the incision can be intense, and full recovery of mobility can take several weeks or more.

For more information see http://www.pregnancy-info.net/c-section_recovery.html.

Prevalence

The World Health Organisation estimates that the rate of caesarian sections at between 10% and 15% of all births in developed countries compared to about 20% in the United Kingdom and 23% in the United States. In 2003, the Canadian caesarian section rate was 21%, with regional variations.

Concerns have been raised in recent years that the procedure is frequently performed for reasons other than medical necessity. For instance, critics worry that caesareans are performed because they are profitable for the hospital, or because a quick caesarian is more convenient for an obstetrician than a lengthy vaginal birth. Organisations have been formed to make the public aware of caesarean operations and their dramatically increased incidence. Attendance by a midwife and out-of-hospital labor are associated with much lower rates of caesarean section, when controlled for all relevant maternal and fetal indicators.

Anaesthesia

The mother usually receives regional anaesthesia (spinal or epidural), allowing her to remain awake for the delivery and avoiding sedation of the infant.

In modern practice, general anesthesia for caesarean section is becoming increasingly rare as scientific research has now clearly established the benefits of regional aneasthesia for both the mother and baby.

Vaginal births after caesarean

Vaginal births after caesarean (VBAC) are not uncommon today. In the past, caesarean sections used a vertical incision which cut the uterine muscle fibers. Modern caesareans typically involve a horizontal incision along the muscle fibers. 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 differ on the relative merits of vaginal and caesarian birth following a caesarean birth. Some still recommend a caesarian routinely, others do not; still others respect the wishes of the expectant mother.

History

Caesarean sections were known in ancient Rome, and it was said that this is the method by which the Roman dictator Julius Caesar was delivered (see etymology, above).

The first recorded incidence of a woman surviving a caesarean section was in Germany in 1500: Jacob Nufer, a pig gelder, is supposed to have performed the operation on his wife after a prolonged labor. For most of the time, the procedure had a high mortality. In Great Britain and Ireland the mortality 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 nineteenth 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, Ines Ramirez performed a caesarean section on herself and survived, as did her son, Orlando Ruiz Ramirez. She is believed to be the only woman to have performed a successful caesarean section on herself.

Caesareans in fiction

A Caesarean section appears in Shakespeare's play Macbeth. Macbeth faces a prophesized enemy not of woman-born, an impossibility but that MacDuff was "from his mother's womb untimely ripp'd," the product of a caesarean section birth.

The stillborn child of character Catherine Barkley is delivered by caesarean section in the Hemingway novel A Farewell to Arms.

References

• Williams Obstetrics. 14th Edition. Appleton Century-Crofts, New York, 1971, pages 1163-1190.

External links

• Caesareans and VBACs FAQ (http://www.plus-size-pregnancy.org/CSANDVBAC/csvbacindex.html): a private research site
• C-section recovery (http://www.csectionrecovery.com/), practical tips
• VBAC Backlash (http://www.slate.com/id/2111499/)"Why are hospitals forbidding women who have had C-sections the right to have vaginal births?" Slate, Dec. 2004da:Kejsersnit

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