A cesarean section is a surgical procedure in which incisions are made through a woman's abdomen and uterus to deliver her baby.
Description
The most common reason that a cesarean section is performed (in 35% of all cases, according to the United States Public Health Service) is that the woman has had a previous c-section. The "once a cesarean, always a cesarean" rule originated when the classical uterine incision was made vertically; the resulting scar was weak and had a risk of rupturing in subsequent deliveries. Today, the incision is almost always made horizontally across the lower end of the uterus (this is called a "low transverse incision"), resulting in reduced blood loss and a decreased chance of rupture. This kind of incision allows many women to have a vaginal birth after a cesarean (VBAC).
The second most common reason that a c-section is performed (in 30% of all cases) is difficult childbirth due to nonprogressive labor (dystocia). Uterine contractions may be weak or irregular, the cervix may not be dilating, or the mother's pelvic structure may not allow adequate passage for birth. When the baby's head is too large to fit through the pelvis, the condition is called cephalopelvic disproportion (CPD).
Another 12% of c-sections are performed to deliver a baby in a breech presentation: buttocks or feet first. Breech presentation is found in about 3% of all births.
In 9% of all cases, c-sections are performed in response to fetal distress. Fetal distress refers to any situation that threatens the baby, such as the umbilical cord getting wrapped around the baby's neck. This may appear on the fetal heart monitor as an abnormal heart rate or rhythm.
The remaining 14% of c-sections are indicated by other serious factors. One is prolapse of the umbilical cord: the cord is pushed into the vagina ahead of the baby and becomes compressed, cutting off blood flow to the baby. Another is placental abruption: the placenta separates from the uterine wall before the baby is born, cutting off blood flow to the baby. The risk of this is especially high in multiple births (twins, triplets, or more). A third factor is placenta previa: the placenta covers the cervix partially or completely, making vaginal delivery impossible. In some cases requiring c-section, the baby is in a transverse position, lying horizontally across the pelvis, perhaps with a shoulder in the birth canal.
The mother's health may make delivery by c-section the safer choice, especially in cases of maternal diabetes, hypertension, genital herpes, Rh blood incompatibility, and preeclampsia (high blood pressure related to pregnancy).
Surgical removal of a fetus from the uterus through an abdominal incision at or before full term. It is usually performed when vaginal delivery would endanger the life or health of the mother or the child. Vaginal delivery is often possible in subsequent pregnancies. Cesarean section carries the usual risks of major surgery. Once overused, largely for fear of malpractice suits, its use has been greatly reduced by the natural childbirth movement.
Who Performs the Procedure and Where Is It Performed?
Cesarean sections are considered to be major surgery and are therefore usually performed under the strict conditions of a hospital operating room. The procedure is generally performed by an obstetrician who specializes in the areas of women's general health, pregnancy, labor and childbirth, prenatal testing, and genetics.
Questions to Ask the Doctor
What is your medical training and how many c-sections have you performed?
What percentage of women receive c-sections in your practice?
If I have an elective c-section, what happens if I go into labor before the procedure is scheduled?
What options are available to me for pain relief during and after the c-section?
May a person of my choice remain with me during the procedure?
When will I be able to hold/breastfeed my child?
Definition
A cesarean section is a surgical procedure in which incisions are made through a woman's abdomen and uterus to deliver her baby.
Purpose
Cesarean sections, also called c-sections or cesarean deliveries, are performed whenever abnormal conditions complicate labor and vaginal delivery, threatening the life or health of the mother or the baby. Dystocia, or difficult labor, is the other common cause of c-sections. The procedure is performed in the United States on nearly one of every four babies delivered—more than 900,000 babies each year. The procedure is often used in cases where the mother has had a previous c-section.
The most common reason that a cesarean section is performed (in 35% of all cases, according to the United States Public Health Service) is the woman has had a previous c-section. The "once a cesarean, always a cesarean" rule originated when the uterine incision was made vertically (termed a "classical incision"); the resulting scar was weak and had a risk of rupturing in subsequent deliveries. Today, the incision is almost always made horizontally across the lower end of the uterus (called a low transverse incision), resulting in reduced blood loss and a decreased chance of rupture. This kind of incision allows many women to have a vaginal birth after a cesarean (VBAC).
The second most common reason that a c-section is performed (in 30% of all cases) is difficult childbirth due to non-progressive labor (dystocia). Difficult labor is commonly caused by one of the three following conditions: abnormalities in the mother's birth canal; abnormalities in the position of the fetus; or abnormalities in the labor, including weak or infrequent contractions. The mother's pelvic structure may not allow adequate passage for birth. When the baby's head is too large to fit through the pelvis, the condition is called cephalopelvic disproportion (CPD).
Another 12% of c-sections are performed to deliver a baby in a breech presentation (buttocks or feet first). Breech presentation is found in about 3% of all births.
In 9% of all cases, c-sections are performed in response to fetal distress, which refers to any situation that threatens the baby such as the umbilical cord wrapped around the baby's neck. This may appear on the fetal heart monitor as an abnormal heart rate or rhythm. Fetal brain damage can result from oxygen deprivation. Fetal distress is often related to abnormalities in the position of the fetus or abnormalities in the birth canal, causing reduced blood flow through the placenta.
The remaining 14% of c-sections are indicated by other serious factors. One is prolapse of the umbilical cord: the cord is pushed into the vagina ahead of the baby and becomes compressed, cutting off blood flow to the baby. Another is "placental abruption," whereby the placenta separates from the uterine wall before the baby is born, cutting off blood flow to the baby. The risk of this is especially high in multiple births (twins, triplets, or more). A third factor is "placenta previa," in which the placenta covers the cervix partially or completely, making vaginal delivery impossible. In some cases requiring c-section, the baby is in a transverse position, lying horizontally across the pelvis, perhaps with a shoulder in the birth canal.
The mother's health may make delivery by c-section the safer choice, especially in cases of maternal diabetes, hypertension, genital herpes, malignancies of the genital tract, and preeclampsia (high blood pressure related to pregnancy).
Choosing Cesarean Section
A 1997 survey of female obstetricians found that 31% would choose to have a c-section without trial of labor if they had an uncomplicated pregnancy. This finding mirrors a growing movement to allow women the right to choose c-section over vaginal delivery, even when no indications for c-section exist.
There are a number of reasons why a woman might choose a c-section in the absence of the usual indications. These include:
Convenience. A scheduled c-section would allow a woman to choose the time and date of delivery to avoid conflicting with work or family obligations.
Fear of childbirth. A woman might fear the pain of labor and delivery and feel that a scheduled c-section would allow her to circumvent it.
Avoiding risks of vaginal delivery. Certain risks inherent to vaginal delivery (urinary or rectal incontinence, sexual dysfunction, dystocia) are avoided in a c-section.
Demographics
Women of higher socioeconomic status are more likely to have a c-section, 22.9%, compared to 13.2% of women who live in low-income families. C-section rates are highest among non-Hispanic white women (20.6%). Asian-American women have a c-section rate of 19.2%; African-American women, a rate of 18.9%, and Hispanic women, a rate of 13.9%.
Description
Regional anesthesia, either a spinal or epidural, is the preferred method of pain relief during a c-section. The benefits of regional anesthesia include allowing the mother to be awake during the surgery, avoiding the risks of general anesthesia, and allowing early contact between mother and child. Spinal anesthesia involves inserting a needle into a region between the vertebrae of the lower back and injecting numbing medications. An epidural is similar to a spinal except that a catheter is inserted so that numbing medications may be administered continuously. Some women experience a drop in blood pressure when a regional anesthetic is administered; this can be countered with fluids and/or medications.
In some instances, use of general anesthesia may be indicated. General anesthesia can be more rapidly administered in the case of an emergency (e.g., severe fetal distress). If the mother has a coagulation disorder that would be complicated by a drop in blood pressure (a risk with regional anesthesia), general anesthesia is an alternative. A major drawback of general anesthesia is that the procedure carries with it certain risks such as pulmonary aspiration and failed intubation. The baby may also be affected by the anesthetics since they cross the placenta; this effect is generally mild if delivery occurs within 10 minutes after anesthesia is administered.
Once the patient has received anesthesia, the abdomen is washed with an antibacterial solution and a portion of the pubic hair may be shaved. The first incision opens the abdomen. Infrequently, it will be vertical from just below the navel to the top of the pubic bone or, more commonly, it will be a horizontal incision across and above the pubic bone (informally called a "bikini cut").
The second incision opens the uterus. In most cases, a transverse incision is made. This is the favored type because it heals well and makes it possible for a woman to attempt a vaginal delivery in the future. The classical incision is vertical. Because it provides a larger opening
To remove a baby by cesarean section, an incision is made into the abdomen, usually just above the pubic hairline (A). The uterus is located and divided (B), allowing for delivery of the baby (C). After all the contents of the uterus are removed, the uterus is repaired, and the rest of the layers of the abdominal wall are closed (D). (Illustration by GGS Inc.)
than a low transverse incision, it is used in the most critical situations such as placenta previa. However, the classic incision causes more bleeding, a greater risk of abdominal infection, and a weaker scar.
Once the uterus is opened, the amniotic sac is ruptured and the baby is delivered. The time from the initial incision to birth is typically five minutes. The umbilical cord is clamped and cut, and the newborn is evaluated. The placenta is removed from the mother, and her uterus and abdomen are stitched closed (surgical staples may be used instead in closing the outermost layer of the abdominal incision). From birth through suturing may take 30–40 minutes; the entire surgical procedure may be performed in less than one hour.
Diagnosis/Preparation
There are several ways that obstetricians and other doctors diagnose conditions that may make a c-section necessary. Ultrasound testing reveals the positions of the baby and the placenta and may be used to estimate the baby's size and gestational age. Fetal heart monitors, in use since the 1970s, transmit any signals of fetal distress. Oxygen deprivation may be determined by checking the amniotic fluid for meconium (feces); a lack of oxygen may cause an unborn baby to defecate. Oxygen deprivation may also be determined by testing the pH of a blood sample taken from the baby's scalp; a pH of 7.25 or higher is normal, between 7.2 and 7.25 is suspicious, and below 7.2 is a sign of trouble.
When a c-section becomes necessary, the mother is prepped for surgery. A catheter is inserted into her bladder and an intravenous (IV) line is inserted into her arm. Leads for monitoring the mother's heart rate, rhythm, and blood pressure are attached. In the operating room, the mother is given anesthesia, usually a regional anesthetic (epidural or spinal), making her numb from below her breasts to her toes. In some cases, a general anesthetic will be administered. Surgical drapes are placed over the body, except the head; these drapes block the direct view of the procedure.
Aftercare
A woman who undergoes a c-section requires both the care given to any new mother and the care given to any patient recovering from major surgery. She should be offered pain medication that does not interfere with breastfeeding. She should be encouraged to get out of bed and walk around eight to 24 hours after surgery to stimulate circulation (thus avoiding the formation of blood clots) and bowel movement. She should limit climbing stairs to once a day, and avoid lifting anything heavier than the baby. She should nap as often as the baby sleeps, and arrange for help with the housework, meals, and care of other children. She may resume driving after two weeks, although some doctors recommend waiting for six weeks, the typical recovery period from major surgery.
Risks
Because a c-section is a surgical procedure, it carries more risk to both the mother and the baby. The maternal death rate is less than 0.02%, but that is four times the maternal death rate associated with vaginal delivery. Complications occur in less than 10% of cases.
The mother is at risk for increased bleeding (a c-section may result in twice the blood loss of a vaginal delivery) from the two incisions, the placental attachment site, and possible damage to a uterine artery. The mother may develop infection of the incision, the urinary tract, or the tissue lining the uterus (endometritis); infections occur in approximately 7% of women after having a c-section. Less commonly, she may receive injury to the surrounding organs such as the bladder and bowel. When a general anesthesia is used, she may experience complications from the anesthesia. Very rarely, she may develop a wound hematoma at the site of either incision or other blood clots leading to pelvic thrombophlebitis (inflammation of the major vein running from the pelvis into the leg) or a pulmonary embolus (a blood clot lodging in the lung).
Undergoing a c-section may also inflict psychological distress on the mother, beyond hormonal mood swings and postpartum depression ("baby blues"). The woman may feel disappointment and a sense of failure for not experiencing a vaginal delivery. She may feel isolated if the father or birthing coach is not with her in the operating room, or if an unfamiliar doctor treats her rather than her own doctor or midwife. She may feel helpless from a loss of control over labor and delivery with no opportunity to actively participate. To overcome these feelings, the woman must understand why the c-section was necessary. She must accept that she could not control the unforeseen events that made the c-section the optimum means of delivery, and recognize that preserving the health and safety of both her and her child was more important than her delivering vaginally. Women who undergo a c-section should be encouraged to share their feelings with others. Hospitals can often recommend support groups for such mothers. Women should also be encouraged to seek professional help if negative emotions persist.
Normal Results
The after-effects of a c-section vary, depending on the woman's age, physical fitness, and overall health. Following this procedure, a woman commonly experiences gas pains, incision pain, and uterine contractions (also common in vaginal delivery). Her hospital stay may be two to four days. Breastfeeding the baby is encouraged, taking care that it is in a position that keeps the baby from resting on the mother's incision. As the woman heals, she may gradually increase appropriate exercises to regain abdominal tone. Full recovery may be achieved in four to six weeks.
The prognosis for a successful vaginal birth after a cesarean (VBAC) may be at least 75%, especially when the c-section involved a low transverse incision in the uterus and there were no complications during or after delivery.
Morbidity and Mortality Rates
Surgical injuries to the ureter or bowel occur in approximately 0.1% of c-sections. The risk of infection to the incision ranges from 2.5% to 15%. Urinary tract infections occur in 2–16% of patients post-c-section. The risk for developing a deep-vein thrombosis is three to five times higher in patients undergoing c-section than vaginal delivery.
Of the hundreds of thousands of women in the United States who undergo a c-section each year, about 500 die from serious infections, hemorrhaging, or other complications. The overall maternal mortality rate is estimated to be between six and 22 deaths per 100,000 births; approximately one-third of maternal deaths that occur after c-section can be attributed to the procedure. These deaths may be related to the health conditions that made the operation necessary, and not simply to the operation itself.
Alternatives
When a c-section is being considered because labor is not progressing, the mother should first be encouraged to walk around to stimulate labor. Labor may also be stimulated with the drug oxytocin. A woman should receive regular prenatal care and be able to alert her doctor to the first signs of trouble. Once labor begins, she should be encouraged to move around and to urinate. The doctor should be conservative in diagnosing dystocia and fetal distress, taking a position of "watchful waiting" before deciding to operate.
Approximately 3–4% of babies present at term in the breech position. Before opting to perform an elective c-section, the doctor may first attempt to reposition the baby; this is called external cephalic version. The doctor may also try a vaginal breech delivery, depending on the size of the mother's pelvis, the size of the baby, and the type of breech position the baby is in. However, a c-section is safer than a vaginal delivery when the baby is 8 lb (3.6 kg) or larger, in a breech position with the feet crossed, or in a breech position with the head hyperextended.
A vaginal birth after cesarean (VBAC) is an option for women who have had previous c-sections and are interested in a trial of labor (TOL). TOL is a purposeful attempt to deliver vaginally. The success rate for VBAC in patients who have had a prior low transverse uterine incision is approximately 70%. The most severe risk associated with TOL is uterine rupture: 0.2–1.5% of attempted VBACs among women with a low transverse uterine scar will end in uterine rupture, compared to 12% of women with a classic uterine incision. To minimize this risk, the American College of Obstetricians and Gynecologists (ACOG) recommends that VBAC be limited to women with full-term pregnancies (37–40 weeks) who have only had one previous low transverse c-section.
Resources
Books
Enkin, Murray, et al. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. Oxford: Oxford University Press, 2000.
Periodicals
Harer, W. Benson. "Vaginal Birth After Cesarean Delivery: Current Status." Journal of the American Medical Association 287, no. 20 (May 2002).
Murphy, Deirdre, Rachel Liebling, Lisa Verity, Rebecca Swingler, and Roshni Patel. "Early Maternal and Neonatal Morbidity Associated with Operative Delivery in Second Stage of Labour: A Cohort Study." The Lancet 358 (October 13, 2001): 1203–07.
Delivery of a baby by the surgical incision of the mother's abdominal wall and uterus has a long history although it is only in the last century that the procedure of Caesarean section has carried any realistic expectation of maternal survival. The origin of the name ‘Caesarean’ is obscure. Although it is commonly linked to Julius Caesar, his mother is known to have been alive at the time of the invasion of Britain by his Roman army. It is highly unlikely that she would have survived delivery by ‘section’. Some have suggested that the term is derived instead from the Latin verb ‘to cut’, caedare.
Many early Caesarean sections were performed post-mortem as attempts to ensure survival of the baby after death of the mother. This may have been the case with MacDuff, who caused the downfall of Shakespeare's Scottish king, Macbeth, and who was ‘from his mother's womb, untimely ript’. Caesarean sections were performed sporadically during the seventeenth, eighteenth, and nineteenth centuries as deliberate surgical procedures on living women with obstructed labour, although survival was rare. During the twentieth century, improvements in anaesthesia and the availability of antibiotics and blood transfusion made the operation increasingly less hazardous. It is now commonplace for the mother to be awake during Caesarean section, but pain-free as a result of epidural or spinal anaesthesia.
Caesarean section may be performed as a planned (‘elective’) or an emergency procedure. Reasons for elective operations include breech presentation (a controversial issue), placenta praevia (in which the placenta is below the baby and would bleed during labour), or previous Caesarean sections for recurring complications. Emergency operations are mainly performed for ‘fetal distress’, or for ‘failure to progress’ during labour. The main causes of failed progress are poor contractions of the uterus, a baby too large to be accommodated by the mother's pelvis, or an occipito-posterior position (the baby's head facing away from the mother's spine).
Caesarean section is almost always, now, performed as the ‘lower segment’ operation, which produces a wound in the womb that heals well and which will be strong enough usually to cope with future labours. The formerly favoured ‘classical’ operation produced a wound that was, in contrast, prone to falling apart in subsequent pregnancies.
A procedure in which a child is delivered through a surgical incision made in the walls of the abdomen and uterus. Also called a Caesarean or C-section.
A cesarean section (also referred to as c-section) is the birth of a fetus accomplished by performing a surgical incision through the maternal abdomen and uterus. It is one of the oldest surgical procedures known throughout history.
Purpose
Although Healthy People 2010 established a goal of a 15 percent rate for c-sections in the United States, the ideal rate has not been established. As of 2004, the average c-section rate is one out of every four births or approximately 26 percent of all births. A c-section allows safe and quick delivery of a baby when a vaginal delivery is not possible. The surgery is performed in the presence of a variety of maternal and fetal conditions with the most commonly accepted indications being complete placenta previa, cephalopelvic disproportion (CPD), placental abruption, active genital herpes, umbilical cord prolapse, failure to progress in labor or dystocia, proven nonreassuring fetal status, and benign and malignant tumors that obstruct the birth canal. Indications that are more controversial include breech presentation, previous c-section, major congenital anomalies, cervical cerclage, and severe Rh isoimmunization. C-sections have a higher maternal mortality rate than vaginal births with approximately 5.8 women per 100,000 live births dying, and half of these deaths are ascribed to the operation and a coexisting medical condition. Perinatal morbidity is associated with infections, reactions to anesthesia agents, blood clots, and bleeding.
Description
According to the United States Public Health Service, 35 percent of all c-sections are performed because the woman has had a previous c-section. The skin incision for a c-section is either transverse (Pfannenstiel) or vertical and does not indicate the type of incision made into the uterus. "Once a cesarean, always a cesarean," is a rule that originated with the classical, vertical uterine incision. It was believed that the resulting scar weakened the uterus wall and was at risk of rupture in subsequent deliveries. As of 2004, the incision is almost always made horizontally across the lower uterine segment, called a low transverse incision. This results in reduced blood loss and a decreased chance of rupture. This kind of incision allows many women to have a vaginal birth after a cesarean (VBAC).
Failure to progress and/or dystocia is the second most common reason for a c-section and represents about 30 percent of all cases. Uterine contractions may be weak or irregular, the cervix may not be dilating, or the mother's pelvic structure may not allow adequate passage for birth. When the baby's head is too large to fit through the pelvis, the condition is called cephalopelvic disproportion (CPD). Failure to progress, however, can only be diagnosed with documentation of adequate contraction strength. The force of the contractions can be measured with an intrauterine pressure catheter (IUPC), which is a catheter that can be placed through the cervix into the uterus to measure uterine pressure during labor. Calculation of this force is determined by subtracting the baseline (resting) pressure from the peak pressure recorded for all contractions in a ten-minute period. This pressure calculation results in a force termed Montevideo units. A minimum of 200 Montevideo units are required before the forces of labor can be considered adequate. If the Montevideo units are less than this ten-minute sum and the fetal heart rate is reassuring, augmentation of labor with pitocin may be necessary.
Breech presentation occurs in about 3 percent of all births, and approximately 12 percent of c-sections are performed to deliver a baby in a breech presentation: buttocks or feet first. Breech presentations were still delivered vaginally in the 1970s, but with the advent of the malpractice climate, many doctors shied away from this practice, opting to perform a c-section. As a result, physicians who were being trained during that time period never learned how to manage a breech vaginal delivery. There was some change in this approach in the 1990s, and doctors are once again learning how to manage this situation; however, it is still uncertain whether this knowledge will be used in their practice.
Fetal distress or the more appropriate term, nonreassuring fetal heart rate, accounts for almost 9 percent of c-sections. With the introduction of electronic fetal monitoring (EFM) in the 1970s, doctors had more information for assessing fetal well-being. It was assumed that fetal monitoring would transmit signals of distress, thus, the EFM tracing became a legal document. There is still considerable debate as to what a non-reassuring FHR really is, but there are other parameters available to assist in this interpretation. When a fetus experiences stress, (oxygen deprivation) in utero, it may pass meconium (feces) into the amniotic fluid. The appearance of meconium in the fluid along with a questionable EFM tracing may indicate that a fetus is becoming compromised. At this point, if a woman is in early labor, a c-section may have to be performed. If, however, she is close to delivery, a vaginal delivery is often quicker. Oxygen deprivation may also be determined by testing the pH of a blood sample taken from the baby's scalp: a pH of 7.25-7.35 is normal; between 7.2 and 7.25 is suspicious; and below 7.2 is a sign of trouble. If the sample is equivocal, it can be repeated every 20 to 30 minutes.
The remaining 14 percent of c-sections occur secondary to other emergency situations, including the following:
Umbilical cord prolapse: This situation occurs when the cord is the presenting part from the vagina. It becomes compressed and cuts off blood flow to the baby. The birth attendant must insert a hand into the vagina and relieve pressure on the cord until a c-section is performed.
Placental abruption: The placenta separates from the uterine wall before the baby is born. If it is a complete abruption, the baby's blood flow will be cut off completely. The mother experiences severe pain, possible bleeding, and her abdomen feels rock hard. This situation demands an immediate c-section. Partial abruptions can occur without endangering the mother or the baby, but they need to be closely monitored. The risk of placental abruption is higher in multiple births and in women with high blood pressure.
Placenta previa: With a complete previa, the placenta covers the cervix completely, and the mother may experience painless bleeding. With a complete previa, a c-section is mandatory as cervical dilation would cause bleeding. The baby is often in a transverse position in this case, which means it is lying horizontally across the pelvis. Women with partial previas will usually need a c-section due to bleeding problems, but those with marginal previas can often deliver vaginally.
Active genital herpes: Any active herpetic lesions in the vaginal area can infect the baby as it passes through the birth canal. This is especially true for those with a primary outbreak, a first-time exposure.
Mother's health status: A c-section may be necessary in women with pre-existing diseases, such as diabetes, hypertension, pregnancy induced hypertension (preeclampsia), autoimmune diseases such as lupus erythematosus, and blood incompatibilities. Each case must be evaluated on an individual basis in these instances to achieve the optimal outcome for baby and mother.
Precautions
There are some precautions any pregnant woman can follow to enhance her chances of preventing a c-section. These include the following:
She should check her doctor's c-section rate to see if it is unnecessarily high. She can ask what his/her rate is and verify it by checking with the labor and delivery nurses at the hospital or with a childbirth educator.
She should not stay on her back during labor. She can walk, rock, or use a hot shower or whirlpool.
From the beginning, she should discuss with her doctor that she wants to avoid having a c-section if at all possible and enlist his opinion on how to achieve it.
Studies show that women who go to the hospital early have a higher c-section rate than those who do not. Therefore, when labor starts, the woman should stay home for as long as she safely can. She should not go in if contractions are further apart than four to five minutes.
She should use a midwife since studies show that they have a higher percentage of natural childbirths without surgical intervention than obstetricians do.
She should hire a doula to assist during labor birth. Doulas have a lower c-section rate and can offer massage, different positions, and support alternatives during the difficult phases of labor.
She should gather as much information as possible on hospital policies to educate herself and then discuss this information with her doctor or midwife. She should keep an open mind and stay informed.
Preparation
There is no perfect anesthesia for a c-section because every choice has its advantages and disadvantages. When a c-section becomes necessary and if it is not an emergency, the mother and her significant other should take part in the choice of anesthetic by being informed of risks and side effects. The anesthesia is usually a regional anesthetic (epidural or spinal), which makes her numb from below her breasts to her toes. In some cases, a general anesthetic will be administered if the regional does not work or if it is an emergency c-section. Every effort should be made to include the significant other in the preparations and recovery as well as the surgery if at all possible. An informed consent needs to be signed, and the physician should explain the surgery at that time. The mother may already have an intravenous (IV) line of fluid running into a vein in her arm. A catheter is inserted into her bladder to keep it drained and out of the way during surgery and the upper pubic area is usually shaved. Antacids are frequently administered to reduce the likelihood of damage to the lungs should aspiration of gastric contents occur. The abdominal area is then scrubbed and painted with betadine or another antiseptic solution. Drapes are placed over the surgical area to block a direct view of the procedure.
The type of skin incision, transverse or vertical, is determined by time factor, preference of mother, or physician preference. Two major locations of uterine incisions are the lower uterine segment and the upper segment of the body of the uterus (classical incision). The most common lower uterine segment incision is a transverse incision because the lower segment is the thinnest part of the pregnant uterus and involves less blood loss. It is also easier to repair, heals well, is less likely to rupture during subsequent pregnancies and makes it possible for a woman to attempt a vaginal delivery in the future. The classical incision provides a larger opening than a low transverse incision and is used in emergency situations, such as placenta previa, preterm and macrosomic fetuses, abnormal presentation, and multiple births. With the classical incision, there is more bleeding and a greater risk of abdominal infection. This incision also creates a weaker scar, which places the woman at risk for uterine rupture in subsequent pregnancies.
Once the uterus is opened, the amniotic sac is ruptured and the baby is delivered. The time from the initial incision to birth is typically five to ten minutes. The umbilical cord is clamped and cut, and the newborn is given to the nursery personnel for evaluation. Cord blood is normally obtained for analysis of the infant's blood type and pH. The placenta is removed from the mother and her uterus is closed with suture. The abdominal area may be closed with suture or surgical staple. The time from birth through suturing may take 30 to 40 minutes. The entire surgical procedure may be performed in less than one hour. Physical contact or holding of the newborn may take place briefly while the mother is on the operating table if the baby is stable. The significant other can go with the baby to the nursery for the remainder of the operation.
Aftercare
Immediate postpartal care after a c-section is similar to post-operative care with the exception of palpating the fundus (top of the uterus) for firmness. If an epidural or spinal were used, Duramorph (a pain medication similar to morphine) is often administered through these catheters just prior to completion of surgery. It does very well in controlling pain but may cause itching, which can be managed. During recovery the mother is encouraged to turn, cough, and deep breathe to keep her lungs clear, and the neonate is usually brought to the mother to breastfeed if she so desires. The mother will be encouraged to get out of bed about eight to 24 hours after surgery. Walking stimulates the circulation to avoid formation of blood clots and promotes bowel movement. Once discharged home, the mother should limit stair climbing to once a day, and she should avoid lifting anything heavier than the baby. It is important to nap as often as the baby does and make arrangements for help with the housework, meals, and care of other children. Driving may be resumed after two weeks, although some doctors recommend waiting for six weeks, which is the typical recovery period from major surgery.
Risks
The maternal death rate for c-section is less than 0.02 percent (5.8 per 100,000 live births), but that is four times the maternal death rate associated with vaginal delivery. The mother is at risk for increased bleeding from two incision sites and a c-section usually has twice as much blood loss as a vaginal delivery during surgery. Complications occur in less than 10 percent of cases, but these complications can include an infection of the incision, urinary tract, or tissue lining the uterus (endometritis). Less commonly, injury can occur to the surrounding organs, i.e., the bladder and bowel.
Normal Results
The after-effects of a c-section vary, depending on the woman's age, physical fitness, and overall health. Following this procedure, a woman commonly experiences gas pains, incision pain, and uterine contractions, which are also common with vaginal delivery. The hospital stay may be three to four days. Breastfeeding the baby is encouraged, taking care that it is in a position that keeps the baby from resting on the mother's incision. As the woman heals, she may gradually increase appropriate exercises to regain abdominal tone. Full recovery may be seen in four to six weeks.
The prognosis for a successful vaginal birth after a cesarean (VBAC) may be at least 75 percent, especially when the c-section involved a low transverse incision in the uterus, and there were no complications during or after delivery.
Of the hundreds of thousands of women in the United States who undergo a c-section each year, about 500 die from serious infections, hemorrhaging, or other complications. These deaths may be related to the health conditions that made the operation necessary and not simply to the operation itself.
Parental Concerns
Undergoing a c-section may inflict psychological distress on the mother, beyond hormonal mood swings and postpartum depression. The woman may feel disappointment and a sense of failure for not experiencing a vaginal delivery. She may feel isolated if the father or birthing coach is not with her in the operating room or if she is treated by an unfamiliar doctor rather than by her own doctor or midwife. She may feel helpless from a loss of control over labor and delivery with no opportunity to actively participate. To overcome these feelings, the woman needs to understand why the c-section was crucial. It is important that she be able to verbalize an understanding that she could not control the events that made the c-section necessary and recognize the importance of preserving the health and safety of both herself and her child. Women who undergo a c-section should be encouraged to share their feelings with others. Hospitals can often recommend support groups for such mothers. Women should also be encouraged to seek professional help if negative emotions persist.
cesarean section (sĭzâr'ēən), delivery of an infant by surgical removal from the uterus through an abdominal incision. The operation is of ancient origin: indeed, the name derives from the legend that Julius Caesar was born in this fashion. Until advancements in the late 19th cent., the mother generally died in surgery. The procedure was also aided by antisepsis, anesthetics, and other developments that made surgery as a whole more successful. Cesarean section is performed nowadays when factors exist that make natural childbirth hazardous, such as an abnormally narrow pelvis, pelvic tumors, hemorrhage, active infection with herpes simplex, multiple births, or an abnormal position of the fetus within the uterus. Subsequent deliveries are largely also by cesarean section. In the last few decades there has been a significant increase in the number of cesarean sections performed-a response both to the increase in malpractice litigation arising from problems attendant to vaginal deliveries and to the information provided by the many new devices that monitor the well-being of the fetus in the uterus.
Childbirth by surgical removal of the fetus through an incision made in the wall of the abdomen and in the uterus, usually used as an alternative when natural delivery through the vagina is considered risky. The number of Cesarean sections in the United States has increased sharply in recent years, causing concern among patients, surgeons, and insurers.
The term derives from the traditional belief that Julius Caesar was born by this method.
The procedure is often referred to colloquially as a “C-section.”
Delivery of a fetus by incision through the abdominal wall and uterus. The procedure takes its name from the Latin word caedere, to cut, and has no relation to the birth of Caesar as is sometimes believed.
A team of obstetricians perform a Caesarean section in a modern hospital. The image shows the very first moment the mother glimpses her new-born child.
A Caesarean section (or Cesarean section in American English), also known as C-section or Caesar, 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 could otherwise have been natural.[1][2][3] The World Health Organization (WHO) recommends that the rate of Caesarean sections should not exceed 15% in any country.
There are three theories about the origin of the name:
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.[4] (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.)
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.[5]
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,[6] 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 dictatorJulius Caesar, or with Roman Emperors 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 section").[7] The German term has also been imported into Japanese (帝王切開) and Korean (제왕 절개), both literally meaning "emperor incision." The South Slavic term is carski rez, which literally means caesarean cut, whereas the Western Slavic (Polish) has an analogous term: cesarskie cięcie. The Russian term kesarevo secheniye (кесарево сечение) literally means Caesar's section. The Arabic term (القيصرية) also means pertaining to Caesar or literally Caesarean. In Portugal it is usually called cesariana, meaning from (or related to) Caesar. The expression in Portuguese usually does not include other words to designate the section. Usual uses of the term are I'm going to have a cesariana next week or I was delivered by cesariana.
The cap-versus-lowercase variation reflects a style of lowercasing some eponymous terms (e.g., cesarean, eustachian, fallopian, mendelian, parkinsonian, parkinsonism).[8] Cap and lowercase stylings coexist in prevalent usage. Intradocument style consistency is usually advocated.
History
Successful Cesarean 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 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 Latinnon natus ("not born") — because he was born by Caesarean section. His mother died while giving birth to him.[9]
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. 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 Caeserean sections being performed on a regular basis.[10] 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.[10]
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.[11]
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 Cesarean 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 [12][13].
Types
Pulling out the baby.
A Caesarean section in progress.
Suturing of the uterus after extraction.
Incision for lower uterine segment section after stapling has been completed.
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.
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, Sweden, 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.
Complications
A 7 week old Caesarean section scar and linea nigra visible on a 31 year old female.
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
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.
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)
Other
Lack 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])[15]
Improper Use of Technology (Electric Fetal Monitoring [EFM])[15][16]
Risks
Risks for the mother
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.[17] The UKNational Health Service gives the risk of death for the mother as three times that of a vaginal birth.[18] 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 cesarean delivery and by their physicians.[19]
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.[17] 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.[20] Other risks include severe blood loss (which may require a blood transfusion) and post spinal headaches.[17]
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.[21]
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 cesarean, rather than due to the procedure itself.[22]
Risks for the child
For the baby, complications can also include neonatal depression due to anesthesia and fetal injury due to the uterine incision and extraction.[17]
One study found an increased risk of complications if a repeat elective Caesarean section is performed even a few days before the recommended 39 weeks.[23]
Risks for both mother and child
Due to extended hospital stays, both the mother and child are at risk for developing a hospital-borne infection.[17]
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.[17]
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.[24]
In Italy the incidence of Caesarean sections is particularly high, albeit it varies from Region to Region.[25] In Campania reportedly 60% of 2008 birth occurred via Ceasarean sections.[26] In the Rome region, the mean incidence is around 44%, but can reach as high as 85% in some private clinics. [2][27]
In the United States the Caesarean rate has risen 48% since 1996,[28] reaching a level of 31.8% in 2007.[28] 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.[29]
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%.[citation needed]
Studies have shown that continuity of care with a known carer may significantly decrease the rate of Caesarean delivery[30] 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.[31]
Research into reasons for emergency cesareans found that 66% occur between the 25% of day shift hours of 8 AM and 3 PM, and the least between 5 AM and 6 AM leading the authors to conclude that physician convenience is a leading cause of "emergency cesareans." (Goldstick O, Weissman A, Drugan A.The circadian rhythm of "urgent" operative deliveries.Isr Med Assoc J. 2003 Aug;5(8):564-6.)
Dr S. Bewley has written extensively about the issues surrounding these procedures, which are often given the misnomer: 'cesarean by choice'.(Bewley S, Cockburn J. The unfacts of 'request' caesarean section. BJOG. 2002 Jun;109(6):597-605.) A cesarean is a life threatening medical procedure that is obviously ultimately decided upon by a doctor or several doctors.
Analyzing the rise in caesarean section rates
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:
Some authors have proposed an “ideal rate” of all cesarean deliveries (such as 15 percent) for a population. 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. Thus, optimal cesarean delivery rates will vary over time and across different populations according to individual and societal circumstances.[32]
Nonetheless, some commentators are concerned by the rise and have tried to generate theories to explain it. 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."[33]
In India the raise of the section rates is due to the higher fees charged by the doctors for caesarean when compared to normal delivery. To earn more money the hospitals and doctors force caesarean on the patient, even if the patient is unwilling.
Silverton's analysis is controversial. 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.'[33]
A previously unexplored reason for the increasing section rate is the evolution of birth weight and maternal pelvis size. Since the advent of successful Cesarean 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. Even without fears of malpractice, without maternal obesity and diabetes, and without other widely quoted factors, the C-section rate will continue to rise simply due to slow changes in population genetics.[34]
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.[35].
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) [36]. 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 her to [get a c-section]” [25]
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.[37] 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.[38] 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.[citation needed]
Some 42% of obstetricians blame expectant mothers (among other sources) for the rising caesarean section rates[39]. Studies from Sweden also confirm this.[40].
Anaesthesia
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.[41] 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 Oesophagealintubation.[42]
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.[43] 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.[42]
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 birth after caesarean (VBAC) are not uncommon today, their numbers are shrinking[44]. 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[neutrality disputed] 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.
In the United States of America, the American College of Obstetricians and Gynecologists (ACOG) modified the guidelines on vaginal birth after previous cesarean delivery in 1999 and again in 2004[45]. 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.[46]
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[47]. 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[48].
Recovery Period
Typically the recovery time depends on the patient and their 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 two weeks.
^Finger, C. (2003). "Caesarean section rates skyrocket in Brazil. Many women are opting for Caesareans in the belief that it is a practical solution.". Lancet362: 628. doi:10.1016/S0140-6736(03)14204-3. PMID12947949.
^ England, Pam and Rob Horowitz, Birthing From Within, p. 149
^ For a summary (in German), of an article (also in German) that deals usefully with many of the relevant historical and linguistic questions raised here, go here.
^Silver RM, Landon MB, Rouse DJ, et al. (June 2006). "Maternal morbidity associated with multiple repeat cesarean deliveries". Obstet Gynecol107 (6): 1226–32. doi:10.1097/01.AOG.0000219750.79480.84 (inactive 2008-12-31). PMID16738145. (see also review by WebMD.com)
^Kennare R, Tucker G, Heard A, Chan A (February 2007). "Risks of adverse outcomes in the next birth after a first cesarean delivery". Obstet Gynecol109 (2 Pt 1): 270–6. doi:10.1097/01.AOG.0000250469.23047.73 (inactive 2008-12-31). PMID17267823.
^Homer CS, Davis GK, Brodie PM, et al. (January 2001). "Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care with standard hospital care". BJOG108 (1): 16–22. doi:10.1016/S0306-5456(00)00022-X. PMID11212998.
^Hodnett ED (2000). "Continuity of caregivers for care during pregnancy and childbirth". Cochrane Database Syst Rev (2): CD000062. doi:10.1002/14651858.CD000062. PMID10796108. Hodnett ED (2008). "WITHDRAWN: Continuity of caregivers for care during pregnancy and childbirth". Cochrane Database Syst Rev (4): CD000062. doi:10.1002/14651858.CD000062.pub2. PMID18843605.
^NIH (2006). "State-of-the-Science Conference Statement. Cesarean Delivery on Maternal Request". Obstet Gynecol107: 1386–97, also [1].
^MacKenzie IZ, Cooke I, Annan B (May 2003). "Indications for caesarean section in a consultant obstetric unit over three decades". J Obstet Gynaecol23 (3): 233–8. doi:10.1080/0144361031000098316. PMID12850849.
^ abAfolabi BB, Lesi FE, Merah NA (2006). "Regional versus general anaesthesia for caesarean section". Cochrane Database Syst Rev (4): CD004350. doi:10.1002/14651858.CD004350.pub2. PMID17054201.
