Caesarian section

A caesarean section (cesarean section AE), 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 lead to medical complications, although it is increasingly common for otherwise normal births as well.

Etymology
There are several elements which contribute to an 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 Roman military and political leader Julius Caesar who allegedly was so delivered. Historically, this is unlikely as his mother was alive after he reached adulthood (extremely implausible if such a procedure was performed with the technology of the day ), 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 the term is the product of 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 caesarean 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 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 caesaren performed once labour has commenced.
 * A crash caesarean section is a caesarean performed in an obstetrical emergency.
 * 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 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.

Indications
Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. Reasons for caesarean delivery include:
 * prolonged labour or a failure to progress (dystocia)
 * apparent foetal distress
 * apparent maternal distress
 * complications (pre-eclampsia, active herpes)
 * catastrophes such as cord prolapse or uterine rupture
 * multiple births (though this is controversial)
 * abnormal presentation (breech or transverse positions)
 * failed induction of labour
 * failed instrumental delivery (by forceps or ventouse)
 * the baby is too large (macrosomia)
 * placental problems (placenta praevia, placental abruption or placenta accreta)
 * contracted pelvis
 * 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)

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 physicians and hospitals are much higher than are those for others. The medico-legal restrictions on VBAC, vaginal birth after caesarean, 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 labour 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, 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 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.

A study published in the June 2006 issue of the journal Obstetrics and Gynecology found that women who had multiple caesarian sections were more likely to have problems with later pregnancies, and recommended that women who want larger families should not seek caesarian 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 cesarean 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 labour.

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. Obstetrical hemorrhage may lead to anemia or to a clotting disorder.

Prevalence
The World Health Organisation estimates that the rate of caesarean sections at between 10% and 15% of all births in developed countries. In 2004, the caesarean rate in the United Kingdom was about 20% and 29.1% in the United States. During 2001–2002, the Canadian caesarean section rate was 22.5%.

While many obstetricians report cesarean rates over 30%, traditional midwives regularly report a cesarean rate lower than 10%, with a decreased risk of maternal and infant morbidity and no increase in mortality (Gaskin 2003). Attendance by a midwife and out-of-hospital labour are associated with much lower rates of caesarean section, when controlled for all relevant maternal and fetal indicators.

Choosing Caesarian Section as an Elective Procedure
Concerns have been raised in recent years that caesarian section is frequently performed for reasons other than medical necessity. Critics worry that caesareans are performed because they are profitable for the hospital, or because a quick caesarean is more convenient for an obstetrician than a lengthy vaginal birth. Another contributing factor may be fear of medical malpractice lawsuits. For example, the failure to perform a caesarean section became the core of numerous lawsuits against obstetricians over incidents of cerebral palsy. Medico-legal restrictions on VBAC, vaginal birth after caesarean, are also driving the caesarean rate.

Concerns have also arisen regarding those who choose caesareans to avoid the pain of delivery. The term "too posh to push" has been coined by the entertainment media regarding those rich and/or famous women who choose to avoid natural childbirth for allegedly selfish reasons, including most recently Angelina Jolie and Britney Spears. A recent study in the British Medical Journal retrospectively analysed a large number of caesarean sections 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. While such 'vanity' 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.

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 current practice, general anaesthesia for caesarean section is becoming less common as scientific research has now clearly established the benefits of regional anaesthesia for both the mother and baby. General anaesthesia tends to be reserved for high-risk cases or emergencies. The risks of general anaesthesia for mother and baby are still extremely small overall.

Anaesthetic care is not limited to the operation itself. Anaesthetic teams in the United Kingdom and New Zealand are responsible for post-operative pain relief.

There seems to be a link between the use of anaesthesia during labour and birth, as a form of pain relief for women planning a vaginal birth, and caesareans. Recent medical research concluded that epidural anaesthesia did not lead to labour failure leading to a caesarean, but medical practice is to use labour induction drugs after anaesthesia is applied to counteract the obvious sedative effect that causes labours to slow down or often stop.

Vaginal births after caesarean
See Vaginal birth 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. 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 and other caregivers differ on the relative merits of vaginal and caesarean birth following a caesarean birth. Some still recommend a caesarean routinely, others do not; still others respect the wishes of the expectant mother.

Twenty years of medical research on VBAC, support a woman's choice to have a vaginal birth after caesarean. Because the consequences of cesareans 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, VBAC remains a safer option.

History
Although most believe that Caesar himself was born by c-section, that is not 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, therefore ruling out the possibility that the dictator was a c-section baby. 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 wasn't performed. This would seem that, according to what Maimonides knew, c-sections weren't 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 (see below).

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: Jacob 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. 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 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.

Caesareans in fiction
The first caesarean section according to mythology was performed by Apollo on his lover Coronis when he delivered Asklepios.

In Persian mythology, Rudaba's labour of Rostam was prolonged due to the extraordinary size of her baby. Zal, her lover and husband, was certain that his wife would die in labour. Rudaba was near death when Zal decided to summon the Simurgh. The Simurgh appeared and instructed him upon how to perform a cesarean section, thus saving Rudaba and the child, who later on became one of the greatest Persian heroes.

A caesarean section appears in Shakespeare's play Macbeth. Macbeth hears a prophecy that "none of woman born shall harm Macbeth," an impossibility, but later finds out that MacDuff was "from his mother's womb untimely ripp'd," the product of a caesarean section birth (not unlike Robert II of Scotland).

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

In the video game Metal Gear Solid 3: Snake Eater, a main character called 'The Boss' exposes a c-section scar to Naked Snake (The player's character). The scar is possibly from a blundered procedure and runs from the abdomen to the breasts, and is in the shape of a snake.

In the movie Robin Hood: Prince of Thieves, Azeem performs a caesarean section on Fanny, the wife of Little John, to deliver her baby. Friar Tuck is humbled by Azeem's "worldly ways."