Caesarean section

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A team of obstetricians performing a Caesarean section in a modern hospital. A Caesarean section, (also C-section, Caesarian section, Cesarean section, Caesar, etc.) is a surgical procedure in which one or more incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies, or, rarely, to remove a dead fetus. A late-term abortion using Caesarean section procedures is termed a hysterotomy abortion and is very rarely performed. The first modern Caesarean section was performed by German gynecologist Ferdinand Adolf Kehrer in 1881. A Caesarean section 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] In recent years the rate has risen to a record level of 46% in China and to levels of 25% and above in many Asian and European countries, Latin America, and the USA.[4]

Contents
[hide]

1 Etymology 2 Orthography 3 History

4 Types 5 Indications 6 Risks o 6.1 Risks for the mother o 6.2 Risks for the child o 6.3 Risks for both mother and child 7 Incidence 8 Analyzing the rise in Caesarean section rates 9 Elective Caesarean sections 10 Anaesthesia 11 Vaginal birth after Caesarean o 11.1 Recovery period 12 Within Judaism 13 See also 14 References 15 External links

[edit] Etymology
The Roman Lex Regia, (later the Lex Caesarea) of Numa Pompilius (715-673 BC), required that the child of a mother dead in childbirth be cut from her womb. [5] This seems to have begun as a religious requirement that mothers not be buried pregnant, [6] and to have evolved into a way of saving the fetus, with Roman practice requiring a living mother be in her 10th month of pregnancy before the procedure was resorted to, reflecting the knowledge that she could not survive the delivery. [7] Rumours that the term refers to the birth of the Roman dictator Julius Caesar are false; although Caesarean sections were performed in Roman times, no classical source records a mother surviving such a delivery,[5][8] the earliest recorded survival dates to 1500 AD[9] and Caesar's mother Aurelia Cotta lived to serve him as an advisor in his adulthood.[7] The term has also been explained as deriving from the verb caedo, 'to cut', with children delivered this way referred to as caesones. Pliny the Elder refers to a certain Julius Caesar (not the dictator, but a remote ancestor) as ab utero caeso, "cut from the womb", a godly attribute comparable to rumors about the birth of Alexander the Great.[10] This and Caesar's name may have led to a false etymological connection with the dictator. Some link with the Roman dictator Julius 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 csszrmetszs (literally: "Emperor's cut").[11] The German term has also been imported into Japanese ( teisekkai) and Korean ( jewang jeolgae), both literally meaning "emperor incision." Similar in Western Slavic (Polish) cicie cesarskie, (Czech) csask ez and (Slovak) csarsk rez (literally "imperial cut"), whereas the South Slavic term is (Slovenian) crski rz, which literally means tzar cut. The Russian term kesarevo secheniye ( ksarevo senije) literally means Caesar's

section. The Arabic term ( wilaada qaySaryya) also means pertaining to Caesar or literally Caesarean. The Hebrew term ( nitakh Keisri) translates literally as Caesarean Surgery. In Romania and Portugal it is usually called cesariana, meaning from (or related to) Caesar. According to Shahnameh ancient Persian book, the hero Rostam was the first person who was born with this method and term (rostamineh) is corresponded to Caesarean. Finally, the Roman praenomen (given name) Caeso was said to be given to children who were born via c-section. While this was probably just folk etymology made popular by Pliny the Elder, it was well known by the time the term came into common use.

[edit] Orthography

The e/ae/ variation reflects American and British English spelling differences. The cap-versus-lowercase variation reflects a style of lowercasing some eponymous terms (e.g., cesarean, eustachian, fallopian, mendelian, parkinsonian, parkinsonism).[12] Cap and lowercase stylings coexist in prevalent usage. Intradocument style consistency is usually advocated.

[edit] History

Successful Caesarean section performed by indigenous healers in Kahura, Uganda. As observed by R. W. Felkin in 1879. Bindusara (Born c. 320 BC, ruled: 298 - c.272 BC) , the second Mauryan emperor of India after Chandragupta Maurya the Great, is said to be first child born by surgery. His mother, wife of Chandragupta Maurya, accidentally consumed poison and died when she was close to delivering him. Chanakya, the Chandragupta's teacher and advisor, made up his mind that the baby should survive. He cut open the belly of the queen and took out the baby, thus saving the baby's life. Pliny the Elder theorized that Julius Caesar's name 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 (12041240), received his surnamefrom the Latin non natus ("not born")because he was born by Caesarean section. His mother died while giving birth to him.[13] In 1316 the future Robert II of Scotland was delivered by Caesarean sectionhis mother, Marjorie Bruce, died. This may have been the inspiration for Macduff in Shakespeare's play Macbeth". (see below). Caesarean section usually resulted in the death of the mother; the first recorded incidence of a woman surviving a Caesarean section was in the 1580s, in Siegershausen, Switzerland: Jakob Nufer, a pig gelder, is supposed to have performed the operation on his wife after a prolonged labour.[14] However, there is some basis for supposing that women regularly survived the operation in Roman times. [15] For most of the time since the sixteenth century, the procedure had a high mortality rate. 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:

Introduction of the transverse incision technique to minimize bleeding by Ferdinand Adolf Kehrer in 1881. This is thought to be first modern CS performed. The introduction of uterine suturing by Max Snger in 1882. Extraperitoneal CS and then moving to low transverse incision (Krnig, 1912).
[clarification needed]

Adherence to principles of asepsis. Anesthesia advances. Blood transfusion. Antibiotics.

European travelers in the Great Lakes region of Africa during the 19th century observed Caesarean sections being performed on a regular basis.[16] 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.[16] 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.[17] On March 5, 2000, Ins Ramrez performed a Caesarean section on herself and survived, as did her son, Orlando Ruiz Ramrez. She is believed to be the only woman to have performed a successful Caesarean section on herself.

An early account of Caesarean 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.[18][19]

[edit] Types

Pulling out the baby.

A Caesarean section in progress.

Suturing of the uterus after extraction.

Closed Incision for low transverse abdominal incision 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, Finland, 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.

[edit] Indications

A 7-week old Caesarean section scar and linea nigra visible on a 31-year-old mother. 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

prolonged labor or a failure to progress (dystocia) fetal distress cord prolapse uterine rupture increased blood pressure (hypertension) in the mother or baby after amniotic rupture increased heart rate (tachycardia) in the mother or baby after amniotic rupture placental problems (placenta praevia, placental abruption or placenta accreta) abnormal presentation (breech or transverse positions) failed labor induction 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. overly large baby (macrosomia) umbilical cord abnormalities (vasa previa, multi-lobate including bi-lobate and succenturiate-lobed placentas, velamentous insertion) contracted pelvis

Other complications of pregnancy, preexisting conditions and concomitant disease such as

pre-eclampsia hypertension [20] multiple births precious (High Risk) Fetus HIV infection of the mother 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) Bi-corniute uterus

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])[21] Improper Use of Technology (Electric Fetal Monitoring [EFM])[21][22]

[edit] Risks

One of the most common risks: 2 weeks after the Caesarean section, fluid retention in the wound. Incision had to be opened to use a negative pressure wound therapy unit to drain the body fluids to prevent infection.

[edit] 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.[23] The UK National Health Service gives the risk of death for the mother as three times that of a vaginal birth.[24] 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 Caesarean delivery and by their physicians.[25] 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.[23] 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.[26] Other risks include severe blood loss (which may require a blood transfusion) and post spinal headaches.[23] 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.[27] 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 Caesarean, rather than due to the procedure itself.[28]

[edit] Risks for the child

This list is currently incomplete and should not be taken as comprehensive or reflective of current research. It covers some of the most commonly discussed risks to the child posed by the procedure itself rather than the medical indications that may call for it. Some risks are rare, and as with most medical procedures the likelihood of any risk is highly dependent on individual factors such as whether other pregnancy complications exist, whether the operation is planned or done as an emergency measure, and how and where it is performed.

Lower apgar scores/ neonatal depression: babies may experience a period of inactivity or sluggishness after delivery, possibly due to an adverse reaction to the anesthesia given to the mother.[23] Potential for infant injury: it is possible though very rare for surgical tools used for the uterine incision to injure the infant.[23] Wet lung: retention of fluid in the lungs can occur if not expelled by the pressure of contractions during labor.[29] Potential for early delivery and complications: Pre-term delivery is possible if due date calculation is inaccurate. 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. [30] Higher infant mortality risk: in c-sections which are performed with no indicated risk (singleton at full term in a head-down position), the risk of death in the first 28 days of life has been cited as 1.77 per 1,000 live births among women who had c-sections, compared to 0.62 per 1,000 for women who delivered vaginally [31]

[edit] 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.[23] Studies have shown that mothers who have their babies delivered by Caesarean take longer to first interact with their child when compared with mothers who had their babies vaginally.[23]

[edit] Incidence
The World Health Organization recommends the rate of Caesarean sections between 10% and 15% of all births in developed countries. However, in 2004, the Caesarean rate was about 20% in the United Kingdom, while the Canadian rate was 22.5% in 2001-2002.[32] In Italy the incidence of Caesarean sections is particularly high, although it varies from region to region.[33] In Campania, 60% of 2008 births reportedly occurred via Caesarean sections.[34] In the Rome region, the mean incidence is around 44%, but can reach as high as 85% in some private clinics. [2][35] In the United States the Caesarean rate has risen 48% since 1996,[36] reaching a level of 31.8% in 2007.[36] 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.[37] In Brazil's public health network, the rate reaches 35%, while in private hospitals the rate approaches 80%.[citation needed] China has been cited as having the highest rates of C-sections in the world at 46% as of 2008[38] Studies have shown that continuity of care with a known carer may significantly decrease the rate of Caesarean delivery[39] but 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.[40] More emergency Caesareansabout 66%are performed during the day rather than during the night.[41]

[edit] 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:

The World Health Organization has determined an ideal rate of all cesarean deliveries (such as 15 percent) for a population. One surgeon's opinion is that there is no consistency in this ideal rate, and artifcial 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. This opinion is based on the idea that if left unchallenged, optimal cesarean delivery rates will vary over time and across different populations according to individual and societal circumstances.[42] There has been a rapid growth in the number of c-sections performed. For example, there has been a fourfold increase from 1971 to 1991. (From 4.2 c-sections per 100 births). This may be accredited to the improved technology in detecting pre-birth distress. Malpractice has been looked into because of the rapid increase in c-sections. Some argue that the higher costs of c-section births compared to regular births make physicians quicker to recommend a c-section. Usually, if a doctor makes a recommendation people are quick to take it to heart and act upon it. The effect of relative c-section price on csection usage should be examined. However, some commentators are concerned by the rise and have noted several evidencebased studies. Louise Silverton, deputy general-secretary of the Royal College of Midwives, says that not only has societys 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."[43] Silverton's analysis is controversial among some surgeons. 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 lifesaving.'[43] A previously unexplored hypothesis for the increasing section rate is the evolution of birth weight and maternal pelvis size. It is proposed that since the advent of successful Caesarean 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. Such a hypothesis is based upon the idea that even without fears of malpractice, without maternal obesity and diabetes, and without other widely quoted factors, the C-section rate would continue to rise simply due to slow changes in population genetics.[44]

[edit] Elective Caesarean sections

Main article: Elective caesarean section

This section may stray from the topic of the article into the topic of another article, Elective_caesarean_section. Please help improve this section or discuss this issue on the talk page. (January 2011) 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.[45] Another reason for doctors to recommend C-section is money. In China, doctors are compensated based on the monetary value of medical treatments offered. As a result, doctors have an incentive to persuade mothers to choosing the more expensive C-section. 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). [46] 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 she gets a C-section "[33] 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.[47] 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.[48] 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 have suggested that due to the comparative risks of Caesarean section with an uncomplicated vaginal delivery, patients should be discouraged or forbidden from choosing it.[49]

Some 42% of obstetricians believe the media and women are responsible for the rising Caesarean section rates.[50] Some studies, however, conclude that relatively few women wish to be delivered by Caesarean section.[51]

[edit] 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.[52] 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 Oesophageal intubation.
[53]

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.[54] 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 Caesarean delivery is also higher than that required for labor analgesia.[53] 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.

[edit] Vaginal birth after Caesarean

Main article: Vaginal birth after caesarean While vaginal birth after Caesarean (VBAC) are not uncommon today, their numbers are shrinking.[55] 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 be emphasized in modern obstetric care is that the decision should be a mutual decision between the obstetrician and the mother/birth partner after assessing the risks and benefits of each type of delivery. 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 US, the American College of Obstetricians and Gynecologists (ACOG) modified the guidelines on vaginal birth after previous Caesarean delivery in 1999 and again in 2004.[56] This modification to the guideline included the addition of the 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.[57] This recommendation has, in some cases, had a major impact on the availability of VBACs to birthing mothers in the US. 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.[58] 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.[59]

[edit] 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.

[edit] Within Judaism

There is a dispute among the poskim (Rabbinic authorities) as to whether a first born son from a Cesarean section has the laws of a Bechor.[60] Every pregnant woman hopes for a short labor and delivery with no complications manageable contractions, some pushing, then a beautiful baby but it doesn't always work out that way. These days, about 30% of all babies in the United States are delivered via cesarean section (C-section).

Even if you're envisioning a traditional vaginal birth, it may help to ease some fears to learn why and how C-sections are performed, just in case everything doesn't go as planned.

What Is a C-Section?
A C-section is the surgical delivery of a baby that involves making incisions in the mother's abdominal wall and uterus. Generally considered safe, C-sections do have more risks than vaginal births. Plus, you can come home sooner and recover quicker after a vaginal delivery. However, C-sections can help women at risk for complications avoid dangerous deliveryroom situations and can save the life of the mother and/or baby when emergencies occur. C-sections are done by obstetricians (doctors who care for pregnant women before, during, and after birth) and some family physicians. Although more and more women are choosing midwives to deliver their babies, midwives of any licensing degree cannot perform C-sections.

Why They're Needed

Some C-sections are scheduled if the doctor is aware of certain factors that would make a vaginal birth risky. That means some women know ahead of time that they will be delivering via C-section and are able to schedule their baby's "birth day" well in advance. This allows them to prepare themselves emotionally and mentally for the birth which can help to lessen the feelings of disappointment that many mothers who are unable to deliver vaginally experience. So what determines if a woman is scheduled for a C-section? A doctor may schedule one if:

the baby is in breech (feet- or bottom-first) or transverse (sideways) position in the womb (although some babies can be turned before labor begins or delivered vaginally using forceps and anesthesia) the baby has certain birth defects (such as severe hydrocephalus) the mother has problems with the placenta, such as placenta previa (when the placenta sits too low in the uterus and covers the cervix) the mother has a medical condition that could make a vaginal delivery risky for herself or the baby (such as HIV or an active case of genital herpes) some multiple pregnancies the mother previously had surgery on her uterus or a C-section (although many such women can safely have a vaginal birth after a C-section, called a VBAC)

Some C-sections are unexpected emergency deliveries performed when complications arise with the mother and/or baby during pregnancy or labor. An emergency C-section might be required if:

labor stops or isn't progressing as it should (and medications aren't helping) the placenta separates from the uterine wall too soon (called placental abruption) the umbilical cord becomes pinched (which could affect the baby's oxygen supply) or enters the birth canal before the baby (called umbilical cord prolapse) the baby is in fetal distress certain changes in the baby's heart rate may mean that the baby is not getting enough oxygen the baby's head or entire body is too big to fit through the birth canal

Of course, each woman's pregnancy and delivery is different. If your doctor has recommended a C-section and it's not an emergency, you can ask for a second opinion. In the end, you most often need to rely on the judgment of the doctors. BackContinue

The Procedure
The thought of having surgery can be unnerving for any woman. Here's a quick look at what usually happens during a scheduled C-section. Your labor coach can be right by your side, clad in a surgical mask and gown, during the entire delivery (although partners may not be allowed to stay during emergency Csections). Before the procedure begins, an anesthesiologist will discuss your options. To prepare for the delivery, you'll probably have:

various monitors in place to keep an eye on your heart rate, breathing, and blood pressure your mouth and nose covered with an oxygen mask or a tube placed in your nostrils to give you oxygen a catheter (a thin tube) inserted into your bladder through your urethra (which may be uncomfortable when it is placed, but should not be painful) an IV in your arm or hand your belly washed and any hair between the bellybutton and pubic bone shaved a privacy screen put around your belly

After being given anesthesia, the doctor makes an incision on the skin of the abdomen either vertically (from the bellybutton down to the pubic hair line) or horizontally (1-2 inches above the pubic hairline, sometimes called "the bikini cut"). The doctor then gently parts the abdominal muscles to get to the uterus, where he or she will make another incision in the uterus itself. This incision can also be vertical or horizontal. Doctors usually use a horizontal incision in the uterus, also called transverse, which heals better and makes a VBAC much more possible. Once the uterine incision is made, the baby is gently pulled out. The doctor suctions the baby's mouth and nose, then clamps and cuts the umbilical cord. As with a vaginal birth,

you should be able to see your baby right away. Then, the little one is handed over to the nurses and a pediatrician or other doctor who will be taking care of your newborn for a few minutes (or longer, if there are concerns). The obstetrician then removes the placenta from the uterus, closes the uterus with dissolvable stitches, and closes the abdominal incision with stitches or surgical staples that are usually removed, painlessly, a few days later. If the baby is OK, you can hold and/or nurse your newborn in the recovery room by lying on your side (since holding your baby will put too much pressure on your abdomen).

How You Might Feel

You won't feel any pain during the C-section, although you may feel sensations like pulling and pressure. With a planned C-section, the anesthesiologist will give you the option to be unconscious (or "asleep") during the delivery using general anesthesia or awake and simply numbed from the waist down using regional anesthesia (an epidural and/or a spinal block). Many women want to be awake to see and hear their baby being born. A curtain will be over your abdomen during the surgery, but you may be able to take a peek as your baby is being delivered from your belly. However, women who need to have an emergency C-section occasionally require general anesthesia, so they're unconscious during the delivery and won't remember anything or feel any pain.

Risks
C-sections today are, in general, safe for both mother and baby. However, there are risks with any kind of surgery. Potential C-section risks include:

increased bleeding (that could, though rarely, result in a blood transfusion) infection (antibiotics are usually given to help prevent infection) bladder or bowel injury reactions to medications blood clots death (very rare) possible injury to the baby

Some of the regional anesthetic used during a C-section does reach the baby, but it's much less than what the newborn would get if the mother received general anesthesia (which sedates the baby as well as the mother). Babies born by C-section sometimes have breathing problems (transient tachypnea of the newborn) after birth since labor hasn't jump-started the clearance of fluid from their lungs. This usually gets better on its own within the first day or two of life.

Having a C-section may or may not affect future pregnancies and deliveries. Many women can have a successful and safe vaginal birth after cesarean but, in some cases, future births may have to be C-sections, especially if the incision on the uterus was vertical rather than horizontal. A C-section can also put a woman at increased risk of possible problems with the placenta during future pregnancies. In the case of emergency C-sections, the benefits usually far outweigh the risks. A Csection could save your life or your baby's.

Recovery
As with any surgery, there's usually some degree of pain and discomfort after a Csection. The recovery period is also a little longer than for vaginal births. Women who've had C-sections usually remain in the hospital for about 3 or 4 days and need to stay in bed for at least a day after the delivery. Right after, you may feel itchy, sick to your stomach, and sore these are all normal reactions to the anesthesia and surgery. If you needed general anesthesia for an emergency C-section, you may feel groggy, confused, chilly, scared, alarmed, or even sad. Your doctor can give you medications to ease any discomfort or pain. For the first few days and even weeks, you might:

feel tired have soreness around the incision (the doctor can prescribe medications and/or recommend over-the-counter pain relievers that are safe to take if you're breastfeeding) be constipated and gassy have a hard time getting around and/or lifting your baby

After about 6 to 8 weeks, the uterus is usually healed and you can probably get back to your normal routine. At the beginning, you'll need to avoid driving or lifting anything heavy so that you don't put any unnecessary pressure on your incision. Check with your doctor about when you can get back to your usual activities. And as with a vaginal delivery, you should refrain from having sex until about 6 weeks after delivery and your doctor has given you the go-ahead. Frequent and early walking may help ease some post-cesarean pains and discomfort. Among other things, it can help prevent blood clots and keep your bowels moving. But don't push yourself take it easy and have someone help you get around, especially up and down stairs. Enlist friends, family, and neighbors to lend a helping hand with meals and housework for a while, especially if you have other children. Although breastfeeding may also be a little painful at first, lying on your side to nurse or using the clutch (or football) hold can take the pressure off your abdomen.

Also, C-sections scars fade over time. They'll start to decrease in size and become a natural skin color in the weeks and months after delivery. And because incisions are often made in the "bikini" area, many C-section scars aren't even noticeable. Call your doctor if you have:

fever signs of infection around your incision (swelling, redness, warmth, or pus) pain around your incision or in your abdomen that comes on suddenly or gets worse foul-smelling vaginal discharge heavy vaginal bleeding leg pains, or swelling or redness of your legs difficulty breathing or chest pain feelings of depression pain in one or both breasts

Emotionally, you may feel a little disappointed if you'd been hoping for a vaginal birth or had gone through labor that ended in a C-section. Although it can be disheartening when the traditional way doesn't work for your delivery, having a C-section does not make the birth of your baby any less special or your efforts any less amazing. After all, you went through major surgery to deliver your baby! It might not be the birth experience you'd imagined, but you can finally meet the little one you've been nurturing all this time!

Cesarean section
Approved by the BabyCenter Philippines Medical Advisory Board Last reviewed: October 2010

What is a cesarean section? What's the difference between an elective and an emergency cesarean? What will happen before my cesarean? What happens during a cesarean? What will happen after my baby is born?

What is a cesarean section?

A cesarean section is an operation in which an obstetrician makes a cut through your belly and uterus (womb) so that your baby can be born. It's the most common major surgery that women have.

What's the difference between an elective and an emergency cesarean?

An elective cesarean is planned to take place before your labor begins. An emergency cesarean is not planned before labor begins and happens in a range of situations. Although many cesareans are unplanned, only about a small percent of these are genuine emergencies. Most unplanned cesareans give you, your partner, and the maternity staff enough time to be well prepared for the operation. The reasons for needing a cesarean section vary, because every pregnancy and birth is different. Read about reasons that may require a cesarean. Much may depend on whether this is your first baby, or whether you've already had one baby or more by cesarean. Your circumstances may mean that your doctor advises you to have a planned repeat cesarean. Occasionally, the operation may be carried out as an emergency. We've drawn up a birth plan to help you decide what to do if you have a cesarean section -- whether you are expecting to give birth that way or not. Simply print out our checklist.

What will happen before my cesarean?

Your doctor should talk you through the procedure. They will:

tell you what will happen during the cesarean section

explain why they think you need the operation

explain any possible risks it poses to you and your baby

ask for your consent, which you have the right to refuse

Before surgery, you will need to change into a hospital gown and to take off jewelery (apart from a wedding ring, which can be taped over). If you have a brace or false teeth, you'll need to remove these too for safety reasons. You will also need to take off make-up and nail varnish, so your skin tone can be monitored during the operation. You won't be able to wear contact lenses. If you wear glasses, give them to your partner or one of the nurses, so that you can put them on to see your baby. Some hospitals will allow the baby's father to be with you during your cesarean. If so, he will have to change into thin cotton theater clothes, which include a mask for his nose and mouth, a cap and special footwear. During your cesarean you'll lie on an operating table, which is tilted or wedged to the left. It's tilted so the weight of your uterus doesn't reduce the blood supply to your lungs and make your blood pressure drop. Quite a lot of things will happen to prepare you for your cesarean:

You'll have a blood sample taken to check your iron levels are high enough and that you haven't got anemia.

A drip will be inserted into a vein in your arm to give you fluids and to make it easy to give you drugs later if you need them.

You'll be given an anesthetic. This will usually be regional, which means it numbs your bottom half, via a spinal or epidural. If so, you'll be awake for your baby's birth and it's safer for you and your baby than a general anesthetic, which puts you to sleep.

A thin tube, or catheter, will be inserted into your bladder via your urethra. This will make sure your bladder is empty. It can be put in after the anesthetic is working so that you don't feel it.

The area where the cut will be made will be cleaned with antiseptic to help prevent infection.

You'll be given either white stockings, extra fluid or blood-thinning injections to reduce the risk of a clot forming in one of your leg veins (deep vein thrombosis).

You'll have a cuff put on your arm to monitor your blood pressure.

Electrodes will be placed on your chest to monitor your heart rate and you may have a finger-pulse monitor attached, too.

A sticky plastic plate will be attached to your leg. This is the earth for the electronic equipment used by your obstetrician to stop bleeding during the surgery don't worry, you won't feel this happening.

You'll be offered:

an injection of antibiotics to help prevent infection

anti-sickness medicine to stop you from vomiting

diamorphine for strong pain relief during and just after the cesarean

pain relief for after the operation, which your doctor will have discussed with you beforehand

oxygen through a mask, if your baby is in distress

You may be surprised how many people are needed to do a cesarean section.

What happens during a cesarean?

If it's your first cesarean, your baby will be with you very soon. Once everything is set up it can take just five or 10 minutes for your baby to be born. You're likely to be in theatre for an hour or so because it takes longer to close you up afterwards. Closing you up takes longer if you have had one or more cesareans. It largely depends on how much scar tissue or adhesions (bands of scar tissue) you have from previous operations. A screen is put up over your chest so that you can't see the operation, but you can ask for this to be lowered as your baby is born. Your anesthesiologist will check that your painkiller is working properly. Once you're completely numb, your doctor will make a straight cut into the skin of your belly. You may want to ask for a bikini cut -- two fingers width above your pubic bone, at the top of your pubic hair. This sort of cut is less painful after the operation and looks better as it heals than a cut down the middle of your tummy. Further openings are made through layers of tissue and muscle before reaching your uterus. Your tummy muscles are parted, rather than cut, and your bladder will be moved down to expose the lower part of your uterus. The cut to your uterus is usually small, but your doctor makes the opening bigger using scissors or fingers, so that it is torn rather than cut. This causes less bleeding than a sharp incision. The opening to your uterus is usually in the lower part, which is why the operation is sometimes called a lower segment cesarean section (LSCS). If you have a lot of fluid, you may be able to hear it whoosh out through the opening. Your obstetrician will lift out your baby. You may feel the assistant pressing on your belly to help your baby be born. If your baby is breech, he will be born bottom first. If you're having twins the lower twin is born first, just as if you'd given birth vaginally. Occasionally, forceps are used during a cesarean to deliver your baby's head carefully. They are usually only needed when your baby is in a breech position or is premature. Surgeons may occasionally make a larger, vertical cut in your uterus if your baby is very premature, or is lying across your uterus or if you have a condition such as a low-lying placenta or growths, known as fibroids.

What will happen after my baby is born?

Your baby may be placed on your chest straight away for you to cuddle, or he may need to be checked by a midwife or pediatrician. Your partner can usually hold your baby if you are unable to. If you're having twins, you may be cuddling one baby each sooner than you expected! Babies born by cesarean tend to be a little colder than babies born vaginally, so they need wrapping up well. Your baby will be given an Apgar score one minute and five minutes after he's born. The

score measures your babys wellbeing. If there has been concern about your baby's health or you're under a general anesthetic, a pediatrician will do these checks and give your baby oxygen if he needs it. Some babies need to go to special care (SCBU) for a while. You'll be given the hormone oxytocin via a drip to help your uterus contract and to reduce blood loss. Your doctor will pull gently on the umbilical cord to remove the placenta. This will be checked to make sure it is complete before you're stitched up. Your doctor will probably use a double layer of stitches to repair your uterus, and the cut in your belly will be closed in layers. Finally, your skin wound will be closed with stitches or staples. When you're ready, you'll be moved into the recovery room where you, your partner and, if all is well, your baby or babies can be together. You may start shivering after your cesarean, because your core body temperature drops during the operation. The anesthetic hinders your body's ability to regulate your temperature, and the effect may be worsened if the theatre is cool. It can be unnerving, but is usually harmless and only lasts 20 or 30 minutes. The midwife or nurse looking after you will warm you up with blankets and fluids. If you want to breastfeed, it's a good idea to try while you're still in the recovery room before moving to the postnatal ward. A midwife will be there to help you find a comfortable position for breastfeeding and to take care of you immediately after the operation. Postnatal Care For Caesarean Section Learn how to deal after having a Caesarean delivery.

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CAESAREAN VS. NORMAL DELIVERY Teresa Bongala, M.D. of St. Lukes Hospital explains, Usually people who underwent Caesarean section will have less vaginal bleeding compared to somebody who delivered normally. According to the American College of Obstetricians and Gynecologists, most women spend about one to two days in the hospital after a vaginal birth. But if you had a caesarean birth or if problems occur, you will likely stay longer. Mommies who give birth via Caesarean section ought to expect some pain due to the incision. Mothers who undergo ligation after will have a little bit more pain.

WOUND CARE The University of Michigan Health System recommends some tips when it comes to wound care: The incision should be kept clean and dry. You may shower and wash the incision with soap and water after the dressing is removed. Air drying for 15 minutes, two to three times daily is recommended. Wear cotton underwear and no tight fitting clothing. The skin from the incision will heal in several days, but takes 6-8 weeks to heal entirely.

Taking a bath may be tricky because of the wound, which is why Dr. Bongala suggests using a clear, waterproof dressing. Aileen Serate, an operations manager and mommy to Katherine Anne and Joshua Connor, who underwent Caesarean delivery, adds that if the bandage does get wet, you should immediately change it.

Serate suggests having somebody who is willing and would know how to clean and re-dress your wound for you. Serate also adds that it was helpful to have a big mirror which someone else could hold up for her as she dressed her wound.

MOVING AROUND Wear a binder. Avoid exercise during the first six weeks after delivery. This is the time when your body returns to the normal state, says Dr. Bongala. Basic stretching is encouraged. However, abdominal exercises should be avoided because the abdominal wall is not that strong yet. Strolls around the hospital or rocking in a chair can help speed up recovery and help with gas that often occurs after abdominal surgery.

Both Serate and Dr. Bongala caution against lifting heavy objects during the postpartum period.

INVOLVING OTHER MEMBERS OF THE FAMILY Dr. Bongala also mentions that husbands and other family members should help take care of the mother and the new baby. Aside from taking care of the mother, they can also lighten their load by participating in infant care. Serate suggests having somebody else do your regular household chores of cooking or cleaning so you can rest.

NUTRITION Aside from eating a well-balanced diet and food that are rich in iron and calcium, take plenty of ascorbic acid in order to speed up the healing of the incision, says Dr. Bongala. Avoid carbonated beverages, citrus juices, any other beverages which might cause uncomfortable gas pains.