http://emedicine.medscape.

com/article/263424-overview

Cesarean delivery is defined as the delivery of a fetus through surgical incisions made through the abdominal
wall (laparotomy) and the uterine wall (hysterotomy).

Essential update: ACOG/SMFM guidelines released for prevention of primary

cesarean delivery
The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine
(SMFM) have released joint guidelines for the safe prevention of primary cesarean delivery. These include the
following[1, 2] :

Prolonged latent (early)-phase labor should be permitted

The start of active-phase labor can be defined as cervical dilation of 6 cm, rather than 4 cm
In the active phase, more time should be permitted for labor to progress
Multiparous women should be allowed to push for 2 or more hours and primiparous women for 3 or
more hours; pushing may be allowed to continue for even longer periods in some cases, as when epidural
anesthesia is administered
Techniques to aid vaginal delivery, such as the use of forceps, should be employed
Patients should be encouraged to avoid excessive weight gain during pregnancy
Access to nonmedical interventions during labor, such as continuous support during labor and delivery,
should be increased
External cephalic version should be performed for breech presentation
Women with twin gestations should, if the first twin is in cephalic presentation, be permitted a trial of
labor
In 2011, one in three women who gave birth in the United States did so by cesarean delivery. The rapid
increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in
maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. The
most common indications for primary cesarean delivery include labor dystocia, abnormal or indeterminate fetal
heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of
the primary cesarean delivery rate will require different approaches for these indications, as well as others.
Increasing women's access to nonmedical interventions during labor has also been shown to reduce cesarean
birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations
when the first twin is in cephalic presentation are examples of interventions that can help to safely lower the
primary cesarean delivery rate.[3] A practice bulletin from the American College of Obstetricians and
Gynecologists (ACOG) recommends that all eligible women with breech presentations who are near term
should be offered external cephalic version (ECV) to decrease the overall rate of cesarean delivery.[4, 5]

Indications
Cesarean deliveries were initially performed to separate the mother and the fetus in an attempt to save the
fetus of a moribund patient. They subsequently developed to resolve maternal or fetal complications not
amenable to vaginal delivery, either for mechanical limitations or to temporize delivery for maternal or fetal
benefit.
The leading indications for cesarean delivery (85%) are previous cesarean delivery, breech presentation,
dystocia, and fetal distress.[6]
Maternal indications for cesarean delivery include the following:

Repeat cesarean delivery

Obstructive lesions in the lower genital tract, including malignancies, large vulvovaginal condylomas,
obstructive vaginal septa, and leiomyomas of the lower uterine segment that interfere with engagement of the
fetal head
Pelvic abnormalities that preclude engagement or interfere with descent of the fetal presentation in
labor

Fetal indications for cesarean delivery include the following:

Situations in which neonatal morbidity and mortality could be decreased by the prevention of trauma
Malpresentations (eg, preterm breech presentations, non-frank breech term fetuses)
Certain congenital malformations or skeletal disorders
Infection
Prolonged acidemia
Indications for cesarean delivery that benefit the mother and the fetus include the following:
Abnormal placentation (eg, placenta previa, placenta accreta)
Abnormal labor due to cephalopelvic disproportion
Situations in which labor is contraindicated

Contraindications
There are few contraindications to performing a cesarean delivery. In some circumstances, a cesarean delivery
should be avoided, such as the following:

When maternal status may be compromised (eg, mother has severe pulmonary disease)
If the fetus has a known karyotypic abnormality (trisomy 13 or 18) or known congenital anomaly that
may lead to death (anencephaly)

Cesarean delivery on maternal request

Controversy exists regarding elective cesarean delivery on maternal request (CDMR). The 2013 American
College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice [7] and 2006 National
Institutes of Health (NIH) consensus committee[8] determined that the evidence supporting this concept was not
conclusive and that more research is needed.
Both committees provided the following recommendations regarding CDMR [7, 8] :

Unless there are maternal or fetal indications for cesarean delivery, vaginal delivery should be
recommended

CDMR should not be performed before 39 weeks gestation without verifying fetal lung maturity (due to
a potential risk of respiratory problems for the baby)

CDMR is not recommended for women who want more children (due to the increased risk for placenta
previa/accreta and gravid hysterectomy with each cesarean delivery)

The inavailability of effective analgesia should not be a determinant for CDMR

The NIH consensus panel on CDMR also noted the following [8] :

CDMR has a potential benefit of decreased risk of hemorrhage for the mother and decreased risk of
birth injuries for the baby
CDMR requires individualized counseling by the practitioner of the potential risks and benefits of both
vaginal and cesarean delivery

Preoperative management
Guidelines recommend a minimum preoperative fasting time of at least 2 hours from clear liquids, 6 hours from
a light meal, and 8 hours from a regular meal.[9]However, patients are usually asked not to eat anything for 12
hours prior to the procedure.[10]
The following are also included in preoperative management:

Placement of an intravenous (IV) line

Infusion of IV fluids (eg, lactated Ringer solution or saline with 5% dextrose)
Placement of a Foley catheter (to drain the bladder and to monitor urine output)
Placement of an external fetal monitor and monitors for the patients blood pressure, pulse, and
oxygen saturation
Preoperative antibiotic prophylaxis (decreases risk of endometritis after elective cesarean delivery by
76%, regardless of the type of cesarean delivery [emergent or elective]) [11]

Evaluation by the surgeon and the anesthesiologist

Laboratory testing
The following laboratory studies may be obtained prior to cesarean delivery:

Complete blood count

Blood type and screen, cross-match
Screening tests for human immunodeficiency virus, hepatitis B, syphilis
Coagulation studies (eg, prothrombin and activated partial thromboplastin times, fibrinogen level)
Imaging studies
In labor and delivery, document fetal position and estimated fetal weight. Although ultrasonography is
commonly used to estimate fetal weight, a prospective study reported the sensitivity of clinical and
ultrasonographic prediction of macrosomia, respectively, as 68% and 58%. [12]

Cesarean delivery
The technique for cesarean delivery includes the following:

Laparotomy via midline infraumbilical, vertical, or transverse (eg, Pfannenstiel, Mayland, Joel Cohen)
incision
Hysterotomy via a transverse (Monroe-Kerr) or vertical (eg, Kronig, DeLee) incision
Fetal delivery
Uterine repair
Closure

Postoperative management
See the list below:

Routine postoperative assessment

Monitoring of vital signs, urine output, and amount of vaginal bleeding
Palpation of the fundus
IV fluids; advance to oral diet as appropriate
IV or intramuscular (IM) analgesia if patient did not receive a long-acting analgesic or had general
anesthesia; analgesia is usually not needed if patient received regional anesthesia, with/without a long-acting
analgesic
Ambulation on postoperative day 1; advance as tolerated
If patient plans to breastfeed, initiate within a few hours after delivery; if patient plans to bottle feed,
she may use a tight bra or breast binder in the postoperative period
Discharge on postoperative day 3 or 4, if no complications
Discuss contraception as well as refraining from intercourse for 4-6 weeks postpartum

Complications
See the list below:

Approximately 2-fold increase in maternal mortality and morbidity with cesarean delivery relative to a
vaginal delivery [13] : Partly related to the procedure itself, and partly related to conditions that may have led to
needing to perform a cesarean delivery
Infection (eg, postpartum endomyometritis, fascial dehiscence, wound, urinary tract)
Thromboembolic disease (eg, deep venous thrombosis, septic pelvic thrombophlebitis)
Anesthetic complications
Surgical injury (eg, uterine lacerations; bladder, bowel, ureteral injuries)
Uterine atony
Delayed return of bowel function
The graph below depicts cesarean delivery rates in the US (1991-2007).

Cesarean delivery rates, United States.

Background
Cesarean delivery is defined as the delivery of a fetus through surgical incisions made through the abdominal
wall (laparotomy) and the uterine wall (hysterotomy). Because the words "cesarean" and "section" are both
derived from verbs that mean to cut, the phrase "cesarean section" is a tautology. Consequently, the terms
"cesarean delivery" and "cesarean birth" are preferable.
Cesarean deliveries were initially performed to separate the mother and the fetus in an attempt to save the
fetus of a moribund patient. This operation subsequently developed into a surgical procedure to resolve
maternal or fetal complications not amenable to vaginal delivery, either for mechanical limitations or to
temporize delivery for maternal or fetal benefit.
The cesarean delivery has evolved from a vain attempt performed to save the fetus to one in which physician
and patient both participate in the decision-making process, striving to achieve the most benefit for the patient
and her unborn child.
Currently, cesarean deliveries are performed for a variety of fetal and maternal indications (see Indications).
The indications have expanded to consider the patients wishes and preferences. Controversy surrounds the
current rates of cesarean delivery in developed countries and its use for indications other than medical
necessity.Go to Perimortem Cesarean Delivery and Vaginal Birth After Cesarean Delivery for complete
information on these topics.

Frequency
From 1910-1928, the cesarean delivery rate at Chicago Lying-in Hospital increased from 0.6% to 3%. The
cesarean delivery rate in the United States was 4.5% in 1965. According to the National Hospital Discharge
Survey, the cesarean rate rose from 5.5% in 1970 to 24.1% in 1986. Fewer than 10% of mothers had a vaginal
birth after a prior cesarean, and women spent an average of 5 days in the hospital for a cesarean delivery and
only 2.6 days for a vaginal delivery.
It was predicted that if age-specific cesarean rates continued at the steady pattern of increase observed since
1970, 40% of births would be by cesarean in the year 2000. [14] Those predictions fell short, but not by much. The
National Center for Health Statistics reported that the percentage of cesarean births in the United States
increased from 20.7% in 1996 to 32% in 2007.[15] Cesarean rates increased for women of all ages, races/ethnic
groups, and gestational ages and in all states (see the image below). Both primary and repeat cesareans
increased.

Cesarean delivery rates, United States.

Increases in the primary cesareans with no specified indication were faster than in the overall population and
appear to be the result of changes in obstetric practice rather than changes in the medical risk profile or
increases in maternal request.[16]
This has occurred despite several studies that note an increased risk for neonatal and maternal mortality for all
cesarean deliveries as well as for medically elective cesareans compared with vaginal births. [17] The decrease in
total and repeat cesarean delivery rates noted between 1990 and 2000 was due to a transient increase in the
rate of vaginal births after cesarean delivery.[18]
The cesarean delivery rate has also increased throughout the world, but rates in certain parts of the world are
still substantially lower than in the United States. The cesarean delivery rate is approximately 21.1% for the
most developed regions of the globe, 14.3% for the less developed regions, and 2% for the least developed
regions.[19]
In a 2006 publication reviewing cesarean delivery rates in South America, the median rate was 33% with rates
fluctuating between 28% and 75% depending on public service versus a private provider. The authors conclude
that higher rates of cesarean delivery do not necessarily indicate better perinatal care and can be associated
with harm.[20]
Why the rate of cesarean delivery has increased so dramatically in the United States is not entirely clear. Some
reasons that may account for the increase are repeat cesarean delivery, delay in childbirth and reduced parity,
decrease in the rate of vaginal breech delivery, decreased perinatal mortality with cesarean delivery,
nonreassuring fetal heart rate testing, and fear of malpractice litigation, as described in the following
paragraphs.
In 1988, when the cesarean delivery rate peaked at 24.7%, 36.3% (351,000) of all cesarean deliveries were
repeat procedures. Although reports concerning the safety of allowing vaginal birth after a cesarean delivery
had been present since the 1960s,[21] by 1987, fewer than 10% of women with a prior cesarean delivery were
attempting a vaginal delivery.
In 2003, the repeat cesarean delivery rate for all women was 89.4%; the rate for low-risk women was 88.7%.
Today, low-risk women giving birth for the first time who have a cesarean delivery are more likely to have a
subsequent cesarean delivery.[22]
In the past decade, an increase in the percentage of births to women aged 30-50 years has occurred despite a
decrease in their relative size within the population. [23]The cesarean rate for mothers aged 40-54 years in 2007
was more than twice the cesarean rate for mothers younger than 20 years (48% and 23%, respectively). [23]The
risk of having a cesarean delivery is higher in nulliparous patients, and, with increasing maternal age, the risk
for cesarean delivery is increased secondary to medical complications such as diabetes and preeclampsia.
By 1985, almost 85% of all breech presentations (3% of term fetuses) were delivered by cesarean. In 2001, a
multicenter and multinational prospective study determined that the safest mode of delivery for a breech
presentation was cesarean delivery.[24] This study has been criticized for differences in the standards of care
among the study centers that does not allow a standard recommendation. [25]
The most recent recommendation from the American College of Obstetricians and Gynecologists (ACOG)
regarding breech delivery is that planned vaginal delivery may be reasonable under hospital-specific protocol

guidelines for both eligibility and labor management.[26] This may lead to a small decrease in breech delivery
rates, but the overwhelming majority of cases will probably continue to be delivered by elective cesarean.
A cluster-randomized controlled trial by Chaillet et al reported a significant but small reduction in the rate of
cesarean delivery. The benefit was driven by the effect of the intervention in low-risk pregnancies. [27, 28]

Indications
Many indications exist for performing a cesarean delivery. In those women who are having a scheduled
procedure (ie, an elective or indicated repeat, for malpresentation or placental abnormalities), the decision has
already been made that the alternate of medical therapy, ie, a vaginal delivery, is least optimal.
For other patients admitted to labor and delivery, the anticipation is for a vaginal delivery. Every patient
admitted in this circumstance is admitted with the thought of a successful vaginal delivery. However, if the
patients situation should change, a cesarean delivery is performed because it is believed that outcome may be
better for the fetus, the mother, or both.
A cesarean delivery is performed for maternal indications, fetal indications, or both. The leading indications for
cesarean delivery are previous cesarean delivery, breech presentation, dystocia, and fetal distress. These
indications are responsible for 85% of all cesarean deliveries. [6]

Maternal indications
Maternal indications for cesarean delivery include the following:

Repeat cesarean delivery

Obstructive lesions in the lower genital tract, including malignancies, large vulvovaginal condylomas,
obstructive vaginal septa, and leiomyomas of the lower uterine segment that interfere with engagement of the
fetal head

Pelvic abnormalities that preclude engagement or interfere with descent of the fetal presentation in
labor
Relative maternal indications include conditions in which the increasing intrathoracic pressure generated by
Valsalva maneuvers could lead to maternal complications. These include left heart valvular stenosis, dilated
aortic valve root, certain cerebral arteriovenous malformations (AVMs), and recent retinal detachment. Women
who have previously undergone vaginal or perineal reparative surgery (eg, colporrhaphy or repair of major anal
involvement from inflammatory bowel disease) also benefit from cesarean delivery to avoid damage to the
previous surgical repair.
No clear evidence supports planned cesarean delivery for extreme maternal obesity. A prospective cohort study
from the United Kingdom included women with a body mass index of 50 kg/m 2 or more and noted possible
increased shoulder dystocia (3% vs 0%) but found no significant differences in anesthetic, postnatal, or
neonatal complications between women who underwent planned vaginal delivery and those who underwent
planned caesarean delivery.[29]
Dystocia in labor (labor dystocia) is a very commonly cited indication for cesarean delivery, but it is not specific.
Dystocia is classified as a protraction disorder or as an arrest disorder. These can be primary or secondary
disorders. Most dystocias are caused by abnormalities of the power (uterine contractions), the passage
(maternal pelvis), or the passenger (the fetus).[30]
When a diagnosis of dystocia in labor is made, the indication should be detailed according to the previous
classification (ie, primary or secondary disorder, arrest or protraction disorder, or a combination of the above).
For further information, seeAbnormal Labor.
Recently, debate has arisen over the option of elective cesarean delivery on maternal request (CDMR).
Evidence shows that it is reasonable to inform the pregnant woman requesting a cesarean delivery of the
associated risks and benefits for the current and any subsequent pregnancies. The clinicians role should be to
provide the best possible evidence-based counseling to the woman and to respect her autonomy and decisionmaking capabilities when considering route of delivery.[31]

In 2006, the National Institutes of Health (NIH) convened a consensus conference to address CDMR. They
resolved that the evidence supporting this concept was not conclusive. [8] Their recommendations included the
following:

CDMR should be avoided by women wanting several children.

CDMR should not be performed before the 39th week of pregnancy or without verifying fetal lung
maturity.

CDMR has a potential benefit of decreased risk of hemorrhage for the mother and decreased risk of
birth injuries for the baby.

CDMR has a potential risk of respiratory problems for the baby.

CDMR is associated with a longer maternal hospital stay and increasing risk of placenta previa and
placenta accreta with each successive cesarean. [32]
The NIH further noted that the procedure requires individualized counseling by the practitioner of the potential
risks and benefits of both vaginal and cesarean delivery, and it should not be motivated by the unavailability of
effective pain management.[8]
Detractors of CDMR argue that the premise of cesarean on request applies to a very small portion of the
population and that it should not be routinely offered on ethical grounds. [33] The emerging consensus is that a
randomized prospective study is required to address this issue. [34]

Fetal indications
Fetal indications for cesarean delivery include the following:

Situations in which neonatal morbidity and mortality could be decreased by the prevention of trauma
Malpresentations
Certain congenital malformations or skeletal disorders
Infection
Prolonged acidemia
A fetus in a nonvertex presentation is at increased risk for trauma, cord prolapse, and head entrapment.
Malpresentation includes preterm breech presentations and non-frank breech term fetuses.
The decision to proceed with a cesarean delivery for the term frank breech singleton fetus has been
challenged. Although most practitioners will always perform a cesarean delivery in this situation, ACOG has left
open the option to consider a breech delivery under the appropriate circumstances, including a practitioner
experienced in the evaluation and management of labor and skilled in the delivery of the breech fetus. [26]
If a patient is diagnosed with a fetal malpresentation (ie, breech or transverse lie) after 36 weeks, the option for
an external cephalic version is offered to try to convert the fetus to a vertex lie, thus allowing an attempt at a
vaginal delivery. An external cephalic version is usually attempted at 36-38 weeks with studies underway to
establish the use of performing external cephalic version at 34 weeks gestational age.
Ultrasonography is performed to confirm a breech presentation. If the fetus is still in a nonvertex presentation,
an intravenous (IV) line is started, and the baby is monitored with an external fetal heart rate monitor prior to
the procedure to confirm well-being. With a reassuring fetal heart rate tracing, the version is attempted.
An external cephalic version involves trying to externally manipulate the fetus into a vertex presentation. This is
accomplished with ultrasonographic guidance to ascertain fetal lie. An attempt is made to manipulate the fetus
through either a "forward roll" or "backward roll." The overall chance of success is approximately 60%. [35] Some
practitioners administer an epidural to the patient before attempting version, and others may give the patient a
dose of subcutaneous terbutaline (a beta-mimetic used for tocolysis) just before the attempt.
Factors that influence the success of an attempted version include multiparity, a posterior placenta, and normal
amniotic fluid with a normally grown fetus. In addition, to be a candidate, a patient must be eligible for an
attempted vaginal delivery.
Relative contraindications include poor fetal growth or the presence of congenital anomalies. Risks of an
external cephalic version include rupture of membranes, labor, fetal injury, and the need for an emergent

cesarean delivery due to placental abruption. A recent review reported a severe complication rate of 0.24% and
a cesarean section rate secondary to complications of 0.34%.[35]
If the version is successful, the patient is placed on a fetal monitor in close proximity to the labor and delivery
unit or in the labor and delivery unit itself. If fetal heart rate testing is reassuring, the patient is discharged to
await spontaneous labor, or she may be induced if the fetus is of an appropriate gestational age or the patient
has a favorable cervix.
The first twin in a nonvertex presentation is an indication for a cesarean delivery, as are higher order multiples
(triplets or greater). A large body of literature supports both outright cesarean delivery as well as spontaneous
breech delivery or extraction of the second twin.
The decision is made in conjunction with the patient after appropriate counseling regarding the risks and
benefits as well as under the supervision of a physician experienced in the management of the labor and
delivery of a breech fetus.[36]Evidence suggests that the rate of severe complications of the second breech twin
is independent of the mode of delivery.[37]
Several congenital anomalies are controversial indications for cesarean delivery; these include fetal neural tube
defects (to avoid sac rupture), particularly defects that are larger than 5-6 cm in diameter. One study noted no
difference in long-term motor or neurologic outcomes. [38] Some authors noted no relationship between mode of
delivery and infant outcomes,[39] while others have advocated cesarean delivery of all infants with a neural tube
defect.[40]
Cesarean delivery is indicated in certain cases of hydrocephalus with an enlarged biparietal diameter, and
some skeletal dysplasias such as type III osteogenesis imperfecta.
Whether or not an outright cesarean delivery should be performed in the setting of a fetal abdominal wall defect
(eg, gastroschisis or omphalocele) remains controversial. Most reviews agree that cesarean is not
advantageous unless the liver is extruded, which is a very rare event. [41, 42, 43] The overall incidence of cesarean
delivery in this group of patients is probably due to an increased incidence of intrauterine growth retardation
and fetal distress prior to or in labor.
In the setting of a nonremediable and nonreassuring pattern remote from delivery, a cesarean delivery is
recommended to prevent a mixed or metabolic acidemia that could potentially cause significant morbidity and
mortality. Electronic fetal monitoring was used in 85% of labors in the United States in 2002. [44] Its use has
increased the cesarean delivery rate as much as 40%.[45] This has occurred without a decrease in the cerebral
palsy or perinatal death rate.[46]
ACOG has recommended that any facility providing obstetric care have the capability of performing a cesarean
delivery within 30 minutes of the decision. Despite this recommendation, a decision to delivery time of more
than 30 minutes is not necessarily associated with a negative neonatal outcome. [47]
Among patients with first-episode genital herpes infection, the risk of maternal-fetal transmission is 33 times
higher than with recurrent outbreaks. The largest population-based study reported that for primary infection, the
risk of transmission to the newborn was 35%, compared with a 2% risk for recurrent infection. Among patients
with culture-positive herpes, the transmission rate with vaginal delivery was 7 times that with cesarean delivery.
Currently, all patients with active or symptomatic herpes infection are candidates for cesarean delivery.
[48]
Neonatal infection with herpes can lead to significant morbidity and mortality, especially with a primary
outbreak. With recurrent outbreaks, the risk to the neonate is reduced by the presence of maternal antibodies.
Unfortunately, not all women with active viral shedding can be detected upon admission to labor and delivery.
Treatment of women with HIV infections has undergone tremendous change in the past few years. Women with
a viral count above 1,000 should be offered cesarean delivery at 38 weeks (or earlier if they go into labor). In
women who are being treated with highly active antiretroviral therapy (HAART), cesarean delivery (before labor
or without prolonged rupture of membranes) appears to further lower the risk for neonatal transmission,
particularly among those with viral counts above 1,000.
Among patients with low or undetectable viral counts, the evidence supporting a benefit is not as clear;
nevertheless, the patient should be given the option of a cesarean delivery.[49]

Maternal and fetal indications

Indications for cesarean delivery that benefit both the mother and the fetus include the following:

Abnormal placentation
Abnormal labor due to cephalopelvic disproportion
Situations in which labor is contraindicated
In the presence of a placenta previa (ie, the placenta covering the internal cervical os), attempting vaginal
delivery places both the mother and the fetus at risk for hemorrhagic complications. This complication has
actually increased as a result of the increased incidence of repeat cesarean deliveries, which is a risk factor for
placenta previa and placenta accreta. Both placenta previa and placenta accreta carry increased morbidity
related to hemorrhage and need for hysterectomy.[50, 51, 32]
Cephalopelvic disproportion can be suspected on the basis of possible macrosomia or an arrest of labor
despite augmentation. Many cases diagnosed as cephalopelvic disproportion are the result of a primary or
secondary arrest of dilatation or arrest of descent. Predicting true primary or secondary arrest of descent due to
cephalopelvic disproportion is best assessed by sagittal suture overlap, but not lambdoid suture overlap,
particularly where progress is poor in a trial of labor.[52]
Continuing to attempt a vaginal delivery in this setting increases the risk of infectious complications to both
mother and fetus from prolonged rupture of membranes. [53] Less often, maternal hemorrhagic and fetal
metabolic consequences occur from a uterine rupture, especially among patients with a previous cesarean
delivery.[13] Vaginal delivery can also increase the risk of maternal trauma and fetal trauma (eg, Erb-Duchenne or
Klumpke palsy and metabolic acidosis) from a shoulder dystocia.[54, 55]
Among women who have a uterine scar (prior transmural myomectomy or cesarean delivery by high vertical
incision), a cesarean delivery should be performed prior to the onset of labor to prevent the risk of uterine
rupture, which is approximately 4-10%.[13]

Contraindications
There are few contraindications to performing a cesarean delivery. If the fetus is alive and of viable gestational
age, then cesarean delivery can be performed in the appropriate setting.
In some instances, a cesarean delivery should be avoided. Rarely, maternal status may be compromised (eg,
with severe pulmonary disease) to such an extent that an operation may jeopardize maternal survival. In such
difficult situations, a care plan outlining when and if to intervene should be made with the family in the setting of
a multidisciplinary meeting.
A cesarean delivery may not be recommended if the fetus has a known karyotypic abnormality (trisomy 13 or
18) or known congenital anomaly that may lead to death (anencephaly).

https://en.wikipedia.org/wiki/Caesarean_section

Caesarean section, also commonly known as C-section and other spellings, is

a surgical procedure in which one or more incisions are made through a
mother's abdomen and uterus to deliver one or more babies. A Caesarean section is often performed
when a vaginal delivery would put the baby's or mother's life or health at risk. Some are
also performed upon request without a medical reason to do so.[1] The World Health Organization
recommends that they should be done based only on medical need. [2]
C-sections result in a small overall increase in poor outcomes, in low risk pregnancies. [3] The poor
outcomes that occur with C-sections, differ from those that occur with vaginal delivery. Established
guidelines recommend that caesarean sections not be used before 39 weeks without a medical
indication to perform the surgery.[4]
In 2012 about 23 million C-sections were done globally.[5] In some countries, C-section procedures
are used more frequently than is necessary, and consequently governments and health
organizations promote programs to reduce the use of c section in favor of vaginal delivery.[6] The
international healthcare community has considered the rate of 10% and 15% to be ideal for
caesarean sections.[2] Some evidence supports a higher rate of 19% may result in better outcomes.
[5]

The first modern Caesarean section was performed by German gynecologist Ferdinand Adolf

Kehrer in 1881.[7] The typical method for the Caesarean section is the Pfannenstiel incision named
after Hermann Johannes Pfannenstiel.

A 7-week old Caesarean sectionscar 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.
C-sections are also carried out for personal and social reasons. Systematic reviews have found no
strong evidence about the impact of caesareans for non-medical reasons. [8][9] Recommendations
encourage counseling to identify the reasons for the request, addressing anxieties and information,
and encouraging vaginal birth.[8][10] Elective caesareans at 38 weeks showed increased health
complications in the newborn.[11] For this reason,planned caesarean sections (also known as elective
caesarean sections) should not be scheduled before 39 weeks gestational age unless there is very
good medical reason to do so.

Medical uses[edit]
Some medical indications are below. 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. This decision is a complex one and many factors need to be taken into account.
Complications of labor and factors increasing the risk associated with vaginal delivery, such as:

abnormal presentation (breech or transverse positions)

prolonged labour or a failure to progress (dystocia)

fetal distress

cord prolapse

uterine rupture or an elevated risk thereof

increased blood pressure (hypertension) in the mother or baby after amniotic rupture (the
waters breaking)

increased heart rate (tachycardia) in the mother or baby after amniotic rupture (the waters
breaking)

placental problems (placenta praevia, placental abruption or placenta accreta)

failed labour induction

failed instrumental delivery (by forceps or ventouse (Sometimes a trial of forceps/ventouse

delivery is attempted, and if unsuccessful, the baby will need to be born by caesarean section.)

large baby weighing >4000g (macrosomia)

umbilical cord abnormalities (vasa previa, multilobate including bilobate and succenturiatelobed placentas, velamentous insertion)

Other complications of pregnancy, pre-existing conditions and concomitant disease, such as:

pre-eclampsia[12]

previous (high risk) fetus

HIV infection of the mother with a high viral load (HIV with a low maternal viral load is not
necessarily an indication for caesarean section)

Sexually transmitted diseases, such as a first outbreak of genital herpes very recently before
the onset of labour (which can cause infection in the baby if the baby is born vaginally)

previous classical (longitudinal) Caesarean section

previous uterine rupture

prior problems with the healing of the perineum (from previous childbirth or Crohn's disease)

Bicornuate uterus

Rare cases of posthumous birth after the death of the mother

Other

Decreasing experience of accoucheurs with management of the breech presentation

since the publication of the Term Breech Trial it is clear that planned caesarean section in
women presenting at term in their first pregnancy with a breech presentation has a lower risk of
infant death than planned vaginal breech delivery.[13] Although obstetricians and midwives are
extensively trained in proper procedures for such deliveries using simulation mannequins, there
is decreasing experience with actual vaginal breech delivery which may increase the risk
further.)[14]

Prevention[edit]

It is generally agreed that the prevalence of caesarean section is higher than needed in many
countries and physicians are encouraged to actively lower the rate.[citation needed] Some of these efforts
include: emphasizing that a long latent phase of labor is not abnormal and thus not a justification for
C-section; a new definition of the start of active labor from a cervical dilatation of 4 cm to a dilatation
of 6 cm; and allowing at least 2 hours of pushing for women who have previously given birth and 3
hours of pushing for women who have not previously given birth before labor arrest is considered.
[3]

Physical exercise during pregnancy also decreases the risk.[15]

Risks[edit]
Adverse outcomes in low risk pregnancies occur in 8.6% of vaginal deliveries and 9.2% of
caesarean section deliveries.[3]

Risks to the mother[edit]

In those who are low risk, the risk of death for caesarean sections is 13 per 100,000 and for vaginal
birth 3.5 per 100,000 in the developed world.[3] The UK National Health Service gives the risk of
death for the mother as three times that of a vaginal birth [16] but it is important to remember that the
actual risk of death in either situation is extremely small in resource-rich settings.
In Canada the difference in serious morbidity or mortality for the mother (e.g. cardiac arrest, wound
hematoma, or hysterectomy) was 1.8 additional cases per 100 or three times the risk. [17]

Transvaginal ultrasonography of a uterus years after a caesarean section, showing the characteristic scar
formation in its anterior part.

As with all types of abdominal operations, a caesarean section is associated with risks of
postoperative adhesions, incisional hernias (which may require surgical correction) and wound
infections.[18] 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 risk of
anaesthesia.[19] Other risks include severe blood loss (which may require a blood transfusion)
andpostdural-puncture spinal headaches.[18]
Women who had caesarean sections were more likely to have problems with later pregnancies, and
it is recommended that women who want larger families should not seek an elective caesarean
unless there are medical indications to do so. The risk of placenta accreta, a potentially lifethreatening condition which is more likely to develop where a woman has had a previous caesarean

section, is 0.13% after two caesarean sections, but increases to 2.13% after four and then to 6.74%
after six or more. Along with this is a similar rise in the risk of emergency hysterectomies at delivery.
[20]

Mothers can experience increased incidence of postnatal depression, and can experience significant
psychological trauma and ongoing birth-related post-traumatic stress disorder after obstetric
intervention during the birthing process.[21] Factors like pain in first stage of labor, feelings of
powerlessness, intrusive emergency obstetric intervention are important in the subsequent
development of psychological issues related to labour and delivery.[21]
Subsequent pregnancies[edit]
Further information: Delivery after previous Caesarean section
Women who have had a caesarean for any reason are somewhat less likely to become pregnant
again as compared to women who have previously delivered only vaginally, but the effect is small. [22]
Women who had just one previous caesarean section are more likely to have problems with their
second birth.[3] Delivery after previous Caesarean section is by either of two main options:

Vaginal birth after Caesarean section (VBAC)

Elective repeat Caesarean section (ERCS)

Both have higher risks than a vaginal birth with no previous caesarean section. There are many
issues which must be taken into account when planning the mode of delivery for every pregnancy,
not just those complicated by a previous caesarean section and there is a list of some of these
issues in the list of indications for section in the first part of this article. It is true that compared to
elective repeat caesarean section, a vaginal birth after caesarean section (VBAC) confers a higher
risk for mainly uterine rupture and perinatal death of the child.[23] Furthermore, 20% to 40% of
planned VBAC attempts result in caesarean section being needed, with greater risks of
complications in an emergency repeat caesarean section than in an elective repeat caesarean
section.[24][25] On the other hand, VBAC confers less maternal morbidity and a decreased risk of
complications in future pregnancies than elective repeat caesarean section. [26]
Adhesions[edit]

Suturing of the uterus after extraction.

Closed Incision for low transverse abdominal incision after stapling has been completed.

There are number of steps that can be taken during abdominal or pelvic surgery to minimize
postoperative complications, such as the formation of adhesions. Such techniques and principles
may include:
Handling all tissue with absolute care
Using powder-free surgical gloves
Controlling bleeding
Choosing sutures and implants carefully
Keeping tissue moist
Preventing infection with antibiotics given intravenously to the mother before skin incision
However, despite these proactive measures, adhesion formation is a
recognised complication of any abdominal or pelvic surgery. In order to
prevent adhesions from forming following caesarean section, adhesion
barrier can be placed during surgery to minimize the risk of adhesions
between the uterus and ovaries, the small bowel, and almost any tissue in
the abdomen or pelvis. This is not current UK practise though as there is no
compelling evidence to support the benefit of this intervention.
Adhesions can cause long term problems, such as:
Infertility, which may result when adhesions distort the tissues of the ovaries and tubes,
impeding the normal passage of the egg (ovum) from the ovary to the uterus. One in five
infertility cases may be adhesion related (stoval)
Chronic pelvic pain, which may result when adhesions are present in the pelvis. Almost 50
percent of chronic pelvic pain cases are estimated to be adhesion related (stoval)
Small bowel obstruction the disruption of normal bowel flow, which can result when
adhesions twist or pull the small bowel.
The risk of adhesion formation is one of the reasons why
vaginal delivery is usually considered safer than elective

caesarean section where there is no medical indication for

section for either maternal or fetal reasons.

Risks to the child[edit]

Non-medically indicated (elective) childbirth before 39 weeks
gestation "carry significant risks for the baby with no known
benefit to the mother." Complications from elective caesarean
before 39 weeks include: newborn mortality at 37 weeks may
be up to 3 times the number at 40 weeks, and was elevated
compared to 38 weeks of gestation. These early term births
were also associated with increased death during infancy,
compared to those occurring at 39 to 41 weeks ("full term").
[27]

Researchers in one study and another review found many

benefits to going full term, but no adverse effects in the health

of the mothers or babies.[27][28]
The American Congress of Obstetricians and
Gynecologists and medical policy makers review research
studies and find increased incidence of suspected or
proven sepsis, RDS, hypoglycemia, need for respiratory
support, need for NICU admission, and need for hospitalization
> 45 days. In the case of caesarean sections, rates of
respiratory death were 14 times higher in pre-labor at 37
compared with 40 weeks gestation, and 8.2 times higher for
pre-labor caesarean at 38 weeks. In this review, no studies
found decreased neonatal morbidity due to non-medically
indicated (elective) delivery prior to 39 weeks.[27]
For otherwise healthy twin pregnancies where both twins are
head down a trial of vaginal delivery is recommended at
between 37 and 38 weeks.[8][29] Vaginal delivery in this case
does not worsen the outcome for either infant as compared
with caesarean section.[29] There is some controversy on the
best method of delivery where the first twin is head first and the
second is not, but most obstetricians will recommend normal
delivery unless there are other reasons to avoid vaginal birth.
[29]

When the first twin is not head down a caesarean section is

often recommended.[29] Regardless of whether the twins are

delivered by section or vaginally, the medical literature
recommends delivery of dichorionic twins at 38 weeks, and

monochorionic twins (identical twins sharing a placenta) by 37

weeks due to the increased risk of stillbirth in monochorionic
twins who remain in utero after 37 weeks.[30][31] The consensus is
that late preterm delivery of monochorionic twins is justified
because the risk of stillbirth for post-37 week delivery is
significantly higher than the risks posed by delivering
monochorionic twins near term (i.e., 3637 weeks).[32] The
consensus concerning monoamniotic twins (identical twins
sharing an amniotic sac), the highest risk type of twins, is that
they should be delivered by caesarean section at or shortly
after 32 weeks, since the risks of intrauterine death of one or
both twins is higher after this gestation than the risk of
complications of prematurity.[33][34][35]
In a research study widely publicized, singleton children born
earlier than 39 weeks may have developmental problems,
including slower learning in reading and math.[36]
Other risks include:

Wet lung: Retention of fluid in the lungs can occur if not

expelled by the pressure of contractions during labor.[37]

Potential for early delivery and complications: Preterm

delivery may be inadvertently carried out if due-date
calculation is inaccurate. One study found an increased
complication risk if a repeat elective caesarean section is
performed even a few days before the recommended 39
weeks.[38]

Higher infant mortality risk: In caesarean sections

performed with no indicated medical risk (singleton at full
term in a head-down position with no other obstetric or
medical complications), 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 caesarean sections, compared to 0.62 per
1,000 for women who delivered vaginally.[39]

Classification[edit]

Caesarean sections have been classified in various ways by

different perspectives.[40] One way to discuss all classification
systems is to group them by their focus either on the urgency
of the procedure, characteristics of the mother, or as a group
based on other, less commonly discussed factors.[40]
It is most common to classify caesarean sections by the
urgency of performing them.[40]

By urgency[edit]
This section may be confusing
or unclear to readers. (May
2015)

Conventionally, caesarean sections are classified as being

either an elective surgery or an emergency operation.
[41]

Classification is used to help communication between the

obstetric, midwifery and anaesthetic team for discussion of the

most appropriate method of anaesthesia. The decision whether
to perform general anesthesia or regional anesthesia(spinal or
epidural anaesthetic) is important and is based on many
indications, including how urgent the delivery needs to be as
well as the medical and obstetric history of the woman.
[41]

Regional anaesthetic is almost always safer for the woman

and the baby but sometimes general anaesthetic is safer for

one or both, and the classification of urgency of the delivery is
an important issue affecting this decision.
A planned caesarean (or elective/scheduled caesarean),
arranged ahead of time, is most commonly arranged for
medical indications which have developed before or during the
pregnancy, and ideally after 39 weeks of gestation.[citation needed] In
the UK this is classified as a 'grade 4' section (delivery timed to
suit the needs of the service) since there is no rush in these
situations. Emergency caesarean sections (those where
vaginal delivery has been planned beforehand, and the
indication for section has developed since this plan was
agreed, usually after assessment by a healthcare professional)
are classified in the UK as grade 3(delivery within 4 hours of
the decision, no maternal or fetal compromise), grade 2

(delivery required within 90 minutes of the decision but no

immediate threat to the life of the woman or the fetus) or grade
1 (delivery required within 30 minutes of the decision:
immediate threat to the life of the mother or the baby)
Elective caesarean sections may be performed on the basis of
an obstetrical or medical indication, or because of a medically
non-indicated maternal request.[8] Among women in the United
Kingdom, Sweden and Australian about 7% preferred
caesarean section as a method of delivery.[8] In cases without
medical indications the American Congress of Obstetricians
and Gynecologists and the UK Royal College of Obstetricians
and Gynaecologists recommend a planned vaginal delivery.
[42]

The National Institute for Health and Care

Excellence recommends that if after a women has been

provided information on the risk of a planned caesarean
section and she still insists on the procedure it should be
provided.[8] If provided this should be done at 39 weeks of
gestation or later.[42]

By characteristics of the mother[edit]

Caesarean delivery on maternal request[edit]
Main article: Caesarean delivery on maternal request
Caesarean delivery on maternal request (CDMR) is a medically
unnecessary caesarean section, where the conduct of
achildbirth via a caesarean section is requested by
the pregnant patient even though there is not a
medical indication to have the surgery.[43]
After previous Caesarean[edit]
See also: Delivery after previous Caesarean section
Mothers who have previously had a caesarean section are
more likely to have a caesarean section for future pregnancies
than mothers who have never had a caesarean section. There
is discussion about the circumstances under which women
should have a vaginal birth after a previous caesarean.
Vaginal birth after caesarean (VBAC) is the practice of birthing
a baby vaginally after a previous baby has been delivered by
caesarean section (surgically).[44] According to The American

Congress of Obstetricians and Gynecologists (ACOG),

successful VBAC is associated with decreased maternal
morbidity and a decreased risk of complications in future
pregnancies.[45] According to the American Pregnancy
Association, 90% of women who have undergone caesarean
deliveries are candidates for VBAC.[24] Approximately 60-80% of
women opting for VBAC will successfully give birth vaginally,
which is comparable to the overall vaginal delivery rate in the
United States in 2010.[24][25][46]
Twins[edit]
For otherwise healthy twin pregnancies where both twins are
head down a trial of vaginal delivery is recommended at
between 37 and 38 weeks.[8][29] Vaginal delivery in this case
does not worsen the outcome for either infant as compared
with caesarean section.[29] There is controversy on the best
method of delivery where the first twin is head first and the
second is not.[29] When the first twin is not head down at the
point of labour starting, a caesarean section should be
recommended.[29] Although the second twin typically has a
higher frequency of problems, it is not known if a planned
caesarean section affects this.[8] It is estimated that 75% of twin
pregnancies in the United States were delivered by caesarean
section in 2008.[47]
Breech birth[edit]
Main article: Breech birth
A breech birth is the birth of a baby from a breech presentation,
in which the baby exits the pelvis with the buttocks or feetfirst
as opposed to the normal head-first presentation. In breech
presentation, fetal heart sounds are heard just above the
umbilicus.
The bottom-down position presents some hazards to the baby
during the process of birth, and the mode of delivery (vaginal
versus caesarean) is controversial in the fields
of obstetrics and midwifery.
Though vaginal birth is possible for the breech baby, certain
fetal and maternal factors influence the safety of vaginal breech

birth. The majority of breech babies born in the United States

and the UK are delivered by caesarean section as studies have
shown increased risks of morbidity and mortality for vaginal
breech delivery, and most obstetricians counsel against
planned vaginal breech birth for this reason. As a result of
reduced numbers of actual vaginal breech deliveries,
obstetricians and midwives are at risk of de-skilling in this
important skill. All those involved in delivery of obstetric and
midwifery care in the UK undergo mandatory training in
conducting breech deliveries in the simulation environment
(using dummy pelvises and mannequins to allow practice of
this important skill) and this training is carried out regularly to
keep skills up to date.
Resuscitative hysterotomy[edit]
Main article: Resuscitative hysterotomy
A resuscitative hysterotomy, also known as a peri-mortem
caesarean delivery, is an emergency caesarean delivery
carried out where maternal cardiac arrest has occurred, to
assist in resuscitation of the mother by removing the aortocaval
compression generated by the gravid uterus. Unlike other
forms of caesarean section, the welfare of the fetus is a
secondary priority only, and the procedure may be performed
even prior to the limit of fetal viability if it is judged to be of
benefit to the mother.

Other ways, including by surgery

technique[edit]
There are several types of caesarean section (CS). An
important distinction lies in the type of incision (longitudinal or
transverse) made on the uterus, apart from the incision on the
skin: the vast majority of skin incisions are a transverse
suprapubic approach known as a Pfannenstiel incision but
there is no way of knowing from the skin scar which way the
uterine incision was conducted.

The classical caesarean section involves a midline incision

on the uterus longitudinal incision which allows a larger
space to deliver the baby. It is performed at very early

gestations where the lower segment of the uterus is

unformed as it is safer in this situation for the baby: but it is
rarely performed other than at these early gestations, as
the operation is more prone to complications than a low
transverse uterine incision. Any woman who has had a
classical section will be recommended to have an elective
repeat section in subsequent pregnancies as the vertical
incision is much more likely to rupture in labour than the
transverse incision.

The lower uterine segment section is the procedure most

commonly used today; it involves a transverse cut just
above the edge of the bladder. It results in less blood
loss and has fewer early and late complications for the
mother, as well as allowing her to consider a vaginal birth
in the next pregnancy.

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.

The EXIT procedure is a specialized surgical delivery

procedure used to deliver babies who have airway
compression.
The Misgav Ladach method is a modified caesarean section
which has been used nearly all over the world since the 1990s.
It was described by Michael Stark, the president of the New
European Surgical Academy, at the time he was the director
ofMisgav Ladach, a general hospital in Jerusalem. The method
was presented during a FIGO conference in Montral in
1994[48] and then distributed by the University of Uppsala,
Sweden, in more than 100 countries. This method is based on
minimalistic principles. He examined all steps in caesarean
sections in use, analyzed them for their necessity and, if found
necessary, for their optimal way of performance. For the
abdominal incision he used the modified Joel Cohen incision
and compared the longitudinal abdominal structures to strings
on musical instruments. As blood vessels and muscles have

lateral sway, it is possible to stretch rather than cut them. The

peritoneum is opened by repeat stretching, no abdominal
swabs are used, the uterus is closed in one layer with a big
needle to reduce the amount of foreign body as much as
possible, the peritoneal layers remain unsutured and the
abdomen is closed with two layers only. Women undergoing
this operation recover quickly and can look after the newborns
soon after surgery. There are many publications showing the
advantages over traditional caesarean section methods.
However, there is an increased risk of abruptio placenta and
uterine rupture in subsequent pregnancies for women who
underwent this method in prior deliveries.[49][50]

Technique[edit]

Pulling out the baby

Illustration depicting Caesarean section.

Antibiotic prophylaxis is used before an incision.[51] The uterus is

incised, and this incision is extended with blunt pressure along
a cephalad-caudad axis.[51] The infant is delivered, and
the placenta is then removed.[51] The surgeon then makes a
decision about uterine exteriorization.[51] Single-layer uterine
closure is used when the mother does not want a future

pregnancy.[51] When subcutaneous tissue is 2 cm thick or

more, surgical suture is used.[51] Discouraged practices include
manualcervical dilation, any subcutaneous drain, or
supplemental oxygen therapy with intent to prevent infection.[51]
Caesarean section can be performed with single or double
layer suturing of the uterine incision.[52] A Cochrane
review came to the result that single layer closure compared
with double layer closure was associated with a statistically
reduction in mean blood loss.[53] Standard procedure includes
the closure of the peritoneum. However, research questions
this may not be needed, with some studies indicating peritoneal
closure is associated with longer operative time and hospital
stay.[54]
In many hospitals, especially in Argentina, the United
States, United
Kingdom,Canada, Norway, Sweden, Finland, 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.[citation needed]

Anaesthesia[edit]
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.[55] 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 esophageal intubation.[56]
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.[57] Regional anaesthesia during Caesarean section is
different from 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.[56]
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.

Prevention of complications[edit]
Postpartum infection is one of the main causes of bad
outcomes[8][58] and death around childbirth, accounting for
around 10% of maternal deaths globally.[59] Caesarean section
greatly increases the risk of infection and associated morbidity
(estimated to be between 5 and 20 times as high). [58] Infection
can occur in around 8% of women who have caesareans,
[8]

largely endometritis, urinary tract infections and wound

infections.
Women who have caesareans need to understand the signs of
fever that indicate the possibility of wound infection. [8]Antibiotic
prophylaxis is effective for endometritis, preventing as many as
3 out of 4 cases.[8][58] Taking antibiotics before skin incision
rather than after cord clamping reduces the risk for the mother,
without increasing adverse effects for the baby.[8][60] Whether a
particular type of skin cleaner improves outcomes in unclear.[61]
Some doctors believe that during a caesarean section,
mechanical cervical dilation with a finger or forceps will prevent
the obstruction of blood and lochia drainage, and thereby
benefit the mother by reducing risk of death.[62] The available
clinical evidence is not sufficient to draw a conclusion on the
effect of this practice.[62]

Recovery[edit]

Abdominal, wound and back pain can continue for months after
a caesarean section, with some evidence that non-steroidal
anti-inflammatory drugs are helpful.[8] Women who have had a
caesarean are more likely to experience pain that interferes
with their usual activities than women who have vaginal births,
although by six months there is generally no longer a
difference.[63] However, pain during sexual intercourse is less
likely than after vaginal birth, although again, by six months
there is no difference.[8]
There may be a somewhat higher incidence of postnatal
depression in the first weeks after childbirth for women who
have caesarean sections, but this difference does not persist.
[8]

Some women who have had caesarean sections, especially

emergency caesareans, experience post-traumatic stress

disorder.[8]

Usage[edit]
In the United Kingdom, in 2008, the Caesarean section rate
was 24%.[64] In Ireland the rate was 26.1% in 2009.
[65]

TheCanadian rate was 26% in 20052006.[66] Australia has a

high Caesarean section rate, at 31% in 2007.[67] In the United

States the rate of C-section is around 33% and varies from
23% to 40% depending on the state in question.[3]
In Italy the incidence of Caesarean sections is particularly high,
although it varies from region to region.[68] In Campania, 60% of
2008 births reportedly occurred via Caesarean sections.[69] In
the Rome region, the mean incidence is around 44%, but can
reach as high as 85% in some private clinics.[70][71]
With nearly 1.3 million stays, Caesarean section was one of the
most common procedures performed in U.S. hospitals in 2011.
It was the second-most common procedure performed for
people ages 18 to 44 years old.[72] Caesarean rates in the U.S.
have risen considerably since 1996.[73] The procedure increased
60% from 1996 to 2009. In 2010, the Caesarean delivery rate
was 32.8% of all births (a slight decrease from 2009's high of
32.9% of all births).[74] A study found that in 2011, women

covered by private insurance were 11% more likely to have a

caesarean section delivery than those covered by Medicaid.[75]
China has been cited as having the highest rates of C-sections
in the world at 46% as of 2008.[76]
Studies have shown that continuity of care with a known carer
may significantly decrease the rate of Caesarean delivery [77]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. [78]
More emergency Caesareansabout 66%are performed
during the day rather than during the night.[79]
The rate has risen to 46% in China and to levels of 25% and
above in many Asian, European and Latin American countries.
[80]

The rate has increased in the United States, to 33% of all

births in 2012, up from 21% in 1996.[3] Across Europe, there are

differences between countries: in Italy the Caesarean section
rate is 40%, while in the Nordic countries it is 14%.[81]

Increasing use[edit]
In the United States C-section rates have increased from just
over 20% in 1996 to 33% in 2011.[3] This increase has not
resulted in improved outcomes resulting in the position that Csections may be done too frequently.[3]
The World Health Organization officially withdrew its previous
recommendation of a 15% C-section rates in June 2010. Their
official statement read, "There is no empirical evidence for an
optimum percentage. What matters most is that all women who
need caesarean sections receive them."[82]
The US National Institutes of Health says 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
caesarean deliveries (such as 15 percent) for a population.
One surgeon's opinion[who?] is that there is no consistency in this
ideal rate, and artificial declarations of an ideal rate should be
discouraged. Goals for achieving an optimal caesarean

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
caesarean delivery rates will vary over time and across
different populations according to individual and societal
circumstances."[43]
Joseph Walsh has speculated that caesarean section rates
have increased due to a relationship between birth weight and
maternal pelvis size, positing on the basis of Darwinianinspired logic that since the advent of successful Caesarean
birth over the last 150 years, more mothers with small pelvises
and babies with large birth weights have survived and
contributed to these traits. He notes that this hypothesis would
predict an increased average birth weight, which some studies
have borne out. However, Walsh cautions that it is unclear what
component of this trend is due to evolution, as environmental
factors may be responsible as well.[83]

History[edit]

Successful Caesarean section performed by indigenous healers

in Kahura, Uganda. As observed by R. W. Felkin in 1879.

The mother of Bindusara (born c. 320 BCE, ruled 298 c.272

BCE), the second Mauryan Samrat (emperor) of India,
accidentally consumed poison and died when she was close to
delivering him. Chanakya, the Chandragupta's teacher and
adviser, 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.[84][85]

According to the ancient Chinese Records of the Grand

Historian, Luzhong, a sixth-generation descendant of
the Yellow Emperor, had six sons, all born by "cutting open the
body". The sixth son Jilian founded the House of Mi that ruled
the State of Chu (c. 1030223 BCE).[86]
In the Irish mythological text the Ulster Cycle, the
character Furbaide Ferbend is said to have been born by
posthumous caesarean section, after his mother was murdered
by his evil aunt Medb.
The Babylonian Talmud, an ancient Jewish religious text,
mentions a procedure similar to the caesarean section. The
procedure is termed yotzei dofen.[85]
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 discussion of the etymology
of Caesar). The Ancient Roman caesarean section was first
performed to remove a baby from the womb of a mother who
died during childbirth. Julius Caesar's mother, Aurelia, lived
through childbirth and successfully gave birth to her son, ruling
out the possibility the Roman ruler and general was born by
caesarean section. His first wife however died in childbirth,
giving birth to a stilborn son who might have lived had a
caesarean taken place.
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.[87]
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.[88]
[89]

According to the Shahnameh,

the Simurgh instructed Zalupon how to perform a Caesarean

section, thus saving Rudaba and the child Rostam.[90]
Caesarean section usually resulted in the death of the mother;
the first well-recorded incident 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.
[91]

However, there is some basis for supposing that women

regularly survived the operation in Roman times.[92] For most of

the time since the 16th century, the procedure had a
highmortality 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 is
thought to be first modern CS performed.

The introduction of uterine suturing by Max Snger in 1882

Modification by Hermann Johannes Pfannenstiel in 1900,

see Pfannenstiel incision

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.[93] 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 they
had been employed for some time.[93] Dr. James Barry carried
out the first successful Caesarean by a European doctor in

Africa in Cape Town, while posted there between 1817 and

1828.[94]
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.[95]
On March 5, 2000, in Mexico, Ins Ramrez performed a
Caesarean section on herself and survived, as did her son,
Orlando Ruiz Ramrez.[96] She is believed to be the only woman
to have performed a successful Caesarean section on herself.
[citation needed]

Society and culture[edit]

Etymology[edit]
The Roman Lex Regia (royal law), later the Lex
Caesarea (imperial law), of Numa Pompilius (715673 BCE),
[97]

required the child of a mother dead in childbirth to be cut

from her womb.[98] There was a cultural taboo that mothers not
be buried pregnant,[99] that may have reflected a way of saving
some fetuses. Roman practice requiring a living mother to be in
her tenth month of pregnancy before resorting to the
procedure, reflecting the knowledge that she could not survive
the delivery.[100] Speculation that the Roman dictator Julius
Caesar was born by the method now known as C-section is
apparently false.[101] Although Caesarean sections were
performed in Roman times, no classical source records a
mother surviving such a delivery.[98][102] As late as the 12th
century, scholar and physician Maimonides expresses doubt
over the possibility of a woman's surviving this procedure and
again falling pregnant (see Commentary to Mishnah Bekhorot
8:2).[citation needed] The term has also been explained as deriving
from the verb caedere, "to cut", with children delivered this way
referred to as caesones. Pliny the Elder refers to a certain
Julius Caesar (an ancestor of the famous Roman statesman)
as ab utero caeso, "cut from the womb" giving this as an
explanation for the cognomen "Caesar" which was then carried

by his descendents.[98] Nonetheless, even if the etymological

hypothesis linking the caesarean section to Julius Caesar is
a false etymology, it has been widely believed. For example,
the Oxford English Dictionary defines Caesarean birth as "the
delivery of a child by cutting through the walls of
the abdomen when delivery cannot take place in the natural
way, as was done in the case of Julius Caesar".[103] MerriamWebster's Collegiate Dictionary (11th edition) leaves room for
etymological uncertainty with the phrase, "from the legendary
association of such a delivery with the Roman
cognomenCaesar"[104]
Some link with Julius Caesar or with Roman emperors exists in
other languages as well. For example, the
modern German,Norwegian, Danish, Dutch, Swedish, Turkish
and Hungarian terms are
respectively Kaiserschnitt, keisersnitt,kejsersnit,keizersnede, k
ejsarsnitt, sezaryen, and csszrmetszs (literally: "Emperor's
cut").[105] 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) cisrsky rez(literally
"imperial cut"), whereas the south Slavic term
is Serbian and 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 "Caesarean birth." The Hebrew term
( nitakh Keisri) translates literally as Caesarean
surgery. In Romania and Portugal,[106] it is usually
called cesariana, meaning from (or related to) Caesar.[citation needed]
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.[citation needed] Also, Hindu mythical monkey
god Hanuman was born through a similar procedure on his
mother Anjani.

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.[107]

Orthography[edit]
The term "Caesarean section" is spelled in many different
ways.
One variation is the e/ae/ variation which reflects American
and British English spelling differences. Because some sources
say the procedure is named after Julius Caesar, the
procedure's name is sometimes capitalized. The capitalversus-lowercase variation reflects a style of lowercasing some
eponymous terms (e.g., caesarean, eustachian, fallopian,
mendelian, parkinsonian, parkinsonism).[108] Capital and
lowercase stylings coexist in prevalent usage.
Because of (1) the e-vs-ae digraph variation, (2) the related aevs- typographic ligature variation, (3) the capital-vslowercase variation (which is based on the idea of eponymous
origin, whether that is historically accurate or not; seeeponym >
orthographic conventions), and (4) the -ean-vs-ian suffix variation, these factors cross-multiplied in a table
cause this word to be one of the very few words in presentday English orthography to have many different normative
spellings or orthographic stylings, which amount to 12 from the
point of view of character encoding (that is, there are 12
different character strings that are all accepted as normative
orthographic representations of this one word):
Multiplication table

ae

ae

C
e es
a ar
n ea
n

i
a
n

ce
sa
re
an

Ca

ca

es

es

ar

ar

sa

sa

ea

ea

re

re

an

an

sa

sa

ria

ria

ce

Ca

ca

es

sa

es

es

ari ria

ari

ari

an

an

an

Special cases[edit]
In Judaism there is a dispute among the poskim (Rabbinic
authorities) as to whether a first-born son from a Caesarean
section has the laws of a bechor.[109] Traditionally, a male child
delivered by Caesarean is not eligible for the Pidyon
HaBendedication ritual.[110][111]
In rare cases, caesarean sections can be used to remove a
dead fetus. A late-term abortion using Caesarean section
procedures is termed a hysterotomy abortion and is very rarely
performed.[citation needed]
Self-inflicted caesarean section is the concept of a mother
alone performing her own caesarean section. There have
apparently been a few successful cases, notably Ins Ramrez
Prez of Mexico who in March 2000, performed a successful
Caesarean section on herself.[112][113]

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