cesarean section

cesarean section, surgical removal of a fetus from the uterus through an abdominal incision.

History

Little is known of either the origin of the term or the history of the procedure. According to ancient sources, whose veracity has been challenged, the procedure takes its name from a branch of the ancient Roman family of the Julii whose cognomen, Caesar (Latin caedere, “to cut”), originated from a birth by this means. Roman law (Lex Caesarea) mandated the cutting out from the womb a child whose mother had died during labour. A common misperception holds that Julius Caesar himself was born in this fashion. However, since Caesar’s mother, Aurelia, is believed to have been alive when he was a grown man, it is widely held that he could not have been born in this way. The law was followed initially to comply with Roman ritual and religious custom, which forbade the burial of pregnant women, but the procedure was later pursued specifically in an attempt to save the child’s life.

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The first documented cesarean section on a living woman was performed in 1610; she died 25 days after the surgery. Abdominal delivery was subsequently tried in many ways and under many conditions, but it almost invariably resulted in the death of the mother from sepsis (infection) or hemorrhage (bleeding). Even in the first half of the 19th century, the recorded mortality was about 75 percent, and fetal craniotomy—in which the life of the child is sacrificed to save that of the mother—was usually preferred. Eventually, however, improvements in surgical techniques, antibiotics, and blood transfusion and antiseptic procedures so reduced the mortality that cesarean section came to be frequently performed as an alternative to normal childbirth.

Medical uses

In modern obstetrical care, cesarean section usually is performed when the life of either the mother or the child would be endangered by attempting normal delivery. The medical decision is based on physical examination, special tests, and patient history. The examination includes consideration of any diseases the mother may have had in the past and disorders that may have arisen because of pregnancy. Special tests that might be performed include fetal scalp blood analysis and fetal heart rate monitoring. Common indications for cesarean section include obstructed labour, failure of labour to progress, placenta praevia (development of the placenta in an abnormally low position near the cervix), fetal distress, gestational diabetes mellitus, and improper positioning of the fetus for delivery. In addition, cesarean section is often used if the birth canal is too small for normal delivery. Sometimes when a woman has had a child by cesarean section, any children born after the first cesarean section are also delivered by that method, but vaginal delivery is often possible.

Risks

The risks of cesarean section are low but real. The operation constitutes major surgery. Compared with the risks of normal vaginal delivery, it is more dangerous for the mother. The risk of complications—such as infection, hemorrhage, blood clots, and injury to the bladder or intestines—is greater. If the baby is delivered by cesarean section planned in advance of labour, the infant can be premature, and it has been suggested that elective cesarean section may rob the infant of hormones and other substances released by the mother during labour. Researchers have also identified a correlation between infant birth by cesarean section and increased risk of asthma and childhood obesity.

In addition, infants born by cesarean section have been shown to harbour atypical types of bacteria in the gut relative to babies born vaginally. These atypical bacterial populations frequently include potentially harmful microorganisms that are a common cause of opportunistic infections in hospital environments. Although, over time, the microbiome in affected infants becomes more similar to that in infants delivered vaginally, early differences in the microbiome may impact infant health or contribute to health issues that arise later.

Issues

In 1985 the World Health Organization (WHO) recommended an optimal cesarean section rate of 10 to 15 percent within a given population; if performed above this rate, the procedure was found by WHO to place an excessive burden on the resources necessary for the proper prenatal and postnatal care of mother and child, thereby increasing the number of women and infants exposed to the risks associated with the operation. Despite the recommendations set forth by WHO, by the late 20th century the incidence of cesarean section in the United States had risen dramatically, largely as a result of an increase in the number of malpractice suits brought against obstetricians for failing to operate if there was an indication of trouble in delivery. In the first decade of the 21st century, the rate of cesarean section far exceeded WHO’s recommendation in many other countries as well, including the United Kingdom, Australia, Germany, France, and Italy. The rate had also increased in countries such as India, China, and Brazil.