A caesarean section (American English: cesarean section), or c-section, is a form of childbirth in which a surgical incision is made through a mother’s abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies. It is usually performed when a vaginal delivery would put the baby’s or mother’s life or health at risk, although in recent times it has been also performed upon request for births that would otherwise have been normal.
There are several types of caesarean sections (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 labor has commenced.
A crash caesarean section is a caesarean performed in an obstetrical emergency, where complications of pregnancy onset suddenly during the process of labor, 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 CS have been used, such as extraperitoneal CS or Porro CS.
A repeat caesarean section is done when a patient had a previous section. Typically it is performed through the old scar.
In many hospitals, especially in the United States, United Kingdom, Canada, Australia, and New Zealand the mother’s birth partner is encouraged to attend the surgery to support the mother and share the experience. The anesthetist will usually lower the drape temporarily as the child is delivered so the parents can see their newborn.
Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. Reasons for caesarean delivery include:
- prolonged labor or a failure to progress (dystocia)
- apparent fetal distress
- apparent maternal distress
- complications (pre-eclampsia, active herpes)
- catastrophes such as cord prolapse or uterine rupture
- multiple births
- abnormal presentation (breech or transverse positions)
- failed induction of labor
- 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. This takes place in the operating theater.
- the baby is too large (macrosomia)
- placental problems (placenta previa, placental abruption or placenta accreta)
- contracted pelvis
- Sexually transmitted infections such as genital herpes (which can be passed on to the baby, if the baby is born vaginally)
- prior problems with the healing of the perineum (from previous childbirth or Crohn’s Disease)
- hypertension (ie. Pregnancy-induced Hypertension or PIH)
However, different providers may disagree about when a caesarean is required. For example, while one obstetrician may feel that a woman is too small to deliver her baby, another might well disagree. Similarly, some care providers may be much quicker to cite “failure to progress” than others. Disagreements like this help to explain why caesarean rates for some physicians and hospitals are much higher than are those for others. The medico-legal restrictions on vaginal birth after caesarean (VBAC), have also increased the caesarean rate.
Few contraindications exist 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) such 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).
Both general and regional anesthesia (spinal, epidural or combined spinal and epidural anaesthesia) are acceptable for use during caesarean section. Regional anesthesia is preferred as it allows the mother to be awake and interact immediately with her baby. Other advantages of regional anesthesia include the absence of typical risks of general anesthesia: pulmonary aspiration of gastric contents (which has a relatively high incidence in patients undergoing anesthesia in late pregnancy) and Oesophageal intubation.
Regional anesthesia is used in 95% of deliveries, with spinal and combined spinal and epidural anesthesia being the most commonly used regional techniques in scheduled caesarean section. Regional anesthesia 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.
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.
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. 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 anesthesia risk. Other risks include severe blood loss (which may require a blood transfusion) and post spinal headaches.
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.
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.
Risks for the child
- Neonatal depression: babies may have an adverse reaction to the anesthesia given to the mother, causing a period of inactivity or sluggishness after delivery.
- Fetal injury: injury may occur to the baby during uterine incision and extraction.
- Breathing problems: babies born by c-section, even at full term, are more likely to have breathing problems than are babies who are delivered vaginally.
- Breastfeeding problems: babies born by c-section are less likely to successfully breastfeed than those delivered vaginally.
- Potential for early delivery and complications: 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.
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.
1. Turner R (1990). “Caesarean Section Rates, Reasons for Operations Vary Between Countries”. Fam Plann Perspect. 22 (6): 281–2. doi:10.2307/2135690.
3. Hawkins JL, Koonin LM, Palmer SK, Gibbs CP (February 1997). “Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990″. Anesthesiology 86 (2): 277–84. PMID 9054245. Retrieved 2008-08-27.
5. Bucklin BA, Hawkins JL, Anderson JR, Ullrich FA (September 2005). “Obstetric anesthesia workforce survey: twenty-year update”. Anesthesiology 103 (3): 645–53. doi:10.1097/00000542-200509000-00030. PMID 16129992. Retrieved 2008-08-27.
6. Pai, Madhukar (2000). “Medical Interventions: Caesarean Sections as a Case Study”. Economic and Political Weekly 35 (31): 2755–61.
7. Silver RM, Landon MB, Rouse DJ, et al. (June 2006). “Maternal morbidity associated with multiple repeat cesarean deliveries”. Obstet Gynecol 107 (6): 1226–32. doi:10.1097/01.AOG.0000219750.79480.84 (inactive 2008-12-31). PMID 16738145.
8. Kennare R, Tucker G, Heard A, Chan A (February 2007). “Risks of adverse outcomes in the next birth after a first cesarean delivery”. Obstet Gynecol 109 (2 Pt 1): 270–6. PMID 17267823.