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C-section

Article

23. 09. 2019

A cesarean section (C-section) is an obstetric operation during which the surgeon makes an incision in the abdomen and womb, and lifts the newborn out. 

The C-section is an operation that's been performed for hundreds of years, and was probably already known by the ancient Egyptians. Historically, the first documented C-section during which both the mother and child survived was performed in Prague in 1337. 
 
Currently, the caesarean section is the most commonly performed obstetric operation, and is probably the most common abdominal operation on the whole. This method of delivery makes up about 25% of all births in the Czech Republic. In specialised perinatology centres where most high-risk births take place, cesarean sections make up more than 30% of all births, compared to 10% in all other maternity hospitals. 
 

Indications for cesarean section:

Generally, most cesarean sections can be split into two groups: planned, and unplanned (i.e. acute). Even in the case of an acute caesarean section, the consent of the mother is always necessary, as undergoing a C-section is six times more risky for the mother than spontaneous childbirth. That is one of the reasons why in the Czech Republic a C-section cannot be performed on the ‘request of the mother’. A C-section is only considered when the life of the baby, the mother or both would be in danger if a spontaneous birth was to be carried through. Another condition for a C-section is that a large part of the infant's head must not be descended and it must be fixed deep inside the pelvis, otherwise there is a serious risk of injury to both the mother and the child. The most common indications for caesarean section: 
  • Disparity in the size of the mother's pelvis to the size of the child (small maternal pelvis)
  • Obstacles in the birth canal 
  • Placenta previa (anomalous placental position, impeding vaginal delivery)
  • Umbilical cord prolapse (could lead to fetal asphyxia)
  • Acute fetal distress (hypoxia)
  • Maternal diseases (eclampsia and HELLP syndrome)
  • Herpetic infection of the maternal external genitalia
  • Multiple pregnancy: collisional position of twins
  • Irregular fetal position
  • Cancer or mental illness in the mother
  • Dying/deceased mother. 

 

C-section procedure:

The procedure is always performed under anesthesia, either general, or increasingly under epidural anesthesia (the anesthetic is injected into the spinal canal, and ensures complete anesthesia of only the lower half of the body. 
The surgeon accesses the uterus through the abdominal wall, where they make a horizontal incision above the pubic bone (the Pfannenstiel-Kerr incision), which is the most cosmetically suitable option, and has less risk of complications post-surgery. In some acute situations, a much wider/faster access point is necessary, in which case a vertical incision is made directly between the abdominal muscles- from the pubic bone to the navel (lower midline laparotomy). The uterus is most often opened by a horizontal incision in the lower uterine segment. The primary incision is bluntly extended by the surgeon’s fingers. The incision in the uterus is called a hysterotomy and it must be large enough to ensure a safe extraction of the fetus from the uterine cavity. The placenta is also removed, and the wound in the uterus is sutured using absorbable stitches. The abdominal cavity is then sutured together following its anatomical layers. 

 

Why is the occurence of C-sections increasing? 

  • Increasing maternal age. The age of mothers conceiving in the age categories of 30,35 and 40 is constantly increasing. The older a woman is at her first birth, the higher the risk of needing a C-section. 
  • Assisted reproduction. The fertility of the population is continually deteriorating, and therefore a higher than ever proportion of children are conceived through in vitro fertilisation methods (IVF). Children conceived through this method more often come into the world by caesarean section. 
  • Repeated C-section. The proportion of women who give birth by C-section is increasing, and only 10% of women can give birth spontaneously following a previous caesarean section. 
  • Breech birth. More than 3% of all pregnant women at term have a breech baby, where the baby is facing bottom first rather than head first. Almost 90% of all breech births are delivered by caesarean section. 
  • Premature birth. C-sections are associated with the improvement of perinatal outcomes in extremely high-risk pregnancies. C-sections are also utilised in low weight infants. 
  • Hypoxia. Approximately 15% of caesarean sections are realised during a high risk of fetal hypoxia during labour. C-sections have significantly increased the amount of newborn babies that would have otherwise not been live births due to hypoxia. 
     

Risks and complications of C-section:

  • Anaesthesia risks: there is a risk of complications due to the administered anaesthetics, as well as the risk of allergic reactions to the administered substances. 
  • Risk of the surgery: blood loss, uterine removal, injuries of surrounding organs in a smaller pelvis, pulmonary embolism, coagulation disorders, venous thrombosis. 
  • Post-operative risks: infection of incision site, post-operative bleeding, pulmonary embolism and others.
  • Future complications: formation of adhesions in the abdominal cavity, chronic pelvic pain, complicated wound healing. There is a risk of rupture of the scar site during a following pregnancy, and a high risk of the need to have a C-section at following births.
  • Risks to breastfeeding. The administration of painkillers increases the likelihood of delayed lactation. Short or delayed skin-to-skin contact may interfere with breast milk production. 

 

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