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Caesarean section
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==Risks== Adverse outcomes in low-risk pregnancies occur in 8.6% of vaginal deliveries and 9.2% of caesarean section deliveries.<ref name=ACOG2014/> ===Mother=== In those who are low risk, the [[mortality rate|risk of death]] for caesarean sections is 13 per 100,000 vs. for vaginal birth 3.5 per 100,000 in the developed world.<ref name=ACOG2014/> The United Kingdom [[National Health Service]] gives the risk of death for the mother as three times that of a vaginal birth.<ref>{{cite web|url=http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=71§ionId=7681 |title=Caesarean Section |publisher=[[NHS Direct]] |access-date=26 July 2006 |url-status=dead |archive-url=https://web.archive.org/web/20090201155120/http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=71§ionId=7681 |archive-date=1 February 2009 }}</ref> 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.<ref name=Liu2007/> The difference in in-hospital maternal death was not significant.<ref name=Liu2007>{{cite journal | vauthors = Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS | title = Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term | journal = CMAJ | volume = 176 | issue = 4 | pages = 455β460 | date = February 2007 | pmid = 17296957 | pmc = 1800583 | doi = 10.1503/cmaj.060870 }}</ref> [[File:Normal post-Caesarean.jpg|thumb|[[Transvaginal ultrasonography]] of a uterus years after a caesarean section, showing the characteristic scar formation in its anterior part]] A caesarean section is associated with risks of postoperative [[Adhesion (medicine)|adhesions]], incisional hernias (which may require surgical correction), and wound infections.<ref name=Pai00>{{cite journal | vauthors = Pain M |title=Medical Interventions: Caesarean Sections as a Case Study |journal=[[Economic and Political Weekly]] |volume=35 |issue=31 |pages=2755β61 |year=2000}}</ref> If a caesarean is performed in an emergency, the risk of the surgery may be increased due to several factors. The patient's stomach may not be empty, increasing the risk of anaesthesia.<ref>{{cite web |url=http://www.gynaecworld.com/Pregnancy/pg9.html#3 |title=Why are Caesareans Done? |publisher=Gynaecworld |access-date=26 July 2006 |url-status=dead |archive-url=https://web.archive.org/web/20081203134401/http://www.gynaecworld.com/Pregnancy/pg9.html#3 |archive-date=3 December 2008 }}</ref> Other risks include severe blood loss (which may require a blood transfusion) and [[Post dural puncture headache|post-dural-puncture spinal- headaches]].<ref name=Pai00/> Wound infections occur after caesarean sections at a rate of 3β15%.<ref name="Saee2017">{{cite journal | vauthors = Saeed KB, Greene RA, Corcoran P, O'Neill SM | title = Incidence of surgical site infection following caesarean section: a systematic review and meta-analysis protocol | journal = BMJ Open | volume = 7 | issue = 1 | pages = e013037 | date = January 2017 | pmid = 28077411 | pmc = 5253548 | doi = 10.1136/bmjopen-2016-013037 }}</ref> The presence of [[chorioamnionitis]] and [[obesity]] predisposes the woman to develop a surgical site infection.<ref name="Saee2017" /> Women who had caesarean sections are more likely to have problems with later pregnancies, and women who want larger families should not seek an elective caesarean unless medical indications to do so exist. The risk of [[placenta accreta]], a potentially life-threatening condition that 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.<ref>{{cite journal | vauthors = Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, Peaceman AM, O'Sullivan MJ, Sibai B, Langer O, Thorp JM, Ramin SM, Mercer BM | title = Maternal morbidity associated with multiple repeat cesarean deliveries | journal = Obstetrics and Gynecology | volume = 107 | issue = 6 | pages = 1226β1232 | date = June 2006 | pmid = 16738145 | doi = 10.1097/01.AOG.0000219750.79480.84 | s2cid = 257455 }}</ref> Mothers can experience an increased incidence of [[postnatal depression]], and can experience significant psychological trauma and ongoing [[Childbirth-related posttraumatic stress disorder|birth-related post-traumatic stress disorder]] after obstetric intervention during the birthing process.<ref name=Olde2006>{{cite journal | vauthors = Olde E, van der Hart O, Kleber R, van Son M | title = Posttraumatic stress following childbirth: a review | journal = Clinical Psychology Review | volume = 26 | issue = 1 | pages = 1β16 | date = January 2006 | pmid = 16176853 | doi = 10.1016/j.cpr.2005.07.002 | hdl-access = free | s2cid = 22137961 | hdl = 1874/16760 }}</ref> Factors like pain in the first stage of labor, feelings of powerlessness, intrusive emergency obstetric intervention are important in the subsequent development of psychological issues related to labor and delivery.<ref name="Olde2006"/> ====Subsequent pregnancies==== {{Further|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.<ref name="Gurol-UrganciBou-Antoun2013">{{cite journal | vauthors = Gurol-Urganci I, Bou-Antoun S, Lim CP, Cromwell DA, Mahmood TA, Templeton A, van der Meulen JH | title = Impact of Caesarean section on subsequent fertility: a systematic review and meta-analysis | journal = Human Reproduction | volume = 28 | issue = 7 | pages = 1943β1952 | date = July 2013 | pmid = 23644593 | doi = 10.1093/humrep/det130 | doi-access = free }}</ref> Women who had just one previous caesarean section are more likely to have problems with their second birth.<ref name=ACOG2014/> [[Delivery after previous caesarean section]] is by either of two main options:<ref>{{Cite web |title=UpToDate |url=https://www.uptodate.com/contents/choosing-the-route-of-delivery-after-cesarean-birth |access-date=2024-02-10 |website=www.uptodate.com}}</ref> * Vaginal birth after caesarean section (VBAC) * [[Elective surgery|Elective]] repeat caesarean section (ERCS) Both have higher risks than a vaginal birth with no previous caesarean section. A vaginal birth after caesarean section (VBAC) confers a higher risk of [[uterine rupture]] (5 per 1,000), blood transfusion or [[endometritis]] (10 per 1,000), and [[perinatal death]] of the child (0.25 per 1,000).<ref name=rcog2007>{{cite web |url=https://www.rcog.org.uk/globalassets/documents/guidelines/gtg4511022011.pdf |title=Birth After Previous Caesarean Birth, Green-top Guideline No. 45 |date=February 2007 |publisher=Royal College of Obstetricians and Gynaecologists |url-status=dead |archive-url=https://web.archive.org/web/20141207031819/https://www.rcog.org.uk/globalassets/documents/guidelines/gtg4511022011.pdf |archive-date=7 December 2014 }}</ref> Furthermore, 20% to 40% of planned VBAC attempts end in caesarean section being needed, with greater risks of complications in an emergency repeat caesarean section than in an elective repeat caesarean section.<ref name="americanpregnancy"/><ref name="mayoclinic"/> On the other hand, VBAC confers less [[maternal morbidity]] and a decreased risk of complications in future pregnancies than elective repeat caesarean section.<ref name="American Congress of Obstetricians and 450β63">{{cite journal | vauthors = | title = ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery | journal = Obstetrics and Gynecology | volume = 116 | issue = 2 Pt 1 | pages = 450β463 | date = August 2010 | pmid = 20664418 | doi = 10.1097/AOG.0b013e3181eeb251 }}</ref> ====Adhesions==== [[File:Suturing uterus.JPG|thumb|Suturing of the uterus after extraction]] [[Image:C-sec suture.jpg|thumb|right|Closed incision for ''low transverse abdominal incision'' after stapling has been completed]] Several steps can be taken during abdominal or pelvic surgery to minimize postoperative complications, such as developing [[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 Despite these proactive measures, adhesion formation is a recognized abdominal or pelvic surgery complication. To prevent adhesions from forming after 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 practice, as there is no compelling evidence to support the benefit of this intervention.{{cn|date=April 2025}} Adhesions can cause long-term problems, such as: * [[Female Infertility|Infertility]], which may end 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% 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 reason 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. ===Child=== Non-medically indicated (elective) childbirth before 39 weeks gestation "carry significant risks for the baby with no known benefit to the mother." Newborn mortality at 37 weeks may be up to 3 times the number at 40 weeks and is elevated compared to 38 weeks gestation. These early-term births were associated with more death during infancy, compared to those occurring at 39 to 41 weeks (full-term).<ref name="urlwww.patientsafetycouncil.org">{{cite web |url=http://www.patientsafetycouncil.org/uploads/MOD_39_Weeks_Toolkit.pdf |title=Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age |access-date=13 July 2012 |url-status=dead |archive-url=https://web.archive.org/web/20121120003529/http://www.patientsafetycouncil.org/uploads/MOD_39_Weeks_Toolkit.pdf |archive-date=20 November 2012 }}</ref> 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.<ref name="urlwww.patientsafetycouncil.org"/><ref name="urlTerm Pregnancy: A Period of Heterogeneous Risk for Infant Mortality">{{cite journal | vauthors = Reddy UM, Bettegowda VR, Dias T, Yamada-Kushnir T, Ko CW, Willinger M | title = Term pregnancy: a period of heterogeneous risk for infant mortality | journal = Obstetrics and Gynecology | volume = 117 | issue = 6 | pages = 1279β1287 | date = June 2011 | pmid = 21606738 | pmc = 5485902 | doi = 10.1097/AOG.0b013e3182179e28 }}</ref> The [[American Congress of Obstetricians and Gynecologists]] and medical policymakers review research studies and find more incidence of suspected or proven [[sepsis]], RDS, hypoglycemia, need for respiratory support, need for NICU admission, and need for hospitalization > 4β5 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 before 39 weeks.<ref name="urlwww.patientsafetycouncil.org"/> For otherwise healthy [[twin]] pregnancies where both twins are head down a trial of [[vaginal delivery]] is recommended at between 37 and 38 weeks.<ref name="NICE2011">{{cite report | title = Caesarean Section: NICE Clinical Guidelines, No. 132 | year = 2011 | pmid = 23285498 | url = https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0050826/ | url-status = live | publisher = National Institute of Health and Clinical Excellence | series = National Institute for Health and Clinical Excellence: Guidance | archive-url = https://web.archive.org/web/20160102022125/http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0050826/ | archive-date = 2 January 2016 }}</ref><ref name=Bis2013/> Vaginal delivery, in this case, does not worsen the outcome for either infant as compared with caesarean section.<ref name=Bis2013>{{cite journal | vauthors = Biswas A, Su LL, Mattar C | title = Caesarean section for preterm birth and, breech presentation and twin pregnancies | journal = Best Practice & Research. Clinical Obstetrics & Gynaecology | volume = 27 | issue = 2 | pages = 209β219 | date = April 2013 | pmid = 23062593 | doi = 10.1016/j.bpobgyn.2012.09.002 }}</ref> 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.<ref name=Bis2013/> When the first twin is not head down, a caesarean section is often recommended.<ref name=Bis2013/> 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.<ref>{{cite journal | vauthors = Lee YM | title = Delivery of twins | journal = Seminars in Perinatology | volume = 36 | issue = 3 | pages = 195β200 | date = June 2012 | pmid = 22713501 | doi = 10.1053/j.semperi.2012.02.004 }}</ref><ref>{{cite journal | vauthors = Hack KE, Derks JB, Elias SG, Franx A, Roos EJ, Voerman SK, Bode CL, Koopman-Esseboom C, Visser GH | title = Increased perinatal mortality and morbidity in monochorionic versus dichorionic twin pregnancies: clinical implications of a large Dutch cohort study | journal = BJOG | volume = 115 | issue = 1 | pages = 58β67 | date = January 2008 | pmid = 17999692 | doi = 10.1111/j.1471-0528.2007.01556.x | s2cid = 20983040 | doi-access = }}</ref> The consensus is that [[Late preterm infant|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., 36β37 weeks).<ref>{{cite journal | vauthors = Danon D, Sekar R, Hack KE, Fisk NM | title = Increased stillbirth in uncomplicated monochorionic twin pregnancies: a systematic review and meta-analysis | journal = Obstetrics and Gynecology | volume = 121 | issue = 6 | pages = 1318β1326 | date = June 2013 | pmid = 23812469 | doi = 10.1097/AOG.0b013e318292766b | s2cid = 5152813 }}</ref> 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 are higher after this gestation than the risk of complications of prematurity.<ref>{{cite journal | vauthors = Pasquini L, Wimalasundera RC, Fichera A, Barigye O, Chappell L, Fisk NM | title = High perinatal survival in monoamniotic twins managed by prophylactic sulindac, intensive ultrasound surveillance, and Cesarean delivery at 32 weeks' gestation | journal = Ultrasound in Obstetrics & Gynecology | volume = 28 | issue = 5 | pages = 681β687 | date = October 2006 | pmid = 17001748 | doi = 10.1002/uog.3811 | s2cid = 26098748 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Murata M, Ishii K, Kamitomo M, Murakoshi T, Takahashi Y, Sekino M, Kiyoshi K, Sago H, Yamamoto R, Kawaguchi H, Mitsuda N | title = Perinatal outcome and clinical features of monochorionic monoamniotic twin gestation | journal = The Journal of Obstetrics and Gynaecology Research | volume = 39 | issue = 5 | pages = 922β925 | date = May 2013 | pmid = 23510453 | doi = 10.1111/jog.12014 | s2cid = 40347063 }}</ref><ref>{{cite journal | vauthors = Baxi LV, Walsh CA | title = Monoamniotic twins in contemporary practice: a single-center study of perinatal outcomes | journal = The Journal of Maternal-Fetal & Neonatal Medicine | volume = 23 | issue = 6 | pages = 506β510 | date = June 2010 | pmid = 19718582 | doi = 10.3109/14767050903214590 | s2cid = 37447326 }}</ref> In a research study widely publicized, singleton children born earlier than 39 weeks may have developmental problems, including slower learning in reading and math.<ref name="urlAcademic Achievement Varies With Gestational Age Among Children Born at Term">{{cite journal |url=http://pediatrics.aappublications.org/content/early/2012/06/27/peds.2011-2157d.abstract?sid=b95d99e5-556e-45d3-8326-e77459528363 |title=Academic Achievement Varies With Gestational Age Among Children Born at Term |journal=Pediatrics |date=June 2012 |access-date=12 July 2012 |url-status=live |archive-url=https://web.archive.org/web/20150904045302/http://pediatrics.aappublications.org/content/early/2012/06/27/peds.2011-2157d.abstract?sid=b95d99e5-556e-45d3-8326-e77459528363 |archive-date=4 September 2015 }}</ref> Other risks include: * [[Wet lung]] (Transient Tachypnea of the Newborn): Failure to pass through the birth canal does not expose the baby to cortisol and epinephrine which typically would reverse the potassium/sodium pumps in the baby's lung. This causes fluid to remain in the lung.<ref>{{cite book | vauthors = Jha K, Nassar GN, Makker K | chapter = Transient Tachypnea of the Newborn |date=2022 | chapter-url= http://www.ncbi.nlm.nih.gov/books/NBK537354/ | title =StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=30726039 |access-date=2022-06-22 }}</ref> * Potential for early delivery and complications: Preterm delivery may be inadvertently carried out if the 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.<ref>{{cite web | url = https://www.npr.org/templates/story/story.php?storyId=99132594 | title = Study: Early Repeat C-Sections Puts Babies At Risk | archive-url = https://web.archive.org/web/20160131115102/http://www.npr.org/templates/story/story.php?storyId=99132594 | archive-date = 31 January 2016 | work = NPR.org | date = 8 January 2009 | access-date = 26 July 2011 }}</ref> * 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.<ref>{{cite web |url=http://www.medicineonline.com/news/12/6008/High-infant-mortality-seen-with-elective-c-section.html |title=High infant mortality rate seen with elective c-section |work=Reuters HealthβSeptember 2006 |publisher=Medicineonline.com |date=14 September 2006 |access-date=26 July 2011 |url-status=dead |archive-url=https://web.archive.org/web/20110718123744/http://www.medicineonline.com/news/12/6008/High-infant-mortality-seen-with-elective-c-section.html |archive-date=18 July 2011 }}</ref> Birth by caesarean section also seems to be associated with worse health outcomes later in life, including overweight or obesity, problems in the immune system, and poor digestive system.<ref>{{cite journal | vauthors = Mueller NT, Zhang M, Hoyo C, Γstbye T, Benjamin-Neelon SE | title = Does cesarean delivery impact infant weight gain and adiposity over the first year of life? | journal = International Journal of Obesity | volume = 43 | issue = 8 | pages = 1549β1555 | date = August 2019 | pmid = 30349009 | pmc = 6476694 | doi = 10.1038/s41366-018-0239-2 }}</ref><ref>C. Yuan et al. (2016), "Association Between Cesarean Birth and Risk of Obesity in Offspring in Childhood, Adolescence, and Early Adulthood", ''[[JAMA Pediatrics]]''.</ref> However, caesarean deliveries are found to not affect a newborn's risk of developing food allergies.<ref>{{cite journal | vauthors = Currell A, Koplin JJ, Lowe AJ, Perrett KP, Ponsonby AL, Tang ML, Dharmage SC, Peters RL | title = Mode of Birth Is Not Associated With Food Allergy Risk in Infants | language = English | journal = The Journal of Allergy and Clinical Immunology. In Practice | volume = 10 | issue = 8 | pages = 2135β2143.e3 | date = August 2022 | pmid = 35597762 | doi = 10.1016/j.jaip.2022.03.031 | s2cid = 248903112 }}</ref> This finding contradicts a previous study that claims babies born via caesarean section have lower levels of ''[[Bacteroides]]'' that is linked to peanut allergy in infants.<ref>{{Cite web |date=2021-04-30 |title=Why C-Section Babies May Be at Higher Risk for a Food Allergy |url=https://consumer.healthday.com/4-29-why-c-section-babies-may-be-at-higher-risk-for-a-food-allergy-2652675840.html |access-date=2022-05-25 |website=Consumer Health News {{!}} HealthDay |language=en}}</ref>
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