Editing Caesarean section (section)

==Classification==
Caesarean sections have been classified in various ways by different perspectives.<ref name="AlthabeTorloni2011">{{cite journal | vauthors = Torloni MR, Betran AP, Souza JP, Widmer M, Allen T, Gulmezoglu M, Merialdi M | title = Classifications for cesarean section: a systematic review | journal = PLOS ONE | volume = 6 | issue = 1 | pages = e14566 | date = January 2011 | pmid = 21283801 | pmc = 3024323 | doi = 10.1371/journal.pone.0014566 | doi-access = free | bibcode = 2011PLoSO...614566T }}</ref> One way to discuss all classification systems is to group them by their focus either on the urgency of the procedure (most common), characteristics of the mother, or as a group based on other, less commonly discussed factors.<ref name="AlthabeTorloni2011"/>

===By urgency===
Conventionally, caesarean sections are classified as being either an [[elective surgery]] or an [[emergency]] operation.<ref name="classification 2000">{{cite journal | vauthors = Lucas DN, Yentis SM, Kinsella SM, Holdcroft A, May AE, Wee M, Robinson PN | title = Urgency of caesarean section: a new classification | journal = Journal of the Royal Society of Medicine | volume = 93 | issue = 7 | pages = 346–350 | date = July 2000 | pmid = 10928020 | pmc = 1298057 | doi = 10.1177/014107680009300703 }}</ref> 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.<ref name="classification 2000"/> 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. In the UK, this is classified as a 'grade 4' section (delivery timed to suit the mother or hospital staff) or as a 'grade 3' section (no maternal or fetal compromise but early delivery needed).
Emergency caesarean sections are performed in pregnancies in which a vaginal delivery was planned initially, but an indication for caesarean delivery has since developed. In the UK they are further classified as 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 or both.)<ref>{{cite web| vauthors = Miheso J, Burns S |title=Care of women undergoing emergency caesarean section|url=https://www.wwl.nhs.uk/Library/FOI/Requests/2013-2014/July_2013/1678_Emergency_Caesarean_Section_Jul12.pdf|website=NHS Choices|access-date=7 March 2018|archive-date=8 March 2018|archive-url=https://web.archive.org/web/20180308103403/https://www.wwl.nhs.uk/Library/FOI/Requests/2013-2014/July_2013/1678_Emergency_Caesarean_Section_Jul12.pdf|url-status=dead}}</ref>

Elective caesarean sections may be performed based on an obstetrical or medical indication, or because of a medically non-indicated [[Caesarean delivery on maternal request|maternal request]].<ref name=NICE2011 /> Among women in the United Kingdom, Sweden, and Australia, about 7% preferred caesarean section as a method of delivery.<ref name=NICE2011 /> 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.<ref name=ACOG559>{{cite journal | vauthors =  | title = ACOG committee opinion no. 559: Cesarean delivery on maternal request | journal = Obstetrics and Gynecology | volume = 121 | issue = 4 | pages = 904–907 | date = April 2013 | pmid = 23635708 | doi = 10.1097/01.AOG.0000428647.67925.d3 }}</ref> The [[National Institute for Health and Care Excellence]] recommends that if after a woman has been provided information on the risk of a planned caesarean section and she still insists on the procedure it should be provided.<ref name=NICE2011 /> If provided this should be done at 39 weeks of gestation or later.<ref name=ACOG559/> There is no evidence that ECS can reduce mother-to-child [[Hepatitis B virus|hepatitis B]] and [[hepatitis C virus]] transmission.<ref>{{cite journal | vauthors = Yang J, Zeng XM, Men YL, Zhao LS | title = Elective caesarean section versus vaginal delivery for preventing mother to child transmission of hepatitis B virus--a systematic review | journal = Virology Journal | volume = 5 | issue = 1 | pages = 100 | date = August 2008 | pmid = 18755018 | pmc = 2535601 | doi = 10.1186/1743-422X-5-100 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Borgia G, Carleo MA, Gaeta GB, Gentile I | title = Hepatitis B in pregnancy | journal = World Journal of Gastroenterology | volume = 18 | issue = 34 | pages = 4677–4683 | date = September 2012 | pmid = 23002336 | pmc = 3442205 | doi = 10.3748/wjg.v18.i34.4677 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Hu Y, Chen J, Wen J, Xu C, Zhang S, Xu B, Zhou YH | title = Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus | journal = BMC Pregnancy and Childbirth | volume = 13 | issue = 1 | pages = 119 | date = May 2013 | pmid = 23706093 | pmc = 3664615 | doi = 10.1186/1471-2393-13-119 | doi-access = free }}</ref><ref>{{cite journal | vauthors = McIntyre PG, Tosh K, McGuire W | title = Caesarean section versus vaginal delivery for preventing mother to infant hepatitis C virus transmission | journal = The Cochrane Database of Systematic Reviews | volume = 2006 | issue = 4 | pages = CD005546 | date = October 2006 | pmid = 17054264 | pmc = 8895451 | doi = 10.1002/14651858.CD005546.pub2 }}</ref><ref>{{cite journal | title = A significant sex--but not elective cesarean section--effect on mother-to-child transmission of hepatitis C virus infection | journal = The Journal of Infectious Diseases | volume = 192 | issue = 11 | pages = 1872–1879 | date = December 2005 | pmid = 16267757 | doi = 10.1086/497695 | doi-access = free | author1 = European Paediatric Hepatitis C Virus Network }}</ref>

===By characteristics of the mother===

====Caesarean delivery on maternal request====
{{main|Caesarean delivery on maternal request}}
Caesarean delivery on maternal request (CDMR) is a medically unnecessary caesarean section, where the conduct of a [[childbirth]] via a caesarean section is requested by the [[pregnancy|pregnant]] patient even though there is not a medical [[Indication (medicine)|indication]] to have the surgery.<ref name="NIH">{{cite journal | vauthors = NIH | title = National Institutes of Health state-of-the-science conference statement: Cesarean delivery on maternal request March 27-29, 2006 | journal = Obstetrics and Gynecology | volume = 107 | issue = 6 | pages = 1386–1397 | date = June 2006 | pmid = 16738168 | doi = 10.1097/00006250-200606000-00027 | url = http://consensus.nih.gov/2006/CesareanStatement_Final053106.pdf | url-status = dead | access-date = 30 December 2008 | archive-url = https://web.archive.org/web/20170118080344/https://consensus.nih.gov/2006/CesareanStatement_Final053106.pdf | archive-date = 18 January 2017 }}</ref> Systematic reviews have found no strong evidence about the impact of caesareans for nonmedical reasons.<ref name="NICE2011" /><ref name="Lavender&nbsp;— non-medical">{{cite journal | vauthors = Lavender T, Hofmeyr GJ, Neilson JP, Kingdon C, Gyte GM | title = Caesarean section for non-medical reasons at term | journal = The Cochrane Database of Systematic Reviews | volume = 2012 | issue = 3 | pages = CD004660 | date = March 2012 | pmid = 22419296 | pmc = 4171389 | doi = 10.1002/14651858.CD004660.pub3 }}</ref> Recommendations encourage counseling to identify the reasons for the request, addressing anxieties and information, and encouraging vaginal birth.<ref name="NICE2011" /><ref>{{cite web|url=http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Ethics/Elective-Surgery-and-Patient-Choice|title=Elective Surgery and Patient Choice – ACOG|archive-url=https://web.archive.org/web/20150925012637/https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Ethics/Elective-Surgery-and-Patient-Choice|archive-date=25 September 2015|url-status=live|access-date=4 October 2015}}</ref> Elective caesareans at 38 weeks in some studies showed increased health complications in the newborn. For this reason [[American Congress of Obstetricians and Gynecologists|ACOG]] and [[National Institute for Health and Care Excellence|NICE]] recommend that elective caesarean sections should not be scheduled before 39 weeks gestation unless there is a medical reason.<ref>{{cite journal | vauthors = Glavind J, Uldbjerg N | title = Elective cesarean delivery at 38 and 39 weeks: neonatal and maternal risks | journal = Current Opinion in Obstetrics & Gynecology | volume = 27 | issue = 2 | pages = 121–127 | date = April 2015 | pmid = 25689238 | doi = 10.1097/gco.0000000000000158 | s2cid = 32050828 }}</ref><ref name=":1">{{Cite web|url=https://www.nice.org.uk/guidance/CG132|title=Caesarean section {{!}} Guidance and guidelines {{!}} NICE|website=www.nice.org.uk|date=23 November 2011 |access-date=5 January 2019}}</ref><ref name="ACOG559"/> [[Caesarean section#By urgency|Planned caesarean section]]s may be scheduled earlier if there is a medical reason.<ref name=":1" />

====After previous caesarean====
{{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 a 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 [[Childbirth|birthing a baby]] vaginally after a previous baby has been delivered by caesarean section (surgically).<ref>{{cite web | vauthors = ((WebMD Editorial Contributors)) | veditors = Johnson TC | url = http://www.webmd.com/baby/tc/vaginal-birth-after-cesarean-vbac-overview | title = Vaginal Birth After Cesarean (VBAC) – Overview | archive-url = https://web.archive.org/web/20091230133854/http://www.webmd.com/baby/tc/vaginal-birth-after-cesarean-vbac-overview | archive-date=30 December 2009 | work = [[WebMD]] }}</ref> According to [[the American College of Obstetricians and Gynecologists]] (ACOG), successful VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies.<ref name="American Congress of Obstetricians and 450–63"/> According to the American Pregnancy Association, 90% of women who have undergone caesarean deliveries are candidates for VBAC.<ref name="americanpregnancy">{{cite web |url=http://www.americanpregnancy.org/labornbirth/vbac.html |title=Vaginal Birth after Cesarean (VBAC) |publisher=American Pregnancy Association |access-date=16 June 2012 |url-status=dead |archive-url=https://web.archive.org/web/20120621050450/http://www.americanpregnancy.org/labornbirth/vbac.html |archive-date=21 June 2012  }}</ref> 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.<ref name="americanpregnancy"/><ref name="mayoclinic">{{cite web | url = http://www.mayoclinic.com/health/vbac/VB99999 | title = Vaginal birth after C-section (VBAC) guide | archive-url = https://web.archive.org/web/20100312103525/http://www.mayoclinic.com/health/vbac/vb99999 | archive-date=12 March 2010 | work = [[Mayo Clinic]] }}</ref><ref>{{cite web |url=https://www.cdc.gov/nchs/data/databriefs/db35.htm#ref1 |title=NCHS Data Brief: Recent Trends in Cesarean Delivery in the United States Products |publisher=Centers for Disease Control and Prevention |date=March 2010 |access-date=16 June 2012 |url-status=live |archive-url=https://web.archive.org/web/20120517145002/http://www.cdc.gov/nchs/data/databriefs/db35.htm#ref1 |archive-date=17 May 2012  }}</ref>

====Twins====
For otherwise healthy twin pregnancies where both twins are head down a trial of vaginal delivery is recommended between 37 and 38 weeks.<ref name=NICE2011 /><ref name=Bis2013/> Vaginal delivery in this case does not worsen the outcome for either infant as compared with caesarean section.<ref name="Bis2013"/> There is controversy on the best method of delivery where the first twin is head first and the second is not.<ref name=Bis2013/> When the first twin is not head down at the point of labor starting, a caesarean section should be recommended.<ref name=Bis2013/> Although the second twin typically has a higher frequency of problems, it is unknown if a planned caesarean section affects this.<ref name=NICE2011 /> It is estimated that 75% of twin pregnancies in the United States were delivered by caesarean section in 2008.<ref name="pmid22015878">{{cite journal | vauthors = Lee HC, Gould JB, Boscardin WJ, El-Sayed YY, Blumenfeld YJ | title = Trends in cesarean delivery for twin births in the United States: 1995-2008 | journal = Obstetrics and Gynecology | volume = 118 | issue = 5 | pages = 1095–1101 | date = November 2011 | pmid = 22015878 | pmc = 3202294 | doi = 10.1097/AOG.0b013e3182318651 }}</ref>

====Breech birth====
{{main|Breech birth}}
A breech birth is the birth of a baby from a breech [[presentation (obstetrics)|presentation]], in which the baby exits the pelvis with the [[buttocks]] or [[foot|feet]] first as opposed to the normal [[cephalic presentation|head-first presentation]]. In breech presentation, fetal heart sounds are heard just above the umbilicus.

Babies are usually born head first. If the baby is in another position the birth may be complicated. In a 'breech presentation', the unborn baby is bottom-down instead of head-down. Babies born bottom-first are more likely to be harmed during a normal (vaginal) birth than those born head-first. For instance, the baby might not get enough oxygen during the birth. Having a planned caesarean may reduce these problems. A review looking at planned caesarean section for singleton breech presentation with planned vaginal birth, concludes that in the short term, births with a planned caesarean were safer for babies than vaginal births. Fewer babies died or were seriously hurt when they were born by caesarean. There was tentative evidence that children who were born by caesarean had more health problems at age two. Caesareans caused some short-term problems for mothers such as more abdominal pain. They also had some benefits, such as less urinary incontinence and less perineal pain.<ref>{{cite journal | vauthors = Hofmeyr GJ, Hannah M, Lawrie TA | title = Planned caesarean section for term breech delivery | journal = The Cochrane Database of Systematic Reviews | volume = 2015 | issue = 7 | pages = CD000166 | date = July 2015 | pmid = 26196961 | pmc = 6505736 | doi = 10.1002/14651858.CD000166.pub2 }}</ref>

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 [[childbirth|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 the practice of this important skill) and this training is carried out regularly to keep skills up to date.

====Resuscitative hysterotomy====
{{main|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 syndrome|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 before the limit of [[fetal viability]] if it is judged to be of benefit to the mother.

===Other ways, including the surgery technique===
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 [[sagittal plane|longitudinal]] midline incision on the uterus 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 labor 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 [[Urinary bladder|bladder]]. It results in less [[Bleeding|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 that has been used nearly globally since the 1990s. It was described by Michael Stark, the president of the New European Surgical Academy, at the time he was the director of [[Misgav Ladach]], a general hospital in Jerusalem. The method was presented during a FIGO conference in Montréal in 1994<ref>Stark M. Technique of cesarean section: Misgav Ladach method. In: Popkin DR, Peddle LJ (eds): Women's Health Today. Perspectives on current research and clinical practice. Proceedings of the XIV World Congress of Gynaecology and Obstetrics, Montreal. Parthenon Publishing Group, New York, 81–5</ref> 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 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. Many publications are showing the advantages over traditional caesarean section methods. There is also an increased risk of abruptio placentae and uterine rupture in subsequent pregnancies for women who underwent this method in prior deliveries.<ref name="pmid17904561">{{cite journal | vauthors = Nabhan AF | title = Long-term outcomes of two different surgical techniques for cesarean | journal = International Journal of Gynaecology and Obstetrics | volume = 100 | issue = 1 | pages = 69–75 | date = January 2008 | pmid = 17904561 | doi = 10.1016/j.ijgo.2007.07.011 | s2cid = 5847957 }}</ref><ref name="pmid22752598">{{cite journal | vauthors = Hudić I, Bujold E, Fatušić Z, Skokić F, Latifagić A, Kapidžić M, Fatušić J | title = The Misgav-Ladach method of cesarean section: a step forward in operative technique in obstetrics | journal = Archives of Gynecology and Obstetrics | volume = 286 | issue = 5 | pages = 1141–1146 | date = November 2012 | pmid = 22752598 | doi = 10.1007/s00404-012-2448-6 | s2cid = 809690 }}</ref>

Since 2015, the [[World Health Organization]] has endorsed the [[Robson classification]] as a holistic means of comparing childbirth rates between different settings, to allow more accurate comparison of caesarean section rates.<ref name="pmid26278843">{{cite journal | vauthors = ((World Health Organization Human Reproduction Programme)) | title = WHO Statement on caesarean section rates | journal = Reproductive Health Matters | volume = 23 | issue = 45 | pages = 149–150 | date = May 2015 | pmid = 26278843 | doi = 10.1016/j.rhm.2015.07.007 | hdl-access = free | s2cid = 40829330 | hdl = 11343/249912 | url = https://lirias.kuleuven.be/handle/123456789/532062 }}</ref>