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Cesarean Section - Its History, Risks, and Diastasis Recti

baby being born through cesarean section

This week, I have received requests from our readers to write about cesarean sections. It is often a controversial issue where opinions diverge, especially when it comes to whether a woman should have the right to decide whether or not to have a cesarean section.

I will now try to describe my standpoint after having performed over 5000 cesarean sections during my 35-year professional career. Sometimes I think of it as having delivered a small community through this method.

History of Cesarean Section

Firstly, the question arises: why is it called a cesarean section?

Initially, cesarean sections were performed without any intention to save either the woman or the baby. For religious reasons, if the mother had passed away, the baby would be separated from her before the burial.

This separation was to ensure that they would each have their own grave.

In the Roman Empire, there was a law stating that no pregnant woman should be buried until the fetus was taken out of her abdomen.

Later, the operation was named "sectio cesarea." It is derived from a legend that Julius Caesar was born (alive) by cesarean section. So, the name is said to originate from Julius Caesar.

Other hypotheses suggest that the word comes from the Latin verb "caedare," which means "to cut".

The first successful operation on a living woman, aside from Julius Caesar, was described in the early 17th century. However, cesarean sections remained risky until the end of the 19th century. It was a feared operation for a long time.

Infection and bleeding were the most common causes of both maternal and infant mortality. Even today, there are parts of the world where women are afraid of undergoing a cesarean section because they know it can go wrong.

At the end of the 19th century, the importance of carefully stitching up the uterus was recognized. Up until then, it wasn't something that had been done.

Today, cesarean section is a relatively safe operation, thanks to improved techniques and better protection against bacteria.


Different Incisions and Types of Cesarean Section

In my 35-year professional career, having performed over 5000 surgeries, I remember as a young doctor using different types of incisions.

  • In emergency operations, a "midline incision" was used,

  • while planned and calm operations utilized a "bikini incision".

The idea at the time was that midline incisions were faster. However, that has changed, and today, almost all cesarean sections are performed using a bikini incision, regardless of the urgency.

If a woman has had multiple previous surgeries and the area is highly scarred, a midline incision can still be made.

scar from a Cesarean Section

There are three types of cesarean sections (as defined in Swedish healthcare):

  1. Planned cesarean section: The operation is scheduled for a specific date before the woman goes into labor.

  2. Emergency cesarean section: It is performed if there are complications for the mother or baby during an ongoing delivery. In emergency cases, the goal is usually to deliver the baby within a couple of hours.

  3. Immediate cesarean section (formerly referred to as "urgent cesarean section" or "catastrophic cesarean section"): This is a variant of emergency cesarean section performed when there is an urgent danger to the mother or baby, and it is a matter of life or death. In such cases, the baby should be delivered within a few minutes.

Quality Indicator

The number of cesarean sections performed in a country is often used as a quality indicator for maternity care.

As a reference for high and low levels, there was a recommendation from the WHO in 1985 stating that the frequency should be between 10-15%.

However, the recommendation was later withdrawn, and it was vaguely stated that: "There is no empirical evidence for an optimal rate of cesarean sections. What matters is that all women who need a cesarean section get one."

If we look at different countries, the rate of cesarean sections varies greatly

Scandinavia has the lowest frequency in the world, and at the same time, we have good outcomes for both mother and baby.

  • The Nordic countries all have a frequency of just under 20%.

  • In comparison, countries like the USA or England have rates above or around 30%.

  • Brazil and Turkey are among the highest, with rates exceeding 50% in many areas.

I once visited a maternity clinic in Istanbul, Turkey, where they performed cesarean sections on 90% of the women. Those who were not operated on managed to give birth before anyone operated on them.

When inquired about the reasons, it turned out that most doctors had their own private clinics where they had to go in the afternoon. They wanted to have "cut" everyone before then. This seems like a strange indication for surgery.

the nordic flags

How is it done practically?

Today, we use an incision known as the Joel-Cohen incision. It describes the location on the abdomen where the cut begins.

The abdomen consists of multiple layers.

The incision starts with the skin, then the fat layer, followed by the fascia. After passing through these and several muscles, we reach the abdominal membrane.

Once inside the abdominal cavity, we open the uterus (which is a large muscle) and deliver the baby.

We also remove the amniotic fluid and placenta. Afterward, we stitch the muscle (the uterus) and all the layers back together.

The Joel-Cohen incision

The Joel-Cohen incision has been further developed by a German obstetrician named Michael Stark. His technique is considered optimal in terms of providing the least discomfort and pain afterward.

I once sat next to this man at a dinner. Unfortunately, I had no idea who he was, and he was very disappointed in me for not recognizing him. Sorry!

In any case, he is one of those whose name has made an impact.


The risks of a cesarean section

Why are we so negative about performing cesarean sections then?

Why can't each woman/family decide for themselves?

Why don't we recommend everyone to give birth by C-section?

The simple answer is that this is a major abdominal surgery associated with a number of risks and complications.

That's why, as a doctor with my experience, I'm there.

Of course, a cesarean section should be performed if needed, no doubt about it, but for non-medical reasons? I'm not entirely sure about that.

One of the major risks is bleeding. Over the years, I have witnessed women who have bled a lot! Up to 20 liters!

Read the last sentence again.

As a pregnant woman, you have a blood volume of about 5 liters. That means it is replaced 4 times during the operation. It requires our blood banks to be well-stocked. The risk of infection is also always present in the background.

Then there are studies showing how important it is for the baby to pass through the mother's microbiome. You probably remember my previous posts about the flora in the intestines.

If that doesn't happen, the risk of allergies and type 1 diabetes in the child increases significantly. Is it worth it?

It is also common for the baby to experience what we call "respiratory distress" during planned cesarean sections. This means the baby is not quite "ready to start breathing on its own." And they end up in the neonatal clinic because of it.

So, is it worth it? Are we being too eager? Although respiratory distress is almost always temporary, it's still a concern.

Furthermore, there is a high risk that the next pregnancy will be complicated because there is a scar in the uterus.

That's why I'm hesitant about non-medically indicated cesarean sections. The risks are too great. That's why, as a doctor, I'm there to advise the woman/couple for the best.

I don't say no just because I want to, but because I have seen things go wrong. It's very rare, but it happens.


Muscle Diastasis

As a young doctor, I used to suture the large abdominal muscle with one or two stitches during cesarean sections.

The gap between the two halves of the abdominal muscle is called "muscle diastasis." It occurs when the abdominal muscles move sideways as the belly grows during pregnancy.

Then we stopped doing these stitches because women experienced significant pain afterward.

abdominal muscles

The other day, I suddenly came across an advertisement from a private company offering surgery for separated abdominal muscles after pregnancy! At a high cost, of course!

This is what was written in the medical journal Läkartidningen in 2018:

A remaining separation of the large abdominal muscles in women after pregnancy, especially after cesarean sections, is common and can result in impaired core muscle function and significantly reduced quality of life for some patients. However, the scientific evidence for choosing treatment is weak (!).

Physical therapy with core stabilizing exercises should be the first choice. Surgical correction may be an option for a small group with more severe symptoms when physical therapy has not been effective.

However, there is no national consensus regarding the indication for surgery, which means there are significant regional differences in accessibility".

My question is, should we offer this to women at all? At a high cost?

After all, it is an operation. I'm not sure what I think about it. Making money from this doesn't feel right in any case.

One never ceases to wonder about people's ingenuity when it comes to making a lot of money.

Do you think I am provocative? Perhaps a bit?

/Doctor Eva


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