Cesarian

Although Cesarian sections were done in Roman times, there isn't evidence that Julius Caesar was born through one. Indeed, they appeared to be done for mothers who died in childbirth as it was against the law to bury someone who was pregnant. In any case, the C-section has been described many times through history, but it isn't until the last century that its safety has really improved.

What interests me about C-sections is that its incidence is so high. The rate in the United States is about 30%, and it is even higher in some other countries. Why are we doing so many surgeries for childbirth? Part of it is self-sustaining; after one C-section, many patients elect to have future C-sections because of the risks associated with trial of labor after Cesarian (TOLAC). But it still strikes me that we are doing more C-sections than we need to be.

Of course I don't make that decision as an anesthesiologist; if an obstetrician calls a C-section, I prepare the patient for surgery. While the ideal technique is a single shot spinal - local anesthetic into the intrathecal space giving surgical numbness - we occasionally do a combined spinal-epidural technique and rarely, the general anesthetic.

One issue I see is that we don't have great monitors of the fetus during labor. While fetal bradycardia and nonreassuring decelerations worry the obstetricians and can lead to a stat section, most of those babies do great after delivery. We simply cannot differentiate between true fetal distress and false positives. And the legal environment doesn't help; it is easy to sue someone for not acting and having a poor neonatal outcome rather than acting, even if that meant unnecessary surgery. I also wonder how long someone ought to be laboring without progress before a C-section is called for arrest of descent. I'm not sure anyone really knows, and perhaps that is leading to the wide variation from country to country in the rate of C-sections.

Image of baby being delivered by Cesarian shown under Creative Commons Attribution Share-Alike License, from Wikipedia.