Birth - Caesarean Delivery

From Embryology


Birth caesarean.jpg

The term "caesarean" comes from the historic description of Julius Ceasar's birth, though probably ficticious as his mother Aurelia survived his birth. The procedure involves surgically cutting skin, abdominal wall and uterus to allow abdominal delivery.

The rate of caesarean delivery compared to normal vaginal birth is variable between countries (12-25%, 20% of all births in Australia) and increasing, particularly in older women. There are a number of different explanations as to why this is occuring, including maternal or fetal complications of either development or delivery.

Importantly this is a maternal surgical procedure which requires time for recovery and there are several studies that have looked also into the effects of caesarean delivery on potential future normal vaginal births.

Please note the UK/Australian "Caesarean" versus USA "Cesarean" spelling differences. Clinically, cesarean section may also be abbreviated to c-section or C/S.

Video Webcast: Hartford Hospital Cesarean Childbirth (September 23rd, 2005)

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Some Recent Findings

  • Could Revision of the Embryology Influence Our Cesarean Delivery Technique[1] "Until today, there is no standardized Cesarean Section method and many variations exist. The main variations concern the type of abdominal incision, usage of abdominal packs, suturing the uterus in one or two layers, and suturing the peritoneal layers or leaving them open. One of the questions is the optimal location of opening the uterus. Recently, omission of the bladder flap was recommended. The anatomy and histology as results from the embryological knowledge might help to solve this question. The working thesis is that the higher the incision is done, the more damage to muscle tissue can take place contrary to incision in the lower segment, where fibrous tissue prevails. In this perspective, a call for participation in a two-armed prospective study is included, which could result in an optimal, evidence-based Cesarean Section for universal use."
  • Does the presence of a Caesarean section scar affect implantation site and early pregnancy outcome in women attending an early pregnancy (12 weeks gestation) assessment unit?[2]"Implantation was most frequently posterior (53%) in the CS group and fundal in the non-CS group (42%). Gestation sac implantation was 8.7 mm lower in the CS group. Presenting complaints differed in women with and without a previous CS (P = 0.0009). More frequent vaginal bleeding yet no clearly increased spontaneous abortion rates were noted in the CS group compared with the non-CS group. A weakness of the study is the lack of a reference technique to verify the location of implantation."
  • NIH Consensus Development Conference Draft Statement on Vaginal Birth After Cesarean: New Insights[3]
  • WHO global survey on maternal and perinatal health in Latin America: classifying caesarean sections[4]"Caesarean section (CS) rates have increased significantly worldwide during the last decades but in particular in middle and high income countries. In several countries of Latin America, the proportion of deliveries by CS is approaching 40% at national level. In United States, the CS rate in 2006 was 31.1%, and the latest estimates for several European countries are also above 30%. This steady increase has fuelled the debate over acceptable rates of CS and the risk-benefit analysis in ensuring optimum maternal and perinatal outcomes in different populations with different access to health resources."
  • Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08.[5]"To improve maternal and perinatal outcomes, caesarean section should be done only when there is a medical indication."
  • Trends and determinants of caesarean sections births in Queensland, 1997-2006.[6] "In Queensland, in 2006, CS rates were 26.9 and 48.0% among public and private sector patients, respectively. ....The CS rate in Queensland in 2006 was higher than in any other Australian state. The increase in Queensland's CS rates can be attributed to both the rising number of primary caesarean births and the rising number of repeat caesareans."
  • Long-term maternal morbidity associated with repeat cesarean delivery[7] "Concern regarding the association between cesarean delivery and long-term maternal morbidity is growing as the rate of cesarean delivery continues to increase. Observational evidence suggests that the risk of morbidity increases with increasing number of cesarean deliveries. The dominant maternal risk in subsequent pregnancies is placenta accreta spectrum disorder and its associated complications. A history of multiple cesarean deliveries is the major risk factor for this condition. Pregnancies following cesarean delivery also have increased risk for other types of abnormal placentation, reduced fetal growth, preterm birth, and possibly stillbirth."
More recent papers
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This table shows an automated computer PubMed search using the listed sub-heading term.

  • Therefore the list of references do not reflect any editorial selection of material based on content or relevance.
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References listed on the rest of the content page and the associated discussion page (listed under the publication year sub-headings) do include some editorial selection based upon both relevance and availability.

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Search term: Caesarean Birth

Bruna Dias Alonso, Flora Maria Barbosa da Silva, Maria do Rosário Dias de Oliveira Latorre, Carmen Simone Grilo Diniz, Debra Bick Caesarean birth rates in public and privately funded hospitals: a cross-sectional study. Rev Saude Publica: 2017, 51;101 PubMed 29166449

Keila Cristina Mascarello, Bernardo Lessa Horta, Mariângela Freitas Silveira Maternal complications and cesarean section without indication: systematic review and meta-analysis. Rev Saude Publica: 2017, 51;105 PubMed 29166440

Anita Pettersen-Dahl, Gulim Murzakanova, Leiv Sandvik, Katariina Laine Maternal body mass index as a predictor for delivery method. Acta Obstet Gynecol Scand: 2017; PubMed 29164597

Lingyu Luo, Hao Zen, Hongrong Xu, Yin Zhu, Pi Liu, Liang Xia, Wenhua He, Nonghua Lv Clinical characteristics of acute pancreatitis in pregnancy: experience based on 121 cases. Arch. Gynecol. Obstet.: 2017; PubMed 29164335

Alessandra Paparelli, Keiko Iwata, Tomoyasu Wakuda, Conrad Iyegbe, Robin M Murray, Nori Takei Perinatal Asphyxia in Rat Alters Expression of Novel Schizophrenia Risk Genes. Front Mol Neurosci: 2017, 10;341 PubMed 29163023

USA Caesarean Rate by Gestational Age

Latest 2013 data[8]

USA Cesarean Births 2013.jpg USA cesarean rate by gestational age.jpg

Trial of Labor

Trial of Labor (TOL) or trial of labor after cesarean (TOLAC) is a term used in relation to the offer for a normal vaginal delivery after a previous cesarean delivery. The resulting birth is described as vaginal birth after cesarean (VBAC), in recent years this option has been decreasing while the general caesarian rate increases.

USA data - Vaginal birth after cesarean.jpg

Positive Factors

(increased likelihood of successful VBAC)

  • Maternal age <40 years
  • Prior vaginal delivery (particularly prior successful VBAC)
  • Favorable cervical factors
  • Presence of spontaneous labor
  • Nonrecurrent indication that was present for prior cesarean delivery

Negative Factors

(decreased likelihood of successful VBAC)

  • Increased number of prior cesarean deliveries
  • Gestational age >40 weeks
  • Birth weight >4,000 g
  • Induction or augmentation of labor

Links: USA Guideline (2005) | NIH Consensus - Vaginal Birth After Cesarean (2010)

Caesarean Classification

Distribution of the 73 articles on Robson's classification according to country of origin.[9]

There is no standard clinical classification system for caesarean delivery, with at least 27 classifications identified.[10] Recent studies of data from several countries[9] suggests that the 10 group classification system (Robson Classification[11]), or a modification of this system, may be the current best applied system.

Robson Classification

The Robson's classification[11] (10 group classification) is based on several simple obstetrical parameters; parity, previous CS, gestational age, onset of labour, fetal presentation and the number of foetuses. The classification categories are totally inclusive and also mutually exclusive.

Links: WHO Robson Classification


  1. Michael Stark, Ospan Mynbaev, Yuri Vassilevski, Patrick Rozenberg Could Revision of the Embryology Influence Our Cesarean Delivery Technique: Towards an Optimized Cesarean Delivery for Universal Use. AJP Rep: 2016, 6(3);e352-e354 PubMed 28078171
  2. O Naji, L Wynants, A Smith, Y Abdallah, S Saso, C Stalder, S Van Huffel, S Ghaem-Maghami, B Van Calster, D Timmerman, T Bourne Does the presence of a Caesarean section scar affect implantation site and early pregnancy outcome in women attending an early pregnancy assessment unit? Hum. Reprod.: 2013, 28(6);1489-96 PubMed 23585560
  3. F Gary Cunningham, Shrikant I Bangdiwala, Sarah S Brown, Thomas Michael Dean, Marilynn Frederiksen, Carol J Rowland Hogue, Tekoa King, Emily Spencer Lukacz, Laurence B McCullough, Wanda Nicholson, Nancy Frances Petit, Jeffrey Lynn Probstfield, Adele C Viguera, Cynthia A Wong, Sheila Cohen Zimmet NIH consensus development conference draft statement on vaginal birth after cesarean: new insights. NIH Consens State Sci Statements: 2010, 27(3);1-42 PubMed 20228855
  4. Ana P Betrán, A Metin Gulmezoglu, Michael Robson, Mario Merialdi, João P Souza, Daniel Wojdyla, Mariana Widmer, Guillermo Carroli, Maria R Torloni, Ana Langer, Alberto Narváez, Alejandro Velasco, Anibal Faúndes, Arnaldo Acosta, Eliette Valladares, Mariana Romero, Nelly Zavaleta, Sofia Reynoso, Vicente Bataglia WHO global survey on maternal and perinatal health in Latin America: classifying caesarean sections. Reprod Health: 2009, 6;18 PubMed 19874598
  5. Pisake Lumbiganon, Malinee Laopaiboon, A Metin Gülmezoglu, João Paulo Souza, Surasak Taneepanichskul, Pang Ruyan, Deepika Eranjanie Attygalle, Naveen Shrestha, Rintaro Mori, Duc Hinh Nguyen, Thi Bang Hoang, Tung Rathavy, Kang Chuyun, Kannitha Cheang, Mario Festin, Venus Udomprasertgul, Maria Julieta V Germar, Gao Yanqiu, Malabika Roy, Guillermo Carroli, Katherine Ba-Thike, Ekaterina Filatova, José Villar, World Health Organization Global Survey on Maternal and Perinatal Health Research Group Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08. Lancet: 2010, 375(9713);490-9 PubMed 20071021
  6. Stuart Howell, Trisha Johnston, Sue-Lynne Macleod Trends and determinants of caesarean sections births in Queensland, 1997-2006. Aust N Z J Obstet Gynaecol: 2009, 49(6);606-11 PubMed 20070708
  7. Erin A S Clark, Robert M Silver Long-term maternal morbidity associated with repeat cesarean delivery. Am. J. Obstet. Gynecol.: 2011, 205(6 Suppl);S2-10 PubMed 22114995
  8. Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data for 2013. National vital statistics reports; vol 64 no 1. Hyattsville, MD: National Center for Health Statistics. 2015.
  9. 9.0 9.1 Ana Pilar Betrán, Nadia Vindevoghel, Joao Paulo Souza, A Metin Gülmezoglu, Maria Regina Torloni A systematic review of the Robson classification for caesarean section: what works, doesn't work and how to improve it. PLoS ONE: 2014, 9(6);e97769 PubMed 24892928 | PLoS One.
  10. Maria Regina Torloni, Ana Pilar Betran, Joao Paulo Souza, Mariana Widmer, Tomas Allen, Metin Gulmezoglu, Mario Merialdi Classifications for cesarean section: a systematic review. PLoS ONE: 2011, 6(1);e14566 PubMed 21283801 | PLoS One.
  11. 11.0 11.1 M S Robson Can we reduce the caesarean section rate? Best Pract Res Clin Obstet Gynaecol: 2001, 15(1);179-94 PubMed 11359322


Caesarean Section NICE Clinical Guidelines, No. 13 National Collaborating Centre for Women's and Children's Health (UK). London: RCOG Press; 2004 Apr. ISBN-10: 1-904752-02-0 Bookshelf


D Horey, J Weaver, H Russell Information for pregnant women about caesarean birth. Cochrane Database Syst Rev: 2004, (1);CD003858 PubMed 14974041


Jill Milne, Amiram Gafni, Diane Lu, Stephen Wood, Reg Sauve, Sue Ross Developing and pre-testing a decision board to facilitate informed choice about delivery approach in uncomplicated pregnancy. BMC Pregnancy Childbirth: 2009, 9;50 PubMed 19874628

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Cite this page: Hill, M.A. 2017 Embryology Birth - Caesarean Delivery. Retrieved November 24, 2017, from

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