Cesarean section

Definition

A cesarean section (also referred to as c-section) is the birth of a fetus accomplished by performing a surgical incision through the maternal abdomen and uterus. It is one of the oldest surgical procedures known throughout history.

Purpose

Although Healthy People 2010 established a goal of a 15 percent rate for c-sections in the United States, the ideal rate has not been established. As of 2004, the average c-section rate is one out of every four births or approximately 26 percent of all births. A c-section allows safe and quick delivery of a baby when a vaginal delivery is not possible. The surgery is performed in the presence of a variety of maternal and fetal conditions with the most commonly accepted indications being complete placenta previa, cephalopelvic disproportion (CPD), placental abruption, active genital herpes, umbilical cord prolapse, failure to progress in labor or dystocia, proven nonreassuring fetal status, and benign and malignant tumors that obstruct the birth canal. Indications that are more controversial include breech presentation, previous c-section, major congenital anomalies, cervical cerclage, and severe Rh isoimmunization. C-sections have a higher maternal mortality rate than vaginal births with approximately 5.8 women per 100,000 live births dying, and half of these deaths are ascribed to the operation and a coexisting medical condition. Perinatal morbidity is associated with infections, reactions to anesthesia agents, blood clots, and bleeding.

Description

According to the United States Public Health Service, 35 percent of all c-sections are performed because the woman has had a previous c-section. The skin incision for a c-section is either transverse (Pfannenstiel) or vertical and does not indicate the type of incision made into the uterus. "Once a cesarean, always a cesarean," is a rule that originated with the classical, vertical uterine incision. It was believed that the resulting scar weakened the uterus wall and was at risk of rupture in subsequent deliveries. As of 2004, the incision is almost always made horizontally across the lower uterine segment, called a low transverse incision. This results in reduced blood loss and a decreased chance of rupture. This kind of incision allows many women to have a vaginal birth after a cesarean (VBAC).

Failure to progress and/or dystocia is the second most common reason for a c-section and represents about 30 percent of all cases. Uterine contractions may be weak or irregular, the cervix may not be dilating, or the mother's pelvic structure may not allow adequate passage for birth. When the baby's head is too large to fit through the pelvis, the condition is called cephalopelvic disproportion (CPD). Failure to progress, however, can only be diagnosed with documentation of adequate contraction strength. The force of the contractions can be measured with an intrauterine pressure catheter (IUPC), which is a catheter that can be placed through the cervix into the uterus to measure uterine pressure during labor. Calculation of this force is determined by subtracting the baseline (resting) pressure from the peak pressure recorded for all contractions in a ten-minute period. This pressure calculation results in a force termed Montevideo units. A minimum of 200 Montevideo units are required before the forces of labor can be considered adequate. If the Montevideo units are less than this ten-minute sum and the fetal heart rate is reassuring, augmentation of labor with pitocin may be necessary.

Breech presentation occurs in about 3 percent of all births, and approximately 12 percent of c-sections are performed to deliver a baby in a breech presentation: buttocks or feet first. Breech presentations were still delivered vaginally in the 1970s, but with the advent of the malpractice climate, many doctors shied away from this practice, opting to perform a c-section. As a result, physicians who were being trained during that time period never learned how to manage a breech vaginal delivery. There was some change in this approach in the 1990s, and doctors are once again learning how to manage this situation; however, it is still uncertain whether this knowledge will be used in their practice.

Fetal distress or the more appropriate term, nonreassuring fetal heart rate, accounts for almost 9 percent of c-sections. With the introduction of electronic fetal monitoring (EFM) in the 1970s, doctors had more information for assessing fetal well-being. It was assumed that fetal monitoring would transmit signals of distress, thus, the EFM tracing became a legal document. There is still considerable debate as to what a non-reassuring FHR really is, but there are other parameters available to assist in this interpretation. When a fetus experiences stress, (oxygen deprivation) in utero, it may pass meconium (feces) into the amniotic fluid. The appearance of meconium in the fluid along with a questionable EFM tracing may indicate that a fetus is becoming compromised. At this point, if a woman is in early labor, a c-section may have to be performed. If, however, she is close to delivery, a vaginal delivery is often quicker. Oxygen deprivation may also be determined by testing the pH of a blood sample taken from the baby's scalp: a pH of 7.25-7.35 is normal; between 7.2 and 7.25 is suspicious; and below 7.2 is a sign of trouble. If the sample is equivocal, it can be repeated every 20 to 30 minutes.

The remaining 14 percent of c-sections occur secondary to other emergency situations, including the following:

• Umbilical cord prolapse: This situation occurs when the cord is the presenting part from the vagina. It becomes compressed and cuts off blood flow to the baby. The birth attendant must insert a hand into the vagina and relieve pressure on the cord until a c-section is performed.
• Placental abruption: The placenta separates from the uterine wall before the baby is born. If it is a complete abruption, the baby's blood flow will be cut off completely. The mother experiences severe pain , possible bleeding, and her abdomen feels rock hard. This situation demands an immediate c-section. Partial abruptions can occur without endangering the mother or the baby, but they need to be closely monitored. The risk of placental abruption is higher in multiple births and in women with high blood pressure.
• Placenta previa: With a complete previa, the placenta covers the cervix completely, and the mother may experience painless bleeding. With a complete previa, a c-section is mandatory as cervical dilation would cause bleeding. The baby is often in a transverse position in this case, which means it is lying horizontally across the pelvis. Women with partial previas will usually need a c-section due to bleeding problems, but those with marginal previas can often deliver vaginally.
• Active genital herpes: Any active herpetic lesions in the vaginal area can infect the baby as it passes through the birth canal. This is especially true for those with a primary outbreak, a first-time exposure.
• Mother's health status: A c-section may be necessary in women with pre-existing diseases, such as diabetes, hypertension , pregnancy induced hypertension (preeclampsia), autoimmune diseases such as lupus erythematosus, and blood incompatibilities. Each case must be evaluated on an individual basis in these instances to achieve the optimal outcome for baby and mother.

Precautions

There are some precautions any pregnant woman can follow to enhance her chances of preventing a c-section. These include the following:

• She should check her doctor's c-section rate to see if it is unnecessarily high. She can ask what his/her rate is and verify it by checking with the labor and delivery nurses at the hospital or with a childbirth educator.
• She should not stay on her back during labor. She can walk, rock, or use a hot shower or whirlpool.
• From the beginning, she should discuss with her doctor that she wants to avoid having a c-section if at all possible and enlist his opinion on how to achieve it.
• Studies show that women who go to the hospital early have a higher c-section rate than those who do not. Therefore, when labor starts, the woman should stay home for as long as she safely can. She should not go in if contractions are further apart than four to five minutes.
• She should use a midwife since studies show that they have a higher percentage of natural childbirths without surgical intervention than obstetricians do.
• She should hire a doula to assist during labor birth. Doulas have a lower c-section rate and can offer massage, different positions, and support alternatives during the difficult phases of labor.
• She should gather as much information as possible on hospital policies to educate herself and then discuss this information with her doctor or midwife. She should keep an open mind and stay informed.

Preparation

There is no perfect anesthesia for a c-section because every choice has its advantages and disadvantages. When a c-section becomes necessary and if it is not an emergency, the mother and her significant other should take part in the choice of anesthetic by being informed of risks and side effects. The anesthesia is usually a regional anesthetic (epidural or spinal), which makes her numb from below her breasts to her toes. In some cases, a general anesthetic will be administered if the regional does not work or if it is an emergency c-section. Every effort should be made to include the significant other in the preparations and recovery as well as the surgery if at all possible. An informed consent needs to be signed, and the physician should explain the surgery at that time. The mother may already have an intravenous (IV) line of fluid running into a vein in her arm. A catheter is inserted into her bladder to keep it drained and out of the way during surgery and the upper pubic area is usually shaved. Antacids are frequently administered to reduce the likelihood of damage to the lungs should aspiration of gastric contents occur. The abdominal area is then scrubbed and painted with betadine or another antiseptic solution. Drapes are placed over the surgical area to block a direct view of the procedure.

The type of skin incision, transverse or vertical, is determined by time factor, preference of mother, or physician preference. Two major locations of uterine incisions are the lower uterine segment and the upper segment of the body of the uterus (classical incision). The most common lower uterine segment incision is a transverse incision because the lower segment is the thinnest part of the pregnant uterus and involves less blood loss. It is also easier to repair, heals well, is less likely to rupture during subsequent pregnancies and makes it possible for a woman to attempt a vaginal delivery in the future. The classical incision provides a larger opening than a low transverse incision and is used in emergency situations, such as placenta previa, preterm and macrosomic fetuses, abnormal presentation, and multiple births. With the classical incision, there is more bleeding and a greater risk of abdominal infection. This incision also creates a weaker scar, which places the woman at risk for uterine rupture in subsequent pregnancies.

Once the uterus is opened, the amniotic sac is ruptured and the baby is delivered. The time from the initial incision to birth is typically five to ten minutes. The umbilical cord is clamped and cut, and the newborn is given to the nursery personnel for evaluation. Cord blood is normally obtained for analysis of the infant's blood type and pH. The placenta is removed from the mother and her uterus is closed with suture. The abdominal area may be closed with suture or surgical staple. The time from birth through suturing may take 30 to 40 minutes. The entire surgical procedure may be performed in less than one hour. Physical contact or holding of the newborn may take place briefly while the mother is on the operating table if the baby is stable. The significant other can go with the baby to the nursery for the remainder of the operation.

Aftercare

Immediate postpartal care after a c-section is similar to post-operative care with the exception of palpating the fundus (top of the uterus) for firmness. If an epidural or spinal were used, Duramorph (a pain medication similar to morphine) is often administered through these catheters just prior to completion of surgery. It does very well in controlling pain but may cause itching , which can be managed. During recovery the mother is encouraged to turn, cough , and deep breathe to keep her lungs clear, and the neonate is usually brought to the mother to breastfeed if she so desires. The mother will be encouraged to get out of bed about eight to 24 hours after surgery. Walking stimulates the circulation to avoid formation of blood clots and promotes bowel movement. Once discharged home, the mother should limit stair climbing to once a day, and she should avoid lifting anything heavier than the baby. It is important to nap as often as the baby does and make arrangements for help with the housework, meals, and care of other children. Driving may be resumed after two weeks, although some doctors recommend waiting for six weeks, which is the typical recovery period from major surgery.

Risks

The maternal death rate for c-section is less than 0.02 percent (5.8 per 100,000 live births), but that is four times the maternal death rate associated with vaginal delivery. The mother is at risk for increased bleeding from two incision sites and a c-section usually has twice as much blood loss as a vaginal delivery during surgery. Complications occur in less than 10 percent of cases, but these complications can include an infection of the incision, urinary tract, or tissue lining the uterus (endometritis). Less commonly, injury can occur to the surrounding organs, i.e., the bladder and bowel.

Normal results

The after-effects of a c-section vary, depending on the woman's age, physical fitness, and overall health. Following this procedure, a woman commonly experiences gas pains, incision pain, and uterine contractions, which are also common with vaginal delivery. The hospital stay may be three to four days. Breastfeeding the baby is encouraged, taking care that it is in a position that keeps the baby from resting on the mother's incision. As the woman heals, she may gradually increase appropriate exercises to regain abdominal tone. Full recovery may be seen in four to six weeks.

The prognosis for a successful vaginal birth after a cesarean (VBAC) may be at least 75 percent, especially when the c-section involved a low transverse incision in the uterus, and there were no complications during or after delivery.

Of the hundreds of thousands of women in the United States who undergo a c-section each year, about 500 die from serious infections, hemorrhaging, or other complications. These deaths may be related to the health conditions that made the operation necessary and not simply to the operation itself.

Parental concerns

Undergoing a c-section may inflict psychological distress on the mother, beyond hormonal mood swings and postpartum depression. The woman may feel disappointment and a sense of failure for not experiencing a vaginal delivery. She may feel isolated if the father or birthing coach is not with her in the operating room or if she is treated by an unfamiliar doctor rather than by her own doctor or midwife. She may feel helpless from a loss of control over labor and delivery with no opportunity to actively participate. To overcome these feelings, the woman needs to understand why the c-section was crucial. It is important that she be able to verbalize an understanding that she could not control the events that made the c-section necessary and recognize the importance of preserving the health and safety of both herself and her child. Women who undergo a c-section should be encouraged to share their feelings with others. Hospitals can often recommend support groups for such mothers. Women should also be encouraged to seek professional help if negative emotions persist.

KEY TERMS

Breech presentation —The condition in which the baby enters the birth canal with its buttocks or feet first.

Cephalopelvic disproportion —The condition in which the baby's head is too large to fit through the mother's pelvis.

Cervical cerclage —A procedure in which the cervix of the uterus is sewn closed, it is used in cases when the cervix starts to dilate too early in a pregnancy to allow the birth of a healthy baby.

Doula —A doula is someone who undergoes special training to enable them to support women during childbirth and into the postpartum period.

Dystocia —Failure to progress in labor, either because the cervix will not dilate (expand) further or because the head does not descend through the mother's pelvis after full dilation of the cervix.

Genital herpes —A life-long, recurrent sexually transmitted infection caused by the herpes simplex virus (HSV).

Perinatal —Referring to the period of time surrounding an infant's birth, from the last two months of pregnancy through the first 28 days of life.

Pitocin —A synthetic hormone that produces uterine contractions.

Placenta previa —A condition in which the placenta totally or partially covers the cervix, preventing vaginal delivery.

Placental abruption —An abnormal separation of the placenta from the uterus before the birth of the baby, with subsequent heavy uterine bleeding. Normally, the baby is born first and then the placenta is delivered within a half hour.

Postpartal —The six-week period following childbirth.

Rh blood incompatibility —Incompatibility between the blood of a mother and her baby due the absence of the Rh antigen in the red blood cells of one and its presence in the red blood cells of the other.

Umbilical cord prolapse —A birth situation in which the umbilical cord, the structure that connects the placenta to the umbilicus of the fetus to deliver oxygen and nutrients, falls out of the uterus and becomes compressed, thus preventing the delivery of oxygen.

See also Apgar testing; Electronic fetal monitoring.

Resources

BOOKS

Olds, Sally et al. Maternal-Newborn Nursing & Women's Health Care, 7th ed. Saddle River, NJ: Prentice Hall, 2004.

ORGANIZATIONS

Association of Women's Health, Obstetric and Neonatal Nursing. 2000 L Street, NW, Suite 740, Washington, DC 20036. Web site: <www.awhonn.org>.

International Childbirth Education Association Inc. (ICEA). PO Box 20048, Minneapolis, MN 55420. Web site: <www.icea.org/info.htm>.

WEB SITES

"Cesarean Section." MedlinePlus. Available online at <www.nlm.nih.gov/medlineplus/cesareansection.html> (accessed December 7, 2004).

"Cesarean Section Homepage." Childbirth. Available online at <www.childbirth.org/section/section.html> (accessed December 7, 2004).

"C-Section." March of Dimes. Available online at <www.marchofdimes.com/pnhec/240_1031.asp> (accessed December 7, 2004).

Linda K. Bennington, RNC, MSN, CNS

Cesarean section

Definition

A cesarean section is a surgical procedure in which incisions are made through a woman's abdomen and uterus to deliver her baby.

Purpose

Cesarean sections, also called c-sections or cesarean deliveries, are performed whenever abnormal conditions complicate labor and vaginal delivery, threatening the life or health of the mother or the baby. Dystocia, or difficult labor, is the other common cause of c-sections. The procedure is performed in the United States on nearly one of every four babies delivered—more than 900,000 babies each year. The procedure is often used in cases where the mother has had a previous c-section.

The most common reason that a cesarean section is performed (in 35% of all cases, according to the United States Public Health Service) is the woman has had a previous c-section. The "once a cesarean, always a cesarean" rule originated when the uterine incision was made vertically (termed a "classical incision"); the resulting scar was weak and had a risk of rupturing in subsequent deliveries. Today, the incision is almost always made horizontally across the lower end of the uterus (called a low transverse incision), resulting in reduced blood loss and a decreased chance of rupture. This kind of incision allows many women to have a vaginal birth after a cesarean (VBAC).

The second most common reason that a c-section is performed (in 30% of all cases) is difficult childbirth due to non-progressive labor (dystocia). Difficult labor is commonly caused by one of the three following conditions: abnormalities in the mother's birth canal; abnormalities in the position of the fetus; or abnormalities in the labor, including weak or infrequent contractions. The mother's pelvic structure may not allow adequate passage for birth. When the baby's head is too large to fit through the pelvis, the condition is called cephalopelvic disproportion (CPD).

Another 12% of c-sections are performed to deliver a baby in a breech presentation (buttocks or feet first). Breech presentation is found in about 3% of all births.

In 9% of all cases, c-sections are performed in response to fetal distress, which refers to any situation that threatens the baby such as the umbilical cord wrapped around the baby's neck. This may appear on the fetal heart monitor as an abnormal heart rate or rhythm. Fetal brain damage can result from oxygen deprivation. Fetal distress is often related to abnormalities in the position of the fetus or abnormalities in the birth canal, causing reduced blood flow through the placenta.

The remaining 14% of c-sections are indicated by other serious factors. One is prolapse of the umbilical cord: the cord is pushed into the vagina ahead of the baby and becomes compressed, cutting off blood flow to the baby. Another is "placental abruption," whereby the placenta separates from the uterine wall before the baby is born, cutting off blood flow to the baby. The risk of this is especially high in multiple births (twins, triplets, or more). A third factor is "placenta previa," in which the placenta covers the cervix partially or completely, making vaginal delivery impossible. In some cases requiring c-section, the baby is in a transverse position, lying horizontally across the pelvis, perhaps with a shoulder in the birth canal.

The mother's health may make delivery by c-section the safer choice, especially in cases of maternal diabetes, hypertension, genital herpes, malignancies of the genital tract, and preeclampsia (high blood pressure related to pregnancy).

Choosing cesarean section

A 1997 survey of female obstetricians found that 31% would choose to have a c-section without trial of labor if they had an uncomplicated pregnancy. This finding mirrors a growing movement to allow women the right to choose c-section over vaginal delivery, even when no indications for c-section exist.

There are a number of reasons why a woman might choose a c-section in the absence of the usual indications. These include:

• Convenience. A scheduled c-section would allow a woman to choose the time and date of delivery to avoid conflicting with work or family obligations.
• Fear of childbirth. A woman might fear the pain of labor and delivery and feel that a scheduled c-section would allow her to circumvent it.
• Avoiding risks of vaginal delivery. Certain risks inherent to vaginal delivery (urinary or rectal incontinence, sexual dysfunction, dystocia) are avoided in a c-section.

Demographics

Women of higher socioeconomic status are more likely to have a c-section, 22.9%, compared to 13.2% of women who live in low-income families. C-section rates are highest among non-Hispanic white women (20.6%). Asian-American women have a c-section rate of 19.2%; African-American women, a rate of 18.9%, and Hispanic women, a rate of 13.9%.

Description

Regional anesthesia, either a spinal or epidural, is the preferred method of pain relief during a c-section. The benefits of regional anesthesia include allowing the mother to be awake during the surgery, avoiding the risks of general anesthesia, and allowing early contact between mother and child. Spinal anesthesia involves inserting a needle into a region between the vertebrae of the lower back and injecting numbing medications. An epidural is similar to a spinal except that a catheter is inserted so that numbing medications may be administered continuously. Some women experience a drop in blood pressure when a regional anesthetic is administered; this can be countered with fluids and/or medications.

In some instances, use of general anesthesia may be indicated. General anesthesia can be more rapidly administered in the case of an emergency (e.g., severe fetal distress). If the mother has a coagulation disorder that would be complicated by a drop in blood pressure (a risk with regional anesthesia), general anesthesia is an alternative. A major drawback of general anesthesia is that the procedure carries with it certain risks such as pulmonary aspiration and failed intubation. The baby may also be affected by the anesthetics since they cross the placenta; this effect is generally mild if delivery occurs within 10 minutes after anesthesia is administered.

Once the patient has received anesthesia, the abdomen is washed with an antibacterial solution and a portion of the pubic hair may be shaved. The first incision opens the abdomen. Infrequently, it will be vertical from just below the navel to the top of the pubic bone or, more commonly, it will be a horizontal incision across and above the pubic bone (informally called a "bikini cut").

The second incision opens the uterus. In most cases, a transverse incision is made. This is the favored type because it heals well and makes it possible for a woman to attempt a vaginal delivery in the future. The classical incision is vertical. Because it provides a larger opening than a low transverse incision, it is used in the most critical situations such as placenta previa. However, the classic incision causes more bleeding, a greater risk of abdominal infection, and a weaker scar.

Once the uterus is opened, the amniotic sac is ruptured and the baby is delivered. The time from the initial incision to birth is typically five minutes. The umbilical cord is clamped and cut, and the newborn is evaluated. The placenta is removed from the mother, and her uterus and abdomen are stitched closed (surgical staples may be used instead in closing the outermost layer of the abdominal incision). From birth through suturing may take 30–40 minutes; the entire surgical procedure may be performed in less than one hour.

Diagnosis/Preparation

There are several ways that obstetricians and other doctors diagnose conditions that may make a c-section necessary. Ultrasound testing reveals the positions of the baby and the placenta and may be used to estimate the baby's size and gestational age. Fetal heart monitors, in use since the 1970s, transmit any signals of fetal distress. Oxygen deprivation may be determined by checking the amniotic fluid for meconium (feces); a lack of oxygen may cause an unborn baby to defecate. Oxygen deprivation may also be determined by testing the pH of a blood sample taken from the baby's scalp; a pH of 7.25 or higher is normal, between 7.2 and 7.25 is suspicious, and below 7.2 is a sign of trouble.

When a c-section becomes necessary, the mother is prepped for surgery. A catheter is inserted into her bladder and an intravenous (IV) line is inserted into her arm. Leads for monitoring the mother's heart rate, rhythm, and blood pressure are attached. In the operating room , the mother is given anesthesia, usually a regional anesthetic (epidural or spinal), making her numb from below her breasts to her toes. In some cases, a general anesthetic will be administered. Surgical drapes are placed over the body, except the head; these drapes block the direct view of the procedure.

Aftercare

A woman who undergoes a c-section requires both the care given to any new mother and the care given to any patient recovering from major surgery. She should be offered pain medication that does not interfere with breastfeeding. She should be encouraged to get out of bed and walk around eight to 24 hours after surgery to stimulate circulation (thus avoiding the formation of blood clots) and bowel movement. She should limit climbing stairs to once a day, and avoid lifting anything heavier than the baby. She should nap as often as the baby sleeps, and arrange for help with the housework, meals, and care of other children. She may resume driving after two weeks, although some doctors recommend waiting for six weeks, the typical recovery period from major surgery.

Risks

Because a c-section is a surgical procedure, it carries more risk to both the mother and the baby. The maternal death rate is less than 0.02%, but that is four times the maternal death rate associated with vaginal delivery. Complications occur in less than 10% of cases.

The mother is at risk for increased bleeding (a c-section may result in twice the blood loss of a vaginal delivery) from the two incisions, the placental attachment site, and possible damage to a uterine artery. The mother may develop infection of the incision, the urinary tract, or the tissue lining the uterus (endometritis); infections occur in approximately 7% of women after having a c-section. Less commonly, she may receive injury to the surrounding organs such as the bladder and bowel. When a general anesthesia is used, she may experience complications from the anesthesia. Very rarely, she may develop a wound hematoma at the site of either incision or other blood clots leading to pelvic thrombophlebitis (inflammation of the major vein running from the pelvis into the leg) or a pulmonary embolus (a blood clot lodging in the lung).

Undergoing a c-section may also inflict psychological distress on the mother, beyond hormonal mood swings and postpartum depression ("baby blues"). The woman may feel disappointment and a sense of failure for not experiencing a vaginal delivery. She may feel isolated if the father or birthing coach is not with her in the operating room, or if an unfamiliar doctor treats her rather than her own doctor or midwife. She may feel helpless from a loss of control over labor and delivery with no opportunity to actively participate. To overcome these feelings, the woman must understand why the c-section was necessary. She must accept that she could not control the unforeseen events that made the c-section the optimum means of delivery, and recognize that preserving the health and safety of both her and her child was more important than her delivering vaginally. Women who undergo a c-section should be encouraged to share their feelings with others. Hospitals can often recommend support groups for such mothers. Women should also be encouraged to seek professional help if negative emotions persist.

Normal results

The after-effects of a c-section vary, depending on the woman's age, physical fitness, and overall health. Following this procedure, a woman commonly experiences gas pains, incision pain, and uterine contractions (also common in vaginal delivery). Her hospital stay may be two to four days. Breastfeeding the baby is encouraged, taking care that it is in a position that keeps the baby from resting on the mother's incision. As the woman heals, she may gradually increase appropriate exercises to regain abdominal tone. Full recovery may be achieved in four to six weeks.

The prognosis for a successful vaginal birth after a cesarean (VBAC) may be at least 75%, especially when the c-section involved a low transverse incision in the uterus and there were no complications during or after delivery.

Morbidity and mortality rates

Surgical injuries to the ureter or bowel occur in approximately 0.1% of c-sections. The risk of infection to the incision ranges from 2.5% to 15%. Urinary tract infections occur in 2–16% of patients post-c-section. The risk for developing a deep-vein thrombosis is three to five times higher in patients undergoing c-section than vaginal delivery.

Of the hundreds of thousands of women in the United States who undergo a c-section each year, about 500 die from serious infections, hemorrhaging, or other complications. The overall maternal mortality rate is estimated to be between six and 22 deaths per 100,000 births; approximately one-third of maternal deaths that occur after c-section can be attributed to the procedure. These deaths may be related to the health conditions that made the operation necessary, and not simply to the operation itself.

Alternatives

When a c-section is being considered because labor is not progressing, the mother should first be encouraged to walk around to stimulate labor. Labor may also be stimulated with the drug oxytocin. A woman should receive regular prenatal care and be able to alert her doctor to the first signs of trouble. Once labor begins, she should be encouraged to move around and to urinate. The doctor should be conservative in diagnosing dystocia and fetal distress, taking a position of "watchful waiting" before deciding to operate.

Approximately 3–4% of babies present at term in the breech position. Before opting to perform an elective c-section, the doctor may first attempt to reposition the baby; this is called external cephalic version. The doctor may also try a vaginal breech delivery, depending on the size of the mother's pelvis, the size of the baby, and the type of breech position the baby is in. However, a c-section is safer than a vaginal delivery when the baby is 8 lb (3.6 kg) or larger, in a breech position with the feet crossed, or in a breech position with the head hyperextended.

A vaginal birth after cesarean (VBAC) is an option for women who have had previous c-sections and are interested in a trial of labor (TOL). TOL is a purposeful attempt to deliver vaginally. The success rate for VBAC in patients who have had a prior low transverse uterine incision is approximately 70%. The most severe risk associated with TOL is uterine rupture: 0.2–1.5% of attempted VBACs among women with a low transverse uterine scar will end in uterine rupture, compared to 12% of women with a classic uterine incision. To minimize this risk, the American College of Obstetricians and Gynecologists (ACOG) recommends that VBAC be limited to women with full-term pregnancies (37–40 weeks) who have only had one previous low transverse c-section.

Resources

books

Enkin, Murray, et al. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. Oxford: Oxford University Press, 2000.

periodicals

Harer, W. Benson. "Vaginal Birth After Cesarean Delivery: Current Status." Journal of the American Medical Association 287, no. 20 (May 2002).

Murphy, Deirdre, Rachel Liebling, Lisa Verity, Rebecca Swingler, and Roshni Patel. "Early Maternal and Neonatal Morbidity Associated with Operative Delivery in Second Stage of Labour: A Cohort Study." The Lancet 358 (October 13, 2001): 1203–07.

Wagner, Marsden. "Choosing Cesarean Section." The Lancet 356 (November 11, 2000): 1677–80.

Yokoe, Deborah, et al. "Epidemiology of and Surveillance for Postpartum Infections." Emerging Infectious Diseases 7, no. 5 (2001).

organizations

American Academy of Family Physicians. 8880 Ward Parkway, Kansas City, MO 64114. (816) 333-9700. <http://www.aafp.org>.

American Board of Obstetrics and Gynecology. 2915 Vine Street, Dallas, TX 75204. (214) 871-1619. <http://www.abog.org>.

American College of Obstetricians and Gynecologists. 409 12th St., SW, PO Box 96920, Washington, DC 20090-6920. <http://www.acog.org>.

International Cesarean Awareness Network. 1304 Kingsdale Ave., Redondo Beach, CA 90278. (310) 542-6400. <http://www.ican-online.org>.

other

"Cesarean Birth." American College of Obstetricians and Gynecologists, March 1999 [cited February 26, 2003]. <http://www.medem.com>.

Duriseti, Ram. "Cesarean Section." eMedicine, August 29, 2001 [cited February 26, 2003]. <http://www.emedicine.com/aaem/topic99.htm>.

Sehdev, Harish. "Cesarean Delivery." eMedicine, February 22, 2002 [cited February 26, 2003]. <http://www.emedicine.com/med/topic3283.htm>.

Bethany Thivierge Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Cesarean sections are considered to be major surgery and are therefore usually performed under the strict conditions of a hospital operating room. The procedure is generally performed by an obstetrician who specializes in the areas of women's general health, pregnancy, labor and childbirth, prenatal testing, and genetics.

QUESTIONS TO ASK THE DOCTOR

• What is your medical training and how many c-sections have you performed?
• What percentage of women receive c-sections in your practice?
• If I have an elective c-section, what happens if I go into labor before the procedure is scheduled?
• What options are available to me for pain relief during and after the c-section?
• May a person of my choice remain with me during the procedure?
• When will I be able to hold/breastfeed my child?

Cesarean Section

Definition

A cesarean section is a surgical procedure in which incisions are made through a woman's abdomen and uterus to deliver her baby.

Purpose

Cesarean sections, also called c-sections, are performed whenever abnormal conditions complicate labor and vaginal delivery, threatening the life or health of the mother or the baby. In 2003, about 27% of U.S. deliveries were cesarean, up 6% from 2002. The procedure is often used in cases where the mother has had a previous c-section. Dystocia, or difficult labor, is the other common cause of c-sections.

Difficult labor is commonly caused by one of the three following conditions: abnormalities in the mother's birth canal; abnormalities in the position of the fetus; or abnormalities in the labor, including weak or infrequent contractions.

Another major factor is fetal distress, a condition where the fetus is not getting enough oxygen. Fetal brain damage can result from oxygen deprivation. Fetal distress is often related to abnormalities in the position of the fetus or abnormalities in the birth canal, causing reduced blood flow through the placenta. Other conditions also can make c-section advisable, such as vaginal herpes, hypertension, and diabetes in the mother.

Precautions

There are several ways that obstetricians and other doctors diagnose conditions that may make a c-section necessary. Ultrasound testing reveals the positions of the baby and the placenta and may be used to estimate the baby's size and gestational age. Fetal heart monitors, in use since the 1970s, transmit any signals of fetal distress. Oxygen deprivation may be determined by checking the amniotic fluid for meconium (feces)—a lack of oxygen causes an unborn baby to defecate. Oxygen deprivation may also be determined by testing the pH of a blood sample taken from the baby's scalp; a pH of 7.25 or higher is normal, between 7.2 and 7.25 is suspicious, and below 7.2 is a sign of trouble.

When a c-section is being considered because labor is not progressing, the mother should first be encouraged to walk around to stimulate labor. Labor may also be stimulated with the drug oxytocin.

When a c-section is being considered because the baby is in a breech position, the doctor may first attempt to reposition the baby; this is called external cephalic version. The doctor may also try a vaginal breech delivery, depending on the size of the mother's pelvis, the size of the baby, and the type of breech position the baby is in. However, a c-section is safer than a vaginal delivery when the baby is 8 lbs (3.6 kg) or larger, in a breech position with the feet crossed, or in a breech position with the head hyperextended.

A woman should receive regular prenatal care and be able to alert her doctor to the first signs of trouble. Once labor begins, she should be encouraged to move around and to urinate. The doctor should be conservative in diagnosing dystocia (nonprogressive labor) and fetal distress, taking a position of "watchful waiting" before deciding to operate.

Description

The most common reason that a cesarean section is performed (in 35% of all cases, according to the United States Public Health Service) is that the woman has had a previous c-section. The "once a cesarean, always a cesarean" rule originated when the classical uterine incision was made vertically; the resulting scar was weak and had a risk of rupturing in subsequent deliveries. Today, the incision is almost always made horizontally across the lower end of the uterus (this is called a "low transverse incision"), resulting in reduced blood loss and a decreased chance of rupture. This kind of incision allows many women to have a vaginal birth after a cesarean (VBAC).

The second most common reason that a c-section is performed (in 30% of all cases) is difficult childbirth due to nonprogressive labor (dystocia). Uterine contractions may be weak or irregular, the cervix may not be dilating, or the mother's pelvic structure may not allow adequate passage for birth. When the baby's head is too large to fit through the pelvis, the condition is called cephalopelvic disproportion (CPD).

Another 12% of c-sections are performed to deliver a baby in a breech presentation: buttocks or feet first. Breech presentation is found in about 3% of all births.

In 9% of all cases, c-sections are performed in response to fetal distress. Fetal distress refers to any situation that threatens the baby, such as the umbilical cord getting wrapped around the baby's neck. This may appear on the fetal heart monitor as an abnormal heart rate or rhythm.

The remaining 14% of c-sections are indicated by other serious factors. One is prolapse of the umbilical cord: the cord is pushed into the vagina ahead of the baby and becomes compressed, cutting off blood flow to the baby. Another is placental abruption : the placenta separates from the uterine wall before the baby is born, cutting off blood flow to the baby. The risk of this is especially high in multiple births (twins, triplets, or more). A third factor is placenta previa : the placenta covers the cervix partially or completely, making vaginal delivery impossible. In some cases requiring c-section, the baby is in a transverse position, lying horizontally across the pelvis, perhaps with a shoulder in the birth canal.

The mother's health may make delivery by c-section the safer choice, especially in cases of maternal diabetes, hypertension, genital herpes, Rh blood incompatibility, and preeclampsia (high blood pressure related to pregnancy ).

Preparation

When a c-section becomes necessary, the mother is prepped for surgery. A catheter is inserted into her bladder and an intravenous (IV) line is inserted into her arm. Leads for monitoring the mother's heart rate, rhythm, and blood pressure are attached. In the operating room, the mother is given anesthesia—usually a regional anesthetic (epidural or spinal), making her numb from below her breasts to her toes. In some cases, a general anesthetic will be administered. Surgical drapes are placed over the body, except the head; these drapes block the direct view of the procedure.

The abdomen is washed with an anti-bacterial solution and a portion of the pubic hair may be shaved. The first incision opens the abdomen. Infrequently, it will be vertical from just below the navel to the top of the pubic bone, or more commonly, it will be a horizontal incision across and above the pubic bone (informally called a "bikini cut").

The second incision opens the uterus. In most cases a transverse incision is made. This is the favored type because it heals well and makes it possible for a woman to attempt a vaginal delivery in the future. The classical incision is vertical. Because it provides a larger opening than a low transverse incision, it is used in the most critical situations, such as placenta previa. However, the classical incision causes more bleeding, a greater risk of abdominal infection, and a weaker scar, so the low transverse incision is preferred.

Once the uterus is opened, the amniotic sac is ruptured and the baby is delivered. The time from the initial incision to birth is typically five minutes.

Once the umbilical cord is clamped and cut, the newborn is evaluated. The placenta is removed from the mother, and her uterus and abdomen are stitched closed (surgical staples may be used instead in closing the outermost layer of the abdominal incision). From birth through suturing may take 30-40 minutes. Thus the entire surgical procedure may be performed in less than one hour.

Aftercare

A woman who undergoes a c-section requires both the care given to any new mother and the care given to any patient recovering from major surgery. She should be offered pain medication that does not interfere with breastfeeding. She should be encouraged to get out of bed and walk around eight to 24 hours after surgery to stimulate circulation (thus avoiding the formation of blood clots ) and bowel movement. She should limit climbing stairs to once a day, and avoid lifting anything heavier than the baby. She should nap as often as the baby sleeps, and arrange for help with the housework, meals, and care of other children. She may resume driving after two weeks, although some doctors recommend waiting for six weeks, the typical recovery period from major surgery.

Risks

Because a c-section is a surgical procedure, it carries more risk to both the mother and the baby. The maternal death rate is less than 0.02%, but that is four times the maternal death rate associated with vaginal delivery. However, many women have a c-section for serious medical problems. The mother is at risk for increased bleeding (because a c-section may result in twice the blood loss of a vaginal delivery) from the two incisions, the placental attachment site, and possible damage to a uterine artery. Complications occur in less than 10% of cases. The mother may develop infection of either incision, the urinary tract, or the tissue lining the uterus (endometritis). Less commonly, she may receive injury to the surrounding organs, like the bladder and bowel. When a general anesthesia is used, she may experience complications from the anesthesia. A 2004 report said that spinal anesthesia and obesity impair a mother's respiratory function during cesarean section procedures. Obese women were particularly susceptible to breathing problems. Very rarely, a woman may develop a wound hematoma at the site of either incision or other blood clots leading to pelvic thrombophlebitis (inflammation of the major vein running from the pelvis into the leg) or a pulmonary embolus (a blood clot lodging in the lung).

Normal results

The after-effects of a c-section vary, depending on the woman's age, physical fitness, and overall health. Following this procedure, a woman commonly experiences gas pains, incision pain, and uterine contractions—which are also common in vaginal delivery. Her hospital stay may be two to four days. Breastfeeding the baby is encouraged, taking care that it is in a position that keeps the baby from resting on the mother's incision. As the woman heals, she may gradually increase appropriate exercises to regain abdominal tone. Full recovery may be seen in four to six weeks.

KEY TERMS

Breech presentation— The condition in which the baby enters the birth canal with its buttocks or feet first.

Cephalopelvic disproportion (CPD)— The condition in which the baby's head is too large to fit through the mother's pelvis.

Classical incision— In a cesarean section, an incision made vertically along the uterus; this kind of incision makes a larger opening but also creates more bleeding, a greater chance of infection, and a weaker scar.

Dystocia— Failure to progress in labor, either because the cervix will not dilate (expand) further or (after full dilation) the head does not descend through the mother's pelvis.

Low transverse incision— Incision made horizontally across the lower end of the uterus; this kind of incision is preferred for less bleeding and stronger healing.

Placenta previa— The placenta totally or partially covers the cervix, preventing vaginal delivery.

Placental abruption— Separation of the placenta from the uterine wall before the baby is born, cutting off blood flow to the baby.

Prolapsed cord— The umbilical cord is pushed into the vagina ahead of the baby and becomes compressed, cutting off blood flow to the baby.

Respiratory distress syndrome (RDS)— Difficulty breathing, found in infants with immature lungs.

Transverse presentation— The baby is laying side-ways across the cervix instead of head first.

VBAC— Vaginal birth after cesarean.

The prognosis for a successful vaginal birth after a cesarean (VBAC) may be at least 75%, especially when the c-section involved a low transverse incision in the uterus and there were no complications during or after delivery.

Abnormal results

Of the hundreds of thousands of women in the United States who undergo a c-section each year, about 500 die from serious infections, hemorrhaging, or other complications. These deaths may be related to the health conditions that made the operation necessary, and not simply to the operation itself. New research in 2004 reported that c-section delivery affects the amount of breast milk an infant may receive from its mother for the first five days following birth. This can result in lower post-birth weighs as well. But the study found that by the sixth day, mother who had delivered by c-section began to produce milk at the same rate as those who delivered vaginally.

Undergoing a c-section may also inflict psychological distress on the mother, beyond hormonal mood swings and postpartum depression ("baby blues"). The woman may feel disappointment and a sense of failure for not experiencing a vaginal delivery. She may feel isolated if the father or birthing coach is not with her in the operating room, or if she is treated by an unfamiliar doctor rather than by her own doctor or midwife. She may feel helpless from a loss of control over labor and delivery with no opportunity to actively participate. To overcome these feelings, the woman must understand why the c-section was necessary. She must accept that she couldn't control the unforeseen events that made the c-section the optimum means of delivery, and recognize that preserving the health and safety of both her and her child was more important than her delivering vaginally. Women who undergo a c-section should be encouraged to share their feelings with others. Hospitals can often recommend support groups for such mothers. Women should also be encouraged to seek professional help if negative emotions persist.

Resources

PERIODICALS

"Cesarean Affects Breast Milk Intake." Mothering July-August 2004: 24.

"Spinal Anesthesia, Obesity Impair Maternal Breathing During Cesarean Section." Life Science Weekly September 28, 2004: 916.

ORGANIZATIONS

American Academy of Family Physicians. 8880 Ward Parkway, Kansas City, MO 64114. (816) 333-9700. 〈http://www.aafp.org〉.

Childbirth Org. 〈http://www.childbirth.org〉.

International Cesarean Awareness Network. 1304 Kingsdale Ave., Redondo Beach, CA 90278. (310) 542-6400.

March of Dimes Birth Defects Foundation. 1275 Mamaroneck Ave., White Plains, NY 10605. (914) 428-7100. resourcecenter@modimes.org. 〈http://www.modimes.org〉.

National Institute of Child Health and Human Development. Bldg 31, Room 2A32, MSC 2425, 31 Center Drive, Bethesda, MD 20892-2425. (800) 505-2742. 〈http://www.nichd.nih.gov/sids/sids.htm〉.

United States Department of Health and Human Services. 200 Independence Avenue SW, Washington DC 20201. (202) 619-0257. 〈http://www.hhs.gov〉.

OTHER

"Cesarean Childbirth." Perspectives: A Mental Health Magazine. 〈http://mentalhelp.net/perspectives〉.

Cesarean section

Cesarean section is the removal of an unborn child from the uterus by means of surgical incision through the abdominal wall. Originally practiced only on dead women, cesarean section today is a common and relatively safe birth method.

Surgical removal of a fetus (name given to unborn young from the end of the eighth week of development to birth) from a dead or dying mother was mandated for religious purposes by several ancient cultures. Examples of these mandates (or rules) were chronicled in Egypt in 3000 b.c. and in India in 1500 b.c.. In these cases, a cesarean procedure was performed in order to provide separate burials for the mother and the baby. The ancient Roman law code, known as lex caesaria (the "Law of the Caesars"), sometimes ordered this procedure in an attempt to save the baby. It is the law's name that is the probable source of the operation's name, not the legend about the unlikely surgical birth of emperor Julius Caesar (100-144 b.c.).

Sporadic attempts to perform cesarean sections as a means of saving both mother and baby seem to have occurred in medieval Europe. Records from Frankfurt-am-Main, Germany, claim seven cesareans were performed there before 1411. A French physician reported fifteen cesarean operations by 1581. It is unlikely that many of these cases had nonfatal consequences for the mother because of the incredibly crude surgical practices of the times.

Early Successes

One of the earliest reports of a successful cesarean operation dates to the year 1500, when a Swiss pork butcher or sow gelder named Jacob Nufer used his practiced skills to deliver his own wife of their child. The first reliably documented cesarean section was performed by Jeremiah Trautman in 1610 in Wittenberg, Germany. A renowned Dutch physician, Hendrik van Roonhuyze, championed the procedure. van Roonhuyze included illustrations of his method of cesarean incision in his 1663 book on operative gynecology. Cesarean section came to the British Isles in 1738, when an Irish midwife named Mary Donally performed a successful emergency operation. Cesarean delivery was practiced successfully in the United States by John Lambert of Ohio in 1827 and Francois Prevost in Louisiana before 1832. A patient of William Gibson of Baltimore, Maryland, lived for fifty years after her first delivery of two cesarean births in 1835.

Although cesarean delivery could be successful, the operation was largely avoided throughout the eighteenth and most of the nineteenth century because the maternal (mother's) mortality rate associated with the surgery was between 50 and 75 percent. Also, anesthesia had not been discovered, making the operation an agonizing procedure for the mother. In addition, massive infection was an extremely likely outcome and internal bleeding problems killed many mothers.

Modern Advances

Once anesthesia, antisepsis, and uterine suture (sewing with stitches) became standard, cesarean delivery became a viable and sensible option. During the early 1900s cesarean section gradually replaced other alternatives such as high forceps (an instrument resembling tongs used to help pull a baby from the birth canal) delivery, cutting of the pubic bone, and destruction of the fetus. As the birthplace moved from home to hospital, the cesarean mortality rate dropped to near zero by 1960. The rate of cesarean delivery however, rose dramatically. This rate was spurred on by a doctor's 1916 dictum (saying) "Once a cesarean, always a cesarean". Today, 25 of every 100 births in the United States are by cesarean section.

cesarean section , delivery of an infant by surgical removal from the uterus through an abdominal incision. The operation is of ancient origin: indeed, the name derives from the legend that Julius Caesar was born in this fashion. Until advancements in the late 19th cent., the mother generally died in surgery. The procedure was also aided by antisepsis, anesthetics, and other developments that made surgery as a whole more successful. Cesarean section is performed nowadays when factors exist that make natural childbirth hazardous, such as an abnormally narrow pelvis, pelvic tumors, hemorrhage, active infection with herpes simplex , multiple births, or an abnormal position of the fetus within the uterus. Subsequent deliveries are largely also by cesarean section. In the last few decades there has been a significant increase in the number of cesarean sections performed; among the factors encouraging the rise are the increase in malpractice litigation arising from problems attendant to vaginal deliveries and the information provided by the many new devices that monitor the well-being of the fetus in the uterus.

ce·sar·e·an / siˈze(ə)rēən/ (also cae·sar·e·an, Cae·sar·e·an, or Cae·sar·i·an) • adj. of or effected by cesarean section: a cesarean delivery. • n. a cesarean section: I had to have a cesarean born by cesarean.

ce·sar·e·an sec·tion • n. a surgical operation for delivering a child by cutting through the wall of the mother's abdomen.

Cesarean •antipodean, Crimean, Judaean, Korean •Albion •Gambian, Zambian •lesbian •Arabian, Bessarabian, Fabian, gabion, Sabian, Swabian •amphibian, Libyan, Namibian •Sorbian •Danubian, Nubian •Colombian • Serbian • Nietzschean •Chadian, Trinidadian •Andean, Kandyan •guardian •Acadian, Akkadian, Arcadian, Barbadian, Canadian, circadian, Grenadian, Hadean, Orcadian, Palladian, radian, steradian •Archimedean, comedian, epicedian, median, tragedian •ascidian, Derridean, Dravidian, enchiridion, Euclidean, Floridian, Gideon, Lydian, meridian, Numidian, obsidian, Pisidian, quotidian, viridian •Amerindian, Indian •accordion, Edwardian •Cambodian, collodion, custodian, melodeon, nickelodeon, Odeon •Freudian • Bermudian • Burundian •Burgundian •Falstaffian, Halafian •Christadelphian, Delphian, Philadelphian •nymphean • ruffian • Brobdingnagian •Carolingian • Swedenborgian •logion, Muskogean •Jungian •magian, Pelagian •collegian •callipygian, Cantabrigian, Phrygian, Stygian •Merovingian • philologian • Fujian •Czechoslovakian • Pickwickian •Algonquian • Chomskian •Kentuckian •battalion, galleon, medallion, rapscallion, scallion •Anglian, ganglion •Heraklion •Dalian, Malian, Somalian •Chellean, Machiavellian, Orwellian, Sabellian, Trevelyan, triskelion •Wesleyan •alien, Australian, bacchanalian, Castalian, Deucalion, episcopalian, Hegelian, madrigalian, mammalian, Pygmalion, Salian, saturnalian, sesquipedalian, tatterdemalion, Thessalian, Westphalian •anthelion, Aristotelian, Aurelian, carnelian, chameleon, Karelian, Mendelian, Mephistophelian, Pelion, Sahelian •Abbevillian, Azilian, Brazilian, caecilian, Castilian, Chilean, Churchillian, civilian, cotillion, crocodilian, epyllion, Gillian, Lilian, Maximilian, Pamphylian, pavilion, postilion, Quintilian, reptilian, Sicilian, Tamilian, vaudevillian, vermilion, Virgilian •Aeolian, Anatolian, Eolian, Jolyon, Mongolian, napoleon, simoleon •Acheulian, Boolean, cerulean, Friulian, Julian, Julien •bullion •mullion, scullion, Tertullian •Liverpudlian •Bahamian, Bamian, Damian, Mesopotamian, Samian •anthemion, Bohemian •Endymion, prosimian, Simeon, simian •isthmian • antinomian •Permian, vermian •Oceanian •Albanian, Azanian, Iranian, Jordanian, Lithuanian, Mauritanian, Mediterranean, Panamanian, Pennsylvanian, Pomeranian, Romanian, Ruritanian, Sassanian, subterranean, Tasmanian, Transylvanian, Tripolitanian, Turanian, Ukrainian, Vulcanian •Armenian, Athenian, Fenian, Magdalenian, Mycenaean (US Mycenean), Slovenian, Tyrrhenian •Argentinian, Arminian, Augustinian, Carthaginian, Darwinian, dominion, Guinean, Justinian, Ninian, Palestinian, Sardinian, Virginian •epilimnion, hypolimnion •Bosnian •Bornean, Californian, Capricornian •Aberdonian, Amazonian, Apollonian, Babylonian, Baconian, Bostonian, Caledonian, Catalonian, Chalcedonian, Ciceronian, Devonian, draconian, Estonian, Etonian, gorgonian, Ionian, Johnsonian, Laconian, Macedonian, Miltonian, Newtonian, Oregonian, Oxonian, Patagonian, Plutonian, Tennysonian, Tobagonian, Washingtonian •Cameroonian, communion, Mancunian, Neptunian, Réunion, union •Hibernian, Saturnian •Campion, champion, Grampian, rampion, tampion •thespian • Mississippian • Olympian •Crispian •Scorpian, scorpion •cornucopian, dystopian, Ethiopian, Salopian, subtopian, Utopian •Guadeloupian •Carian, carrion, clarion, Marian •Calabrian, Cantabrian •Cambrian • Bactrian •Lancastrian, Zoroastrian •Alexandrian • Maharashtrian •equestrian, pedestrian •agrarian, antiquarian, apiarian, Aquarian, Arian, Aryan, authoritarian, barbarian, Bavarian, Bulgarian, Caesarean (US Cesarean), centenarian, communitarian, contrarian, Darien, disciplinarian, egalitarian, equalitarian, establishmentarian, fruitarian, Gibraltarian, grammarian, Hanoverian, humanitarian, Hungarian, latitudinarian, libertarian, librarian, majoritarian, millenarian, necessarian, necessitarian, nonagenarian, octogenarian, ovarian, Parian, parliamentarian, planarian, predestinarian, prelapsarian, proletarian, quadragenarian, quinquagenarian, quodlibetarian, Rastafarian, riparian, rosarian, Rotarian, sabbatarian, Sagittarian, sanitarian, Sauveterrian, sectarian, seminarian, septuagenarian, sexagenarian, topiarian, totalitarian, Trinitarian, ubiquitarian, Unitarian, utilitarian, valetudinarian, vegetarian, veterinarian, vulgarian •Adrian, Hadrian •Assyrian, Illyrian, Syrian, Tyrian •morion • Austrian •Dorian, Ecuadorean, historian, Hyperborean, Nestorian, oratorian, praetorian (US pretorian), salutatorian, Salvadorean, Singaporean, stentorian, Taurean, valedictorian, Victorian •Ugrian • Zarathustrian •Cumbrian, Northumbrian, Umbrian •Algerian, Cancerian, Chaucerian, Cimmerian, criterion, Hesperian, Hitlerian, Hyperion, Iberian, Liberian, Nigerian, Presbyterian, Shakespearean, Siberian, Spenserian, Sumerian, valerian, Wagnerian, Zairean •Arthurian, Ben-Gurion, centurion, durian, holothurian, Khachaturian, Ligurian, Missourian, Silurian, tellurian •Circassian, Parnassian •halcyon • Capsian • Hessian •Albigensian, Waldensian •Dacian • Keatsian •Cilician, Galician, Lycian, Mysian, Odyssean •Leibnizian • Piscean • Ossian •Gaussian • Joycean • Andalusian •Mercian • Appalachian • Decian •Ordovician, Priscian •Lucian •himation, Montserratian •Atlantean, Dantean, Kantian •bastion, Erastian, Sebastian •Mozartian • Brechtian • Thyestean •Fortean • Faustian • protean •Djiboutian •fustian, Procrustean •Gilbertian, Goethean, nemertean •pantheon •Hogarthian, Parthian •Lethean, Promethean •Pythian • Corinthian • Scythian •Lothian, Midlothian •Latvian • Yugoslavian •avian, Batavian, Flavian, Moldavian, Moravian, Octavian, Scandinavian, Shavian •Bolivian, Maldivian, oblivion, Vivian •Chekhovian, Harrovian, Jovian, Pavlovian •alluvion, antediluvian, diluvian, Peruvian •Servian • Malawian • Zimbabwean •Abkhazian • Dickensian •Caucasian, Malaysian, Rabelaisian •Keynesian •Belizean, Cartesian, Indonesian, Milesian, Salesian, Silesian •Elysian, Frisian, Parisian, Tunisian •Holmesian •Carthusian, Malthusian, Venusian