For otherwise healthy  twin  pregnancies where both twins are head down a trial of  vaginal delivery  is recommended at between 37 and 38 weeks. [ 36 ] [ 37 ]  Vaginal delivery, in this case, does not worsen the outcome for either infant as compared with caesarean section. [ 37 ]  There is some controversy on the best method of delivery where the first twin is head first and the second is not, but most obstetricians will recommend normal delivery unless there are other reasons to avoid vaginal birth. [ 37 ]  When the first twin is not head down, a caesarean section is often recommended. [ 37 ]  Regardless of whether the twins are delivered by section or vaginally, the medical literature recommends delivery of dichorionic twins at 38 weeks, and monochorionic twins (identical twins sharing a placenta) by 37 weeks due to the increased risk of stillbirth in monochorionic twins who remain in utero after 37 weeks. [ 38 ] [ 39 ]  The consensus is that  late preterm delivery  of monochorionic twins is justified because the risk of stillbirth for post-37-week delivery is significantly higher than the risks posed by delivering monochorionic twins near term (i.e., 36–37 weeks). [ 40 ]
The consensus concerning monoamniotic twins (identical twins sharing an amniotic sac), the highest risk type of twins, is that they should be delivered by caesarean section at or shortly after 32 weeks, since the risks of intrauterine death of one or both twins is higher after this gestation than the risk of complications of prematurity. [ 41 ] [ 42 ] [ 43 ]


In a research study widely publicized, singleton children born earlier than 39 weeks may have developmental problems, including slower learning in reading and math. [ 44 ]


Other risks include:


Birth by caesarean section also seems to be associated with worse health outcomes later in life, including overweight or obesity, problems in the immune system, and poor digestive system. [ 48 ] [ 49 ]  However, caesarean deliveries are found to not affect a newborn's risk of developing food allergy. [ 50 ]  This finding contradicts a previous study that claims babies born via caesarean section have lower levels of  Bacteroides  that is linked to peanut allergy in infants. [ 51 ]


Caesarean sections have been classified in various ways by different perspectives. [ 52 ]  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. [ 52 ]


Conventionally, caesarean sections are classified as being either an  elective surgery  or an  emergency  operation. [ 53 ]  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. [ 53 ]  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.) [ 54 ]


Elective caesarean sections may be performed on the basis of an obstetrical or medical indication, or because of a medically non-indicated  maternal request . [ 36 ]  Among women in the United Kingdom, Sweden and Australia, about 7% preferred caesarean section as a method of delivery. [ 36 ]  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. [ 55 ]  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. [ 36 ]  If provided this should be done at 39 weeks of gestation or later. [ 55 ]  There is no evidence that ECS can reduce mother-to-child  hepatitis B  and  hepatitis C virus  transmission. [ 56 ] [ 57 ] [ 58 ] [ 59 ] [ 60 ]


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  pregnant  patient even though there is not a medical  indication  to have the surgery. [ 61 ]  Systematic reviews have found no strong evidence about the impact of caesareans for nonmedical reasons. [ 36 ] [ 62 ]  Recommendations encourage counseling to identify the reasons for the request, addressing anxieties and information, and encouraging vaginal birth. [ 36 ] [ 63 ]  Elective caesareans at 38 weeks in some studies showed increased health complications in the newborn. For this reason  ACOG  and  NICE  recommend that elective caesarean sections should not be scheduled before 39 weeks gestation unless there is a medical reason. [ 64 ] [ 65 ] [ 55 ]   Planned caesarean sections  may be scheduled earlier if there is a medical reason. [ 65 ]


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 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  birthing a baby  vaginally after a previous baby has been delivered by caesarean section (surgically). [ 66 ]  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. [ 33 ]  According to the American Pregnancy Association, 90% of women who have undergone caesarean deliveries are candidates for VBAC. [ 31 ]  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. [ 31 ] [ 32 ] [ 67 ]


For otherwise healthy twin pregnancies where both twins are head down a trial of vaginal delivery is recommended at between 37 and 38 weeks. [ 36 ] [ 37 ]  Vaginal delivery in this case does not worsen the outcome for either infant as compared with caesarean section. [ 37 ]  There is controversy on the best method of delivery where the first twin is head first and the second is not. [ 37 ]  When the first twin is not head down at the point of labor starting, a caesarean section should be recommended. [ 37 ]  Although the second twin typically has a higher frequency of problems, it is not known if a planned caesarean section affects this. [ 36 ]  It is estimated that 75% of twin pregnancies in the United States were delivered by caesarean section in 2008. [ 68 ]


A breech birth is the birth of a baby from a breech  presentation , in which the baby exits the pelvis with the  buttocks  or  feet  first as opposed to the normal  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. [ 69 ]


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


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  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 prior to the limit of  fetal viability  if it is judged to be of benefit to the mother.


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  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 which has been used nearly all over the world 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 [ 70 ]  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 way of 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. There are many publications 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. [ 71 ] [ 72 ]


Since 2015, the  World Health Organization  has endorsed the  Robson classification  as a holistic means of comparing childbirth rates between different settings, with a view to allowing more accurate comparison of caesarean section rates. [ 73 ]


Antibiotic prophylaxis  is used before an incision. [ 74 ]  The  uterus  is incised, and this incision is extended with blunt pressure along a cephalad-caudad axis. [ 74 ]  The infant is delivered, and the  placenta  is then removed. [ 74 ]  The surgeon then makes a decision about uterine exteriorization. [ 74 ]  Single-layer uterine closure is used when the mother does not want a future pregnancy. [ 74 ]  When subcutaneous tissue is 2 cm thick or more,  surgical suture  is used. [ 74 ]  Discouraged practices include manual  cervical dilation , any subcutaneous  drain , [ 75 ]  or supplemental  oxygen therapy  with intent to prevent infection. [ 74 ]


Caesarean section can be performed with  single  or  double layer suturing  of the uterine incision. [ 76 ]  Single layer closure compared with double layer closure has been observed to result in reduced blood loss during the surgery. It is uncertain whether this is the direct effect of the suturing technique or if other factors such as the type and site of abdominal incision contribute to reduced blood loss. [ 77 ]  Standard procedure includes the closure of the  peritoneum . Research questions whether this is needed, with some studies indicating peritoneal closure is associated with longer operative time and hospital stay. [ 78 ]  The Misgav Ladach method is a surgery technical that may have fewer secondary complications and faster healing, due to the insertion into the muscle. [ 79 ]


Both  general  and  regional anaesthesia  ( spinal ,  epidural  or  combined spinal and epidural anaesthesia ) are acceptable for use during caesarean section. Evidence does not show a difference between regional anaesthesia and general anaesthesia with respect to major outcomes in the mother or baby. [ 80 ]  Regional anaesthesia may be preferred as it allows the mother to be awake and interact immediately with her baby. [ 81 ]  Compared to general anaesthesia, regional anaesthesia is better at preventing  persistent postoperative pain  3 to 8 months after caesarean section. [ 82 ]  Other advantages of regional anesthesia may include the absence of typical risks of general anesthesia:  pulmonary aspiration  (which has a relatively high incidence in patients undergoing anesthesia in late pregnancy) of gastric contents and  esophageal   intubation . [ 80 ]  One trial found no difference in satisfaction when general anaesthesia was compared with either spinal anaesthesia. [ 80 ]


Regional anaesthesia is used in 95% of deliveries, with spinal and combined spinal and epidural anaesthesia being the most commonly used regional techniques in scheduled caesarean section. [ 83 ]  Regional anaesthesia during caesarean section is different from the  analgesia  (pain relief) used in labor and vaginal delivery. [ 84 ] [ 85 ] [ 86 ]  The pain that is experienced because of surgery is greater than that of labor and therefore requires a more intense  nerve block .


General anesthesia may be necessary because of specific risks to mother or child. Patients with heavy, uncontrolled bleeding may not tolerate the hemodynamic effects of regional anesthesia. General anesthesia is also preferred in very urgent cases, such as severe fetal distress, when there is no time to perform a regional anesthesia.


Postpartum infection is one of the main causes of maternal death and may account for 10% of maternal deaths globally. [ 87 ] [ 36 ] [ 88 ]  A caesarean section greatly increases the risk of infection and associated morbidity, estimated to be between 5 and 20 times as high, and routine use of antibiotic prophylaxis to prevent infections was found by a  meta-analysis  to substantially reduce the incidence of febrile morbidity. [ 88 ]  Infection can occur in around 8% of women who have caesareans, [ 36 ]  largely  endometritis ,  urinary tract infections  and wound infections. The use of preventative antibiotics in women undergoing caesarean section decreased wound infection, endometritis, and serious infectious complications by about 65%. [ 88 ]  Side effects and effect on the baby is unclear. [ 88 ]


Women who have caesareans can recognize the signs of fever that indicate the possibility of wound infection. [ 36 ]  Taking antibiotics before skin incision rather than after  cord clamping  reduces the risk for the mother, without increasing adverse effects for the baby. [ 36 ] [ 89 ]  Moderate certainty evidence suggest that  chlorhexidine gluconate  as a skin preparation is slightly more effective in prevention surgical site infections than  povidone-iodine  but further research is needed. [ 90 ]


Some doctors believe that during a caesarean section, mechanical  cervical dilation  with a finger or forceps will prevent the obstruction of blood and  lochia  drainage, and thereby benefit the mother by reducing the risk of death. The evidence as of 2018 [update]  neither supported nor refuted this practice for reducing postoperative morbidity, pending further large studies. [ 91 ]


Hypotension  (low blood pressure) is common in women who have spinal anaesthesia; intravenous fluids such as  crystalloids , or compressing the legs with bandages, stockings, or inflatable devices may help to reduce the risk of hypotension but the evidence is still uncertain about their effectiveness. [ 92 ]


The  WHO  and  UNICEF  recommend that infants born by Caesarean section should have skin-to-skin contact (SSC) as soon as the mother is alert and responsive.  Immediate SSC following a spinal or epidural anesthetic is possible because the mother remains alert; however, after a general anesthetic the father or other family member may provide SSC until the mother is able. [ 93 ]


It is known that during the hours of labor before a vaginal birth a woman's body begins to produce  oxytocin  which aids in the bonding process, and it is thought that SSC can trigger its production as well.  Indeed, women have reported that they felt that SSC had helped them to feel close to and bond with their infant.  A review of literature also found that immediate or early SSC increased the likelihood of successful breastfeeding and that newborns were found to cry less and relax quicker when they had SSC with their father as well. [ 93 ]


It is common for women who undergo caesarean section to have reduced or absent bowel movements for hours to days.  During this time, women may experience abdominal cramps, nausea and vomiting. This usually resolves without treatment. [ 94 ]  Poorly controlled pain following non-emergent caesarean section occurs in between 13% and 78% of women. [ 95 ]  Following caesarean delivery, complementary and alternative therapies (e.g.,  acupuncture ) may help to relieve pain, though evidence supporting the efficacy of such treatments is extremely limited. [ 96 ]  Abdominal, wound and back pain can continue for months after a caesarean section.  Non-steroidal anti-inflammatory drugs  can be helpful. [ 36 ]  For the first couple of weeks after a caesarean, women should avoid lifting anything heavier than their baby. To minimize pain during breastfeeding, women should experiment with different breastfeeding holds including the football hold and side-lying hold. [ 97 ]  Women who have had a caesarean are more likely to experience pain that interferes with their usual activities than women who have vaginal births, although by six months there is generally no longer a difference. [ 98 ]  Pain during sexual intercourse is less likely than after vaginal birth; by six months there is no difference. [ 36 ]


There may be a somewhat higher incidence of postnatal depression in the first weeks after childbirth for women who have caesarean sections, but this difference does not persist. [ 36 ]  Some women who have had caesarean sections, especially emergency caesareans, experience  post-traumatic stress disorder . [ 36 ]


A woman who undergoes caesarean section has 18.3% chance of chronic surgical pain at three months and 6.8% chance of surgical pain at 12 months. [ 99 ]


In recent meta-analyses, caesarean section has been associated to a lower risk of urinary incontinence and pelvic organ prolapse compared to vaginal delivery. [ 100 ] [ 101 ]  Women who have vaginal births, after a previous caesarean, are more than twice as likely to subsequently have pelvic floor surgery as those who have another caesarean. [ 102 ] [ 103 ]


Global rates of caesarean section are increasing. [ 25 ]  It doubled from 2003 to 2018 to reach 21%, and is increasing annually by 4%. The trend towards increasing rates is particularly strong in middle and high income countries. [ 104 ] : 101   In southern Africa, the cesarean rate is less than 5%; while the rate is almost 60% in some parts of Latin America. [ 105 ]  The Canadian rate was 26% in 2005–2006. [ 106 ]  Australia has a high caesarean section rate, at 31% in 2007. [ 107 ]  At one time a rate of 10% to 15% was thought to be ideal; [ 4 ]  a rate of 19% may result in better outcomes. [ 8 ]  The World Health Organization officially withdrew its previous recommendation of a 15% C-section rate in June 2010. Their official statement read, "There is no empirical evidence for an optimum percentage. What matters most is that all women who need caesarean sections receive them." [ 108 ]


More than 50 nations have rates greater than 27%. Another 45 countries have rates less than 7.5%. [ 8 ]  There are efforts to both improve access to and reduce the use of C-section. [ 8 ]  Globally, 1% of all caesarean deliveries are carried out without medical need. Overall, the caesarean section rate was 25.7% for 2004–2008. [ 109 ] [ 110 ]


There is no significant difference in caesarean rates when comparing midwife continuity care to conventional fragmented care. [ 111 ]  More emergency caesareans—about 66%—are performed during the day rather than the night. [ 112 ]


The rate has risen to 46% in  China  and to levels of 25% and above in many Asian, European and Latin American countries. [ 113 ]  In Brazil and Iran the caesarean section rate is greater than 40%. [ 114 ]  Brazil has one of the highest caesarean section rates in the world, with rates in the public sector of 35–45%, and 80–90% in the private sector. [ 115 ]


Across Europe, there are differences between countries: in Italy the caesarean section rate is 40%, while in the  Nordic countries  it is 14%. [ 116 ]  In the United Kingdom, in 2008, the rate was 24%. [ 117 ]  In Ireland the rate was 26.1% in 2009. [ 118 ]


In Italy, the incidence of caesarean sections is particularly high, although it varies from region to region. [ 119 ]  In  Campania , 60% of 2008 births reportedly occurred via caesarean sections. [ 120 ]  In the  Rome  region, the mean incidence is around 44%, but can reach as high as 85% in some private clinics. [ 121 ] [ 122 ]


In the United States, cesarean deliveries began rising in the 1960s and started becoming routine in the 1960s and 1970s. [ 104 ] : 101


In the United States the rate of C-section is around 33%, varying from 23% to 40% depending on the state. [ 3 ]  One of three women who gave birth in the US delivered by caesarean in 2011. In 2012, close to 23 million C-sections were carried out globally. [ 8 ]


With nearly 1.3 million stays, caesarean section was one of the most common procedures performed in U.S. hospitals in 2011. It was the second-most common procedure performed for people ages 18 to 44 years old. [ 123 ]  Caesarean rates in the U.S. have risen considerably since 1996. [ 124 ]  The rate has increased in the United States, to 33% of all births in 2012, up from 21% in 1996. [ 3 ]  In 2010, the caesarean delivery rate was 32.8% of all births (a slight decrease from 2009's high of 32.9% of all births). [ 125 ]  A study found that in 2011, women covered by private insurance were 11% more likely to have a caesarean section delivery than those covered by Medicaid. [ 126 ]  The increase in use has not resulted in improved outcomes, resulting in the position that C-sections may be done too frequently. [ 3 ]   It is believed that the high rate of induced deliveries has also led to the high rate of c-sections because they are twice as likely to lead to one. [ 127 ]


Hospitals and doctors make more money from C-section births than vaginal deliveries. Economists have calculated that hospitals may make a few thousand dollars more and doctors a few hundred. It has been found that for-profit hospitals do more c-sections than non-profit hospitals. [ 127 ]  One study looked at the rate of c-sections done for women who were themselves doctors.  It found that there was a 10 percent decrease to the rate of c-sections vs the general population.  But if the hospital paid their doctors a flat salary removing the incentive to do the surgical procedures, which take more time, the rate of c-sections done on women who were themselves physicians exceeded that of the procedure done on non-medically knowledgeable mothers, suggesting that some women who actually needed c-sections were not getting them. [ 128 ]


Concerned over the rising number of cesarean deliveries and hospital costs, in 2009  Minnesota  introduced a blended payment rate for either vaginal or cesarean uncomplicated births (i.e., a similar payment regardless of delivery mode).  As a result, the prepolicy cesarean rate of 22.8% dropped 3.24 percentage points. The cost of childbirth hospitalizations in Minnesota dropped by $425.80 at the time the policy was initiated and continued to drop by $95.04 per quarter with no significant effects on maternal morbidity. [ 129 ]


The rise of cesarean births in the United States has coincided with counter-movements emphasizing  natural childbirth  with a lesser degree of medical intervention. [ 104 ] : 101–102


The rate of cesarean sections began to sharply increase in China in the 1990s. [ 104 ] : 101   This increase was driven by the  expansion of China's modern hospital infrastructure , and occurred first in urban areas. [ 104 ] : 101   The rise in cesarean deliveries has also resulted in social critique of the medical establishment over the medical necessity of performing cesarean sections. [ 104 ] : 101–102


Historically, caesarean sections performed upon a live woman usually resulted in the death of the mother. [ 130 ]  It was considered an extreme measure, performed only when the mother was already dead or considered to be beyond help. By way of comparison, see the  resuscitative hysterotomy  or perimortem caesarean section.


According to the ancient Chinese  Records of the Grand Historian , Luzhong ( 陸終 ), a sixth-generation descendant of the mythical  Yellow Emperor , had six sons, all born by "cutting open the body".  The sixth son  Jilian  founded the House of Mi that ruled the  State of Chu  ( c.  1030 –223 BC). [ 131 ]


The  Sanskrit  medical treatise  Sushruta Samhita , composed in the early 1st millennium CE, mentions post-mortem caesarean sections. [ 132 ]  The first available non-mythical record of a C-section is the mother of  Bindusara  (born  c.  320 BC , ruled 298 –  c.  272 BC ), the second  Mauryan   Samrat  ( emperor ) of India, accidentally consumed poison and died when she was close to delivering him.  Chanakya , Chandragupta's teacher and adviser, made up his mind that the baby should survive. He cut open the belly of the queen and took out the baby, thus saving the baby's life. [ 133 ]


An early account of caesarean section in Iran (Persia) is mentioned in the book of  Shahnameh , written around 1000 AD, and relates to the birth of  Rostam , the legendary hero of that country. [ 134 ] [ 135 ]  According to the  Shahnameh , the  Simurgh  instructed  Zal  upon how to perform a caesarean section, thus saving  Rudaba  and the child Rostam. In Persian literature caesarean section is known as  Rostamina  ( رستمینه ). [ 136 ]


In the  Irish mythological  text the  Ulster Cycle , the character  Furbaide Ferbend  is said to have been born by posthumous caesarean section, after his mother was murdered by his evil aunt  Medb .


The  Babylonian Talmud , an ancient  Jewish  religious text, mentions a procedure similar to the caesarean section. The procedure is termed  yotzei dofen . It also discusses at length the permissibility of performing a C-section on a dying or dead mother. [ 133 ]  There is also some basis for supposing that Jewish women regularly survived the operation in Roman times (as early as the 2nd century AD). [ 137 ]


Pliny the Elder  theorized that Julius Caesar's (born 100 BC) name came from an ancestor who was born by caesarean section, but the truth of this is debated (see the discussion of  the etymology of  Caesar ). Some popular misconceptions involve Caesar himself being born from the procedure; which is considered false because the procedure was lethal to mothers in ancient Rome and Caesar's mother  Aurelia Cotta  lived until he was an adult. [ 138 ] [ 11 ]  The Ancient Roman caesarean section was first performed to remove a baby from the womb of a mother who died during childbirth, a practice sometimes called the  Caesarean law . [ 139 ]


The  Spanish  saint  Raymond Nonnatus  (1204–1240) received his surname—from the  Latin   non-natus  ('not born')—because he was born by caesarean section. His mother died while giving birth to him. [ 140 ]


There is some indirect evidence that the first caesarean section that was survived by both the mother and child was performed in  Prague  in 1337. [ 141 ] [ 142 ]  The mother was  Beatrice of Bourbon , the second wife of the  King of Bohemia John of Luxembourg .  Beatrice  gave birth to the king's son  Wenceslaus I , later the duke of Luxembourg, Brabant, and Limburg, and who became the half brother of the later  King of Bohemia and Holy Roman Emperor, Charles IV .


In an account from the 1580s,  Jakob Nufer , a  veterinarian  in  Siegershausen , Switzerland, is supposed to have performed the operation on his wife after a prolonged labour, with her surviving. His wife allegedly bore five more children, including twins, and the baby delivered by caesarean section purportedly lived to the age of 77. [ 143 ] [ 144 ] [ 145 ]


For most of the time since the 16th century, the procedure had a high mortality rate by modern standards. Key steps in reducing mortality were:


Indigenous people in the  Great Lakes region  of Africa, including  Rwanda  and  Uganda , performed caesarean sections which in one account by  Robert William Felkin  from 1879 resulted in the survival of both mother and child. Banana wine was used, although the site of the incision was then also washed with water and, post operation, covered with a paste made by chewing two different roots. From the well-developed nature of the medical procedures employed he concluded that these procedures had been employed for some time. [ 146 ] [ 147 ] [ 148 ]   James Barry  was the first European doctor to carry out a successful caesarean in Africa, while posted to Cape Town between 1817 and 1828. [ 149 ]


The first successful caesarean section to be performed in the United States took place in Rockingham County, Virginia in 1794. The procedure was performed by Dr.  Jesse Bennett  on his wife Elizabeth. [ 150 ]


The  patron saint  of caesarean section is  Caesarius , a young deacon martyred at  Terracina , who has replaced and Christianized the pagan figure of  Caesar . [ 151 ]  The martyr (Saint Cesareo in Italian) is invoked for the success of this surgical procedure, because it was considered the new "Christian Caesar" – as opposed to the "pagan Caesar" – in the Middle Ages it began to be invoked by pregnant women to wish a physiological birth, for the success of the expulsion of the baby from the uterus and, therefore, for their salvation and that of the unborn. The practice continues, in fact the martyr Caesarius is invoked by the future mothers who, due to health problems or that of the baby, must give birth to their child by caesarean section. [ 152 ]


The origin of the term is not definitively known. Roman  Lex Regia  (royal law), later the  Lex Caesarea  (imperial law), of  Numa Pompilius  (715–673 BC), [ 153 ]  required the child of a mother who had died during childbirth to be cut from her womb. [ 154 ]
There was a cultural  taboo  that mothers should not be buried pregnant, [ 155 ]  that may have reflected a way of saving some fetuses. Roman practice required a living mother to be in her tenth month of pregnancy before resorting to the procedure, reflecting the knowledge that she could not survive the delivery. [ 156 ]


Speculations that the Roman dictator  Julius Caesar  was born by the method now known as C-section are false. [ 157 ]  Although caesarean sections were performed in  Roman  times, no classical source records a mother surviving such a delivery, while Caesar's mother lived for years after his birth. [ 154 ] [ 158 ]  As late as the 12th century, scholar and physician  Maimonides  expresses doubt over the possibility of a woman's surviving this procedure and again becoming pregnant. [ 159 ]  The term has also been explained as deriving from the verb  caedere , 'to cut', with children delivered this way referred to as  caesones .  Pliny the Elder  refers to a certain Julius Caesar (an ancestor of the famous Roman statesman) as  ab utero caeso , 'cut from the womb' giving this as an explanation for the  cognomen   Caesar  which was then carried by his descendants. [ 154 ]  Nonetheless,  the  false etymology  has been widely repeated until recently. For example, the first (1888) and second (1989) editions of the  Oxford English Dictionary  say that caesarean birth "was done in the case of Julius Cæsar". [ 160 ]  More recent dictionaries are more diffident: the online edition of the OED (2021) mentions "the traditional belief that Julius Cæsar was delivered this way", [ 161 ]  and  Merriam-Webster's Collegiate Dictionary  (2003) says "from the legendary association of such a delivery with the Roman cognomen  Caesar ". [ 162 ]


The word  Caesar , meaning either Julius Caesar or an emperor in general, is also borrowed or  calqued  in the name of the procedure in many other languages in Europe and beyond. [ 163 ]


Finally, the Roman  praenomen  (given name)  Caeso  was said to be given to children who were born via C-section. While this was probably just  folk etymology  made popular by Pliny the Elder, it was well known by the time the term came into common use. [ 164 ]


The term  caesarean  is spelled in various accepted ways,  as discussed at Wiktionary . The  Medical Subject Headings  (MeSH) of the  United States National Library of Medicine  (NLM) uses  cesarean section , [ 165 ]  while some other American medical works, e.g.  Saunders Comprehensive Veterinary Dictionary , use  caesarean , [ 166 ]  as do most British works. The online versions of the US-published  Merriam-Webster Dictionary [ 167 ]  and  American Heritage Dictionary [ 166 ]  list  cesarean  first and other spellings as "variants".


In re A.C. , 573  A.2d  1235 (1990), was a  District of Columbia Court of Appeals  case. It was the first American appellate court case decided against a forced Caesarean section, although the decision was issued after the fatal procedure was performed. [ 168 ]  Physicians performed a Caesarean section upon patient Angela Carder (née Stoner) without informed consent in an unsuccessful attempt to save the life of her baby. [ 169 ]   The case stands as a landmark in United States  case law  establishing the  rights  of informed consent and bodily integrity for pregnant women.


In Illinois,  In re Baby Boy Doe , 632 N.E.2d 326 (Ill. App. Ct. 1994) was a court case holding that courts may not balance whatever rights a fetus may have against the rights of a competent woman, whose choice to refuse medical treatment as invasive as a Cesarean section must be honored even if the choice may be harmful to the fetus.


Pemberton v. Tallahassee Memorial Regional Center , 66 F. Supp. 2d 1247 (N.D. Fla. 1999), is a case in the  United States  regarding  reproductive rights . Pemberton had a previous Caesarean section (vertical incision), and with her second child attempted to have a  VBAC  (vaginal birth after c-section). [ 170 ]  When a doctor she had approached about a related issue at the  Tallahassee Memorial Regional Center  found out, he and the hospital sued to force her to get a c-section. The court held that the rights of the fetus at or near birth outweighed the rights of Pemberton to determine her own medical care. [ 171 ] [ 172 ]  She was physically forced to stop laboring, and taken to the hospital, where a c-section was performed. [ 170 ]  Her suit against the hospital was dismissed. [ 170 ]   The court held that a cesarean section at the end of a full-term pregnancy was here deemed to be medically necessary by doctors to avoid a substantial risk that the fetus would die during delivery due to uterine rupture, a risk of 4–6% according to the hospital's doctors and 2% according to Pemberton's doctors. Furthermore, the court held that a state's interest in preserving the life of an unborn child outweighed the mother's constitutional interest of bodily integrity. [ 173 ]  The court held that  Roe v. Wade  was not applicable, because bearing an unwanted child is a greater intrusion on the mother's constitutional interests than undergoing a cesarean section to deliver a child that the mother affirmatively desires to deliver. The court further distinguished  In re A.C.  by stating that it left open the possibility that a non-consenting patient's interest would yield to a more compelling countervailing interest in an "extremely rare and truly exceptional case." The court then held this case to be such. [ 170 ] [ 174 ]


In many hospitals, the mother's partner is encouraged to attend the surgery to support her and share the experience. [ 175 ]  While traditionally there has been an opaque surgical drape obstructing the parents' view, some patients and doctors are opting for a "gentle C-section" using a clear drape, allowing the parents to watch the delivery and see their infant immediately. [ 176 ]


In  Judaism , there is a dispute among the  poskim  (Rabbinic authorities) as to whether the first-born son from a caesarean section has the laws of a  bechor . [ 177 ]  Traditionally, a male child delivered by caesarean is not eligible for the  Pidyon HaBen  dedication ritual. [ 178 ] [ 179 ]


In rare cases, caesarean sections can be used to remove a dead  fetus ; otherwise, the woman has to labour and deliver a baby known to be a  stillbirth . A  late-term abortion  using caesarean section procedures is termed a  hysterotomy abortion  and is very rarely performed. [ 180 ]


The mother may perform  a caesarean section on herself ; there have been successful cases, such as Inés Ramírez Pérez of Mexico who, on 5 March 2000, took this action. She survived, as did her son, Orlando Ruiz Ramírez. [ 181 ] [ 182 ] [ 183 ]


In 2024, a female  western lowland gorilla  had a successful cesarean section after zoo veterinarians diagnosed her with  pre-eclampsia . The premature gorilla infant survived, as a result of similar methods used with human infants. [ 184 ]


The  EXIT procedure , or  ex utero intrapartum treatment procedure , is a specialized surgical delivery procedure used to deliver babies who have airway compression. [ 1 ]   Causes of airway compression in newborn babies result from a number of  rare   congenital disorders , including  bronchopulmonary sequestration ,  congenital cystic adenomatoid malformation , mouth or neck tumor such as  teratoma , and lung or pleural tumor such as  pleuropulmonary blastoma . [ 2 ]   Airway compression discovered at birth is a medical emergency.  In many cases, however, the airway compression is discovered during prenatal ultrasound exams, permitting time to plan a safe delivery using the EXIT procedure or other means.


The EXIT is an extension of a standard classical  Caesarean section , where an opening is made on the midline of the anesthetized mother's abdomen and uterus.  Then comes the EXIT:  the baby is partially delivered through the opening but remains attached by its  umbilical cord  to the  placenta , while a pediatric otolaryngologist-head & neck surgeon establishes an airway so the fetus can breathe.   Once the EXIT is complete, the umbilical cord is clamped then cut  and the infant is fully delivered.  Then the remainder of the C-section proceeds. [ citation needed ]


The ex utero intrapartum treatment (EXIT) procedure was originally developed to reverse temporary tracheal occlusion in patients who had undergone fetal surgery for severe  congenital diaphragmatic hernia  (CDH). In a select group of fetuses with CDH, tracheal occlusion is used to obstruct the normal flow of fetal lung fluid and to stimulate lung expansion and growth. With the airway obstructed, airway management at birth is critical. The solution was to arrange delivery in such a way that the occlusion could be removed and the airway secured while the baby remained on placental support. If the uterus was kept relaxed and the utero-placental blood flow kept intact, the fetus could remain on a maternal 'heart-lung machine' while the airway was secured. While the technique of tracheal occlusion remains under study in clinical trials, EXIT procedures have been shown to be useful for management of other causes of fetal airway obstruction. [ citation needed ]


The EXIT is much more complex than a standard C-section, as it requires careful coordination between the mother's physicians and the specialists operating on the newborn baby. The difficulty lies in preserving enough blood flow through the umbilical cord, protecting the placenta, and avoiding contractions of the uterus so that there is sufficient time to establish the airway. Also, the umbilical cord should not be manipulated, but should be kept in warmed fluids to avoid physiological occlusion. [ 3 ]


Fetendo  or  Fetal Endoscopic surgery [ 1 ]  is a form of  fetal intervention  in the treatment of  birth defects  and other fetal problems. The procedure uses real-time video imagery from  fetoscopy  and  ultrasonography  to guide very small surgical instruments into the uterus in order to surgically help the fetus. The name Fetendo was adopted for the procedure because of how the video-based manipulation recalls a video game.


Fetendo intervention is less invasive than  open fetal surgery . [ 2 ]  It can be often be achieved with just a small guided wire sent through a needle-puncture of the skin (percutaneous), though in some cases it may require that a small opening be made in the mother's abdomen.


The fact that it is less invasive reduces the mother's postoperative recovery and lessens the troubles with preterm labor.


Fetendo has proven to be very useful for some, but not all, fetal conditions. Some examples include:


Fetoscopy  is an endoscopic procedure during  pregnancy  to allow surgical access to the  fetus , the  amniotic cavity , the  umbilical cord , and the fetal side of the  placenta . A small (3–4 mm) incision is made in the  abdomen , and an  endoscope  is inserted through the  abdominal wall  and  uterus  into the amniotic cavity. Fetoscopy allows for medical interventions such as a  biopsy  (tissue sample) or a  laser  occlusion of abnormal blood vessels (such as  chorioangioma ) or the treatment of  spina bifida . [ 1 ]


Fetoscopy is usually performed in the second or third trimester of pregnancy. The procedure can place the fetus at increased risk of adverse outcomes, including fetal loss or preterm delivery, so the risks and benefits must be carefully weighed in order to protect the health of the mother and fetus(es). The procedure is typically performed in an  operating room  by an  obstetrician-gynecologist . [ citation needed ]


In 1945,  Björn Westin  published a study which documented his use of a  panendoscope  to directly observe embryos. [ 2 ]  In 1966, Agüero et al. published a study which used  hysteroscopy  to observe various features of the fetus, cervix, and uterus. [ 2 ]  In 1972, Carlo Valenti of the  SUNY Downstate Medical Center  recorded a technique which he called "endoamnioscopy", which allowed for direct visualization of the developing fetus. [ 3 ]  Gallinat made the first attempt to standardize these techniques in 1978. [ 2 ]


Because of the invasiveness of these procedures and the high risk they posed to the fetus, they were largely discarded in favor of  transvaginal sonography  until the 1990s. [ 2 ]  By that time, smaller instruments had been developed which reduced the risk to the fetus and provided a better visual for the physician. This in turn allowed for the development of techniques for surgical interventions such as biopsy. [ 2 ]  By 1993, authors such as Cullen, Ghirardini, and Reece had referred to this technique as "fetoscopy". [ 2 ]


The field of minimally-invasive surgical fetoscopy has continued to develop since the 2000s. Physicians such as  Michael Belfort  and  Ruben Quintero  have used the technique to remove tumors and correct  spina bifida  on fetuses within the uterus. [ 4 ] [ 5 ]


Fetoscopy is a surgical procedure which may involve the use of a fibreoptic device called a  fetoscope . Some confusion may arise from the use of specialized forms of  stethoscopes , including  Pinard horns  and  Doppler wands , to audibly monitor fetal heart rate (FHR). These audio diagnostic tools are also called "fetoscopes" but are not related to visual fetoscopy. [ 6 ]


Joel-Cohen incision  is a skin incision used for  Caesarean section . It is a straight incision that is 3 cm below the line joining both anterior superior  iliac spines . It is similar to the Pfannenstiel incision, another commonly used incision in obstetric surgery. The Joel-Cohen cesarean section technique relies more heavily on blunt dissection than the traditional  Pfannenstiel technique . [ 1 ]  Joel-Cohen technique has lower rates of fever, hospital stay, post-operative pain and blood loss compared to Pfannenstiel. The operating time and use of analgesia are also reduced. Additionally, the time needed to get out of bed, walk without support and time for re-appearance of audible intestinal sounds were shorter in Joel-Cohen group than the Pfannenstiel group in a study conducted with 153 women. [ 2 ]  In the two studies  (with 411 participants) that compared the Joel-Cohen incision with the Pfannenstiel incision, the Joel-Cohen incision was associated with a 65% reduction in postoperative febrile morbidity. [ 3 ]


The skin incision is made 3 cm above the location of Pfannenstiel incision. The subcutaneous tissue is incised in three medial centimetres. The lateral tissue separation is done manually and the fascia is divided by blunt dissection using both index fingers. This incision is extended laterally by the fingers. [ 2 ]


A  lower  ( uterine )  segment caesarean section  ( LSCS ) is the most commonly used type of  caesarean section . [ 1 ]  Most commonly, a baby is delivered by making a  transverse incision  in the lower uterine segment, above the attachment of the  urinary bladder  to the uterus. This type of incision results in less  blood loss  and is easier to repair than other types of caesarean sections.


A vertical incision in the lower uterine segment may be performed in the following circumstances: [ 2 ]


The location of an LSCS is beneficial for the following reasons: [ citation needed ]


Most bleeding takes place from the angles of the incision, and  forceps  can be applied to control it. Green Armytage forceps are specifically designed for this purpose. [ 3 ]


Although the incision is made using a sharp scalpel, care must be taken not to injure the foetus, especially if the membranes are ruptured, or in emergencies like  abruption . The incision can be extended to either sides using scissors or by blunt dissection using hands. While using the scissors, the surgeon should ensure that a finger is placed underneath the uterus so that the foetus in protected from unintentional injury. If blunt dissection is done, intraoperative blood loss can be minimized. In cases where Pfannenstiel incision cannot be done (such as large baby),  Kronig incision  (low vertical incision), [ 4 ]  classical (midline), J [ 5 ]  or T-shaped incisions [ 6 ]  may be used to incise the uterus. [ 7 ]


The German gynecologist  Hermann Johannes Pfannenstiel  (1862–1909) invented the technique. [ 8 ]  In the  United Kingdom , the surgery was first popularised by Dr.  Monroe Kerr , who first used it in 1911, so in English speaking countries it is sometimes called the Kerr incision or the Pfannenstiel-Kerr incision. Kerr published the results in 1920, proposing that this method would cause less damage to the vascularized areas of uterus than the classical operation. He claimed that it was better than the longitudinal uterine incision in terms of chances for scar rupture and injury to vessels. [ 9 ]


Obstetric anesthesia  or  obstetric anesthesiology , also known as  ob-gyn anesthesia  or  ob-gyn anesthesiology , is a sub-specialty of  anesthesiology  that provides peripartum (time directly preceding, during or following childbirth) [ 1 ]  pain relief ( analgesia ) for labor and  anesthesia  (suppress consciousness) for  cesarean deliveries  ('C-sections'). [ 2 ]


Other subspecialty options for anesthesiology include cardiac anesthesiology, pediatric anesthesiology, pain medicine, critical care, neuroanesthesia, regional anesthesia, transplant anesthesia and trauma anesthesia. [ citation needed ]


Obstetric anesthesiologists typically serve as consultants to ob-gyn physicians and provide pain management for both complicated and uncomplicated pregnancies. [ 3 ]  An obstetric anesthesiologist's practice may consist largely of managing pain during vaginal deliveries and administering anesthesia for cesarean sections; however, the scope is expanding to involve anesthesia for both maternal as well as fetal procedures. [ 4 ]


Maternal-specific procedures include  cerclage , external  cephalic version  (ECV), postpartum bilateral  tubal ligation  (BTL), and  dilation and evacuation  (D and E). [ 4 ]   Fetus-specific procedures include fetoscopic laser photocoagulation and  ex-utero intrapartum treatment (EXIT) . [ 4 ]   However, the majority of care given by anesthesiologists on most labor and delivery units is management of labor analgesia and anesthesia for cesarean section. [ 4 ]


The administration of general anesthesia in operative procedures was publicly demonstrated by  William Thomas Green Morton  (1819–1868) in Boston, October 1846 as the first successful practice of its kind. [ 5 ]  This practice revealed the pain-annulling properties of ether inhalation during surgery. Pioneers of obstetric anesthesia extended these findings to cases of parturition or childbirth, notably including   James Young Simpson  of Scotland (1811–1870),  John Snow  of London (1813–1858) and  Walter Channing  of the United States (1786–1876). [ citation needed ]


Prior to the anesthetizing of  Queen Victoria  in 1853, the use of diethyl ether and chloroform as obstetric anesthetics faced social, religious, and medical opposition. [ 6 ]  With the shift in social attitudes, women became less reserved towards this novel practice and began coercing physicians to administer powerful anesthetics during labor. Medical objections were similarly disintegrated with casebook publications that reflected the safety of obstetric anesthesia for both mother and child. Thus the advent of obstetric anesthesia facilitated the use of instruments during delivery as obstetricians were afforded greater scope in terms of these materials. [ citation needed ]


Following Morton's use of ether as an anesthetic, James Simpson conducted his own obstetric anesthetic trial on January 19, 1847 using an open-drop approach to administer ether. [ 7 ] [ 8 ] [ 9 ]  However, due to its post-analgesic effect of nausea and vomiting, he later switched to using chloroform instead. [ 8 ]  Simpson's later personal discovery of chloroform's anesthetic properties inspired subsequent trials with chloroform that he went on to make public in November 1847. The Medico Surgical Society publication of Simpson's findings was not well received and required significant defense thereafter. Three months later, on April 7, 1847, ether was used for the first time in American obstetrics. [ 7 ] [ 8 ]  Following that initial administration documented in the Boston Medical and Surgical Journal by N.C Keep, Walter Channing described several obstetric cases in which he successfully employed sulfuric ether in the United States. [ 7 ]


John Snow was responsible for anesthetizing the Queen and is also attributed for influencing public and medical opinions on obstetric anesthesia through his various recorded experiences  Though the birth of the Queen's 8th child  Prince Leopold  on April 7, 1853, was not generally publicized, the London social elite were aware of the use of chloroform in this delivery and found it appealing. [ 7 ] [ 8 ] [ 10 ]  Until this time, there had been considerable public and religious opposition to obstetric anesthesia. [ 10 ]  A woman, Eufame MacAlayne, was buried alive in Scotland in 1591 just for  seeking  pain relief for the birth of her two sons. [ 10 ]  This societal aspect of childbirth was recognized by Dr. Churchill of Dublin and later published on the statistics of obstetric anesthesia. [ 11 ]  Churchill suggested wealthier individuals were recorded to have easier births from the use of such drugs. In the practice of obstetric anesthesia,  John Snow greatly differed from Simpson in that Snow emphasized proper quantity measurements and the delay of administration until the second stage of labor commenced. [ 12 ]  Snow additionally disagreed with Simpson's argument that the laboring patient should be anesthetized to the level of unconsciousness. These differences among others are why the title "Father of Obstetric Anesthesia" has become so controversial. [ 13 ]


Labor analgesia was debated on the grounds of religion and morality, which John Simpson used as his own weapon against opposition. Biblical literalism led many to interpret labor pains as punishment for sin and deemed obstetric anesthesia impious with respect to the primeval curse. [ 14 ]  Simpson advocated that “whosoever shall keep the whole law and yet offend in one point, is guilty of all”. In this sentiment he is referring to many of the medical practitioners who mitigate minor pains but avoid obstetric anesthetics for fear of opposition or religious persecution. [ 15 ]  Critic Charles Meigs exemplified this belief of the physiological value in parturition pain, which the greater public supported throughout the mid 19th century.


The natural benefits of such labor pains which initially inhibited the practice of obstetrical analgesia, originated from another religious consideration of perfection. Religious opponents argued that individuals of God’s creation and His standard of perfection should not be in need of such obstetrical interference. Natural processes employed by the Almighty Himself should be left untouched. In support of this claim, M. Roussel advocated that the refinement of society through technical operations (i.e. anesthesia) causes more harm then good to the natural process of childbirth. [ 16 ]


Medical historian Richard Shyrock suggested that humanitarian sentiments motivated 19th century physicians, while science shaped their practice. [ 17 ]  Victorian practitioners believed that if suffering was preventable it was their duty to abolish it in any way possible. Though physicians responsible for administering anesthesia were known to evade interfering in delivery if the mother was an uncivilized member of society. These individuals were left to their own resources, perhaps benefiting from midwife assistance. [ 18 ]   The pathological process of childbirth was seen to be of necessity for successful delivery and dulling the pain of contractions would hinder this process, until Simpson was able to overturn this theory in 1854. The inhalation of anesthetic agents do not affect the act of labor or the mechanism by which uterine contractions occur, but rather renders the woman insensible to the high degree of pain. [ 19 ]  With this finding, along with the statistical records of safely executed anesthetic administrations, the medical opposition to obstetric analgesia for pain annulment was suppressed.


The conflicting clinical interpretation of obstetric labor as natural pain, as opposed to discomfort induced by an abnormal or diseased condition, led obstetric practitioners and midwives alike to endorse laissez-faire treatment. Natural, animalistic functions of child rearing were determined thereafter not to require the assistance of obstetricians or subsequent labor analgesia. Following an era of natural philosophy, physicians evoked the ability of wild animals and ‘savaged individuals’ to deliver offspring in regions where the practice of child rearing had never been reduced to an art form. The likening of any obstetrical practice to mere pretend science, including the delivery of anesthetic agents, further prolonged the advancement of this field considerably throughout the 19th century. [ 20 ]


The social distinction of labor analgesia practice strengthened the divide between savaged and civilized society, while highlighting gender roles in medical practice. The results of unassisted labor in uncivilized communities, specifically the vitality of both mom and fetus, were not documented well. The news of this ‘anti-obstetric’ practice failed to spread to the civilized community, allowing the means of obstetric interference through general and anesthetic intervention to persist. [ 21 ]  Documentation and statistical evidence was favored throughout the development of obstetric anesthesia to determine the viability of physician strategies. The obstetric diary of midwife   Martha Ballard  (1735–1812) is historically valued for she documented the details of all midwife calls, as well as physician assistance, instrument usage, and symptoms. Being one of the first women to provide a history of obstetrical practice, Martha Ballard’s notes regarding the marginalization of women in medical practice and the arrogance of male physicians were taken into careful consideration. [ citation needed ]


The isolation of morphine in the early 1800s was yet another milestone in obstetric anesthesia. [ 7 ] [ 8 ]  However, the drug would not be widely used until the invention of the hypodermic needle in the 1850s. [ 7 ] [ 8 ]  The first to use a hypodermic syringe in the United States was  Fordyce Barker , who actually received the syringe from H.J Simpson as a gift during a visit to Edinburgh. [ 8 ]  Eventually, the use of morphine for pain control during labor lost favor due to its effects of respiratory depression in the newborn and was replaced largely by meperidine, a synthetic narcotic, first made in Germany in 1939, that had less of an effect on respiratory depression. [ 7 ] [ 8 ]  Meperidine is still popular in obstetrics today. [ 8 ]


Probably the most important discovery in obstetric anesthesia was the introduction of  regional anesthesia , [ 8 ]  in which local anesthetics are used to block pain from a large area (or nerve distribution). Cocaine, the first local anesthetic [ 9 ]  was used topically in ophthalmology in 1884 by Carl Koller. [ 8 ] [ 9 ]  William Halstead completed the first  nerve block ; [ 8 ]  August Bier, the first clinical  spinal anesthesia ; [ 8 ]  Sicard and Cathlein, the caudal approach to epidural anesthesia in 1901; [ 8 ]  and Fidel Pages, the  lumbar epidural  approach in 1921. [ 7 ] [ 8 ]  In 1921, the first vaginal delivery under spinal analgesia was reported by Kreiss in Germany. [ 8 ]  George Pitkin is credited with popularizing obstetric spinal anesthesia in the United States. [ 8 ]  Charles B. Odom introduced lumbar epidural analgesia to obstetrics in 1935. [ 7 ] [ 8 ]


The anesthesiologist relies on several patient monitors intraoperatively to safely care for the patient. These include, but are not limited to,  pulse oximetry ,  capnography ,  electrocardiogram , non-invasive blood pressure cuff monitoring and temperature. [ 22 ]  In some cases, arterial blood gas monitoring may be used. [ 22 ]


Anesthesia for labor and vaginal delivery includes various modalities including pharmacological and non-pharmacological techniques. [ 23 ]


Non-pharmacological techniques include  Lamaze  breathing,  acupuncture ,  acupressure , LeBoyer technique, transcutaneous nerve stimulation, massage, hydrotherapy, vertical positioning, presence of a support person, intradermal water injections, and biofeedback amongst many more. [ 24 ]


Water immersion in the first stage of labor may reduce women's use of epidural. [ 25 ]  A meta analysis showed there may be benefits to the presence of a support individual (doula, family member) including lower use of pharmacologic analgesia, decreased length of labor, and lower incidence of cesarian section. [ 24 ] [ 26 ]  Hypnosis warrants further investigation. [ 23 ]


Obstetric anesthesiologists employ the following pharmacological agents and techniques:


Anesthesia for cesarean sections (C-sections) most commonly uses neuraxial (regional) anesthesia due to its better safety profile for both mother and baby. [ 24 ] [ 27 ]  However, for emergencies or cases where neuraxial anasthesia cannot be used, general anesthesia is used instead. [ 24 ]  Drugs used to induce general anesthesia include  thiopental ,  propofol ,  etomidate , and  ketamine . [ 24 ]  Unconsciousness is maintained using inhalation agents, and muscle relaxing agents are used as needed. [ 24 ]   Opioids are less commonly used prior to delivery due to fear of adverse effects on the neonate.  However under certain circumstances it is important to attenuate the hypertensive responses to induction and incision and ultra-short acting opioids (remifentanil and alfentanil) appear to be efficacious and safe. [ 28 ]


In the United States, obstetric anesthesiology is a sub-specialty of anesthesiology (i.e., an anesthesiologist trains for an additional year as a fellow to qualify as an obstetric anesthesiologist).  [ citation needed ]


After earning a four-year undergraduate bachelor's degree, students enroll in a four-year graduate education leading to a degree in medicine (the  Doctor of Medicine  degree (M.D.)) or in osteopathic medicine (the  Doctor of Osteopathic Medicine  degree (D.O.)). [ 29 ]  After receiving a medical degree, students must complete a four-year residency training at an approved anesthesiology program [ 30 ]  and pass certification exams to become a  board-certified, general anesthesiologist. [ 29 ]  Obstetric anesthesiologists then complete an additional year of study (fellowship) to gain specialized experience. [ 29 ]  Currently, obstetric anesthesia is not associated with an additional certification period over being board-certified in anesthesiology. [ 30 ]


Anesthesiologists use safe blood transfusions in certain situations as a therapy for patients with low oxygen carrying capacity or to correct coagulation problems. [ 31 ]  Certain religions (e.g.,  Jehovah's Witnesses ) prohibit the use of blood transfusions based on their religious beliefs. [ 32 ]  Medical ethics stand on the four pillars of autonomy, beneficence, non-maleficence and justice. [ 33 ]  Based on the basis of patient autonomy, a person who is deemed to have capacity and refuses a blood transfusion for religious reason has the right to do so. [ 34 ] [ 35 ]


Symphysiotomy  is a surgical procedure in which the  cartilage  of the  pubic symphysis  is divided to widen the  pelvis  allowing  childbirth  when there is a mechanical problem ( obstructed labour ).  It is also known as  pelviotomy [ 1 ]  and  synchondrotomy. [ 1 ]  It has largely been supplanted by  C-sections , with the exception of certain rare obstetric emergencies or in resource poor settings. It is different than  pubiotomy , where the pelvic bone itself is cut in two places, rather than cutting though the symphysis pubis joint. [ 2 ]


Symphysiotomy was advocated in 1597 by  Severin Pineau  after his description of a  diastasis of the pubis  on a hanged pregnant woman. [ 3 ]   Thus symphysiotomies became a routine surgical procedure for women experiencing an obstructed labour. [ citation needed ]  They became less frequent in the late 20th century after the risk of maternal death from  caesarean section  decreased (due to improvement in techniques, hygiene, and clinical practice). [ 4 ]


The most common indications are a trapped head of a  breech baby , [ 5 ] [ 6 ]   shoulder dystocia  which does not resolve with routine manoeuvres, and obstructed labor at full  cervical dilation , especially with failed  vacuum extraction . [ 5 ]  Use for shoulder dystocia is controversial. [ 5 ]


Currently the procedure is rarely performed in developed countries, but is still performed in "rural areas and resource-poor settings of developing countries" [ 7 ]  where caesarean sections are not available, or where obstetricians may not be available to deliver subsequent pregnancies. [ 8 ]  Current practice guidelines in Canada recommend symphysiotomy for trapped head during vaginal delivery of a breech birth.


A 2016 meta-analysis found that in low and middle income countries, there was no difference between maternal and perinatal mortality following either symphysiotomy or C-section. [ 9 ]  There was a lower risk of infection following symphysiotomy, but a higher risk of fistula, compared to C-section. [ 9 ]


Symphysiotomy results in a temporary increase in pelvic diameter (up to 2 centimetres (0.79 in)) by surgically dividing the  ligaments  of the  symphysis  under local anaesthesia. This procedure should be carried out only in combination with  vacuum extraction . [ 10 ]  Symphysiotomy can be a life-saving procedure in areas of the world where caesarean section is not feasible or immediately available as it does not require an operating theatre or "advanced" surgical skills. [ 5 ]  Since this procedure does not scar the  uterus , the concern of future uterine rupture that exists with cesarean section is not a factor. [ 11 ]


The procedure carries the risks of urethral and bladder injury,  fistulas , [ 9 ]  infection, pain, and long-term walking difficulty. [ 10 ]  Symphysiotomy should, therefore, be carried out only when there is no safe alternative. [ 10 ]   It is advised that this procedure should not be repeated due to the risk of  gait  problems and continual pain. [ 10 ]  Abduction of the thighs more than 45 degrees from the midline may cause tearing of the urethra and bladder. If long-term walking difficulties and pain are reported, the patient's condition generally improves with physical therapy. [ 10 ]


In 2002 an advocacy group called Survivors of Symphysiotomy (SoS) was set up alleging religiously motivated symphysiotomies were performed without consent and against best medical practice in  Republic of Ireland  between 1944 and 1987. [ 12 ] [ 13 ]  In 2014 Ireland agreed to pay women who received the procedure compensation without admitting liability. [ 14 ]


From approximately 2000, there was a controversy over the use of  symphysiotomies  during childbirth in the  Republic of Ireland  between 1944 and 1987. In 2002 an advocacy group called Survivors of Symphysiotomy (SoS) was set up in Ireland alleging religiously motivated symphysiotomies were performed without consent and against best medical practice in  Republic of Ireland  between 1944 and 1987. [ 1 ] [ 2 ]  In 2014 Ireland agreed to pay women who received the procedure compensation without admitting liability. [ 3 ]  Some media reported that  pubiotomy  was also practised, [ 4 ]  but only one payout was given in 2014 for an "accidental" pubiotomy that occurred in the 1950s. [ 5 ]


It is estimated that 1,500 women unknowingly and without consent underwent symphysiotomies during childbirth in the  Republic of Ireland  between 1944 and 1987. [ 6 ]  A 2012 report found that many of the victims say the  Catholic Church  "encouraged, if not insisted upon, symphysiotomies." [ 7 ]  It has been suggested that during that period, non-Catholic doctors recommended  sterilisation of women  after three  caesarean section  operations, while Catholic doctors usually recommended "compassionate hysterectomies" as a solution to the prohibition on sterilisations. [ 8 ]  Despite  legal restrictions  being placed on the use of artificial contraceptives, the average size of families in Ireland declined from the 1930s. [ 9 ] [ 10 ] [ 11 ]


Dr. Alex Spain was master of the  National Maternity Hospital  during the mid-20th century, and performed 43 symphysiotomies during his tenure. Spain's successor, Arthur Barry, was also a strong supporter of Catholicism and the practice of symphysiotomy. [ 12 ]


In 2002, survivor Matilda Behan and her daughter, Bernadette, set up an advocacy group for the victims called Survivors of Symphysiotomy (SoS). [ 13 ]  Matilda was operated upon at NMH 17 days before her baby was born. She thought she was being brought to theatre for a caesarean section. No one told her the plan was to do the 'new procedure,' a pubiotomy. [ 14 ]  In 2008, the  Irish Human Rights Commission  recommended that the Government should reconsider its decision not to set up an independent inquiry into symphysiotomy. The Minister for Health refused. [ 15 ]


On 18 February 2010, an  RTÉ   Prime Time  documentary revealed that, over half a century, some 1,500 women had symphysiotomies performed on them during childbirth by doctors in order to train medical personnel and perfect the surgery for Africa. Following the programme, victims of the procedure called on the Minister for Health,  Mary Harney , to initiate an independent inquiry. Instead, she commissioned the IOG, a training body, to inquire into itself by reviewing operations carried out by some of its own members for teaching purposes. [ 16 ] [ 17 ]


A  Dáil  debate on the issue was heard on 15 March 2012, which was organised by Deputy  Caoimhghín Ó Caoláin . Leading the debate in the Dáil, Ó Caoláin compared symphysiotomy to  clerical abuse : "The infliction of symphysiotomy on women in Ireland is one of the greatest medical scandals not only here but on an international scale. Symphysiotomy is a clinical scandal on a par with the clerical scandals we have seen exposed in the past two decades." [ 18 ]   Gerry Adams  described the procedure as "institutional abuse involving acts of butchery against women." [ 19 ]  While  Clare Daly  declared that "it is an important acknowledgment by the State of the crimes committed against many of the women present today, crimes which led to the suffering endured by them and their families for decades". [ 18 ]


Eight days later, on 23 March 2012, a  County Louth  woman, Olivia Kearney, who was subjected to a post caesarean-section symphysiotomy, which was performed by Dr. Gerard Connolly, was awarded €450,000 by the  High Court . [ 20 ]  The Kearney case was appealed to the  Irish Supreme Court , which found in favour of Ms. Kearney and declared that symphysiotomy was not a generally approved obstetric practice in 1969. While the Supreme Court reduced the award of damages from €450,000 to €325,000, the decision represented the first court condemnation of the practice of symphysiotomy by an institution of the Irish state. [ 21 ]


In June 2012 details of Professor Oonagh Walsh's draft report on the use of this procedure in Ireland were released. The report by Prof. Walsh (UCC) found that although symphysiostomies were phased out in most medical institutions across the country, Our Lady of Lourdes Hospital was practising the procedure until the 1980s, a fact linked to the "unswervingly Catholic ethos" of the hospital. [ 22 ]  The draft Walsh report nevertheless found that symphysiotomy was justifiable and sought to consult with survivors on its findings. [ 23 ]


The draft Walsh report was criticised by victims' advocate group Survivors of Symphysiotomy, as well as by a number of opposition TDs and journalists, for failing to adequately address issues such as patient consent and for perceivably justifying the performance of the operation. Survivors of Symphysiotomy members subsequently decided to boycott the second stage of the Walsh report. [ 24 ] [ 25 ]


Also in June 2012, Survivors of Symphysiotomy testified publicly before the Joint Oireachtas (Select) Committee on Justice. Catherine McKeever, a private patient at the Lourdes Hospital, Drogheda in 1969, told the Committee that she did not realise what had happened: 'I saw him [the doctor] with an instrument which I thought was a  bit brace  because my father was a wood turner. I felt a crack ... Nobody answered me or said anything'. Margaret Conlan, who was operated upon in 1962 in St Finbarr's Hospital, Cork, testified that she had never been told anything about it: 'My baby's head was perforated and the baby died... I did not find out [about the symphysiotomy] until I read it in the newspaper'. [ 26 ]


Ó Caoláin introduced the Statute of Limitations (Amendment) Bill, which was unanimously supported by Dáil on 17 April 2013. [ 27 ]  The proposed legislation sought to lift the statute of limitations for a period of one year, to enable all survivors of symphysiotomy to bring their cases through the Irish courts. By July 2013, the Bill had stalled before the Joint Oireachtas (Select) Committee on Justice, leading SoS to protest outside the Parliament on 26 June. [ 28 ]


In November 2013, Minister for Health  James Reilly  announced that Judge Yvonne Murphy had been appointed to review the findings of the Walsh report, to meet with survivors of symphysiotomy, hospital authorities, and insurers with a view to deciding on whether an ex gratia redress scheme would be preferred to allowing legal actions to proceed. The terms of reference for the Murphy inquiry were criticised by  Caoimhghín Ó Caoláin , who stated that the "type of scheme outlined in the terms of reference offers the women no prospect of adequate compensation for what was so barbarically done to them nor the choice to pursue their rights in the courts". [ 29 ]  It also emerged that the Government would no longer support the statute of limitations bill, which had been unanimously adopted by the Dáil in April 2013. [ 30 ]  SoS  rejected the Government's statement and described their plans as 'paternalistic'. [ 31 ]


In March 2014, Survivors of Symphysiotomy made a complaint to the  United Nations Committee Against Torture  about the Irish State's failure to properly, thoroughly or impartially investigate the practice of symphysiotomy in Ireland. [ 32 ] [ 33 ] [ 34 ]  In July, the United Nations committee on human rights called for the Irish government to hold an investigation into the issue. [ 4 ] [ 35 ]  In 2014 an investigation was established under Judge Harding Clark to allow the Ex-gratia Payment. In October 2016, this body published their report establishing that this procedure was used only rarely, and in very difficult labours. She found no evidence to support the claim that a symphysiotomy caused lifelong disability or suffering. Nevertheless, women who had the procedure were awarded compensation. The report found that at least one third of women claiming to have suffered from having the procedure never had symphysiotomies. Although these claimants were denied compensation, others with weak evidence received pay-outs. Judge Harding Clark stated 'I believe that early uncritical reliance on medical reports led me to make awards where it is highly probable that no symphysiotomy was performed.'  [ 36 ]
Commenting on the Harding Clark report, Nil Muižnieks on behalf of the Council for Europe stated that he was ‘particularly struck by the patronising tone’ of the report and that it did not ‘give acknowledgement to women’s suffering and seems to perpetuate some gender stereotypes against (elderly) women.’ [ 37 ]


Bariatrics  is a discipline that deals with the causes, prevention, and treatment of  obesity , [ 1 ]  encompassing both  obesity medicine  and  bariatric surgery .


The term  bariatrics  was coined around 1965, [ 2 ]  from the  Greek  root  bar - ("weight" as in  barometer ),  suffix  - iatr  ("treatment," as in  pediatrics ), and  suffix  - ic  ("pertaining to"). The field encompasses  dieting ,  exercise  and  behavioral therapy  approaches to  weight loss , as well as  pharmacotherapy  and  surgery . The term is also used in the medical field as somewhat of a euphemism to refer to people of larger sizes without regard to their participation in any treatment specific to weight loss, such as medical supply catalogs featuring larger hospital gowns and hospital beds referred to as "bariatric".


Being  overweight  or  obese  are both rising medical problems. [ 3 ] [ 4 ]  There are many detrimental health effects of obesity: [ 5 ] [ 6 ]  Individuals with a  BMI  (Body Mass Index) exceeding a healthy range have a much greater risk of medical issues. [ 7 ]  These include  heart disease ,  diabetes mellitus , many types of  cancer ,  asthma ,  obstructive sleep apnea , and chronic  musculoskeletal  problems. There is also a focus on the correlation between obesity and  mortality . [ 8 ]


Overweight and obese people, including children, may find it difficult to lose weight on their own. [ 9 ]  It is common for dieters to have tried fad diets only to find that they gain weight, or return to their original weight, after ceasing the diet. [ 10 ]  Some improvement in patient psychological health is noted after bariatric surgery. [ 11 ]  51% of bariatric surgery candidates report a history of  mental illness , specifically  depression , as well as being prescribed at least one psychotropic medication at the time of their surgery candidacy. [ 12 ] [ 13 ]


Although  diet ,  exercise ,  behavior therapy  and  anti-obesity drugs  are first-line treatment, [ 14 ]  medical therapy for severe obesity has limited short-term success and very poor long-term success. [ 15 ]   Weight loss surgery  generally results in greater weight loss than conventional treatment, and leads to improvements in  quality of life  and obesity related diseases such as  hypertension  and  diabetes mellitus . [ 16 ]  A meta-analysis of 174772 participants published in  The Lancet  in 2021 found that bariatric surgery was associated with 59% and 30% reduction in all-cause mortality among obese adults with or without  type 2 diabetes  respectively. [ 17 ]  This meta-analysis also found that median life-expectancy was 9.3 years longer for obese adults with diabetes who received bariatric surgery as compared to routine (non-surgical) care, whereas the life expectancy gain was 5.1 years longer for obese adults without diabetes. [ 17 ]


The combination of approaches used may be tailored to each patient. [ 18 ]   Bariatric treatments in youth  must be considered with great caution and with other conditions that may not have to be considered in adults.


Techniques used in bariatrics include  bioelectrical impedance analysis , a method to measure  body fat percentage .


A  bariatric ambulance  is an  ambulance  vehicle modified to carry the severely  obese . They have extra-wide interiors and carry "bariatric stretchers" and specialized  lifting gear  that is capable of carrying very large patients. [ 1 ]  They are required as a result of the increasing prevalence of obesity in the general population. [ 2 ] [ 3 ]  Currently, there is no  standardized  weight capacity for bariatric ambulances, and requirements may vary in populations according to epidemiological demand. However, they are typically designed to carry weights between 350 kg (770 lb) and up to at least 450 kg (990 lb). [ 4 ] [ 5 ]


This vehicle-related article is a  stub . You can help Wikipedia by  expanding it .


The  American Society for Metabolic & Bariatric Surgery (ASMBS)  is a non-profit medical organization dedicated to metabolic and  bariatric surgery , and  obesity -related diseases and conditions. [ 1 ] [ 2 ]  It was established in 1983. [ 3 ]


The ASMBS, as part of its mission statement, says it is “committed to educating  health professionals  and the  lay public  about metabolic and bariatric surgery as an option for the treatment of obesity and  morbid obesity  and improving the care and treatment of people with obesity and obesity-related diseases and conditions.” This surgical specialty organization says it “encourages its members to investigate and discover new advances in metabolic and bariatric surgery, while maintaining a steady exchange of experiences and ideas that may lead to improved patient outcomes.” [ 4 ]


In 2012, the ASMBS had approximately 4,000 members, [ 5 ]  which includes  surgeons ,  nurses , bariatricians,  psychologists ,  dietitians , and other medical specialists focused on the disease of obesity. [ 6 ]


The ASMBS is also an advocate for  healthcare policy  to promote patient access to high quality  prevention  and treatment of obesity. [ 7 ]


The ASMBS was established in 1983. Its founding president was  Edward Eaton Mason , MD, a surgeon who is considered the "father" of bariatric or obesity surgery. [ 8 ]


On August 15, 2007, the ASBS changed its name to the American Society for Metabolic & Bariatric Surgery (ASMBS) to reflect mounting clinical evidence demonstrating the effectiveness of surgery on  metabolic diseases , particularly  type 2 diabetes , [ 9 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ]  in addition to its effectiveness on obesity and morbid obesity. [ 14 ] [ 15 ] [ 16 ]


The ASMBS has held 29 annual scientific meetings. In 2013, the ASMBS and  The Obesity Society (TOS)  combined their respective annual meetings for "ObesityWeek," which was held from November 11 to November 16, 2013 in Atlanta, Georgia.  The scientific and educational conference drew  clinicians  and  scientists  from all over the world to review and discuss new data on the full spectrum of the disease of obesity. [ 17 ]


In 2006,  Centers for Medicare and Medicaid Services  (CMS) established a national coverage policy for bariatric/metabolic surgery to help reduce health risks associated with obesity, including death and disability, as long as the procedures were performed at facilities certified by the AMBS or the American College of Surgeons. [ 18 ]


In 2012, the ACS and ASMBS announced plans to combine their respective national bariatric surgery  accreditation  programs into a single unified program to achieve one national accreditation standard for bariatric surgery centers. [ 19 ]  More than 750 facilities are now enrolled in the program called Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program MBSAQIP) in the United States. [ 20 ]


The ASMBS Certified Bariatric Nurse (CBN) program was established in June 2007. [ 21 ]  Certification indicates nurses have met all testing requirements and have proven to be competent in the care of obese and bariatric surgery patients. [ 22 ]


Aspiration therapy  is a  bariatric approach  to siphon ingested food from the  stomach  via an implanted tube and port to the outside of the body to be discarded. [ 1 ]  The device for this approach was developed by researchers at  Washington University in St. Louis  to treat  obesity  and  has been named  AspireAssist . [ 1 ]  The device has also been termed a  reverse feeding tube . [ 2 ]   It was approved by the  Food and Drug Administration  (FDA) on June 14, 2016. [ 3 ]


AspireAssist is made by Aspire Bariatrics. It is inserted in an outpatient setting using an  endoscope  during an about 15 minutes procedure. [ 4 ]  People with the device can discharge yet undigested food via the port into the toilet, typically 20 to 30 minutes after a meal. Critics have called the approach “assisted bulimia”. [ 2 ]  In an initial study 18 people those with the device lost more weight than controls. [ 5 ]  The therapy is supported by a lifestyle counseling program, and requires regular medical supervision.


Candidates for the device cannot have an eating disorder, should be 22 years old or more, and should have a body mass index of 35 to 55. Short-term use is not encouraged. [ 3 ]  Contraindications for the device are certain eating disorders (i.e.  bulimia ), certain types of previous abdominal surgery, pregnancy, stomach ulcers and inflammatory bowel disease. [ 3 ]  Side effects reported are local skin irritation at the port site and abdominal discomfort, nausea, vomiting, constipation, and diarrhea. [ 3 ]  Local infection may require removal of the tube. [ 4 ]


The device is removable. [ 4 ]  Removal is performed on an outpatient basis and requires about ten minutes. [ 4 ]


Stanley K. Bernstein  is a  Canadian   physician  who founded and is the current owner of 60  weight-loss   clinics  in  Canada  known collectively as the Dr. Bernstein Diet & Health Clinics. Bernstein has owned and operated weight-loss clinics since 1974 [ 1 ]  and employs a weight-loss regimen involving a low  calorie  intake, frequent physician visits and injections of a  Vitamin B  solution. Bernstein is a member of the American Society of  Bariatric  Physicians.


Bernstein was raised near the  Moss Park  area of  Toronto  by Polish immigrant parents who owned a used clothing outlet called Bernstein's Second Hand Store on  Queen East . [ 2 ]  Bernstein graduated from the  University of Toronto  in 1966 and followed this by interning at  Mount Sinai Hospital  in Toronto. [ 2 ]


After completing his  internship , Bernstein set up a general family practice in 1967 near Gerrard and Greenwood in  Toronto , [ 2 ]  and was also involved in  geriatric  work at  Baycrest Centre.


In 1972, Bernstein traveled to  Las Vegas  to attend a conference hosted by the American Society of Bariatric Physicians. [ 2 ]  It was at this conference where Bernstein learned about a group of physicians who were using what was called the Simeons Approach as a way to help patients achieve weight loss. In order to achieve weight loss, the Simeons Approach prescribed a very low-calorie intake and injections of a hormone called  Human Chorionic Gonadotropin , or hCG, a hormone produced by pregnant women to break down fat stores thought to feed the baby. [ 3 ]


Bernstein returned to Toronto and began using this knowledge to treat patients at his practice by helping them achieve a state of Ketosis. [ 2 ]  Subsequently, Bernstein opened his first dedicated weight-loss clinic at the  Richmond-Adelaide Centre  of Toronto in 1977 and in 1978, his second clinic in Toronto's Yorkville neighbourhood and his third in 1978 at  Yonge and Eglinton , also in Toronto. [ 2 ]  By the early 2000s, Bernstein had 14 diet clinics in  Ontario . Over the next few years, his practice expanded to Ottawa, Vancouver, Edmonton and Calgary. Around 2005, Bernstein opened his first American clinics in  Virginia  and  Florida . [ 2 ]


As of 2010, Bernstein owned and operated 62 clinics across Canada, treating nearly 10,000 active patients. [ 4 ]  It is estimated that Bernstein's clinics have treated approximately 450,000 patients over the years, including Canadian Archbishop Marcel Gervais and comedian  Mike Bullard , who appeared in company advertisements for a period of time. [ 5 ]


Starting in 1979, the  Ontario College of Physicians and Surgeons  warned against the use of hCG in the treatment of  obesity  due to the lack of scientific evidence concerning the effects of its use. [ 3 ]  The Ontario College also warned against a 500-calorie diet used in conjunction with hCG treatment, citing the treatment's risk to a patient's health. [ 3 ]  Several doctors, including Bernstein, continued to administer and use hCG in their weight-loss treatments. In 1987, the Ontario College formally banned hCG as a weight-loss treatment. [ 3 ]


Following the ban on hCG, Bernstein discontinued using hCG injections as part of his diet program and replaced it with injections of a Vitamin B complex, the exact composition of which is a closely guarded secret. While on Bernstein's diet program, patients are administered Vitamin B injections multiple times a week and are instructed to maintain an intake of 800 to 1,500 calories per day on a strict diet regimen. [ 5 ]


In February 2009, Bernstein publicly complained that an editorial in the  Canadian Medical Association Journal  (CMAJ) concerning commercial diets unfairly targeted his clinics. [ 6 ]  CMAJ's editorial commented on commercial diet clinics and specifically their pattern of manipulating patients with false hopes and using medically unproven weight-loss techniques. As evidence of the latter, CMAJ's editorial specifically pointed out the use of Vitamin B injections. [ 6 ]


Bernstein's use of Vitamin B injections as part of his weight-loss program has met with skepticism and a lack of agreement by multiple members of the medical community. [ 3 ]


In 1988, Glenn Duffin, a thirty-one-year-old Canadian died of  cardiac arrhythmia  eight days after beginning Bernstein's diet program. [ 5 ]  Following Duffin's death, a  jury  concluded that his death was caused by stress brought about by family and financial issues and Bernstein's diet program. The jury also advised that patients using commercial weight-loss programs should be encouraged to lose no more than two pounds a week when considering a diet of 1,200 calories per day. [ 7 ]  Duffin's family filed a malpractice suit against Bernstein and was awarded $700,000 in damages in an out-of-court settlement. [ 2 ]


Bernstein has been a part of a number of litigation suits involving the proprietary secrets of his weight-loss clinics and his Vitamin B-based weight-loss program. In 2007, Bernstein brought to court Daniela Stoytcheva-Todorova and Vesselin Todorov under allegations that their weight-loss clinic, Veda Healthy Weight Loss Centre Inc., used trade secrets and confidential information belonging to Bernstein. Bernstein ended up discontinuing all claims against Todorov and Todorova. [ 8 ]  In 2009, Bernstein sought litigation against Dr. Nadia Brown under similar claims, [ 9 ]  and, following this, in 2011, Bernstein filed suit against Dr. Scott Seagrist, a former partner at two of  Bernstein's clinics, and his spouse, seeking $10.5 million in damages under allegations that Seagrist had improperly used trade secrets to begin his own weight-loss clinic. Bernstein's lawsuit against Seagrist was settled in an out-of-court agreement. [ 10 ]


In September 2009, Bernstein launched a lawsuit against Pat Poon, a  Canadian  weight-loss doctor who operates four weight-loss clinics in the Greater Toronto Area. [ 11 ]  In the lawsuit, Bernstein argued that Poon had defamed Bernstein in Poon's book  Dr. Poon's Metabolic Diet , as well as in a subsequent television show that Poon was a guest on. Dr. Poon's Metabolic Diet book has numerous breathing techniques for assisting with passing large bowel movements.


After a six-year lawsuit, the judge ruled in Bernstein’s favor, awarding $10,000 to Bernstein in damages.[12] In making the final decision, the judge admitted that the trial was more than a reputational dispute, saying, “It is more about turf warfare in the competitive world of diet medicine than about reputation”.[11]


In April 2014, the  College of Physicians and Surgeons of Ontario  ruled that Bernstein had repeatedly breached rules established by the College by advertising his weight-loss clinics through customer testimonials, before and after photos and medically unproven, superlative language. [ 4 ]  The College also ruled that Bernstein had acted against medical standards by connecting himself with the sale of his product, in this case, his diet clinics. As a result, Bernstein was instructed to appear before the College for a verbal warning. [ 4 ]


In May 2014, it was reported that Bernstein was set to contest the formal caution imposed on him by the College of Physicians and Surgeons. [ 12 ]


In February 2015, the  Health Professions Appeal and Review Board  dismissed a protest from Bernstein and his request that a formal caution on his use of advertising be thrown out. [ 13 ]  The appeal board found that previous investigations into the complaint that Bernstein had violated advertising rules were “adequate and reasonable”. The appeal board requested that further investigation be done into whether Bernstein was guilty of “steering” members of the public to visit doctors in his own clinics, which is a violation of rules. [ 13 ]


In October 2013 Bernstein applied for an order for inspectorship over 31 jointly owned properties with The Rose & Thistle Group owners and Toronto attorneys, Norma and Ronauld Walton.  In November 2013 he petitioned their entire real estate portfolio into receivership without notice to the lenders. [ 14 ]


Bernstein and the Waltons were legal partners in a property investment agreement, in which Bernstein financed the ventures and the Waltons were responsible for the finances, bookkeeping, accounting and filing of tax returns. < [ 15 ]  By 2013, Bernstein had invested $110 million into 31 different projects through the Rose & Thistle Group.


Bernstein's receivership caused the portfolio to go into automatic default across all 31 joint entities and receivership and power of sale of the portfolio followed by Schonfeld & Associates, receivers.


In 2016, Bernstein was awarded $66.9 million in damages also by Justice Newbould via application.  The Waltons asked for a trial but that request was denied by the Court.


The Waltons have communicated publicly that they "strongly disagree" with the accusations and have appealed the findings of  Ontario Superior Court 's ordered investigation. [ 14 ]


In 2015 Trez Capital sued Bernstein for over $14 million, alleging fraud and deceit. Trez Capital, a mortgage lender, financed four of the projects owned by Rose & Thistle and Bernstein. [ 16 ]


Bernstein brought a motion to dismiss Trez's claim on the basis of his and his CFO James Reitan’s evidence that Trez knew about their claim in September 2013 and thus were outside of the limitation period for filing. During a mini trial, the judge did not accept the testimony of Bernstein and Reitan as credible in comparison to the evidence of Coscia. Bernstein later appealed to the Court of Appeal and lost. [ 17 ]


Bernstein has now paid Trez money to settle the Trez litigation that alleged fraud and deceit. [ 18 ]  He paid this money pursuant to a Pierringer Agreement that mandates confidentiality of the amount paid by him.  An amended Statement of Claim is being filed with the Court accordingly.


Bernstein has been married to his second wife, Judy Bernstein, since 1992. [ 2 ]  Bernstein also has three adult sons, one who is a  radiologist  in  New York City , one a lawyer, and the third son, a business graduate who works at Bernstein's clinics. [ 2 ]


In 1977, Bernstein was instructed to testify before the Discipline Committee of the College of Physicians and Surgeons of Ontario in allegations that he had inappropriate sexual relations with Jo-Anne Johnston, who was mentally fragile and a patient of his from 1970 to 1973. The Committee concluded that Bernstein was guilty of the charge and disciplined Bernstein with a suspension from practice for 12 months, as well as a fine of $4,500. Bernstein successfully appealed this ruling and the guilty charge, fine and suspension were removed from his record. [ 19 ]


In 1992, Bernstein was arrested alongside Peter Gassyt and Arnold Markowitz, who were arrested and charged in a conspiracy to murder a business colleague and a friend. [ 20 ]  In the trial that followed, both Gassyt and Markowitz were charged with a conspiracy to murder, and in 1993, the two were convicted on a sole count of conspiracy to commit murder. [ 21 ]  At the time of Bernstein's arrest, undercover officers undertook an unannounced search of Bernstein's residence, where they found $2 million in stolen goods, including 24  Rolex  watches. [ 10 ]  As a result, along with conspiracy to murder, Bernstein was also charged with possession of stolen property. Both charges  were later dropped. [ 10 ]


In 1998, Bernstein, along with his wife, were robbed at gunpoint in their Toronto residence and bound and forced into the trunk of Bernstein's Mercedes. [ 22 ]  The assailants emptied Bernstein's safe of valuables and fled. Both Bernstein and his wife were unharmed in the robbery and the assailants were never captured. [ 22 ]


Pradeep Kumar Chowbey  is an Indian surgeon, known for  laparoscopic  and  bariatric  surgeries. [ 3 ]  He is the incumbent Executive vice chairman of the  Max Healthcare , Chairman of the  Minimal Access, Metabolic & Bariatric Surgery  and  Allied Surgical Specialities  of the Max Healthcare Institute, New Delhi. [ 4 ]  He is the founder of the  Minimal Access, Metabolic & Bariatric Surgery Centre  at the  Sir Ganga Ram Hospital , New Delhi [ 2 ]  and has served as the Honorary Surgeon to the  President of India ,  Dalai Lama  and the  Indian Armed Forces  (AFMS). [ 3 ]   The Government of India awarded him the fourth highest civilian honour of the  Padma Shri  in 2002. [ 5 ]


Chowbey graduated in medicine (MBBS) and secured his master's degree in surgery (MS) from  Netaji Subhash Chandra Bose Medical College  (then known as Government Medical College),  Jabalpur , after which he earned a diplomate from the  National Board of Examinations , New Delhi, in 1979. [ 6 ]  After starting his medical practice at a public hospital in Delhi, he moved to  Sir Ganga Ram Hospital  in 1984 to take up the post of a consultant surgeon, handling  hepatobiliary , pancreatic and breast surgeries. When  minimally invasive surgical method  was first developed in France in 1989, Chowbey underwent training in the procedure at  Singapore General Hospital  from the pioneers of the technology such as  Mohan Chellappa  which helped him to perform the first  Laparoscopic   Cholecystectomy  in North India. [ 6 ]