Immediately after the birth, ongoing assessments are performed with recommendations from the  American Academy of Pediatrics  and  American College of Obstetricians and Gynecologists . They have identified that  vital signs  of blood pressure, and pulse, uterine position, and bleeding should be assessed every 15 minutes for the first two hours after birth. [ 1 ] [ 16 ]  The temperature is then measured twice, four hours and eight hours after birth. This is to guard against  postpartum infections , previously known as childbed fever or puerpal sepsis, one of the main causes of  maternal mortality .


The care during the early postpartum period often continues when the patient returns home. A 2023 systematic review found that blood pressure monitoring at home appears to increase patient satisfaction while reducing hypertension-related hospital admissions. [ 18 ]


The caloric needs will change based upon the production of milk for the infant. The caloric requirement for a non-breastfeeding, non-pregnant woman changes from 1,800-2,000 kcal/day to 2,300 to 2500 kcal/day for the breastfeeding woman. Nutritional supplementation is often prescribed and recommended. In some instances women are encouraged to continue to take pre-natal vitamins. Increasing the intake of fluids is discussed. The need for additional levels of minerals is most likely due to lactation. Calcium and iron needs increase postpartum. [ 19 ]  Calories may need to increase by 333 kcal/day during the first four to six weeks postpartum and then by 400 kcal/day 6 months postpartum. [ 2 ]


Other foods or substances are not recommended postpartum if breastfeeding because they may have effects on the baby via breastmilk. Some clinicians discourage the use of caffeine. This could produce fussiness in the baby. Alcohol use is strongly discouraged. Consuming fish is healthy and provides vitamins, minerals and proteins. Consumption of  oily fish  like haddock, herring, sardines, grouper, and tuna may need to be limited due to pollutants. [ 20 ] [ 21 ]


Weight loss should be monitored to ensure recovery. Quick weight loss can reduce milk supply. Low carb and high protein diets may not be appropriate. A realistic weight loss goal is one pound per week. [ 2 ]


A  urinary catheter  is usually put in place before the  cesarean section  to prevent  urinary retention . The abdominal incision will be another site for pain and possible infection.  Moving out of bed  may be delayed. As with any surgical procedure, the risk is higher for the development of  blood clots  in the legs. In such cases intermittent  pneumatic pressure device  may be used or much simpler  compression stockings  could be given. Leg exercise will also be effective in promoting blood circulation in the legs. Higher levels of pain medication may be needed related to abdominal incisions. If the cesarean was not planned, some women will be disappointed and may benefit from encouraging counseling from clinicians. [ 2 ]


An  amniotic stem cell bank  is a facility that stores  stem cells  derived from  amniotic fluid  for future use. Stem cell samples in private (or family) banks are stored specifically for use by the individual person from whom such cells have been collected and the banking costs are paid by such person.  The sample can later be retrieved only by that individual and for the use by such individual or, in many cases, by her or his first-degree blood relatives. In case of amniotic fluid stem cell banking, the mother providing the donation initially has ownership of the stem cells and financial responsibility for its storage. When the child from that pregnancy reaches legal age, the ownership and responsibility for the sample may be transferred. The first private amniotic stem cell bank in the US was opened by  Bio cell Center  in October 2009 in  Medford, Massachusetts . [ 1 ] [ 2 ] [ 3 ]


Amniotic stem cells are collected from amniotic fluid extracted during a genetic  amniocentesis , a prenatal diagnosis procedure typically performed during the 2nd trimester of pregnancy.  For the purpose of stem cell preservation, a small amount of the fluid withdrawn for genetic analysis is saved in a collection container for transport to a processing and storage facility. Collection of the sample causes no change to the standard amniocentesis procedure and therefore adds no additional risk to the mother.
In the United States, the Food and Drug Administration regulates amniotic stem cells under the category of “Human Cells, Tissues, and Cellular and Tissue Based-Products.”


After the collection, the amniotic fluid sample containing the stem cells is shipped to a lab for processing, cryopreservation and storage. The processed sample is exposed to a gradual freezing process which is important because it keeps the cells alive during the cryopreservation process. After freezing, the sample is transferred to a liquid nitrogen storage tank. The protocols used for the cryopreservation process have largely been adapted from those originally designed for bone marrow haematopoietic stem cells.


Regenerative medicine is a field of medical research developing treatments to repair or re-grow specific tissue in the body. Because a person’s own (autologous) amniotic stem cells can be safely infused back into that individual without being rejected by the body’s immune system - and because they have unique characteristics compared to other sources of stem cells - they are an increasing focus of regenerative medicine research.
Research in this area has the potential to revolutionize medicine. It is advancing so rapidly that it is even difficult for medical professionals to supply the most up-to-date information for their patients. Possible future uses in the field of regenerative medicine include repairing heart tissue, birth defects, and other damaged tissues.


An  anonymous birth  is a birth where the mother gives birth to a child without disclosing her identity, or where her identity remains unregistered. In many countries, anonymous births have been legalized for centuries in order to prevent formerly frequent  killings of newborn children , particularly outside of marriage.


In an anonymous birth, the mother's right of  informational self-determination  severely curtails the children's right to know about their biological  ancestry , therefore going beyond the concept of a  confidential birth , where the identity of the mother is registered but remains undisclosed, unless the grown up child requests disclosure at a later point.


High rates of infant abandonment, child neglect, and neonaticide created the preventative systems of  baby hatches , anonymous birth, confidential birth, which are forms of giving birth without personal information or privately disclosing information. [ 1 ]  Infant abandonment is a form of  child abandonment  where a parent leaves their infant in attempt to end their guardianship.  Child neglect  is the lack of care given to a child.  Neonaticide  is a form of infanticide where babies are killed within 24 hours of their birth. [ 2 ]  Particularly with neonaticide, women are predominantly young, unmarried, with  unintended pregnancies . They also typically do not have a mental disorder. [ 2 ]  These women often hide their pregnancy and do not receive pre-natal care. [ 3 ]  Prevention of neonaticide, as well as, the other forms of child neglect, are through the anonymous and secretive measures of anonymous birth, confidential birth, and baby hatches. [ 2 ]


Early systems of anonymous birth can be found in  France  and  Sweden  in the 1600s and 1700s. Within beginning of the 21st century, nations proposing the policy of anonymous birth, along with baby hatches, have been  Switzerland ,  Austria , and  Germany . In addition, the  Czech Republic ,  Greece ,  Italy ,  Russia , and  Ukraine , allow mothers to keep their identity private. [ 4 ]  Alternatively, a form of anonymous birth and confidential birth occurs in the U.S. through  Safe-haven laws .
Early anonymous birth legislation can be found in  Sweden  where the  Infanticide Act  of 1778 granted mothers both the right and all means to give birth to their child anonymously. [ 5 ]


In  France  the tradition of anonymous births can be traced to 1638 when  Vincent de Paul  who instituted the  tour , a form of baby hatch. [ 6 ]  During the  French Revolution  anonymous births were legalized in 1793, when Article 326 of the  Code Civil  introduced both the concepts of  anonymous  and  confidential births . [ 7 ]  The decree provided for the creation of safe spaces for women to give birth safely. In 1811 the assistance was replaced with a system of baby hatches. This however caused a surge in abandoned babies and was never fully implemented. By 1860 the system of baby hatches called tours were all closed, and the practice was officially abolished in 1904 in favor of other  pro-birth  policies between 1870 and 1945. The pro-birth policies developed out of historical events of war and revolution. Anonymous birth still continued from the 1870s to 1940s with approximately 1000 children every year ending up in the system. Public hospitals, by 1941 were required to allow women to give birth anonymously if requested. In the 1940s, the official birth certificates in France recorded "sous X" meaning born under X in the place of their biological mother. [ 8 ]  In 1943 there was a waiting period of a month where mothers were still able to retain custody of their child if they gave them up. In 1960s waiting periods were extended to three months, health and social aid offices opened, and birth control was publicized by law. In 1978 a law allowed citizens access to personal documents, which for those born under X brought them to protest for their origins. In the 1990s conversation of the mother's right to privacy against the right of a child to know his origins was discussed, with the mother's right continuing to be upheld. In the 1990s there was also discussion of creating an organization to aid in information holding if a mother changes the decision to be anonymous which was created in the early 2000s. In 2002 a 'national council for access to personal origins' (CNAOP) was created to mediate between anonymous mothers and children. The birth mother is asked to leave information about her identity behind in a sealed envelope that can be opened by the CNAOP if the child ever asks, so that the birth mother can be contacted. However, the information is not to be given to the child without consent. [ 7 ]


Early anonymous birth legislation can be found in Sweden where the Infanticide Act of 1778 granted mothers both the right and all means to give birth to their child anonymously. Children born were documented with an unknown mother and would become a foster child. The measure lasted through the 1800s as infant deaths decreased. During this time other factors that contributed to child death as premarital intercourse and unmarried childbearing was punishable by fines to prison time between 1734 and 1865. The system of anonymous birth lasted in Sweden until 1917 when the child's right to know and be supported by mother was decided. After 1917 there were increased legislation on familial bonds and systems that still continue today. In 1998 Swedish legislation added a section of law to provide what is best for a child in custody. A social welfare committee investigates cases where children have been left anonymously to establish guardianship. Currently, there is no legislation allowing mothers to give birth anonymously. [ 5 ]


From 1784 to 1910 at the General Hospital of Vienna mothers could give birth anonymously and leave their child with the hospital. The hospital was created by Emperor Joseph II and nearly 100 births a month were recorded in this practice. The children left had a high mortality rate, nearly all the children died in placement at a nursery or foster home, but this changed over time. [ 9 ]


In 1974 Austria identified neonaticide as a major issue making it a specific crime. In 2002 Austria implicated the systems of anonymous birth and baby hatches legislation. From 2002 to 2004 Austria ran a campaign along with the preventive measures to lower neonaticide rates, but after 2004 neonaticide has been on the rise to rates comparable to pre-anonymous birth legislation in the late 1990s to early 2000s. [ 9 ]


In the late 1990s and early 2000s the proposal of legal legislation for the system of anonymous birth in  Germany  was brought. Groups outside of the German government attempted to push for the policy three times in the early 2000s they each failed. [ 10 ]  An anonymous birth policy was passed in 2013 in Germany. [ 4 ]


In 2003, the  European Court of Human Rights  ruled in a case involving anonymous birth in  Odièvre v. France . [ 11 ]  The applicant's mother had given birth anonymously; when the applicant later asked for more information, she was only given non-identifying information. The applicant appealed to the Court citing  Article 8 of the European Convention on Human Rights , stating that it was a violation to the right to a family life. The Court noted that the case could not simply be viewed as a conflict between the rights of the birth mother and the child, because it also affected the rights of the adoptive parents and any family of the birth mother. The Court ruled that, given that the recently created National Council on Access to Information about Personal Origins presented an avenue to contact the birth mother in a controlled way, the state had attempted to strike a sufficient balance between the competing rights; the application was therefore denied.


Babies are occasionally  switched at birth  or soon thereafter, leading to the babies being unknowingly raised by parents who are not their biological  parents . The occurrence has historically rarely been discovered in real life, but since the availability of  genealogical testing  of  DNA  has been discovered more frequently. The phenomenon has been common as a  plot device  in fiction since the 18th century.


In real life, such a switch occurs rarely. [ 1 ]  Since many cases of babies switched at birth are likely undocumented or unknown, the following is presumably not an exhaustive list. The below is ordered by birth year, if known.


Some hospitals take fingerprints, foot prints, or palm prints of newborns to prevent babies from being mixed up. Nurses also double check with the mother, checking the identity of that person as well, in order to prevent errors. [ 37 ] [ 38 ]  Many hospitals also have policies in which a medical record number is assigned to an infant at birth, and bands with this number as well as the last name of the mother of the infant, the sex of the infant, and the date and time of birth are placed on the infant and the mother immediately after parturition before the mother and child are separated. A band may also be placed on the father (or other person chosen by the mother) at the time of birth. [ citation needed ]


The  plot device  of babies who are switched at birth, or in their cradles, has been a common one in fiction since the 18th century. It is one of the several identifiable characteristics of melodrama that are plot devices dealing with situations that are highly improbable in real life. [ 1 ]


The use of this common theme has continued ever since. The device was used a number of times by  W. S. Gilbert , including in the  Gilbert and Sullivan   comic operas   H.M.S. Pinafore  and  The Gondoliers . In both cases, well-born babies were switched with commoners. In the original version of the French fairy tale  Beauty and the Beast  (1740) by  Gabrielle-Suzanne de Villeneuve , Beauty is a princess whose fairy aunt switched her at birth with a merchant's dead daughter to protect her from an evil fairy who had attempted to kill her and had also turned the Prince into a Beast.  Mark Twain  later used this plot device in  The Tragedy of Pudd'nhead Wilson  (1893), where two babies, one white and one black, are switched at birth, resulting in both  passing  for races that they are not. [ 39 ]  It is one of the themes that television films regularly exploited in the 1970s and 1980s. [ 40 ]


Possibly the most complex storyline involving the switched-at-birth plot device ran simultaneously on  All My Children  and  One Life to Live,  from March 2004 to February 2005. [ 41 ]  Involved were  All My Children ' s Bianca Montgomery and Babe Chandler, and  One Life to Live ' s Kelly Cramer Buchanan, as well as many other characters.


In the manga/anime  Kakkou no Iinazuke ,  Nagi Umino, whose biological parents are hotel tycoons; and Erika Amano, whose biological parents are owners of a local diner, are actually accidentally switched at birth. When they become older, their parents agree to have the two engaged. [ 42 ]


An Indian film named  Ala Vaikunthapurramuloo , an employee switches his son Raj with his rich employer's son Bantu at birth. Knowing this after 25 years, the grownup Bantu joins the company without revealing his real identity to his biological parents to solve their problems and ends up taking the ownership of the company.


Back labor  (less commonly called  posterior labor [ 1 ] [ 2 ] ) is a term referring to sensations of pain or discomfort that occur in the lower back, just above the  tailbone , to a mother during  childbirth . [ 3 ]


Back labor may be noted when the baby is face up in the birth canal (occiput posterior), and not face down, so that the back of the baby's skull ( occiput ) is pushed against the mother's  sacrum .  However back labor can also occur when the baby is in a different position. [ 3 ]   The discomfort is often noted to be intensely painful, and may not completely abate between contractions. [ 4 ]   Whether back labor will occur cannot be predicted.  Reports of how many mothers experience back labor vary, [ 5 ]  though estimates in the range of 30% are common. [ 6 ] [ 7 ]


Actions that have been suggested to ameliorate back labor include physical activity, changing positions, [ 8 ]  back rubbing, water massage, application of hot or cold to the lower back, use of a  birthing ball [ 9 ]  and medication including an  epidural . [ 3 ] [ 10 ]   Some research has suggested that injecting sterile water into the lower back may provide pain relief, but there is no consensus that it actually helps. [ 11 ]


Birth injury  refers to damage or injury to the child before, during, or just after the birthing process. " Birth trauma " refers specifically to mechanical damage sustained during delivery (such as nerve damage and broken bones). [ 1 ]


The term "birth injury" may be used in two different ways:


Birth injuries must be distinguished from birth defects. " Birth defect " refers to damage that occurs while the fetus is in the womb, which may be caused by genetic mutations, infections, or exposure to toxins. There are more than 4,000 types of birth defects. [ 2 ]


Difficult labor, also known as  dystocia  or obstructed labor, occurs when the child cannot easily pass through the  birth canal . This can result in  fetal distress  or physical trauma to the child, especially broken clavicles and  damage to the brachial plexus nerves . It can also deprive the child of  oxygen  as the umbilical cord is pinched, potentially causing  brain damage  or death. [ 3 ]


Difficult labor may occur because the baby is abnormally large ( macrosomia ), because the mother's pelvis or birth canal is small or deformed, or because the baby is in an  abnormal presentation  for the birth (such as  breech  or transverse presentation). [ 4 ]


Fetal malformations and birth injuries may occur as a result of exposure to  environmental toxins  such as  mercury  or  lead . [ 5 ]  Many medications can also affect the development of the fetus, as can alcohol, tobacco, and illicit drugs. [ 6 ]


Genetic  mutations  can cause a wide variety of fetal malformations, ranging from relatively mild  cleft lips  to severe and even fatal deformities. [ medical citation needed ]


Maternal infection  may be transmitted to the fetus; this is called a  vertically transmitted infection . The fetus has a weak immune system, so infections that are relatively minor in adults can be serious in a developing fetus. [ medical citation needed ]  In addition, some studies suggest that maternal infections increase the risk of  neurodevelopmental disorders , including  schizophrenia , in the child. [ 7 ]


Intrauterine hypoxia , or oxygen deprivation in the womb, can cause serious brain damage in the fetus. It most commonly occurs because of damage to or malformation of the  umbilical cord  or  placenta .  Intrauterine hypoxia can cause brain damage, including  cerebral palsy  and other neurological and psychiatric disorders. [ 8 ]


Certain maternal health issues can cause birth injuries.  Gestational diabetes  can cause  premature birth ,  macrosomia , or  stillbirth . [ 9 ]


Complications such as  placenta previa ,  placental abruption ,  placenta accreta ,  retained placenta ,  placental insufficiency ,  placental infarcts ,  anemia , and  preeclampsia  can limit the supply of oxygen and nutrients to the fetus, increasing the risk of birth defects. Severe cases may be fatal to the fetus. [ 10 ]


The  brachial plexus  is the plexus of nerves that lies between the neck and axilla and controls the motion of the arm and hand. The brachial plexus may be stretched and damaged during a difficult delivery. In minor cases, the nerves heal and full use of the hand and arm is recovered. In more severe cases, the child may sustain permanent nerve damage and may not have full use of the shoulder, arm, or hand. Brachial plexus injuries occur in 1–3 children per 1,000 live births. [ 11 ]


See  Erb's palsy  and  Klumpke's palsy .


Brain damage  may be caused by a number of factors, including fetal malformation due to genetic mutation or exposure to toxins,  intrauterine hypoxia , or physical trauma during delivery. [ 12 ]


Cerebral palsy  is one example of brain damage incurred before or during delivery; about 10,000 children are diagnosed with cerebral palsy every year. [ 13 ]


A difficult delivery may lead to bruising, especially on the head and face, from pressure against the mother's pelvis or pressure caused by  forceps  or a vacuum device (see  ventouse ) used in delivery. [ 14 ]


Bone fractures can occur during a difficult delivery. Fracture of the clavicle is the most common birth injury. [ 15 ]


Meconium  is a sticky substance that usually makes up the child's first bowel movement. If the fetus is stressed before or during delivery, the meconium may be released and may mix with the  amniotic fluid . If it gets into the child's airways or lungs, it can cause  meconium aspiration syndrome . Serious cases may result in  pneumonia  or a  collapsed lung . [ 16 ]


Birth injuries may be unavoidable or they may be attributable to  medical malpractice . When a legal claim results, birth injury cases are a subset of medical malpractice cases. Legal claims from birth injury cases typically seek compensation for the medical costs associated with the injury, including ongoing therapeutic and medical support for the child.


In order to prevail in a birth injury malpractice case, the  plaintiff  must show (1) that the medical care provider owed a duty to the child, (2) that the medical care provider breached that duty by failing to meet the accepted  standard of care , (3) that the child sustained an injury that was caused by the medical care provider's breach of duty to the child, and (4) the child sustained damages as a result of the injury. All four elements must be present in order for the plaintiff to win. [ 17 ]


Birth spacing ,  pregnancy spacing ,  inter-birth interval  ( IBI ) or  inter-pregnancy interval  refers to how soon after a prior pregnancy a woman becomes pregnant or gives birth again. There are health risks associated both with pregnancies placed closely together and those placed far apart, but the majority of health risks are associated with births that occur too close together. [ 1 ]  The  WHO  recommends 24 months between pregnancies. [ 2 ]  A shorter interval may be appropriate if the pregnancy ended in  abortion  or  miscarriage . [ 2 ]  If the mother has had a prior  C-section , it is advisable to wait before giving birth again due to the risk of  uterine rupture  in the mother during childbirth, with recommendations of a minimum  inter-delivery interval  ranging from a year to three years. Pregnancy intervals longer than five years are associated with an increased risk of  pre-eclampsia . [ 3 ]  The global public health burden of short inter-pregnancy intervals is substantial. [ 2 ]   Family planning  can help increase inter-pregnancy interval. [ 4 ]


Family planning , such as the use of  contraceptives  can increase inter-pregnancy interval. [ 4 ]   Breastfeeding  and  extended breastfeeding  can also increase birth spacing due to  lactational amenorrhea . [ 5 ] [ 6 ] [ 7 ] [ 8 ]


Cultural and religious attitudes towards both sex and the use of contraceptives, [ 9 ]  price and availability of health care, and poverty are all factors which can affect inter-pregnancy intervals. [ 10 ]


Short inter-pregnancy interval is associated with an increase in  maternal mortality , [ 4 ] [ 11 ]   stillbirth , and  child mortality . [ 12 ]  Inter-pregnancy interval of lower than 18 months is associated with an increased risk of  pre-term birth . [ 13 ]


Short inter-pregnancy interval after a prior  C-section  can be a  contraindication  for having a vaginal birth after a prior C-section ( VBAC ). In one study inter-pregnancy intervals shorter than 6 months were associated with 2-3 times increased risk of  uterine rupture , major  morbidity , and  blood transfusion  during vaginal delivery in mothers with at least one prior C-section. [ 14 ]


Complications of a short inter-pregnancy interval are lower after an abortion or miscarriage compared to a full-term pregnancy. [ 12 ]


An inter-pregnancy interval of greater than five years is associated with an increased risk of  pre-eclampsia . [ 3 ] [ 11 ]


In one study taking place in Saudi Arabia, children born after a short birth interval (under 17 months) were more likely to have poorer performance at school and poorer cognitive development. [ 15 ] [ 16 ] [ 17 ]  Risk of accidental injury also increases with decreasing birth interval. [ 15 ]  Long IPIs greater than 24 months were associated with language deficits, and greater than 60 months were associated with an increased risk of deficits in communication skills and less general knowledge. [ 15 ]


The global  public health  burden of short inter-pregnancy intervals is substantial. [ 2 ]  In developing countries, children born two years or earlier after an older sibling were at a 60% increased risk of death in infancy, while those born between two and three years had a 10% increase, compared with those born after intervals of four to five years. [ 18 ]  Various organisations, including the  World Health Organization [ 2 ]  have identified birth spacing as an important area of public health intervention. Evidence for causality of these associations in high-resource environments is weak. [ 19 ]


In one study, the average birth interval across all countries was 32.1 months (2.7 years). The region with the greatest percentage of short interbirth intervals was central Asia, where a third of children were born less than 24 months apart. The region with lowest burden was Sub-Saharan Africa, with 20% of births having an interval of less than 24 months. [ 20 ]


Birth intervals have been found to be higher in traditional  hunter-gatherer  societies. The median birth interval of the Gainj people of the  New Guinea Highlands  has been reported as 3.6 years (43 months), [ 21 ]  and that of the  !Kung people  of Africa as 3.7 years (44 months). [ 22 ]


The inter-birth intervals in wild  apes  are reported to be significantly longer than those in  humans , with median birth intervals at 3.8 years for  gorillas , 5.6 years for  chimpanzees  and 7.7 years for  orangutans . [ 21 ]


Birth tourism  is the practice of traveling to another country or city for the purpose of  giving birth  in that country. The main reason for birth tourism is to obtain citizenship for the child in a country with birthright citizenship ( jus soli ). [ 1 ]  Such a child is sometimes called an " anchor baby " if their citizenship is intended to help their parents obtain  permanent residency  in the country. Other reasons for birth tourism include access to public schooling, healthcare, sponsorship for the parents in the future, [ 2 ]  hedge against corruption and political instability in the children’s home country. [ 3 ]  Popular destinations include the  United States  and  Canada . Another target for birth tourism is  Hong Kong , where some mainland Chinese citizens travel to give birth to gain  right of abode  for their children.


In an effort to discourage birth tourism, Australia, France, Pakistan, Germany, Ireland, New Zealand, South Africa, and the United Kingdom have modified their citizenship laws at different times, mostly by granting citizenship by birth only if at least one parent is a citizen of the country or a legal permanent resident who has lived in the country for several years. Germany has never granted unconditional birthright citizenship, but has traditionally used  jus sanguinis , so, by giving up the requirement of at least one citizen parent, Germany has softened rather than tightened  its citizenship laws .


Since the  Twenty-seventh Amendment of the Constitution of Ireland  was enacted in 2004, no European country presently grants unconditional birthright citizenship; [ 4 ] [ 5 ]  however, most countries in the Americas, e.g., the United States, Canada, Mexico, Argentina, and Brazil do so. In Africa,  Chad ,  Lesotho  and  Tanzania  grant unconditional birthright citizenship, [ 6 ]  as do some in the Asian-Pacific region including Fiji, Pakistan, and  Tuvalu .  [ citation needed ] [ 7 ]


The United States, Canada, and Mexico all grant unconditional birthright citizenship and allow dual citizenship. The United States taxes its citizens and green card holders worldwide, even if they have never lived in the country. In Mexico, only naturalized citizens can lose their Mexican citizenship again (e.g., by naturalizing in another country).


The  Fourteenth Amendment to the United States Constitution , which was ratified after the Civil War to ensure that the freed slaves along with their children would get American citizenship, [ 1 ]  guarantees  U.S. citizenship  to those born in the United States, provided the person is "subject to the jurisdiction" of the United States. [ 8 ]  Congress has further extended birthright citizenship to all inhabited U.S. territories except  American Samoa . (A person born in American Samoa becomes a  non-citizen US national ). The parent(s) and child are still subject to  de jure  and  de facto  deportation, respectively. [ 9 ]  However, once they reach 21 years of age, American-born children, as birthright citizens, are able to sponsor their foreign families' U.S. citizenship and residency. [ 10 ] [ 3 ]


There are no statistics about the 7,462 births to foreign residents in the United States in 2008, [ 1 ]  the most recent year for which statistics are available. That is a small fraction of the roughly 4.3 million total births that year. [ 11 ]  The  Center for Immigration Studies , a  conservative think tank , estimated in 2012 that there were approximately 40,000 annual births to parents in the United States as birth tourists. [ 12 ] [ 13 ]  The center also estimated in 2012 that total births to temporary immigrants in the United States (e.g., tourists, students, guest workers) could be as high as 200,000. [ 14 ] [ unreliable source? ]


Russian birth tourism to Florida to 'maternity hotels' in the 2010s is documented. [ 10 ] [ 15 ] [ 16 ]  Birth tourism packages complete with lodging and medical care delivered in Russian begin at $20,000, and go as high as $84,700 for an apartment in Miami's Trump Tower II complete with a "gold-tiled bathtub and chauffeured Cadillac Escalade." [ 16 ]


One option for mainland Chinese mothers to give birth is  Saipan ,  Northern Mariana Islands , where the cost is cheaper and travel does not require a  U.S. visa . [ 17 ]  More than 70% of the newborns in Saipan have birth tourist PRC parents who take advantage of the 45-day visa-free visitation rules of the territory and the Covenant of the Northern Mariana Islands to ensure that their children can have American citizenship. There were 282 of these births in 2012. [ 18 ]  At least one  airline  in  Hong Kong  requests that women who are "observed to have a body size or shape resembling a pregnant woman" submit to a  pregnancy test  before they are allowed to fly to  Saipan . [ 19 ]


As of 2015 [update] ,  Los Angeles  is considered a center of the maternity tourism industry, which caters mostly to Asian women from  China  and  Taiwan ; [ 3 ]  authorities in the city there closed 14 maternity tourism "hotels" in 2013. [ 20 ]  The industry is difficult to close down since it is not illegal for a pregnant woman to travel to the U.S. [ 20 ]  On March 3, 2015, Federal agents in Los Angeles conducted a series of raids on three "multimillion-dollar birth-tourism businesses" expected to produce the "biggest federal criminal case ever against the booming 'anchor baby' industry", according to  The Wall Street Journal . [ 20 ] [ 21 ] [ 22 ]


Numerous "maternity businesses" advise pregnant mothers to hide their pregnancies from officials and commit visa fraud—lying to customs agents about their true purpose in the U.S. [ 23 ]  Once they give birth, several 'birth tourism' agencies aid the mothers in defrauding the U.S. hospital, taking advantage of discounts reserved for impoverished American mothers. [ 24 ] [ 25 ]  Some mothers will refuse to pay the bill for the medical care received during their hospital stay. [ 26 ]


On October 18, 2014, the North American Chinese language  Daily World Journal  reported that for several weeks the immigration authorities at  LAX  had been closely questioning pregnant Chinese women arriving there from China, and in many cases denying them entry to the United States and repatriating them within 12 hours, often on the same airplane on which they had flown to the United States. [ 27 ]  In March 2015, federal agents conducted raids on a series of large-scale maternity tourism operations bringing thousands of mainland Chinese women intent on giving their children American citizenship. [ 20 ] [ 21 ]  Congressional representatives such as  Phil Gingrey , who have tried to put an end to birth tourism, said these people are " gaming the system ". [ 28 ]  In August 2015, the issue was discussed among U.S. presidential candidates, including  Donald Trump  and  Jeb Bush .


In January 2019,  U.S. Immigration and Customs Enforcement investigations  led to the arrest of three southern California operators of "multimillion-dollar birth-tourism businesses" catering primarily to Chinese nationals. [ 29 ]


Effective January 24, 2020, a new policy was adopted that made it more difficult for pregnant foreign women to come to the US to give birth on US soil to ensure their children become US citizens. The country will no longer issue temporary B-1/B-2 visitor visas to applicants seeking to enter the United States for birth tourism. [ 30 ] [ 31 ]


In December 2020, federal prosecutors charged six  Long Island  residents who were operating a birth tourism scheme that cost U.S. taxpayers over $2 million. The suspects submitted over 99  Medicaid  claims for different women, assisting the births of about 119 children who now have U.S. citizenship. The suspects were charged with conspiracy to commit  health care fraud ,  visa fraud ,  wire fraud  and  money laundering . [ 32 ]


The United States, Eritrea, Hungary, Myanmar, and Tajikistan are currently the only countries in the world to tax their citizens worldwide, even if they have never lived in the country and were born to citizens living abroad. [ 33 ]  (see  International taxation )


A U.S.-born person is, as a citizen, automatically subject to U.S. taxation. This is true even if both parents are non-U.S. citizens, their child holds multiple citizenships, and the family leaves the U.S. right after the child's birth and never returns again. Children born to U.S. citizens living abroad are also automatically subject to U.S. taxation, even if he/she never enters the U.S.


U.S. permanent residents are also subject to worldwide taxation. Worldwide taxation is often cited as a reason for U.S. citizens or permanent residents to relinquish their citizenship or residency status. [ 33 ]


In 2015, the fee for renunciation of U.S. citizenship was raised by 422%. It went from US$450 to $2,350 and is the highest fee for the renunciation of a citizenship worldwide. [ 34 ]


Canada's citizenship law has, since 1947, generally conferred Canadian citizenship at birth to anyone born in Canada, regardless of the citizenship or immigration status of the parents. The only exception is for children born in Canada to representatives of foreign governments or international organizations. The Canadian government has considered limiting  jus soli  citizenship, [ 35 ]  and as of 2012 [update]  continues to debate the issue [ 36 ]  but has not yet changed this part of Canadian law.


Some expectant Chinese parents who have already had one child travel to Canada to give birth in order to circumvent China's  one-child policy , [ 37 ]  additionally acquiring Canadian citizenship for the child and applying for a passport before returning to China.


A Québec birth certificate entitles a student enrolled in that province to pay university tuition at the lower in-province rate; [ 38 ]  on average this was  $ 3760/year in 2013. [ 39 ]


Mexicans who are citizens by birth are individuals that were born in Mexican territory regardless of parents' nationality or immigration status in Mexico. Individuals born on Mexican merchant or Navy ships or Mexican-registered aircraft, regardless of parents' nationality, are still considered Mexican citizens. Only naturalized Mexicans can lose their Mexican citizenship.


In the  Canada–US border  region, the way to a hospital in the neighboring country is sometimes shorter than to a hospital in the patient's own country. So, Canadian women sometimes give birth to their children in U.S. hospitals, and U.S. women in Canadian hospitals. These children (sometimes called  "border babies" ) are usually dual citizens of both the country of their parents and their birth country.


Canada has entered the medical tourism field. [ 40 ]  In comparison to U.S. health costs, medical tourism patients can save 30 to 60 percent on health costs in Canada.


Mexican women sometimes engage in birth tourism to the United States or Canada to give their children U.S. or Canadian citizenship.


While some non-legal obstacles exist, Canada is one of only a few countries without legal restrictions on abortion. Regulations and accessibility vary between provinces.


In the United States, different states have different abortion laws, so that women in states with restrictive laws sometimes engage in abortion tourism, either to the U.S. states with more liberal laws or to Canada.


Most South American countries grant unconditional birthright citizenship and allow dual citizenship, however, some countries have strict abortion laws that make them risky birth-tourism destinations in case of complications during the pregnancy. In Brazil, abortion is illegal with exception to cases of rape, incest or if the mother's life is in danger. [ 41 ]  It is restricted to cases of maternal life, mental health, health, rape, or fetal defects. In Chile, abortion was forbidden completely, even if the pregnant woman's life is in danger until 2017. Current law allows abortion in Chile only if the mother's life is in danger, if the fetus is inviable and in rape cases.


Some countries do not allow their citizens to renounce their citizenship or only if the citizenship was acquired by birth there to non-citizen parents. In Argentina, Brazil, Ecuador, Peru, and Uruguay, voting is compulsory for citizens. In Bolivia, Brazil, Chile, Colombia, Cuba, Guatemala, Paraguay, and Venezuela, military service is mandatory.


Any person born in Argentine territory acquires Argentine citizenship at birth, [ 42 ]  excepting children of persons in the service of a foreign government (e.g. foreign diplomats). This can be also applied to people born in the Falkland Islands, a disputed territory between Argentina and the United Kingdom. Argentine citizens cannot renounce their Argentine citizenship.


A person born in Brazil acquires Brazilian citizenship at birth, regardless of their parents' ancestry. [ 43 ]  It is said Brazilian citizens cannot renounce their Brazilian citizenship, but it is possible to renounce it through a requirement made in the Brazilian consulate if they already have acquired another citizenship voluntarily. Foreign tourists, parents of a Brazilian child, may apply for permanent residency in Brazil based on their child's nationality. [ 44 ]


As of 2023, all children born in Chile acquire Chilean citizenship at birth, the only exception being children born of people working for foreign diplomatic missions. Chilean Supreme Court ruled that children of irregular immigrants are not to be considered "Transient foreigners" and therefore receive Chilean citizenship as well. [ 45 ]


Any person born in Paraguay territory acquires Paraguayan citizenship at birth. The only exception applies to children of persons in the service of a foreign government (like foreign diplomats).


As a non-sovereign territory,  Hong Kong  does not have its own citizenship; the status akin to citizenship in Hong Kong is the  right of abode , also known as  permanent residence . Hong Kong permanent residents regardless of citizenship are accorded all rights normally associated with citizenship, with few exceptions such as the right to a  HKSAR passport  and the eligibility to be elected as the  chief executive  which are only available to Chinese citizens with right of abode in Hong Kong.


According to the  Basic Law of Hong Kong , Chinese citizens born in Hong Kong have the right of abode in the territory. The 2001 court case  Director of Immigration v. Chong Fung Yuen  affirmed that this right extends to the  children of mainland Chinese parents who themselves are not residents of Hong Kong . [ 46 ]  As a result, there has been an influx of mainland mothers giving birth in Hong Kong in order to obtain right of abode for the child. In 2009, 36% of babies born in Hong Kong were born to parents originating from  Mainland China . [ 47 ]  This has resulted in backlash from some circles in Hong Kong to increased potential stress on the territory's social welfare net and education system. [ 48 ]  Attempts to restrict benefits from such births have been struck down by the territory's courts. [ 47 ]  A portion of the Hong Kong population has reacted negatively to the phenomenon, which has exacerbated social and cultural tensions between Hong Kong and mainland China. The situation came to a boiling point in  early 2012 , with Hong Kongers taking to the street to protest the influx of birth tourism from mainland China. [ citation needed ]


Malta changed the principle of citizenship to jus sanguinis on 1 August 1989 in a move that also relaxed restrictions against multiple citizenships.


Because of an enormous population [ citation needed ] , India abolished  jus soli  on 3 December 2004. This was in response to the fear of having mass immigration from Bangladesh. [ 49 ]   Jus soli  had already been progressively weakened in India since 1987.


India allows a form of " overseas citizenship ", but no real dual citizenship. In 2005, India introduced a new category of permanent residency which allowed people of Indian descent to live and work in the country. [ 50 ]


Irish nationality law  conveyed birthright citizenship to anyone born anywhere on the  island of Ireland  (including in  Northern Ireland , which is part of the  United Kingdom ) until the 27th Amendment was passed by referendum in 2004. The amendment was preceded by media reports of heavily pregnant women  claiming political asylum , who expected that, even if their application was rejected, they would be allowed to remain in the country if their new baby was a citizen. [ 51 ]  Irish birthright citizenship could also serve for immigration purposes abroad: the case of  Chen v Home Secretary  involved a  Chinese  woman living temporarily in the UK who travelled to  Belfast  to give birth, for the purpose of using her daughter's Irish (and thus  European Union ) citizenship to obtain the permanent right to reside in the UK as a parent of a dependent  EU citizen . Until 2004, Ireland was the last European country to grant unconditional birthright citizenship.


Ireland retains  jus soli  citizenship for people born anywhere on the island of Ireland with at least one parent who is (i) Irish; (ii) British; (iii) has the right to live permanently in Ireland or Northern Ireland (e.g. EU citizens); or (iv) has resided legally in Ireland or Northern Ireland for at least 3 of the 4 years preceding the child's birth (time spent as an asylum seeker does not count). The island of Ireland is expected to become an attractive birth tourism destination post-Brexit for British people from England, Wales and Scotland since the child is entitled to Irish citizenship and thus EU citizenship. [ 52 ]


The constitutional court of the Dominican Republic reaffirmed in TC 168-13 that children born in the Republic from individuals that were "in transit" are excluded from Dominican citizenship as per the Dominican Republic's constitution. The "in-transit" clause includes those individuals residing in the country without legal documentation, or with expired documentation. TC 168-13 also required the civil registry to be cleaned from abnormalities going as far back as 1929, when the "in-transit" clause was first put in place in the constitution. The Dominican government does not consider it a retroactive decision but only a reaffirmation of a clause that has been present in every revision of the Dominican constitution as far back as 1929.


In former times, some countries (Latin American countries and Canada) advertised their policy of unconditional birthright citizenship to become more attractive for immigrants. [ citation needed ]


Some women engage in birth tourism not to give their children a foreign citizenship, but because the other country has a better or cheaper medical system or allows procedures that are forbidden in the women's home countries (e.g. in-vitro fertilization, special tests on fetuses and embryos, or  surrogacy ).


But this may lead to legal problems for the babies in the home country of their future parents. For example, Germany, like 14 other EU countries, forbids surrogacy, and a baby born abroad to a foreign surrogate mother has no right to German citizenship. According to German law, the woman who gives birth to a baby is its legal mother, even if it is not genetically related to her, and if the foreign surrogate mother is married, her husband is regarded as the legal father.


Many women travel abroad only for some procedures forbidden in their home countries, but then return to their home countries to give birth to their children ("pregnancy tourism").


Birth trauma  refers to damage of the tissues and organs of a newly delivered child, often as a result of physical pressure or trauma during  childbirth . It encompasses the long term consequences, often of cognitive nature, of damage to the brain or cranium. [ 1 ]  Medical study of birth trauma dates to the 16th century, and the morphological consequences of mishandled delivery are described in Renaissance-era medical literature.  Birth injury  occupies a unique area of concern and study in the medical canon. In  ICD-10  "birth trauma" occupied 49 individual codes (P10–Р15).


However, there are often clear distinctions to be made between brain damage caused by birth trauma and that induced by  intrauterine asphyxia . It is also crucial to distinguish between "birth trauma" and " birth injury ". Birth injuries encompass any systemic damages incurred during delivery ( hypoxic ,  toxic ,  biochemical , infection factors, etc.), but "birth trauma" focuses largely on mechanical damage.  Caput succedaneum ,  bruises , bleeding along the displacements of cranial bones, and  subcapsular hematomas  of the  liver  are among reported birth injuries. Birth trauma, on the other hand, encompasses the enduring side effects of physical birth injuries, including the ensuing compensatory and adaptive mechanisms and the development of pathological processes ( pathogenesis ) after the damage. [ 2 ]


Complications from birth trauma can include damage to the head, spinal cord, soft tissues, and organs. [ 2 ]


Trauma to the head of the infant can manifest as  caput succedaneum ,  skull fractures , extracranial and  intracranial hemorrhages , and  cranial nerve injuries . Caput succeedaneum is seen as  edema  in the scalp due to squeezing of the veins from increased pressure while passing through the  birth canal . [ 2 ]


Birth trauma is uncommon in the Western world in relation to rates in the third world. In the West injury occurs in 1.1% of C-sections. [ 3 ] [ 4 ]


While any number of injuries may occur during the birthing process, a number of specific conditions are well described.   Brachial plexus palsy  occurs in 0.4 to 5.1 infants per 1000 live births. [ 6 ]  Head trauma and brain damage during delivery can lead to a number of conditions include:  caput succedaneum ,  cephalohematoma ,  subgaleal hemorrhage ,   subdural hemorrhage ,  subarachnoid hemorrhage ,  epidural hemorrhage , and  intraventricular hemorrhage . [ citation needed ]


The most common fracture during delivery is that of the  clavicle  (0.5%). [ 7 ]


Bonzun   is a Swedish-based company, with backing from both the  World Health Organization  and  UNICEF .  Bonzun helps pregnant women get access to information previously not available online. Their main focus is pregnancy information to the  Chinese  people.


The success of the website and app in China has led to the founder receiving a number of awards for her innovation.


Bonzun is a fem tech company that built the first symptom checker for pregnant women in the world, a virtual midwife that is recommended by both UNICEF and WHO.  Bonzun was first founded in 2010, after  Bonnie Roupé  got seriously ill during the pregnancy of her second child and she could not find any information online. Bonnie Roupé and her baby survived, but she could not get over the fact that so many women around the world suffer and die because of lack of information online. She wanted to create a service to make research available to doctors and mothers all over the world. Information that helps and saves lives. Bonnie Roupe stated that around 20 million women a year fall pregnant in  China , meaning there was a large market for the  medical  information. The website describes common and serious pregnancy complications and make information accessible in China so pregnant women and health care professionals can improve their knowledge, especially in  rural areas .


Bonnie Roupé is a native of  Sweden , but started the company without a local partner in mainland  China . In an interview, she stated that it was a good learning curve to go through the processes alone, but admitted that it may have been faster to use a local partner.


In 2012, Bonzun was selected for the Innovation Against Poverty, which was received from the  Swedish International Development Cooperation Agency  (SIDA). During the same year, the company's founder Bonnie Roupé was selected as one of Sweden's super-talents under 40 years old, by the  Swedish  magazine,  Veckans Affärer .


The company announced in 2014 that they were receiving support for their work from both the  World Health Organization  and  United Nations’ Children's Rights & Emergency Relief Organization (UNICEF) . The company's focus on the  Chinese  health market led the company to have its innovations present in various hospitals across  China , along with 3,700 clinics.


During that year, Bonzun also created a  mobile app , which is now being used by pregnant women to understand their tests at various hospitals across  China .


In autumn of 2016, Bonzun participated in  Chinaaccelerator ´s three-month mentorship-driven program for internet startups from all over the world. The program was finalised on December 6, 2016 at  Chinaccelerator Batch 10 Demo Day  in Shanghai, China.


In June 2016,  InspiringFifty  selected Bonzun founder Bonnie Roupé as one of the  Nordic region´s 50 most inspirational tech women .


In March 2017 she was listed as one of Sweden's 125 most powerful women and ranked as the  10th most powerful women entrepreneur , Trade and Industry 2017 ( Veckans Affärer ).


In 2019 Bonnie Roupé was awarded Founder of the Year in Sweden by the Swedish governmental agency Tillväxtverket at Demoday.


The  born alive rule  is a  common law  legal principle that holds that various  criminal laws , such as  homicide  and  assault , apply only to a child that is " born alive ". U.S. courts have overturned this rule, citing recent advances in science and medicine, and in several states  feticide  statutes have been explicitly framed or amended to include  fetuses   in utero .  Abortion in Canada  is still governed by the born alive rule, as courts continue to hold to its foundational principles. In 1996, the  Law Lords  confirmed that the rule applied in  English law  but that alternative charges existed in lieu, such as a charge of unlawful or negligent  manslaughter  instead of  murder . [ 1 ]


The born alive rule was originally a principle at  common law  in England that was carried to the United States and other former colonies of the British Empire. First formulated by  William Staunford , it was later set down by  Edward Coke  in his  Institutes of the Laws of England . Coke says: "If a woman be quick with childe, and by a potion or otherwise killeth it in her wombe, or if a man beat her, whereby the child dyeth in her body, and she is delivered of a dead childe, this is great  misprision , and no murder; but if he childe be born alive and dyeth of the potion, battery, or other cause, this is murder; for in law it is accounted a reasonable creature, in rerum natura, when it is born alive. [ 2 ] [ 3 ]


The term "reasonable creature" echoes the language of an influential strand of Catholic doctrine on the nature of the soul and the  beginning of human personhood  which Aristotle generally adopted in holding, that it is the "rational soul" that infuses the fetus with "human beingness." There was disagreement as to whether this occurred at the moment of conception, or at the moment of  quickening , as Aristotle had held. [ 4 ]  As for  rerum natura ,  William Staunford  had explained "the thing killed must be in part of the world of physical beings (in rerum
natura). This has been interpreted as meaning completely expelled from the womb. [ 5 ]  Finally, the "thing killed" must be in the King's peace, i.e. in a situation where the protection of the King's peace applied. An outlaw, for instance, was not in the King's peace, and not subject to protection of the law.


The designation "misprision, and no murder", can be traced to the  Leges Henrici Primi  of 1115, which designated abortion "quasi homicide". [ citation needed ]  Here, we find the penalties for abortion were varying lengths of penance, indicating it was dealt with by  ecclesiastical courts , while homicide, being a breach of the King's peace, was dealt with in secular courts. Penalties for abortion varied depending on whether the fetus was formed or unformed, that is before or after  quickening , and were only imposed on women who had aborted the product of "fornication" (illicit sex), a distinction previously made by the  Venerable Bede . [ 6 ]


The personhood status of the fetus once born is a matter of speculation, as children had little recognition at law prior to the  Offences against the Person Act 1828 , and today are still not considered full persons until they reach the age of majority and are deemed capable of entering into legally binding contracts. [ 7 ]   As the  Eliza Armstrong case  shows, however, it was still legal for a father to sell his child as late as 1885, long after the slave trade had been abolished in England.


In the nineteenth century, some began to argue for legal recognition of the moment of conception as the beginning of a human being, basing their argument on growing awareness of the processes of  pregnancy  and  fetal development . [ 8 ]  They succeeded in drafting laws which criminalized abortion in all forms and made it punishable in secular courts.


Advances in the state of the art in medical science, including medical knowledge related to the  viability of the fetus , and the ease with which the fetus can be observed in the womb as a living being, treated clinically as a human being, and (by certain stages) demonstrate neural and other processes considered as  human , have led a number of jurisdictions – in particular in the United States – to supplant or abolish this common law principle. [ 8 ]


Examples of the evidence cited can be found within studies in  ultrasonography ,  fetal heart monitoring ,  fetoscopy , and  behavioral neuroscience . Studies in  Neonatal perception  suggest that the physiology required for  consciousness  does not exist prior to the 28th week, as this is when the thalamic afferents begin to enter the cerebral cortex. How long it takes for the requisite connection to be properly established is unknown at this time. Additionally, it is unclear whether the presence of certain hormones may keep the fetal brain sedated until birth. [ 9 ]


The rule forms the foundation of  UK law  related to the fetus. In the case  Attorney General's Reference No. 3 of 1994   Lord Mustill  noted that the legal position of the unborn, and other pertinent rules related to  transferred malice , were very strongly embedded in the structure of the law and had been considered relatively recently by the courts. [ 1 ]  The  Law Lords  concurred that a fetus, although protected by the law in a number of ways, is legally not a separate person from its mother in English law. They described this as outdated and misconceived but legally established as a principle, adding that the fetus might be or not be a person for legal purposes, but could not in modern times be described as a part of its mother. The concept of transferred malice and general malice were also not without difficulties; these are the legal principles that say when a person engages in an unlawful act, they are responsible for its consequences, including (a) harm to others unintended to be harmed, and (b) types of harm they did not intend. [ 1 ]  For example, the concept of transferred malice was applied where an assault caused a child to die not because it injured the child, but because it caused the child's  premature birth . [ 10 ]  It was also applied where manslaughter through a midwife's gross negligence caused a child to die before its complete birth. [ 11 ]


In Attorney General's Reference No. 3 of 1994 where a husband stabbed his pregnant wife, causing premature birth, and the baby died due to that premature birth, in English law no murder took place. "Until she had been born alive and acquired a separate existence she could not be the victim of homicide". The requirement for murder under English law, involving transfer of malice to a fetus, and then (notionally) from a fetus to the born child with legal personality, who died as a child at a later time despite never having suffered harm as a child with legal personality, nor even as a fetus having suffered any fatal wound (the injury sustained as a fetus was not a contributory cause), nor having malice deliberately directed at it, was described as legally "too far" to support a murder charge. [ 1 ]  They noted that English law allowed for alternative remedies in some cases, specifically those based on "unlawful act" and "gross negligence"  manslaughter  and other offenses which do not require intent to harm the victim (manslaughter in English law is capable of a sentence up to and including  life imprisonment ): "Lord Hope has, however, ... [directed]... attention to the foreseeability on the part of the accused that his act would create a risk ... All that it  [sic]  is needed, once causation is established, is an act creating a risk to anyone; and such a risk is obviously established in the case of any violent assault ... The unlawful and dangerous act of B changed the maternal environment of the foetus in such a way that when born the child died when she would otherwise have lived. The requirements of causation and death were thus satisfied, and the four attributes of 'unlawful act' manslaughter were complete." [ 1 ]


In the same ruling,  Lord Hope  drew attention to the parallel case of  Regina v. Mitchell  ([1983] Q.B. 741) where a blow aimed at one person caused another to suffer harm leading to later death, and summarized the legal position of the 1994 case: "The intention which must be discovered is an intention to do an act which is unlawful and dangerous ... irrespective of who was the ultimate victim of it. The fact that the child whom the mother was carrying at the time was born alive and then died as a result of the stabbing is all that was needed for the offence of manslaughter when  actus reus  for that crime was completed by the child's death. The question, once all the other elements are satisfied, is simply one of causation. The defendant must accept all the consequences of his act, so long as the jury are satisfied that he did what he did intentionally, that what he did was unlawful and that, applying the correct test, it was also dangerous. The death of the child was unintentional, but the nature and quality of the act which caused it was such that it was criminal and therefore punishable. In my opinion that is sufficient for the offence of manslaughter. There is no need to look to the doctrine of transferred malice ... ." [ 1 ]  In other cases where the fetus has not achieved independent existence, an act causing harm to an unborn child may be treated legally as harm to the mother herself. For example, in the case  St George's Healthcare NHS Trust v S; R v Collins & Ors, ex parte S [ 12 ]  it was held a  trespass to the person  when a hospital terminated a pregnancy involuntarily because the mother was diagnosed with severe  pre-eclampsia . The court held that an unborn child's need for medical assistance does not prevail over the mother's autonomy and she is entitled to refuse  consent  to treatment, whether her own life or that of her unborn child depends on it. [ citation needed ]


The abolition of the rule has proceeded piecemeal, from case to case and from statute to statute, rather than wholesale. One such landmark case with respect to the rule was  Commonwealth vs. Cass , in the  Commonwealth of Massachusetts , where the court held that the stillbirth of an eight-month-old fetus, whose mother had been injured by a motorist, constituted  vehicular homicide .  By a majority decision, the Supreme Court of Massachusetts held that a viable fetus constituted a "person" for the purposes of vehicular homicide law. In the opinion of the justices, "We think that the better rule is that infliction of perinatal injuries resulting in the death of a viable fetus, before or after it is born, is homicide." [ 13 ]


Several courts have held that it is not their function to revise statute law by abolishing the born alive rule, and have stated that such changes in the law should come from the  legislature . In 1970 in  Keeler v. Superior Court of Amador County , the  California Supreme Court  dismissed a murder indictment against a man who had caused the stillbirth of the child of his estranged pregnant wife, stating that "the courts cannot go so far as to create an offense by enlarging a statute, by inserting or deleting words, or by giving the terms used false or unusual meanings ... Whether to extend liability for murder in California is a determination solely within the province of the Legislature." [ 13 ] [ 14 ]  Several legislatures have, as a consequence, revised their statutes to explicitly include deaths and injuries to fetuses in utero. The general policy has been that an attacker who causes the stillbirth of a fetus should be punished for the destruction of that fetus in the same way as an attacker who attacks a person and causes their death. Some legislatures have simply expanded their existing offences to explicitly include fetuses in utero. Others have created wholly new, and separate, offences. [ 13 ]


Braxton Hicks contractions , also known as  practice contractions  or  false labor , are sporadic  uterine contractions  that may start around six weeks into a pregnancy. [ 1 ]  However, they are usually felt in the  second  or  third trimester  of  pregnancy . [ 2 ]


Braxton Hicks contractions are often confused for labor. Braxton Hicks contractions allow the pregnant woman's body to prepare for labor. [ 1 ]  However, the presence of Braxton Hicks contractions does not mean a woman is in labor or even that labor is about to commence. [ 1 ]  Another common cause of pain in pregnancy is  round ligament pain .


Table 1. Braxton Hicks contractions vs. true labor [ 1 ]


Although the exact causes of Braxton Hicks contractions are not fully understood, there are known triggers that cause Braxton Hicks contractions, such as when a pregnant woman: [ 1 ] [ 3 ]


There are two thoughts for why these intermittent uterine muscle contractions may be occurring. The first is that these early “practice contractions” could be helping to prepare the body for true labor by strengthening the uterine muscle. [ 1 ]  The second is that these contractions may occur when the fetus is in a state of physiological stress, in order to help provide more oxygenated blood to the fetal circulation. [ 1 ]


The determination of Braxton Hicks contractions is dependent on the history and physical assessment of the pregnant woman's abdomen, as there are no specific imaging tests for diagnosis. [ 1 ]  The key is to differentiate Braxton Hicks contractions from true labor contractions (see Table 1 above).


Most commonly, Braxton Hicks contractions are weak and feel like mild cramping that occurs in a localized area in the front abdomen at an infrequent and irregular rhythm (usually every 10-20 minutes), with each contraction lasting up to 2 minutes. [ 1 ] [ 2 ]   [ 3 ]  They may be associated with certain triggers and can disappear and reappear; they do not get more frequent, longer, or stronger over the course of the contractions. [ 1 ]  However, as the end of a pregnancy approaches, Braxton Hicks contractions tend to become more frequent and more intense. [ 1 ]


On a physical exam, some uterine muscle tightening may be palpable, but there should be no palpable contraction in the uterine fundus and no cervical changes or cervical dilation. [ 1 ]  Braxton Hicks contractions do not lead to birth. [ 1 ]


More concerning symptoms that may require assessment by a healthcare professional include: [ 1 ]


Although there is no specific medical treatment for Braxton Hicks contractions, some alleviating factors include: [ 1 ] [ 3 ]


Braxton Hicks contractions are named after  John Braxton Hicks , the  English   physician  who first wrote about them in Western medicine. [ 4 ]  In 1872, he investigated the later stages of pregnancy and noted that many pregnant women felt contractions without being near birth. [ 4 ]  He examined the prevalence of uterine contractions throughout pregnancy and determined that contractions that do not lead to labor are a normal part of pregnancy. [ 4 ]


Caesarean section , also known as  C-section , cesarean, or  caesarean delivery , is the  surgical procedure  by which one or more babies are  delivered  through an incision in the mother's abdomen. It is often performed because  vaginal delivery  would put the mother or child at risk. [ 2 ]  Reasons for the operation include  obstructed labor ,  twin pregnancy ,  high blood pressure  in the mother,  breech birth ,  shoulder presentation , and problems with the  placenta  or  umbilical cord . [ 2 ] [ 3 ]  A caesarean delivery may be performed based upon the shape of the mother's  pelvis  or history of a previous C-section. [ 2 ] [ 3 ]  A trial of  vaginal birth after C-section  may be possible. [ 2 ]  The  World Health Organization  recommends that caesarean section be performed only when medically necessary. [ 3 ] [ 4 ]


A C-section typically takes 45 minutes to an hour. [ 2 ]  It may be done with a  spinal block , where the woman is awake, or under  general anesthesia . [ 2 ]  A  urinary catheter  is used to drain the  bladder , and the skin of the  abdomen  is then cleaned with an  antiseptic . [ 2 ]  An  incision  of about 15 cm (6 inches) is then typically made through the mother's lower abdomen. [ 2 ]  The  uterus  is then opened with a second incision and the baby delivered. [ 2 ]  The incisions are then  stitched  closed. [ 2 ]  A woman can typically begin  breastfeeding  as soon as she is out of the  operating room  and awake. [ 5 ]  Often, several days are required in the hospital to recover sufficiently to return home. [ 2 ]


C-sections result in a small overall increase in poor outcomes in low-risk pregnancies. [ 3 ]  They also typically take about six weeks to heal from, longer than vaginal birth. [ 2 ]  The increased risks include breathing problems in the baby and  amniotic fluid embolism  and  postpartum bleeding  in the mother. [ 3 ]  Established guidelines recommend that caesarean sections not be used before 39  weeks of pregnancy  without a medical reason. [ 6 ]  The method of delivery does not appear to have an effect on subsequent  sexual function . [ 7 ]


In 2012, about 23 million C-sections were done globally. [ 8 ]  The international healthcare community has previously considered the rate of 10% and 15% to be ideal for caesarean sections. [ 4 ]  Some evidence finds a higher rate of 19% may result in better outcomes. [ 8 ]  More than 45 countries globally have C-section rates less than 7.5%, while more than 50 have rates greater than 27%. [ 8 ]  Efforts are being made to both improve access to and reduce the use of C-section. [ 8 ]  In the United States as of 2017, about 32% of deliveries are by C-section. [ 9 ]  The surgery has been performed at least as far back as 715 BC following the death of the mother, with the baby occasionally surviving. [ 10 ]  A popular idea is that the Roman statesman  Julius Caesar  was born via caesarean section and is the namesake of the procedure, but if this is the true etymology, it is based on a misconception: until the modern era, C-sections seem to have been invariably fatal to the mother, and Caesar's mother  Aurelia  not only survived her son's birth but lived for nearly 50 years afterward. [ 11 ] [ 12 ]  There are many ancient and medieval legends, oral histories, and historical records of laws about C-sections around the world, especially in Europe, the Middle East and Asia. [ 13 ] [ 14 ]  The first recorded successful C-section (where both the mother and the infant survived) was performed on a woman in Switzerland in 1500 by her husband,  Jakob Nufer , though this was not recorded until 8 decades later. [ 13 ]  With the introduction of antiseptics and  anesthetics  in the 19th century, survival of both the mother and baby, and thus the procedure, became significantly more common. [ 10 ] [ 15 ]


Caesarean section (C-section) is recommended when  vaginal delivery  might pose a risk to the mother or baby. C-sections are also carried out for personal and social reasons on  maternal request  in some countries.


Complications of labor and factors increasing the risk associated with vaginal delivery include:


Other complications of pregnancy, pre-existing conditions, and concomitant disease, include:


The prevalence of caesarean section is generally agreed to be higher than needed in many countries, and physicians are encouraged to actively lower the rate, as a caesarean rate higher than 10–15% is not associated with reductions in maternal or infant mortality rates, [ 4 ]  although some evidence support that a higher rate of 19% may result in better outcomes. [ 8 ]


Some of these efforts are: emphasizing a long  latent phase  of labor is not abnormal and not a justification for C-section; a new definition of the start of active labor from a cervical dilatation of 4 cm to a dilatation of 6 cm; and allowing women who have previously given birth to push for at least 2 hours, with 3 hours of pushing for women who have not previously given birth, before  labor arrest  is considered. [ 3 ]   Physical exercise  during pregnancy decreases the risk. [ 19 ]  Additionally, results from a 2021 systematic review of the evidence on outpatient  cervical ripening  found that in women with low-risk pregnancies, the risk of cesarean delivery with harms to the mother or child were not significantly different from when done in an inpatient setting. [ 20 ]


Adverse outcomes in low-risk pregnancies occur in 8.6% of vaginal deliveries and 9.2% of caesarean section deliveries. [ 3 ]


In those who are low risk, the  risk of death  for caesarean sections is 13 per 100,000 vs. for vaginal birth 3.5 per 100,000 in the developed world. [ 3 ]  The United Kingdom  National Health Service  gives the risk of death for the mother as three times that of a vaginal birth. [ 21 ]


In Canada, the difference in serious morbidity or mortality for the mother (e.g. cardiac arrest, wound hematoma, or hysterectomy) was 1.8 additional cases per 100. [ 22 ]  The difference in in-hospital maternal death was not significant. [ 22 ]


A caesarean section is associated with risks of postoperative  adhesions , incisional hernias (which may require surgical correction), and wound infections. [ 23 ]  If a caesarean is performed in an emergency, the risk of the surgery may be increased due to a number of factors. The patient's stomach may not be empty, increasing the risk of anaesthesia. [ 24 ]  Other risks include severe blood loss (which may require a blood transfusion) and  post-dural-puncture spinal- headaches . [ 23 ]


Wound infections occur after caesarean sections at a rate of 3–15%. [ 25 ]  The presence of  chorioamnionitis  and  obesity  predisposes the woman to develop a surgical site infection. [ 25 ]


Women who had caesarean sections are more likely to have problems with later pregnancies, and women who want larger families should not seek an elective caesarean unless medical indications to do so exist. The risk of  placenta accreta , a potentially life-threatening condition which is more likely to develop where a woman has had a previous caesarean section, is 0.13% after two caesarean sections, but increases to 2.13% after four and then to 6.74% after six or more.  Along with this is a similar rise in the risk of emergency hysterectomies at delivery. [ 26 ]


Mothers can experience an increased incidence of  postnatal depression , and can experience significant psychological trauma and ongoing  birth-related post-traumatic stress disorder  after obstetric intervention during the birthing process. [ 27 ]  Factors like pain in the first stage of labor, feelings of powerlessness, intrusive emergency obstetric intervention are important in the subsequent development of psychological issues related to labor and delivery. [ 27 ]


Women who have had a caesarean for any reason are somewhat less likely to become pregnant again as compared to women who have previously delivered only vaginally. [ 28 ]


Women who had just one previous caesarean section are more likely to have problems with their second birth. [ 3 ]   Delivery after previous caesarean section  is by either of two main options: [ 29 ]


Both have higher risks than a vaginal birth with no previous caesarean section. A vaginal birth after caesarean section (VBAC) confers a higher risk of  uterine rupture  (5 per 1,000), blood transfusion or  endometritis  (10 per 1,000), and  perinatal death  of the child (0.25 per 1,000). [ 30 ]  Furthermore, 20% to 40% of planned VBAC attempts end in caesarean section being needed, with greater risks of complications in an emergency repeat caesarean section than in an elective repeat caesarean section. [ 31 ] [ 32 ]  On the other hand, VBAC confers less  maternal morbidity  and a decreased risk of complications in future pregnancies than elective repeat caesarean section. [ 33 ]


There are several steps that can be taken during abdominal or pelvic surgery to minimize postoperative complications, such as the formation of  adhesions . Such techniques and principles may include:


Despite these proactive measures, adhesion formation is a recognized complication of any abdominal or pelvic surgery. To prevent adhesions from forming after caesarean section,  adhesion barrier  can be placed during surgery to minimize the risk of adhesions between the uterus and ovaries, the small bowel, and almost any tissue in the abdomen or pelvis. This is not current UK practice, as there is no compelling evidence to support the benefit of this intervention.


Adhesions can cause long-term problems, such as:


The risk of adhesion formation is one reason why vaginal delivery is usually considered safer than elective caesarean section where there is no medical indication for section for either maternal or fetal reasons.


Non-medically indicated (elective) childbirth before 39 weeks gestation "carry significant risks for the baby with no known benefit to the mother." Newborn mortality at 37 weeks may be up to 3 times the number at 40 weeks, and is elevated compared to 38 weeks gestation. These early term births were associated with more death during infancy, compared to those occurring at 39 to 41 weeks (full term). [ 34 ]  Researchers in one study and another review found many benefits to going full term, but no adverse effects in the health of the mothers or babies. [ 34 ] [ 35 ]


The  American Congress of Obstetricians and Gynecologists  and medical policy makers review research studies and find more incidence of suspected or proven  sepsis , RDS, hypoglycemia, need for respiratory support, need for NICU admission, and need for hospitalization > 4–5 days. In the case of caesarean sections, rates of respiratory death were 14 times higher in pre-labor at 37 compared with 40 weeks gestation, and 8.2 times higher for pre-labor caesarean at 38 weeks. In this review, no studies found decreased neonatal morbidity due to non-medically indicated (elective) delivery before 39 weeks. [ 34 ]


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 ]