{{Interventions infobox | Name = Caesarean section | Image = Caesarian.jpg | Caption = A team of obstetricians performing a Caesarean section in a modern hospital. | ICD10 = | ICD9 = | MeshID = D002585 | OPS301 = | OtherCodes = }} A Caesarean section, (also C-section, Caesarian section, Cesarean section, Caesar, etc.) is a surgical procedure in which one or more incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies, or, rarely, to remove a dead fetus. A late-term abortion using Caesarean section procedures is termed a hysterotomy abortion (not to be confused with hysterectomy) and is very rarely performed. The first modern Caesarean section was performed by German gynecologist Ferdinand Adolf Kehrer in 1881.

A Caesarean section is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk. More recently it has been performed upon request for childbirths that may otherwise have been natural. In recent years the rate has risen to a record level of 46% in China and to levels of 25% and above in many Asian and European countries, Latin America, and the United States.

Etymology

The Roman ''Lex Regia'' (royal law), later the ''Lex Caesarea'' (imperial law) of Numa Pompilius (715–673 BC), required the child of a mother dead in childbirth be cut from her womb. This seems to have begun as a religious requirement that mothers not be buried pregnant, and to have evolved into a way of saving the fetus, with Roman practice requiring a living mother be in her 10th month of pregnancy before the procedure was resorted to, reflecting the knowledge that she could not survive the delivery. Speculation that the Roman dictator Julius Caesar was born by the method now known as C-section is apparently false. Although Caesarean sections were performed in Roman times, no classical source records a mother surviving such a delivery, – the earliest recorded survival dates to 1500 AD – and Caesar's mother Aurelia Cotta lived to serve him as an advisor in his adulthood.

The term has also been explained as deriving from the verb ''caedere'', to cut, with children delivered this way referred to as ''caesones''. Pliny the Elder refers to a certain Julius Caesar (not the dictator, but a remote ancestor) as ''ab utero caeso'', "cut from the womb", a godly attribute comparable to rumours about the birth of Alexander the Great. This and Caesar's name may have led to a false etymological connection with the ancient monarch. Notably, the Oxford English Dictionary does not credit a derivation from "caedere", and defines Caesarean birth as "the delivery of a child by cutting through the walls of the abdomen when delivery cannot take place in the natural way, as was done in the case of Julius Cæsar".

Some link with Julius Caesar, or with Roman dictators generally, exists in other languages, as well. For example, the modern German, Danish, Dutch and Hungarian terms are respectively ''Kaiserschnitt'', ''kejsersnit'', ''keizersnede'', and ''császármetszés'' (literally: "Emperor's cut"). The German term has also been imported into Japanese (帝王切開 ''teiōsekkai'') and Korean (제왕 절개 ''jewang jeolgae''), both literally meaning "emperor incision". Similar in western Slavic (Polish) ''cięcie cesarskie'', (Czech) ''císařský řez'' and (Slovak) ''cisársky rez'' (literally "imperial cut"), whereas the south Slavic term is Serbian ''царски рез'' and Slovenian ''cárski réz'', which literally means "tzar" cut. The Russian term ''kesarevo secheniye'' (Кесарево сечение ''késarevo sečénije'') literally means ''Caesar's section''. The Arabic term (ولادة قيصرية ''wilaada qaySaríyya'') also means pertaining to Caesar or literally Caesarean. The Hebrew term ניתוח קיסרי (''nitúakh Keisári'') translates literally as Caesarean surgery. In Romania and Portugal, it is usually called ''cesariana'', meaning from (or related to) Caesar. According to Shahnameh ancient Persian book, the hero Rostam was the first person who was born with this method and term رستمينه (''rostamineh'') is corresponded to Caesarean.

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

Orthography

The e/ae/æ variation reflects American and British English spelling differences.

The cap-versus-lowercase variation reflects a style of lowercasing some eponymous terms (e.g., ''cesarean, eustachian, fallopian, mendelian, parkinsonian, parkinsonism''). Cap and lowercase stylings coexist in prevalent usage. Intradocument style consistency is usually advocated.

History

Bindusara (born c. 320 BC, ruled 298 – c.272 BC), the second Mauryan Samrat (emperor) of India, is said to be the first child born by surgery. His mother, wife of Chandragupta Maurya, accidentally consumed poison and died when she was close to delivering him. Chanakya, the Chandragupta's teacher and advisor, made up his mind that the baby should survive. He cut open the belly of the queen and took out the baby, thus saving the baby's life.

According to the Shahnameh, the Simurgh instructed Zal upon how to perform a Caesarean section, thus saving Rudaba and the child Rostam.

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

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

The Babylonian Talmud, an ancient Jewish religious text, mentions a procedure similar to the Caesarean section. The procedure is termed ''yotzei dofen''.

Pliny the Elder theorized that Julius Caesar's name came from an ancestor who was born by Caesarean section, but the truth of this is debated (see the article on the Etymology of the name of Julius Caesar). The Ancient Roman Caesarean section was first performed to remove a baby from the womb of a mother who died during childbirth. Caesar's mother, Aurelia, lived through childbirth and successfully gave birth to her son, ruling out the possibility the Roman dictator and general was born by Caesarean section. The Catalan saint Raymond Nonnatus (1204–1240), received his surname—from the Latin ''non natus'' ("not born")—because he was born by Caesarean section. His mother died while giving birth to him.

In 1316, the future Robert II of Scotland was delivered by Caesarean section—his mother, Marjorie Bruce, died. This may have been the inspiration for Macduff in Shakespeare's play ''Macbeth''.).

Caesarean section usually resulted in the death of the mother; the first recorded incidence of a woman surviving a Caesarean section was in the 1580s, in Siegershausen, Switzerland: Jakob Nufer, a pig gelder, is supposed to have performed the operation on his wife after a prolonged labour. However, there is some basis for supposing that women regularly survived the operation in Roman times. For most of the time since the 16th century, the procedure had a high mortality rate. However, it was long considered an extreme measure, performed only when the mother was already dead or considered to be beyond help. In Great Britain and Ireland, the mortality rate in 1865 was 85%. Key steps in reducing mortality were:

Introduction of the transverse incision technique to minimize bleeding by Ferdinand Adolf Kehrer in 1881 is thought to be first modern CS performed.

The introduction of uterine suturing by Max Sänger in 1882

Extraperitoneal CS and then moving to low transverse incision (Krönig, 1912)

Adherence to principles of asepsis

Anesthesia advances

Blood transfusion

Antibiotics

European travelers in the Great Lakes region of Africa during the 19th century observed Caesarean sections being performed on a regular basis. The expectant mother was normally anesthetized with alcohol, and herbal mixtures were used to encourage healing. From the well-developed nature of the procedures employed, European observers concluded they had been employed for some time.

The first successful Caesarean section to be performed in America took place in what was formerly Mason County, Virginia (now Mason County, West Virginia), in 1794. The procedure was performed by Dr. Jesse Bennett on his wife Elizabeth.

On March 5, 2000, Inés Ramírez performed a Caesarean section on herself and survived, as did her son, Orlando Ruiz Ramírez. She is believed to be the only woman to have performed a successful Caesarean section on herself.

An early account of Caesarean section in Iran is mentioned in the book of Shahnameh, written around 1000 AD, and relates to the birth of Rostam, the national legendary hero of Iran.

Types

There are several types of Caesarean section (CS). The type of incision used is dependent upon a number of factors and will be either (longitudinal or latitudinal). The incision on the skin may be different from the one used internally. There are two main types of incision used:

The classical incision involves a midline longitudinal cut in the uterus which allows a larger space to deliver the baby. However, it is rarely performed today, as it is more prone to complications and is only typically used in situations where the baby needs to be delivered very quickly and the latitudinal cut cannot be used for some reason

The lower uterine incision involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair. It is the procedure most commonly used today. The external cut is most typically horizontal too and is often referred to as the bikini cut as the skin incision is typcially below the bikini line just above the pubic hair

There are planned caesareans and emergency caesareans. Though terminology varies from one hospital or one practitioner to the next, the following categories hold:

Planned, Scheduled and Elective – These are pre-arranged caesareans. In this instance you may have requested the caesarean or had it recommended by a practitioner and labour has not usually begun. The term elective has become an emotive one often used in the "too posh to push" debate Emergency, Unplanned, Critical and Crash – These refer to situations where a vaginal birth is planned but events have taken over before or during labour and the baby is delivered by caesarean

Additional relevant terms:

Repeat caesarean - A delivery which ends with another caesarean (planned or emergency) when a patient has had one for a previous birth. Typically, a repeat caesarean is performed through the existing scar

Caesarean hysterectomy - A caesarean followed by the removal of the uterus. This rare operation may be performed in cases of intractable bleeding or in which the placenta cannot be separated from the uterus. The procedure can be used as a form of birth control

Extraperitoneal caesarean - No longer in use since the advent of antibiotics as the technique has greater degree of risk associated

Indications

Caesarean section is typically recommended when vaginal delivery might pose a risk to the mother or baby. Not all of the listed conditions represent a mandatory indication. Many fall into a rather 'grey' area where it should be a negotiation between the practitioner and the mother as to whether a caesarean is going to be performed. Informed choice ought to be instrumental in birth planning, however this is frequently not the case where 'grey' indications are identified. "Many grey areas exist and what is labelled a complication in one hospital is not necessarily the case in the birthing unit down the road." Knowing more 'balanced' detail about indications is crucial to successfully negotiating your birth preferences.

Indications for caesarean delivery E.g. complications of labor and factors impeding vaginal delivery:

prolonged labour or a failure to progress (dystocia)

fetal distress

cord prolapse

uterine rupture (An actual rupture, specifically NOT simply the risk of rupture due to prior caesarean for example)

increased blood pressure (hypertension) in the mother or baby after amniotic rupture

increased heart rate (tachycardia) in the mother or baby after amniotic rupture

placental problems (placenta praevia, placental abruption or placenta accreta)

abnormal presentation (breech or transverse positions)

failed labour induction

failed instrumental delivery (by forceps or ventouse (Sometimes a trial of forceps/ventouse delivery is attempted, and if unsuccessful, it will be switched to a Caesarean section.)

overly large baby (macrosomia)

umbilical cord abnormalities (vasa previa, multilobate including bilobate and succenturiate-lobed placentas, velamentous insertion)

contracted pelvis

Several of the indications above are open to negotiation and choice, based on informed risk analysis, ('failure to progress' in particular).

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

pre-eclampsia

hypertension

multiple births

Transverse baby (baby lies across the uterus)

Breech baby (baby presents bottom down rather than head down)

Precious (high risk) fetus

HIV infection of the mother

Sexually transmitted infections, such as genital herpes (which can be passed on to the baby if the baby is born vaginally, but can usually be treated in with medication and do not require a Caesarean section)

previous Caesarean section (though this is controversial – see discussion below)

prior problems with the healing of the perineum (from previous childbirth or Crohn's disease)

Bicornuate uterus

Rare cases of posthumous birth after the death of the mother

Several of the indications above are open to negotiation and choice, based on informed risk analysis, ('multiple birth', 'Breech', 'previous caesarean' 'HIV' in particular).

Other Lack of obstetric skill, e.g. practitioners not being skilled/comfortable performing breech births, multiple births, etc. (In this case women may birth under these circumstances naturally. However, practitioners are not always trained in proper procedures) Improper Use of Technology (Electric Fetal Monitoring [EFM]) and unfortunately in some places dedicated staff for the duration of labor cannot be guaranteed making certain vaginal births more stressful without support.

Risks

Risks for the mother

The mortality rate for both Caesarian sections and vaginal birth, in the Western world, continues to drop steadily. In 2000, the mortality rate for Caesareans in the United States were 20 per 1,000,000. The UK National Health Service gives the risk of death for the mother as three times that of a vaginal birth. However, it is misleading to directly compare the mortality rates of vaginal and Caesarean deliveries. Women with severe medical conditions, or higher-risk pregnancies, often require a Caesarean section which can distort the mortality figures.

A study in the ''Canadian Medical Association Journal'' found the absolute differences in severe maternal morbidity and mortality was small - 19.3 additional cases in 1000 or three times the risk, but this additional risk over vaginal delivery should be considered by women contemplating an elective Caesarean delivery and by their physicians.

As with all types of abdominal surgeries, a Caesarean section is associated with risks of postoperative adhesions, incisional hernias (which may require surgical correction) and wound infections. If a Caesarean is performed under emergency situations, the risk of the surgery may be increased due to a number of factors. The patient's stomach may not be empty, increasing the anaesthesia risk. Other risks include severe blood loss (which may require a blood transfusion) and postdural-puncture spinal headaches.

A study published in ''Obstetrics and Gynecology'' found women who had multiple Caesarean sections were more likely to have problems with later pregnancies, and recommended women who want larger families should not seek Caesarean section as an elective. The risk of placenta accreta, a potentially life-threatening condition, is only 0.13% after two Caesarean sections, but increases to 2.13% after four and then to 6.74% after six or more surgeries. Along with this is a similar rise in the risk of emergency hysterectomies at delivery. The findings were based on outcomes from 30,132 Caesarean deliveries.

It is difficult to study the effects of Caesarean sections because it can be difficult to separate out issues caused by the procedure itself versus issues caused by the conditions that require it. For example, one study found women who had just one previous Caesarean section were more likely to have problems with their second birth. Women who delivered their first child by Caesarean delivery had increased risks for malpresentation, placenta previa, antepartum hemorrhage, placenta accreta, prolonged labor, uterine rupture, preterm birth, low birth weight, and stillbirth in their second deliveries. However, the authors concluded some risks may be due to confounding factors related to the indication for the first Caesarean, rather than due to the procedure itself.

Risks for the child

This list is currently incomplete and should not be taken as comprehensive or reflective of current research. It covers some of the most commonly discussed risks to the child posed by the procedure itself rather than the medical indications that may call for it. Some risks are rare, and as with most medical procedures, the likelihood of any risk is highly dependent on individual factors, such as whether other pregnancy complications exist, whether the operation is planned or done as an emergency measure, and how and where it is performed.

Wet lung: Retention of fluid in the lungs can occur if not expelled by the pressure of contractions during labor.

Potential for early delivery and complications: Preterm delivery is possible if due-date calculation is inaccurate. One study found an increased risk of complications if a repeat elective Caesarean section is performed even a few days before the recommended 39 weeks.

Higher infant mortality risk: In C-sections performed with no indicated risk (singleton at full term in a head-down position), the risk of death in the first 28 days of life has been cited as 1.77 per 1,000 live births among women who had C-sections, compared to 0.62 per 1,000 for women who delivered vaginally

Incidence

In 2004, the Caesarean rate was about 20% in the United Kingdom, while the Canadian rate was 22.5% in 2001–2002.

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

In the United States the Caesarean rate has risen 48% since 1996, reaching a level of 31.8% in 2007. A 2008 report found that fully one-third of babies born in Massachusetts in 2006 were delivered by Caesarean section. In response, the state's Secretary of Health and Human Services, Dr. Judy Ann Bigby, announced the formation of a panel to investigate the reasons for the increase and the implications for public policy.

In Brazil's public health network, the rate reaches 35%, while in private hospitals the rate approaches 80%.

China has been cited as having the highest rates of C-sections in the world at 46% as of 2008

Studies have shown that continuity of care with a known carer may significantly decrease the rate of Caesarean delivery but there is also research that appears to show that there is no significant difference in Caesarean rates when comparing midwife continuity care to conventional fragmented care.

More emergency Caesareans—about 66%—are performed during the day rather than during the night.

Analyzing the rise in Caesarean section rates

The World Health Organization officially withdrew its previous recommendation of a 15% C-section rates in June 2010. Their official statement read, "There is no empirical evidence for an optimum percentage. What matters most is that all women who need caesarean sections receive them."

The US National Institutes of Health says rises in rates of Caesarean sections are not, in isolation, a cause for concern, but may reflect changing reproductive patterns:

The World Health Organization has determined an “ideal rate” of all cesarean deliveries (such as 15 percent) for a population. One surgeon's opinion is that there is no consistency in this ideal rate, and artificial declarations of an ideal rate should be discouraged. Goals for achieving an optimal cesarean delivery rate should be based on maximizing the best possible maternal and neonatal outcomes, taking into account available medical and health resources and maternal preferences. This opinion is based on the idea that if left unchallenged, optimal cesarean delivery rates will vary over time and across different populations according to individual and societal circumstances.

The number of C-sections performed has grown rapidly, for example, a fourfold increase from 1971 to 1991 (from 4.2 per 100 births). This may be accredited to the improved technology in detecting prebirth distress. Malpractice has been looked into because of the rapid increase. Some argue the higher costs of C-section births compared to regular births make physicians quicker to recommend surgery. Usually, if a doctor makes a recommendation, people are quick to take it to heart and act upon it. The effect of relative C-section price on C-section usage should be examined.

However, some commentators are concerned by the rise and have noted several evidence-based studies. Louise Silverton, deputy general-secretary of the Royal College of Midwives, says not only has society’s tolerance for pain and illness been “significantly reduced”, but also women are scared of pain and think if they have a Caesarean, there will be less, if any, pain. In the opinion of Silverton and the Royal College of Midwives, “women have lost their confidence in their ability to give birth."

Silverton's analysis is controversial among some surgeons. Dr Maggie Blott, a consultant obstetrician at University College Hospital, London and then a Royal College of Obstetricians and Gynaecologists (RCOG) spokeswoman on Caesareans (and Vice President of the RCOG), responded: 'There isn't any evidence to support Louise Silverton's view that increasingly pain-averse women are pushing up the Caesarean rate. There's an undercurrent that Caesarean sections are a bad thing, but they can be life-saving.'

A previously unexplored hypothesis for the increasing rate is the evolution of birth weight and maternal pelvis size. It is proposed that since the advent of successful Caesarean birth over the last 150 years, mothers with small pelvises and babies with large birth weights have survived and contributed to these traits, increasing in the population percentage. Such a hypothesis is based upon the idea that even without fears of malpractice, without maternal obesity and diabetes, and without other widely quoted factors, the C-section rate would continue to rise simply due to slow changes in population genetics.

Elective Caesarean sections

Caesarean sections are in some cases performed for reasons other than medical necessity. These can vary, with a key distinction being between hospital- or doctor-centric reasons and mother-centric reasons. Critics of doctor-ordered Caesareans worry that Caesareans are in some cases performed because they are profitable for the hospital, because a quick Caesarean is more convenient for an obstetrician than a lengthy vaginal birth, or because it is easier to perform surgery at a scheduled time than to respond to nature's schedule and deliver a baby at an hour that is not predetermined. Another reason for doctors to recommend C-sections is money. In China, doctors are compensated based on the monetary value of medical treatments offered. As a result, they have an incentive to persuade mothers to choosing the more expensive C-section.

In this context, it is worth remembering many studies have shown operations performed out-of-hours tend to have more complications (both surgical and anaesthetic). For this reason, if a Caesarean is anticipated to be likely to be needed for a woman, it may be preferable to perform this electively (or pre-emptively) during daylight operating hours, rather than wait for it to become an emergency with the increased risk of surgical and anaesthetic complications that can follow from emergency surgery.

Another contributing factor for doctor-ordered procedures may be fear of medical malpractice lawsuits. Italian gynaecologyst Enrico Zupi, whose clinic in Rome, Mater Dei, was under media attention for carrying a record of Caesarian sections (90% over total birth), explained: “We shouldn't be blamed. Our approach must be understood. We doctors are often sued for events and complications that cannot be classified as malpractice. So we turn to defensive medicine. We will keep acting this way as long as medical mistakes are not depenalized. We are not martyrs. So if a pregnant woman is facing an even minimum risk, we suggest she gets a C-section "

Studies of United States women have indicated married white women giving birth in private hospitals are more likely to have a Caesarean section than poorer women, although they are less likely to have complications that may lead to a Caesarean section being required. The women in these studies have indicated their preference for Caesarean section is more likely to be partly due to considerations of pain and vaginal tone. In contrast, a recent study in the British Medical Journal retrospectively analysed a large number of Caesarean sections in England and stratified them by social class. Their finding was Caesarean sections are not more likely in women of higher social class than in women in other classes. Some have suggested, due to the comparative risks of Caesarean section with an uncomplicated vaginal delivery, patients should be discouraged or forbidden from choosing it.

Some 42% of obstetricians believe the media and women are responsible for the rising Caesarean section rates. Some studies, however, conclude that relatively few women wish to be delivered by Caesarean section.

Anaesthesia

Both general and regional anaesthesia (spinal, epidural or combined spinal and epidural anaesthesia) are acceptable for use during Caesarean section. Regional anaesthesia is preferred as it allows the mother to be awake and interact immediately with her baby. Other advantages of regional anesthesia 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 Oesophageal intubation.

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. Regional anaesthesia during Caesarean section is different to the analgesia (pain relief) used in labor and vaginal delivery. The pain that is experienced because of surgery is greater than that of labor and therefore requires a more intense nerve block. The dermatomal level of anesthesia required for Caesarean delivery is also higher than that required for labor analgesia.

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.

Vaginal birth after Caesarean

While vaginal births after Caesarean (VBAC) are not uncommon today, the rate of VBAC has declined to include less than 10% of births after previous Cesarean. Although Caesarean deliveries made up only 5% of births overall in the USA until the mid-1970s, it was commonly believed that for women with previous Caesarean sections, "Once a Caesarean, always a Caesarean". A consumer-driven movement supporting VBAC changed medical practice and led to soaring rates of VBAC in the 1980s and early 1990s, but rates of VBAC dramatically dropped after the publication of a highly publicized scientific study showing worse outcomes for VBACs as compared to repeat Caesarean and the resulting medicolegal changes within obstetrics. In 2010, the National Institutes of Health, U.S. Department of Health and Human Services, and American College of Obstetrics and Gynecology all released statements in support of increasing VBAC access and rates.

In the past, Caesarean sections used a vertical incision which cut the uterine muscle fibres in an up and down direction (a classical Caesarean). Modern Caesareans typically involve a horizontal incision along the muscle fibres in the lower portion of the uterus (hence the term lower uterine segment Caesarean section). The uterus then better maintains its integrity and can tolerate the strong contractions of future childbirth. Cosmetically, the scar for modern Caesareans is below the "bikini line".

Obstetricians and other caregivers differ on the relative merits of vaginal and Caesarean section following a Caesarean delivery; some still recommend a Caesarean routinely, while others do not. In the US, the American College of Obstetricians and Gynecologists (ACOG) modified the guidelines on vaginal birth after previous Caesarean delivery in 1999, 2004, and again in 2010. In 2004, this modification to the guideline included the addition of the following recommendation:

Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.

In 2010, ACOG modified these guidelines again to express more encouragement of VBAC, but maintained it should still be undertaken at facilities capable of emergency care, though patient autonomy in assuming increased levels of risk should be respected (ACOG Practice Bulletin Number 115, August 2010).

The recommendation for access to emergency care during trial of labor has, in some cases, had a major impact on the availability of VBACs to birthing mothers in the US. For example, a study of the change in frequency of VBAC deliveries in California after the change in guidelines, published in 2006, found the VBAC rate fell to 13.5% after the change, compared with 24% VBAC rate before the change. The new recommendation has been interpreted by many hospitals as indicating a full surgical team must be standing by to perform a Caesarean section for the full duration of a VBAC woman's labor. Hospitals that prohibit VBACs entirely are said to have a 'VBAC ban'. In these situations, birthing mothers are forced to choose between having a repeat Caesarean section, finding an alternate hospital in which to deliver their babies or attempting delivery outside the hospital setting.

Most recently, enhanced access to VBAC has been recommended based on updated scientific data on the safety of VBAC as compared to repeat Caesarean section, including the following recommendation emerging from the NIH VBAC conference panel in March 2010, "We recommend that hospitals, maternity care providers, health care and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor." The U.S Department of Health and Human Services' Healthy People 2020 initiative includes objectives to reduce the primary cesarean rate and to increase the VBAC rate by at least 10% each.

Recovery period

Typically, the recovery time depends on the patient and her pain tolerance and inflammation levels. Doctors do recommend abstention from strenuous work (i.e., lifting objects over 10 lbs (4.5 kg)., running, walking up stairs, or athletics) for up to six months, and a waiting period of ~18 months before attempting to conceive another child.

Within Judaism

There is a dispute among the ''poskim'' (Rabbinic authorities) as to whether a first born son from a Caesarean section has the laws of a ''bechor''. Traditionally, a male child delivered by Caesarean is not eligible for the ''Pidyon HaBen'' dedication ritual.

See also

Fetal abduction

External links

International Caesarean Awareness Network

csections.org - a balanced view of caesareans - a possible outcome of your birth

References

Category:Obstetric surgery

ar:ولادة قيصرية az:Sezar kəsiyi bn:সিজারিয়ান সেকশন be:Кесарава сячэнне be-x-old:Кесарава сячэньне bg:Цезарово сечение ca:Cesària cs:Císařský řez da:Kejsersnit de:Schnittentbindung es:Cesárea eo:Cezara sekco fa:عمل سزارین fr:Césarienne ko:제왕 절개 hi:शल्य प्रसव hr:Carski rez id:Bedah sesar it:Taglio cesareo he:ניתוח קיסרי lt:Cezario pjūvis ml:സിസേറിയൻ mr:सीजेरियन सेक्शन शस्त्रक्रिया mn:Кесарево хагалгаа nl:Keizersnede ja:帝王切開 no:Keisersnitt pl:Cięcie cesarskie pt:Cesariana ru:Кесарево сечение simple:Cesarean section sl:Carski rez sr:Царски рез fi:Keisarileikkaus sv:Kejsarsnitt te:సిజేరియన్ ఆపరేషన్ th:การผ่าท้องทำคลอด tr:Sezaryen uk:Кесарів розтин vi:Mổ lấy thai zh:剖宫产

name	Anna Nicole Smith
birth name	Vickie Lynn Hogan
birth date	November 28, 1967
birth place	Houston, Texas
death date	February 08, 2007
death place	Hollywood, Florida
alias	Vickie Lynn Marshall (when married to Marshall), Vickie Lynn Smith (consideration moniker), Vickie Smith (early Playboy career)
occupation	model, actress, television personality
years active	1991–2007
spouse	Billy Smith (m.1985-1993; divorced) J. Howard Marshall II (m.1994-1995; his death)
children	Daniel Wayne Smith (1986–2006) Dannielynn Hope Marshall (b. 2006)
website	http://www.annanicole.com }}

Vickie Lynn Hogan (November 28, 1967 – February 8, 2007), known briefly as Vickie Smith, before settling on Anna Nicole Smith as her moniker, was an American model, actress and television personality. Smith first gained popularity in ''Playboy'', becoming the 1993 Playmate of the Year. She modeled for clothing companies, including Guess jeans and Lane Bryant.

Smith dropped out of high school and was married in 1985. Her highly publicized second marriage to oil business mogul J. Howard Marshall, 62 years her senior, resulted in speculation that she married the octogenarian for his money, which she denied. Following Marshall's death, Smith began a lengthy legal battle over a share of his estate; her case, ''Marshall v. Marshall'', reached the U.S. Supreme Court on a question of federal jurisdiction and again on a question of bankruptcy court authority (now called ''Stern v. Marshall''). She died on February 8, 2007 in a Hollywood, Florida hotel room as a result of an overdose of prescription drugs. Within the final six months of her life, Smith was the focus of renewed press coverage surrounding the death of her son, Daniel and the paternity and custody battle over her biological daughter Dannielynn.

Early life

Born Vickie Lynn Hogan in Harris County, Texas, Anna Nicole was the child of Donald Eugene Hogan (July 12, 1947 – September 19, 2009) and Virgie Mae (née Tabers; born July 12, 1951), who married on February 22, 1967 and divorced on November 4, 1969. She had five half siblings including half-sister Donna Hogan. Anna Nicole was raised by her mother and aunt. Virgie subsequently married Donald R. Hart in 1971. After Virgie married Donald, Anna Nicole changed her name from Vickie Hogan to Nikki Hart. Anna Nicole attended Durkee Elementary School and Aldine Intermediate School in Houston. When she was in the 9th grade, she was sent to live with her mother's younger sister, Kay Beall, in Mexia, Texas. At Mexia High School, Anna Nicole failed her freshman year and later quit school during her sophomore year. While working at Jim's Krispy Fried Chicken in Mexia, Anna Nicole met Billy Wayne Smith, who was a cook at the restaurant. The couple married April 4, 1985; when she was 17 and he was 16. Anna Nicole gave birth to their son, Daniel Wayne Smith on January 22, 1986. She and Billy separated in 1987 and she moved to Houston with one-year-old Daniel. They were officially divorced February 3, 1993, in Houston. Initially, Anna Nicole found employment at Wal-Mart, then as a waitress at Red Lobster. She then became a stripper, and in 1991, began taking modeling and voice lessons. In October of that year, she saw an ad in the newspaper to audition for ''Playboy'' magazine.

''Playboy'' and modeling career

name	Anna Nicole Smith
issue	May 1992
birth place	Harris County, Texas, United States
birth date	November 28, 1967
death date	February 08, 2007
death place	Hollywood, Florida, United States
bust	36DD (97DD cm)
waist
hips
natural bust	34A
height
weight
preceded	Cady Cantrell
succeeded	Angela Melini
pmoy-year	1993
pmoy-preceded	Corinna Harney
pmoy-succeeded	Jenny McCarthy }}

In 1992 Smith was chosen by Hugh Hefner to appear on the cover of the March issue of ''Playboy'', where she was listed as Vickie Smith, wearing a low-cut evening gown. The centerfold was photographed by Stephen Wayda. Smith said she planned to be "the next Marilyn Monroe". Becoming one of ''Playboys most popular models, Smith was heavier and larger than the typical Playboy model. Smith was chosen to be the 1993 Playmate of the Year. By the time of her PMOY pictorial, she had settled on the name Anna Nicole Smith'''.

Smith secured a contract to replace supermodel Claudia Schiffer in the Guess jeans ad campaign in a series of sultry black and white photographs. Guess capitalized on Smith's strong resemblance to Jayne Mansfield and put her in Jayne-inspired photo sessions. In 1993, before Christmas, she modeled for the Swedish clothing company Hennes & Mauritz (H&M;). She appeared on big posters in Sweden and Norway.

A photograph of Smith was used by ''New York'' magazine on the cover of its August 22, 1994 issue titled ''White Trash Nation''. In the photo, she appears squatting in a short skirt and cowboy boots as she eats chips. In October 1994, Smith's lawyer initiated a $5,000,000 lawsuit against the magazine claiming unauthorized use of her photo and that the article had damaged her reputation. Her lawyer said that Smith was told she was being photographed to embody the "all-American-woman look", and that they wanted glamor shots. He further stated that the picture used was taken for fun during a break.

Marriage to Marshall

While performing at Gigi's (now renamed as "Pleasures"), a Houston strip club, in October 1991, Smith met elderly oil tycoon J. Howard Marshall and they began a relationship. During their two-year relationship, he reportedly lavished gifts on her and asked her to marry him several times. She divorced her husband Billy on February 3, 1993, in Houston. On June 27, 1994, Smith, 26, and Marshall, 89, married in Houston. This resulted in a great deal of gossip about her marrying him for his money. Though she reportedly never lived with him, Smith maintained that she loved her husband, and age did not matter to her. Thirteen months after his marriage to Smith, Marshall died on August 4, 1995, in Houston.

Inheritance court cases

Within weeks of J. Howard Marshall's death, Smith and her husband's son, E. Pierce Marshall, battled over her claim for half of her late husband's US$1.6 billion estate. She temporarily joined forces with J. Howard's other son, James Howard Marshall III, whom the elder Howard had disowned. Howard III claimed J. Howard orally promised him a portion of his estate; like Smith, Howard III was also left out of J. Howard's will. The case has gone on for more than a decade, producing a highly publicized court battle in Texas and several judicial decisions that have gone both for and against Smith in that time.

In 1996, Smith filed for bankruptcy in California as a result of a $850,000 judgment against her for sexual harassment of an employee. As any money potentially due to her from the Marshall estate was part of her potential assets, the bankruptcy court involved itself in the matter.

Smith claimed J. Howard orally promised her half of his estate if she married him. In September 2000, a Los Angeles bankruptcy judge awarded her $449,754,134. In July 2001, Houston judge Mike Wood affirmed the jury findings in the probate case by ruling that Smith was entitled to nothing and ordered Smith to pay over $1 million in fees and expenses to Pierce's legal team. The conflict between the Texas probate court and California bankruptcy court judgments forced the matter into federal court.

In March 2002, a federal judge vacated the California bankruptcy court's ruling and issued a new ruling but reduced the award to $88 million. In December 2004, a three-judge panel of the U.S. 9th Circuit Court of Appeals reversed the March 2002 decision, on the reasoning that the federal courts lacked jurisdiction to overrule this probate decision.

The U.S. Supreme Court decided in September 2005 to hear the appeal of that decision. The Bush administration subsequently directed the Solicitor General to intercede on Smith's behalf out of an interest to expand federal court jurisdiction over state probate disputes. After months of waiting, Smith and her stepson Pierce learned of the Supreme Court's decision on May 1, 2006. The justices unanimously decided in favor of Smith; Justice Ruth Bader Ginsburg wrote the majority opinion. The decision did not give Smith a portion of her husband's estate, but affirmed her right to pursue a share of it in federal court. On June 20, 2006, E. Pierce Marshall died at age 67 from an "aggressive infection". His widow, Elaine T. Marshall, now represents his estate. The case was remanded to the 9th Circuit to adjudicate the remaining appellate issues not previously resolved.

After Smith's death, the ''New York Times'' reported that the case over the Marshall fortune "is likely to continue in the name of Ms. Smith’s infant daughter." The current situation is that Anna Nicole Smith's estate will not inherit any of her late husband's estate. Following the decision by the Appeals Court for the Ninth Circuit, lawyers for the estate of Anna Nicole Smith requested the appeal be heard before the entire 9th circuit. However on May 6, 2010 the appeal was denied. On September 28, 2010, the U.S. Supreme Court again agreed to hear the case.

On June 23, 2011, the U.S. Supreme Court issued a ruling against the estate of Anna Nicole Smith, holding that a bankruptcy court ruling giving her estate a sum of 475 million was decided without jurisdiction (now called ''Stern v. Marshall''). A California bankruptcy court awarded Smith part of the estate, but the 9th U.S. Circuit Court of Appeal said that a bankruptcy court could not make a decision on an issue outside of bankruptcy law. The U.S. Supreme Court agreed with the ruling of the 9th Circuit Court of Appeals.

Film and television career

In 1994, after a long wish of having an acting career, Smith debuted with a minor role in the screwball comedy film ''The Hudsucker Proxy''. Later the same year she played a supporting role opposite Leslie Nielsen and Fred Ward in the cop comedy film ''Naked Gun 33⅓: The Final Insult''. Though both of these appearances were higly publicized, little was done to further Smith's acting career.

Her first major role was as Colette Dubois, a retired spy seeking revenge for the murder of her husband, in the action/thriller ''To the Limit'' (1995). Smith next starred in the direct-to-video "soft porn" action/thriller ''Skyscraper'' (1996), which she also produced, as a helicopter pilot, Carrie Wisk, who lands on a high rise building and, upon learning it has been taken over by terrorists, becomes engaged in a deadly fight to save hostages.

Both ''To the Limit'' and ''Skyscraper'', and Smith's performances in them, were critically panned. During the course of the litigation over her late husband's estate, her career stalled. Her legal battle, her increasing weight, and her reportedly bizarre behavior made her regular fodder for late night television comedians.

In 2002, after a severe weight-gain, a faltered movie career, and struggling financial problems, Smith debuted in her own reality television series on the E! cable network, ''The Anna Nicole Show''. The series focused on her personal and private life in the manner of other reality shows, such as the ratings hit ''The Osbournes''.

The debut of ''The Anna Nicole Show'' was the highest rated series on the network, but critics blasted it and ratings dropped with each successive week. However, it achieved a cult status among some, particularly college fraternities. The show was canceled in February 2004 due to "creative differences," but has retained some life in reruns and on DVD releases.

Smith's next appearance on the big screen was as herself in ''Wasabi Tuna'' (2003), about a group of friends who kidnap her dog, Sugar-Pie, on Halloween. She appeared as herself again in ''Be Cool'' (2005), a crime/comedy about the film and music industries that stars John Travolta, Uma Thurman and The Rock. She produced and starred as "Lucy" in ''Illegal Aliens'', a sci-fi/comedy about beautiful space aliens saving the earth from evil. The film is a mixture of the 1970s television drama series ''Charlie's Angels'' and the sci-fi film ''Men in Black''.

Smith as spokesperson

In an interview on ''Late Night with Conan O'Brien'', Smith was asked what her "Playmate diet" consisted of. She instantly replied, "fried chicken". In October 2003, she became a spokesperson for TrimSpa, which helped her lose a reported 69 lb (31 kg).

In November 2004, she appeared at the American Music Awards to introduce a musical performance and attracted attention because of her slurred speech and behavior. During her live appearance, she threw her arms up and exclaimed, "Like my body?". Smith murmured other comments and alluded to TrimSpa. The incident became comic material for presenters throughout the rest of the program.

The following day, her appearance was featured in the media. Tabloids speculated that Smith was under the influence of pills or some other controlled substance. Her representatives explained that she was in pain due to a series of grueling workouts.

In March 2005, at the first MTV Australia Video Music Awards in Sydney's Luna Park, she spoofed Janet Jackson's wardrobe malfunction by pulling down her dress to reveal both breasts, each covered with the MTV logo.

Smith has also been featured in advertisements for the animal rights group PETA. Spoofing Marilyn Monroe's "Diamonds Are a Girl's Best Friend" segment in ''Gentlemen Prefer Blondes'', a 2004 ad states "Gentlemen prefer fur-free blondes." Due to her support of the anti-fur movement, in particular her criticism of Canadian seal hunting, PETA began a petition in memory of Smith to the Canadian Prime Minister Stephen Harper to end the annual tradition. In another ad the following year, Smith posed with her dogs in a campaign against Iams dog food for their alleged cruelty to animals, as well as the manufacturer Procter and Gamble, and sister company Eukanuba.

Personal life

Smith stated that she was Christian in an interview, saying: "Jesus Christ is my Lord and Savior, and will always be, and I pray every day."

Birth of daughter

Smith announced on June 1, 2006, in a video clip posted on her official website that she was pregnant. "Let me stop all the rumors," she said, while floating on an inflatable raft in a swimming pool. "Yes, I am pregnant. I'm happy, I'm very, very happy about it. Everything's goin' really, really good and I'll be checking in and out periodically on the web, and I'll let you see me as I'm growing."

Though her announcement did not provide any details, in an interview with Larry King on CNN's ''Larry King Live'' after her daughter's birth and her son's death, Smith's longtime personal attorney Howard K. Stern said that he and Smith had been in a secret relationship for "a very long time" and that, due to the timing of the pregnancy, he was confident that he was the father of the baby. Her ex-boyfriend, entertainment photojournalist Larry Birkhead, steadfastly maintained that he was the baby's father and filed a lawsuit to establish paternity. Smith's daughter, Dannielynn Hope Marshall Stern, was born September 7, 2006, at Doctors Hospital in Nassau, Bahamas. The Bahamian birth certificate recorded the father as Howard K. Stern.

A judge in the United States ordered that DNA tests be performed to determine the biological father of Dannielynn. Following Smith's death, Debra Opri, the lawyer for Larry Birkhead, asked for an emergency DNA sample to be taken from her body. Smith's lawyer, Ron Rale objected strongly to this request. The request was denied by a judge, who instead ordered Smith's body preserved until February 20.

According to a story published in the ''New York Daily News'', Donna Hogan, Smith's younger half-sister, has said that the model froze the sperm of her second husband, Marshall, prior to his death. The newspaper said that Hogan wrote in her unpublished manuscript about her sister, entitled ''Train Wreck'', that "To her family, she hinted that she had used the old man's frozen sperm, and would be giving birth to Howard Marshall's child". However, the publisher of Hogan's book described the newspaper's claims as a hoax. On February 9, 2007, Zsa Zsa Gabor's husband Frédéric Prinz von Anhalt said that he had had a decade-long affair with Smith and could potentially be the father of her infant girl, Dannielynn. Alexander Denk, a former bodyguard for Anna Nicole Smith, reportedly told the tabloid television program ''Extra'' that he had had an affair with his former employer, and that it was possible he could be Dannielynn's father.

After Smith's death, ''TMZ.com'' reported that Smith had been given a prescription for methadone under a false name while she was in her eighth month of pregnancy. The Medical Board of California launched a review into the matter; the prescribing doctor, Sandeep Kapoor, said his treatment was "sound and appropriate."

On April 10, 2007, a Bahamian judge ruled Larry Birkhead, a former boyfriend, as the father of Dannielynn. DNA tests had established Birkhead as the father, with 99.99% certainty. Commenting on the revelation, Birkhead stated, "I hate to be the one to tell you this but, I told you so. I'm the father...My baby's going to be coming home pretty soon." Birkhead subsequently applied for an amended birth certificate listing him as the father, which paved the way for him to obtain a passport for the baby to leave with him for the United States. Howard K. Stern did not contest the DNA results or the ruling. Subsequent to the ruling, Birkhead returned to the United States with the baby. Virgie Arthur's appeal of the ruling was later denied and she was ordered to pay costs.

Death of son

Smith's 20-year-old son, Daniel Smith, died on September 10, 2006 in his mother's hospital room while visiting her and his half sister. After the coroner labeled the death "reserved," Smith hired forensic pathologist Cyril Wecht to perform a second autopsy.

His death certificate was issued on September 21, 2006, so that he could be buried. While Smith remained in the Bahamas with Dannielynn and Stern, Daniel's family in the United States, including his father, Billy Smith, gathered with friends on October 7, 2006, in Mexia, Texas, for a memorial service. Daniel was buried at Lake View Cemetery on New Providence, Bahamas, on October 19, 2006, almost six weeks after his death. According to Howard K. Stern, Smith's longtime partner, she was devastated over her son's death. "Anna and Daniel were inseparable. Daniel was without question the most important person in Anna’s life," Stern told Florida Circuit Judge Larry Seidlin during his testimony in the legal battle after the model’s death. "At Daniel’s funeral, she had them open the coffin and tried to climb inside. She said that 'if Daniel has to be buried, I want to be buried with him,'" Stern testified. "She was ready to go down with him." Howard K. Stern revealed that "Anna saw herself as both mother and father to Daniel. From the time I met her, everything was for Daniel. I would say that physically, she died last week, but in a lot of ways, emotionally she died when Daniel died," he added.

Dr. Wecht announced on ''Larry King Live'' that the autopsy he performed showed that Daniel died from a lethal combination of Zoloft, Lexapro and methadone. Although he explained that methadone is used in the treatment of heroin and morphine addiction, Wecht said he had no information to make any conclusion why Daniel was using the drug. On February 8, 2007, Wecht said on Fox News that he still had no information about how Daniel obtained methadone.

Commitment ceremony with Stern

On September 28, 2006, Smith and Howard K. Stern exchanged vows and rings in an informal commitment ceremony aboard the catamaran Margaritaville off the coast of the Bahamas. She wore a white dress and carried a bouquet of red roses, while he wore a black suit with white shirt. Although they pledged their love and made a commitment to be there for one another before a Baptist minister, no marriage certificate was issued and the ceremony is not legally binding.

After the ceremony, they landed on the island of Sandy Cay where they had a party and celebrated with champagne and apple cider that had been brought over for the occasion by sailboat.

Regarding the questionable timing of the ceremony, Smith's attorney in Nassau, stated, "They needed a little adrenaline boost because things have been so hectic and devastating in their life recently." The photos of their ceremony were sold through Getty Images to ''People'' magazine for around $1,000,000.

Residency in the Bahamas

Anna Nicole Smith and Howard K. Stern were reportedly staying in the Bahamas to avoid paternity testing of her daughter in the United States. In late 2006, Smith was granted permanent resident status in the Bahamas by Immigration Minister Shane Gibson. On February 11, 2007, newspaper photographs were published showing Smith lying clothed in bed in an embrace with Gibson. Opposition politicians in the Bahamas accused the minister of improper behavior. Gibson resigned as a result of the controversy and claimed that the photos, taken by Stern, were innocent.

The basis of Smith's permanent residency status was the claim that she owned a $900,000 mansion, which she said was given to her by a former boyfriend, real estate developer G. Ben Thompson of South Carolina. Thompson asserted that he loaned Smith the finances to purchase the property, but that she failed to repay the loan, and was attempting to regain control of the property. Thompson sued to evict Smith from the property in Bahama Court, and received a default judgment against her when she failed to respond to the eviction, or appear in court on November 28, 2006. Ford Shelley, son-in-law of G. Ben Thompson, claimed that methadone was found in Anna's bedroom refrigerator while the mansion was being reclaimed. A photograph provided by TMZ shows a large bottle of methadone along with vials of injectable cyanocobalamin in her refrigerator.

Death and funeral

On February 8, 2007, Smith was found unresponsive in room 607 at the Seminole Hard Rock Hotel and Casino in Hollywood, FL. Tasma Brighthaupt, a friend of Smith who was a trained emergency nurse, performed CPR for 15 minutes until her husband, Maurice "Big Moe" Brighthaupt, Smith's friend and bodyguard, took over CPR. He had driven back to the hotel after being notified by his wife of Smith's condition. According to Seminole Police Chief Charlie Tiger, at 1:38 pm (18:38 UTC) Maurice Brighthaupt, who was also a trained paramedic, called the hotel front desk from her sixth-floor room. The front desk in turn called security, who then called 911. At 1:45 pm the bodyguard administered CPR until paramedics arrived and she was rushed to Memorial Regional Hospital at 2:10 p.m and pronounced dead on arrival at 2:49 pm

A phone call was released to the public on February 13, 2007, involving Seminole police and the local 911 operators, saying: }}

After a seven-week investigation led by Broward County Medical Examiner and Forensic Pathologist Dr. Joshua Perper in combination with the Seminole police and several independent forensic pathologists and toxicologists, Dr. Perper announced that Smith died of "combined drug intoxication" with the sleeping medication chloral hydrate as the "major component." No illegal drugs were found in her system. The official report states that her death was not considered to be due to homicide, suicide, or natural causes. The full investigative report has been made public and can be found online. Additionally, an official copy of the autopsy report was publicly released on March 26, 2007, and can be found online.

Ultimately her death was ruled an accidental drug overdose of the sedative chloral hydrate that became increasingly lethal when combined with other prescription drugs in her system, specifically four benzodiazepines: Klonopin (Clonazepam), Ativan (Lorazepam), Serax (Oxazepam), and Valium (Diazepam). Furthermore, she had taken Benadryl (Diphenhydramine) and Topamax (Topiramate), an anticonvulsant AMPA/Kainate antagonist, which likely contributed to the sedative effect of chloral hydrate and the benzodiazepines. Although the individual levels of any of the benzodiazepines in her system would not have been sufficient to cause death, their combination with a high dose of chloral hydrate led to her overdose. The autopsy report indicates that chloral hydrate was the "toxic/lethal" drug, but it is difficult to know if chloral hydrate ingestion alone would have killed her, since Dr. Perper indicated (in the March 26 press conference) that she had built up a tolerance to the drug and took more than the average person. He indicated that she took about three tablespoons, whereas the normal dosage is between one and two teaspoons. Chloral hydrate, first synthesized in 1832, was the first depressant developed for the specific purpose of inducing sleep. The infamous “Mickey Finn” or “knockout drops” was a solution of alcohol and chloral hydrate that was popular in Victorian England and in that era’s literature. When used properly, and without the introduction of alcohol or other depressants, chloral hydrate is effective in easing sleeplessness due to pain or insomnia. But according to Avis (1990), the effective dose and lethal dose of chloral hydrate are so close that the sedative should be considered dangerous. Today, the use of chloral hydrate has declined as other agents, including barbiturates and benzodiazepines, have largely replaced them. Despite rumors of methadone use due to its involvement in her son's death, Dr. Perper found only methadone in her bile, indicating that it could only have been ingested 2–3 days prior to her death and was not a contributing factor. The autopsy report indicates that abscesses on her buttocks (presumably from prior injections of vitamin B12 (cyanocobalamin) and human growth hormone), and viral enteritis were contributory causes of death. Tests for influenza A and B were negative.

It was reported that 8 of the 11 drugs in Smith's system, including the chloral hydrate, were prescribed to Howard K. Stern, not Smith. Additionally, two of the prescriptions were written for Alex Katz and one was written for Smith's friend and psychiatrist, Dr. Khristine Eroshevitz. Dr. Perper acknowledged that all 11 prescriptions were written by Dr. Eroshevitz herself.

Before Smith's body was buried, it began decomposing at a faster-than-normal pace. Possible factors in her more rapid decomposition were the drugs found in her body in the autopsy, the fact that the legal battles delayed her embalming until over a week after her death, and the nearly month-long wait for her burial in the warm Bahama weather. This resulted in the family having a closed-casket funeral.

Smith's will, drawn up in April 2001, named her son Daniel as the sole beneficiary of her estate, specifically excluded other children, and named Howard K. Stern as the executor. It indicated personal property valued at $10,000 and real property valued at $1.8 million (with a $1.1 million mortgage) at the time of death. A petition to probate Smith's will was filed in Los Angeles County Superior Court. The petition to probate lists Larry Birkhead as a party with interest to Anna's estate. A six-foot-deep black granite monument was installed at Smith's grave in the Bahamas, as of February 2009.

Appearances

Film

''The Hudsucker Proxy'' (1994)

''Naked Gun 33⅓: The Final Insult'' (1994)

''To the Limit'' (1995)

''Skyscraper'' (1997)

''Anna Nicole Smith: Exposed'' (1998)

''Wasabi Tuna'' (2003)

''Be Cool'' (2005)

''Illegal Aliens'' (2007) (posthumously released)

Television

''The Naked Truth'' (1995) episode: ''Wilde Again'' – Herself

''Sin City Spectacular'' (1998)

''Veronica's Closet'' (1999) episode: ''Veronica's Wedding Bell Blues'' – Donna

''Ally McBeal'' (1999) episode: ''Pyramids on the Nile'' – Myra Jacobs

''The Three Stooges N.Y.U.K.'' (2000) – Dr. Anita Hugg

''Larry King Live'' (2002) interview date: May 29, 2002

''The Anna Nicole Show'' (2002–2004) – Herself

''Comedy Central Roast of Pamela Anderson'' (2005) – Herself (In Audience)

''Comedy Central Roast of Jeff Foxworthy'' (2005) – Herself (Via Satellite)

Music

In 1993, Smith appeared in the music video for Bryan Ferry's single "Will You Love Me Tomorrow."

In 1997, Smith did a remake and music video of the Marilyn Monroe song "My Heart Belongs to Daddy" (music and lyrics by Cole Porter), the video made by Nicolaï Lo Russo in France.

In 1997, Smith appeared in the music video for Supertramp's single "You Win, I Lose".

In 2004, Smith appeared in the music video for Kanye West's single "The New Workout Plan".

She appeared in the Third Eyed Blind Video for "Jumper"

The opera ''Anna Nicole'' by Mark-Anthony Turnage premiered on February 17, 2011, at the Royal Opera House to a mixed reception

See also

List of Playboy Playmates of the Month

List of models who died during their careers in the 21st century

References

External links

Anna Nicole Smith at Find A Grave

FBI file on Anna Nicole Smith

Category:Accidental deaths in Florida Category:Actors from Texas Category:American erotic dancers Category:American Christians Category:American film actors Category:Drug-related deaths in Florida Category:Glamour models Category:Marshall family Category:Participants in American reality television series Category:People from Houston, Texas Category:People from Limestone County, Texas Category:Playboy Playmates (1990–1999) Category:Playboy Playmates of the Year Category:1967 births Category:2007 deaths Category:American expatriates in the Bahamas Category:American female models Category:Plus-size models Category:Animal rights advocates

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