CESAREAN SECTION OPTIONS

In terms of its frequency, Cesarean section lags behind some other obstetrical operations, but when judged by its importance, the fascination of its history, and the drama of its technique, it commands the leading position. The operation consists of incising the lower abdomen, cutting into the uterus, and removing a child of viable (large enough to have a chance to survive) size.

Origin of Name

Pliny the Elder (A.D. 23-79) mentions the operation and states that it is the source of the surname of the Roman emperors, since ‘Caesar’ is related to the Latin word for ‘cut,’ and it is romantically assumed that Julius Caesar (c 100-44 B.C.) was ‘cut’ from his mother’s womb. It seems highly improbable that he was born in this way: first, because his mother survived his birth for many years, and Cesareans at this time were almost certainly never done on living women; and, second, because the ancients favored a very different origin for the name of their emperors. In the Punic language, caesar meant elephant, and since Julius once slew an elephant he was probably given this heroic sobriquet, which passed on to his successors.

Another improbable derivation for the term ‘Cesarean section’ is the claim that at about 750 B.C., during the reign of Numa Pompilius, a law was passed which made it obligatory to open the belly of any woman who died near term in order to rescue the infant from its uterine grave. Originally codified as lex regia, under the emperors it became lex caesarea. It would have been a most remarkable law if it had been enacted in this, the earliest period of Roman history; however, its authenticity is highly questionable. And so it remains totally uncertain as to how the operation got its name.

History of the Operation

The early history of the operation is equally vague. What did Pliny know about it? Was it ever done in his day? Was there a law in antiquity in regard to post-mortem Cesarean sections? There are uncertain references to Cesarean sections in the Talmud, the book of Jewish post-Biblical law and lore written between the second and fifth centuries A.D. DO these references in the Talmud to women who survived after being delivered by ‘yoze dofan’ a ‘cut in the side,’ mean that women actually lived after Cesarean section in the fifth century?

It is somewhat apocryphally reported that in 1500 Jacob Nufer, a swine-gelder, wiped his butcher’s knife on his Swiss Alpine trousers and before a gallery of thirteen midwives delivered his own wife by Cesarean section. Frau Nufer is said to have survived the operation and subsequently presented the bold Jacob with two more children born normally.

Post-mortem (Latin: ‘after-death’) Cesarean section was probably freely practiced in antiquity; unquestionably it was widely used in the late medieval period and the early Renaissance.

The first detailed report of a Cesarean on a living woman was the account of an operation done in Germany in 1610.

Of the thirty-eight Cesarean operations performed in Great Britain from 1739 to 1845, a period of more than a century, but four women recovered.

According to the researches of the pre-eminent medical historian, the late Colonel Fielding H. Garrison, the first Cesarean section in this country was performed by Dr. Jessee Bennett in rural Virginia. The surgeon-husband did not publish a report of the remarkable feat, and several years later, when asked why, he replied, ‘No doctor with any feelings of delicacy would report an operation that he had done on his own wife,’ and added mat ‘no strange doctors would believe that operation could be done in the Virginia backwoods and the mother live, and he’d be damned if he would give them a chance to call him a liar.’

On January 14, 1794, in a frontier settlement of the Shenandoah Valley, Mrs. Bennett was confined in her first preg- nancy. Labor was difficult because of a contracted pelvis, and neither her husband nor the consulting doctor was successful in his attempt at delivery by forceps. The choice lay between a destructive operation on the child, its death and piecemeal removal, and a Cesarean section. The patient chose the latter and, since the other doctor firmly refused to have anything to do with so dangerous a procedure, the unpleasant task fell to the husband. The patient, stretched on a crude plank table, was put under the influence of a large dose of opium. Assisted by two women, Dr. Bennett laid open the abdomen and uterus with a single, reckless stroke of the knife and rapidly delivered his daughter, who was still alive. He paused long enough to remove both of his wife’s ovaries. As one of the witnesses declared, ‘He spayed her, remarking as he did so, ‘This shall be the last one.’‘ The wound was closed with stout linen thread and, contrary to expectation, mother and child did well. The first Cesarean-section baby in this country lived to be seventy-three.

Before 1876 few women survived a Cesarean birth by many days, partly because of the crude surgery of that period and partly because the operation was reserved for desperately ill women—women who had labored for days and who were already profoundly infected. In that year Professor Edorado Porro of Pavia contended that it would be best to remove the whole uterus at the time of the operation, for with the removal of the large wounded organ the chance for post-operative hemorrhage and inflammation would be lessened. The wisdom of Porro’s teaching soon became obvious; however, the great drawback to his technique was the fact that it rendered the woman permanently sterile. Today this type of Cesarean section, removal of the uterus after its incision to deliver the baby, is referred to as the Porro or Cesarean hysterectomy.

In 1882, twenty-nine-year-old, red-headed Max Sanger,; then a lowly Privatdozent in Leipzig, published an epoch-making two-hundred-page treatise on Der Kaiserschnitt (The Cesarean Section). He called attention to the importance of sewing the uterine incision firmly together again after cutting open the uterus to deliver the baby. Of course it had always been customary to suture (sew) the wound in the abdomen, but previous to Sanger’s contribution the un-sutured uterus was dropped back in the abdomen, to remain there a constant source of danger—danger from hemorrhage and danger from growth of bacteria out of the open uterine wound into the abdominal cavity. An American, Harris, and others too, had suggested stitching the uterine incision together, but they did not suggest the orderly and thorough way which Sanger evolved and published. Since Sanger’s operation was only a refinement of the old type of Cesarean section, and since it did not remove the uterus, it is referred to as either the classical or the conservative Cesarean section.

Because of dissatisfaction with the results of Sanger’s operation if performed on women who had been in labor for several hours, Frank of Cologne brought forth the low cervical Cesarean section in 1907. Frank’s new technique consisted of freeing the bladder from its filmy attachment to the lower portion of the uterus (the low cervical segment), then pushing the bladder out of the way, down in the pelvis, and incising the uterus through the area from which the bladder had just been dissected free. After child and placenta are removed, the wound in the uterus is sewn together, and then the bladder drawn up and tacked by sutures in its original position. This seals off the uterine wound from the abdominal cavity by plastering the bladder entirely over it. It is like putting a large rubber patch over a cut inner tube whose edges had previously been cemented together.

Modern Results

The results of Cesarean section today are a far cry from those of eighty years ago or even twenty years ago. The procedure has become extremely simple, adding little if any extra time to the hospital stay, and above all it is as free of danger as any other uncomplicated operation. In our first 2500 Cesarean sections at the newly opened maternity ward of the Mount Sinai Hospital we have had two maternal deaths associated with a Cesarean section, and in neither instance was the actual operation responsible. These figures are far from unique and can be duplicated or improved by many first-class obstetrical hospitals.

What has caused the improvement? Primarily the advance in general surgical technique with its great emphasis on asepsis (Greek: ‘not’ + ‘to make rotten’), prevention of bacterial contamination. Then, too, there is the growth in obstetrical knowledge. In the first years of the century it was observed that the earlier in labor the operation was done, the safer the outcome; in fact the very safest time was even before labor had begun. This was a radical discovery, for the pioneers in the field believed that a woman would bleed to death if operated on before the contractions of labor had set in. In the last decade the less safe type of classical section has been virtually abandoned, except in the face of a very acute emergency for child or mother, and the slightly slower technique of the lower segment operation substituted as standard routine. In explaining the dramatic improvement in the safety of today’s Cesarean section one must mention enthusiastically expert anesthesia, and antibiotics and transfusion when indicated.

As far as the baby is concerned, Cesarean section offers it as good a chance as a very simple vaginal delivery, and a far better chance than a complicated vaginal delivery.

Indications for Cesarean Section

The most common indication for Cesarean section is pelvic dystocia—usually from a contracted pelvis. Less frequently dystocia is due to a pelvic tumor that blocks the pelvis or to a transverse position of the fetus. Cesarean section is usually done in the treatment of the two serious hemorrhage complications of late pregnancy, premature separation of the placenta and placenta praevia. It is also occasionally performed to check a fulminating, severe toxemia which threatens to develop into eclampsia (childbed convulsions). Some clinics perform Cesarean sections on most elderly primiparas, women of thirty-five or more in their first pregnancy. Most, however, allow the elderly primipara a test of labor, remaining alert to the necessity of intervention by low-cervical Cesarean section if cervical dystocia (failure of the cervix to dilate) or uterine inertia (inadequate pains) develops. If the infant presents transversely, crosswise, and the mother is in active labor, delivery by Cesarean section is usually chosen.

Repeat Cesarean Sections ‘Once a Cesarean, always a Cesarean’ is the terse dictum which means that if the uterus is once emptied by Cesarean section the operation must be repeated for the delivery of each succeeding pregnancy. This rule is based on the fact that a small percentage of those patients who have had Cesarean sections will rupture (burst asunder) the uterine scar in late pregnancy or labor. However, some authorities believe that it is usually unnecessary to repeat the section, unless the cause for the original operation, such as a small pelvis, is still present.

The decision whether or not to repeat the Cesarean section depends on several factors in addition to the indication for the original operation: the teachings and experience of the doctor; whether the patient has had a previous vaginal delivery in addition to a Cesarean section; whether the previous type of operation was classical or low cervical; and the position of the baby’s head and the feel of the cervix near term.

In our own clinic, four out of five patients have a repeat Cesarean section for each subsequent delivery; in the country as a whole, I estimate, it runs nine out of ten.

Incidence of Cesarean Section

Cesarean section incidence has gradually risen until it is now between 5 and 7 per cent of all births. This figure has shown little fluctuation during the past decade. The operations are about equally divided between primary section—first Cesareans—and repeat sections.

The increased incidence of Cesarean section follows quite logically its own increased safety. Statistically it once equaled and has now clearly surpassed in safety for both mother and child several alternative obstetrical procedures —notably, version, difficult forceps deliveries, and breech births through narrowed pelves. Naturally, in well-trained hands and minds, Cesarean section has all but replaced them. Then, too, its relative superiority to most other methods in the treatment of severe late bleeding complications has added to its frequency.

How Many Cesarean Births?

People are always curious as to how many Cesarean sections one woman can have. I know a patient who is well and strong after eleven, and I do not nominate her for the world’s record. Patients are ordinarily sterilized by tying the tubes or removing the uterus at the third section, unless they desire more children. The logic of sterilization more or less routinely at the third Cesarean section is open to question, since ordinarily the third operation carries no more risk than the first, and the fifth no more risk than the third. However, each Cesarean birth is a major operation, which means a less comfortable convalescence than after vaginal delivery. Then, too, though the risk attendant upon a Cesarean birth is so magnificently low today, it is still two or three times that of normal birth. We encourage our patients to have more than three Cesarean births if their original family planning included more than three children. In a recently published study we showed that it does not take longer to conceive following a Cesarean birth than after a vaginal birth.

Many think that the abdomen bears a scar for each operation, a sort of service stripe. Of course this is not true. The scar of the previous operation is cut around and the old scar excised, so that, at the time of closure, normal skin edges can be brought together.

The Operation

It requires about three-quarters of an hour to perform a Cesarean operation; either a longitudinal midline incision is made through skin, fat, and fascia (the tough membrane overlying the abdominal muscles) from just below the navel to the pubic bone, or a low, wide, transverse incision is made just above the pubis. This, the Pfannenstiel type of incision, is made in the area covered by pubic hair, so that when the hair grows back the scar is virtually invisible. Then the abdominal muscle fibers beneath the fascia are separated, revealing the peritoneum, the thin, glistening lining of the peritoneal or abdominal cavity. The peritoneum is opened longitudinally in the midline, which exposes the intact large uterus just beneath it. A small incision is made by a knife in the lower midportion of the uterus, and enlarged upward and downward to a distance of about six inches, if one elects to perform a classical Cesarean section. When the low cervical type is done, the bladder must first be freed of its attachments to the front of the uterus and pushed down in the pelvis beneath the pubic bone. Then a six-inch longitudinal or transverse incision is made in the lowermost portion of the uterus, that portion previously overlain by the bladder. The membranes usually rupture at this point, and a quantity of amniotic fluid wells forth. When the uterine incision is completed, the operator gently shoehorns the infant’s head out of the incision and then extracts the rest of the child. The naval cord is clamped and cut and the child is turned over to an assistant. From the beginning of the skin incision to the delivery of the child is the shortest part of the operation, taking five or six minutes. The repair of the uterine and abdominal wounds takes many times longer. The placenta is manually removed from the opened uterus and an oxytocic drug given intramuscularly or intravenously to encourage the uterus to contract and remain contracted. Two or three rows of absorbable catgut sutures are placed in the uterus to close its incision, and then the abdominal cavity is mopped dry and clean of clots and blood. The abdominal wall is closed in its separate layers, also with absorbable sutures. Usually the skin sutures are of non-absorbable silk and must be removed between the fifth and seventh days.

Some operators prefer metal clips for skin closure; these too should be removed in a week or less.

Several anesthetics are satisfactory for Cesarean section. The most widely used and probably the best is spinal; in using conduction anesthesia of any type the operator can be more leisurely in delivering the infant than when a general anesthetic is used which crosses the placenta to the baby. It is common practice to use a spinal or local until the baby is born, and then put the patient lightly asleep with a general anesthetic.

The blood loss at Cesarean section is usually about a pint. If the patient has a borderline hemoglobin preoperatively, or loses more than a pint at operation, a transfusion while the operation is being concluded is more or less standard procedure.

Convalescence

Following the example set by the general surgeon in the early ambulation of abdominal cases, the obstetrician usually gets his Cesarean mother up the day after operation. This reduces her hospital stay to about a week. Fortunately, the day of heavy post-operative dressings and abdominal binders is past, so don’t feel cheated if you wake to find only thin gauze covering your incision. A liberal diet immediately after operation and the short stay in bed have almost abolished post-operative gaseous distention and weakness. There is no medical reason why a Cesarean mother should not nurse her baby. Physicians vary in their advice as to how soon it is safe to commence another pregnancy after Cesarean section. My observations lead me to believe that such a wound is as firmly and securely healed after three months as it is after three years; but ask your own doctor, since he is likely to dissent from my unorthodox opinion.

Forceps, breech extractions, versions, induction of labor, and Cesarean sections do not comprise all the operations employed by obstetricians, but these five are much the most common.