By Kirsten Franklin, M.D., FACOG
From ATLANTA Medicine, 2012, Women’s Health, Vol. 83, No. 1
Cesarean section has been around for hundreds of years but not without serious consequences for the mother. Originally the procedure was used postmortem to satisfy religious and cultural requirements that the dead infant be buried separately from the mother. There are early reports of its use as a last resort to attempt to save the woman’s life, but historical record of success in this arena is absent. The first written record of a live birth and living mother after cesarean delivery originates from Switzerland in 1500. There is some question regarding the accuracy of the story, but it has been reported that a sow gelder, Jacob Nufer, was granted permission by local authorities to attempt the procedure after his wife spent several days in labor and was unable to deliver despite help from 13 midwives. The child lived to the age of 77 and his mother subsequently delivered five more children, including a set of twins, via vaginal birth.
Although the sixteenth and seventeenth centuries brought numerous works of art illustrating human anatomy in detail, it was not until the mid to late 1800s that human cadavers were available to medical students and practical experience allowed physicians to gain a true understanding of anatomy. Thereafter, cesarean sections were attempted in greater numbers. Until then, unsuccessful deliveries had been treated via craniotomy and a mutilating extraction of the fetus through the vagina in an effort to save the mother’s life. When ether was used for the first time in 1846 at Massachusetts General Hospital by dentist William T.G. Morton during surgery to remove a facial tumor, the future of cesarean section (and surgery as a whole), changed dramatically. There was initial reluctance to use anesthesia in obstetrics based upon the concept that women should suffer during childbirth to atone for Eve’s sin. However, once Queen Victoria was administered chloroform for the births of two of her children in 1853 and 1857, widespread acceptance of anesthesia for childbirth took hold.
Initial mortality rates for cesarean section were high. Germ theory was introduced in the mid 1860s but was not widely accepted. Physicians and hospital staff did not wash hands between patients and wore street clothes to operate. Additionally, surgeons did not suture the uterine incision for fear that the sutures would cause infection and promote uterine rupture in future pregnancies. Adherence to this theory resulted in high maternal death rates from hemorrhage and infection. For a brief time, hysterectomy in conjunction with cesarean was used to decrease those rates. Once Max Sanger’s monograph advocating silver sutures to close internal wounds was widely circulated in 1882, confidence in the procedure increased and hysterectomy was abandoned.
The more modern low cervical uterine incision was popularized by British obstetrician Munro Kerr in the early 20th century, and the surgical details were further refined after the widespread availability of penicillin in the 1940s. Population growth in the cities and the trend toward medical management of pregnancy in the 1940s led to a boom in growth of women’s hospitals. In 1938, about half of births in the United States were taking place in hospitals, rising to 99 percent by 1955. In 1965, the cesarean section rate was 4.5 percent.
Over the past 40 years, cultural shifts have changed the focus of obstetrics. Paternal involvement in the delivery process, the advent of fetal monitoring in the early 1970s, and the assessment of fetal development with ultrasound have led to a major shift in perspective. The delivery process is no longer centered on the mother; it is now an infant-focused condition. When comparing cesarean section to vaginal delivery, there is a small increase in risk for the mother but a decrease in risk for the fetus. As parents became increasingly involved in decision making surrounding the pregnancy, the impartiality of the physician’s clinical judgment was muted by the parents’ inherent bias in favor of their child. Parents began expecting perfect babies and healthy moms, and the cesarean section rate rose rapidly to 24.7 percent in 1988. A push for vaginal birth after cesarean (VBAC) began in the mid 1980s and eventually did lead to a decline in cesarean section rates in the 1990s to a new low of 21 percent in 1996.
In 1999 the American College of Obstetricians and Gynecologists released new guidelines requiring the presence of an obstetrician and anesthesiologist, as well as staff capable of performing an emergency cesarean section, for any patient undergoing a trial of labor after previous cesarean section. Many smaller hospitals were unable to meet these in-house requirements, and many physicians cover more than one hospital and are unable to be in the hospital during labor. The immediate impact of these guidelines was apparent. The cesarean delivery rate increased to 29.2 percent by 2004, and the VBAC rate decreased from 28 percent in 1996 to 8 percent in 2004. The cesarean section rate has continued to climb yearly to a high of 32.9 percent in 2009. Finally, in 2010, the rate fell very slightly to 32.8 percent. Only time will tell whether this downward trend will continue. 2010 ACOG guidelines relaxed the earlier requirements for VBAC somewhat, indicating that trial of labor after cesarean(TOLAC) should be undertaken at a facility capable of emergency delivery and stated that most women with prior low transverse incision are candidates for TOLAC.
Prominent causes of the high current cesarean rates include the epidemic of maternal obesity in the United States, excess weight gain in pregnancy, macrosomic infants resulting from increased weight gain during pregnancy, and the increase in gestational diabetes. There is also an increase in twin/triplet/multiple pregnancies and a significant increase in pregnancy rates in women over 40 years of age. Despite a decrease of 3% in total number of births between 2009 and 2010, there was a 2% increase in births in women over 40. Women over 40 have a cesarean section rate 21 percent higher than women in their early 20s. The desire of women to have control over their delivery schedule has led to a rise in the induction rate of labor. Induction is clearly associated with increased cesarean
section rates, particularly in patients with an unfavorable cervix. In a retrospective study done by Zhang, et. al., the cesarean section rate for women who were induced was twice that of women who went into labor spontaneously. Finally, the current legal climate and parental expectations for perfect neonatal outcomes promote quicker decision for cesarean section. There is some thought that maternal demand for elective cesarean section in the United States has had an impact on surgical rates, but a survey by Declor, et. al. in 2006, revealed only 1 of 1,600 patients requested an elective primary cesarean section.
Worldwide, the cesarean rate is increasing. In Asian and South American countries, women have been requesting elective cesarean sections in high numbers for social convenience and from a cultural desire to deliver on certain days. In a sampling done by the World Health Organization, 46 percent of births in certain areas of China were by cesarean, and half of those were patient-requested elective procedures. Vietnam has a 36 percent cesarean rate and Thailand’s is 34 percent. The cesarean rate in Latin America is 35 percent, but certain areas like Paraguay (42 percent) and Ecuador (40 percent) are even higher. Some of the lowest rates worldwide are found in India, 18 percent, and Cambodia, at 15 percent.
Although overall cesarean delivery rates have significant impact on the health care system in the United States as a whole, the practicing clinician must make decisions based on the individual patient, her needs, her desires and her risk factors. It remains to be seen what the future holds for cesarean delivery and how the newest ACOG guidelines will impact the latest statistics.
Kirsten Franklin, M.D., FACOG is a board-certified obstetrician gynecologist. She has been in private practice at Northside Hospital for the past 16 years and is a current member of the Medical Executive Committee.