There are references to Caesarean section operations in ancient Hindu, Egyptian, Greek, Roman, Chinese and European stories, photos and ancient historical records. While it is commonly believed the name ‘Caesarean’ is from the surgical birth of Julius Caesar, this is considered unlikely as his mother lived to hear of her son’s invasion of Britain. Roman law under Caesar decreed that only if the mother-to-be was dead or dying then she was to be cut open to deliver the infant. This decree is the more likely origin of the name.
Over the centuries the operation was done to deliver the infant from a dead or dying mother in the hope of saving the baby’s life, or because of a religious ruling so the infant must be buried separately from the mother. Until the 19th-century Caesarean section operations were not intended to preserve the mother’s life. There are only sporadic reports of where the operation was done to also save a pregnant woman’s life.
In the 1700’s instruments were gradually introduced to do operative vaginal deliveries when there was an obstructed labour (baby was too big for the birth canal). These operative vaginal deliveries were associated with significant maternal and foetal trauma and death, but at that time there was no other option. These procedures included high forceps vaginal deliveries (where the forceps were applied to the baby’s head when it was still ‘high’ in the pelvis) and craniotomy (decapitation of the baby’s head and removing it piecemeal).
In the late 1800’s there were reports of Caesarean section deliveries to save the mother and baby’s lives in Africa, Europe, the United States and England. With increased urbanization, the growth of hospitals and the introduction of anaesthetic agents the operation began to be performed more often. With increasing attention to aseptic techniques, with increasing knowledge of the female anatomy it gradually became accepted that a Caesarean section delivery was safer than a difficult risky operative vaginal delivery when there was an obstructed labour.
Sterile catgut suture was achieved in the early 1900’s with iodine treatment. The catgut suture was made from sheep intestines. It was strong, was broken down by the body and so was suitable for internal sutures. Sterile catgut became very popular for internal sutures with Caesarean sections. In the early 1930s, numerous absorbable and non-absorbable synthetic sutures were developed. Catgut sutures, while still available, were gradually replaced by synthetic internal sutures in Australia the 1980’s.
In late 1800s obstetricians started doing transverse incisions in the lower segment of the uterus in preference to the classical uterine incision (vertical incision in the anterior wall of the uterus). This changed access to the uterine cavity reduced the risk of infection and of uterine rupture in subsequent pregnancy.
Penicillin was discovered by Alexander Fleming in 1928 and in the 1940s became generally available. Its use dramatically reduced maternal mortality for both normal deliveries and Caesarean section deliveries.
Since World War 2, the trend toward medically managed pregnancy and childbirth has steadily increased. New maternity hospitals were being built. By 1938, approximately half of U.S. births were taking place in hospitals. By 1955, this had risen to ninety-nine per cent.
Advances in anaesthesia contributed to improving the safety of Caesarean section deliveries. Epidural anaesthesia started to be used for pain relief in labour. Subsequently, epidurals were introduced for anaesthesia for Caesarean section deliveries. I recall when I started my obstetrician training all Caesarean sections were done under a general anaesthetic. Spinal anaesthetics were sometimes done but as the size of needles was larger than those used now there was a relatively high incidence of post-Caesarean section cerebrospinal fluid (CSF) leaks and associated headache. With a Caesarean section there needs to be better anaesthetic block than in labour and so they took longer and sometimes despite extra waiting did not give adequate regional anaesthesia for the operation. I recall epidural anaesthetics for Caesarean sections often taking longer to do than the operation time. I recall that despite best attempts epidural blocks could be patchy and so general anaesthetic was needed. Now with a better epidural and spinal needles and better anaesthetic medications usually Caesarean sections are done under an effective spinal or joint spinal-epidural anaesthetic. Usually, the regional block can be administered and be working quickly and be very effective, a huge improvement compared with the past.
Caesarean sections were done only for a limited number of indications. These included concern about cephalo-pelvic disproportion (baby’s head is too big for the maternal pelvis), obstructed labour (consequence of cephalo-pelvic disproportion), a failed attempt at a vaginal forceps delivery, preterm delivery for conditions such as severe preeclampsia when the cervix was unfavourable for induction of labour, placenta praevia, transverse lie of baby, foetal distress before labour or in first stage labour. Foetal monitoring began to be introduced in the 1970s. With that, it was possible to more accurately diagnose foetal distress (heart rate conges suggesting a lack of oxygen in the baby). Repeat Caesarean sections were only done if the indication for the first Caesarean section was relevant for the second delivery (such as cephalopelvic disproportion), the first had been a classical Caesarean section, there had been uterine surgery such as a myomectomy (fibroid removal). These circumstances were associated with an increased likelihood of uterine rupture in labour. Overall that meant the incidence of Caesarean sections was less than 10% of all deliveries.
Where possible delivery was vaginal. Most breech and twin deliveries were vaginal. Mid-cavity and rotational forceps deliveries were popular when there was a lack of progress of foetal distress in second stage labour. There were more challenging operative vaginal deliveries which were potentially dangerous for mother and baby. A Caesarean section was done if in second stage labour it was not possible to deliver the baby with forceps.
Gradually the incidence of Caesarean sections has increased. Now the usual reported incidence of Caesarean section deliveries in Australian hospitals is just over 30% of all deliveries. There are some hospitals where the incidence is 50%. It cannot be argued that the relatively high incidence of Caesarean section can be justified as being a necessity for the safety of mother and baby with childbirth.
This increased incidence has to do with the increased safety of Caesarean section operations, changing attitudes and expectation in the community and increased medical litigation. A vaginal delivery was preferred in the past as it was viewed a Caesarean section was more dangerous. This is no longer necessarily the case. Certainly, straightforward spontaneous vaginal and most operative vaginal deliveries are done now are safer than Caesarean section deliveries. A Caesarean section done by an experienced obstetrician is now a very safe operation and is safer than the more difficult operative vaginal deliveries. A Caesarean section is far more popular for a breech presentation as the operation is a safer delivery mode for the baby than a breech vaginal delivery. There now a much higher incidence of Caesarean section for twins as it a safer mode for the babies. As foetal monitoring in labour became more popular and of better quality, there are more Caesarean sections for foetal distress. In the past, most women who have a Caesarean section had a vaginal delivery in a subsequent pregnancy. This is no longer the case and now the large majority have a repeat Caesarean section. This is because Caesarean sections are safer than in the past, because of the increased incidence of medical litigation and more women not being prepared to accept the risk of uterine rupture in labour. There now are women who want a Caesarean section delivery by choice without there being any obstetric indication whatsoever. This would never have been agreed to in the past. But society had changed, and the consumer has far more say than in the past.
There has been a gradual increase in the incidence of Caesarean sections in many countries in the world. There are still some poor countries with a very low rate or no Caesarean sections, with a consequential adverse impact on mother and baby mortality and morbidity. In contrast, there has been an increase in incidence in some of the world’s poorest countries has had a huge positive impact on mother and baby mortality and morbidity. I am a Director of Hamlin Fistula Australia, a charity whose function is to support Dr Catherine Hamlin and her team in eradicating obstetric fistulae (abnormal channel that forms between the bladder or rectum or both and vagina because of obstructed labour) in Ethiopia. Early detection of obstructed labour and Caesarean section delivery when this occurs is not only reducing maternal and foetal mortality rates but also has helped to significantly reduce the incidence of obstetric fistulae in Ethiopia.
I was at a College (RANZCOG) meeting recently where a urogynaecologist was arguing that we should get ‘informed consent’ for all vaginal delivery. That was because of the greater likelihood of prolapse and bladder incontinence problems after vaginal delivery than after a Caesarean section. He was arguing that many women if they were fully aware of the associated risk, would opt for Caesarean section. He said there is the possibility of litigation in the future where the woman with gynaecology problems argues that she would have had a Caesarean section if she had been informed of the risks of having a vaginal delivery.
There was pushback in the UK with a midwife programme called ‘Campaign for Normal Birth’. The programme started in 2005 and ended in 2017. The programme was to encourage more childbirth without medical intervention, including Caesarean section. It was reported because of the programme there was a higher incidence of postnatal depression amongst women who were motivated to have a normal delivery but failed to do so. The programme was closed after criticism linking the programme to an increased incidence of deaths of babies and mothers.
There has been a pushback from some who have suggested that a Caesarean section delivery can have a detrimental impact on the mother and baby’s long-term health. There are undeniable risks of major surgery. These risks are now far less than in the past. These are greater risks if the operation is done by an inexperienced or poorly trained surgeon. There is a consequently uterine scar which increases the risk of uterine rupture especially in labour with subsequent pregnancies. Views that a Caesarean section delivery can have other long-term detrimental health impacts for mother and baby are not widely held and lack support in medical literature.
There is a push back in NSW by the State Government with a policy called ‘Towards normal birth’ which has the stated aim ‘To increase the vaginal birth rate in NSW and decrease the caesarean section (CS) operation rate’. The Government fails to mention in promoting this policy it is cheaper for the hospital and Government if there were fewer Caesarean section deliveries done on public patients and so I suspect a significant motivation of this policy is the financing saving.
As a consequence of the push to reduce the incidence of Caesarean section deliveries, an increase in operative vaginal deliveries has been reported. Not only are the more difficult operative vaginal deliveries more dangerous for mother and baby per se, this danger is compounded because often now trainee obstetricians and some fully qualified obstetricians haven’t had the same level of training or support or same experience that was the case in the past when there were far more operative vaginal deliveries.
The next move was for husbands/partners to be more involved. Husbands/partners have been encouraged to be with and support their wives in labour since the 1980s. With regional anaesthetics this it has become popular for husbands/partners to be in the operating theatre during the Caesarean section. It is now possible in some hospitals for a husband/partner to go to the Recovery Ward with his wife/partner and their new baby (called a ‘baby friendly’ or ‘family friendly’ Caesarean section).
Helpful extra reading:
https://theconversation.com/why-uk-midwives-stopped-the-campaign-for-normal-birth-82779
https://www.theguardian.com/society/2017/aug/12/midwives-to-stop-using-term-normal-birth
