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The Cesarean Wars Looking Back into the Future

The Cesarean Wars Looking Back into the Future. Thomas R. Allan, MD January 8, 2009 . “The Present is the Living Total Sum of the Past” Thomas Carlyle. The Birth of Asclepius (Son of Apollo) . The Birth of Julius Caesar (100 B.C. ???). Cesarean Section Wars Etymology

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The Cesarean Wars Looking Back into the Future

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  1. The Cesarean WarsLooking Back into the Future Thomas R. Allan, MD January 8, 2009

  2. “The Present is the Living Total Sum of the Past” Thomas Carlyle

  3. The Birth of Asclepius (Son of Apollo)

  4. The Birth of Julius Caesar (100 B.C. ???)

  5. Cesarean Section Wars Etymology The Premier Eponym in Medicine • “Lex Regia ” In early Rome, a legal degree that abdominal delivery be performed upon the hope of saving the child. In the time of the Caesars became “Lex Caeserea.” • “Caedere” (past particle “caesus,”) the Latin word to cut. • The traditional legend of the birth of Julius Caesar. Pliny the Elder, a historian in the first century A.D., stated that the first Caesar was cut from the uterus of his mother. Other historic generals, kings and mythical figures were recorded as having been born by abdominal delivery.

  6. The Birth, Marriage and Death of Julius Caesar

  7. Cesarean Wars • France • 1579 – Paré condemned C/S • 1581 – Rousset. First book on C/S • 1598 – Guillimeau. Child birth or Happy delivery of Women • 1668 – Mariceau against C/S. Warned against “killing the mother to save the child” • 1790 – Baudiloque recorded 31 maternal survivals in 73 C/S • 1797 – Sacombe formed anti-cesarean society

  8. Cesarean Wars • England • 1751 – John Burton. Advocates C/S in cases where “instruments are of no value and the only means we have of saving the mother is by cesarean section.” • 1752 – William Smellie. C/S “ought to be delayed until the women expires and then immediately performed with a view of saving the child.” • 1793 – Hull-Simmons Controversy. Up to the end of the 18th century only 2 surviving mothers in 180 operations in England.

  9. Apache Birth Observed by Walter Reed

  10. Ob/Gyn instruments 1st or 2nd Century B.C.

  11. Destructive scissors and crotchets William Smellie, 1754

  12. Symphysiotomy

  13. Gigli Wire Saw

  14. Case 299 Three Hundred Consultations in Midwifery Robert Lee 1863. London On the 2nd of December 1863, I was consulted to see a patient who was 38 hours in labor with a contracted pelvis, the sacrum almost reaching the symphysis pubis. At 1:30 PM the cervix was not fully dilated. Cesarean section was considered, but we decided to wait for more dilatation. 8 hours later, after more dilatation and confirmation of vertex presentation, craniotomy was attempted. The head was opened and brain escaped. For the next 4 hours every effort was made to extract the head. The bones of the head were broken up, craniotomy forceps were tried, but the head could not be brought through the brim of the pelvis. The crotchet was then passed into the mouth, but all the bones of the face came away with the remainder of the head still above the brim.

  15. Case 299 Three Hundred Consultations in Midwifery Robert Lee 1863. London At 1:30 AM being completely exhausted, we resolved to give the patient some hours repose. In the afternoon three eminent practitioners were consulted. Two were in favor of cesarean section, after another attempt with the crotchet. The patient asked to be insensible with chloroform before another attempt was resumed. After 4 hours, “I succeeded in dragging the shattered bones of the head into the world.” A cord was tied around the neck for traction, and an attempt was made to reach the arms with the crotchet. All efforts to deliver the trunk were unsuccessful and being thoroughly exhausted, it was resolved not to persevere. Next morning the patient was in a moribund state, and died in the evening. At autopsy, the distance from the base of the sacrum to the symphysis pubis was 1 ½ inches.

  16. Oophorectomy in 19th century

  17. Cesarean Wars 19th—20th Century 1844 - Horace Wells- Nitrous Oxide Anesthesia (Hartford, CT) 1847-61 - Ignaz Semmelweis – Antiseptic Childbirth 1867 – Joseph Lister- Antisepsis in Surgery 1879 – Louis Pasteur – Hemolytic Streptococcus in Puerperal Fever 1882 – Max Sanger – Suturing of Uterus 1929 – Alexander Fleming – Penicillin Antibiotic 1937 – Domagyk - Sulfonamides

  18. Horace Wells

  19. Louis Pasteur

  20. Ithaca Journal (Ithaca, NY) 8/18/1981

  21. Hartford Hospital December 12, 1891

  22. First Hartford Hospital Cesareans • Dec. 12th, 1891 • Jimmy “Caesar” R. • Mother lived • 1904, 2nd Case • Could not be delivered at home with forceps • Mother and child lived • 1906 • Body torn from head in attempt to deliver vaginally • C-section done to deliver the head • Mother lived

  23. John Whitridge Williams

  24. The Place of Cesarean SectionBoston Lying In Hospital Maternal Mortality Fetal Mortality _______________________________________________________ Delivery Cases Deaths Percent Deaths Percent Ceserean 584 18 3.1 52 8.8 Craniotomy 16 0 0 16 100.0 High forceps 9 0 0 4 44.4 Version 106 1 0.9 30 28.3 Breech extraction 403 4 0.8 122 24.5 Midforceps 90 1 1.1 12 12.0 Low forceps 3,020 14 0.5 78 2.6 Normal 9,351 21 0.2 348 3.7 *Irving F.C. The place of Cesarean section. J. Conn. State Medical Society. Nov. 39, 483-491

  25. The Place of Cesarean Section:Irving, 1937 Conclusions: • “In cases where there is a fair choice between pelvic delivery and Cesarean section one should consider well the increased risk to the mother, who is vastly more important than the infant, before one performs an operation which gives the baby an advantage [if it increases the risk to the mother]” • “Cesarean section in the United States is accompanied by a 5.8% mortality.”

  26. Maternal Mortality in the United States Deaths per 100,000 Live Births (1915 – 1960): 800 700 600 500 400 300 200 100

  27. Cesarean Section Rate and Forceps Rate Hartford Hospital 1916 - 1961 Forceps Rate C-Section Rate

  28. Maternal Mortality Rates at Hartford Hospital: 1916 - 1961 per 100,000 Births 5000 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 C/S Maternal Mortality Total Maternal Mortality 0 Total Maternal Mortality 760 370 130 10 30 20 20 C/S Maternal Mortality 4800 1500 350 260 90 120 70

  29. Total and Primary Cesarean Section Rate VBAC Rate 1970 - 2004

  30. Battle lines drawn over C-Sections By Rita Rubin, USA TODAY • “For some women, birth has become the latest battleground for reproductive rights.” • “At a growing number of hospitals, women are being forced to schedule a repeat Cesarean Section just because they already had one. Doctors and hospitals say they fear lawsuits if they allow a patient to attempt a vaginal birth after a C-Section — called a VBAC — and something goes awry.”

  31. Maternal Fetal Medicine and Cesarean Sections 1960-2000 • Neonatal Medicine, Respiratory Care, Intravenous Fluids, Surfactant – M.E. Avery • L/S Ratio – L. Gluck • Ultrasound – I. Donald • Antenatal Steroids for Fetal Lung Maturity – J. Liggins • Fetal Monitoring – E. Hon • Reassessment Breech, Midforceps • Advances Antibiotics, Anesthesia, Blood Banking • Assisted Reproductive Technology

  32. Cesarean Section Rate at Hartford Hospital 1990 - 2006

  33. Increasing Cesarean Section Rate • Older mothers • Lower Parity • Increasing Obesity • More Multiple Gestations • Vaginal Breech not Recommended • Concerns over Forcep and Vacuum Delivery • Increase inductions • Fetal Monitoring • Medical Liability

  34. Maternal Mortality and Severe MorbidityAssociated with low-risk planned Cesarean delivery versus planned vaginal delivery at term(among healthy women in Canada, 1991-2005) Type of planned delivery; no. (%) Type or cause Cesarean Vaginal Adjusted of illness or death n=46,766 n=2,292,42 Odds Ratio Overall severe morbidity1279 (2.7%) 20,639 (0.90%) 3.1 Hemorrhage req. hysterectomy12 (0.03%) 254 (0.01%) 2.1 Any hysterectomy27 (0.06%) 367 (0.02%) 3.2 Uterine rupture 7 (0.02%) 660 (0.03%) 0.5 Cardiac arrest89 (0.02%) 887 (0.04%) 5.1 Venous Thromboembolism 28 (0.06%) 623 (0.03%) 2.2 Major puerperal infection281 (0.60%) 4833 (0.21%) 3.0 In-Hospital Death 0 (0.00%) 41 (0.002%) / *Liu S, Liston RM, et.al. Can Med Assoc J. 176(4), 455-460, 2007.

  35. Elective Cesarean Section on Demand • Impact on Shoulder Dystocia, Fetal Trauma, Neonatal Encephalopathy and Intrauterine Fetal Demise • Maternal Mortality • Maternal Morbidity • Cesarean Section and Future Deliveries • Urinary Incontinence and Pelvic Organ Prolapse • Anal Incontinence and Delivery • Neonatal Mortality and Morbidity • Financial Resources and Cesarean Section Rate

  36. Cultural Selection of Cesarean Section • Change in Technology • Change in Social Conditions and Norms

  37. Darwinian Natural Selection of Cesarean Section • Human Birth is Very Difficult • A “Tight” Squeeze • Human Birth is Integral to the Key Processes in Evolution of Homo Sapiens • Upright Posture • Brain Enlargement and Development

  38. Evolutionary Changes in Human Birth • Enlargement of human pelvis (at it’s limit) • Internal rotation of human babies head in labor (only primate or mammal with this evolutionary mechanism) • Slower development of fetus including fetal head. Human brain at birth is less than one-fourth it’s final adult size. Other primates at birth average about one-half adult size. • Shorter gestation for fetal development

  39. Natural Selection of Shorter Gestation • Major feature of human evolution (in utero and in childhood) is slowing of development • If human birth occurred at the same fetal development of physical characteristics, birth in humans would occur not at 9 months but at 16 to 17 months of gestation. • Human babies at 9 months are essentially “still an embryo.” • Birth at 9 months as compared to other primates is preterm as a result of evolution of upright posture and brain size.

  40. Natural Selection Today • Due to changing medical practice • Increased Cesarean sections due to changes in technology and social values is selecting genes for smaller pelvises and larger babies • Neonatal maternal fetal medicine through natural selection is increasing preterm labor

  41. “What’s Past is Prologue” The Tempest William Shakespeare 1610

  42. Thank-you! Maggie Brian Patrick Sophie Kevin Grace

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