Yet, the early history of cesarean section remains shrouded in myth and is of dubious accuracy. Even the origin of “cesarean” has apparently been distorted over time. It is commonly believed to be derived from the surgical birth of Julius Caesar, however this seems unlikely since his mother Aurelia is reputed to have lived to hear of her son’s invasion of Britain. At that time the procedure was performed only when the mother was dead or dying, as an attempt to save the child for a state wishing to increase its population. Roman law under Caesar decreed that all women who were so fated by childbirth must be cut open; hence, cesarean. Other possible Latin origins include the verb “caedare,” meaning to cut, and the term “caesones” that was applied to infants born by postmortem operations. Ultimately, though, we cannot be sure of where or when the term cesarean was derived. Until the sixteenth and seventeenth centuries the procedure was known as cesarean operation. This began to change following the publication in 1598 of Jacques Guillimeau’s book on midwifery in which he introduced the term “section.” Increasingly thereafter “section” replaced “operation.”

During its evolution cesarean section has meant different things to different people at different times. The indications for it have changed dramatically from ancient to modern times. Despite rare references to the operation on living women, the initial purpose was essentially to retrieve the infant from a dead or dying mother; this was conducted either in the rather vain hope of saving the baby’s life, or as commonly required by religious edicts, so the infant might be buried separately from the mother. Above all it was a measure of last resort, and the operation was not intended to preserve the mother’s life. It was not until the nineteenth century that such a possibility really came within the grasp of the medical profession.

There were, though, sporadic early reports of heroic efforts to save women’s lives. While the Middle Ages have been largely viewed as a period of stagnation in science and medicine, some of the stories of cesarean section actually helped to develop and sustain hopes that the operation could ultimately be accomplished. Perhaps the first written record we have of a mother and baby surviving a cesarean section comes from Switzerland in 1500 when a sow gelder, Jacob Nufer, performed the operation on his wife. After several days in labor and help from thirteen midwives, the woman was unable to deliver her baby. Her desperate husband eventually gained permission from the local authorities to attempt a cesarean. The mother lived and subsequently gave birth normally to five children, including twins. The cesarean baby lived to be 77 years old. Since this story was not recorded until 82 years later historians question its accuracy. Similar skepticism might be applied to other early reports of abdominal delivery þ those performed by women on themselves and births resulting from attacks by horned livestock, during which the peritoneal cavity was ripped open.

The history of cesarean section can be understood best in the broader context of the history of childbirth and general medicine þ histories that also have been characterized by dramatic changes. Many of the earliest successful cesarean sections took place in remote rural areas lacking in medical staff and facilities. In the absence of strong medical communities, operations could be carried out without professional consultation. This meant that cesareans could be undertaken at an earlier stage in failing labor when the mother was not near death and the fetus was less distressed. Under these circumstances the chances of one or both surviving were greater. These operations were performed on kitchen tables and beds, without access to hospital facilities, and this was probably an advantage until the late nineteenth century. Surgery in hospitals was bedeviled by infections passed between patients, often by the unclean hands of medical attendants. These factors may help to explain such successes as Jacob Nufer’s.

By dint of his work in animal husbandry, Nufer also possessed a modicum of anatomical knowledge. One of the first steps in performing any operation is understanding the organs and tissues involved, knowledge that was scarcely obtainable until the modern era. During the sixteenth and seventeenth centuries with the blossoming of the Renaissance, numerous works illustrated human anatomy in detail. Andreas Vesalius’s monumental general anatomical text De Corporis Humani Fabrica, for example, published in 1543, depicts normal female genital and abdominal structures. In the eighteenth and early nineteenth centuries anatomists and surgeons substantially extended their knowledge of the normal and pathological anatomy of the human body. By the later 1800s, greater access to human cadavers and changing emphases in medical education permitted medical students to learn anatomy through personal dissection. This practical experience improved their understanding and better prepared them to undertake operations.

At the time, of course, this new type of medical education was still only available to men. With gathering momentum since the seventeenth century, female attendants had been demoted in the childbirth arena. In the early 1600s, the Chamberlen clan in England introduced obstetrical forceps to pull from the birth canal fetuses that otherwise might have been destroyed. Men’s claims to authority over such instruments assisted them in establishing professional control over childbirth. Over the next three centuries or more, the male-midwife and obstetrician gradually wrested that control from the female midwife, thus diminishing her role.

Part 1

Cesarean section has been part of human culture since ancient times and there are tales in both Western and non-Western cultures of this procedure resulting in live mothers and offspring. According to Greek mythology Apollo removed Asclepius, founder of the famous cult of religious medicine, from his mother’s abdomen. Numerous references to cesarean section appear in ancient Hindu, Egyptian, Grecian, Roman, and other European folklore. Ancient Chinese etchings depict the procedure on apparently living women. The Mischnagoth and Talmud prohibited primogeniture when twins were born by cesarean section and waived the purification rituals for women delivered by surgery.

By dint of his work in animal husbandry, Nufer also possessed a modicum of anatomical knowledge. One of the first steps in performing any operation is understanding the organs and tissues involved, knowledge that was scarcely obtainable until the modern era. During the sixteenth and seventeenth centuries with the blossoming of the Renaissance, numerous works illustrated human anatomy in detail. Andreas Vesalius’s monumental general anatomical text De Corporis Humani Fabrica, for example, published in 1543, depicts normal female genital and abdominal structures. In the eighteenth and early nineteenth centuries anatomists and surgeons substantially extended their knowledge of the normal and pathological anatomy of the human body. By the later 1800s, greater access to human cadavers and changing emphases in medical education permitted medical students to learn anatomy through personal dissection. This practical experience improved their understanding and better prepared them to undertake operations.

At the time, of course, this new type of medical education was still only available to men. With gathering momentum since the seventeenth century, female attendants had been demoted in the childbirth arena. In the early 1600s, the Chamberlen clan in England introduced obstetrical forceps to pull from the birth canal fetuses that otherwise might have been destroyed. Men’s claims to authority over such instruments assisted them in establishing professional control over childbirth. Over the next three centuries or more, the male-midwife and obstetrician gradually wrested that control from the female midwife, thus diminishing her role.

Part 2

In Western society women for the most part were barred from carrying out cesarean sections until the late nineteenth century, because they were largely denied admission to medical schools. The first recorded successful cesarean in the British Empire, however, was conducted by a woman. Sometime between 1815 and 1821, James Miranda Stuart Barry performed the operation while masquerading as a man and serving as a physician to the British army in South Africa.

While Barry applied Western surgical techniques, nineteenth-century travelers in Africa reported instances of indigenous people successfully carrying out the procedure with their own medical practices. In 1879, for example, one British traveller, R.W. Felkin, witnessed cesarean section performed by Ugandans. The healer used banana wine to semi-intoxicate the woman and to cleanse his hands and her abdomen prior to surgery. He used a midline incision and applied cautery to minimize hemorrhaging. He massaged the uterus to make it contract but did not suture it; the abdominal wound was pinned with iron needles and dressed with a paste prepared from roots. The patient recovered well, and Felkin concluded that this technique was well-developed and had clearly been employed for a long time. Similar reports come from Rwanda, where botanical preparations were also used to anesthetize the patient and promote wound healing.

While many of the earliest reports of cesarean section issue from remote parts of Europe and the United States and from places far removed from the latest developments in Western medicine, it was only with increased urbanization and the growth of hospitals that the operation began to be performed routinely. Most rural births continued to be attended by midwives in the late nineteenth and early twentieth centuries, but in the cities obstetrics — a hospital-based specialty — squeezed out midwifery. In urban centers large numbers of uprooted working class women gave birth in hospitals because they could not rely on the support of family and friends, as they could in the countryside. It was in these hospitals, where doctors treated many patients with similar conditions, that new obstetrical and surgical skills began to be developed.

Special hospitals for women sprang up throughout the United States and Europe in the second half of the nineteenth century. Reflecting that period’s budding medical interest in the sexuality and the diseases of women, these institutions nurtured the emerging specialties and provided new opportunities for medical practitioners, as well as new treatments for patients. Specialties such as neurology and psychiatry centered on mental and nervous disorders and obstetrics and gynecology centered on the functions and disorders of the female reproductive tract.

As a serious abdominal operation, the development of cesarean section both sustained and reflected changes within general surgery. In the early 1800s, when surgery still relied on age-old techniques, its practitioners were dreaded and viewed by the public as little better than barbers, butchers, and tooth pullers. Although many surgeons possessed the anatomical knowledge and the courage to perform serious procedures they had been limited by the patient’s pain and the problems of infection. Well into the 1800s surgery continued to be barbarous and the best operators were known for the speed with which they could amputate a limb or suture a wound.

During the nineteenth century, however, surgery was transformed — both technically and professionally. A new era in surgical practice began in 1846 at Massachusetts General Hospital when dentist William T. G. Morton used diethyl ether while removing a facial tumor. This medical application of anesthesia rapidly spread to Europe. In obstetrics, though, there was opposition to its use based on the biblical injunction that women should sorrow to bring forth children in atonement for Eve’s sin. This argument was substantially demolished when the head of the Church of England, Queen Victoria, had chloroform administered for the births of two of her children (Leopold in 1853 and Beatrice in 1857). Subsequently, anesthesia in childbirth became popular among the wealthy and practical in cases of cesarean section.

By the century’s close, a wide range of technological innovations had enabled surgeons to revolutionize their practice and to professionalize their position. Anesthetics permitted surgeons to take the time to operate with precision, to cleanse the peritoneal cavity, to record the details of their procedures, and to learn from their experiences. Women were spared the agony of operations and were less susceptible to shock, which had been a leading cause of post-operative mortality and morbidity.

As many doctors discovered, anesthesia allowed them to replace craniotomy with cesarean section. Craniotomy had been practiced for hundreds, perhaps even thousands, of years. This unhappy procedure involved the destruction (by instruments such as the crotchet) of the fetal skull and the piecemeal extraction of the entire fetus from the vagina. Although this was a gruesome operation, it entailed far lower risk to the mother than attempts to remove the fetus through an abdominal incision.

While obstetrical forceps helped to remove the fetus in some cases, they had limitations. They undoubtedly saved the lives of some babies who would otherwise have suffered craniotomy, but even when the mother’s life was saved, she might well suffer severely for the rest of her life from tears in the vaginal wall and perineum. The low forceps that are still commonly used today could cause vaginal tears, but they were less likely to do so than the high forceps that in the nineteenth century were too frequently employed. Inserted deep into the pelvis in cases of protracted labor, these instruments were associated with high levels of fetal damage, infection, and serious lacerations to the woman. Dangerous as it was, cesarean section may have seemed preferable in some instances when the fetus was trapped high in the pelvis. Where severe pelvic distortion or contraction existed, neither craniotomy nor obstetrical forceps were of any avail, and then cesarean section was probably the only hope.

While doctors and patients alike were encouraged by anesthesia to resort to cesarean section rather than craniotomy, mortality rates for the operation remained high, with the infections septicemia and peritonitis accounting for a large percentage of post-operative deaths. Prior to the establishment of the germ theory of disease and the birth of modern bacteriology in the second half of the nineteenth century, surgeons wore their street clothes to operate and washed their hands infrequently while passing from one patient to another. In the mid-1860s, the British surgeon Joseph Lister introduced an antiseptic method using carbolic acid, and many operators adopted some part of his antisepsis. Others, however, were concerned about its corrosiveness and experimented with various aseptic measures that emphasized cleanliness. By the end of the century antisepsis and asepsis gradually were making inroads into the problems of surgical infections.

Unfortunately, surgical techniques of that day also contributed to the appallingly high maternal mortality rates. According to one estimate not a single woman survived cesarean section in Paris between 1787 and 1876. Surgeons were afraid to suture the uterine incision because they thought internal stitches, which could not be removed, might set up infections and cause uterine rupture in subsequent pregnancies. They believed the muscles of the uterus would contract and close spontaneously. Such was not the case. As a result some women died of blood loss — more from infection.

Part 3

Once anesthesia, antisepsis, and asepsis were firmly established obstetricians were able to concentrate on improving the techniques employed in cesarean section. As early as 1876, Italian professor Eduardo Porro had advocated hysterectomy in concurrence with cesareans to control uterine hemorrhage and prevent systemic infection. This enabled him to reduce the incidence of post-operative sepsis. But his mutilating elaboration on cesarean section was soon obviated by the employment of uterine sutures. In 1882, Max Saumlnger, of Leipzig made such a strong case for uterine sutures that surgeons began to change their practice. Saumlnger’s monograph was based largely on the experience of U.S. healers (surgeons and empirics) who had used internal sutures. The silver wire stitches he recommended were themselves new, having been developed by America’s premier nineteenth-century gynecologist J. Marion Sims. Sims had invented his sutures to treat the vaginal tears (fistulas) that resulted from traumatic childbirth.

As cesarean section became safer, obstetricians increasingly argued against delaying surgery. Rather than waiting for many hours of unsuccessful labor, doctors such as Robert Harris in the United States, Thomas Radford in England, and Franz von Winckel in Germany opted for an early resort to the operation in order to improve the outcome. If the woman was not in a state of collapse when taken to surgery her recovery would be more certain, they claimed. This was an argument sweeping through the general surgical community and one that resulted in greater numbers of operations on an expanding patient population. In obstetrical surgery the new approach also assisted in reducing maternal and perinatal infant mortality rates.

As surgeons’ confidence in the outcome of their procedures increased, they turned their attention to other issues, including where to incise the uterus. Between 1880 and 1925, obstetricians experimented with transverse incisions in the lower segment of the uterus. This refinement reduced the risk of infection and of subsequent uterine rupture in pregnancy. A further modification — vaginal cesarean section — helped avoid peritonitis in patients who were already suffering from certain infections. The need for that form of section, however, was virtually eliminated in the post World War II period by the development of modern antibiotics. Penicillin was discovered by Alexander Fleming in 1928 and, after it was purified as a drug in 1940, became generally available and dramatically reduced maternal mortality for both normal and cesarean section births. Meanwhile, the low cervical cesarean section, advocated in the early twentieth century by the British obstetrician Munro Kerr, had become popular. Promulgated by Joseph B. DeLee and Alfred C. Beck in the United States, this technique reduced the rates of infection and of uterine rupture and is still the operation of preference.

In addition to surgical advances, the development of cesarean section was influenced by the continued growth in number of hospitals, by significant demographic changes, and by numerous other factors — including religion. Religion has affected medicine throughout recorded history and, as noted earlier, both Jewish and Roman law helped shape early medical practice. Later, in early to mid-nineteenth century France, Roman Catholic religious concerns, such as removal of the infant so that it could be baptized, prompted substantial efforts to pioneer cesarean section, efforts launched by some of the country’s leading surgeons. Protestant Britain avoided cesarean section during the same period, even though surgeons were experimenting with other forms of abdominal procedures (mainly ovarian operations). British obstetricians were far more inclined to consider the mother primarily and, with cesarean section maternal mortality over fifty percent, they usually opted for craniotomy.

As the rate of urbanization rapidly increased in Britain, throughout Europe, and the United States there arose at the turn of the century an increased need for cesareans. Cut off from agricultural produce and exposed to little sunlight, city children experienced a sharply elevated rate of the nutritional disease rickets. In women where improper bone growth had resulted, malformed pelvises often prohibited normal delivery. As a result the rate of cesarean section went up markedly. By the 1930s, when safe milk became readily available in schools and clinics in much of the United States and Europe, improper bone growth became less of a problem. Yet, many in the medical profession were slow to respond to the decreased need for surgical delivery. After World War II, in fact, the cesarean section rate never returned to the low levels experienced before rickets became a large-scale malady, despite considerable criticism of the too frequent resort to surgery.

The safe milk movement was a measure of preventive medicine promoted by public health reformers in the United States and abroad. These reformers worked with governments to improve many aspects of maternal and infant health. Yet while more and more women received prenatal attention — indeed more than ever before — surgical intervention continued to rise. So too did the involvement of state and federal governments in financing and overseeing maternal and fetal care. Accompanying these trends was a tendency over the past half century for the status of the fetus increasingly to be given center stage.

Since 1940, the trend toward medically managed pregnancy and childbirth has steadily accelerated. Many new hospitals were built in which women gave birth and in which obstetrical operations were performed. By 1938, approximately half of U.S. births were taking place in hospitals. By 1955, this had risen to ninety-nine percent.

During that same period medical research flourished and technology was greatly expanded in scope and application. Advances in anesthesia contributed to improving the safety and the experience of cesarean section. In numerous countries, including the United States, spinal or epidural anesthesia is used to alleviate pain in normal childbirth. It has also largely replaced general anesthesia in cesarean deliveries, permitting women to remain conscious during surgery. It results in better outcomes for mothers and babies and facilitates immediate contact and bonding to occur.

These days, too, fathers are able to make that important early contact and support their partners during both normal and cesarean births. When childbirth was moved from homes to hospitals fathers were initially removed from the birthing scene and this distancing became even more complete in relation to surgical delivery. But, the use of conscious anesthesia and the increased ability to maintain an antiseptic and antibiotic field during operations allowed fathers to be present during cesarean section. Meanwhile, changes in gender relations were altering the involvement of many fathers in pregnancy, childbirth, and parenting. The modern father participates in childbirth classes and seeks a prominent role in birthing — normal and cesarean.

Currently in the United States slightly more than one in seven women experiences complications during labor and delivery that are due to conditions existing prior to pregnancy; these include diabetes, pelvic abnormalities, hypertension, and infectious diseases. In addition, a variety of pathological conditions that develop during pregnancy (such as eclampsia and placenta praevia) are indications for surgical delivery. These problems can be life-threatening for both mother and baby, and in approximately forty percent of such cases cesarean section provides the safest solution. In the United States almost one quarter of all babies are now delivered by cesarean section — approximately 982,000 babies in 1990. In 1970, the cesarean section rate was about 5%; by 1988, it had peaked at 24.7%. In 1990, it had decreased slightly to 23.5%, primarily because more women were attempting vaginal births after cesarean deliveries.

How can we explain this dramatic increase? It certainly far exceeds any rise in the birth rate, which went up by only 2% between 1970 and 1987. In fact there were several factors that contributed to the rapid rise in cesarean sections. Some of the factors were technological, some cultural, some professional, others legal. The growth in malpractice suits no doubt promoted surgical intervention, but there were many other influences at work.

Part 4

While the operation historically has been performed largely to protect the health of the mother, more recently the health of the fetus has played a larger role in decisions to go to surgery. Hormonal pregnancy tests — tests that confirm fetal existence — have been available since the 1940′s. The fetal skeleton could be seen using X-rays, but, the long-term hazards of radiation prompted researchers to seek other imaging technology. The answer in the post-war era came from wartime technology. Ultrasound, or sonar equipment that had been developed to detect submarines, became the springboard for soft tissue ultrasonography in the late 1940′s and early 1950′s. Ultrasound made it possible to measure fetal growth and fetal skull width in relation to the mother’s pelvic dimensions and now has become a routine diagnostic device. While this type of visualization provided medical personnel with valuable information, it also influenced attitudes toward the fetus. When the fetus could be visualized and its sex and chromosomal makeup determined through this and other more modern tests such as amniocentesis and chorionic villus sampling, it became more of a person. Indeed, many fetuses were named months before birth.

The fetus then has become a patient. Today it can even be surgically and pharmaceutically treated in utero. This changes the emotional and financial investment both medical practitioners and expectant parents have in a fetus. This is even more pronounced after the commencement of labor when the fetus increasingly becomes the primary patient. Since the advent of heart monitors in the early 1970′s, fetal monitoring routinely tracks fetal heart rate and indicates any signs of distress. As a result of the ability to detect signs of fetal distress, many cesarean sections are swiftly undertaken to prevent such serious problems as brain damage due to oxygen deficiency.

With these innovations came criticism. Fetal monitoring as well as numerous other antenatal diagnostics have been faulted in recent years by some of the lay public and members of the medical profession. The American College of Obstetricians and Gynecologists and similar organizations in several other countries have been working to reduce some of the reliance on high-cost and high-tech features of childbirth and to encourage women to attempt normal delivery whenever possible.

The trend toward hospital births, including cesarean section, has been challenged. Since 1940, the experience of giving birth has become safer and less frightening, and many women have come to view that experience more positively. Thus was spawned the natural childbirth movement, a development fueled by the modern feminist movement, which has urged women to take greater responsibility for their own bodies and health care. The soaring cesarean section rate of the past two decades has also been questioned by lay people. Consumer advocacy organizations and women’s groups have been working to reduce what they see as unnecessary surgery. Some doctors have for many years expressed doubts about the rates of cesarean section. Recently many medical practitioners have responded to this situation and have begun to work with lay organizations to encourage more women to undertake normal delivery.

These efforts seem to be having some effect. Despite the recent increase in cesarean section rates there appears to be a leveling off þ the figure for 1988 was almost identical to that for 1987. Perhaps one of the most important factors is the changing opinion toward the formula “once a cesarean section, always a cesarean section.” This expression embodied the notion that once a woman had a cesarean she would require surgery for all subsequent deliveries. This was, apparently, the cause of the greatest increase in cesarean sections between 1980 and 1985. But many women were deeply concerned about that edict and the morbidity following major surgery. They organized vaginal-birth-after-cesarean groups to encourage normal births subsequent to surgery. Soaring health care costs have also contributed to efforts to avoid the more expensive cesarean births. The American College of Obstetricians and Gynecologists responded swiftly to calls from within the organization and from the patient population and in 1982, as a standard of care, recommended a trial of labor in selected cases of prior cesarean section. In 1988, the guidelines were expanded to include more women with previous cesarean births. Consequently, there was a steady increase in vaginal births after cesarean in the late 1980′s. In 1990, an estimated 90,000 women gave birth vaginally after cesarean section.

The trend in Western medicine seems now to be away from higher levels of cesarean section, and a new ten-year study by an Oxford University research team emphasizes this point. The study involved a comparison of cesarean section rates that average almost 25% in the United States and 9% in Great Britain, and suggests that the trends in the United States need to be questioned. This study indicates that, while cesarean section continues to be a procedure that saves the lives of mothers and infants and prevents disabilities, both the medical and lay communities must bear in mind that most births are normal and more births should progress without undue intervention.

As this brief history suggests, the indications for cesarean section have varied tremendously through our documented history. They have been shaped by religious, cultural, economic, professional, and technological developments — all of which have impinged on medical practice. The operation originated from attempts to save the soul, if not the life, of a fetus whose mother was dead or dying. Since ancient times, however, there have been occasional efforts to save the mother, and during the nineteenth century, systematic improvement of cesarean section techniques eventually led to lower mortality for women and their fetuses. Increasingly the operation was performed in cases where the mother’s health was considered endangered, in addition to those in which her life was immediately at stake. Finally, in the late twentieth century, in mainstream Western medical society the fetus has become the primary patient once labor has commenced. As a result, we have seen in the last 30 years a marked increase in resort to surgery on the basis of fetal health indications.

While there is sound reason to believe that cesarean section has been employed too frequently in some societies during the last two or three decades, the operation clearly changes the outcome favorably for a significant percentage of women and babies. In our society now women may be afraid of the pain of childbirth, but they do not expect it to kill them. Such could not be said of many women as late as the nineteenth century. Moreover, most women now expect their babies to survive birth. These are modern assumptions and ones that cesarean section has helped to promulgate. An operation that virtually always resulted in a dead woman and dead fetus now almost always results in a living mother and baby — a transformation as significant to the women and families involved as to the medical profession.

Selected References

Ackerknecht, Erwin H.,
A Short History of Medicine,
Baltimore: The Johns Hopkins University Press, 1982

Boley, J.P.,
“The History of Cesarean Section,”
Canadian Medical Association Journal,
Vol. 145, No. 4, 1991, pp. 319-322.

Donnison, Jean,
Midwives and Medical Men: A History of the Struggle for the Control of Childbirth,
London: Historical Publications Ltd., 1988.

Eastman, N.J.,
“The Role of Frontier America in the Development of Cesarean Section,”
American Journal of Obstetrics and Gynecology,
Vol. 24, 1932, p. 919.

Gabert, Harvey A., “History and Development of Cesarean Operation,” in Obstetrics and Gynecology Clinics of North America,
Vol. 15, No. 4. 1988, pp. 591-605.

Horton, Jacqueline A., ed.,
The Women’s Health Data Book.
A Profile of Women’s Health in the United States,
New York: Elsevier, 1992, pp. 18-20.

Leavitt, Judith Walzer,
Brought to Bed: Childbearing in America, 1750-1950,
New York: Oxford University Press, 1986.

Leonardo, Richard A.,
History of Gynecology,
New York: Froben Press, 1944.

Ludmerer, Kenneth M.,
Learning to Heal: The Development of American Medical Education,
New York: Basic Books Inc., 1985.

Martin, Emily,
The Woman in the Body: A Cultural Analysis of Reproduction,
Boston: Beacon Press, 1987.

Maulitz, Russell C.,
Morbid Appearances: The Anatomy of Pathology in the Early Nineteenth Century,
Cambridge: Cambridge University Press, 1987.

Miller, Joseph L.,
“Cesarean Section in Virginia in the Pre-Aseptic Era, 1794-1879,”
Annals of Medical History, January, 1938, pp. 23-35.

Miller, Joseph M.,
“First Successful Cesarean Section in the British Empire,” Letters,
Vol. 166, No. 1, Part 1, p. 269.

Moscucci, Ornella,
The Science of Woman: Gynaecology and Gender in England, 1800-1929,
Cambridge: Cambridge University Press, 1990.

Oakley, Ann,
The Captured Womb: A History of the Medical Care of Pregnant Women,
Oxford: Basil Blackwell Ltd., 1984, 1986.

Pernick, Martin S.,
A Calculus of Suffering: Pain, Professionalism, and Anesthesia in Nineteenth-Century America,
New York: Columbia University Press, 1985.

Ricci, J.V.,
The Genealogy of Gynaecology: History of the Development of Gynaecology Throughout the Ages,
Philadelphia: The Blakiston Company, 1943.

Ricci, J.V.,
One Hundred Years of Gynaecology, 1800-1900,
Philadelphia: The Blakiston Company, 1945.

Rothstein, William G.,
American Medical Schools and the Practice of Medicine: A History,
New York: Oxford University Press, 1987.

Rucker M. Pierce and Edwin M. Rucker,
“A Librarian Looks at Cesarean Section,”
Bulletin of the History of Medicine, March 1951, pp. 132-148.

Sewell, Jane Eliot,
Bountiful Bodies: Spencer Wells, Lawson Tait, and the Birth of British Gynaecology,
Ann Arbor, Michigan: U.M.I., 1990.

Shryock, Richard Harrison,
The Development of Modern Medicine: An Interpretation of the Social and Scientific Factors Involved,
Madison, Wisconsin: The University of Wisconsin Press, 1936, 1979.

Shryock, Richard Harrison,
Medicine and Society in America: 1660-1860,
Ithaca: Cornell University Press, 1977.

Speert, Harold,
Obstetrics and Gynecology in America: A History,
Baltimore: Waverly Press, 1980.

Towler, Jean and Joan Bramell,
Midwives in History and Society,
London: Croom Helm, 1986.

Wertz, Richard W. and Dorothy C. Wertz,
Lying-In: A History of Childbirth in America,
New Haven: Yale University Press, 1989.

Willson, J. Robert,
“The Conquest of Cesarean Section-Related Infections: A Progress Report,”
Obstetrics and Gynecology, Vol. 72, No. 3, Part 2, September 1988, pp. 519-532.

Wolfe, Sidney M.,
Women’s Health Alert,
Reading, Massachusetts: Addison-Wesley Publishing Company Inc., 1991

Young, J.H.,
Caesarean Section: The History and Development of the Operation From Early Times,
London: H.K. Lewis and Co. Ltd., 1944.

The National Library of Medicine has a rich collection of written works on the history of Cesarean section as well as numerous film and other visual sources.

Source: National Library of Medicine, National Institutes of Health – https://www.nlm.nih.gov/exhibition/cesarean/

• Health problems in the mother
• The position of the baby
• Not enough room for the baby to go through the vagina
• Signs of distress in the baby

C-sections are also more common among women carrying more than one baby.

The surgery is relatively safe for mother and baby. Still, it is major surgery and carries risks. It also takes longer to recover from a C-section than from vaginal birth. After healing, the incision may leave a weak spot in the wall of the uterus. This could cause problems with an attempted vaginal birth later. However, more than half of women who have a C-section can give vaginal birth later.

Source: National Library of Medicine, National Institutes of Health, MedlinePlus – http://www.nlm.nih.gov/medlineplus/cesareansection.html

This report provides a framework for comparing the harms and benefits of delivery options for women with prior cesarean delivery (CD). The information is designed to help consumers, providers, payers, and policymakers in decisionmaking about repeat cesarean or trial of labor (TOL).

Reporting the Evidence

The strength and suitability of the evidence regarding the risks of major maternal and infant morbidity and mortality associated with TOL or elective repeat cesarean delivery (ERCD) in women with prior low transverse or unknown scar. The scope of the review was to examine events that were specifically related to having had a prior CD. Comparisons purely about vaginal versus cesarean delivery such as incontinence, pelvic support disorders, and respiratory consequences but not specifically about VBAC or repeat cesarean, were not considered, though these topics are important to consider when deciding upon route of delivery. In judging the suitability of evidence, we took the perspective that the first thing a decision-maker would want to know is whether the risk of these complications is higher for a trial of labor, versus an elective cesarean delivery, under optimal conditions of care. That is, the most relevant evidence would compare the outcomes and risks of a properly managed trial of labor to that of a properly conducted elective cesarean delivery. Some components of obstetric care, as well as some aspects of the setting of this care, might increase the risks of TOL or ERCD. For example, it has been hypothesized that the use (or misuse) of drugs for induction and augmentation might increase the risk of uterine rupture in patients who have had a prior cesarean delivery. We examined the strength of evidence that these factors influence these outcomes and adverse effects and to what extent these factors can explain the results of observational studies of VBAC complications.

Methodology

Key Questions

Two types of key questions were addressed. The first group (Questions 1- 7) compares the outcomes of a TOL and an ERCD:

1. What is the frequency of vaginal delivery in women who undergo a TOL (spontaneous onset, induced, and augmented) after prior low transverse cesarean or unknown scar?
2. How accurate are risk assessment tools for identifying patients who will have a vaginal delivery after a TOL?
3. What are the relative harms associated with a TOL (spontaneous onset, induced, and augmented) and repeat cesarean?
4. What is the incidence of uterine rupture, and are there methods for preventing major morbidity and mortality due to uterine rupture?
5. What are the health status and health-related quality of life for VBAC and repeat cesarean patients?
6. Regarding VBAC and repeat cesarean, what factors influence patient satisfaction/dissatisfaction with their childbirth experience?
7. How are economic outcomes related to VBAC, repeat CD, and their respective complications?

The second group (Questions 8-10) address factors influencing the decision to have a TOL:

1. What individual factors influence route of delivery?
2. What factors influence a patient’s decisionmaking regarding VBAC or ERCD?
3. How do legislation, policy, guidelines, provider characteristics, insurance type, and access to care affect health outcomes for VBAC candidates?

Relevant studies were identified from multiple searches of MEDLINE® (1966 to 2002) and HealthSTAR (1975 to 2002), from the reference lists of systematic reviews and from local and national experts. The online Cochrane systematic reviews and controlled trials registries, DARE, National Centre for Reviews and Dissemination, and EMBASE databases were searched for relevant literature on specific topics as well. For topics related to patient preferences and satisfaction, PsycINFO and CINAHL® databases were searched. Databases were searched twice during the course of the project, with the final search in March 2002. For all VBAC topics combined, 14,449 citations were retrieved, including 4,867 about spontaneous labor and uterine rupture, 2,528 about ERCD, 2,416 about induction of labor, 2,945 citations about predictors, 1,257 about patient satisfaction, preference and health status, and 436 about cost and access.

All searches were limited to English-language articles published since 1980 (the date of the NIH Consensus Conference on VBAC) in developed countries. The report focused on studies that identified a group of patients with prior cesarean. For patient preferences and satisfaction, studies of the general birthing population, were considered if there were no studies that identified patients with prior cesarean. Studies were excluded if they focused on patients with particular conditions such as gestational diabetes, HIV, preeclampsia, and so on. Exclusions were also made for studies that focused primarily on the following: nulliparous women, vertical, lower vertical, “classical” or “classic” cesarean, vaginal breech delivery, preterm delivery, multiple gestation, or low birth weight.

Two investigators reviewed a random set of titles and abstracts for each topic to select articles for full-text review. When an appropriate level of reliability was reached for inclusion and exclusion of studies, the primary investigator reviewed the remaining titles and abstracts on the topic. Investigators read the full-text version of the retrieved papers and reapplied the initial eligibility criteria. Data from 224 studies were abstracted and included in the evidence tables described in the results section of this report.

Data Abstraction

Included study designs were determined by topic area. Study designs of included articles consisted of randomized controlled trials, cohort studies, case-control studies, cross-sectional studies, large case series (more than 10 subjects), and economic or decision models. All data were abstracted by the lead investigator for the topic. If the lead investigator encountered difficulty in finding or interpreting information in the published report, a second investigator reviewed the article and a consensus was reached.

Assessment of Study Quality

To assess the internal validity of individual studies, we applied a set of design-specific criteria developed by the current U.S. Preventive Services Task Force and additional criteria developed by the NHS Centre for Reviews and Dissemination, based at the University of York in England. In general, studies were rated good if they met all criteria, fair if they addressed some but not all criteria, and poor if they had a “fatal flaw.” Investigators were asked to use the study quality ratings as previously described to determine for their topic which quality components were most important in assessing internal validity. This process allowed for some individual topic fit for fatal flaws, etc. A second investigator independently rated all included articles, and disagreements were resolved by consensus.

Data Synthesis

Where appropriate, meta-analysis was performed using WinBugs® or StatsDirect® software. To reduce potential bias, only studies of fair or good quality were included in the analyses.

Findings

Question 1. Likelihood of Vaginal Delivery

• Rates of vaginal delivery when attempting TOL ranged from 60 to 82 percent. The largest population-based study reported a rate of 60.4 percent. The combined vaginal delivery rate for all prospective cohort studies, largely conducted in tertiary care centers and university settings, was 75.9 percent.
• There are limited data on the effect of medical induction and augmentation of labor.
• There was a 10-percent reduction in the likelihood of vaginal delivery when oxytocin was used for ether induction or augmentation. There was a similar trend in reduced likelihood of vaginal delivery with prostaglandins.

Question 2. Predictive Tools

• Two validated scoring systems categorized women into groups with likelihoods of vaginal delivery ranging from roughly 45 to 95 percent.
• One tool was able to stratify more of the population (up to 50 percent of women choosing TOL) into high and low probability subgroups, with a relatively low false-positive rate.
• By using a prospective cohort design and the largest study population, the best scoring system created a 10-point score based on the presence or absence of five variables commonly available for most patient admissions.
• An RCT clearly demonstrated the inability of X-ray pelvimetry (XRP) to predict route of delivery reliably.
• Imaging studies that combined the measurements of the pelvis and fetus showed promising results, but were limited by their lack of control for confounding and biases.

Question 3. Maternal and Infant Outcomes

General

• In the absence of RCTs of TOL versus repeat cesarean, evidence that is most generalizable comes from large country, State, or regional population-based studies (referred to as population-based studies) followed by large multicenter cohort studies, large single-institution or single-practice cohort studies, then smaller cohort studies, respectively.
• There is no direct evidence regarding the benefits and harms of TOL relative to ERCD in women who are similar in every respect except choice of delivery route.
• Several fair and good quality studies provide indirect evidence about relative benefits and harms of each route.

Maternal

• Maternal death rates did not differ between TOL and ERCD.
• The best evidence suggests that hysterectomy rates do not differ between TOL and ERCD.
• No studies examined specifically the risks of incontinence or pelvic support disorders in women with prior cesarean.
• Rates of infection were increased in ERCD versus TOL overall. Studies that performed subgroup analyses for TOL with and without vaginal delivery consistently found increased rates of infection for women who attempted TOL but ultimately had a cesarean delivery.
• There is conflicting evidence regarding whether induction of labor affects infection rates.

Infant

• There is insufficient evidence regarding the effect of selected route of delivery and Apgar score or respiratory morbidity.
• No study measured infant death directly attributable to a mother’s choice of TOL or repeat CD.
• There is uncertainty about the magnitude of risk of perinatal death due to TOL. Results from two large studies differ in the magnitude of increased risk from TOL versus ERCD (90/1,000 TOL versus 50/1,000 ERCD compared with 12.9/1,000 TOL versus 1.1/1,000 ERCD). Neither study provides direct evidence of risk.

Question 4. Uterine Rupture

• The use of terms among studies is inconsistent.
• Definitions among studies for similar terms are ambiguous.
• There is no difference in asymptomatic uterine rupture rates in TOL versus ERCD.
• Symptomatic uterine rupture is significantly more common in TOL versus ERCD, with an increased risk of 2.7/1000.
• Based on the frequency and severity of symptomatic uterine rupture, the risk of perinatal death due to a rupture of a uterine scar is 1.5/10,000 and the risk of maternal hysterectomy is 4.8/10,000. These rates of serious complications such as perinatal death are probably more precise than overall risks from studies measuring death directly.
• The definition of uterine rupture as an outcome is confounded by a definition that includes the potential predictor of fetal heart rate (FHR) tracing abnormality.
• Measurement of frequency of occurrence, predictors for what population is at greatest risk, and predictors for poor outcomes are not possible, because of the lack of standard case definition.

Question 5. Health Status

• There were no studies of health status or health-related quality of life for VBAC or repeat CD patients.

Question 6. Patient Satisfaction

• Studies of patient satisfaction largely consisted of the patient’s own provider obtaining information about patient satisfaction, introducing the possibility of measurement bias.
• Only two cross-sectional studies used methods other than the patient’s own provider to obtain satisfaction information.
• No study measured satisfaction for the three types of delivery outcomes that could be experienced by women with prior CDs (VBAC, TOL followed by CD, or ERCD).

Question 7. Cost and Health Care Resources

• For a TOL success probability of 76 percent or greater, TOL is more cost-effective and provides higher quality of life.
• Further evaluation is needed of the sensitivity of the probability cut point of 76 percent to other potential predictor variables.

Question 8. Individual Factors

• The vast majority of studies looking at individual factors that influence the route of delivery were of poor quality due to the lack of control for confounding factors.
• The factors that were significantly associated with an increased likelihood of vaginal delivery (i.e., successful TOL) were maternal age less than 40 years, prior vaginal delivery (particularly vaginal delivery after cesarean), a nonrecurrent indication for the prior CD, and favorable cervical factors.
• The factors that were significantly associated with a decreased likelihood of vaginal delivery (i.e., failed TOL) were an increasing number of prior CD, gestational age greater than 40 weeks, birthweight greater than 4000 g, and augmentation of labor.

Question 9. Patient Preferences

• Patient preferences for birth choice are unclear because of the heterogeneity of the 11 included studies.
• Several factors appear related to choice for TOL (White race, prior vaginal delivery, lower levels of anxiety during the pregnancy).
• Lack of medical information along with cultural ideologies might account for minority women being less likely to attempt a TOL when compared with white women.
• A woman’s choice for delivery was often based on social motives (e.g., easier recovery, so she can care for baby and children at home).
• Only four of 11 studies cited safety for mother or baby as important reasons for delivery choice.
• It remains unclear whether VBAC education increases the proportion of women who choose TOL.

Question 10. Legal, Provider, Hospital, Insurance Characteristics

General

• Studies of legislation, policy, guidelines, hospital characteristics, provider characteristics, insurance type, or access to care focus exclusively on VBAC rates rather than safety.

Legal

• No study provides direct evidence for the impact of malpractice issues on VBAC or ERCD.
• One study reported that VBAC rates increased when legislation was enacted that standardized VBAC guidelines had to be provided to obstetric providers.
• The best evidence suggests that use of opinion leaders provides a greater likelihood of changing practice compared with audit and feedback.

Provider

• Studies of provider characteristics failed to control for important variables such as patient selection bias.

Hospital

• VBAC rates were higher in teaching hospitals compared to private, community, regional, or non-teaching hospitals.
• Three studies conflicted over the effect of hospitals containing a neonatal intensive care unit (NICU).

Insurance

• There was conflicting evidence regarding whether insurance status predicts VBAC.

Summary of Evidence

The following summarizes the type of study design, the quality of the evidence from studies, and the suitability of the study design to answer the particular question for each key question.

¹ Study design categories—I: randomized, controlled trials; II-1: controlled trials without randomization; II-2: cohort or case-control; II-3: multiple time series; III: opinions, descriptive epidemiology. U.S. Preventive Services Task Force (1996).

² Suitability of study design categories—Greatest: For comparison studies: Concurrent comparison groups and prospective measurement of exposure and outcome; For rates: population-based or multicenter prospective cohort studies. Moderate: All retrospective designs or multiple pre or post measurements but no concurrent comparison group; Least: Single pre and post measurements and no concurrent comparison group or exposure and outcome measured in a single group at the same point in time. Community Preventive Services Task Force (2000).

Limitations

• Data are insufficient to allow conclusions about the most appropriate delivery choice for a given patient.
• Studies suffered from inconsistent and imprecise definitions for important outcomes.
• Studies frequently failed to ensure comparability between TOL and ERCD groups.
• No study or collection of studies, provide data about the impact of practice variation, provider characteristics, legal considerations such as the effect of rising malpractice rates on the safety of TOL or ERCD.
• The degree to which the association between fetal bradycardia and poor perinatal outcome from uterine rupture rather than confounding by factors detection bias is unclear.
• The degree to which the association between TOL and perinatal death reflects causation rather than confounding by factors such as misclassification of cases, lethal conditions of the fetus, or detection bias is unclear.

Evidence Report/Technology Assessment: Number 71

Under its Evidence-based Practice Program, the Agency for Healthcare Research and Quality (AHRQ) is developing scientific information for other agencies and organizations on which to base clinical guidelines, performance measures, and other quality improvement tools. Contractor institutions review all relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities.

Future Research

Future research should focus on conducting methodologically rigorous studies to provide direct evidence regarding the relative benefits and harms of TOL and ERCD. If randomized trials are not done, good-quality studies of TOL versus ERCD must pay attention to the following:

Population. Studies should be conducted in populations of women who are similar in every respect except choice of delivery route (comparability of groups).

Specificity of intervention. Studies should pay close attention to and account for the importance of co-interventions such as use of oxytocin and other medical agents for augmentation or induction of labor.

Precise and standard outcome measures. Variations in reporting of important clinical outcomes were striking. Studies should consider the following factors in developing outcome measures:

• Etiology. Outcomes such as hysterectomy, infection, maternal mortality, and perinatal mortality must pay specific attention to explicitly identifying the etiology. Lack of precision in this regard allows for both under and overreporting of cases due to misclassification. Examples include whether hysterectomy was performed due to maternal hemorrhage secondary to clinically significant uterine rupture versus hemorrhage due to abruption, uterine rupture through the uterine fundus in a woman with a low transverse incision either due to trauma or other non-incisional causes, and perinatal death due to lethal anomaly versus intolerance or management of labor.
• Standard terminology. In order to accurately measure outcomes, there must be a consistent terminology. Lack of this prevents accurate and meaningful comparisons of risks for each delivery choice. Outcomes such as infection, hemorrhage, and uterine rupture were not consistently defined.
• Separating prevention/prediction strategies from outcomes. As long as potentially important predictors of events such as prolonged fetal bradycardia as a predictor for clinically significant uterine rupture are included in the definition of uterine rupture, their true value as a predictor rather than a confounder will remain unknown.

Predictive Tools

Additional studies are needed to measure the accuracy and yields of existing predictive tools. Future studies of predictive tools should include measurements of the consequences of false-positive screens and false-negative screens to determine whether there are clinically important harms that result from screening.

Cost

The costs (rather than charges) of labor and delivery and of the surgical processes are poorly understood. Detailed time-in-motion studies would help to estimate these costs.

Availability of Full Report

The full evidence report from which this summary was taken was prepared for the Agency for Healthcare Research and Quality (AHRQ) by the Oregon Health & Science University Evidence-based Practice Center (EPC), Portland, OR, under Contract No. 290-97-0018. Printed copies may be obtained free of charge from the AHRQ Publications Clearinghouse by calling 1-800-358-9295. Requesters should ask for Evidence Report/Technology Assessment No. 71, Vaginal Birth After Cesarean (VBAC).

The Evidence Report is also online on the National Library of Medicine Bookshelf.

AHRQ Publication Number 03-E017

Current as of March 2003

Source: Agency for Healthcare Research and Quality – http://www.ahrq.gov/clinic/epcsums/vbacsum.htm