Transcript Slide 1

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
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.
The Birth, Marriage and Death of Julius Caesar
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
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.
Apache Birth
Observed by Walter Reed
Ob/Gyn instruments 1st or 2nd Century B.C.
Destructive scissors and crotchets
William Smellie, 1754
Symphysiotomy
Gigli Wire Saw
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.
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.
Oophorectomy in 19th century
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
Horace Wells
Louis Pasteur
Ithaca Journal (Ithaca, NY)
8/18/1981
Hartford Hospital
December 12, 1891
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
John Whitridge Williams
The Place of Cesarean Section
Boston Lying In Hospital
Maternal Mortality
Fetal Mortality
_______________________________________________________
Delivery
Cases Deaths Percent
Deaths
Percent
Ceserean
Craniotomy
High forceps
Version
Breech extraction
Midforceps
Low forceps
Normal
584
16
9
106
403
90
3,020
9,351
18
0
0
1
4
1
14
21
3.1
0
0
0.9
0.8
1.1
0.5
0.2
52
16
4
30
122
12
78
348
8.8
100.0
44.4
28.3
24.5
12.0
2.6
3.7
*Irving F.C. The place of Cesarean section. J. Conn. State Medical Society. Nov. 39, 483-491
The Place of Cesarean Section:
Irving, 1937
Conclusions:
1. “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]”
2. “Cesarean section in the United States is
accompanied by a 5.8% mortality.”
Maternal Mortality in the United States
Deaths per 100,000 Live Births (1915 – 1960):
800
700
600
500
400
300
200
100
Cesarean Section Rate and Forceps Rate
Hartford Hospital
1916 - 1961
Forceps Rate
C-Section Rate
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
Total and Primary Cesarean Section Rate
VBAC Rate 1970 - 2004
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.”
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
Cesarean Section Rate at Hartford Hospital
1990 - 2006
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
Maternal Mortality and Severe Morbidity
Associated 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
of illness or death
Overall severe morbidity
Cesarean
n=46,766
Vaginal
n=2,292,42
Adjusted
Odds Ratio
1279 (2.7%)
20,639 (0.90%)
3.1
Hemorrhage req. hysterectomy
12 (0.03%)
254 (0.01%)
2.1
Any hysterectomy
27 (0.06%)
367 (0.02%)
3.2
Uterine rupture
7 (0.02%)
660 (0.03%)
0.5
Cardiac arrest
89 (0.02%)
887 (0.04%)
5.1
Venous Thromboembolism
28 (0.06%)
623 (0.03%)
2.2
Major puerperal infection
281 (0.60%)
4833 (0.21%)
3.0
0 (0.00%)
41 (0.002%)
In-Hospital Death
*Liu S, Liston RM, et.al. Can Med Assoc J. 176(4), 455-460, 2007.
/
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
Cultural Selection of Cesarean
Section
• Change in Technology
• Change in Social Conditions and Norms
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
1. Upright Posture
2. Brain Enlargement and Development
Evolutionary Changes in Human
Birth
1. Enlargement of human pelvis
(at it’s limit)
2. Internal rotation of human babies head in labor
(only primate or mammal with this evolutionary
mechanism)
3. Slower development of fetus including fetal
head. Human brain at birth is less than onefourth it’s final adult size. Other primates at
birth average about one-half adult size.
4. Shorter gestation for fetal development
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.
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
“What’s Past is Prologue”
The Tempest
William Shakespeare
1610
Thank-you!
Maggie
Brian
Patrick
Sophie
Kevin
Grace