Caesarean Section – Past and Present

1. 1500 – 1700 >1850 • 1700-1850 Historically, failure to deliver has always been a challenge • Difficult Delivery • Key Developments Key Developments Man Midwife • Mechanism of Labour • Mothers had confidence in their midwives. • Midwives because of limited experience-faced with failure to deliver – turned to male surgeons after the child had died – to save the mother • Craniotomy – a grim business Anaesthesia Antisepsis Surgical Technique • 1847 surgical anaesthesia introduced • Physicians gradually became skilled in the use of chloroform and ether • 1875 Porro section – hysterectomy in • the presence of infection – mortality 25% • 1882 Sanger described two layer closure • of uterine incision • 1881 Transverse lower uterine segment • incision proposed • 1870s Lister introduced the principle of surgical antisepsis • Led to the rapid expansion of operative intervention in obstetric practice Caesarean Section – Past and Present • 1650 Glisson described rickets • 1701 Van Deventer provided an accurate description of pelvic architecture and the significance of rickets • 1754 Image of normal labour from Smellie’s atlas • First detailed description of the mechanism of labour • Man Midwife • Craniotomy – because of earlier consultations – man midwives faced with ethical question of craniotomy in the living child • Obstetric forceps – available but use delayed • Crochet Caesarean Section Caesarean Operation • Postmortem section following sudden death of a • woman late in pregnancy advocated in an effortto save the child During the last half of 19th Century The key developments led to a cautious increase in the support for caesarean section that is expressed in the recommendations at the end of the 19th century “Contracted pelvis when absolute – section before or early in labour with hysterectomy in the presence of infection. Relative contracted pelvis, section if the child is alive, craniotomy if the child is dead” For Caesarean Operation James A. Low Department of Obstetrics and Gynecology, Queen’s University • Caesarean operation in the living woman initially proposed by Rousset in 1581 and Mercurio in 1604 For • Williams-1901 • 1733 Theological opinion – “One can make use of caesarean operation if one has hope of saving either the mother or child” • 1752 William Smellie stated “ when a woman cannot be delivered by any other means on account of the narrowness of the pelvis into which it is impossible to introduce a hand; in such emergencies if the woman is strong, the caesarean operation is certainly advisable and should be performed; because the mother and child have no other chance of being saved, and it is better to have recourse to an operation which has sometimes succeeded than to leave them both to inevitable death” Present Role of Caesarean Section During the 20th century • 1612 illustration of Caesarean operation in “La Commare o riccoglitrice dell eccmo” by Mercurio • The rates of caesarean section vary widely by country, • health care facility and delivering physician because of • differing perceptions of its benefits and risks There has been a progressive reduction of maternal mortality following caesarean section as expressed by maternal mortality in Canada There has been a parallel increase in use of caesarean section as reflected by the rate of caesarean section in Kingston Against • Continuing examination of issues to assure the optimal outcome of the mother and child is required Against Opposition to caesarean operation expressed by many because of the maternal mortality. Opposition reflected in the recommendations at the end of this era • Maternal outcome – increased risk of mortality • and morbidity with section • Indications – current reassessment of VBAC • and breech delivery • Fetal/Newborn outcome – low rates of mortality • with low section rates • Caesarean operation was opposed by the leading authorities of the day including Jacques Guillimeau in 1598 and Francois Mauriceau in 1668, both of whom were determined opponents • “Caesarean section when no other method is practical . Caesarean section not an alternative for craniotomy” • Ramsbotham 1856