The 13th Annual PAN EUROPE PACIFIC MEDICAL & LEGAL CONFERENCE PARIS, FRANCE

1. Charles P. McCuskerHead of Department of Obstetrics and Gynecology andExecutive Clinical Director, Fairfield HospitalAssociate Professor School of Medicine, University of Western Sydney The 13th Annual PAN EUROPE PACIFIC MEDICAL & LEGAL CONFERENCE PARIS, FRANCE Monday 1 April 2013 - Monday 8 April 2013

2. Etymology The second king of Rome, Numa Pompilius [715 – 673BC], proclaimed in his Lex Regia [Royal Law] , “It is forbidden to bury a pregnant woman before her foetus has been cut out of the womb”. The expression Caesarean Section has always been associated with Julius Caesar (100 - 44 BC), the assassinated Roman leader. During the subsequent period of the Roman Empire, the Lex Regia became the Lex Caesarea, so it might be that the term Caesarean section was derived from this law, but certainly not from Julius Caesar. He was the first child of Aurelia, who delivered 7 children, and who died in 54 BC. Because of the presumed 100 per cent maternal mortality as a result of Caesarean Section in those days, it is highly improbable that Julius Caesar was born via the abdominal route

3. Woodcut of the purported birth of Julius Caesar in 1506

4. Woodcut of the birth of Asklepios by his father Apollo in 1549 Asklepios, the god of medicine, was delivered , abdominally by his father Apollo. When Apollo learned that his beloved nymph Coronis had been unfaithful, he had her killed by Artemis. In compassion, he removed their son from her body on the funeral pyre

6. The first successful CS was allegedly performed in 1500 by a Swiss sow gelder, Jacob Nufer, on his wife. According to legend, she survived, bearing more children and dying at the age of 77. The first reliable account of a CS was in 1610 in Germany. Ursula Opitz had an accident during pregnancy, resulting in a huge abdominal hernia through which the uterus protruded. When labour started, it was clear that a spontaneous delivery was impossible. After consultations with three physicians of the medical faculty, midwives and priests, a CS was performed by the surgeon JeremiasTrautmann. The baptismal register of the Wittenberg church states that ‘disesKindtistausMutter Leib geschnitten uns als baldt dohaim getaufft’. The patient died suddenly from infection 25 days after the procedure but the child Martin lived for 9 years The first successful Caesarean Sections, i.e. proven survival of mother and child, were described in The Netherlands (1792), South Africa (1826), UK (1834), USA (1835) and Germany (1841)

7. The first documented Caesarean Section on a living woman was performed in 1610.She died 25 days after the surgery. The first modern Caesarean Section was performed by German gynaecologist Ferdinand Adolph Keher in 1881. Ferdinand Adolf Kehrer His grave in Heidelberg

8. James Barry(c. 1789-1799 – 25 July 1865), was a military surgeon in the British Army. After graduation from the University of Edinburgh, Barry served in India and Cape Town. By the end of his career, he had risen to the rank of Inspector General in charge of military hospitals. In his travels he not only improved conditions for wounded soldiers, but also the conditions of the native inhabitants. Among his accomplishments was the first Caesarean Section in Africa by a British surgeon in which both the mother and child survived the operation. He also gained enemies by criticizing local handling of medical matters.

9. European travellers in Uganda during the 19th century observed Caesarean sections being performed on a regular basis. The expectant mother was normally anesthetized with alcohol, and herbal mixtures were used to encourage healing. From the well-developed nature of the procedures employed, European observers concluded they had been employed for some time.

10. Other important developments in preventing maternal mortality were the successful introduction of anaesthesia with ether by Jackson and Morton in Boston (1846), the technique of asepsis by Ignace Semmelweis in Vienna (1847), and antisepsis by Lord Lister in Edinburgh (1867). Until 1880, maternal mortality varied from 18% (UK) to 100% (France), and perinatal mortality from 28% (UK) to 55% (USA). Eduardo Porro was unable to stop severe bleeding after a CS in 1876 and proceeded with a supracervical hysterectomy after placing a piano wire around the lower uterine segment. The stump was secured in the abdominal wall, thus preventing much-dreaded peritonitis. Using this procedure for all his successive patients, maternal mortality decreased to 15%.

11. So what “sort” of Caesarean Sections are there? • Elective Caesarean Section – but what does this mean? • Emergency Caesarean Section – But what does this mean? Emergency / Code 3 / CodeGreen Urgent / Code 2 / Code Yellow Critical / Code 1 / Code Red

12. Type of birth by Health Area of hospital, NSW, 2007

15. Ines Ramírez Pérez is a peasant living in rural Mexico. She had no medical training, but nevertheless performed a successful Caesarean section on herself: both she and her baby survived. Ramírez was alone in her cabin in Southern Mexico, when her labour started. The nearest midwife was more than 50 miles away over rough terrain and rough roads. Her husband, who had assisted her through her previous labours, was drinking at a cantina. Rio Talea has 500 people and only one phone, but it was not nearby. Ramírez had given birth to eight children, seven living, at the time of the pregnancy in question. The last pregnancy, three years prior, had ended in fetal death during labour. Rather than experience the loss of another child in the same way, Ramírez decided to operate on herself. At midnight, on 5 March 2000 — after 12 hours of continual pain, Ramírez sat down on a bench and drank three small glasses of hard liquor. She then used a 15 centimetres (5.9 in)kitchen knife to cut open her abdomen in a total of three attempts. Ramírez cut through her skin in a 17 centimetres (6.7 in) vertical line several centimetres to the right of her navel, starting near the bottom of the ribs and ending near the pubic area. After operating on herself for an hour, she reached inside her uterus and pulled out her baby boy. She then severed the umbilical cord with a pair of scissors and became unconscious. She used clothes to bandage her wound after regaining consciousness, and sent her son to find help. Several hours later, the village health assistant and a second man found Ramírez conscious and alert, along with her live baby. He sewed her incision with an available needle and thread. Ramírez is believed to be the only person known to have performed a successful caesarean section on herself.

17. 23 November 2011 Last updated at 00:38 GMT Women can choose Caesarean birthBy James Gallagher Health reporter, BBC News Pregnant women who ask for a Caesarean delivery should be allowed to have the operation, even if there is no medical need, according to new guidelines for England and Wales. The National Institute of Health and Clinical Excellence (NICE) states that women should be offered counselling and told of the risks first. Ultimately, however, the decision would be made by the mother-to-be, it said. NICE said this was "a very long way" from offering all women surgery. The last set of NICE guidelines, which were published in 2004, clearly stated that "maternal request is not on its own an indication for Caesarean section" and that clinicians could decline the procedure "in the absence of an identifiable reason". The rules on requesting a C-section have been revised. Clinicians say this is to bring the instructions into line with what is already taking place in hospitals.

18. Anal sphincter damage after vaginal delivery: functional outcome and risk factors for faecal incontinence ActaObstetGynecol Scand 2001; 80: 830–834. C ActaObstetGynecol Scand 2001 Anal sphincter damage following delivery is significantly associated with subsequent anorectal complaints, but not with urinary incontinence. The extent of sphincter damage is an independent risk factor for the development of faecal incontinence. Mediolateral episiotomy protects for faecal incontinence in primiparous women.

19. Are sphincter defects the cause of anal incontinence after vaginal delivery? Results of a prospective study. Abramowitz L, Sobhani I, Ganansia R, Vuagnat A, Benifla JL, Darai E, Madelenat P, Mignon M. Source Fama de Coloproctologie, Hôpital Bichat-Claude Bernard Paris, France. Anal incontinence after delivery is multifactorial, and anal sphincter defects account for only 45 percent of them. Primiparous and secundiparous patients have the same risk factors for sphincter disruption and anal incontinence. Because external anal sphincter disruptions are more frequent than internal anal sphincter damage, surgical repair should be discussed in symptomatic patients.

21. In the UK, about one in four births is by Caesarean section. The rate has been roughly static for the past four years following years of increases. Across Europe figures vary widely from about 14% in Nordic countries to 40% in Italy.

23. The PulseToo many caesareans?by Peter LavelleCaesareans that aren't medically necessary may be putting women and babies at risk.Published 17/01/2008 Obstetricians also acknowledge (generally amongst themselves) that there's a small percentage of cases driven by the husband, who doesn't want his wife's vagina to be stretched by natural childbirth. Caesarean delivery is especially common in women who only have one or two children, and in educated, more affluent women (it's more common in wealthy suburbs and in private hospitals with private obstetricians). There's a perception among these women that a Caesarean section is safer than a vaginal delivery.

24. The lesson is clear. Estimates of causes of events are warped by Media coverage. The coverage itself is biased toward novelty and poignancy. The Media do not just shape what the Public are interested in, but are also shaped by it. Editors cannot ignore the public’s demands that certain topics and viewpoints receive extensive coverage. Unusual events attract disproportionate attention and are consequently perceived as less unusual than they really are. The world in our heads is not a precise replica of reality: our expectations about the frequency of events are distorted by the prevalence and emotional intensity of the messages to which we are exposed. [Availability and Affect p 138]

25. Caesarean Section Rates throughout the Sydney South West and Sydney Local Health Districts for September 2011 Caesarean Section Rates throughout the Sydney South West and Sydney Local Health Districts for August 2011

26. Emergency Caesarean Section Rates for the Sydney and South West Sydney Local Health Districts for the Period Calendar Year to Date as of the 3rd of November 2011 18 18 14 14 12 11 12 11 9.9 9.1 9.9 8.8 9.1 8.8 4.7 4.7

27. Incidence of Selected Primipara who have a spontaneous Vaginal Birth[A selected Primipara is defined as a woman who is 20 – 34 years of age at the time of giving birth; giving birth for the first time at greater than 20 weeks gestation; singleton pregnancy; cephalic presentation; and at 370 to 410 weeks gestation][from Mothers and Babies 2010]

28. Incidence of Emergency Caesarean Sections [from Mothers and Babies 2010]

29. Maternal Age and the Risk of Caesarean Delivery Gordon Smith et al

30. The Effect of Delaying Childbirth on Primary Caesarean Section Rates Gordon Smith and colleagues found a linear increase in the log odds of caesarean delivery with advancing maternal age from 16 years upwards, and that increasing maternal age is associated with reduced spontaneous uterine activity but increased multiphasic spontaneous myometrial contractions.

31. Why is there a concern? The rising rates of caesarean sections have been a concern for over two decades. An acceptable rate of caesarean sections is between 10% and 15% for countries in the developed world, according to the World Health Organization (WHO). This increase may have implications for the mother, baby, healthcare providers, and policy makers. Though it is difficult to directly compare risks between vaginal and caesarean deliveries, higher mortality and morbidity rates are associated with the latter. But how much? Risks encountered during the operation may include anaesthetic complications and difficulty in stopping bleeding. Later risks include infections, wound healing problems, and increased risk of problems in subsequent pregnancies including malpresentation, placenta praevia, and uterine rupture.

32. Why Was This Study Done? The trend of increased rates of caesarean sections with maternal age appears to be consistent in different countries and has previously been reported by several epidemiological studies. However, it remains unclear why the risk of having caesarean section is associated with advancing maternal age. Could the association reflect a biological effect of advanced age, or is it a consequence of physician and maternal preference? The researchers aimed to (1) characterize the association between maternal age and the outcome of labour, (2) determine the proportion of the increase in primary caesarean rates that could be attributed to changes in maternal age distribution, and (3) determine whether the contractility of uterine smooth muscle (myometrium) varied with maternal age.

33. What Did the Researchers Do and Find? To address aims (1) and (2), the researchers analysed data collected over the period 1980 to 2005 by the Scottish Morbidity Record (SMR2), which has been demonstrated to be 99% complete since the late 1970s and free from substantial errors in more than 98% of the records in most of the specific fields used for their analysis. Their analysis showed a linear association between the risk of having a caesarean section and advancing maternal age in first pregnancies. The caesarean rate also more than doubled over the study period. They estimated that 38% of the additional procedures would have been avoided if maternal age distribution had remained the same as in 1980. Therefore they conclude that a substantial part of the increase may be associated with the trend of delaying of first childbirth. They then hypothesized that this trend is a result of a biological effect of aging on the contractility of the uterus. This hypothesis was further evaluated with aim (3) of the study, where they biopsied the uteri of 62 women (of mixed parity) undergoing routine elective caesarean delivery to test their contractility. They found that advancing age was associated with impaired uterine function as evidenced by a reduced degree of spontaneous contraction and the type of spontaneous contraction.

34. The Breech Trials • Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial - The Lancet, Volume 356, Issue 9239, Pages 1375 - 1383, 21 October 2000 – Hannah et al: Interpretation Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups. • Maternal outcomes at 2 years after planned caesarean section versus planned vaginal birth for breech presentation at term: The international randomized Term Breech Trial American Journal of Obstetrics & Gynaecology Volume 191, Issue 3 , Pages 917-927, September2004 – Hannah et al - Maternal outcomes at 2 years postpartum are similar after planned caesarean section and planned vaginal birth for the singleton breech fetus at term. • Outcomes of children at 2 years after planned caesarean birth versus planned vaginal birth for breech presentation at term: The international randomized Term Breech Trial - American Journal of Obstetrics & GynecologyVolume 191, Issue 3 , Pages 864-871, September 2004 – Whyte Hannah et al. Planned caesarean delivery is not associated with a reduction in risk of death or neurodevelopmental delay in children at 2 years of age.

36. The PulseToo many caesareans?by Peter LavelleCaesareans that aren't medically necessary may be putting women and babies at risk.Published 17/01/2008 Greater risk of death But how accurate is this? A series of recent studies indicates that caesareans are far from risk-free. In one study, published in the November 2007 British Medical Journal, Latin American researchers looked at nearly 100,000 births from 120 Latin American hospitals. About a third were by caesarean, and about half of these were elective. Compared to those who underwent vaginal deliveries, women who underwent caesarean had twice the risk of dying and of developing severe complications like hysterectomy, blood transfusions, or the need for admission to intensive care. In babies, a caesarean increased the risk of death or the need for neonatal intensive care. The study has been criticised for not properly accounting for the kinds of problems that lead to caesareans in the first place.

37. For obstetricians, a big factor is the threat of litigation. Obstetrics leads the field in medical negligence payouts, after complications following a vaginal delivery. But an obstetrician being sued after a caesarean is almost unheard of. In fact a common accusation during litigation after childbirth is 'failure to perform a timely caesarean'. So there's huge pressure on obstetricians to recommend a caesarean if there's even a hint of a potential problem. In New Zealand, where there is a publicly funded no-fault compensation scheme for personal injury, caesarean section rates are lower than in Australia.

39. Thank you, any questions?