Birth by Cesarean Section

By Dr. Clarence Addo Yobo

The origin of the term had been dubious and controversial. The historical myths about Cesarean Section are numerous and very difficult to conjecture.

Ancient Poets cited the most powerful leaders as being born by Cesarean Section, even though such a procedure never existed. Even if it did happen the maternal mortality should have been 100%. If Julius Cesar was extracted from the mothers’ womb via abdominal incision, how did she survive after the fact and lived for several years?

Many of such powerful warriors were believed to have been endowed with supernatural powers and had been cited as offspring via Cesarean Section; Scipio Africanus, Maritius and Hannibal.

Was it possible that Okomfo Anokye of the then Gold Coast was also a Legendary Cesarean Section baby?

Other Historian believes that Cesarean Section was an order by Emperor Numa Pumpilius to perform such procedure on a dying pregnant woman during the 8th Century. This law-“Lex Legia” was to help to salvage some of the viable unborn babies.

Some also believe that the term was a Latin word “Caesura” meaning to cut. Anesthesia and suturing of the wound were never known and therefore mortality was 100%.

There are no historical records of Cesarean Section procedures in the Mosaic, Christian or Islamic periods.

The Bible does mention on instance of the act of God in the Book of Genesis Chap 2:21-23

“And the Lord God caused a deep sleep to fall upon Adam and he slept , and he took one of his ribs out of which a woman was created named Eve-who became the partner of Adam.

A Historian by named Francois Mauriceou had published an article in 1668 that such operations had been performed but with 100% maternal mortality.

What contributed immensely to the revolution of the procedure was a magnificent introduction of the closure of the cut wounds with wire sutures-by a young assistant Clinician a 28 years old Sanger in 1882 at Leipzig University.

The mortality rate was 85-90% during the 19th century. Much improvement was achieved during the 20th century by the ingenious work of some of the legendary Doctors in Europe and America, viz Ker, Delee and Beck.

I. Operations were performed under asceptic conditions especially in the theatre

II. Introduction of fluid replacement and blood transfusion

III. Better techniques and control of blood loss.

IV. Advanced techniques and medications during anesthesia .

V. Emergency Hysterectomy during C/Section if indicated particularly with uncontrollable bleeding.

Indications for Cesarean Section may vary and more are being developed.

The most important consideration must be given to the benefits to both mother and the unborn.

Mention may be made of an incident in 1969 for which this author of this article was a junior resident and was part of the Surgical Team. The patient survived, but was hospitalised for about 3 weeks with intensive care.

Her labour was protracted with breech presentation “Legging” of the unborn. (Legs hanging outside the vagina) She had had no antenatal care as was noted and was a heroin addict. It was found out that the unborn had a big head-“Humpty Dumpty” or Hydrocephalus.

There was no palpable pulse of the hanging umbilical cord, the baby was dead. The alternative at that time was to punch a hole at the base of the skull to empty it and render the skull compressible. Thus the entire dead baby with compressed large head was delivered via the vagina with manual removal of the placenta under light general anesthesia. 4 pints of blood were given during the procedure. It was a ghoulish scenario for the 1st year trainees.

The footling breech is one of the indications for C/Section. Cesarean Section rate (Primary) in Brazil is about 80% (Private clinics).

In 2008, America had about 4.1 million births of which 750,000 involved primary Cesarean Section, i.e 18%.

The rate is climbing further with other indications such as failure to progress during labour i.e cervical dilatation is not progressing favourably even with oxytocin augmentation about 25% (1986).

Some Indications for Cesarean Section

I. Cephalopevic disproportion-thus the inlet of the pelvis is not adequate enough to allow the baby to go through. Bony deformities (Lumber Lordosis) where the bony outlet is deformed.

II. Fetal Heart Rate is dropping gravely and does not return to baseline and upwards.

III. Multiple fetuses (unborn) particularly Triplets or twins with adverse positions.

IV. Previous Cesarean Section for which the uterine incision was longitudinal. Tendency to rupture during labour.

V. Abnormal placental (after birth) localisation

VI. Placental insertion covering the mouth of the wounds, Placental, accrete and percreta.

VII. Unborn babies found to have congenital anomalies-Cesarean Section to prevent further injuries.

VIII. Pregnant women with detectable Herpes, lesions or Extensive vaginal warts.

IX. HIV pregnant women.

X. Pregnant women near Term or at Term with premature rupture of amniotic fluid-with virtually empty amniotic Sac.

Other Indications for the benefit of the unborn

I. Reduction of neonatal mortality.

II. Decrease risk of intracranial hemorrhage.

III. Decrease risk of hand and shoulder injury (Brachial plexus injury)

The current use of sonogram (SCAN) had helped to ascertain the age of the unborn especially calculating from 8th week to 12th week antenatal visit. This has helped a lot to reduce pre-maturity of the unborn.

Other blood tests to ascertain the maturity of the unborn is now being conducted in doubtful cases-“fetal fibronectin”.

Blood loss during Cesarian Section is now by far less if not better than vaginal delivery and episiotomy.

Planned Cesarean Section is safer than unplanned Cesarian Section during failed vaginal delivery with forceps and vacuum extractor.

Anesthesia for Cesarean Section had been preferred especially-Epidural and spinal. General anesthesia is equally improved with the pressure on cricoids-to avoid aspiration of stomach contents into the lungs. A drink of alkaline fluid prior to Cesarean Section.

Pre anesthesia Hydration with Ringers Lactate Fluids prevents Hypotension and promotes placental blood perfusion-and therefore alert newborns.

Please feel free to ask your Doctor pertinent questions before signing consent forms for C/Section taking a cue from the above article.