Cesarean Section - A Brief History

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.