CESAREAN DELIVERY
In the cesarean delivery (_partus cesareus_, celiohysterotomy) the
infant is brought out through an opening made in the abdominal and
uterine walls. The chief indications for this operation may be a
contracted maternal pelvis, an abnormally large fetal head or body,
death of the pregnant mother before delivery, certain forms of
rigidity of the cervix uteri, some cases of stenosis of the vagina,
relative vaginal narrowness, blocking tumors, or a ventrofixed
uterus. Sometimes abruptio placentae, eclampsia, placenta praevia,
and other accidents of pregnancy are taken as indications for
cesarean delivery.
An abnormal bony pelvic girdle is the most frequent obstruction to
delivery of the fetus. The lower part of the pelvis, called the
pelvis minor or true pelvis, supports the muscles of the pelvic
floor, and gives shape and trend to the parturient canal. The inlet
and outlet of the true pelvis are narrower than its middle portion
and are called the superior and inferior straits. The inlet is
somewhat cordate in outline, and normally from front to back, at
its so-called conjugata vera, it averages 11 centimetres (4-5/16
inches) in depth; from side to side it measures 13 centimetres (5-1/8
inches); obliquely from the right posteriorly to the left anteriorly
it is 12-1/2 centimetres (nearly 5 inches), and the other oblique
conjugate is 12 centimetres (4-3/4 inches) long. The transverse
diameter of the outlet, from right to left, is 11 centimetres; the
diameter from front to back, because the coccyx can be pushed back
in labor, is from 9-1/2 (3-3/4 inches) to 12 cm. Normal fetal head
measurements average from side to side at the widest part, 9-1/2 cm.
(3-3/4 inches); from the root of the nose to the occiput, 11 cm.;
from the chin to the occiput, 13 cm.; from the vertex to the neck
behind, 9-1/2 cm. The size of the fetal head is the most important
factor in delivery, so far as the child is concerned, because, as
a rule, when the head is delivered the compressible trunk follows
readily. Normally the child presents in delivery with the vertex of
the head first; other presentations are transitional, abnormal or
pathologic. In 48,499 cases Karl Braun found vertex presentations in
95.9 per cent., and Schroeder in 250,000 cases found an average of 95
per cent. The child's head is "engaged" when its largest diameter has
passed the plane of the inlet.
An abnormal pelvis may be generally contracted, dwarfed, in all its
diameters; it may be flat or narrow from front to back; it may be
contracted from side to side; it may be generally contracted and flat
at the same time; it may be obliquely contracted (Nägeli's pelvis);
or it may be crowded together irregularly. Rachitis, osteomalacia,
curvature of the spine, habit scoliosis, hip dislocation, and similar
pathologic states cause these distortions and contractions.
Contraction of the pelvis affects the mother and child in parturition
in proportion to the degree of the narrowing. Besides this, the
prognosis depends on the size of the child, its presentation,
position, and attitude, the strength of the pains, the skill and
surgical cleanliness of the operator, and the presence or absence of
complications. Obstruction may bring about rupture of the uterus,
septicemia, exhaustion and shock, pressure narcosis, or tears of the
cervix or vagina. If the child's head becomes impacted the vagina
and vulva may become even gangrenous. Pressure may cause areas of
necrosis resulting in fistulas into the bladder, rectum, or between
the uterus and the vagina. When the contracture is sufficient to let
the fetus just engage, pressure may interfere with the placental
circulation and kill the child. Compression of the vagus nerve may
slow the child's pulse and asphyxiate it through lack of oxygen in
the blood. The cord may prolapse. The pressure on the child's head
may cause fatal intracranial hemorrhage, or effect permanent injury
to the brain.
Often it is extremely difficult to find out the best plan for
delivering a woman who has a contracted pelvis. Where the conjugata
vera is 9.5 cm. (3-5/8 inches) or above, Ludwig and Savor found that
75 per cent. were delivered without instrumental help. At 9 cm.
(3-1/2 inches), 58 per cent. so end; at 8 cm. (3-3/16 inches), 25
per cent. Should the conjugata vera be less than 5-1/2 cm. (2-3/16
inches) in a flat pelvis, or 6 cm. (2-3/8 inches) in a generally
contracted pelvis, this is an absolutely contracted pelvis according
to the old standard, and the delivery must be by cesarean section,
whether the child is living or dead. The minimal requirements have
been gradually extended. In 1901 Williams of Johns Hopkins University
advocated that the absolute indication for cesarean section be
changed to 7 cm. in the generally contracted pelvis, and to 7.5 cm.
in the simple flat pelvis. His opinion was accepted by Webster,
Jewett, Edgar, and others. Now some obstetricians of authority
extend the measurements to 8 cm. If the woman is seen before labor,
or early in labor, cesarean delivery alone is done. When the uterus
is infected it is usually necessary to remove it after taking away
the child, because an infected uterus left in place causes death by
sepsis, as a rule.
Text-books on obstetrics have a series of rules, based on pelvic
measurements, concerning the indications for cesarean or other
methods of delivery in cases of contracted pelvis, but the problems
are not so simple and uniform as to be always accurately solved by
the data derived from measurements. One woman with a contracted
pelvis may require cesarean delivery; another woman with the same
measurements may have a normal parturition because the child happens
to be small or its skull compressible. The best pelvic measurement
is made with the fetal head. A difficult decision as to whether a
cesarean delivery is necessary or not comes up in the majority of
cases in primiparae; in multiparae the physician has the experience
from former births to guide him. In over 90 per cent. of primiparae
the fetal head normally is found engaged in the pelvis in the last
week of gestation, and can be felt by a vaginal examination. In
multiparae the head usually is not engaged until labor begins. If the
fetal head does not engage in a primipara, this fact at once suggests
an absolutely or relatively narrow pelvis. When labor has begun, if
the fetal head cannot be pushed into the true pelvis of a primipara,
especially after anesthesia, the necessity for cesarean delivery may
be clearly evident.
In the cases where there is doubt that the child can get through
the pelvis, but good reason to think that it can, many obstetrical
experts try the effect of labor for two hours or a little more,
and if there is no real progress they deliver through laparotomy.
There is considerable objection now to version or the application of
high forceps, but many skilful men prefer these methods at times.
When version has been done and it fails there is no chance to save
the child's life. In the trial of labor, the expectant treatment,
extraordinary watchfulness is required and a full knowledge of the
special procedure that may be necessary.
In minor degrees of pelvic contraction the obstetrical practice is
either to induce premature labor at the thirty-second week, or to
deliver by a cesarean operation, or to delay and try labor. In the
last event there may be one of the following issues: spontaneous
delivery, version and delivery, extraction by high forceps, cesarean
delivery, symphyseotomy, hebosteotomy, or craniotomy. Craniotomy on
a living child is never to be considered under any circumstances.
Symphyseotomy is a cutting of the maternal pelvic girdle through the
symphysis pubis, the rigid joint at the front middle part of the
pelvis, and thus letting the bony girdle dilate. Hebosteotomy or
pubiotomy is a sawing through the pelvis near that joint to get the
dilatation. Symphyseotomy has been replaced by hebosteotomy because
the maternal mortality and morbidity are somewhat lessened by the
latter method. Schläfli in 1908 reported 700 hebosteotomies with a
maternal mortality of 4.96 per cent. and a fetal of 9.18 per cent.
Other operators have a better average; still others a worse. This
operation is done very seldom of late except in a case where the
fetal head is caught low in the pelvis, or there is a chin-posterior
or brow or face presentation, and the cesarean operation would not
deliver the child.
The varieties of the cesarean delivery as practised at present
are the classic cesarean, called also celiohysterotomy, the Porro
cesarean, or celiohysterectomy, where the uterus is removed after
the extraction of the child, and the two sections in the cervical
end of the uterus, viz., the extraperitoneal cesarean and the
transperitoneal cervical cesarean. Before the days of antiseptic
surgery cesarean delivery was practically always fatal to the mother.
Tarnier could not find one successful outcome for the mother in Paris
during the nineteenth century up to his own time, and Spaeth said
the same for Vienna up to 1877. In 1877 Porro of Pavia advised the
supravaginal amputation of the uterus after the child was delivered
to avoid hemorrhage and peritoneal infection. This operation replaced
the classic cesarean until 1882, when Sänger invented a suture
which would keep the uterine incision shut, and applied antisepsis.
Sänger's operation has been improved so much that cesarean delivery,
when performed by skilled obstetricians, has an extremely low
mortality in cases which have not been infected. Routh, in 1910,
collected the statistics of Great Britain, comprising 1282 cases,
which may be taken as a standard for all civilized countries, and he
found a steady decrease in the mortality until now it is near 2 per
cent. in uninfected cases. The dangers in the operation increase with
every hour the woman is in labor, but even then the general mortality
is now down to about 8.1 per cent. This, it must be remembered, is
the rate when competent men operate.
When the ordinary practitioner in small cities, towns, and country
places operates the mortality is very high. Newell[106] said that
in four cities of from 25,000 to 40,000 inhabitants within forty
miles of Boston he collected the following data: in A no patient on
whom cesarean section had been done is known to have recovered--a
mortality of 100 per cent. In B the mortality is from 60 to 70 per
cent. In C the operation is invariably fatal when done by the local
surgeons. In D the fatality is from 10 to 20 per cent. in average
cases, but since cesarean section has become popular as a method of
treatment for eclampsia the mortality is over 50 per cent.
[106] _Jour. Amer. Med. Assoc._, February 24, 1917.
In spite of perfect technic by the best obstetricians, the operation
has a high morbidity: fever, peritonitis, pneumonia, dilatation of
the stomach, and other bad results are common.
Before antiseptic surgery began, opening the abdominal cavity was
almost always fatal, and some obstetricians tried to get the child
out of the uterus in cases where cesarean delivery is indicated
by going in above the pelvis without opening the peritoneum. The
uterus was incised near its cervical end. This method, called
extraperitoneal cesarean delivery, has been restored for use in cases
where there is some infection of the uterus and the operator wishes
to save the child without removing the womb. The technic is more
difficult than in the classic cesarean, and the operation was not
kindly received, but of late some men are having so much success with
it that it is reviving, and rightly so. Baisch[107] says that the
first eleven women he delivered by extraperitoneal cesarean section
recovered more readily than they would from an ordinary laparotomy.
In nineteen cases of transperitoneal but cervical section he had
no trouble, and six of these were infected cases. The technic of
this low incision protects the peritoneal cavity better than the
classic incision, apparently. Two of the nineteen women were in
slight fever and the uterine fluids were fetid. Two primiparae forty
years of age had been in labor seventy hours. Eight of the women
were able to leave the clinic on the tenth day. Only one child was
lost, and that was a delayed case. Hofmeier[108] compiled 194 cases
of transperitoneal cervical cesarean section with three deaths.
Küstner did 110 extraperitoneal cesarean sections with no mortality.
This makes 304 cases of cesarean cervical section, not the classic
operation, with only three deaths, less than 1 per cent. mortality;
and fully 50 per cent. of these cases were not surgically clean. From
these statistics it is evident that the cervical operation in the
hands of competent surgeons should be the operation of choice.
[107] _Zentralblatt f. Gynäkologie._ Leipsic, October 30, 1915.
[108] _Münchener medizinische Wochenschrift_, January 4, 1916.
The ordinary practitioner, however, is utterly unfitted to do a
cesarean section of any kind. In large cities it is easy to find
a trained surgeon to do the operation, but in small towns and in
country places there is seldom any one available. The physician
who chooses to practise medicine in an isolated place knows that
he will almost certainly be called upon to do a cesarean section
some day, and he should not take up the responsibility of the
general practitioner in such a place until he is competent to do
that operation when life depends upon him. This is as things should
be; but unfortunately a man who is trained well enough to do major
surgery will not live in a small town if he can get into a large
city. The physician in any case should be able at least to make the
diagnosis in time, before labor sets in, and have the woman sent to
the nearest city, if possible. Dr. Bull[109] reported that he had
traveled seventy-five miles to see a woman who was having severe
hemorrhages at term. He found her in a log cabin, with a centrally
implanted placenta (_i.e._, right across the opening of the cervix
uteri), and she had had three hemorrhages before his arrival. He
narcotized her, took her in a train to a hospital, delivered her by
cesarean section, and saved her and the child. If he had delivered
her by version in the log cabin, he would almost certainly have lost
both the mother and the child.
[109] _Jour. Amer. Med. Assoc._, September 30, 1916.
The question of removing the uterus comes up when the uterus is
infected, or as a method of sterilizing the woman to avoid the danger
of a subsequent gestation. Whenever a uterus is gravely infected and
a cesarean delivery is finally necessary, the infection is commonly
due to ignorance or carelessness, and the physician or midwife is
guilty. There should be no such business as that of the midwife who
actually delivers the patient. The state should provide physicians
for the poor. Even the midwife who calls herself "a practical nurse,"
but who is not a licensed trained nurse, is commonly a public danger,
although some so-called practical nurses are better than the ordinary
trained nurses.
Suppose, however, that the uterus is infected unavoidably. If this
infection has been done by a competent obstetrician working in a
hospital with sterile instruments, it may be safe to deliver the
woman by an extraperitoneal or cervical trans-peritoneal cesarean
section. If the practitioner has tried to deliver the woman at her
home with forceps and has failed, especially if repeated attempts
have been made by the physician and an assistant or consultant,
the uterus should be amputated. It will not do to deliver by a low
cesarean and await developments, because if the infection is serious
no subsequent removal of the uterus will save the woman's life. The
grave mutilation of removing the uterus is, of course, licit, as it
is the only means of saving the woman's life. Some moralists hold
that a woman from whom the uterus has been removed is impotent, but
this question has never been decided authoritatively, as we shall
show in the chapter on Vasectomy; and until it has been so decided
the woman must be given the benefit of the doubt.
The question of removing the uterus solely to prevent the danger of
subsequent deliveries differs from the condition just considered.
If the woman has had a cesarean delivery for an absolutely narrow
pelvis, her subsequent deliveries must be by the same method. After a
cesarean section there is more or less danger of rupture at the scar
in other labors. Some think the danger is greater if the placenta
becomes implanted on the scar; others think this implantation does
not weaken a good scar. If the convalescence after the cesarean
section already done has been abnormal, the prognosis for rupture
is not good. Where there has been an abnormal convalescence, each
new pregnancy must be watched closely, and often an early subsequent
cesarean is indicated to prevent rupture. No matter how well the
section has been done, latent gonorrhea may prevent perfect healing
of the wound. Twins, hydramnios, and overtime gestation are other
causes of rupture. The tendency with obstetricians in the future
will probably be to do the section toward the cervical end of the
uterus; and as the uterus is thinnest there, it might be thought
that it will be more likely to break, but Spalding[110] found the
contrary true--the rupturing was usually in the thick part of the
uterus. Version, high forceps, uterine tampons, hydrostatic bags,
and pituitary extract should be avoided where an old cesarean scar
exists, but Vogt and Kroback have done version a few times without
rupture. Vogt had one patient with a true conjugate of 6-3/4 cm.
(2-8/16 inches) to 7 cm. (2-3/4 inches). She was delivered in the
first three labors by craniotomy; in the fourth by version; in the
fifth and sixth by cesarean section; in the seventh she had twins
one of which was born spontaneously; in the eighth by version and
perforation of the after-coming head; in the ninth she refused
operation and was delivered spontaneously. Skilful operators have the
fewest ruptures after cesarean delivery. Olshausen had one in 120
cases, Leopold none in 232 cases, Schauta none in 177 cases, Küstner
none in 100 cases. Olshausen, in a series of 29 cases, operated on
two patients twice and upon three patients three times. As early as
1875, Nancrede of Philadelphia had operated the sixth time on the
same woman. In such cases the uterus is commonly so broadly attached
by adhesions to the belly-wall that it is opened without getting into
the peritoneal cavity. In 150 cases of repeated section collected by
Polak in 1909 the mortality was only 5 per cent.
[110] _Jour. Amer. Med. Assoc._, December 1, 1917.
A woman may not be sterilized by having the uterus removed, by
fallectomy, or otherwise, solely to obviate danger or morbidity from
subsequent pregnancies and cesarean deliveries. Such a sterilization
would be a grave mutilation without a present excusing danger, and
it would render the primary end of marriage always impossible. Such
sterilization of a woman is in contravention to the decretal of
Gregory[111] as given in the chapter on Vasectomy. It is also against
the bull _Effraenatam_ of Sixtus V., who extended all penalties
prescribed for abortionists to those who give women drugs which cause
sterility, and to those who purposely prevent the development of the
fetus or in any manner abet the deed; and the penalties are to be
applied to the women themselves who willingly use these means. These
penalties are enumerated in the chapter on Abortion. The Congregation
of the Holy Office, May 22, 1895, answered negatively the following
question: "Si sia lecita la practica sia attiva sia passiva di un
procedimento il quale si propone intenzionalmente come fine espresso
la sterilizatione della donne?"[112]
[111] _Corpus Juris_, lib. v, tit. xii, c. 5.
[112] Is any active or passive procedure licit which is
undertaken with the express end of sterilizing a woman?
The reason for these laws is that any act which deprives one of the
power to generate, and which prevents conception and makes the semen
fail of its end, is against the chief intrinsic end of marriage and
any benefit that arises therefrom, which is the good of offspring.
The act is also against the intrinsic end of the semen, which is to
generate; and since the semen cannot possibly effect its end, the
conjugal act degenerates into an equivalent of onanism. This act of
sterilization, done not to save the whole body from immediate danger,
is intrinsically evil, and therefore unjustifiable.
To say that marriage is also a licit remedy of concupiscence is
no excuse. Marriage is such only in a secondary sense, and this
secondary end is necessarily subordinate to the primary end, and
coexistent with that primary end, which is the generation of
children. Even when a surgeon is doing a Porro operation, his main
intention may not be to sterilize the woman. He must directly intend
to save her life by removing the infected uterus, and reluctantly
permit the sterilization as an evil part of the double effect coming
from the causal amputation.