Caesarean Section: Procedure

Caesarean section is one of the oldest operations in surgery, with its origins lost in the mists of antiquity and mythology. It has been performed by traumatic accident or post mortem for several millennia. Ancient myth and legend have said that Aesculapius and Bacchus, the gods of medicine and wine respectively, were born by caesarean section. Thus, at least in legend, those born by caesarean section are in good company.

The origin of the word ‘caesarean’ is unclear. The weak myth that Julius Caesar was born by this route is contradicted by the fact that his mother survived his birth by many years. It is likely that the term comes from the lex regia or royal law legislated by one of the early kings of Rome, Numa Pompilius, in 715 BC. This law proclaimed that women who died before delivering their infant had to have the infant removed through the abdomen before burial. This law continued under the ruling Caesars when it was called lex caesarea.

Traumatic caesarean sections have probably occurred throughout the course of history during war, acts of violence and accidents. Among the more well documented are those in which the horns of cattle have torn open the woman’s abdomen and uterus. One of the best known cases was reported from Zaandam, Holland, in 1647, in which a bull attacked a farmer and his wife, tearing open her abdomen and uterus with its horn. The woman and her husband later died but the infant survived. Self-performed caesarean section has probably been carried out for many centuries as some women, alone and in desperation, sought to relieve the unrelenting pain of nonprogressive labour. Authentic cases are reported from the 18th century. Caesarean section performed by laypersons also has a long history. One of the earliest reported cases in 1500 was by Jacob Nufer, a swine gelder, who delivered his wife after several days of apparent labour. There was some doubt whether this was an abdominal pregnancy or a caesarean section. Apparently both the mother and infant survived. In Northern Ireland in 1738, Mary Donnally, an illiterate but experienced lay midwife, carried out the first caesarean with survival of the mother in the British Isles.

The first witnessed and documented caesarean section by a physician was performed by Jeremias Trautmann in Wittenberg, Germany, in 1610. However, a number of obstetric texts in the 16th and 17th centuries described the rare performance of caesarean section in cases of contracted pelvis. The reason for the high mortality in the preanaesthetic era was that caesarean sections were usually performed after prolonged labour on women who were dehydrated, exhausted and infected. In addition, after removal of the fetus, the uterus was not sutured, adding haemorrhage to the morbidity equation. Throughout the 19th century, obstetricians devised techniques to try to reduce the risk of sepsis and to preserve the uterus, including a lateral extraperitoneal approach by Ferdinand Ritgen (1787–1867) of Giessen in 1821. Fritz Frank (1856–1923) modified the transperitoneal operation by suturing the edges of the incised lower uterine segment visceral peritoneum to the margins of the abdominal wall incision to contain any sepsis and promote its drainage.

Ferdinand Kehrer (1837–1914) of Heidelberg is one of the underappreciated contributors to the development of the modern caesarean section. In 1881, he performed a transverse lower segment caesarean section. He emphasized the need for careful suturing of the uterine muscle and a separate suture of the peritoneum over the lower uterine segment, later known as the Doppelnaht or ‘double layer’ technique. About a year later, Max Sänger (1853–1903), working in Leipzig, accentuated the need for careful suturing of the uterine incision, which he performed longitudinally in the uterus and called the classical caesarean incision. It was Sänger’s classical caesarean section that held sway while Kehrer’s transverse lower segment technique was forgotten. Munro Kerr was the obstetrician largely responsible for the change from the classical incision back to the low transverse incision. When Kehrer performed his low transverse procedure it was to reduce and contain the risk of sepsis. Kerr’s main argument was that the healed incision was stronger and less liable to rupture in a subsequent pregnancy.

Munro Kerr performed his first transverse lower segment caesarean operation in 1911 and reported his results in the 1920s and 1930s. Together with the lower transverse uterine incision, he introduced the Pfannenstiel skin incision for caesarean section in the UK. This incision is horizontal and slightly curved, placed just above the pubic symphysis ( Fig. 25.1 ). Acceptance came slowly and for many years he was a lone voice in his advocacy for the lower segment procedure. Slowly the lower segment incision became accepted, and after its widespread adoption, the lower segment operation was known in Europe for many years as ‘Kerr’s operation’. Belated acknowledgement of Kerr’s achievement in popularizing the lower segment procedure came at the time of the 12th British Congress of Obstetrics and Gynaecology, held in London in 1948, several years after he had retired from clinical practice. He was invited to the lecture platform and lauded for his achievement. In a dramatic response he raised his arms and declared: ‘Alleluia! The strife is o’er, the battle done!’

A modified surgical technique was developed by Michael Stark in the late 20th century and named after the Misgav Ladach Hospital in Jerusalem. In this method, Stark used the Joel–Cohen transverse skin incision ( Fig. 25.1 ), and the rectus sheath is incised. At this level the rectus muscles move more freely beneath the fascia. The rectus muscles are pulled apart with the forefingers. The parietal peritoneum is then stretched and entered bluntly as high as possible with the index finger. The lower uterine segment is then identified, and the uterovesical peritoneum divided. A retractor is used to withdraw the bladder. The uterus is entered with a scalpel in the normal manner and the incision then enlarged with the fingers. After delivery of the fetus and placenta the uterus is closed in one layer. Neither the visceral or parietal peritoneum is closed, nor are the rectus muscles. The rectus sheath is closed with a running suture. This operative technique has been described in detail. Experience with this method of caesarean section suggests that it results in a shorter operating time, less blood loss and less postoperative analgesic requirement.