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Each year in the United States, approximately one third of more than 4 million neonates are born by cesarean delivery. Indeed, the operation is the most commonly performed major surgery in this country in women aged 18 to 44 years (Boyle, 2012). It follows that the procedure is one of the most often used in modern obstetrics. Until recently, the term "cesarean section" was used to describe operative abdominal delivery, but "cesarean delivery" is considered more accurate for reasons discussed subsequently.


The concept of delivering a living child through an abdominal incision has its origin in prehistoric times. References to these miraculous births are found in the folklore and mythology of both Eastern and Western cultures. Most of the early accounts involved the birth of heroes or gods, demonstrating their superhuman qualities. At the same time, however, the mother was usually dying or dead at the time of birth (Thompson, 1955).

Francis Rousset introduced the idea of performing this operation for a living woman in the 16th century. He suggested several obstetric complications that were more horrific than the surgery itself. In one example, the fetus had escaped into the abdominal cavity during labor and later caused an abdominal abscess that was debilitating to the woman. Next, he sought to establish the feasibility of the operation by giving an account of seven women who survived. He also reported that another successful pregnancy may follow the operation (Young, 1944).

In the 19th century, introductions of diethyl ether as an anesthetic by Morton and of carbolic acid antisepsis by Lister made the possibility of an abdominal operation for childbirth more feasible. Early success in the surgery was compromised by the widespread belief that once uterine muscle was incised it could not be safely sutured, principally out of fear of infection. Against this background, cesarean deliveries performed in Paris between 1787 and 1876 yielded 100-percent maternal mortality rates, mostly due to infection or hemorrhage (Sewell, 1993).

The first major surgical advance in cesarean delivery technique was introduced by Porro in 1876 (Miller, 1992). Influenced by the prevailing concept of not suturing the uterine incision, Porro introduced a technique in which the uterine fundus was amputated following the delivery of the fetus. The cervical stump was then marsupialized to the anterior abdominal wall. Although drastic by modern standards, the Porro technique resulted in a dramatic decline in maternal mortality rates (Speert, 1958). The Porro procedure is described in further detail in Chapter 26 (p. 419).

The era of the modern cesarean operation began when Max Saenger (1882) introduced the technique of suturing the uterus. He advocated performing a vertical incision in the uterus that avoided the lower uterine segment. After delivery of the infant and manual extraction of the placenta, he closed the uterus with two layers. He recommended silver wire for the deep suture and ...

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