as quickly as possible through an abdominal incision
to save its life. In the time of the Caesars this law be-
came the Lex Cesare, from which the modern name for
cesarean birth may have been derived. Also ‘‘cesare-
an’’ may have been derived from the Latin word
cadere, which means ‘‘to cut.’’ Furthermore, in Rome
children born by abdominal delivery were referred to
as caesones. Because of the high maternal death rate
from cesarean births, the operation was rarely per-
formed until the twentieth century, when modern sur-
gery was improved with the development of
anesthesia and the means to control hemorrhage and
to prevent and treat infection. By 1950 it was possible
for a hospital in New York City to report that 1,000
consecutive cesarean deliveries had been performed
without a single maternal death.
Shifting Reasons for Cesarean Delivery
Until 1970 cesarean births accounted for fewer
than one in twenty births in the United States. The
reason cesarean births were performed was largely for
conditions that threatened the life of the mother.
These conditions included uterine hemorrhage, hy-
pertension of pregnancy, tuberculosis, diabetes, heart
disease, and prolonged labor caused by disproportion
between the size of the infant and the size of the birth
canal. A small proportion of the cesarean births were
performed because the baby (fetus) was in danger of
hypoxia (lack of oxygen) as when the umbilical cord
slips out of its normal position. Also, some cesarean
deliveries were performed as repeat cesarean births
for women who had a previous baby by cesarean, be-
cause it was believed that once a cesarean had been
performed, all subsequent births should be by cesare-
an delivery.
In the early 1970s, electronic means of continu-
ously monitoring a baby’s heart rate during labor be-
came available, and intensive care for newborns was
beginning to result in dramatic improvements in the
survival of seriously ill infants. In addition, the fre-
quency of serious maternal complications of cesarean
birth had continued to decline. As a result of these im-
provements in the care of mothers and infants, doc-
tors became more inclined to recommend cesarean
delivery in situations where either the mother or in-
fant were at any increased risk of illness or long-term
developmental abnormality that might be caused by
vaginal birth. For example, before 1970 almost all
breech births (in which the buttocks or feet of a baby
rather than its head are the first to be born) were by
vaginal delivery, but by 1988 almost all such births
were by cesarean delivery. The increase in the use of
cesarean delivery to prevent harm to the fetus from
labor and vaginal delivery accounted for the increase
in the cesarean birthrate from 5 percent of live births
in 1970 to 25 percent in 1988. After 1988 the rate of
cesarean birth began to decline somewhat so that by
1996 it was 21 percent.
One of the common reasons for cesarean birth is
repeat cesarean delivery, which accounts for approxi-
mately 25 percent of all cesarean births. Women who
have had a cesarean delivery are at risk of the uterine
incision rupturing during labor. This can result in the
death of or the serious injury to the infant and life-
threatening hemorrhage and possible need for a hys-
terectomy for the mother. The risk of uterine rupture
depends upon the type of uterine incision. A vertical
incision in the uppermost portion of the uterus has a
12 percent risk of rupturing during labor. This type
of incision was used commonly in the early part of the
twentieth century but now is used only on rare occa-
sions. A woman who has had a cesarean birth by this
method should have all subsequent births by cesarean
delivery before the onset of labor to avoid a cata-
strophic rupture of the uterus. A transverse incision
in the lower portion of the uterus, which is now the
most common method of performing a cesarean de-
livery, is associated with a 0.5 percent risk of rupture
during labor. Most women who had this type of cesar-
ean delivery can safely attempt a trial of labor and
vaginal delivery provided that labor occurs where
there are facilities for and personnel who can perform
an immediate cesarean delivery if signs of uterine
rupture occur. The increase in the incidence of vagi-
nal birth after a previous cesarean birth accounted for
the gradual decline in the cesarean delivery rate after
1988.The Cesarean Operation
The cesarean operation, which usually takes from
thirty to sixty minutes, begins with the administration
of anesthesia by use of intravenous and inhaled anes-
thetic agents (general anesthesia) or the injection of
anesthetic medications into the spinal canal (spinal
anesthesia) or just outside of the spinal canal (epidu-
ral anesthesia). The skin of the abdomen is cleansed
with antiseptic solution and surgical drapes are
placed to maintain a sterile operating field during the
procedure. An incision is made in the abdomen, after
which a second incision is made in the uterus (womb)
that is large enough to permit removal of the baby.
The umbilical cord is clamped and cut, and the infant
is handed to a nurse or doctor assigned specifically to
care for the infant. The placenta (afterbirth) is then
delivered through the same incisions. The incisions
are closed with sutures (stitches) or other types of
wound-closure devices. The expense of a cesarean
birth is about two to three times that of a vaginal birth
because of the additional personnel, equipment, andCESAREAN DELIVERY 75