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 (4⁵/₁₆ inches) in depth; from side to side it measures 13 centimetres (5¹/₈ inches); obliquely from the right posteriorly to the left anteriorly it is 12¹/₂ centimetres (nearly 5 inches), and the other oblique conjugate is 12 centimetres (4³/₄ 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 9¹/₂ (3³/₄ inches) to 12 cm. Normal fetal head measurements average from side to side at the widest part, 9¹/₂ cm. (3³/₄ 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, 9¹/₂ 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. (3⁵/₈ inches) or above, Ludwig and Savor found that 75 per cent. were delivered without instrumental help. At 9 cm. (3¹/₂ inches), 58 per cent. so end; at 8 cm. (3³/₁₆ inches), 25 per cent. Should the conjugata vera be less than 5¹/₂ cm. (2³/₁₆ inches) in a flat pelvis, or 6 cm. (2³/₈ 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.

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.

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.

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 6³/₄ cm. (2⁸/₁₆ inches) to 7 cm. (2³/₄ 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.

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]

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.