Evolution of modern cesarean delivery: historic perspective and new challenges

From a procedure of last resort that caused the death of most mothers and babies, the cesarean delivery has become a lifesaving delivery method and the most common major surgical procedure performed worldwide. The first modern cesarean deliveries, based on accurate anatomic knowledge, were performed 250 years ago. The development of new surgical and anesthesia techniques, antibiotics, uterotonics, blood transfusion, and neonatal care over the last 100 years has transformed the perinatal outcomes of cesarean delivery. The epidemiology of cesarean delivery has changed over the last 30 years with most high- and middle-income countries having rates that surpass 30% and some that exceed 50% of all births. The use of cesarean delivery continues to rise amid inequalities in access to the procedure when medically necessary. Short-term cesarean delivery complications, such as postpartum sepsis and hemorrhage, and long-term postoperative complications, such as permanent defect of the lower uterine segment with a high risk for placentation anomalies in subsequent pregnancies, have a disproportionate impact in low-resource environments. In countries with high numbers of multiple cesarean deliveries, there has been an increase in the incidence of complex cesarean deliveries, including placenta previa accreta, that have a direct impact on maternal morbidity and mortality rates and an indirect impact on local healthcare provision and costs. Obstetrical care bundles, which reduce the indiscriminate use of primary cesarean delivery for nonmedical reasons and also improve access to emergency live-saving cesarean delivery in low-resources communities, are essential. This requires the development of novel and creative alternatives for training, support, and continuous improvement. In low-resource settings with shortages of skilled healthcare personnel, programs can only be sustained by a holistic and cost-effective training approach that includes training in basic obstetrical ultrasonography, the management of complicated labor, and neonatal resuscitation. In well-resourced settings, the limited exposure of modern general obstetrician-gynecologists to open surgical procedures risks leaving them unprepared for increasingly complex caesarean sections surgical procedures. Healthcare systems and educational programs that transcend socioeconomic and geographic factors must evolve to meet contemporary and future demands. Strengthening low-resource health systems by providing access to safe cesarean delivery procedures should be an international priority.