A point that seems to worry operators in different countries is the possibility of successive pregnancies in a woman who has had a Caesarean section. Dr Routh, in a fine monograph, reported quite a large number of women who have been operated on up to five or six times, and with, all things considered, very little mortality. This course I am heartily in favour of.

If a woman has had her Caesarean section as the quickest and safest method of being delivered, while she is unconscious and in danger of dying from an eclamptic seizure, and she and her child are both saved, there is no reason why she should not have another child and many other children. The fact of knowing that she has had this trouble will enable us to take steps to prevent it happening.

If we can deliver the woman quickly by any ordinary means, I say we should certainly do it. But if the cervix is rigid, and there is no prospect of it dilating within the next half-hour, and the convulsions are getting worse and worse, we know that the child will have little chance of surviving unless we do something quickly. There is nothing so quick or so safe as making the incision and having the child within one minute in the nurse’s arms.

Sterilization at the first Caesarean

Another question that gives some writers a great deal of anxiety, is whether they should remove the uterus at the time of the first Caesarean section in every case, or whether, in some cases, they should be content by sterilizing the woman.They go into long discussions about whom the operator should consult; whether it should be the woman alone, the woman and her husband, or the woman and husband and her family, and perhaps his family.

These matters would certainly give me very little trouble.

I should go on removing her child by repeated Caesarean sections, until she had a medium-sized family – say five or six. Then, perhaps, I should say to her that, as she was saved from the danger of being childless in her old age she might like me to prevent another pregnancy occurring, and that I could easily do this in five or ten minutes during the course of the last Caesarean section.Three minutes spent on removing a piece of each tube inside the uterus at the cornu and closing the uterine opening with the peritoneum will for ever seal them up without adding even one-tenth of one per cent to the danger of the operation.

But I warn my readers not to sterilize the woman with her first child; even if she has a narrow pelvis through which no child can be born alive by ordinary or instrumental labour. Many times it has happened, that an over-anxious family doctor has consented, or even advised, the sterilization of the woman at the first Caesarean section, at which both child and mother have recovered, but, a few years later, this only child has been taken from them by accident or epidemic. The grief of the parents can well be imagined when the doctor informs them that what has been done cannot be undone.

One of the greatest mistakes is the conversion of a safe and simple Caesarean section delivery into a most dangerous procedure by doing too much, often with no justification.Why go on, when the child has been delivered alive and well and the mother has every prospect of a good recovery? Why go on, I repeat, and imperil her life by doing a Porro operation, a sub-total, or a panhysterectomy?

All these operations are full of possible complications and are often followed by the woman’s death. Perhaps 30 or 40 per cent mortality in some hands.

Two excuses are given for piling up the danger in this way. One, to my mind indefensible, is for the sterilization of the woman, under the mistaken supposition that a second Caesarean section would be more dangerous than the first whereas they are actually less dangerous than the average first one, for the very good reason that everything is prepared for it and it is done at the time of election instead of in the midst of a battle of sepsis against the woman’s life.

The ideal Caesarean section

I feel sure the ideal Caesarean section will become a reality within the next twenty years. It will be one in which the operation is performed within an hour or two after the beginning of labour in a woman who has not been examined by anyone except the obstetrician, and, moreover, by one who never examines anyone without sterilized rubber gloves.

At present, many of the cases which provide the mortality, low as it is, are those which have been subjected to many examinations by dirty hands amidst dirty surroundings, and even with great violence by instruments which are not perfect as regards asepsis.

The woman who has had one Caesarean section, will have learned not to submit herself to unskilled interference, but will place herself in good time in the hands of a skilled abdominal surgeon.

If possible, Caesarean section should be done before the woman is damaged and not after, and if this truth was recognized by the whole profession, I feel sure that Caesarean section would be almost as safe as natural labour.

The adoption of rubber gloves, made compulsory by public opinion, if not by law, would undoubtedly save thousands of lives every year. Infection by midwives and sometimes by practitioners makes the operator’s death rate nearly 30 per cent more.