This two-part series summarizes the current use and rationale for cesarean section; and the applicable uses for acupuncture within the prevention and recovery of cesarean birth. I've included research on the use of acupuncture for scar healing, malpositioned fetus, induction of labor, and common complaints post-surgery. I also review treatment of birth trauma and gentle cesarean section as a birthing option, as well as barriers to care for acupuncturists.

History of The C-Section

There is a long and interesting history of one for the oldest surgeries on record, with some texts dating it back to Greek mythology, in which the sun god Apollo ripped his son Asclepius from his dying mother's abdomen. There are also ancient Chinese etchings depicting the procedure on living women thousands of years ago.

Chinese medical surgical history by Hua T'o (c.141–208) is well-documented, with his employment of anesthetic herbs in his legendary ma fei san to perform surgeries to internal organs.¹ After his death, Chinese medical surgery was not well-documented; there is a singular case, however, in the Wei Kingdom (220–265), a case of cesarean section performed on the wife of a Tartar prince in the year 225. According to the recording, the woman was "pregnant for 12 months after which a boy was delivered through an incision under the right axilla and above the pubis. Both mother and child remained well."^2-3 Ancient Hindu, Egyptian, Grecian, Roman and other European folklore reference cesarean sections as well.

For centuries, cesarean sections were reserved for the deceased. That began to change in the Middle Ages, although the risks associated with infection from surgeons not understanding germ theory and not washing hands was often a cause of death for the mother. In 15th-century Switzerland, a farmer, Jacob Nufer, supposedly performed the first home-birthed cesarean section on his wife after multiple midwives could not get the baby out. His wife and child lived.⁴

It took another 300 years for women to begin surviving cesarean section regularly. Perhaps one of the most interesting physician histories in the development of cesarean section was by Dr. James Barry, credited with the first successful c-section in the British Empire. The physician was known to be an "eccentric army doctor" who championed humane treatment of, among others, women.

This made more sense once Barry died and an undertaker discovered he was anatomically female. Women were prohibited from both university and the practice of medicine at the time and Barry, born Margaret Ann Bulky, had masqueraded as a man to accomplish both.⁵

With the more regular use of anesthesia in the mid-1800s, cesarean section became less rare. As the skeletal disease rickets led to malformation of the pelvic girdle, more c-sections were necessary. But even as rickets was understood and vitamin D supplementation mostly eliminated it, cesarean deliveries remained.⁶

C-Section Rates and Risks

The World Health Organization suggests cesarean section rates are currently 10-20 percent worldwide. North America and Western Europe are well above this optimal rate, with 32 percent and 27 percent of babies in 2015 delivered by cesarean section, respectively.⁷

Physicians worldwide are aware of the increase in risks for mother and baby, and continue to research long-term effects to children born via cesarean. Women who had c-sections were 80 percent more likely to have complications than those who delivered vaginally, researchers report in the journal CMAJ; and women over age 35 who had c-sections were almost three times more likely to have severe complications.⁸ It is understood and agreed by most obstetricians and midwives that reducing the cesarean rate is a goal.

Prevention of Cesarean Section with Acupuncture

Licensed acupuncturists could be well-poised to help reduce the cesarean section rate. Some of the most common causes of cesarean sections are:

• Prolonged or "stalled" labor
• Abnormal fetal positioning (breech)
• Fetal distress
• Birth defects
• Previous cesarean
• Chronic health condition
• Cord prolapse
• Cephalopelvic disproportion (CPD)

Acupuncturists are well-versed at assisting in reduction of prolonged labor, breech-positioned babies, repeat cesarean and possibly some chronic health conditions. A recent study revealed acupressure may result in reduction of cesarean section.⁹

The turning of a breech-positioned baby, or malpositioned fetus, using moxibustion at bilateral Urinary Bladder 67 acupoint has long been recommended and used in traditional Chinese medical literature. A 1998 randomized, controlled trial by Cardini, et al., published in JAMA, concluded: "moxibustion for 1 to 2 weeks increased fetal activity during the treatment period and cephalic presentation after the treatment period and at delivery."¹⁰ Moxibustion should be utilized for a breech baby, with home care instructions provided to assist in prevention of cesarean section.

Another frequent cause of cesarean section is a previous cesarean delivery. Vaginal birth after cesarean (VBAC) is often the choice of both the provider and the mother, as a vaginal delivery avoids surgery and its possible risks, usually involves a shorter hospital stay, and may honor the woman's desires to experience a vaginal birth.

Not all women are candidates for attempting a VBAC. Providers generally recommend that the previous cesarean section have occurred more than 18 months prior; that the birthing facility can handle an emergency cesarean section; that fewer than two previous cesarean sections were performed; and that the surgical incision used was a low, transverse incision.

One concern about VBACs is the risk of uterine rupture. It is rare; less than 1 percent of women who attempt a VBAC have a uterine rupture. Increased risk factors for uterine rupture include uterine scar condition, intrapartum management and maternal health status. Although recent research suggests "no difference between techniques of uterine incision closure and delivery outcome have been determined,"¹¹ as acupuncturists, we must assess the effects of the qi in the affected meridians. Kidney, stomach, Conception vessel, and likely Dai Mai channels are affected with a transverse, or "bikini," incision.

A 2015 systematic review and meta-analysis showed acupuncture has positive effects on post-operative pain from surgical trauma.¹² A number of studies have shown that acupuncture or electroacupuncture can facilitate the release of specific neuropeptides in the CNS, producing physiological effects and even activating a self-healing mechanism.¹³

In translation to traditional Chinese medicine, with post-operative pain, there is qi stagnation. We must move the qi to reduce the stagnation and bring a free flow to the affected meridians. Local needling to the low abdomen immediately following cesarean section, perhaps with electroacupuncture, will likely increase the flow of qi and blood.

Women with previous histories of cesarean section and hopes for VBAC delivery should utilize acupuncture prior to conception to heal scar tissue to reduce risks of uterine rupture and repeat cesarean section.

Editor's Note: Part 2 of this series will discuss acupuncture for recovery from cesarean birth, healing birth trauma and the future of cesarean section: the gentle cesarean and how acupuncturists should be a part of this revolution in childbirth.

References

1. Tang SH, Kung WY. [Anecdotal Tales of Hua T'o and Pien Chueh] (in Chinese). Taipei: Lin Yu Cultural Enterprises, 1990.
2. Wong KC, Wu LT. History of Chinese Medicine: Being a Chronicle of Medical Happenings in China From Ancient Times to the Present Period. Shanghai: National Quarantine Service, 1936.
3. Fu L. Surgical history of ancient China: part 1. ANZ Journal of Surg, 2009;79:879-885.
4. Sewell JF. "Cesarean Section: A Brief History." National Library of Medicine, 2013.
5. Conis E. "Cesarean Section's Ancient History." Los Angeles Times, May 1, 2006
6. Ibid.
7. World Health Organization. WHO Statement on Caesarean Section Rates, Jan. 24, 2019.
8. Holland B. "The Extraordinary Secret Life of Dr. James Barry." History.com, March 24, 2017.
9. Smith CA, Collins CT, Levett KM, et al. Acupuncture or acupressure for pain management during labour. Cochrane Database of Systematic Reviews, 2020;2:CD009232.
10. Cardini F, Weixin H. Moxibustion for correction of breech presentation: a randomized controlled trial. JAMA,1998;280(18):1580-1584.
11. Tanos V, Toney ZA. Uterine scar rupture - prediction, prevention, diagnosis, and management. Best Pract Res Clin Obstet Gynaecol, 2019;59:115-131. doi:10.1016/j.bpobgyn.2019.01.009
12. Wu MS, Chen KH, Chen IF, et al. The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PloS One, 2016;11(3):e0150367.
13. Mayor D. An exploratory review of the electroacupuncture literature: clinical applications and endorphin mechanisms. Acupunct Med, 2013 Dec;31(4):409-415.

Kerry Boyle is a nationally board certified, licensed acupuncturist in practice at Integrative Acupuncture in both Williston and Montpelier, Vt. (www.acupunctureinvermont.com). A 2003 graduate of Bastyr University, she specializes in integrating acupuncture and Chinese medicine for women's health and fertility. Kerry is a 2020 acupuncture doctoral candidate at Pacific College.