Cesarean Section - A Brief

History
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 Preface

 Part 1

 Part 2

 Part 3

 Part 4

 References

Preface
Cesarean section has been part of human culture since ancient times and there are
tales in both Western and non-Western cultures of this procedure resulting in live
mothers and offspring. According to Greek mythology Apollo removed Asclepius,
founder of the famous cult of religious medicine, from his mother's abdomen.
Numerous references to cesarean section appear in ancient Hindu, Egyptian,
Grecian, Roman, and other European folklore. Ancient Chinese etchings depict the
procedure on apparently living women. The Mischnagoth and Talmud prohibited
primogeniture when twins were born by cesarean section and waived the
purification rituals for women delivered by surgery.

Yet, the early history of cesarean section remains shrouded in myth and is of
dubious accuracy. Even the origin of "cesarean" has apparently been distorted over
time. It is commonly believed to be derived from the surgical birth of Julius Caesar,
however this seems unlikely since his mother Aurelia is reputed to have lived to
hear of her son's invasion of Britain. At that time the procedure was performed only
when the mother was dead or dying, as an attempt to save the child for a state
wishing to increase its population. Roman law under Caesar decreed that all women
who were so fated by childbirth must be cut open; hence, cesarean. Other possible
Latin origins include the verb "caedare," meaning to cut, and the term "caesones"
that was applied to infants born by postmortem operations. Ultimately, though, we
cannot be sure of where or when the term cesarean was derived. Until the
sixteenth and seventeenth centuries the procedure was known as cesarean
operation. This began to change following the publication in 1598 of Jacques
Guillimeau's book on midwifery in which he introduced the term "section."
Increasingly thereafter "section" replaced "operation."

During its evolution cesarean section has meant different things to different people
at different times. The indications for it have changed dramatically from ancient to
modern times. Despite rare references to the operation on living women, the initial
purpose was essentially to retrieve the infant from a dead or dying mother; this
was conducted either in the rather vain hope of saving the baby's life, or as
commonly required by religious edicts, so the infant might be buried separately
from the mother. Above all it was a measure of last resort, and the operation was
not intended to preserve the mother's life. It was not until the nineteenth century
that such a possibility really came within the grasp of the medical profession.

There were, though, sporadic early reports of heroic efforts to save women's lives.
While the Middle Ages have been largely viewed as a period of stagnation in science
and medicine, some of the stories of cesarean section actually helped to develop
and sustain hopes that the operation could ultimately be accomplished. Perhaps the
first written record we have of a mother and baby surviving a cesarean section
comes from Switzerland in 1500 when a sow gelder, Jacob Nufer, performed the
operation on his wife. After several days in labor and help from thirteen midwives,
the woman was unable to deliver her baby. Her desperate husband eventually
gained permission from the local authorities to attempt a cesarean. The mother
lived and subsequently gave birth normally to five children, including twins. The
cesarean baby lived to be 77 years old. Since this story was not recorded until 82
years later historians question its accuracy. Similar skepticism might be applied to
other early reports of abdominal delivery þ those performed by women on
themselves and births resulting from attacks by horned livestock, during which the
peritoneal cavity was ripped open.

The history of cesarean section can be understood best in the broader context of
the history of childbirth and general medicine þ histories that also have been
characterized by dramatic changes. Many of the earliest successful cesarean
sections took place in remote rural areas lacking in medical staff and facilities. In
the absence of strong medical communities, operations could be carried out without
professional consultation. This meant that cesareans could be undertaken at an
earlier stage in failing labor when the mother was not near death and the fetus was
less distressed. Under these circumstances the chances of one or both surviving
were greater. These operations were performed on kitchen tables and beds, without
access to hospital facilities, and this was probably an advantage until the late
nineteenth century. Surgery in hospitals was bedeviled by infections passed
between patients, often by the unclean hands of medical attendants. These factors
may help to explain such successes as Jacob Nufer's.

By dint of his work in animal husbandry, Nufer also possessed a modicum of

anatomical knowledge. One of the first steps in performing any operation is
understanding the organs and tissues involved, knowledge that was scarcely
obtainable until the modern era. During the sixteenth and seventeenth centuries
with the blossoming of the Renaissance, numerous works illustrated human
anatomy in detail. Andreas Vesalius's monumental general anatomical text De
Corporis Humani Fabrica, for example, published in 1543, depicts normal female
genital and abdominal structures. In the eighteenth and early nineteenth centuries
anatomists and surgeons substantially extended their knowledge of the normal and
pathological anatomy of the human body. By the later 1800s, greater access to
human cadavers and changing emphases in medical education permitted medical
students to learn anatomy through personal dissection. This practical experience
improved their understanding and better prepared them to undertake operations.

At the time, of course, this new type of medical education was still only available to
men. With gathering momentum since the seventeenth century, female attendants
had been demoted in the childbirth arena. In the early 1600s, the Chamberlen clan
in England introduced obstetrical forceps to pull from the birth canal fetuses that
otherwise might have been destroyed. Men's claims to authority over such
instruments assisted them in establishing professional control over childbirth. Over
the next three centuries or more, the male-midwife and obstetrician gradually
wrested that control from the female midwife, thus diminishing her role.

Part 1
Cesarean section has been part of human culture since ancient times and there are
tales in both Western and non-Western cultures of this procedure resulting in live
mothers and offspring. According to Greek mythology Apollo removed Asclepius,
founder of the famous cult of religious medicine, from his mother's abdomen.
Numerous references to cesarean section appear in ancient Hindu, Egyptian,
Grecian, Roman, and other European folklore. Ancient Chinese etchings depict the
procedure on apparently living women. The Mischnagoth and Talmud prohibited
primogeniture when twins were born by cesarean section and waived the
purification rituals for women delivered by surgery.
 The extraction of Asclepius from the abdomen of his mother Coronis by his father
Apollo. Woodcut from the 1549 edition of Alessandro Beneditti's De Re Medica.
Yet, the early history of cesarean section remains shrouded in myth and is of
dubious accuracy. Even the origin of "cesarean" has apparently been distorted over
time. It is commonly believed to be derived from the surgical birth of Julius Caesar,
however this seems unlikely since his mother Aurelia is reputed to have lived to
hear of her son's invasion of Britain. At that time the procedure was performed only
when the mother was dead or dying, as an attempt to save the child for a state
wishing to increase its population. Roman law under Caesar decreed that all women
who were so fated by childbirth must be cut open; hence, cesarean. Other possible
Latin origins include the verb "caedare," meaning to cut, and the term "caesones"
that was applied to infants born by postmortem operations. Ultimately, though, we
cannot be sure of where or when the term cesarean was derived. Until the
sixteenth and seventeenth centuries the procedure was known as cesarean
operation. This began to change following the publication in 1598 of Jacques
Guillimeau's book on midwifery in which he introduced the term "section."
Increasingly thereafter "section" replaced "operation."

One of the earliest printed illustrations of Cesarean section. Purportedly the birth of Julius
Caesar. A live infant being surgically removed from a dead woman. From Suetonius' Lives of
the Twelve Caesars, 1506 woodcut.
During its evolution cesarean section has meant different things to different people
at different times. The indications for it have changed dramatically from ancient to
modern times. Despite rare references to the operation on living women, the initial
purpose was essentially to retrieve the infant from a dead or dying mother; this
was conducted either in the rather vain hope of saving the baby's life, or as
commonly required by religious edicts, so the infant might be buried separately
from the mother. Above all it was a measure of last resort, and the operation was
not intended to preserve the mother's life. It was not until the nineteenth century
that such a possibility really came within the grasp of the medical profession.

Cesarean section performed on a living woman by a female practitioner. Miniature

from a fourteenth-century "Historie Ancienne."
There were, though, sporadic early reports of heroic efforts to save women's lives.
While the Middle Ages have been largely viewed as a period of stagnation in science
and medicine, some of the stories of cesarean section actually helped to develop
and sustain hopes that the operation could ultimately be accomplished. Perhaps the
first written record we have of a mother and baby surviving a cesarean section
comes from Switzerland in 1500 when a sow gelder, Jacob Nufer, performed the
operation on his wife. After several days in labor and help from thirteen midwives,
the woman was unable to deliver her baby. Her desperate husband eventually
gained permission from the local authorities to attempt a cesarean. The mother
lived and subsequently gave birth normally to five children, including twins. The
cesarean baby lived to be 77 years old. Since this story was not recorded until 82
years later historians question its accuracy. Similar skepticism might be applied to
other early reports of abdominal delivery þ those performed by women on
themselves and births resulting from attacks by horned livestock, during which the
peritoneal cavity was ripped open.
 The female pelvic anatomy. From Andreas Vesalius' De Corporis Humani Fabrica, 1543.
The history of cesarean section can be understood best in the broader context of
the history of childbirth and general medicine þ histories that also have been
characterized by dramatic changes. Many of the earliest successful cesarean
sections took place in remote rural areas lacking in medical staff and facilities. In
the absence of strong medical communities, operations could be carried out without
professional consultation. This meant that cesareans could be undertaken at an
earlier stage in failing labor when the mother was not near death and the fetus was
less distressed. Under these circumstances the chances of one or both surviving
were greater. These operations were performed on kitchen tables and beds, without
access to hospital facilities, and this was probably an advantage until the late
nineteenth century. Surgery in hospitals was bedeviled by infections passed
between patients, often by the unclean hands of medical attendants. These factors
may help to explain such successes as Jacob Nufer's.

By dint of his work in animal husbandry, Nufer also possessed a modicum of

anatomical knowledge. One of the first steps in performing any operation is
understanding the organs and tissues involved, knowledge that was scarcely
obtainable until the modern era. During the sixteenth and seventeenth centuries
with the blossoming of the Renaissance, numerous works illustrated human
anatomy in detail. Andreas Vesalius's monumental general anatomical text De
Corporis Humani Fabrica, for example, published in 1543, depicts normal female
genital and abdominal structures. In the eighteenth and early nineteenth centuries
anatomists and surgeons substantially extended their knowledge of the normal and
pathological anatomy of the human body. By the later 1800s, greater access to
human cadavers and changing emphases in medical education permitted medical
students to learn anatomy through personal dissection. This practical experience
improved their understanding and better prepared them to undertake operations.

At the time, of course, this new type of medical education was still only available to
men. With gathering momentum since the seventeenth century, female attendants
had been demoted in the childbirth arena. In the early 1600s, the Chamberlen clan
in England introduced obstetrical forceps to pull from the birth canal fetuses that
otherwise might have been destroyed. Men's claims to authority over such
instruments assisted them in establishing professional control over childbirth. Over
the next three centuries or more, the male-midwife and obstetrician gradually
wrested that control from the female midwife, thus diminishing her role.

Part 2
In Western society women for the most part were barred from carrying out
cesarean sections until the late nineteenth century, because they were largely
denied admission to medical schools. The first recorded successful cesarean in the
British Empire, however, was conducted by a woman. Sometime between 1815 and
1821, James Miranda Stuart Barry performed the operation while masquerading as
a man and serving as a physician to the British army in South Africa.

Successful Cesarean section performed by indigenous healers in Kahura, Uganda.

As observed by R. W. Felkin in 1879 from his article "Notes on Labour in Central
Africa" published in the Edinburgh Medical Journal, volume 20, April 1884, pages
922-930.
While Barry applied Western surgical techniques, nineteenth-century travelers in
Africa reported instances of indigenous people successfully carrying out the
procedure with their own medical practices. In 1879, for example, one British
traveller, R.W. Felkin, witnessed cesarean section performed by Ugandans. The
healer used banana wine to semi-intoxicate the woman and to cleanse his hands
and her abdomen prior to surgery. He used a midline incision and applied cautery
to minimize hemorrhaging. He massaged the uterus to make it contract but did not
suture it; the abdominal wound was pinned with iron needles and dressed with a
paste prepared from roots. The patient recovered well, and Felkin concluded that
this technique was well-developed and had clearly been employed for a long time.
Similar reports come from Rwanda, where botanical preparations were also used to
anesthetize the patient and promote wound healing.

The Woman's Hospital of the State of New York, 1867. One of America's first large hospitals for
the diseases of women.
While many of the earliest reports of cesarean section issue from remote parts of
Europe and the United States and from places far removed from the latest
developments in Western medicine, it was only with increased urbanization and the
growth of hospitals that the operation began to be performed routinely. Most rural
births continued to be attended by midwives in the late nineteenth and early
twentieth centuries, but in the cities obstetrics -- a hospital-based specialty --
squeezed out midwifery. In urban centers large numbers of uprooted working class
women gave birth in hospitals because they could not rely on the support of family
and friends, as they could in the countryside. It was in these hospitals, where
doctors treated many patients with similar conditions, that new obstetrical and
surgical skills began to be developed.

A Cesarean patient prior to dressing the wound. From Edward Siebold, Abbildungen

aus dem gesammtgebiete der theoretisch-praktischen geburtshülfe, 1829.
Special hospitals for women sprang up throughout the United States and Europe in
the second half of the nineteenth century. Reflecting that period's budding medical
interest in the sexuality and the diseases of women, these institutions nurtured the
emerging specialties and provided new opportunities for medical practitioners, as
well as new treatments for patients. Specialties such as neurology and psychiatry
centered on mental and nervous disorders and obstetrics and gynecology centered
on the functions and disorders of the female reproductive tract.
 Destructive scissors and crotchets. From William Smellie's A Sett of Anatomical Tables, 1754.
As a serious abdominal operation, the development of cesarean section both
sustained and reflected changes within general surgery. In the early 1800s, when
surgery still relied on age-old techniques, its practitioners were dreaded and viewed
by the public as little better than barbers, butchers, and tooth pullers. Although
many surgeons possessed the anatomical knowledge and the courage to perform
serious procedures they had been limited by the patient's pain and the problems of
infection. Well into the 1800s surgery continued to be barbarous and the best
operators were known for the speed with which they could amputate a limb or
suture a wound.

Craniotomy. Perforation of the skull, removal of cranial contents, and extraction of

the collapsed skull.
During the nineteenth century, however, surgery was transformed -- both
technically and professionally. A new era in surgical practice began in 1846 at
Massachusetts General Hospital when dentist William T. G. Morton used diethyl
ether while removing a facial tumor. This medical application of anesthesia rapidly
spread to Europe. In obstetrics, though, there was opposition to its use based on
the biblical injunction that women should sorrow to bring forth children in
atonement for Eve's sin. This argument was substantially demolished when the
head of the Church of England, Queen Victoria, had chloroform administered for the
births of two of her children (Leopold in 1853 and Beatrice in 1857). Subsequently,
anesthesia in childbirth became popular among the wealthy and practical in cases
of cesarean section.

By the century's close, a wide range of technological innovations had enabled

surgeons to revolutionize their practice and to professionalize their position.
Anesthetics permitted surgeons to take the time to operate with precision, to
cleanse the peritoneal cavity, to record the details of their procedures, and to learn
from their experiences. Women were spared the agony of operations and were less
susceptible to shock, which had been a leading cause of post-operative mortality
and morbidity.

Obstetrical forceps. From André Levret's Observations sur les causes et les accidens de
plusieurs accouchemens laborieux, 1750.
As many doctors discovered, anesthesia allowed them to replace craniotomy with
cesarean section. Craniotomy had been practiced for hundreds, perhaps even
thousands, of years. This unhappy procedure involved the destruction (by
instruments such as the crotchet) of the fetal skull and the piecemeal extraction of
the entire fetus from the vagina. Although this was a gruesome operation, it
entailed far lower risk to the mother than attempts to remove the fetus through an
abdominal incision.

While obstetrical forceps helped to remove the fetus in some cases, they had
limitations. They undoubtedly saved the lives of some babies who would otherwise
have suffered craniotomy, but even when the mother's life was saved, she might
well suffer severely for the rest of her life from tears in the vaginal wall and
perineum. The low forceps that are still commonly used today could cause vaginal
tears, but they were less likely to do so than the high forceps that in the nineteenth
century were too frequently employed. Inserted deep into the pelvis in cases of
protracted labor, these instruments were associated with high levels of fetal
damage, infection, and serious lacerations to the woman. Dangerous as it was,
cesarean section may have seemed preferable in some instances when the fetus
was trapped high in the pelvis. Where severe pelvic distortion or contraction
existed, neither craniotomy nor obstetrical forceps were of any avail, and then
cesarean section was probably the only hope.

Abdominal surgery to remove diseased ovarian tissue (ovariotomy). Surgeon and

anesthesiologist in street clothes. From Thomas Spencer Wells, Diseases of the
Ovaries, 1872.
While doctors and patients alike were encouraged by anesthesia to resort to
cesarean section rather than craniotomy, mortality rates for the operation remained
high, with the infections septicemia and peritonitis accounting for a large
percentage of post-operative deaths. Prior to the establishment of the germ theory
of disease and the birth of modern bacteriology in the second half of the nineteenth
century, surgeons wore their street clothes to operate and washed their hands
infrequently while passing from one patient to another. In the mid-1860s, the
British surgeon Joseph Lister introduced an antiseptic method using carbolic acid,
and many operators adopted some part of his antisepsis. Others, however, were
concerned about its corrosiveness and experimented with various aseptic measures
that emphasized cleanliness. By the end of the century antisepsis and asepsis
gradually were making inroads into the problems of surgical infections.

Unfortunately, surgical techniques of that day also contributed to the appallingly

high maternal mortality rates. According to one estimate not a single woman
survived cesarean section in Paris between 1787 and 1876. Surgeons were afraid to
suture the uterine incision because they thought internal stitches, which could not
be removed, might set up infections and cause uterine rupture in subsequent
pregnancies. They believed the muscles of the uterus would contract and close
spontaneously. Such was not the case. As a result some women died of blood loss
-- more from infection.

Part 3
Once anesthesia, antisepsis, and asepsis were firmly established obstetricians were
able to concentrate on improving the techniques employed in cesarean section. As
early as 1876, Italian professor Eduardo Porro had advocated hysterectomy in
concurrence with cesareans to control uterine hemorrhage and prevent systemic
infection. This enabled him to reduce the incidence of post-operative sepsis. But his
mutilating elaboration on cesarean section was soon obviated by the employment
of uterine sutures. In 1882, Max Saumlnger, of Leipzig made such a strong case for
uterine sutures that surgeons began to change their practice. Saumlnger's
monograph was based largely on the experience of U.S. healers (surgeons and
empirics) who had used internal sutures. The silver wire stitches he recommended
were themselves new, having been developed by America's premier nineteenth-
century gynecologist J. Marion Sims. Sims had invented his sutures to treat the
vaginal tears (fistulas) that resulted from traumatic childbirth.

J. Marion Sims repairing a vesico-vaginal fistula with silver wire sutures. 1870.
As cesarean section became safer, obstetricians increasingly argued against
delaying surgery. Rather than waiting for many hours of unsuccessful labor, doctors
such as Robert Harris in the United States, Thomas Radford in England, and Franz
von Winckel in Germany opted for an early resort to the operation in order to
improve the outcome. If the woman was not in a state of collapse when taken to
surgery her recovery would be more certain, they claimed. This was an argument
sweeping through the general surgical community and one that resulted in greater
numbers of operations on an expanding patient population. In obstetrical surgery
the new approach also assisted in reducing maternal and perinatal infant mortality
rates.

As surgeons' confidence in the outcome of their procedures increased, they turned

their attention to other issues, including where to incise the uterus. Between 1880
and 1925, obstetricians experimented with transverse incisions in the lower
segment of the uterus. This refinement reduced the risk of infection and of
subsequent uterine rupture in pregnancy. A further modification -- vaginal cesarean
section -- helped avoid peritonitis in patients who were already suffering from
certain infections. The need for that form of section, however, was virtually
eliminated in the post World War II period by the development of modern
antibiotics. Penicillin was discovered by Alexander Fleming in 1928 and, after it was
purified as a drug in 1940, became generally available and dramatically reduced
maternal mortality for both normal and cesarean section births. Meanwhile, the low
cervical cesarean section, advocated in the early twentieth century by the British
obstetrician Munro Kerr, had become popular. Promulgated by Joseph B. DeLee and
Alfred C. Beck in the United States, this technique reduced the rates of infection
and of uterine rupture and is still the operation of preference.

In addition to surgical advances, the development of cesarean section was

influenced by the continued growth in number of hospitals, by significant
demographic changes, and by numerous other factors -- including religion. Religion
has affected medicine throughout recorded history and, as noted earlier, both
Jewish and Roman law helped shape early medical practice. Later, in early to mid-
nineteenth century France, Roman Catholic religious concerns, such as removal of
the infant so that it could be baptized, prompted substantial efforts to pioneer
cesarean section, efforts launched by some of the country's leading surgeons.
Protestant Britain avoided cesarean section during the same period, even though
surgeons were experimenting with other forms of abdominal procedures (mainly
ovarian operations). British obstetricians were far more inclined to consider the
mother primarily and, with cesarean section maternal mortality over fifty percent,
they usually opted for craniotomy.

A family with rickets. Paris, 1900.

As the rate of urbanization rapidly increased in Britain, throughout Europe, and the
United States there arose at the turn of the century an increased need for
cesareans. Cut off from agricultural produce and exposed to little sunlight, city
children experienced a sharply elevated rate of the nutritional disease rickets. In
women where improper bone growth had resulted, malformed pelvises often
prohibited normal delivery. As a result the rate of cesarean section went up
markedly. By the 1930s, when safe milk became readily available in schools and
clinics in much of the United States and Europe, improper bone growth became less
of a problem. Yet, many in the medical profession were slow to respond to the
decreased need for surgical delivery. After World War II, in fact, the cesarean
section rate never returned to the low levels experienced before rickets became a
large-scale malady, despite considerable criticism of the too frequent resort to
surgery.

The safe milk movement was a measure of preventive medicine promoted by public
health reformers in the United States and abroad. These reformers worked with
governments to improve many aspects of maternal and infant health. Yet while
more and more women received prenatal attention -- indeed more than ever before
-- surgical intervention continued to rise. So too did the involvement of state and
federal governments in financing and overseeing maternal and fetal care.
Accompanying these trends was a tendency over the past half century for the
status of the fetus increasingly to be given center stage.

Since 1940, the trend toward medically managed pregnancy and childbirth has
steadily accelerated. Many new hospitals were built in which women gave birth and
in which obstetrical operations were performed. By 1938, approximately half of U.S.
births were taking place in hospitals. By 1955, this had risen to ninety-nine percent.

During that same period medical research flourished and technology was greatly
expanded in scope and application. Advances in anesthesia contributed to
improving the safety and the experience of cesarean section. In numerous
countries, including the United States, spinal or epidural anesthesia is used to
alleviate pain in normal childbirth. It has also largely replaced general anesthesia in
cesarean deliveries, permitting women to remain conscious during surgery. It
results in better outcomes for mothers and babies and facilitates immediate contact
and bonding to occur.

These days, too, fathers are able to make that important early contact and support
their partners during both normal and cesarean births. When childbirth was moved
from homes to hospitals fathers were initially removed from the birthing scene and
this distancing became even more complete in relation to surgical delivery. But, the
use of conscious anesthesia and the increased ability to maintain an antiseptic and
antibiotic field during operations allowed fathers to be present during cesarean
section. Meanwhile, changes in gender relations were altering the involvement of
many fathers in pregnancy, childbirth, and parenting. The modern father
participates in childbirth classes and seeks a prominent role in birthing -- normal
and cesarean.

Currently in the United States slightly more than one in seven women experiences
complications during labor and delivery that are due to conditions existing prior to
pregnancy; these include diabetes, pelvic abnormalities, hypertension, and
infectious diseases. In addition, a variety of pathological conditions that develop
during pregnancy (such as eclampsia and placenta praevia) are indications for
surgical delivery. These problems can be life-threatening for both mother and baby,
and in approximately forty percent of such cases cesarean section provides the
safest solution. In the United States almost one quarter of all babies are now
delivered by cesarean section -- approximately 982,000 babies in 1990. In 1970,
the cesarean section rate was about 5%; by 1988, it had peaked at 24.7%. In
1990, it had decreased slightly to 23.5%, primarily because more women were
attempting vaginal births after cesarean deliveries.

How can we explain this dramatic increase? It certainly far exceeds any rise in the
birth rate, which went up by only 2% between 1970 and 1987. In fact there were
several factors that contributed to the rapid rise in cesarean sections. Some of the
factors were technological, some cultural, some professional, others legal. The
growth in malpractice suits no doubt promoted surgical intervention, but there were
many other influences at work.

Part 4
While the operation historically has been performed largely to protect the health of
the mother, more recently the health of the fetus has played a larger role in
decisions to go to surgery. Hormonal pregnancy tests -- tests that confirm fetal
existence -- have been available since the 1940's. The fetal skeleton could be seen
using X-rays, but, the long-term hazards of radiation prompted researchers to seek
other imaging technology. The answer in the post-war era came from wartime
technology. Ultrasound, or sonar equipment that had been developed to detect
submarines, became the springboard for soft tissue ultrasonography in the late
1940's and early 1950's. Ultrasound made it possible to measure fetal growth and
fetal skull width in relation to the mother's pelvic dimensions and now has become
a routine diagnostic device. While this type of visualization provided medical
personnel with valuable information, it also influenced attitudes toward the fetus.
When the fetus could be visualized and its sex and chromosomal makeup
determined through this and other more modern tests such as amniocentesis and
chorionic villus sampling, it became more of a person. Indeed, many fetuses were
named months before birth.
The fetus then has become a patient. Today it can even be surgically and
pharmaceutically treated in utero. This changes the emotional and financial
investment both medical practitioners and expectant parents have in a fetus. This is
even more pronounced after the commencement of labor when the fetus
increasingly becomes the primary patient. Since the advent of heart monitors in the
early 1970's, fetal monitoring routinely tracks fetal heart rate and indicates any
signs of distress. As a result of the ability to detect signs of fetal distress, many
cesarean sections are swiftly undertaken to prevent such serious problems as brain
damage due to oxygen deficiency.

With these innovations came criticism. Fetal monitoring as well as numerous other
antenatal diagnostics have been faulted in recent years by some of the lay public
and members of the medical profession. The American College of Obstetricians and
Gynecologists and similar organizations in several other countries have been
working to reduce some of the reliance on high-cost and high-tech features of
childbirth and to encourage women to attempt normal delivery whenever possible.

The trend toward hospital births, including cesarean section, has been challenged.
Since 1940, the experience of giving birth has become safer and less frightening,
and many women have come to view that experience more positively. Thus was
spawned the natural childbirth movement, a development fueled by the modern
feminist movement, which has urged women to take greater responsibility for their
own bodies and health care. The soaring cesarean section rate of the past two
decades has also been questioned by lay people. Consumer advocacy organizations
and women's groups have been working to reduce what they see as unnecessary
surgery. Some doctors have for many years expressed doubts about the rates of
cesarean section. Recently many medical practitioners have responded to this
situation and have begun to work with lay organizations to encourage more women
to undertake normal delivery.

These efforts seem to be having some effect. Despite the recent increase in
cesarean section rates there appears to be a leveling off þ the figure for 1988 was
almost identical to that for 1987. Perhaps one of the most important factors is the
changing opinion toward the formula "once a cesarean section, always a cesarean
section." This expression embodied the notion that once a woman had a cesarean
she would require surgery for all subsequent deliveries. This was, apparently, the
cause of the greatest increase in cesarean sections between 1980 and 1985. But
many women were deeply concerned about that edict and the morbidity following
major surgery. They organized vaginal-birth-after-cesarean groups to encourage
normal births subsequent to surgery. Soaring health care costs have also
contributed to efforts to avoid the more expensive cesarean births. The American
College of Obstetricians and Gynecologists responded swiftly to calls from within
the organization and from the patient population and in 1982, as a standard of
care, recommended a trial of labor in selected cases of prior cesarean section. In
1988, the guidelines were expanded to include more women with previous cesarean
births. Consequently, there was a steady increase in vaginal births after cesarean in
the late 1980's. In 1990, an estimated 90,000 women gave birth vaginally after
cesarean section.

The trend in Western medicine seems now to be away from higher levels of
cesarean section, and a new ten-year study by an Oxford University research team
emphasizes this point. The study involved a comparison of cesarean section rates
that average almost 25% in the United States and 9% in Great Britain, and
suggests that the trends in the United States need to be questioned. This study
indicates that, while cesarean section continues to be a procedure that saves the
lives of mothers and infants and prevents disabilities, both the medical and lay
communities must bear in mind that most births are normal and more births should
progress without undue intervention.

As this brief history suggests, the indications for cesarean section have varied
tremendously through our documented history. They have been shaped by
religious, cultural, economic, professional, and technological developments -- all of
which have impinged on medical practice. The operation originated from attempts
to save the soul, if not the life, of a fetus whose mother was dead or dying. Since
ancient times, however, there have been occasional efforts to save the mother, and
during the nineteenth century, systematic improvement of cesarean section
techniques eventually led to lower mortality for women and their fetuses.
Increasingly the operation was performed in cases where the mother's health was
considered endangered, in addition to those in which her life was immediately at
stake. Finally, in the late twentieth century, in mainstream Western medical society
the fetus has become the primary patient once labor has commenced. As a result,
we have seen in the last 30 years a marked increase in resort to surgery on the
basis of fetal health indications.

While there is sound reason to believe that cesarean section has been employed too
frequently in some societies during the last two or three decades, the operation
clearly changes the outcome favorably for a significant percentage of women and
babies. In our society now women may be afraid of the pain of childbirth, but they
do not expect it to kill them. Such could not be said of many women as late as the
nineteenth century. Moreover, most women now expect their babies to survive
birth. These are modern assumptions and ones that cesarean section has helped to
promulgate. An operation that virtually always resulted in a dead woman and dead
fetus now almost always results in a living mother and baby -- a transformation as
significant to the women and families involved as to the medical profession.

Selected References
Ackerknecht, Erwin H.,
A Short History of Medicine,
Baltimore: The Johns Hopkins University Press, 1982
Boley, J.P.,
"The History of Cesarean Section,"
Canadian Medical Association Journal,
Vol. 145, No. 4, 1991, pp. 319-322.
Donnison, Jean,
Midwives and Medical Men: A History of the Struggle for the Control of Childbirth,
London: Historical Publications Ltd., 1988.
Eastman, N.J.,
"The Role of Frontier America in the Development of Cesarean Section,"
American Journal of Obstetrics and Gynecology,
Vol. 24, 1932, p. 919.
Gabert, Harvey A., "History and Development of Cesarean Operation," in Obstetrics
and Gynecology Clinics of North America,
Vol. 15, No. 4. 1988, pp. 591-605.
Horton, Jacqueline A., ed.,
The Women's Health Data Book.
A Profile of Women's Health in the United States,
New York: Elsevier, 1992, pp. 18-20.
Leavitt, Judith Walzer,
Brought to Bed: Childbearing in America, 1750-1950,
New York: Oxford University Press, 1986.
Leonardo, Richard A.,
History of Gynecology,
New York: Froben Press, 1944.
Ludmerer, Kenneth M.,
Learning to Heal: The Development of American Medical Education,
New York: Basic Books Inc., 1985.
Martin, Emily,
The Woman in the Body: A Cultural Analysis of Reproduction,
Boston: Beacon Press, 1987.
Maulitz, Russell C.,
Morbid Appearances: The Anatomy of Pathology in the Early Nineteenth Century,
Cambridge: Cambridge University Press, 1987.
Miller, Joseph L.,
"Cesarean Section in Virginia in the Pre-Aseptic Era, 1794-1879,"
Annals of Medical History, January, 1938, pp. 23-35.
Miller, Joseph M.,
"First Successful Cesarean Section in the British Empire," Letters,
Vol. 166, No. 1, Part 1, p. 269.
Moscucci, Ornella,
The Science of Woman: Gynaecology and Gender in England, 1800-1929,
Cambridge: Cambridge University Press, 1990.
Oakley, Ann,
The Captured Womb: A History of the Medical Care of Pregnant Women,
Oxford: Basil Blackwell Ltd., 1984, 1986.
Pernick, Martin S.,
A Calculus of Suffering: Pain, Professionalism, and Anesthesia in Nineteenth-
Century America,
New York: Columbia University Press, 1985.
Ricci, J.V.,
The Genealogy of Gynaecology: History of the Development of Gynaecology
Throughout the Ages,
Philadelphia: The Blakiston Company, 1943.
Ricci, J.V.,
One Hundred Years of Gynaecology, 1800-1900,
Philadelphia: The Blakiston Company, 1945.
Rothstein, William G.,
American Medical Schools and the Practice of Medicine: A History,
New York: Oxford University Press, 1987.
Rucker M. Pierce and Edwin M. Rucker,
"A Librarian Looks at Cesarean Section,"
Bulletin of the History of Medicine, March 1951, pp. 132-148.
Sewell, Jane Eliot,
Bountiful Bodies: Spencer Wells, Lawson Tait, and the Birth of British Gynaecology,
Ann Arbor, Michigan: U.M.I., 1990.
Shryock, Richard Harrison,
The Development of Modern Medicine: An Interpretation of the Social and Scientific
Factors Involved,
Madison, Wisconsin: The University of Wisconsin Press, 1936, 1979.
Shryock, Richard Harrison,
Medicine and Society in America: 1660-1860,
Ithaca: Cornell University Press, 1977.
Speert, Harold,
Obstetrics and Gynecology in America: A History,
Baltimore: Waverly Press, 1980.
Towler, Jean and Joan Bramell,
Midwives in History and Society,
London: Croom Helm, 1986.
Wertz, Richard W. and Dorothy C. Wertz,
Lying-In: A History of Childbirth in America,
New Haven: Yale University Press, 1989.
Willson, J. Robert,
"The Conquest of Cesarean Section-Related Infections: A Progress Report,"
Obstetrics and Gynecology, Vol. 72, No. 3, Part 2, September 1988, pp. 519-532.
Wolfe, Sidney M.,
Women's Health Alert,
Reading, Massachusetts: Addison-Wesley Publishing Company Inc., 1991
Young, J.H.,
Caesarean Section: The History and Development of the Operation From Early
Times,
London: H.K. Lewis and Co. Ltd., 1944.
The National Library of Medicine has a rich collection of written works on
the history of Cesarean section as well as numerous film and other visual
sources.

https://www.nlm.nih.gov/exhibition/cesarean/index.html