Cesarean section has been part of human culture since ancient times and references to it appear in Chinese, Hindu, Egyptian, Grecian, Roman, and other European folklore .Yet, this early history remains shrouded in myth and is of dubious accuracy. Even the origin of "cesarean" has been distorted over time. It is believed to be derived from the surgical birth of Julius Caesar, however this seems unlikely since his mother Aurelia 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. Ultimately, though, we cannot be sure of where or when the term cesarean was derived..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.
Many of the earliest successful cesarean sections took place in remote rural areas lacking in medical staff and facilities. These operations were performed on kitchen tables and beds, without access to hospital facilities, which 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.
In the eighteenth century surgeons substantially extended their knowledge of the normal and pathological anatomy of the human body. By the later 1800s, greater access to human cadavers in medical education permitted students to learn anatomy through dissection. This practical experience better prepared them to undertake operations.
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Of course, this new type of medical education was 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 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..
In Western society women 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.
While Barry applied Western surgical techniques, nineteenth-century travelers in Africa reported instances of indigenous people successfully carrying out the procedure. In 1879, a 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.
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 provided new opportunities for medical practitioners, as well as new treatments for patients.
Although many surgeons possessed the anatomical knowledge 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.
During the nineteenth century, however, surgery was transformed -- both technically and professionally by the introduction of anesthesia. 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 and practical in cases of cesarean section.
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.
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 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, . 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.
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 By the end of the century antisepsis and asepsis significantly reduced surgical infections.
Unfortunately, surgical techniques 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 might set up infections and cause uterine rupture. 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.
As cesarean section became safer, obstetricians increasingly argued against delaying surgery. If the woman was not in a state of collapse when taken to surgery her recovery would be more certain.
Penicillin was discovered by Alexander Fleming in 1928 and was purified as a drug in 1940, dramatically reducing maternal mortality for both normal and cesarean section births.
The development of esarean section was also influenced by religion and, as noted earlier, both Jewish and Roman law helped shape medical practice. In nineteenth century France, Roman Catholic concerns, such as removal of the infant so that it could be baptized, prompted substantial efforts to pioneer cesarean section. Protestant Britain avoided cesarean section during the same period, British obstetricians were more inclined to consider the mother primarily and, with cesarean section maternal mortality over fifty percent, they usually opted for craniotomy.
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, half of U.S. births were taking place in hospitals. By 1955, this had risen to ninety-nine percent.
During that same period medical technology greatly expanded .Advances in anesthesia o improved the safety and the experience of cesarean section.Spinal or epidural anesthesia is used to alleviate pain in normal childbirth and has 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.
Fathers are able to make that important early contact too and support their partners during both normal and cesarean births. When childbirth was moved from homes to hospitals fathers were 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 seeks a prominent role in birthing -- normal and cesarean.
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 such cases cesarean section provides the safest solution. In the United States almost one quarter of all babies are now delivered by cesarean section -- In 1970, the cesarean section rate was about 5%; .
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. There were several factors that contributed to the 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.
While the operation historically has been performed 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 ..Theanswer in the post-war era came from wartime technology. Sonar equipment that had been developed to detect submarines, became the basis for ultrasonography . Ultrasound made it possible to measure fetal growth and fetal skull width. While this provided 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 modern tests such as amniocentesis , it became more of a person.
The fetus then has become a patient. Today it can be surgically and pharmaceutically treated in utero. This changes the investment medical practitioners and expectant parents have in a fetus. This is even more pronounced during 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 as aresult of the ability to detect signs of fetal distress, many cesarean sections are undertaken to prevent such serious problems as brain damage due to oxygen deficiency.
The trend toward hospital births, including cesarean section, has been challenged. Since 1940, the experience of giving birth has become safer , 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 . Many medical practitioners have responded to this situation and encourage women to undertake normal delivery.
Soaring health care costs have also contributed to efforts to avoid the more expensive cesarean births.
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, 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.
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. During the nineteenth century, improvement of cesarean section techniques led to lower mortality for women and their fetuses. Increasingly the operation was performed in cases where the mother's health was considered endangered . Finally, in the late twentieth century, in Western society the fetus has become the primary patient once labor has commenced. As a result, in the last 30 years there has been a marked increase in surgery on the basis of fetal health indications.
While there is reason to believe that cesarean section has been employed too frequently in some societies during the last 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.
