History of the Cesarean

From http://www.nlm.nih.gov/exhibition/cesarean/images/wound.jpg

 

Physician Jesse Bennett’s wife, fearing that she would die and hoping to save her child, asked the doctor attending her 1794 birth for a c-section. The doctor refused and Jesse took the reins, laying planks across two barrels and performing the operation himself. He also removed her ovaries to make sure they never went through such an ordeal again. The tale remains the first account of a successful American c-section in which both parties survived. 

The story was published in the Time Magazine article “Woman’s Ills” on June 18, 1951 after Isaac Harvey Flack published a 700-page history of obstetrics and gynecology entitled Eternal Eve in 1950. The article included the following quote from Flack’s work, which was published under the pen name Harvey Graham.

“To call an obstetrician to an obstructed labor in a modern maternity hospital may seem very different from calling in a witch-doctor to primeval hut,” he says. “The words and the rites … have become more specialized, as has the method of payment. The occasion, however, has not altered at all and for that matter the obstetrician has not much more idea than the shaman why that particular child should try to be born sideways.”

With interest piqued in researching the history of the emergency surgery, I found the entry in the National Library of Medicine’s “History of Medicine” category entitled “Cesarean Section - A Brief History.”  In case you don’t plan to spend fifteen minutes reading the whole entry, here are a few interesting excerpts:

 

Early successful cesarean sections were typically NOT in hospitals because infections and unclean hands made hospitals the most dangerous place to give birth in the past.

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.

 

Rather than enjoy their status as heroes for using tools to save babies that were otherwise destined for demise, “male midwives” and obstetricians decided that they wanted to take control of ALL births. Sound familiar? It’s been going on for 400 years.

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.

 

Fun Fact: The first successful cesarean in the British Empire was conducted in drag.

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.

 

Anesthesia revolutionizes surgery during the 18th century. Obstetricians resist the use of anesthesia because they wanted women to feel pain to atone for Eve’s sins.

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.

 

The deep seated fear that vaginal birth destroys the vagina may stem not just from stories of obstructed labor but from tales of destructive high forceps deliveries being passed down through generations. Not mentioned in this article is that the practice of using high forceps also became routine after anesthesia became available. In conjuncture with anesthesia and a generous episiotomy, high forceps were used to drag babies from the womb, ready or not. Now infants can be blasted out with Pitocin-generated contractions or born via c-section, ready or not.

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

 

Religion has played a large historical role in shaping medicine and medical practices. Yes, all ye medical purists and those who view science as dogma, many of the medical practices that you defend are rooted in religion, sexism, racism and classism. Catholics wanted that baby out of the mother at all cost so it could be baptized, while British Protestants favored saving the mother. We live in amazing times when both mother and child will usually survive a cesarean.

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.

 

Part 4 summarizes the history and discusses the modern c-section situation as well as how technology has rendered the mother invisible to the point that the fetus can now be considered a patient.

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.

[…]

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.

[…]

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.

 

The historically new ability to get the small patient out of the larger patient quickly and more safely is at the crux of many epidemiological, ethical and legal discussions about childbirth and reproductive health in general.