(BEING CONTINUED FROM 21/06/14)
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.
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.
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.
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.
Ackerknecht, Erwin H.,
A Short History of Medicine,
Baltimore: The Johns Hopkins University Press, 1982
“The History of Cesarean Section,”
Canadian Medical Association Journal,
Vol. 145, No. 4, 1991, pp. 319-322.
Midwives and Medical Men: A History of the Struggle for the Control of Childbirth,
London: Historical Publications Ltd., 1988.
“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.
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.
The Science of Woman: Gynaecology and Gender in England, 1800-1929,
Cambridge: Cambridge University Press, 1990.
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.
The Genealogy of Gynaecology: History of the Development of Gynaecology Throughout the Ages,
Philadelphia: The Blakiston Company, 1943.
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.
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
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.