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Monday
Jan192009

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.

 

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Reader Comments (4)

Invisible mother? Invisible parents was more like it. At 37 weeks and healthy, the resident/registrar started talking induction for our normal growth twins. She said that EVERY twin pregnancy was complicated by deadly failure of the placenta, and that we were post-dates. She said our babies would DIE if we didn't agree to induction.

A consultation was scheduled for 38 weeks in which the OB/VMO stated the same "facts" about twins dying from placenta failure. As my body was not ready for induction, she tried to scare me into a c/s. We refused, and made another appointment for a week later to discuss induction again.

I was not able to find any statistics to support what these doctors were saying about twin death in utero, but was greatly pressured by my husband who was so scared by what we had been told that I was seeing tears and hearing pleas every day not to switch care providers.

So, without consent due to lack of information provided on risks, we endured AROM, Syntocinon, epidural, and another unnecessary cesarean for vertex/vertex twins! Failure to progress on the OR forms equates to failure of the OB to practice patience. Failure to provide full information on the risks of any intervention, and then performing the intervention equates assault, battery, and grievous bodily harm.

If you are expecting twins, your Doc will want to induce or section by 39 weeks because of a 2003 study by B. Kahn titled "Prospective Risk of Fetal Death in Singleton, Twin, and Triplet Pregnancies: Implications for Practice" In the study, which is very large so more likely to be accurate, the risk for in utero death of a twin at 40 weeks is 3.09 per 1000. This made our personal risk of death from being overdue less than 1%.

That's right, if you are carrying twins and are being pressured to deliver by or before 39 weeks, your personal risk is less than 1% only one week later at 40 weeks.

Yep, according to the study, we were over 99% likely that everything was just fine! If I had known about this study I never would have allowed induction, but I firmly believe that every family has the right to be informed and make their own decisions concerning statistical risk.

Our personal and parental rights are invisible next to provider dogma which calls for 1000 up to 39 week deliveries of twins just to save 3.09 babies. We are invisible next to provider bias, convenience, and profit. We are invisible next to Big Pharma profits from every drugged delivery and it's aftermath. Our babies are invisible too, seen as units of statistical probability with no concern how a drugged labor or c/s will affect their short and long term health.

All hail the era of Dr. Make-You-Ill!

January 21, 2009 | Unregistered CommenterAnon

The above comment is intended for normal growth twins only. If I could do it again I'd hire an indie middie (independent midwife)

If your babies exhibit TTF, to much or too little amniotic fluid, IUGR, or cord blood flow problems, read up on any medical article you can on your personal diagnosis. It may be that you are being unnecessarily pressured by just being close to the medical parameters for diagnosis. It may also be that you have a genuine problem that necessitates specialist care, so the next step would be to find the best high risk OB available.

By best I mean someone who does nearly 100% LUSCS, double layer uterine closure, and who will guard against adhesions; AND will allow you to watch the surgery if you wish, will place the baby immediately on your chest for as long as you like, will delay cord clamping until the cord has stopped pulsating, and will allow your husband to cut the cord.

January 21, 2009 | Unregistered CommenterAnon

Anon, this is great advice. Very, very well put. Thank you.

January 22, 2009 | Registered CommenterJill

Through no effort on my own I was forced to "shop" for an ob-gyn when pregnant with my twins. My first choice suddenly retired due to a death in her family. My second choice was a mid-wife, but when they learned I was expecting twins they told me my insurance would only cover a regular ob-gyn. By the time I met my 3rd choice I was irritated, I asked him what percentage of twins did he deliver vaginally, and he told me I should probably see dr. x if that was my highest concern. At that point it became my highest concern. When I met Dr.X, she really irritated me, but her attending nurse was like an angel and assured me that no one in town delivered more twin vaginally than Dr. X. At this point I finally figured out that I could just call a doctor's office and ask them about their rate of vaginal births. So I called two docs and both referred me back to Dr. X.
I think fate intervened for me in several ways. I still dislike Dr.X very much, she has a terrible bedside manner as they say, but when it comes to vaginal deliveries she was the best, for twins or singletons. I think she's recently retired (my twins are now 17), or I'd tell everyone her name here.
She did give me pitocin, which in retrospect I did not need and may have contributed to my children's jaundice, but that was before that relationship had been reported and everything turned out okay in the long run. what impressed me was that the 2nd twin hadn't dropped but was still delivered vaginally without hurting any of us. for that i'll always be grateful to her.
My point is that everyone should shop around, even for an ob/gyn. I didn't have the temerity to do that at first, but it happened anyway and my family benefitted. Having articles like this to read may help encourage women/families to do that shopping.
thanks

July 1, 2009 | Unregistered Commentertoriadori
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