The changing motives of cesarean section: from the ancient world to the twenty-first century
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- Lurie, S. Arch Gynecol Obstet (2005) 271: 281. doi:10.1007/s00404-005-0724-4
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Cesarean delivery has been practiced for ages, although originally as a universally postmortem procedure. It is referred to in the myths and folklore of many ancient societies, for some of the infants delivered in this way survived, even though their mothers did not. Since the Renaissance, the objective of the procedure has gradually shifted towards saving the lives of both the mother and the child, and this has become ever more possible, as maternal and perinatal mortality and morbidity decreased dramatically during the twentieth century.
Today (at the beginning of twenty-first century), we are not only concerned with the safety and health of the mother and the child, but also with mother’s desires and preferences and the child’s rights.
A dictionary of obstetrics and gynecology defines cesarean section as the “surgical termination of pregnancy or delivery by operative opening of the uterus” . Delivery of a living child after the death of its mother was probably the original medical objective for performing a postmortem cesarean operation, and the procedure is referred to in the myths and folklore of many ancient societies [2–5]. At the same time, the procedure may have had its origins in society’s requirement that a dead mother be buried separately from her dead infant, and thus may have come to have medical implications only when those in attendance noticed that the shorter the interval between the maternal death and the removal of the fetus, the better the chance for the infant’s survival. No ancient writer comments on the optimal time for initiation of a postmortem cesarean aimed at saving the neonate’s life, but a modern study reports fetal survival from a fatal maternal injury, when delivery took place 47 min after maternal gunshot wound injury without resuscitation until 25 min after . Once it was clear to ancient birthing attendants that a live infant might be rescued from its dead mother and survive, the neonate’s removal became the main medical objective for performing a cesarean section. The intention of this manuscript is to show how the indications (i.e., motives) for cesarean section changed from ancient times to the twenty-first century.
The myths of cesarean delivery may be an accurate reflection of normal medical practice in the culture that tells them, or it may be an expression of glorification of a certain hero. The outcome of cesarean section was poor, so that if a newborn sustained the operation, then, certainly, the Gods must have intended for this person an outstanding future. For example, according to Greek mythology, Asclepius, the god of medicine, was born by a cesarean section, after the death of Coronis, his mother . The “surgeon” was Apollo, Asclepius’s father. Also in Roman writings, there are number of heroes who are ascribed to be born by a cesarean delivery. Scipio Africanus, the Roman general who defeated Hannibal, was conceivably born by a postmortem cesarean section in 237 B.C.E. . Gaius Plinius Secundus, known as Pliny the Elder, in addition to Scipio Africanus, notes that first of the Caesars and Manilius who entered Carthage were also born by a postmortem cesarean (Auspicatius enecta [v.l. e necata] parente gignuntur, sicut Scipio Africanus prioir natus primusque Caesarum a caeseo matris dictus, qua de causa et Caesones appellati, simili modo natus et Maniliu, qui Carthaginem cum exercitu intravit.) . The phrase “the first of the Caesars” was misunderstood by latter readers as referring to Julius Caesar. This connection was once thought to be the origin of the name “cesarean operation.” It is incorrect, mainly because, Aurelia, Julius’s mother was still alive when he invaded Britain . Also, Pliny the Elder probably refers to some earlier Julius Caesar, such as Sextus Julius Caesar who was praetor in 208 B.C.E. .
Another example of glorification of a certain hero appears in Persian mythology. Rustam, the most famous hero of the great Persian epic of the kings was conceivably born by a cesarean section . Although not really dateable as a historic person, he lived sometime in the sixth century, and he had served a succession of Persian monarchs: Kay Kobad, Kay Kaus and Kay Khosrau . He also fought many mythical monsters such as the dragon and the White Demon.
“Ibiq-iltum, the son of Sin-magir, adopted the male child, born through cesarean section (lit. pulled out of the womb), the son of the deceased woman Atkasim.”. This legal text, dating to the 23rd year of Hammurabi of Babylon (1795–1750 B.C.E.), is probably the very first documented evidence of cesarean section . The Akkadian expression silip remim (pulled out of the womb) could mean either cesarean section or forceps delivery. The use of obstetrical forceps is not attested until at least the medieval period . Therefore, it is generally presumed that this expression refers to a cesarean section done on a dead or dying mother.
Cesarean section on dead women was probably done by ancient Egyptians . Sage Susruta, who practiced around 600 B.C.E. and is one of the founders of ancient Hindu medicine, refers to a postmortem cesarean delivery in his medical treatise, “Susruta Samhita” . He states that after the mother has died, the operation should be done quickly since a delay may cause the death of the child too.
“Neget lex regia mulierem, quae praegnans mortua sit, humari, antequam partus ei excidatur; qui contra fecerit, spem animantis cum gravida videtur” (“A royal law forbids the burial of a pregnant woman before the child is extracted from the womb <antequam partus ei excidatur>; whoever violates this law is deemed to have destroyed the child’s expectancy of life along with the mother”.) It was Numa Pompilius, an ancient Roman king (716–673 B.C.E.), who issued this ruling in his “ Lex Regia,” the Law of the Kings . This law of Numa Pompilius is, in fact, the very first legal reference that established a postmortem delivery of a child through an incision in the abdomen. Once ancient Rome became the Roman Empire, the “Lex Regia” turned into the “Lex Cesarea.” From this latter designation, the operation of laparotomy and hysterotomy to deliver a fetus may have taken its name, the cesarean section. A passage in Justinian’s “ Corpus Iuris Civilis” refers to Numa Pompilius’s “Lex Regia” (527–565 C.E.) . This passage enables legal postmortem cesarean after the fall of the Western Roman Empire.
Interestingly, although legally enabled in the Roman World, cesarean section does not exist as an option for terminating protracted labor in the most important gynecological treatise of Roman World, the Soranus of Ephesos’s Gynecology (first to second centuries C.E.) [5, 18]. Also, in Greek and Byzantine medical writings cesarean section is not mentioned . One possible explanation could be that as in early medieval period, postmortem cesareans were presumptively performed by the clergy, the priests and not by medical professionals, and therefore does not appear in the Soranus’s Gynecology.
The first reliable evidence that a cesarean section was performed on living women who survived the operation comes from ancient Jewish writings of the Mishna and the Talmud, i.e., second century B.C.E. to the sixth century C.E. . Initially, cesarean delivery was performed on animals  and afterwards on living women with a fair degree of success. A postmortem cesarean delivery was also allowed: “If a woman was in labor and died on the Sabbath, a knife is brought, her abdomen is opened, and the child extracted” . In the Talmudic writings, there is a description of a woman whose first child was born by cesarean section and who subsequently delivered again, probably via the vaginal route: “Neither Yotze dofen, nor the after coming one can receive the rights of primogeniture either concerning property or the payment of redemption fee to the priest; Rabbi Shimon says: ...the first as to inheritance and the second as to five slai’m” . If the parturient necessarily dies during cesarean section then there is no need to announce legal regulation. It is concerned with the fact that these passages are of a theoretical nature, due to the known tendency of the Jewish writings to provide commentaries for even the most unlikely cases and since there is no medical writings to support maternal survival in the ancient Jewish world. It appears, however, that different terminology is used for theoretical and concrete passages in the Mishna and the Talmud. Thus, it is apparent, that the relevant passages use the concrete terminology.
It could be summarized that the objective of cesarean section in the ancient worlds of Mesopotamia, India, Egypt, the Hebrews, and Rome was mainly postmortem delivery of a dead or live child. In some places, there was an additional indication, probably a protracted labor. Unfortunately, no ancient medical documents mentioning the techniques or exact indications for cesarean sections are extant .
By the middle ages, the Catholic Church required execution of obligatory postmortem cesarean section in order to save the soul of the child through baptism . As late as 1749, a Sicilian physician was condemned to death because of his failure to follow this law . It seems that the Parisian archbishop Odon de Sully (1196–1208) was the first church official to recommend a cesarean if the fetus was alive after the death of the mother . In spite of this recommendation, it is apparent that cesarean section as a medical procedure was not performed in medieval Europe before the early fourteenth century . It was Bernard of Gordon, a Montpellier physician who mentions a postmortem cesarean in 1305 . The objective of the postmortem cesarean was the possible rescue of the child.
Another important issue was raised: if baptism was of such paramount importance, whether the imminent death of the mother might be hastened and the mother sacrificed to save her otherwise doomed child? Saint Thomas Aquinas (1225–1274) clearly stated that the mother should not be killed in order to baptize the child .
Islamic religious authorities also favored postmortem cesarean section, as evident from juridical doctrines written by the Imam Abu Hanifah (699–767 C.E.) . In fact, the first known drawing of a cesarean section was done by Al-Biruni (973–1048 C.E.). The drawing exists in a rare manuscript in Edinburgh University Library . Still, there is no evidence of cesarean section in the writings of Albucasis (Abul Qasim Al-Zahrawi, 936–1013), who is mainly famous for his treatises on surgery, “Kitab Al-tasrif li man aiaz an-il-talif” (English: “The Book of enabling him to manage who cannot cope with the complications”) , which was the leading textbook on surgery in Europe for about 500 years.
It could be therefore affirmed that cesarean section in the medieval period was only performed postmortem. In contrary to ancient times, there is no evidence for performing a cesarean section on living women. Thus, cesarean birth in the medieval period was a cultural rather than a medical event.
Renaissance and modern ages
The first documented, authentic, successful cesarean section on a living woman who survived the operation was done by a Swiss sow-gelder by the name of Jacob Nufer upon his wife in 1500 . However, the case is not entirely accepted by some historians because it was not reported until the year 1581. In 1581, Francois Rousset published a revolutionary work with self-explanatory subtitle: “The extraction of the child through a lateral incision of the abdomen and the uterus of a pregnant woman who cannot otherwise give birth. And that without endangering the life of the one or the other and without preventing subsequent fertility” . In this book, perhaps, for the first time, the concept of cesarean birth shifted from being a cultural to a medical event. The indications for cesareans according to Rousset were large fetus, malformed fetus, dead fetus, twins, malpresentation, extremely young or old mother, a too narrow mother, or not elastic enough. In contrary to the medieval objective of a religious context or of saving the child after his mother’s death, these indications reflect the emerging awareness of maternal and fetal safety.
Following Francois Rousset’s reappraisal until the eighteenth century, cesarean sections performed on living parturients resulted in a mortality rate of nearly 100%. This caused enormous opposition against performing a cesarean on a living woman. Francois Mauriceau, the most famous obstetrician of the seventeenth century, stated: “I do not know that there was ever any law, Christian or civil in which both ordain the martyring and killing the mother to save the child” .
The mortality rate attributed to cesarean section in the USA during the nineteenth century, as calculated by Robert Harris, was around 75% . The main reasons for maternal death were “exhaustion,” peritonitis, septicemia, hemorrhage, and eclampsia. The main indication for cesarean delivery was obstructed labor, typically for days with an intrauterine fetal death [32–34]. It appears, therefore, that most cesareans in the nineteenth century were performed in a possible milieu of severe infection, sepsis, and even disseminated intravascular coagulation. With the introduction of improved surgical techniques, asepsis, modern transfusion techniques, and Harris’s principle of early operation prior to possible infection, the mortality rates improved to 0.1% between the years 1943 and 1952 .These factors also permitted the shift toward the modern objective of cesareans, which is directed toward the safety and health of both the mother and the child. A turning point in providing maternal safety was the introduction of the concept of uterine closure toward the end of the nineteenth century . It was Max Sanger in 1882 who insisted that suturing of the uterus is essential . This view was also supported by Kehrer . Prior to Sanger and Kehrer the only reasonable solution to obviating the risk of death from hemorrhage and infection was offered by Eduardo Porro in 1876, who suggested performing a subtotal hysterectomy after delivery of the fetus . According to Porro, the mother’s life was saved at the expense of her future fertility.
It was during the Renaissance times, that the cesarean section emerged as a medical procedure.
The main indications for cesarean section during the twentieth century can be broadly grouped intp protracted labor, non-reassuring fetal heart rate pattern (i.e., fetal distress), malpresentation of the fetus, previously scarred uterus, placental abnormalities with heavy bleeding, and maternal reasons . During the twentieth century, the definitions of each sub-group as well as absolute and relative indications for cesareans have changed dramatically with the introduction of electronic fetal monitoring, scalp pH monitoring, tremendous improvements in neonatal care, and evidence-based medicinal concepts. Edwin Craigin, in 1916, stated the most quoted dictum in obstetrics: “Once a cesarean, always a cesarean” . The dictum was valid as long as the typical cesarean section included a classical (upper-segment) incision in the uterus. With the introduction of the transverse lower uterine segment incision by John Munro Kerr , and recognition that this type of incision is not associated with an excessively high rate of uterine rupture during labor, a trial of vaginal birth after one previous cesarean section became the most accepted policy. Recently, even a trial of vaginal birth following two previous cesarean sections was suggested with a fair rate of success and safety . A recent randomized multicenter trial indicates strongly that a planned cesarean section is to be preferred to planned vaginal birth for the term fetus in the breech presentation with a similar rate of serious maternal complications . The cesarean section became the favorite method of delivery in term breech presentation following publication of this trial. Postmortem cesareans are still performed today and perimortem cesareans have emerged as a variation of this ancient indication .
Finally, toward the end of the twentieth century, two important issues regarding the objective of cesarean section have emerged, namely cesarean section at patients’ request  and forced cesarean . Vaginal birth has been recognized as being potentially traumatic to the pelvic floor with respect to anal [46, 47] and urinary incontinence [47, 48]. An increased rate of post-traumatic psychological stress was associated with vaginal delivery and emergency cesarean section compared with elective cesarean section . Elective cesarean section might be more convenient to doctors and hospitals . There are additional ethical questions that are still disputed. Is a vaginal delivery a medical treatment? If so, then by virtue of the concept of informed consent a woman has a legitimate right to choose between the two treatments, the vaginal and the cesarean delivery. If a woman is refused for cesarean section because there are no medical indications, does that imply that she will have a “forced” vaginal birth? Has a physician the right to refuse to perform a cesarean that is requested by a woman without medical indication? In any case, it appears that at the beginning of the twenty-first century, the focus among practitioners is moving toward supporting maternal choice for delivery [50, 51].
The indications (i.e., motives) for cesarean section have changed tremendously throughout history. In antiquity, the first cesareans were performed as a part of the burial procedure. Then, the indication became postmortem: the child was saved while the mother died. After that, sporadic cases were done where both the mother and the child were saved. In the medieval period, the only indication was postmortem. During the Renaissance, the indications were expanded and reflect the emerging awareness of maternal and fetal safety. Improvements in surgical technique, antiseptic measures and blood transfusion policies at the end of the nineteenth century permitted the shift toward the modern objective of cesareans, which is directed toward the safety and health of both the mother and the child. Finally, at the beginning of the twenty-first century, we are not only concerned with the safety and health of the mother and the child, but also with the mother’s desires and preferences and the child’s rights.