Caesarean

Just Another Way of Birth?

Rosemary Mander

• Publisher: Routledge
• Year: 2007
• ISBN:
  9781134144792
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This book critically analyzes the place of caesarean in childbearing at the beginning of the twenty first century. It questions the changes that are taking place in childbirth and, in particular, the effects and implications of an increase in caesarean births.

This controversial work by a practising midwife and researcher, includes discussion of:

• the context of the operation and description of it
• health systems around the world and their caesarean incidence rates
• decision-making and cultural/medical constraints
• the short and long term implications of caesarean for baby and mother.

Using up-to-date research, Rosemary Mander bases her argument on a firm evidence-base and argues that the rapidly rising caesarean section rate may not be for the benefit of either the woman giving birth or her baby. Rather, the beneficiaries may actually be those professionals whose investment is in extending the range of their influence and thus increasing the medicalization of normal life.

1 ‘The game of the name’

Like the origins of the operation itself, the origins of the name ‘caesarean’ are obscure. In an attempt to introduce this all-too-familiar intervention in childbearing, I focus, first, on the word and how it and the operation originally came to be used. I then seek to address the significance of caesarean. This is initially in numerical terms, but it is also necessary to relate caesarean, most importantly, to ‘normal childbearing’ and, then, to intervention in childbearing. I argue that the name which this operation was given may have been crucial to its eventual widespread acceptance.

1 BEGINNINGS

The origins of the caesarean are so shrouded in the mists of myth that speculation is not uncommonly presented as fact. In order to disentangle the mythology from more verifiable reality, I approach the origins by differentiating the words used from the history of the operation. While the history, or versions of it, is relatively well-known, the words have passed into common usage, apparently bypassing any thought processes. Although this distinction between words and deeds may appear artificial, I would argue that there is much to learn from both.

1.1 Terminology

I have borrowed the title of this chapter from Sheahan, who used this phrase to examine the meanings of the term ‘nurse’ (1972). In the same way, the name given to this operation speaks volumes about how it is perceived. Further, the variations in terminology to describe the caesarean demonstrate the variety of interested parties. I attempt here to address the terminology and then justify my rationale for using the term ‘caesarean’.

Before focusing on the word itself, though, I would like to offer a definition in order to clarify the nature of this phenomenon. The caesarean is nothing more or less than the delivery of a viable baby (or babies) via a surgical incision through the muscular wall of the mother’s uterus or womb and the layers which make up the wall of her abdomen. The viability of the baby matters, because an operation before the baby is considered viable would constitute a termination of pregnancy or hysterotomy. In the UK at the time of writing the lower limit of viability is twentyfour weeks’ gestation. The definition which I have offered is useful because there are no assumptions about the ‘intendedness’, the indications for, or the circumstances of the delivery; I use the word ‘delivery’ advisedly here, because of the woman usually being quite passive during the actual operation.

The word’s origins relate to their study, or etymology, which, in the medieval world, was crucial to substantiating theory (Blumenfeld-Kosinski, 1990:143). The identification, or possibly the creation, of etymological links was used to lend authority to otherwise spurious claims to veracity. It was in this slightly questionable intellectual environment that ‘legendary and medical material coalesced’ (1990:144) to bequeath to us the legacy of the myth of Gaius Julius Caesar’s birth in 100 BCE (see below).

The word ‘caesarean’ is more likely, though, to derive from the lex regia (royal law), which had been introduced in the eighth century BCE (Blumenfeld-Kosinski, 1990:145). This legislation required that the baby of a woman dying undelivered should be removed surgically, because the burial of a pregnant woman was expressly forbidden. The rationale for this intervention may be explained in terms of an attempt to, at least, rescue the baby (Lurie, 2005). Trolle, though, is less certain. He argues persuasively that an alternative reason would be to prevent the gruesomely unacceptable possibility of a post-mortem spontaneous birth (1982:16) or ‘coffin birth’ (Boyd, 2003). This disconcerting phenomenon may take place a couple of days or more after the pregnant woman’s death, as a result of the increasing pressure of gases resulting from putrefaction.

The lex regia subsequently became known as the lex caesarea, due to caeso matris utero (to cut from the mother’s uterus). Children born by this route were dubbed caesones (Trolle, 1982:25). As de Costa points out, Julius was not a caesone, but he was one in a long line to bear the name ‘Caesar’. She adds that probably one of his ancestors had been born in this way and that ‘the man was named from the operation, rather than the reverse’ (2001:97). There are, additionally, a number of alternative explanations of the origin of the name, which may relate to hairiness, eye colour or hunting prowess (Trolle, 1982:25).

During the first millennium, surgical skills and interest in Julius Caesar developed alongside each other. The name ‘caesarean’, however, was not actually applied to this surgical operation until François Rousset in France in 1581 used the tautologous phrase, ‘section caesarienne’ (Blumenfeld-Kosinski, 1990:153; Trolle, 1982:28). This term, because of the fashionable hagiography of Julius Caesar, was accepted and soon spread widely. The English version appeared in a translation of Guillemeau’s textbook in 1612. Since that time, presumably in honour of the supposedly eponymous hero, an uppercase initial has often been used. This persists, despite the general acceptance of the mythical nature of the link with Gaius Julius Caesar. Similarly mistakenly, the spelling ‘Caesarian’ is defined as ‘of or relating to or in the manner of Julius Caesar’ (Princeton, 2005).

The mythical link between the operation and the Roman emperor Gaius Julius Caesar is further clarified by a brief examination of another language’s terminology. In the various forms of the German language the operation is consistently referred to colloquially as ‘der Kaiserschnitt’ (Frei, 2005; Quecke, 1952). Literally translated, this means ‘the emperor cut’. Whether the emperor in question is Gaius Julius Caesar is not known. The fact that people in German-speaking countries, however, invariably refer to this person as ‘Kaiser Julius Caesar’ suggests that ‘der Kaiserschnitt’ could relate to any emperor.

In the latter part of the twentieth century, though, in association with the globalisation of obstetrics and the medicalisation of childbearing, new terms became more prevalent. Due mainly to the frequency of this operation’s use on the other side of the Atlantic, the terms ‘cesarean’ and ‘c-section’ have become commonplace. Particularly insidious, though, is the abbreviation of the generally accepted caesarean/cesarean section simply to ‘section’: ‘I had an emergency section with [name of baby] after a prolonged latent phase’ (Helen, 2004).

The term ‘section’, and possibly ‘caesarean section’, serves to trivialise this major abdominal surgery, because ‘section’ means nothing more than ‘cut’ (Oakley, 1983). These terms have been accepted into general usage, as shown in Helen’s words from a website (above). These changes in the words have reduced perceptions of the seriousness of this operation and its inherent risks (please see Chapters 6 and 7). Again, the influence of the North American health care systems may be held responsible. The result is that caesarean is trivialised to such an extent that it is now widely accepted as little more than just another form of birth. For this reason the terms ‘caesarean’, ‘caesarean operation’ or ‘caesarean procedure’ are more appropriate and are the words that I use in this book.

While considering the terminology used here, I should mention that, in this book, I write about the ‘baby’, irrespective of how many are involved. This is to avoid clumsy devices, such as ‘baby/babies’.

1.2 History

The discussion of the origins of the word ‘caesarean’ has given us some clues as to the history of the operation. While I now focus on that history, it is necessary to look, first, at the operation’s fabulous associations. Like Trolle (1982), in order to be faithful to the literature, I avoid using the word ‘caesarean’ for any operation before 1581, when Rousset introduced it. It is necessary to recognise, though, that much of the information available about the history of caesarean is inaccurate to the point of myth (NTUH, 2005; Sehdev, 2005).

1.2.1 Legend and myth and fiction

As I have suggested already, the origins of the abdominal delivery extend beyond history into the realms of mythology. Whether it is possible to disentangle history from mythology is not yet certain. Perhaps because of the innate humanness of giving birth vaginally, the alternative abdominal birth has featured frequently and prominently in the myths and legends of the births of deities. Trolle explains this phenomenon in terms of abdominal birth being ‘the godly way to enter the world’ (1982:9). The Greek gods who arrived by this route include Zeus delivering Dionysus, Apollo delivering Aesculapius and the delivery of Adonis. Brahma and Buddha, in eastern mythology, were born in the same way. Abdominal birth also figures in Roman, Persian, Icelandic, Irish and Danish legends. Perhaps significantly, a number of military heroes have been credited with caesarean birth, including Scipio Africanus, who defeated Hannibal, and Rustam a Persian hero (Lurie, 2005).

It is hardly surprising, therefore, that myths about such a hero as Julius Caesar being delivered abdominally were so easily accepted. That they are myths is evidenced by the fact that at the time of his birth in 100 BCE, abdominal delivery was only performed as a post-mortem operation. Caesar’s mother survived his birth by many years, which is demonstrated by his campaign letters to her. Thus, Julius Caesar could not have been born abdominally.

The benefits, or at least the claims to benefit, of caesarean birth were widely recognised as early as the eighteenth century in England. These heroes born in this way are rehearsed by Tristram Shandy’s fictional father as he seeks to persuade his pregnant wife to submit herself to the surgeon’s knife: ‘These, and many more who figured high in the annals of fame,—all came side-way, Sir, into the world’ (Sterne, 1769:Chapter 19).

Scottish heroic legends include the story of Marjory Bruce, the only daughter of King Robert the Bruce. After a hunting accident in which she was mortally injured, her son was delivered abdominally and went on to become King Robert II. It may be that this story is the basis of Shakespeare’s familiar plot, which features Macduff, who was not ‘of woman born’, prevailing against Macbeth:

And let the angel whom thou still has served

Tell thee, Macduff was from his mother’s womb

Untimely ripp’d.

(Shakespeare, Macbeth, Act V, sc 8.14–16)

So, Shakespeare, like others, represents caesarean as imbuing the person who is born in this way with superhuman powers. The experience of Marjory Bruce may serve to qualify the nature of caesarean as originating as only performed post mortem. Because knowledge of physiology was less well developed, the diagnosis of death may have been less precise. Thus, the operation could have been performed when the woman was either dead or moribund.

1.2.2 The post-mortem operation

The relationship between abdominal delivery and the child developing extraordinary powers occurs too frequently to be ignored. This may be associated with the early Roman legislation, mentioned already, which meant that the operation was invariably performed post mortem. This association may involve the child assuming the spirit of their dying mother or, more prosaically, the need for the motherless child to be extraordinarily talented in order to survive and prosper. Such attributes have been recognised since Pliny the Elder (23–79 CE) wrote in his ‘Natural History’: ‘It is a better omen when the mother dies in giving birth to the child’.

The precise date of the first abdominal delivery is difficult to assess, but the ancient Egyptians are likely to have had the skills to perform the post-mortem operation (Trolle, 1982). Further, there is evidence that the ancient Greeks had also developed these skills by the fourth century BCE, as did the Jews in the second century BCE and, of course, the Romans.

The absence of this operation from any extant literature may be due to physicians’ unwillingness to involve themselves with the low status and potentially polluting work of attending the dead (Trolle, 1982:17). This unwillingness is likely to have been aggravated by the traditionally low status and equally polluting attendance at childbirth. In addition, as Trolle suggests, the physician is more than likely to make himself scarce if death is likely to be the outcome (1982:17)

Although we may assume that abdominal delivery has traditionally been the ultimate ‘rescue operation’, there is the suggestion (above) that this may not have been the case. Regardless of the rationale, it is not possible to be certain of the reality of this ‘rescue operation’ until the Christian church gave the matter its attention. This did not happen until Thomas Aquinas (1225–74) proposed the need for the newborn to be baptised, in order for the soul to achieve eternal life. In this way, the Christian church presented the physician with a role in childbirth and abdominal delivery appeared in the literature in the early fourteenth century. The Council of Trent (1545–63) reaffirmed, through its emphasis on the fundamentality of the sacraments, the importance of the operation that had still to become known as caesarean.

In considering the post-mortem nature of abdominal delivery, I have made the assumption that it was undertaken if the woman was moribund or had actually expired. It is obvious that the baby might survive this operation; King Robert II being but one example. Another royal example of a baby surviving a caesarean was Edward, the son of Jane Seymour and Henry VIII of England. In 1537 his mother survived for eleven days after the birth of the baby who, albeit briefly, became Edward VI. Clearly abdominal delivery had developed into a post-mortem rescue operation. It may be that the woman may not have been actually dead when the operation was begun, but it would be extremely likely that she would be dead by the time the baby was born. These two reasonably well-authenticated examples, however, show that only relatively recently did the baby have a chance of surviving.

Eventually the operation began to be used on the living woman, but this happened only gradually and, to some extent, reluctantly. The Scottish obstetrician William Smellie articulated this reluctance: ‘It is better to have recourse to an operation which hath sometimes succeeded than to leave [the woman and baby] to an untimely death’ (1752:380–4).

The transition from caesarean being a post-mortem operation to one being performed with some hope of maternal, and possibly fetal, survival caused it to become an emergency operation. This means that it would be performed in labour when, particularly, the mother’s life was at risk (Ryan, 2002:462). It was not until much more recently that the possibility of caesarean becoming an elective, that is a planned, intervention materialised.

1.2.3 The caesarean operation on a living woman

The words of the Talmud suggest that Jews, who may not have been surgeons, performed abdominal deliveries in 500 CE, and that the women were alive and survived. Firm evidence, however, is lacking. Similarly, early accounts of operations performed by a lay person or by the woman herself may provide a less than complete picture (Trolle, 1982:29).

Particularly notable or notorious, though, is the tale of Jacob Nufer, a sow gelder in Switzerland at the turn of the sixteenth century. He reputedly ended his wife’s prolonged labour by applying his gelding knife to her abdomen. The mother and baby were healthy, so much so that she enjoyed several more successful and physiological pregnancies. That this operation was not reported until ninety-one years later must call into question its veracity. Even if true, however, the ease of the operation and Frau Nufer’s subsequent childbearing career suggest that this operation was not actually a caesarean. These factors point to the pregnancy having been situated in the abdominal cavity rather than the uterus (Ainsworth, 2003). This means that, according to the above definition, this could not have been a caesarean, even if the word had been in use at the time. Other examples of ‘untrained’ people performing abdominal deliveries figure prominently in the literature, suggesting that this operation is not a uniquely medical intervention.

As well as deliberate operations, traumatic abdominal deliveries have been reported (Trolle, 1982:32). Such deliveries feature surprisingly low mortality rates, presumably because of the healthy fetal and maternal condition at the time of the accident.

1.2.4 Factors influencing the historical use of caesarean

As mentioned already the caesarean gradually came to be performed by experienced and/or trained personnel on women who were neither dead nor dying. Surgeons were most likely to perform the operation, although midwives occasionally did so. The poor outcomes (see below), particularly for the mother, gave rise to serious debates about the precedence of maternal life or infant life in emergency situations. These debates resulted in the very different attitudes to caesarean on either side of the English Channel. Whereas the French would be prepared to risk sacrificing the mother in the interests of the survival of the baby, the British were much more reticent about the use of this seriously life-threatening intervention (Churchill, 2003). Although European authors are rather coy about suggesting the influence of religious orientation on historical enthusiasm for the caesarean operation, in America the religious debate was quite explicit (Ryan, 2002). The condition of the mother’s and the baby’s eternal soul, though, may have had more than a little influence on caesarean decisions.

The most common scenario in which caesarean would be considered would be if the mother and baby were both alive and labour had become obstructed. A frequent cause of obstruction would be cephalo-pelvic disproportion associated with contracted pelvis (de Costa, 2001:98) due to disease, such as childhood rickets (Ryan, 2002). In such a scenario, the alternatives to either caesarean or maternal death included a range of, to modern minds, repugnant interventions. The first group of which became known euphemistically as ‘destructive operations’ (Garrey et al, 1969:454). These included:

1. Craniotomy, involving the destruction of the fetal skull in order to allow it to pass through the birth canal. This could be by crushing, or by perforation using some kind of scissors (Ryan, 2002:464), or possibly a combination of the two (Churchill, 2003:26).
2. Embryotomy, comprising the destruction and removal of the baby’s body, possibly after the fetal skull had been reduced by craniotomy (Ryan, 2002:464). Instruments such as the ‘hook’ and the ‘crochet’ would have been used.

As well as destroying the baby, though, these interventions invariably damaged the mother.

The application of obstetric forceps, unlike the ‘hook’ or the ‘crochet’, at least carried the potential to deliver the baby alive. The risk to the mother of trauma, haemorrhage and infection tends to have been disregarded as does injury to the baby. These forceps were intended to be applied in a situation of a marginally contracted pelvis or in a case of dystocia or uterine inertia.

In cases of contracted pelvis giving rise to cephalo-pelvic disproportion, interventions to enlarge the bony pelvis have, as an alternative, been variably fashionable. These operations vary in their approach, but are named according to the structure being divided to enlarge the pelvis (Churchill, 2003:24).

1. Symphysiotomy is a form of pelviotomy in which the cartilaginous joint in the anterior part of the pelvis is divided (Skippen et al, 2004). The success rate of this intervention was dire as: ‘Approximately a third of mothers and two thirds of children died after the operation’ (Skippen et al, 2004:59). Although some may still favour this operation and regard it as lifesaving (Bjorklund, 2002: Wykes et al, 2003), women who have experienced it appear to hold a different view (SOS, 2002).
2. Pubiotomy comprises the division of the pubic bones (Comer, 1921).
3. Hebeosteotomy is another form of pelviotomy which involves ‘cutting the pubic bone just lateral to the symphysis pubis’ (Wenger, 2000:276).

T...

Table of contents

• Cover Page
• Caesarean
• Title Page
• Copyright Page
• Acknowledgements
• Introduction
• 1 ‘The game of the name’
• 2 What are the questions and who’s using the answers? Research into caesarean
• 3 The caesarean operation – issues and debates
• 4 International matters
• 5 Caesarean decision making – who’s choosing the choices?
• 6 The immediate implications of caesarean
• 7 The long-term implications of caesarean
• 8 The significance of trial of labour and VBAC (vaginal birth after caesarean)
• 9 Conclusion
• References