Monday, February 15, 2010

500 Years of Cesarean History

I'm not sure what the message is in the history of cesareans, but I know there is something important there. Every time I delve deeper into studying the history of surgical birth I sleep better, feel clearer, and have brighter thoughts. So, now I have with a birth history book with two whole post-it packs marking pages in it. (beg's the question- if I put a sticky on every page what's the point of any stickies at all?)

As it's now overdue at the library so I thought I would take another turn at summarizing some of it's amazing depth before I have to give it back. Here is my second installment from:

Not of Woman Born, Representations of Caesarean Birth in Medieval and Renaissance Culture, by Renate Blumenfeld-Kosinski

I'd recommend this book to anyone curious about the politicizing of birth and it traces this origin. Blumenfeld-Kosinski has done a thorough investigation of many ancient documents including early European medical treatises, clerical writing, court proceedings and visual representations. All of which depict a time when birth changed from being seen as an everyday activity done by women, to a time when a birthing women was attended by male medical attendants.

I am going to offer the following notes on Blumenfeld-Kosinski's first chapter titled:

Cesarean Birth in Medical Thought

Early Medieval thought was thick with religious connotations. Sex and birth were linked through the idea of virgin birth, the rejection of sexual pleasure of the clergy, and the belief that procreation was the only way to sanctify the sexual act. Infant and early childhood mortality was high. Birthing took place at home, attended by midwives and was considered a non-medical procedure. Cesareans, in the popular mind, were legends of miracles or whispered tales of horrors and mutilations. Cesareans were thought to be preformed only in the case of maternal death in an attempt to baptize the unborn child. They rarely resulted in a live child.

1100Ad the church was intertwined with everyday medical procedures. Priests preformed surgeries and nuns were often midwives. This changed after the pope warned clerical members from interfering with the ways of the world and body. In 1200AD deacons and priest were formally forbade from practicing surgeries. Lay professionals were the only ones preforming the tasks of surgeons, physicians and midwifes.

In 1236AD The Council of Canterbury decreed that cesareans be preformed in order to baptize an infant if the mother dies. The church was both limiting birth attendants to lay midwifes, but then requiring them to preform the clerical job of baptisms. During the 1300's confusion ruled as to how to insure the child's salvation. Generally, if the child died before the mother, or if it was born live and baptized it was saved, but if it died in it's deceased mother it was dammed. Midwives were forced to be not only birth attendants but also caretakers of the child's immortal soul. If a birth proved deadly for the mother they were charged to cut the baby out at just the right moment, to late and the baby would be already dead and it's soul would be doomed. (Wow, now that's pressure!) Too early and they risked killing the mother needlessly.

1400's brought with it a Renaissance of dissection and medical writings including:

"Lilium" by Bernard of Gordon was the first western medical text that included a written account of a cesarean resulting in a live baby. Bernard gathered advice from "old wives" that the baby can survive for a short time after the death of the mother and can be out of mother live.

1423 Piero d'Argella of Bologna authored "Chirurgia" and writes the first male obstetrical first-person account of a post-mortum cesarean.

In Germany in the mid 1400s Midwifery came under official control for the first time. Many statues to govern their procedures were written.

In 1480 a southern German statute contains the following:
"Many mother's ask, when they feel that they are dying, to liberate the child by an incision. In that case, the skillful midwife has to open up one side and pull out the baby. If the woman is still alive, the wound is to be closed with three or four lignatures, and a plaster of eggs and strong hemp fabric. Give the woman a sip of the best wine, and a drink made of salsifry and mountain albanum. The woman will recover, with God's help."

1513 Eucharius Roesslin wrote
"Der Swangern Frawen und Hebammen Rosegarten" (The Pregnant Women's and Midwives Rose Garden) which contains many instructions for the female midwifes but tellingly directs the instructions for cesarean to male surgeons. Birth has entered the realm of male practitioners through cesarean procedures.

1581 Francois Rousset wrote
Traitte Nouveau de l'Hysterotomotokie. ou enfantement Caesarien
Subtitle:The extraction of the child through lateral incision of the abdomen and uterus of a pregnant woman who cannot otherwise give birth.
Rousset coined the term "enfantement Caesarien" ("cesarean birth"). He named it after the first of the Caesars, Scipio Africanus, who was supposedly born this way(often confused with Julius Caesar who was not born by Caesarean)
This writing was, for it's time, radical as he suggested cesarean birth to be preformed on live women in order to save both mother and child.
His reason for this is that he has gathered case histories from "trustworthy" people who reported witnessing cesareans. He also examined women who had abdominal scars they reported to be from Cesareans. One such case was Anne Godart who is reported to have had 6 cesareans before dying during an attempted 7th birth, because her surgeon had died and no one could do the cesarean.
Roussset witnessed the performance of an operation he himself advised for prolonged labour. a young surgeon made an "incision on the woman's right side just lower then the naval, little blood was shed, and a living child was pulled out and the afterbirth. The wound was closed with 5 stitches. After 40 days of bed rest the woman was well again"
Rousset was passionate about innovation and active intervention in childbirth. He professed that surgeons should be "quick to act" but he was disputed by many who believed that his methods would result in the death of women who would have given birth naturally if given enough time (hmm... the first debate about failure to progress?)

Jacques Marchant was probably Rousset's biggest opponent siting many cases of failed cesarean and coining the term "natural versus unnatural" childbirth. He wrote:

"How can a surgeon plunge his hands into the side of a pregnant woman when there is a natural exit? Better to wait for nature then rush into a desperate and doomed operation"

Despite the debate, abdominal surgeries for bladder stones were being done successfully and it is sure that some cesareans were being done with good outcomes for mother's and babies during this time.

It wasn't until the late 1500s that cesareans were accepted by a broader number of medical professionals and were done in attempt to save both the mother and child. It was during this time that women were formally forbade from handling surgical instruments. This meant that birth,in western culture, had moved totally from women's world into male medical realm.

Blumenfeld-Kosinski sums up this chapter by relating the significance of cesarean procedure in bringing birthing into the realm of male obstetrical practice and away from female birth attendants.

There you have it, my attempt to sum up this extremely complex chapter. I'd guess that I included only about 1/100th of the information contained with in the original work.

I find it particularly telling that cesarean procedures were immediately the subject of great debate as to how they affect the preservation of the body and the salvation of the soul.

I believe that many women who have had cesareans will agree that they are a profound experience that affects their heart, body, and soul.

Another thing that struck me was that successful cesareans were most likely first done by women midwives and only later were they attempted by male counterparts. I wonder how birth would look now if we had been able to have both the world wise women and the book wise men work together instead of becoming adversaries. Instead, this time in history led to the vast persecution of women healers and over 150 000 of them were killed during the witch hunts.
We humans are so counterintuitive on so many levels.

Now I best get this book back to the library, I'm sure there are others wanting to read it (maybe?) I'll try again another time to relate more about it's general themes as they are so profound they keep me thinking.