Scot Mcd J 1991; 36: 150-154
0036-9330/91/05791/150 $2.00 in USA (c) 1991 Scottish Medical Journal
CAESAREAN SECTION: HISTORICAL BACKGROUND EM Hillan Department of Nursing Studies, University of Glasgow, Glasgow G12 8QQ
Abstract: Although caesarean section is probably one ofthe oldest operations in the history ofmedicine, its origins are rather obscure. Very few surgical procedures have been the subject ofsuch bitter controversy, and, it is only in relatively recent times that its performance changedfrom a last minute attempt to save a child from an almost dead mother to a safe, often planned, operation.
U
NT IL recent decades caesarean section was usually used as a last resort because of the high maternal mortality and morbidity associated with the operation. The introduction of antibiotics and blood transfusions as well as markedly improved anaesthetic and surgical techniques overcame the problems of shock, sepsis and haemorrhage often associated with caesarean delivery and it came to be used much more frequently in obstetric practice. The last published figures from the Unit'id States show that the caesarean section rate in 1986 was 24.1 %. Although the incidence of caesarean delivery is lower in Scotland than th~ USA, 13.6% of women were delivered by this method in 1987. Interest in caesarean delivery is not confined to modem times, surgical delivery of the unborn child from its mother has been mentioned from antiquity onwards. Religious laws of Egypt in 3000 BC and ofIndia in 1500 BC required abdominal delivery of the fetus from its dead mother. Mythology also has tales of caesarean delivery with the Greek god of sleep, Asclepius, supposedly having been delivered by this ~ethod when his father, Apollo, 'cut' him from the dying Coronis. Caesarean section was also known to the early Jews. The Mishnah (140 BC) states that: "in the case of twins, neither the first child which shall be brought into the world by the cut in the abdomen. nor the second. can receive the right ofprimogeniture, either as regards the office ofpriest or succession to property". Mention of abdominal delivery is also made in the Talmud, a book of Jewish law dating from 400 AD, which states that a women need not obs~rve the usual days of purification following this type of delivery. In these times the operation was carried out after the woman died in late pregnancy in the hope of saving the child.
Origin of the term 'caesarean section' Roman history referred to abdominal delivery as 'a caeso matris utero' in the century before the birth of Christ. Many erroneously believe that the term originated from Julius Caesar being born this way. This, however, is unlikely to be the case as it is known that Caesar's mother, Aurelia, lived for many years after his birth in 100BC - and there are no [ecords of maternal survival after surgical delivery at this time. Another explanation as to the origin of the term is that the King of Rome, Numa Pompilius, codified Roman Law in 715 Be. Part of this Lex Regia, which became the Lex Caesarea under the rule of the emperors, made it mandatory that in the event of a pregnant woman dying the child must be removed from the uterus, even if there was ~o chance of its survival, so that it could be buried separately. Pliny (28-70 AD) in Book VII of his 'Natural History' suggests that the term was derived from the Latin verb 'caedare' which means 'to cut' and therefore implies delivery by cutting. Children delivered f~m their dead mothers in this way were known as 'caesones' . The first author to use the term 'section' in connection with the operation was Jaques Guillimeau in his textbook on midwifery which was published in 1598. However, the term caesarean operation was more frequently used and it was only during the twentieth century that it was replaced by the more familiar
caesarean section. It is also unclear what instruments were used in the early operations. The first caesarean section may have been performed with a sword as this weapon was sometimes used to open the abdomens of 'women big with child' after town and cities were captured in battle. It is said that the King of Syria, Hazail of Damascus, ordered his soldiers to carry out such atrocities on their Jewish captives almost 2800 years ago. 4 Some caesarean deliveries occurred when pregnant women were gored by the horns of an animal such as a bull or cow. The earliest documented case occurred in 1647 in Holland. The wife of a farmer in Zaandam was tossed by a bull in the ninth month of pregnancy and "sustained an incision into the abdominal wall, which stretched from one ischium to the other, and through the pubic bone in the shape of a crescent. She had another wound through skin and peritoneum into the uterus, twelve finger breadths in length.from which the child issued". The child escgped with minor bruising, although the woman died 36 hours later. In summarising the current status of the operation in 1879, Harris observed that a woman in labour had a 50% chance of survival if she performed the surgery herself or was gored by a bull compare9 with a 10% survival rate if attended to by a New York surgeon. The first record of maternal survival following caesarean section relates the tale of Jacob Nufer, a Swiss pig-gelder (pork butcher) who in 1500 was said to have performed the operation on his wife with a razor as she lay on the kitchen table. The reasons why Mrs Nufer failed to progress in labour are unclear, but a total of 13 midwives are said to have been called to assist her without success. Not only is the woman reputed to have survived but she went on to deliver five more children, including a set of twins, vaginally. Some doubt has been cast on the authenticity of this account as it was not published until 1582 and is therefore based on the hearsay of three generations.
Religious influences In the Middle Ages, Christianity influenced obstetric decision making. The Roman Catholic church encouraged the use of caesarean deliveries to offer the souls of unborn children the chance of salvation through baptism. At the same time it barred the use of abortion, craniotomy and fetal dismemberment as techniques to deliver the child in order to save the mother. Other church councils sanctioned the use of the operation on dead pregnant women principally in an attempt to save the child but also to allow baptism of the infant. The surgery was made mandatory by the church councils of Cologne (1280) (which also stated that the dead woman's mouth and vulva must be kept open so that the fetus in utero would not suffocate whilst awaiting surgical delivery), Langres (1404) and Scns (1514). The senate of the Republic of Venice laid down severe penalties for any doctor who failed to make an attempt to save a child in this way (1608). During the Franciscan mission period (1769-1833) in the United S tares, the operation became the responsibility of the missionary priest who attended the dying mother. Priests were given details of the relevant maternal anatomy, actual procedure and
150
Downloaded from scm.sagepub.com at Bobst Library, New York University on May 20, 2015
Caesarean section: Historocal background
Hillan
instruments required to assist them in their task. 5 The obsession with baptism of infants was especially seen in France. Peu in his 'Practique des Accouchements' published in 1694, described in great detail how baptisw was to be accomplished in operative deliveries. Radcliffe paraphrases Peu's method for caesarean deliveries thus: "He advises immediate opening of the abdomen as soon as the mother is assuredly dead and within the space of time taken to say one 'A ve maria', and as soon as the child is visible, pouring water over it and adding to the usual words of baptism, 'si tu as vie'. Although Islamic law is interpreted more liberally nowadays, Islam forbids the performance of caesarean section and directs that any child born this way should be slain as it is the offspring of the devil. Royal deliveries King Robert II of Scotland was supposed to have been delivered abdominally in 1316. His mother, Marjorie Bruce, was returning from Paisley Abbey and was thrown from her horse fracturing her neck in the process. One of the people in her retinue, Sir John Forrester, had some elementary surgical skills and was entrusted with the delivery by caesarean section. The child was delivered alive but sustained an eye injury in the process. The resultant corneal and scleral scarring earned Robert the nickname 'King Bleart The birth was commemorated in Renfrew by a wooden cross. Jane Seymour, the 3rd wife of Henry VIII, is said to have been delivered by caesarean section after two days of 'the most difficult labour'. She died 12 days later on the 24th October 1537. Although the labour started spontaneously, progress was slow and after 24 hours the cervix had only dilated to 5-6 centimetres. The obstetrician in charge, Dr Owen, is said to have consulted with Henry VIII and told him that either craniotomy or caesarean section would be required to terminate the protracted labour. Henry, keen for a legitimate male heir to the throne, is said to have directed the doctors to ;~:~~,:.ie life of the child, for another wife can easily be It is unclear whether the son, Edward VI born sometime after midnight on the 12th October, was delivered vaginally or by caesarean section. The evidence against a caesarean delivery is based on two premises. Firstly, there is no written evidence in existence which mentions an operation and secondly itis unlikely that Jane could have lived until the 24th of October because at that time the uterine incision was not sutured making death almost inevitable from either haemorrhage or infection. On the other hand it is just possible that she might have lived for 12 days ultimately succumbing to peritonitis. At that time, Hampton Court was isolated from the rest of the country because of the plague and the operation could have been performed with little public or written knowledge. Certainly Henry's desire for a male hair was well documented and he had already shown how ruthless he could be by ordering the execution of his previous wife Anne Boleyn. It was a lesser act to sacrifice Jane for a son. Caesarean section in the United Kingdom The first caesarean section in Great Britain on a living patient took place on 29th June 1737 and is described in Srroellies 'Treatise on the Theory and Practice of Midwifery'. The operation was carried out by an Edinburgh surgeon, Mr Smith, on a woman who was 'prodigiously deformed' . Her pelvic deformity was due to a disease known at the time as 'malacosteon' or 'mollites osseum' which was due to calcium deficiency in pregnancy. The woman had been in labour for six days when Smith was called to see her. On examination he found that the space between the pubis and the sacrum, was only 1.5 to 2 inches making delivery with a crochet impossible. In consultation with other doctors it was decided to carry out a caesarean section.
Smith performed the surgery and delivered a stillborn child. The mother herself died 18 hours later. In the same book Smellie describes the first maternal survival following caesarean delivery in the United Kingdom. The surgery was performed by an Irish midwife, Mary Donally, on Alice O'Neale, a farmer's wife, in 1738. Mrs O'Neale had been in labour for 12 days and several other midwives had attempted unsuccessfully to deliver her. Donally 'an illiterate women but eminent among the common peoplefor extracting dead births', was sent for. She tried without success to deliver Mrs O'Neale by the vaginal route. Using a razor to open the abdominal wall and the uterus, she delivered the dead child and placenta. She then 'held the lips of the wound together with her hand till one went a mile and returned with silk and the common needles which tailors used' . The wound was then sutured and dressed with egg-white. Mrs O'Neale survived and within a month was able to walk a mile although she subsequently developed a large ventral hernia. Smellie's book, published in 1752, became a classic British text-book on midwifery. Although Smellie's personal experience of caesarean section was limited to three cases of post-mortem delivery in a futile attempt to save the child, he took a pragmatic stance on the performance of the operation: "When a woman cannot be delivered by any ofthe methods hitherto prescribed and recommended in laborious and preternatural labours, on account of the narrowness or distortion of the pelvis into which it is sometimes impossible to introduce the hand; orfrom large excresences and glandular swellings thatfill up the vagina and cannot be removed; orfrom large cicatrices and adhesions in that part and at the os uteri which cannot be separated; in such emergencies, if the woman is strong and ofgood habit of body, the caesarean operation is certainly advisable and ought to be performed; because the mother and child have no other chance to be saved, and it is better to have recourse to an operation which has sometimes succeeded than leave them both to inevitable death . . . Nevertheless, if the woman is weak, exhausted with fruitless labour, violentfloodings or any other evacuations, which renders her recovery doubtful, even if she were delivered in the natural way; in these circumstances, it would be rashness and presumption to attempt an operation of this kind which ought to be delayed until the woman expires and then immediately performed with a view to saving the. child." Despite the fact that Smcllie.'s textbook was widely used, caesarean section did not gain popularity in Great Britain until much later, no doubt due to the appalling maternal mortality associated with the operation. The first documented case of maternal survival did not occur until 1793. The operation was carried out by James Barlow, a surgeon in Lancashire. The woman, Jane Foster, was around 40 years of age and already had several children. An accident on her return from Wigan market, resulted in her pelvis being crushed underneath the wheel of a loaded cart. She became pregnant shortly afterwards and when labour commenced the usual midwife was called. After several days the midwife in attendance decided to summon help from a Mr Hawarden. On the fourth day Hawarden called in Barlow for a consultation. After a thorough examination Barlow concluded that vaginal delivery was impossible and decided to perform, with great reluctance, a casearean section. The operation was carried out on a ,table and th; patient had a slow, but uneventful postoperauve recovery. It was almost another 40 years before a further successful operation was performed in England, six others were carried out in the interim but the mothers always perished. Throughout the nineteenth century caesarean section was performed with increasing regularity in Europe but in Britain obstetricians 151
Downloaded from scm.sagepub.com at Bobst Library, New York University on May 20, 2015
Caesarean section: Historical background
remained reluctant to use this method of delivery. Thomas Radford in his 'Observations on Caesarean Section' published in 1880 recorded 131 operations in Great Britain and Ireland between 1737 and 187§. Only 23 women survived making the maternal mortality 83%. No doubt due to the number of deaths associated with the operation, obstetricians were much opposed to its use and preferred to use it only as a last res0I!' Other forms of manipulative delivery were more often utilised. These included: 1. Podalic version and extraction (Pare)
2. Forceps delivery (Chamberlain) 3. Premature induction of labour for women with small pelvises 4. Fetal destruction (craniotomy) An indication of the prevailing conservative attitude in obstetrics is seen in the management ofa royal delivery. In 18 I7 four doctors attended the labour of Princess Charlotte of Wales: Sir Richard Croft (obstetrician), Dr John Sims (consultant), Dr Matthew Bailley (Royal Physician) and Sir Everard Home (Royal Surgeon). Charlotte was the only daughter of the Prince Regent (later King George IV) and was herself next in line to the throne. The labour started spontaneously but progress was slow. After 26 hours the cervix was almost fully dilated but Croft was reluctant to intervene with forceps until he consulted with Sims. Five hours later Sims arrived but refused to see or examine the patient, choosing to wait in an adjoining room in case an instrumental delivery became necessary. After 50 hours of labour, including 24 hours in the second stage, a still-born male child weighing9lbwasdelivered. The third stage of labour was delayed and as Charlotte had begun to haemorrhage, Croft proceeded to remove the placenta manually. Her condition deteriorated and despite attempts to resuscitate her she died seven hours after delivery. Although from a modem obstetric perspective, Croft's mistakes in the handling of the case are obvious, by the standards of the time he acted correctly. The most respected obstetric text-book of the era - Denman's 'An Introduction to the Practice of Midwifery' - stated that "A practical rule has been found that the head ofthe child shall have rested for six hours as low as the perineum before the forceps are applied although the pains should have ceased during that time". Similar restrictive rules applied to the conduct of the third stage of labour and Croft merely adhered to them, The death of the princess and her son was mourned by the nation. Lord Byron was so moved that he inserted six verses about it in the almost completed 'Fourth Canto of Childe Harold'. The loudly voiced public criticism of his handling of the case drove Sir Richard to commit suicide three months later. The course of history was changed by these events - with no direct heir to the throne, it led to the eventual accession of Queen Victoria. It also mar~ed a .turpling point in obstetrics away from non -10 tervcnuon. Developments in Glasgow By 186hthe population in Glasgow had risen fourteen fold to 395,503. The small town had become a large industrial city and in the transition, a serious housing problem developed which brought with it ill-health and disease. The combination of poor housing, inadequate diet and industrial pollution resulted in large numbers of children developing rickets. Rickets can result in serious pelvic deformities which in turn leads to difficulties in childbirth. The Glasgow Maternity Hospital statistics for the ten year period from 1889-98 reflect the problems of the contracted pelvis. Of the 4322 cases attended during. this time, around one in four of the women required operative mtervenuon and approximately 10% had gross pelvic
Hillan
contraction. If such contraction was present then the obstetrician had two choices - either to carry out a destructive operation on the ~etuHo effect delivery (craniotomy) or to perform a caesarean
secuon.
As in other parts of Britain, the obstetricians in Glasgow Maternity Hospital only considered caesarean section as a last resort. George Buchanan, the hospital's consulting surgeon, performed two sections in 1879 and 1881 which saved the two babies concerned but not their mothers. The cases prompted a discussion on 'The Contracted Pelvis' in 1881 which was chaired by Buchanan. The obstetricians involved failed to agree on the merits of casearean section aga~st craniotomy and the procedure was abandoned in the hospital. Interest in the subject was revived by Dr J S Nairne in 1887. He presented a paper arguing that the mortality associated with caesarean section could be reduced if obstetricians actively sought solutions to the problems attached to the operation. He urged his colleagues to attempt surgery in preference to cranio\9my or where attempt at delivery with long forceps had failed. By this time other advances in medicine made caesarean section a feasible alternative to craniotomy. Effective anaesthesia was available for the first time and the concept of surgical asepsis, originated by Lister in 1865, dramatically reduced the number of surgical deaths associated with infection. Obstetricians quickly recognised the value of these surgical advances. On April 10th 1888, C.C. a 27 year old primigravida, was admitted to Glasgow Maternity Hospital. Murdoch Cameron in his p~IJCr published in the British Medical Journal of January 26th 1889 described her as: ".. a little woman (height 49 inches) somewhat delicate, and with the appearance of a patient deformed by rickets in a very marked degree" Cameron in consultation with Drs Sloan, Reid, Oliphant and Black agreed that the conjugate of the brim was not more than 1.5 inches and that caesarean section was the only solution. With the
Fig.l The first three cases of successful caesarean section in Glasgow Royal Maternity Hospital.
152
Downloaded from scm.sagepub.com at Bobst Library, New York University on May 20, 2015
Caesarean section: Historical background
Hillan
patient safely anaesthetised by chloroform and ether, Cameron assisted by Reid operated and delivered a healthy male child weighing 61b 120l. The operation lasted for approximately 50 minutes. Further details of the celebrations following this first successful case of caesarean t'fction in Glasgow are given in Dow's book 'The Roucnrow'. He tells how Cameron's house surgeon produced a bottle of champagne on the 4th day and invited Cameron, Miss Gordon (the matron) and the mother to join him in a toast to the baby's health. The mother was unimpressed with the unfamiliar taste of champagne and asked for some 'guid soor dook' (buttermilk) instead. The patient made a slow but steady post-operative recovery, no doubt aided by the regular administration of enemas. She was allowed out of bed on the 24th day and was finally discharged home 36 days after the operation. By this time the baby weighed 81b 120z and was christened Caesar Cameron. The second successful section was carried out just over a year later on May Sth 1889. This time the patient was an 18 year old primigravida also suffering from marked rickets. She was only four feet tall and the true conjugate of the pelvis was estimated to be one inch. This time the patient's ovaries were tied with silk to ensure that no further pregnanci § occurred. Again the 1 post-operative course was uneventful. A further successful caesarean operation quickly followed on a rachitic dwarf who had failed to progress after several days in labour. On this occasion the woman was unmarried and on hearing of this, Cameron promptly arranged her wedding to the father of thf1 child with the other two patients acting as bridesmaids. (Fig 1) Cameron went on to perform a total of 10 caesarean sections hetween 1888 and 1890 without loss of mother or baby. A Lancet leader in 1889, commenting on this remarkable success, stated that: 'This is a condition ofaffairs which probably could not be paralleled in any other hospital in the world." Cameron also received the following tribute from Lister: Portland Place 10 Park Crescent 9th March 1891 Dear Dr Cameron I have read with much interest the report in the British Medical Journal of your remarkable series of caesarean sections. I congratulate you heartily on your success which is, as far as I know quite unparalleled. The various points that you mention seem as important as they are simple . . . Believe me. Yours very sincerely, Joseph Lister Murdoch Cameron (Fig 2) became Rcgius Professor of Midwifery in 1894 and remained so until 1927. The technique of classical caesarean section was further refined by his son, Sam, who became his assistant and later Itfllowed his father as Regius Professor between 1934 and 1943. Development of surgical techniques In 1870, although more commonly employed, caesarean section was still associated with an appalling maternal mortality of 75%. Death was usually due to either shock, sepsis or haemorrhage or a combiruuion of these factors.
Fig.2 Murdoch Cameron. Regius Professor of Midwifery (1894-1927) Although the danger of infection was appreciated there remained the dilemma of how to control it. In an effort to overcome this an Italian obstetrician, Eduardo Porro in 1876 devised a new operative technique. This involved caesarean delivery followed by amputation of the uterus at the internal os together with the adnexa and marsupialization of the cervical stump into the lower end of the abdominal wound. This ensured that the focus of infection, the uterus, was removed and that any drainage was complete. It also meant that the~ was no opportunity for continued intra-peritoneal bleeding. The Porro caesarean hysterectomy technique brought about a considerable reduction in maternal mortality through control of haemorrhage and a reduction in the risk of infection, but had however only a short period ofpopularity due to being superseded by the operations of Kehrer (1881) and Sanger (1882). Both advocated the new step of suturing the uterus in layers prior to wound closure. Before this uterine suturing was only performed to control bleeding vessels as it was gcrcraJly believed that such sutures were superfluous and harmful. These two operations together with other medical advances in anaesthesia and antisepsis reduced the maternal mortality assoicatcd with the operation to between 6 and 10%. If infection did develop however, the mortality rate remained high.
The lower uterine segment approach Johnson in his book 'A New System of Midwifery' (2nd Edition) published in 1786, was the first person to suggest that the uterine incision should be made transversely in the lower segment. This stemmed from his observation of how little haemorrhage had occurred in two cases of ruptured uterus where the rupture had occurred in the region of the lower segment. The operation however was not carried out until 1881 by Kcher, Benjamin Osiander (1805) also devised a lower segment approach although he advocated a vertical incision. Kronig's technique (1912) 153
Downloaded from scm.sagepub.com at Bobst Library, New York University on May 20, 2015
Caesarean section: Historical background
Hillan
developed peritoneal flaps although he still incised the lower segment vertically. This procedure was brought to the ~Tnited States by Beck (1919) and popularised by De Lee (1925). It was another of Murdoch Cameron's pupils, John Martin Munro Kerr, who went on to popularise the lower segment approach for caesarean section. His contention was that the scar, particularly if transversely placed, would be stronger and therefore less likely to rupture in a subsequent pregnancy. Although Munro Kerr first used this approach in 1911, it wasn't until the 1940s that there was widespread acceptance of it as the superior mfJhod. The 9th edition of 'Munro Kerr's Operative Obstetrics' described the final acknowledgement of Munro Kerr's technique. It came at the 12th British Congress of Obstetrics and Gynaecology held in London in 1945. Several obstetricians had presented papers with convincing evidence of the reduction in maternal mortality related to caesarean section, but all failed to mention that one of the major factors associated with the fall was the adoption of the lower segment approach. When Munro Kerr was invited to the platform to comment, he acknowledged the speakers and surgeons whose work had been quoted and finally pointed out that for almost the first time ever the lower segment approach had been referred to in nothing but words of praise at which point he broke off, threw his arms in the air and exclaimed: "Alleluia! The strife is 0' er, the battle done!" The transverse incision remains the most common and preferred method for caesarean section. This type of incision has the lowest incidence of haemorrhage at the time of operation and the lowest incidence of rupture in subsequent pregnancies. It is also thought that due to reperitonealization the incidence of intra-abdominal infections and development of adhesions is reduced. Today classical caesarean section, a vertical incision in the uterine corpus, is rarely performed due to its association with greater blood loss and an increased incidence of infection. The only indications for its performance are when the lower segment
is not formed, as in delivery of a very preterm fetus; where there are problems related to the fetal position, such as an impacted shoulder presentation; in cases of cervical carcinoma; or where fibroid tumours obscure the lower segment. REFERENCES I Placek PJ, Taffel SM, Moien MS. 1986 c-sections rise; VBACS inch upward. Am J Pub Health, 1988; 7: 562-3. 2 Information and Statistics Division. Hospital and Health Board comparisons in obstetrics - 1985-1987. Edinburgh: Common Services Agency, 1989. 3 Brian VA. The deepest cut of all. Nursing Mirror, 1976; 143: 68-9. 4 Young JH. Cesarean Section: the history and development of the operation from earliest times. London: HK Lewis & Co Ltd, 1944. 5 Rosen MG. Caesarean Childbirth: report of a consensus development conference. Bethesda Maryland: National Institute of Health, 1981. Nlll Publication no. 82-2067. 6 Harris RP. Cattle-hom lacerations of the abdomen and uterus in pregnant women. Am J Obstet (NY), 1887; II: 673-85. 7 Harris RP. Remarks on the cesarean operation. Am J Obstet (NY), 1879; 11: 620-6 8 Radcliffe W. Milestones in Midwifery. Bristol: John Wright and Sons Ltd, 1967. 9 Green GH. A Tudor Caesarean section. Surgery, Gynecol and Obstet, 1985; 161: 490-6. 10 McLintock AH (ed). Smcllic's Treatise on the Theory and Practice of Midwifery: Vol III. London: New Sydenham Society, 1876,230-5. 11 Hellman LM. Three deliveries that changed the history of the world. JAOA, 1974; 73: 93-108. 12 Willocks J, Calder AA. The Glasgow Royal Maternity Hospita11834-1984 150 years of service in a changing obstetric world. Scot Med J, 1985; 30: 247-54. 13 Dow DA. The Rottenrow. Lanes: The Parthenon Press Ltd, 1984. 14 Cameron M. The caesarean section: with notes of a successful case. BrMed J, 1889; Jan 26th: 180-3. 15 Cameron M. Remarks on caesarean section, with notes of a second successful case. Br Med J, 1890; March 15th: 583-5. 16 Moir JC, Myerscough PR (eds). Munro Kerr's Operative Obstetrics (9th ed). London: Bailliere Tindall and Cassell, 1971.
154
Downloaded from scm.sagepub.com at Bobst Library, New York University on May 20, 2015
0036-9330/91/05791/150 $2.00 in USA (c) 1991 Scottish Medical Journal
CAESAREAN SECTION: HISTORICAL BACKGROUND EM Hillan Department of Nursing Studies, University of Glasgow, Glasgow G12 8QQ
Abstract: Although caesarean section is probably one ofthe oldest operations in the history ofmedicine, its origins are rather obscure. Very few surgical procedures have been the subject ofsuch bitter controversy, and, it is only in relatively recent times that its performance changedfrom a last minute attempt to save a child from an almost dead mother to a safe, often planned, operation.
U
NT IL recent decades caesarean section was usually used as a last resort because of the high maternal mortality and morbidity associated with the operation. The introduction of antibiotics and blood transfusions as well as markedly improved anaesthetic and surgical techniques overcame the problems of shock, sepsis and haemorrhage often associated with caesarean delivery and it came to be used much more frequently in obstetric practice. The last published figures from the Unit'id States show that the caesarean section rate in 1986 was 24.1 %. Although the incidence of caesarean delivery is lower in Scotland than th~ USA, 13.6% of women were delivered by this method in 1987. Interest in caesarean delivery is not confined to modem times, surgical delivery of the unborn child from its mother has been mentioned from antiquity onwards. Religious laws of Egypt in 3000 BC and ofIndia in 1500 BC required abdominal delivery of the fetus from its dead mother. Mythology also has tales of caesarean delivery with the Greek god of sleep, Asclepius, supposedly having been delivered by this ~ethod when his father, Apollo, 'cut' him from the dying Coronis. Caesarean section was also known to the early Jews. The Mishnah (140 BC) states that: "in the case of twins, neither the first child which shall be brought into the world by the cut in the abdomen. nor the second. can receive the right ofprimogeniture, either as regards the office ofpriest or succession to property". Mention of abdominal delivery is also made in the Talmud, a book of Jewish law dating from 400 AD, which states that a women need not obs~rve the usual days of purification following this type of delivery. In these times the operation was carried out after the woman died in late pregnancy in the hope of saving the child.
Origin of the term 'caesarean section' Roman history referred to abdominal delivery as 'a caeso matris utero' in the century before the birth of Christ. Many erroneously believe that the term originated from Julius Caesar being born this way. This, however, is unlikely to be the case as it is known that Caesar's mother, Aurelia, lived for many years after his birth in 100BC - and there are no [ecords of maternal survival after surgical delivery at this time. Another explanation as to the origin of the term is that the King of Rome, Numa Pompilius, codified Roman Law in 715 Be. Part of this Lex Regia, which became the Lex Caesarea under the rule of the emperors, made it mandatory that in the event of a pregnant woman dying the child must be removed from the uterus, even if there was ~o chance of its survival, so that it could be buried separately. Pliny (28-70 AD) in Book VII of his 'Natural History' suggests that the term was derived from the Latin verb 'caedare' which means 'to cut' and therefore implies delivery by cutting. Children delivered f~m their dead mothers in this way were known as 'caesones' . The first author to use the term 'section' in connection with the operation was Jaques Guillimeau in his textbook on midwifery which was published in 1598. However, the term caesarean operation was more frequently used and it was only during the twentieth century that it was replaced by the more familiar
caesarean section. It is also unclear what instruments were used in the early operations. The first caesarean section may have been performed with a sword as this weapon was sometimes used to open the abdomens of 'women big with child' after town and cities were captured in battle. It is said that the King of Syria, Hazail of Damascus, ordered his soldiers to carry out such atrocities on their Jewish captives almost 2800 years ago. 4 Some caesarean deliveries occurred when pregnant women were gored by the horns of an animal such as a bull or cow. The earliest documented case occurred in 1647 in Holland. The wife of a farmer in Zaandam was tossed by a bull in the ninth month of pregnancy and "sustained an incision into the abdominal wall, which stretched from one ischium to the other, and through the pubic bone in the shape of a crescent. She had another wound through skin and peritoneum into the uterus, twelve finger breadths in length.from which the child issued". The child escgped with minor bruising, although the woman died 36 hours later. In summarising the current status of the operation in 1879, Harris observed that a woman in labour had a 50% chance of survival if she performed the surgery herself or was gored by a bull compare9 with a 10% survival rate if attended to by a New York surgeon. The first record of maternal survival following caesarean section relates the tale of Jacob Nufer, a Swiss pig-gelder (pork butcher) who in 1500 was said to have performed the operation on his wife with a razor as she lay on the kitchen table. The reasons why Mrs Nufer failed to progress in labour are unclear, but a total of 13 midwives are said to have been called to assist her without success. Not only is the woman reputed to have survived but she went on to deliver five more children, including a set of twins, vaginally. Some doubt has been cast on the authenticity of this account as it was not published until 1582 and is therefore based on the hearsay of three generations.
Religious influences In the Middle Ages, Christianity influenced obstetric decision making. The Roman Catholic church encouraged the use of caesarean deliveries to offer the souls of unborn children the chance of salvation through baptism. At the same time it barred the use of abortion, craniotomy and fetal dismemberment as techniques to deliver the child in order to save the mother. Other church councils sanctioned the use of the operation on dead pregnant women principally in an attempt to save the child but also to allow baptism of the infant. The surgery was made mandatory by the church councils of Cologne (1280) (which also stated that the dead woman's mouth and vulva must be kept open so that the fetus in utero would not suffocate whilst awaiting surgical delivery), Langres (1404) and Scns (1514). The senate of the Republic of Venice laid down severe penalties for any doctor who failed to make an attempt to save a child in this way (1608). During the Franciscan mission period (1769-1833) in the United S tares, the operation became the responsibility of the missionary priest who attended the dying mother. Priests were given details of the relevant maternal anatomy, actual procedure and
150
Downloaded from scm.sagepub.com at Bobst Library, New York University on May 20, 2015
Caesarean section: Historocal background
Hillan
instruments required to assist them in their task. 5 The obsession with baptism of infants was especially seen in France. Peu in his 'Practique des Accouchements' published in 1694, described in great detail how baptisw was to be accomplished in operative deliveries. Radcliffe paraphrases Peu's method for caesarean deliveries thus: "He advises immediate opening of the abdomen as soon as the mother is assuredly dead and within the space of time taken to say one 'A ve maria', and as soon as the child is visible, pouring water over it and adding to the usual words of baptism, 'si tu as vie'. Although Islamic law is interpreted more liberally nowadays, Islam forbids the performance of caesarean section and directs that any child born this way should be slain as it is the offspring of the devil. Royal deliveries King Robert II of Scotland was supposed to have been delivered abdominally in 1316. His mother, Marjorie Bruce, was returning from Paisley Abbey and was thrown from her horse fracturing her neck in the process. One of the people in her retinue, Sir John Forrester, had some elementary surgical skills and was entrusted with the delivery by caesarean section. The child was delivered alive but sustained an eye injury in the process. The resultant corneal and scleral scarring earned Robert the nickname 'King Bleart The birth was commemorated in Renfrew by a wooden cross. Jane Seymour, the 3rd wife of Henry VIII, is said to have been delivered by caesarean section after two days of 'the most difficult labour'. She died 12 days later on the 24th October 1537. Although the labour started spontaneously, progress was slow and after 24 hours the cervix had only dilated to 5-6 centimetres. The obstetrician in charge, Dr Owen, is said to have consulted with Henry VIII and told him that either craniotomy or caesarean section would be required to terminate the protracted labour. Henry, keen for a legitimate male heir to the throne, is said to have directed the doctors to ;~:~~,:.ie life of the child, for another wife can easily be It is unclear whether the son, Edward VI born sometime after midnight on the 12th October, was delivered vaginally or by caesarean section. The evidence against a caesarean delivery is based on two premises. Firstly, there is no written evidence in existence which mentions an operation and secondly itis unlikely that Jane could have lived until the 24th of October because at that time the uterine incision was not sutured making death almost inevitable from either haemorrhage or infection. On the other hand it is just possible that she might have lived for 12 days ultimately succumbing to peritonitis. At that time, Hampton Court was isolated from the rest of the country because of the plague and the operation could have been performed with little public or written knowledge. Certainly Henry's desire for a male hair was well documented and he had already shown how ruthless he could be by ordering the execution of his previous wife Anne Boleyn. It was a lesser act to sacrifice Jane for a son. Caesarean section in the United Kingdom The first caesarean section in Great Britain on a living patient took place on 29th June 1737 and is described in Srroellies 'Treatise on the Theory and Practice of Midwifery'. The operation was carried out by an Edinburgh surgeon, Mr Smith, on a woman who was 'prodigiously deformed' . Her pelvic deformity was due to a disease known at the time as 'malacosteon' or 'mollites osseum' which was due to calcium deficiency in pregnancy. The woman had been in labour for six days when Smith was called to see her. On examination he found that the space between the pubis and the sacrum, was only 1.5 to 2 inches making delivery with a crochet impossible. In consultation with other doctors it was decided to carry out a caesarean section.
Smith performed the surgery and delivered a stillborn child. The mother herself died 18 hours later. In the same book Smellie describes the first maternal survival following caesarean delivery in the United Kingdom. The surgery was performed by an Irish midwife, Mary Donally, on Alice O'Neale, a farmer's wife, in 1738. Mrs O'Neale had been in labour for 12 days and several other midwives had attempted unsuccessfully to deliver her. Donally 'an illiterate women but eminent among the common peoplefor extracting dead births', was sent for. She tried without success to deliver Mrs O'Neale by the vaginal route. Using a razor to open the abdominal wall and the uterus, she delivered the dead child and placenta. She then 'held the lips of the wound together with her hand till one went a mile and returned with silk and the common needles which tailors used' . The wound was then sutured and dressed with egg-white. Mrs O'Neale survived and within a month was able to walk a mile although she subsequently developed a large ventral hernia. Smellie's book, published in 1752, became a classic British text-book on midwifery. Although Smellie's personal experience of caesarean section was limited to three cases of post-mortem delivery in a futile attempt to save the child, he took a pragmatic stance on the performance of the operation: "When a woman cannot be delivered by any ofthe methods hitherto prescribed and recommended in laborious and preternatural labours, on account of the narrowness or distortion of the pelvis into which it is sometimes impossible to introduce the hand; orfrom large excresences and glandular swellings thatfill up the vagina and cannot be removed; orfrom large cicatrices and adhesions in that part and at the os uteri which cannot be separated; in such emergencies, if the woman is strong and ofgood habit of body, the caesarean operation is certainly advisable and ought to be performed; because the mother and child have no other chance to be saved, and it is better to have recourse to an operation which has sometimes succeeded than leave them both to inevitable death . . . Nevertheless, if the woman is weak, exhausted with fruitless labour, violentfloodings or any other evacuations, which renders her recovery doubtful, even if she were delivered in the natural way; in these circumstances, it would be rashness and presumption to attempt an operation of this kind which ought to be delayed until the woman expires and then immediately performed with a view to saving the. child." Despite the fact that Smcllie.'s textbook was widely used, caesarean section did not gain popularity in Great Britain until much later, no doubt due to the appalling maternal mortality associated with the operation. The first documented case of maternal survival did not occur until 1793. The operation was carried out by James Barlow, a surgeon in Lancashire. The woman, Jane Foster, was around 40 years of age and already had several children. An accident on her return from Wigan market, resulted in her pelvis being crushed underneath the wheel of a loaded cart. She became pregnant shortly afterwards and when labour commenced the usual midwife was called. After several days the midwife in attendance decided to summon help from a Mr Hawarden. On the fourth day Hawarden called in Barlow for a consultation. After a thorough examination Barlow concluded that vaginal delivery was impossible and decided to perform, with great reluctance, a casearean section. The operation was carried out on a ,table and th; patient had a slow, but uneventful postoperauve recovery. It was almost another 40 years before a further successful operation was performed in England, six others were carried out in the interim but the mothers always perished. Throughout the nineteenth century caesarean section was performed with increasing regularity in Europe but in Britain obstetricians 151
Downloaded from scm.sagepub.com at Bobst Library, New York University on May 20, 2015
Caesarean section: Historical background
remained reluctant to use this method of delivery. Thomas Radford in his 'Observations on Caesarean Section' published in 1880 recorded 131 operations in Great Britain and Ireland between 1737 and 187§. Only 23 women survived making the maternal mortality 83%. No doubt due to the number of deaths associated with the operation, obstetricians were much opposed to its use and preferred to use it only as a last res0I!' Other forms of manipulative delivery were more often utilised. These included: 1. Podalic version and extraction (Pare)
2. Forceps delivery (Chamberlain) 3. Premature induction of labour for women with small pelvises 4. Fetal destruction (craniotomy) An indication of the prevailing conservative attitude in obstetrics is seen in the management ofa royal delivery. In 18 I7 four doctors attended the labour of Princess Charlotte of Wales: Sir Richard Croft (obstetrician), Dr John Sims (consultant), Dr Matthew Bailley (Royal Physician) and Sir Everard Home (Royal Surgeon). Charlotte was the only daughter of the Prince Regent (later King George IV) and was herself next in line to the throne. The labour started spontaneously but progress was slow. After 26 hours the cervix was almost fully dilated but Croft was reluctant to intervene with forceps until he consulted with Sims. Five hours later Sims arrived but refused to see or examine the patient, choosing to wait in an adjoining room in case an instrumental delivery became necessary. After 50 hours of labour, including 24 hours in the second stage, a still-born male child weighing9lbwasdelivered. The third stage of labour was delayed and as Charlotte had begun to haemorrhage, Croft proceeded to remove the placenta manually. Her condition deteriorated and despite attempts to resuscitate her she died seven hours after delivery. Although from a modem obstetric perspective, Croft's mistakes in the handling of the case are obvious, by the standards of the time he acted correctly. The most respected obstetric text-book of the era - Denman's 'An Introduction to the Practice of Midwifery' - stated that "A practical rule has been found that the head ofthe child shall have rested for six hours as low as the perineum before the forceps are applied although the pains should have ceased during that time". Similar restrictive rules applied to the conduct of the third stage of labour and Croft merely adhered to them, The death of the princess and her son was mourned by the nation. Lord Byron was so moved that he inserted six verses about it in the almost completed 'Fourth Canto of Childe Harold'. The loudly voiced public criticism of his handling of the case drove Sir Richard to commit suicide three months later. The course of history was changed by these events - with no direct heir to the throne, it led to the eventual accession of Queen Victoria. It also mar~ed a .turpling point in obstetrics away from non -10 tervcnuon. Developments in Glasgow By 186hthe population in Glasgow had risen fourteen fold to 395,503. The small town had become a large industrial city and in the transition, a serious housing problem developed which brought with it ill-health and disease. The combination of poor housing, inadequate diet and industrial pollution resulted in large numbers of children developing rickets. Rickets can result in serious pelvic deformities which in turn leads to difficulties in childbirth. The Glasgow Maternity Hospital statistics for the ten year period from 1889-98 reflect the problems of the contracted pelvis. Of the 4322 cases attended during. this time, around one in four of the women required operative mtervenuon and approximately 10% had gross pelvic
Hillan
contraction. If such contraction was present then the obstetrician had two choices - either to carry out a destructive operation on the ~etuHo effect delivery (craniotomy) or to perform a caesarean
secuon.
As in other parts of Britain, the obstetricians in Glasgow Maternity Hospital only considered caesarean section as a last resort. George Buchanan, the hospital's consulting surgeon, performed two sections in 1879 and 1881 which saved the two babies concerned but not their mothers. The cases prompted a discussion on 'The Contracted Pelvis' in 1881 which was chaired by Buchanan. The obstetricians involved failed to agree on the merits of casearean section aga~st craniotomy and the procedure was abandoned in the hospital. Interest in the subject was revived by Dr J S Nairne in 1887. He presented a paper arguing that the mortality associated with caesarean section could be reduced if obstetricians actively sought solutions to the problems attached to the operation. He urged his colleagues to attempt surgery in preference to cranio\9my or where attempt at delivery with long forceps had failed. By this time other advances in medicine made caesarean section a feasible alternative to craniotomy. Effective anaesthesia was available for the first time and the concept of surgical asepsis, originated by Lister in 1865, dramatically reduced the number of surgical deaths associated with infection. Obstetricians quickly recognised the value of these surgical advances. On April 10th 1888, C.C. a 27 year old primigravida, was admitted to Glasgow Maternity Hospital. Murdoch Cameron in his p~IJCr published in the British Medical Journal of January 26th 1889 described her as: ".. a little woman (height 49 inches) somewhat delicate, and with the appearance of a patient deformed by rickets in a very marked degree" Cameron in consultation with Drs Sloan, Reid, Oliphant and Black agreed that the conjugate of the brim was not more than 1.5 inches and that caesarean section was the only solution. With the
Fig.l The first three cases of successful caesarean section in Glasgow Royal Maternity Hospital.
152
Downloaded from scm.sagepub.com at Bobst Library, New York University on May 20, 2015
Caesarean section: Historical background
Hillan
patient safely anaesthetised by chloroform and ether, Cameron assisted by Reid operated and delivered a healthy male child weighing 61b 120l. The operation lasted for approximately 50 minutes. Further details of the celebrations following this first successful case of caesarean t'fction in Glasgow are given in Dow's book 'The Roucnrow'. He tells how Cameron's house surgeon produced a bottle of champagne on the 4th day and invited Cameron, Miss Gordon (the matron) and the mother to join him in a toast to the baby's health. The mother was unimpressed with the unfamiliar taste of champagne and asked for some 'guid soor dook' (buttermilk) instead. The patient made a slow but steady post-operative recovery, no doubt aided by the regular administration of enemas. She was allowed out of bed on the 24th day and was finally discharged home 36 days after the operation. By this time the baby weighed 81b 120z and was christened Caesar Cameron. The second successful section was carried out just over a year later on May Sth 1889. This time the patient was an 18 year old primigravida also suffering from marked rickets. She was only four feet tall and the true conjugate of the pelvis was estimated to be one inch. This time the patient's ovaries were tied with silk to ensure that no further pregnanci § occurred. Again the 1 post-operative course was uneventful. A further successful caesarean operation quickly followed on a rachitic dwarf who had failed to progress after several days in labour. On this occasion the woman was unmarried and on hearing of this, Cameron promptly arranged her wedding to the father of thf1 child with the other two patients acting as bridesmaids. (Fig 1) Cameron went on to perform a total of 10 caesarean sections hetween 1888 and 1890 without loss of mother or baby. A Lancet leader in 1889, commenting on this remarkable success, stated that: 'This is a condition ofaffairs which probably could not be paralleled in any other hospital in the world." Cameron also received the following tribute from Lister: Portland Place 10 Park Crescent 9th March 1891 Dear Dr Cameron I have read with much interest the report in the British Medical Journal of your remarkable series of caesarean sections. I congratulate you heartily on your success which is, as far as I know quite unparalleled. The various points that you mention seem as important as they are simple . . . Believe me. Yours very sincerely, Joseph Lister Murdoch Cameron (Fig 2) became Rcgius Professor of Midwifery in 1894 and remained so until 1927. The technique of classical caesarean section was further refined by his son, Sam, who became his assistant and later Itfllowed his father as Regius Professor between 1934 and 1943. Development of surgical techniques In 1870, although more commonly employed, caesarean section was still associated with an appalling maternal mortality of 75%. Death was usually due to either shock, sepsis or haemorrhage or a combiruuion of these factors.
Fig.2 Murdoch Cameron. Regius Professor of Midwifery (1894-1927) Although the danger of infection was appreciated there remained the dilemma of how to control it. In an effort to overcome this an Italian obstetrician, Eduardo Porro in 1876 devised a new operative technique. This involved caesarean delivery followed by amputation of the uterus at the internal os together with the adnexa and marsupialization of the cervical stump into the lower end of the abdominal wound. This ensured that the focus of infection, the uterus, was removed and that any drainage was complete. It also meant that the~ was no opportunity for continued intra-peritoneal bleeding. The Porro caesarean hysterectomy technique brought about a considerable reduction in maternal mortality through control of haemorrhage and a reduction in the risk of infection, but had however only a short period ofpopularity due to being superseded by the operations of Kehrer (1881) and Sanger (1882). Both advocated the new step of suturing the uterus in layers prior to wound closure. Before this uterine suturing was only performed to control bleeding vessels as it was gcrcraJly believed that such sutures were superfluous and harmful. These two operations together with other medical advances in anaesthesia and antisepsis reduced the maternal mortality assoicatcd with the operation to between 6 and 10%. If infection did develop however, the mortality rate remained high.
The lower uterine segment approach Johnson in his book 'A New System of Midwifery' (2nd Edition) published in 1786, was the first person to suggest that the uterine incision should be made transversely in the lower segment. This stemmed from his observation of how little haemorrhage had occurred in two cases of ruptured uterus where the rupture had occurred in the region of the lower segment. The operation however was not carried out until 1881 by Kcher, Benjamin Osiander (1805) also devised a lower segment approach although he advocated a vertical incision. Kronig's technique (1912) 153
Downloaded from scm.sagepub.com at Bobst Library, New York University on May 20, 2015
Caesarean section: Historical background
Hillan
developed peritoneal flaps although he still incised the lower segment vertically. This procedure was brought to the ~Tnited States by Beck (1919) and popularised by De Lee (1925). It was another of Murdoch Cameron's pupils, John Martin Munro Kerr, who went on to popularise the lower segment approach for caesarean section. His contention was that the scar, particularly if transversely placed, would be stronger and therefore less likely to rupture in a subsequent pregnancy. Although Munro Kerr first used this approach in 1911, it wasn't until the 1940s that there was widespread acceptance of it as the superior mfJhod. The 9th edition of 'Munro Kerr's Operative Obstetrics' described the final acknowledgement of Munro Kerr's technique. It came at the 12th British Congress of Obstetrics and Gynaecology held in London in 1945. Several obstetricians had presented papers with convincing evidence of the reduction in maternal mortality related to caesarean section, but all failed to mention that one of the major factors associated with the fall was the adoption of the lower segment approach. When Munro Kerr was invited to the platform to comment, he acknowledged the speakers and surgeons whose work had been quoted and finally pointed out that for almost the first time ever the lower segment approach had been referred to in nothing but words of praise at which point he broke off, threw his arms in the air and exclaimed: "Alleluia! The strife is 0' er, the battle done!" The transverse incision remains the most common and preferred method for caesarean section. This type of incision has the lowest incidence of haemorrhage at the time of operation and the lowest incidence of rupture in subsequent pregnancies. It is also thought that due to reperitonealization the incidence of intra-abdominal infections and development of adhesions is reduced. Today classical caesarean section, a vertical incision in the uterine corpus, is rarely performed due to its association with greater blood loss and an increased incidence of infection. The only indications for its performance are when the lower segment
is not formed, as in delivery of a very preterm fetus; where there are problems related to the fetal position, such as an impacted shoulder presentation; in cases of cervical carcinoma; or where fibroid tumours obscure the lower segment. REFERENCES I Placek PJ, Taffel SM, Moien MS. 1986 c-sections rise; VBACS inch upward. Am J Pub Health, 1988; 7: 562-3. 2 Information and Statistics Division. Hospital and Health Board comparisons in obstetrics - 1985-1987. Edinburgh: Common Services Agency, 1989. 3 Brian VA. The deepest cut of all. Nursing Mirror, 1976; 143: 68-9. 4 Young JH. Cesarean Section: the history and development of the operation from earliest times. London: HK Lewis & Co Ltd, 1944. 5 Rosen MG. Caesarean Childbirth: report of a consensus development conference. Bethesda Maryland: National Institute of Health, 1981. Nlll Publication no. 82-2067. 6 Harris RP. Cattle-hom lacerations of the abdomen and uterus in pregnant women. Am J Obstet (NY), 1887; II: 673-85. 7 Harris RP. Remarks on the cesarean operation. Am J Obstet (NY), 1879; 11: 620-6 8 Radcliffe W. Milestones in Midwifery. Bristol: John Wright and Sons Ltd, 1967. 9 Green GH. A Tudor Caesarean section. Surgery, Gynecol and Obstet, 1985; 161: 490-6. 10 McLintock AH (ed). Smcllic's Treatise on the Theory and Practice of Midwifery: Vol III. London: New Sydenham Society, 1876,230-5. 11 Hellman LM. Three deliveries that changed the history of the world. JAOA, 1974; 73: 93-108. 12 Willocks J, Calder AA. The Glasgow Royal Maternity Hospita11834-1984 150 years of service in a changing obstetric world. Scot Med J, 1985; 30: 247-54. 13 Dow DA. The Rottenrow. Lanes: The Parthenon Press Ltd, 1984. 14 Cameron M. The caesarean section: with notes of a successful case. BrMed J, 1889; Jan 26th: 180-3. 15 Cameron M. Remarks on caesarean section, with notes of a second successful case. Br Med J, 1890; March 15th: 583-5. 16 Moir JC, Myerscough PR (eds). Munro Kerr's Operative Obstetrics (9th ed). London: Bailliere Tindall and Cassell, 1971.
154
Downloaded from scm.sagepub.com at Bobst Library, New York University on May 20, 2015
