“Cesarean Section -- A Brief History” (1993), by Jane Eliot Sewell

Jane Eliot Sewell presented “Cesarean Section--A Brief History” in 1993 as a brochure in the National Library of Medicine’s exhibit on the history of cesarean sections, hereafter c-sections, in Bethesda, Maryland. A c-section is a surgical procedure that doctors use to deliver a fetus through an incision in a pregnant person’s abdomen. The National Library of Medicine’s exhibit included a collection of artwork and photographs that coincide with the historical account of the procedure, and the brochure presents that information in print form. Sewell describes the chronological advancements and evolution of the c-section as well as other medical technological improvements that helped increase surgical survival rates. The brochure and accompanying exhibit provide background and history of the procedure available to the American College of Obstetricians and Gynecologists, for whom it was published, and the general public. “Cesarean Section--A Brief History” provides a cohesive explanation of the chronological history and advancements of c-sections, a procedure that millions of people undergo to give birth each year.

Sewell received her master’s and doctoral degree in the history of medicine from Johns Hopkins University in Baltimore, Maryland. Her dissertation focused on surgeons who developed gynecological procedures such as Lawson Tait, a surgeon who helped develop a method to treat ectopic pregnancy, which is when the fetus grows outside a womb. Sewell created the brochure “Cesarean Section--A Brief History” for the exhibit that was available from April through August of 1993 in the National Library of Medicine, an organization that provides medical professionals with a large database of biomedical research and information.

Throughout “Cesarean Section--A Brief History” Sewell discusses medical innovations that changed the procedure throughout history. The author states that many early recorded c-sections were performed to save the life of a fetus by removing it from the dead or dying pregnant person. However, during the nineteenth century, surgeons developed tools that increased the likelihood of both the pregnant person and fetus surviving. One tool was forceps, which were large handheld tools, like tongs, that doctors used when the fetus was stuck high in the pelvis to pull the fetus out of the pregnant person, but often left lacerations and caused life-threatening infections. Another was anesthesia, which is a kind of gas or other pharmaceutical that numbs pain or makes the patient unconscious, allowing surgeons to spend more time performing the procedure. Sewell discusses how such tools aided the advancement of c-sections over time.

The author splits the brochure “Cesarean Section--A Brief History” into four parts. In “Part 1,” Sewell describes early attempts at c-sections from ancient cultures and folklore surrounding the name “cesarean section,” and the earliest reported successful c-section delivery, which occurred in Switzerland in the early 1500s. In “Part 2,” Sewell discusses the rise of medical advancements like anesthesia and forceps. In “Part 3,” Sewell explores techniques such as a new type of suture employed in the late 1800s and explains that a spike in the number of c-sections occurred due to increasing complications with vaginal births. In “Part 4,” Sewell describes doctors’ advancements in monitoring technology such as ultrasounds, which allowed medical professionals to address the fetus’s health more accurately and perform emergency c-sections if doctors measured fetal distress.

In “Part 1,” Sewell explains ancient cultural references to the procedure, and that people in rural areas performed the earliest c-sections using items from the home such as farm or kitchen tools. C-sections appear in many types of folklore and mythology. The author refers to Greek mythology where Apollo, the sun god, removes Asclepius, the god of medicine, from his mother, Coronis, through an incision in her stomach. Sewell includes an image from the NIH exhibition of a woodcut, a technique that involves carving an image onto a wood block, from 1549 that depicts a man removing Asclepius from his mother’s abdomen through an incision. The writer notes that the origin of c-sections and the word itself are difficult to prove due to the many stories regarding early c-sections and the limited written accounts. She describes that some believe that the word “cesarean” originated from the surgical birth of Julius Caesar, a Roman dictator. However, she states that it is unlikely that Caesar was born via a c-section because his mother is said to have lived after his birth, and most women during that time died during or after the c-section. During Caesar’s rule, he mandated that all dying pregnant women must be cut open to save the newborn and increase the population, which could have led to the term cesarean. The author discusses that the word may have also originated from the Latin verb “caedare,” which means to cut. Sewell mentions that the publication of Jacques Guillimeau’s book on midwifery in 1598 introduced the term section, previously operation, after cesarean. Guillimeau was a surgeon in France.

Sewell maintains that people in Europe performed c-sections on dead or dying mothers to save the infant before and during the fifteenth and sixteenth century. She highlights that the primary purpose of the operation was a last resort to save the newborn’s life, not the mother’s. The author notes that some religious edicts required people to remove the newborn from the mother so that even if the newborn died, the newborn and the mother could be buried separately. Sewell explains that the possibility of saving the mother’s life was not feasible until the nineteenth century.

Also in “Part 1,” Sewell mentions the earliest account of a successful c-section in which both the infant and the mother survived was the case of Jacob Nufer, who performed the procedure on his wife in Switzerland in 1500. Both his wife and child survived. However, historians question the story’s accuracy because it was written eighty-two years after the birth occurred. Sewell states that historians are also skeptical about reports of women performing c-sections on themselves. Up until the late nineteenth century, c-sections most often occurred in rural areas with tools found in the home. Before and during the nineteenth century, the author writes that surgeries that took place in hospitals were often less successful than those in the home due to the lack of hygiene among those performing the procedures, which spread infection and disease as a result.

At the end of “Part 1,” Sewell goes on to describe that due to the differences in access to education and tools between men and women starting from the seventeenth century, more male surgeons started to perform c-sections than female midwives. Sewell discusses the increased use of cadaver dissections as teaching methods in medical schools in the 1800s, which allowed men to advance in the medical field since only men could attend those schools. Medical schools also benefited from the numerous books on human anatomy published. Sewell includes an image detailing the female pelvic anatomy from Andreas Vesalius’s anatomy book called De Humani Corporis Fabrica (On the Fabric of the Human Body). Prior to that point, female midwives performed most c-sections. However, female midwives did not have access to medical education. Women lacked both the education and tools such as forceps, developed in the early 1600s, which were necessary to aid pregnant women in c-sections, pushing them further out of the profession.

In “Part 2,” Sewell starts by describing successful c-sections occurring outside Europe. She describes an account by R. W. Felkin, a British traveler who witnessed a c-section birth in the late nineteenth century in Uganda, a country in east Africa. The healer who performed the c-section used banana wine to slightly intoxicate the pregnant woman and sanitize his hands and her abdomen. He delivered the newborn through an incision and both the mother and newborn recovered well. Another account from Rwanda, also a country in East Africa, describes similar well-developed procedures.

Also in “Part 2”, the author describes and the rise of obstetrics in urban European and US cities in the late 1800s. At that time, midwives still assisted most rural births, including c-sections. However in cities, obstetrics became more popular and special hospitals for women were built throughout the US and Europe. Sewell notes that without the help of close family nearby, most women in cities gave birth in hospitals. The increase in the number of women undergoing a c-section at hospitals allowed doctors to develop more surgical skills.

Continuing in “Part 2,” the author explains the rise of anesthesia in hospitals after the first use of anesthesia in 1846. There was subsequent backlash against the use of anesthesia among people who believed the Bible indicated that women should suffer during childbirth. The backlash subsided after Queen Victoria, the head of the Church of England, opted to use chloroform in 1853 and 1857 for the births of both her children. Anesthesia allowed women to remain unconscious during the procedure, which enabled doctors to slow down, operate more carefully, and cleanse better. Anesthesia also allowed for a shift away from more dangerous procedures and tools like forceps that could hurt the patient.

Towards the end of “Part 2,” Sewell describes that despite some changes, mortality rates for c-sections remained high due to poor surgical techniques and infection. Prior to the mid- nineteenth century, Sewell mentions that doctors wore regular clothes to operate and did not wash their hands frequently when moving from one patient to another. However, after scientists started to conduct more research on germs in the nineteenth century, surgeons took measures to counter the spread of germs, including using different types of antiseptics, and used more hygienic practices. By the end of the nineteenth century, antiseptics became more common.

In “Part 3,” Sewell discusses how anesthesia aided scientists to develop new techniques that made c-sections safer. One technique surgeons attempted involved making a lower uterus incision, which reduced the risk of infection and uterine ruptures in future pregnancies. Another advancement involved performing the operation sooner rather than waiting until the woman was in distress, which reduced maternal and infant mortality rates. Sewell also discusses the vaginal c-section, which combined a vaginal delivery and a c-section by making a vertical incision on the cervix to avoid delivery complications like inflammation, though she notes that surgeons stopped using vaginal c-sections after the development of penicillin, an antibiotic that reduced maternal mortality for c-sections and vaginal deliveries. Lastly, the author writes that Eduardo Porro, a surgeon who worked at the Ospedale Maggiore (Major Hospital) in Milan, Italy, advocated for hysterectomy, a surgery that removes part or all of the uterus, after a c-section to avoid infections and hemorrhages. His push for hysterectomies soon faded with the development of uterine sutures by J. Marion Sims, a physician in the US. Surgeons use uterine sutures to stitch and repair the uterus if a tear occurs.

Continuing in “Part 3,” the author explains that rapid urbanization in Britain and the US starting from the early 1900s increased the number of c-sections. In Europe, Sewell conveys that some religions pushed doctors to develop c-sections so religious officials could baptize the infant. Sewell also states that urbanization increased the rate of the disease rickets, which is caused by lack of sunlight and healthy nutrition. Rickets often impacted the pelvic bone structure of some women, making it difficult to deliver a fetus, which increased the rate of c-sections in the 1900s. Sewell claims that improper bone growth decreased by the 1930s with the availability of safe milk in urban areas because milk contains calcium, which helps build stronger bones. In the exhibit, a photo of a family with rickets in the 1900s shows five young people with abnormal pelvic bone structure.

Sewell explains that in the mid-twentieth century, urbanization led to an increase in access to hospitals and medical attention during childbirth, and in 1955, ninety-nine percent of births occurred in hospitals. During that time, anesthesia became more common, including spinal anesthesia, which allowed women to stay conscious during their c-section. Advancements in anesthesia, coupled with the increase in hygienic practices and use of antisepsis, decreased the rate of complications and mortalities after the c-section for the woman and newborn. Sewell also mentions the steep rise of c-sections, which increased almost twenty percent from 1970 to 1990. At the time of publication, Sewell writes that more than one in seven women in the US undergo labor complications that lead to a c-section. As of 2024, around thirty-two percent of pregnant women in the US have c-sections. During the initial movement from home births to hospital births, fathers were excluded from the birth. Due to developments in antiseptics, antibiotics, and anesthesia, fathers were allowed to be present during c-sections and Sewell emphasizes that fathers became active in the pregnancy and childbirth process.

In “Part 4,” Sewell discusses that the development of the ultrasound and the heart monitor in the mid-twentieth century allowed doctors to begin considering fetal health as a reason to perform a c-section. During a pregnancy, doctors use an ultrasound to visualize the fetus inside the body. Doctors use a heart monitor to track the heart rate of the fetus. Sewell explains that technology such as fetal monitoring and ultrasounds made the fetus the primary patient during labor because the doctors were able to monitor the health and heartbeat of the fetus. Prior to World War II, doctors viewed the fetus through x-rays. However, Sewell writes that there was a possibility of long-term hazards to the fetus due to the radiation. Sewell notes that after the war, ultrasounds used to detect submarines eventually paved the way for pregnancy ultrasounds. The author claims that tools to view the fetus made the public and medical practitioners view the fetus as a patient and more of a person. The advent of the heart monitor in the early 1970s allowed doctors to detect any sign of fetal distress quickly. The author notes that doctors performed c-sections at major signs of fetal distress to avoid more serious problems.

Lastly, in “Part 4,” Sewell gives an overview of the rise of the Natural Childbirth Movement, which formed in the mid-twentieth century in the US and urged women towards natural deliveries over c-sections for bodily autonomy and to reduce reliance on expensive equipment. Sewell states that some feminist organizations pushed for natural birth and argued that c-sections should occur only when necessary and elective c-sections should be limited. Certain feminist groups pushed for natural births due to the increasing cost of the procedure. She concludes the historical account by portraying the shift in views towards the c-section from one that almost always killed the mother and fetus to one that helps both to survive.

“Cesarean Section--A Brief History” provides chronological historical examples of c-sections and the development of the techniques needed for the procedure. The work has been cited in other articles about the history of c-sections, as well as multiple research studies. One study 2019 by Emaline Reyes, a researcher in the Department of Anthropology at the University of Delaware in Newark, Delaware, cites Sewell’s work to addresses the reasons why pregnant people get c-sections. “Cesarean Section--A Brief History” provides specific details and a comprehensive account of the history of the procedure to help those looking to understand its history.