Despair thy charm;
And let the angel whom thou still hast serv'd
Tell thee, Macduff was from his mother's womb
Untimely ripp'd.
- Macduff's rebuttal to Macbeth

The small fact that was the last straw in Macbeth's tragic downfall, the Caesarean section has been shrouded in myth and folklore. Although not quite the 'clean' procedure that so many celebrities would delude themselves to believe, its development throughout the ages has made it one of the most important operative methods of delivery¹.

Just Mythed You...

It seemed that the removal of the baby from the mother by other means than that already graced upon women has been in operation for a very long time. Greek mythology even reflects this - Asclepius, who would grow up to be the Greek god of religious medicine, was said to have been taken from his mother's tummy by Apollo. Certainly, there have been writings about the procedure in other myths and legends - evidence suggests that the section was practised in Hindu, Egyptian, Chinese and other Western myths.

However, if there was one thing that the Romans did for the operation, it was to give it a name.

When in Rome...

Legend has it that the name - Caesarean, was derived from the Roman dictator, Julius Caesar, as he was thought to have been born in this fashion. Logical though it may seem, it would be unlikely for the man to have lived to have veni, vidi, vici had he have been born in this fashion. Indeed, his mother seemed to have recovered well from this major procedure, as she features in many other areas of his later life.

Myth aside, the term 'caesarean' is Roman in origin. In the 8th Century BC, the Roman ruler Numa Pompillus passed a law requiring all women who died in labour to have a post-mortem delivery. This law continued throughout the reign of the Roman Emperors, and was known as Lex Caesarea - caesus being the Latin for 'cut' or 'incision'; a more likely root for the term.

The Middle Ages

The section was reserved for the tragic event of maternal death in labour until the 1500s, when a German pig farmer, Jacob Neufer, was forced to carry out the operation when his wife was suffering from a difficult obstructed labour. The baby was born, and his wife lived long enough to fire out two more kids in the more traditional way.

However, as most things go, the part of the story which states she lived and bore two more children is unlikely to be true. Most of Mrs Neufer's sectioned contemporaries died shortly after the operation, as the uterus wasn't stitched up after the procedure. Not only that, infection was a major killer after the operation. As the Neufer case was also reported about 82 years after the supposed event, one must question its legitimacy.

If there is one thing that is certain about the story, is that if he did carry out the procedure, Neufer's experience in farming pigs may have played a role. He must have had some knowledge about the anatomical features of the pig, and that may have played a huge part in him taking such a huge risk.

As the Middle Ages gave way to the light of the Renaissance, the advances made in anatomical knowledge by the pioneering Vesalius and Leonardo da Vinci shed new light on how things worked inside ourselves, and just which bits were where. By the time the 1900s rolled in, there was another important development.

Surgical Spirit

Couple anatomical knowledge with the advances in infection control and anaesthesia, the C-section was changed beyond all belief. The uterus was sutured up before closure of the skin. Now it could be carried out on living mothers, with a better chance that they and their baby might survive at the end of the procedure. Queen Victoria herself took full advantage of the new range of pain relief available, and all labouring mothers breathed a sigh of relief when 'gas and air' - or a mixture of nitrous oxide gas and air, was made available to them.

But with all the technology and medical knowledge came an unfortunate side effect. For centuries before the enlightenment of anatomy, pregnancy and labour had been in the hands of women - be it midwives, mothers, and so on. Now, with the advent of the obstetrician or 'man-midwife', the process of birth was being wrested from being a normal process to that of the clinical presenting problem. In other words, pregnancy was now being treated as a disease which one could be 'cured' from, and therefore the pregnant woman required medical intervention. Furthermore, most surgeons at the time were men - so this translocation, unsurprisingly, medicalised an otherwise normal process - and the option of a Caesarean didn't really help.

And Now...

Bringing you up to the present day, and attitudes toward labour have now turned full circle. Midwives and obstetricians are now not just happy to persuade a pregnant mother out of a Caesarean, but leave it up to the mother as to how they would like to have their labour. The Caesarean does remain important though, as if the mother experiences a long and dangerous labour, or the baby starts to show signs of distress, the C-section can be performed quickly, thereby saving the mother and the baby's life.

The C-section

There are two ways of performing a C-section, one which uses an incision that runs from the belly-button down, and the most common option which uses the 'bikini line' incision - a transverse cut low down in the abdomen. In both cases though, the aim is to get an incision into the uterus and the baby out as quickly as possible. The following describes an elective or planned Caesarean rather than an emergency or crash C-section, as of course, those situations are unpredictable. If you are of a sensitive disposition, or are queasy at the thought of blood, then be warned, as the following paragraphs graphically describe a surgical procedure.

An Elective or Planned C-section

So, before all this is done, the mother is given an epidural - a spinal anaesthetic which numbs all feeling from the waist down.

Firstly, the skin is reflected (cut and pulled back), then the layer that covers the abdominal muscles (the peritoneum) is reflected too. The surgeon then makes a small hole in the rectus sheath (the covering of the rectus muscle or the six-pack muscles) and then, with the help of the assistant, they put their fingers in the small opening, and rip the rectus muscles along a natural weakness in the muscle, the linea alba. The bladder is pushed down either by the assistant's hands or a retractor, and the covering of the uterus is reflected away. Then an incision is made in the uterus - this incision has to be made very gradually, in order to prevent cutting into the baby. The waters will then shoot out, and then it's time to go fishing for the baby.

The surgeon will now put their hand inside the uterus and try to lift the baby out. For the mother, this can feel like anything from a bit of stretching, to feeling as if the surgeon is doing the washing up in your tummy. This is the most challenging bit of the procedure, as this has to be done very quickly to avoid foetal distress. Then in a moment which can only be described as a messier version of a chest-burster from the film, Alien, the baby is brought kicking and screaming into the world. Once the baby is shown to the parents, it's given a once-over check by the paediatrician on standby.

The afterbirth is then delivered, and checked over to see that it is complete, and once the uterus has contracted down a bit, it is sutured up. That done, the retractors or hands are removed, and the rectus muscles naturally fall back into place - despite the ripping, the linea alba will heal very quickly and easily.

The skin is then sutured, and a very big plaster put on it. Both mother and the baby are then wheeled back to the labour ward, and the midwives will check on the mother for any issues that may arise from the operation.

The Maternal View

It may seem like carnage for those working on the cutting edge of the screen, but what about the mother who has to endure and recover from it?

Here's a personal account of recovery from a C-section.

Recovering from such major abdominal surgery takes at least six weeks - it's very incapacitating. You're advised not to do any lifting, driving or pushing of a pram, for good reason - the wound area and the muscles inside really hurt for that length of time. It might be all right for celebrities with teams of nannies, but these restrictions are extremely inconvenient when you've got a small baby and you're pretty much on your own!

There's another disadvantage to having a Caesarean, which you might not have thought about. Your newborn baby is flashed at you by the doctors and then taken away for a check-up. After the once-over they show you your baby again, but because of the effects of the epidural you can't move your arms, and so you can't hold your baby. The epidural doesn't wear off for ages and so you're not able to bond with your baby as you can if you have a natural birth. It's a little upsetting that you can't hold your baby and it can put you at a disadvantage when you're trying to establish breastfeeding.

Reasons for a Planned Caesarean Section

There are many reasons for opting for a C-section rather than spontaneous vaginal delivery, and here are just a few:

• Breech or other malpresentation of the baby

• Placenta Praevia - this is where the placenta (the way in which the baby gets all that's required from the mother) is close to, or covering the cervical opening, ie blocking the baby's path to freedom.

• Fibroids - these are benign tumours of uterine muscle, some of which can encroach on the uterine space. If there are fibroids in the lower third of the uterus or at the cervix itself, it can lead to obstructed labour, so a section may be wise to avoid the complications of an obstructed labour.

• Other medical concerns within pregnancy which may compromise the baby if delivered naturally, eg high blood pressure.

Reasons for an Emergency or a Crash C-section

The difference between an emergency and a crash may not be so obvious to the uninitiated, but the difference is vast. An emergency Caesarean section can be as simple as one which is not planned - if the labour goes on for far too long, or the shape of the pelvis is not really in the favour of a natural delivery. These are things which you can't predict, and a decision is made on the spot. However, although there may be a sense of urgency, there is no real sense of immediate danger.

A crash Caesarean section - often called just a 'crash section' for brevity, is one step up from an emergency Caesarean. Often the baby will show signs of severe distress, the mother is in a serious medical condition, or - something which instills panic in even the most experienced obstetrician - no foetal heart sounds can be heard. This is the true test of professionalism, as now is the time to get the baby out as quickly as possible without panicking, in order to save not only the baby's, but the mother's life. If the epidural doesn't work here - then a general anaesthetic may be used.

The Maternal View

Not only is it a test of the surgeon's nerve, it can be a truly frightening experience for the mother - here's a personal account of a crash section:

I went into hospital for an ultrasound scan. I was told that the head and the body were not at the same stage of growth. The body was small and there might be a problem. I was asked to come back in the afternoon, so that they could do foetal monitoring.

I did a large amount of shopping at the supermarket, then came back for a large meal in the hospital restaurant.

During the foetal monitoring, the baby's heart started to flatline, which meant that instead of undulations up and down, it was a wiggle. I was told that this was a very bad sign and was told that the baby needed to be born now. A crash team was assembled. Luckily for me, the heart rate recovered to a normal pattern and the crash team stood down. I was told I could have the baby a little later, to give my meal time to digest. I had to keep looking at the monitoring and to press a button if it flatlined again.

I was offered a spinal - a bit like an epidural, but the needle goes further into the cord. They tried twice, but when they pricked me on the leg to see if I could feel anything, I definitely could! I was told I would have to have a general. I was shaking and feeling very cold. I remember being wheeled off, and then nothing.

Later, I awoke with my mouth feeling like the bottom of a budgie's cage - like sandpaper and very thirsty. I was given two polaroid photos of a tiny baby. He weighed just 4lb 1oz.

I didn't get to see him until next day and he seemed quite alien. I had no maternal feelings. He was on a waterbed for two days in the SCBU² and stayed for three days in total. His APGAR³ scores were good. I was told later that the shivering was because I had gone into shock.

Here are two conditions which are serious enough to require a crash section:

• Abrupto placentae (placental abruption) - this happens in 0.5-2.0% of pregnancies, and it's where the placenta comes away from the wall of the uterus. A pool of blood forms and clots in the space between the placenta and the uterus, so that the baby can't get what it needs from the mother. The mother is in severe abdominal pain, the baby may go into severe distress. The mother may go into shock after losing lots of blood, and may go into renal failure.

• Severe Pre-Eclampsia/Eclampsia  - still one of the most common reasons for maternal death in pregnancy, this is a condition of unknown cause, but devastating effect. At the time of writing, the theory is that molecules from the placenta are released when the maternal blood pressure gets very high. This has a detrimental effect on the kidneys, liver, and brain. The cure is delivery of the baby. If the life of the mother is seen to be compromised at any stage of the pregnancy when she is not actively in labour, then delivery by Caesarean section is the only option.

'Too Posh to Push'

Despite the Section primarily being a major operation used to prevent major trauma to the baby and the mother, there are some that opt for this method for convenience alone. Those who opt for the C-section with no medical reason for it may see it as a method of delivery which is supposedly less messy and a method for setting an absolute date of delivery in a busy work schedule. However, these opinions are unfortunately formed on the basis of celebrities who opt for C-sections, often for the sole reason of convenience, and hearsay from those who only have a tiny scar to show for it. However, quite often, and with good reason, the parents do not see just how messy the procedure is - if the suction is broken then those on the cutting side of the screen can be covered in waters, baby poo and blood - hardly the 'clean' delivery that so many are led to believe.

Also, despite what entertainment magazines may misinform, just because you have had a Caesarean section in the past doesn't mean that it is safer to have your next baby by that method. You can go for what is known as a 'Trial of Scar' or TOS. You will be more closely monitored for signs of uterine rupture along the previous scar, but there have been many women who have delivered safely and successfully by TOS.

Help! I'm a Baby - Get Me Outta Here!

From myth to Macbeth, from pigs to celebrities, no other medical procedure has been shrouded in such legend and mystery. For all that is spoken or written about it, it is worthwhile to remember that despite the method, it is the delivery of a new life into the world - and for family and maternity staff alike, it is still a moment of wonder.