AJOG REVIEWS

The history of cesarean technique

Samuel Lurie, MD, and Marek Glezerman, MD
Holon and Tel Aviv, Israel
Cesarean section has been practiced since ancient times. Unfortunately, no ancient medical documents
describing the techniques for cesarean section are extant. In the early medieval period, cesarean section was
usually performed by midwifes. One of the rst explicit instructions in medical literature on cesarean technique
dates from about 1480 CE from southern Germany. We discuss the evolution of cesarean surgical technique
and point up the contribution of many giants in the eld of obstetrics and gynecology, such as Blundell, Frank,
Harris, Joel-Cohen, Kehrer, Kerr, Lebas, Levret, Maylard, Pfannenstiel, Porro, Portes, and Sanger.
(Am J Obstet Gynecol 2003;189:1803-6.)

Key words: Cesarean section, history of medicine

Although universally performed post mortem, cesarean

delivery was practiced for ages and is referred to in the
myths and folklore of many ancient nations.1-4 The
evidence that cesarean section was performed arises from
legal texts: a cuneiform tablet dealing with the adoption
of a small boy during the 23rd year of the renowned king
Hammurabi of Babylon (1795-1750 BCE),5 Lex Regia
(the Law of the Kings) proclaimed by Numa Pompilius, an
ancient Roman king (716-673 BCE),6 and Mishna, the
collection of ancient Jewish laws (2nd century BCE to 6th
century CE).4 Unfortunately, no ancient medical documents mentioning the techniques or exact indication for
cesarean section are extant.
In the context of vanished ancient cesarean section
techniques, it is of interest to mention a cesarean section
witnessed by a missionary British physician, R. W. Felkin,
in Uganda in 1879.7 The surgical technique could have
been used by the Banyoro tribe surgeons for centuries:
The patient was a healthy-looking primipara (1st
pregnancy) of about twenty years of age and she lay on
an inclined bed, the head of which rested against the side
of the hut. She was half-intoxicated with banana wine, was
quite naked and was tied down to the bed by bands of bark
cloth over the thorax and thighs. Her ankles were held by
a man. . .while another man stood on her right steadying

From the Department of Obstetrics and Gynecology, Edith Wolfson

Medical Center, and the Sackler School of Medicine, Tel Aviv University.
Received for publication January 7, 2003; revised April 23, 2003;
accepted June 30, 2003.
Reprints not available from the authors.
2003, Mosby, Inc. All rights reserved.
0002-9378/2003 $30.00 + 0
doi:10.1016/S0002-9378(03)00856-1

her abdomen. . .the surgeon was standing on her left side

holding the knife aloft and muttering an incantation. He
then washed his hands and the patients abdomen first
with banana wine and then water. The surgeon made
a quick cut upwards from just above the pubis to just
below the umbilicus severing the whole abdominal wall
and uterus so that amniotic fluid escaped. Some bleeding
points in the abdominal wall were touched with red hot
irons. The surgeon completed the uterine incision, the
assistant helping by holding up the sides of the abdominal
wall with his hand and hooking two fingers into the
uterus. The child was removed, the cord cut, and the child
was handed to an assistant. The report goes on to say that
the surgeon squeezed the uterus until it contracted,
dilated the cervix from inside with his fingers (to allow
postpartum lochia to escape), removed clots and the
placenta from the uterus, and then sparingly used red hot
irons to seal the bleeding points. The peritoneum, the
abdominal wall, and the skin were approximated back
together and secured with seven sharp spikes. A root paste
was applied over the wound and a bandage of cloth was
tightly wrapped around it. Within 6 days, all the spikes
were removed. Felkin observed the patient for 11 days,
and when he left mother and child were alive and well.
The salient points of the cesarean technique of the
Banyoro tribe surgeons are anesthesia (banana wine),
antisepsis (banana wine), low midline abdominal incision, good hemostasis (red hot iron), blunt incision of
the uterus (minimizing hemorrhage), nonsuturing of the
uterus with manual massage and cautery of uterine
incision bleeding points (minimizing hemorrhage),
suture of abdominal wall, and wound care (root paste).
Currently, uterine suture is thought to reduce the amount
1803

1804 Lurie and Glezerman

of blood loss and to enhance uterine healing.8 Nonsuture

of the uterus is apparently associated with greater
hemorrhage that may even lead to exsanguination.
Conversely, recent experimental data in dogs reveal that
nonclosure of a low transverse uterine incision after safe
hemostasis and administration of uterotropins is associated with good outcome and might even be preferable in
appropriate cases.9
One of the first explicit instructions on how to perform
a cesarean section dates from about 1480 CE, from
southern Germany1,10: . . .the skillful midwife has to
open up one side, but not the right one; for in men the
heart is located on the left side, but in women the right
side. She shall start cutting in the lower part of the belly
around the pubic bone, about the width of one hand.
With her oiled hand she must carefully move aside all the
entrails. The sick women should lie on her back with her
head tilted back so that she can reach the uterus. After the
opening of the uterus, the women should be tilted to one
side. . . .The child should be freed from the membranes.
But the woman, if she still seems to be alive, should be
turned again on her back. The wound should be closed
with three or four ligatures by means of a needle and a silk
or other thread. On top of this should be placed a plaster
made from three eggs and some fabric of strong hemp to
which one may add . . some Armenian clay. . . .The woman
receives a sip of the best wine. Should she survive and
regain consciousness, give her a drink made of the roots of
salsify and of mountain albanum sauteed in wine. Note
that the instructions are addressed to a midwife, the
ignorance regarding anatomy (location of heart in men
versus women), the special care of intestine (oiled hand),
the use of the Trendelenburg position (to improve
exposition of the uterus), the use of analgesia (best
wine), nonsuturing of the uterus, and emphasis on
postoperative wound care.
Abdominal incision
Almost any abdominal area was suggested for abdominal incision for cesarean section.11 At first, the incision
was made on the right or on the left side along the linea
alba.11 An oblique incision was also reported.12 The next
improvement was a midline incision through the linea
alba, which was originated by Levret,13 Solayres, Platner,
or Guenin.11 The apparent advantages of midline incision
were reduced bleeding and good healing, whereas the
disadvantage was the risk of injury to the bladder. James
Blundell (1790-1878) suggested a high longitudinal
incision to minimize the risk of bladder injury and
adhesion formation, once the uterus contracted away
from abdominal wall.11,14 Blundells suggestion was not
accepted, perhaps because of heavier bleeding and
poorer healing. Pfannenstiel introduced the next improvement in 1900.15 At the turn of the 19th century,
gynecologists began to incise the skin transversely but still

December 2003
Am J Obstet Gynecol

cut the fascia longitudinally.16 Pfannenstiels crucial

contribution was to incise the fascia transversely. The
transverse abdominal incision was modified by Alfred
Maylard in 190717 and by Joel-Cohen in 1972.18 The
advantages of the Pfannenstiel incision are potentially
more secure closure, less postoperative pain, and better
cosmetic appearance. Today, apparently, the Pfannenstiel
incision is the most commonly used. Still, for most of us,
the choice of abdominal incision for cesarean section is
determined by surgeons comfort and habit.8
Uterine incision
Most of the early surgeons used a longitudinal (vertical)
incision for opening the uterine cavity.11 The vertical
uterine incision avoids dangerous lateral dissection and
allows a sufficiently enlarged aperture for safe delivery.8,11
The disadvantages include more severe bleeding, the
possibility of downward extension of the incision into the
bladder and the vagina, and a substantial risk of uterine
rupture during subsequent pregnancies.8,11 Kehrer19 in
1882 suggested the low transverse incision at the level of
internal cervical os. He believed that placing the incision
at the level of the internal os would improve the morbidity
because of the natural tendency of uterus to anteflexy.
Kehrers incision did not become popular as well as
Fritschs suggestion for transverse fundal incision.11 The
next development was one of the most dramatic advances
in cesarean technique. In 1926, Monro Kerr made popular
the transverse lower uterine segment incision as opposed
to the upper classical variety.20 In fact, several surgeons
had suggested this approach in the 18th and early 19th
centuries,11 but it did not become popular until its
introduction by Kerr. The apparent advantages are less
bleeding and reduced risk of uterine rupture during
subsequent trials of vaginal delivery. When a larger uterine
incision is needed for the delivery of the fetus, the
transverse lower uterine segment incision may be extended upward in the bilateral J shape8,21 or inverted T
incision.8,22
Uterine closure
In the 15th to 19th centuries, and even later, the
prevailing notion was that the uterine wound at cesarean
section required no treatment except for cleansing. There
was a perception that contraction and relaxation of the
uterus would make the placement of uterine sutures
ineffective, if not impossible.3 In those days, sutures had
to be removed and it was considered impossible to remove
the sutures after the abdomen was closed. For example,
Andre Levret (1703-1780) had taught that uterine sutures
in cesarean section: were not only prejudicial but were
absolutely useless because of the prodigious contractions
which the uterine muscle undergoes following delivery.13,23 Lebas, in 1769, suggested using sutures to close
the uterine incision.3,8,24 The nonabsorbable sutures of

Lurie and Glezerman 1805

Volume 189, Number 6

Am J Obstet Gynecol

silk or linen were left protruding from the wound for later
removal. In view of the ignorance of asepsis in the 18th
century, this, of course, increased maternal mortality from
infection. To obviate the risk of death from hemorrhage
and infection, Eduardo Porro offered a radical solution in
1876.25 After delivering the fetus, he performed a subtotal
hysterectomy. The mothers life was saved at the expense
of her future fertility.
A turning point in the evolution of cesarean technique
came with the appearance of Max Sangers monograph in
1882. Max Sanger insisted that suturing of the uterus was
essential, and he introduced a truly efficient silver suture
that produced minimal tissue reaction.26 Now the
mothers life could be saved without prejudice to her
future fertility. Actually, Robert Harris may have precedence over Max Sanger. Robert Harris was an American
surgeon who, in 1878, suggested the use of uterine sutures
4 years before Max Sanger did.27 However, Harris did not
advocate application of uterine sutures in every cesarean
section but only in certain selected cases. Furthermore,
Max Sanger certainly deserves the credit for awakening
the obstetric community to the importance of uterine
sutures.28 There were two other improvements aimed at
obviating infection that, however, did not become
popular. In 1906, Frank introduced an extraperitoneal
cesarean technique. The principle of this operation was to
unite the cut edges of parietal and visceral peritoneum
before uterine incision.29 In 1923, Portes performed a twostep operation.30 During the first step, the fetus was
delivered, the abdominal incision was closed around
the exteriorized uterus at the cervical level, and the uterus
was closed and left outside the abdomen. If infection was
noted, a hysterectomy was performed. If no infection was
noted, a second operation was performed, returning the
involuted uterus into the pelvic cavity. Eventually, the
incidence of infection attributed to cesarean delivery was
reduced by use of aseptic technique and prophylactic
antibiotics.31

Recent developments
There is a current notion toward simplifying cesarean
techniques to reduce intraoperative blood loss and
operating time. Blunt expansion of the uterine incision
in low isthmic transverse cesarean section was shown to be
associated with better protection of the uterine vessels and
with decreased blood loss.32 Not closing the visceral
peritoneum was shown to be associated with fewer
postoperative complications and to be more cost-effective
and less painful.33,34 Nonclosure of subcutaneous tissue
was not associated with increased risk of wound infection.35 A modified Joel-Cohen technique was shown
to be associated with reduced intraoperative blood loss
and operating time.36 A single-layer uterine closure was
shown to be of similar safety and efficacy as two-layer

closure.37 The salient points of the Misgav Ladach

method include Joel-Cohen incision, single-layer repair of
the low uterine segment transverse incision, and nonsuturing of the visceral and parietal peritoneum and
subcutaneous tissue.35,38 The result is a more speedy
recovery with early ambulation and resumption of
drinking and eating.35,38 The salient points of the
Laniado method are Pfannenstiel incision, blunt
expansion of subcutaneous tissue and the fascia, blunt
opening of parietal peritoneum, blunt expansion of the
uterus in the lower uterine segment, and nonsuturing of
visceral and parietal peritoneum and subcutaneous
tissue.39 In countries with a high prevalence of human
immunodeficiency virus, this technique might decrease
the potential exposure of the surgeons because of
minimized contact with sharp objects during surgery.

Comment
The objective of cesarean section in the ancient worlds
of Mesopotamia, India, Egypt, Israel, and Rome was
mainly postmortem delivery of dead or alive children.1-4
In the early medieval period, cesarean section was
performed by midwives or clergy purely in a religious
context.1 Withdrawal of surgery from religious authority
in Renaissance times led to the emergence of cesarean
birth as a medical procedure.1 From this point onward,
continuing improvement of surgical technique has
occurred.

REFERENCES
1. Blumenfeld-Kosinski R. Not of woman born. Ithaca: Cornell
University Press; 1990.
2. Greenhill JP. Obstetrics. 11th ed. Philadelphia: WB Saunders; 1955.
3. Boley JP. The history of caesarean section. CMAJ 1991;145:319-22.
(1935;32:557-9).
4. Lurie S, Mamet Y. Yotzeh dofen: cesarean section in the days of the
Mishna and the Talmud. Isr J Obstet Gynecol 2001;12:111-3.
5. Oppenheim AL. A cesarean section in the second millennium BC.
J Hist Med 1960;15:292-4.
6. Trolle D. The history of caesarean section. Copenhagen: Reitzel; 1982.
7. Wilson CW, Felkin RW. Uganda and Egyptian Sudan. London: Low;
1882.
8. Field CS. Surgical techniques for cesarean section. Obstet Gynecol
Clin North Am 1988;15:657-72.
9. Gul A, Kotan C, Ugras S, Alan M, Gul T. Transverse uterine incision:
non-closure versus closure: an experimental study in dogs. Eur J
Obstet Gynecol 2000;88:95-9.
10. Ketsch P. Frauen im Mittelalter. Dusseldorf: Schwann-Bagel; 1983.
11. Galbert HA, Bey M. History and development of cesarean operation.
Obstet Gynecol Clin North Am 1988;15:591-605.
12. Weems ML. Am J Med Sci 1836;8:257.
13. Levret A. LArt des accouchements. Paris: Le Prieur; 1753.
14. Blundell J. Principles and practice of obstetricy. London: E Cox; 1834.
15. Pfannenstiel HJ. Uber die Vortheile des Suprasymphysaren Fascienquerschnitts fur die Gynakolodischen Koliotomien zugleich ein
Beitrag zu der Iindikationsstellung der Operationswege. Samml Klin
Vortr Lepzig 1900;268:1735-56.
16. Baskett TE. On the shoulders of giants: eponyms and names in
obstetrics and gynecology. London: RCOG Press; 1996.
17. Maylard AE. Direction of abdominal incisions. BMJ 1907;2:895-901.

1806 Lurie and Glezerman

18. Joel-Cohen S. Abdominal and vaginal hysterectomy: new techniques

based on time and motion studies. London: William Heinemann;
1972.
19. Kehrer FA. Uber ein modifiziertes Verfahren beim Kaiserschnitt.
Arch Gynekol Bd 1882;19:117.
20. Kerr JMM. The technique of cesarean section, with special reference
to the lower uterine segment incision. Am J Obstet Gynecol
1926;12:729-34.
21. Durfee RB. Low classical cesarean section. Postgrad Med 1972;51:
219-22.
22. Patterson LS, OConnell CM, Baskett TF. Maternal and perinatal
morbidity associated with classic and inverted T cesarean incisions.
Obstet Gynecol 2002;100:633-7.
23. Eastman NJ. The role of frontier America in the development of
cesarean section. Am J Obstet Gynecol 1932;24:919-29.
24. Garrigues HJ. The improved cesarean section. Am J Obstet
1883;16:33.
25. Porro E. Della amputazione utero-ovarica come complemento di
taglio cesareo. Ann Univ Med Chir (Milan) 1876;237:289-350.
26. Sanger M. Der Kaiserschnitt. Arch Gynak 1882;19:370.
27. Harris RP. The operation of gastro-hysterotomy (true cesarean
section), viewed in the light of American experience and success; with
the history and results of sewing up the uterine wound; and a full tabular record of the cesarean operation performed in the United States,
many of them not hitherto reported. Am J Med Sci 1878;75:313-42.
28. Sanger M. My work in reference to the cesarean operation: a word in
protest in reply to Doctor Henry J Garrigues. Am J Obstet
1887;20:593.

December 2003
Am J Obstet Gynecol

29. DeLee JB. An illustrated history of the low or cervical cesarean

section. Am J Obstet Gynecol 1925;10:503.
30. Young JH. The history of cesarean sections. London: HK Lewis; 1944.
31. Wilson JR. The conquest of cesarean section-related infections:
a progress report. Obstet Gynecol 1988;72:519-32.
32. Rodrigez AI, Porter KB, OBrien WF. Blunt versus sharp expansion of
the uterine incision in low-segment transverse cesarean section. Am J
Obstet Gynecol 1994;171:1022-5.
33. Orion O, Luzuy F, Beguin F. Nonclosure of the visceral and parietal
peritoneum at cesarean section: a randomised controlled trial. BJOG
1996;106:690-4.
34. Hackmon-Ram R, Piura B. To close or not to close the peritoneum in
abdominal gynecologic and obstetric operations. Harefuah
1999;137:474-7.
35. Stark M, Finkel AR. Comparison between the Joel-Cohen and
Pfannenstiel incisions in cesarean section. Eur J Obstet Gynecol
1994;53:121-2.
36. Wallin G, Fall O. Modified Joel-Cohen technique for cesarean
delivery. BJOG 1999;106:221-6.
37. Enkin MW, Wilkinson C. Single versus two layer suturing for closure
of the uterine incision at cesarean section. Cochrane Database Syst
Rev 2000;2:CD0192.
38. Federici D, Lacelli B, Muggiasca L, Agarosi A, Cipolla L, Conti M.
Cesarean section using the Misgav Ladach method. Int J Gynecol
Obstet 1997;57:273-9.
39. Lurie S, Feinstein M, Mamet Y. Assessment of a newer technique for
cesarean section. Arch Gynecol Obstet 2002;266:195-7.