Islam encouraged the seeking of knowledge.The art of healing was considered to be the most noble of human undertakings. Acquiring medical manuscripts from previous civilizations and translating them
into Arabic proceeded at a great pace. This was followed by the appearance of several great scientists
and physicians who studied these writings and produced their own, with the addition of significant
original contributions to all branches of science and medicine. In this article, I highlight the most interesting contributions to obstetrics of some of the scholars of that era such as al-Majusi, al-Razi, al-Zahrawi, ibn Sina, al-Baladi and ibn Maimon. Notwithstanding the limitations they encountered, and
absent the advanced technology we use now one must admire their conclusions based on astute clinical observations and devotion to the care of their patients as a moral and religious duty.


The period from the seventh to the fourteenth centuries is
considered the golden age of Islamic civilization. Islam
stresses the importance of seeking knowledge more
enthusiastically in the art of healing. This was inspired by
the hadith:

God did not send down any disease
without also sending down its cure.

Implied in that hadith is that Muslims are to study
diseases and find their cures. This movement started
by a determined effort by several scholars and the
support of the rulers to acquire all knowledge available at the time. Translations from Greek,
Persian, and Egyptian manuscripts proceeded at a high
pace in the 8th and 9th centuries CE. Translations of
Hippocrates, Aristotle, and Galen books
became available. These books covered different aspects
of science, but medicine attracted special attention.
Muslim physicians studied the medical knowl
became available. Prominent
books using this information but
corrected prior theories and concepts
own observations based on actual clinical practice and
experimentation. Among these promine
al-Razi (Rhazes, 841-926 CE), al
930-1013 CE), Ali ibn Abbas al
died 994 CE), ibn Sina (Avicenna, 980
Baladi (early 11thc.CE)and ibn Maimon (Maimonides1135-1208 CE). Many of them wrote
several books each. These books were translated into
several languages, including Latin, and were used for
teaching in European medical schools up to the 17
century10-14The following are their most important
books that were used for this article:

Al-Hawi fil Tibb (the comprehensive Book in
Medicine)(Liber Continens) byal
 Al-Qanoun Fil-Tibb(Laws in Medicine)
(Canon) byIbn Sina16
 Al-TasrifLiman `ajaz`an al-Ta’leef
presentation of medical knowledge for the
person who cannot compile it himself
(Chirurgia) by al-Zahrawi17
 Tadbir al-Habalawal-atfalwal
sabayawahifzsihhatihim(Management of
Pregnant women, their newborns, and
Children, and preservation of their health)
 Kamil al-Sina’ah al-Tibbiyyah
al-Maliki (The Royal Book) by Al

European historians in general have ignored the original
contributions of Muslims to the renaissance. They called
the period between Ancient Greek civilization and the
Renaissance “The Dark Ages,” ignoring the great
civilization Muslims built. Some even spread
misinformation about medical practices in Islam. An
example related to obstetrics reported in my previous
article20 is a statement made in Young’s book
“Mohammadanism absolutely forbids it (Cesarean
section) and directs that any child so born must be slain
forthwith, as it is the offspring of the devil”.

This absurd statement unfortunately has been quoted by
othersdespite the fact that there are illustrations showing
theuse of caesarean section in the Islamic world as early
as the eleventh century.11,20,21

Only recently have historians started to uncover and
report the great scientific contributions of Islamic
civilization.21-4It is the duty of present-day Muslim
scientists and physicians to explore their heritage and
bring to light the works of those early prominent

We presented some examples of the contributions of each
of these scholars to obstetrics in a previous paper. Here
I present the sum of these contributions.

Women as Healthcare providers

Women were actively involved in the practice of
medicine, especially labor and delivery. They were called
dayas (midwives). They mostly worked under the
supervision of male physicians, but many were
independent. Ibn Zuhr, known in the West as Avenzoar
(1094-1161), was one of the most renowned physicians
of Ishbiliyyah (Seville, Andalusia)
granddaughter were the first known female
obstetricians.12Darwish and Weber
women healers were able to pursue careers in medical
institutions with established positions and established
salaries both in Egypt and Ottoman society.
on the presence of illustrations of a woman performing
gynecological surgery and another woman extracting a
hydrocephalic dead fetus in the thirteent
also reported the presence of large numbers of female
physicians in Ottoman Egypt.

Prenatal care

Ansaripour et al. reported that ibn Sin
importance of healthy lifestyle of both parents (exercise,
nutrition, retention of necessary materials and excretion
of body waste, psychological balance) to ensure healthy
offspring. Ibn Sina also stressed the importance of
climate and fresh air, indicating his holistic approach to
health and specifically to care during pregnancy

However, it was al-Baladi who first dealt with prenatal
care as a separate entity. He devoted a book to it.
described morning sickness
have stomach upsets, nausea and vomiting
recommended managing itwith the consumption of
different food items and with herbals. He discussed
craving/pica (waham), increased salivation (sialorrhea),
swelling of the lower limbs,
marks) and breast engorgement, the most common
symptoms and signs of pregnancy.

Al-Baladi described treatments to reduce stretch marks.
He prescribed the use of specific ointments and soaking a
piece of cloth in certain fluids derived from herbs and
wrapping it around the legs to reduce the discomfort of
the swelling. He also described methods to
breast engorgement during lactation

Al-Baladi stated that slight vaginal bleeding (threatened
miscarriage) at irregular times is not a significant
problem, but if it occurs frequently, especially at the time
of supposed menstruation, “as if she was not pregnant the bleeding is an indication of weakness of the fetus. He
prescribed medications to help in this situation

Ibn Maimon28 also discussed some aspects of prenatal
care. He described craving for food (pica)and theorized it
to be due to “bad juices in the folds of the stomach.” He
noted that pica subsides at the fourth month because
these “bad juices will be spit up by that time through

Al-Baladi18, along with al-Razi15 and ibn Maimon
described shrivelled (retrogressed) breasts as a sign of
fetal weakness or impending death. This observation is
currently understood to be the result of low levels of
prolactin and progesterone, secondary to severe placental
insufficiency that can be associated with fetal death.

Al-Baladi18 gave detailed recommendations for the care
of the pregnant woman. Some of these are:

The pregnant woman needs more nutrition but not too
much, as this may disturb the stomach and digestion. The
increase should be moderate and consist of easily
digested food. The increase should be gradual and in
successive stages accompanied by an increase in

Bathing is good as it is pleasurable, help
pain, brings comfort and promotes good sleep. It also
quietens harmful strong fetal movement
pregnant woman should not spend a long time taking a
bath. The bath (room) should be of moderate temperature
and should have good ventilation. The water should be
sweet, its temperature should be nice, and it should
contain perfumes and vapor.18

Presumably to avoid getting a common cold, “t
pregnant woman should cover her head when there is
wind, whether it was too cold or too hot.”

She should avoid jumping, carrying heavy loads,
stooping down, loud noises and traumatic events which
can cause miscarriage.18

The pregnant woman should take extra care during the
8th month to avoid preterm delivery.18

It is better to avoid sexual activity in the first 2 months
and after the sixth month. At the latter time, the fetus is
heavy and cannot be trusted to fall during intercourse
because of the excessive movements
already ready to get out.18

We currently repeat Al-Baladi
activity to pregnant women with recurrent miscarriages
or to those who are at risk of preterm delivery.

Multiple pregnancy

Al-Razi15noted “Twins are delivered within a few days of
each other at the most. They have been conceived
together because as soon as the uterus contains the semen
(probably the fertilized egg), it closes. No more semen
can enter.” This probably refers to the inhibition of
ovulation once fertilization occurs, the result of
persistence of the corpus luteum with the secretion of
increasing levels of progesterone inhibiting FSH and LH

Al-Zahrawi17 identified that twins can be born in 2
different sacs (dichorionic diamniotic) or in one sac
(monochorionic monoamniotic
twins usually survive, triplets rarely
or higher or dermultifetal pregnancies
miscarried.17 Multiple pregnancies were recognized to be
one of the fetal causes of difficult labor

Fetal presentation

Al-Razi stated: Fetuses normally present by the head. If it
was presenting by the breech it turns into head by the
eighth month as the head is the heaviest part of the fetus
and will gravitate downwards. … Fetuses delivered
before the eighth month commonly present
they usually die. … [T]hey are weak and therefore could
not turn in head-first position.

It is true that a higher percentage of preterm deliveries
are breech deliveries, but the higher death rate is
primarily because of prematurity. It is
breech delivery is more stressful to the fetal head
especially to the less ossified skull of a preterm fetus

Al-Razi further stated, “If foot or hand presents, it can
cause death of the fetus and mother
referring to transverse/shoulder presentations with
prolapsed arm This malpresentation if uncorrected will
lead to obstructed labor,
maternal death. He further described the complication of
cord around the neck and that it can be a cause fo
difficult labor and fetal death

Other scholars16,18 described some of the fetal mal
presentations, but al-Zahrawi can be credited with a detailed description of all malpresentations and
methods to effect delivery in each case.17

Onset of Labour

Ibn Sina noted that “Initiation of labor occurs when
the fetus cannot get enough blood (nutrition) from
the placenta.”16 We now know the placenta ages
with the advance of gestation and becomes less
efficient in gaseous exchange and transfer of
nutrients. That is termed placental insufficiency
it is,as ibn Sina postulated, is implicated in theories
of labor onset. Ibn Sina continued, “At
fetal organs are completely developed, and it starts
to move towards the exit usually starting at the
seventh month and it comes out on the
Delivery occurs when the membranes are torn.”

Al-Majusi was the first to describe that ute
contractions are what causes the delivery.
that, it was thought that contractions are only the
indication of onset of labor, but subsequently the
fetus swims its way out of the womb and birth
canal.11 Hippocrates likened delivery to the proce
by which the chicken hatches out of the egg.

Al-Razi noted that “sexual intercourse brings on
labor and facilitates delivery.”15This observation is
now explained by the effect of oxytocin release and
deposition of seminal prostaglandins in the vagina
Both are oxytocic agents that initiate and potentiate
uterine contractions.

Management of Labour

Al-Razi noted that” if labor pains are in the pelvic area,
labor will usually be easy, but, if the pain is mostly in the
lower back, labor will usually be difficult
that this latter type of pain is associated with the occipito
posterior position of the fetal head and is associated
withprolonged labor.

Al-Razi instructed that” midwives should examine the
parturient before embarking on the delivery. Specifically,
the cervix needs to be checked to see how much it is
dilated,to determine what is the presenting part, and to
follow the progress of cervical dilation until it is
sufficiently dilated. Then they can ask the parturient to
push down the fetus.”15This is how we manage labor

Causes of Difficult Labour

Ibn Sina16 classified causes of difficult labor into
maternal, fetal, faults in the uterus or placenta, timing of
delivery (preterm and post term), or mistakes by the
midwife. This is still a valid classification.

Ibn Sina enumerated maternal causes. “The parturien
may be weak, malnourished or diseased, too scared, very
young or old, obese, restless, or impatient with the labor
pains”. He also listed some causes that indicate his
knowledge of the mechanical aspects of laboring
pelvic anatomy. He understood
bladder, rectum or colon, urinary retention
hard fecal matter all can cause obstructed labor.

Ibn Sina listed these fetal causes “female gender, big
size, big head, being too small (light) such that it cannot
forcibly “fall down”, anomaly such as double head, mal
presentation, more than one fetus. Also, a dead fetus
cannot help in the process”. The latter seems to indicate
that he was still convinced with Hippocrates’
the fetus pushes itself out of the birth canal
causes, except female gender

Ibn Sina’s uterine causes included small size (probably
referring to a contracted pelvis), improperly healed
cervical ulcers, or tears, and
He did not define what the latter
to what we now call placental abruption
of the placenta separates from the uterine wall causing
vaginal bleeding associated with pain
intermittent and repeated, somewhat similar to the
symptoms of hemorrhoids.

Ibn Sina16 mentioned among placental causes of difficult
labor “thick placenta” without identifying what it is.
Could he be referring to placenta previa? In this
condition the placenta is located in the lower uterine
segment and an examining finger will feel
between itself and the fetal
included “dry uterus” as another placental cause. He is
referring to oligohydramnios probably caused by
premature rupture of the membranes. He ascribed the
difficulty to the fact that ‘the birth canal is not

Ibn Sina considered preterm delivery as a cause of
difficult labor. He discussed the outcome of preterm
delivery: “Fetuses delivered before the seven
too weak to survive. … Fetuses delivered at the eighth
month are more prone to die than those delivered at the
seventh month, especially female fetuses was stated by Hippocrates29 and shared by many
subsequent scholars such as al-Baladi.18
this by the fact that delivery is aided by fetal movements,
like a chicken emerging from an egg,29
at the 7th month, the fetus tries to get out and, if “strong”
enough, will be born and survive. Those who are bor
the eighth month must have been too weak to be
delivered and hence the lower chance of survival. If they
remain in utero till the ninth month they will ‘recover’
and become stronger and will survive when born
we know this is untrue and, in fact, the chance of survival
of a preterm newborn increases the longer the pregnancy
progresses, it is interesting to note that this mistaken
belief still lingers in uneducated lay people until our

Ibn Sina16 specified “faults by the midwife” as a caus
difficult labor. This is very true. For example
application of the forceps, by the obstetrician,
head will result in a failed forceps delivery and both fetal
and maternal complications.

Management of Difficult Labour

Al-Razi15 gave different prescriptions of medicinal herbs
with their respective dosages and recommended special
kinds of food to “facilitate” labor and delivery. He
described different maternal positions to facilitate the
delivery of the fetus in certain malpresent
difficult vertex delivery, he would have the parturient in
the lithotomy position and then insert a catheter in the
uterus and infuse certain fluids. If the fetus were still
alive, he used fluids with lubricant effects. If the fetus
was dead, he used spicy fluids.15

Ibn Sina described the management of difficult labor in
vertex presentations.16He possibly was the first to use an
instrument to be applied to the head of a live fetus and
then to pull it out (a precursor of the obstetric
forceps).Theiry30considered ibn Sina a putative inventor
of the obstetric forceps. He stated that “ibn Sina
Canongave the following directions to the midwives for
delivery of the impactedfetal head: Apply a sling (fillet)
around the child’s head and endeavour to extract it. If this
fails, the forceps are to be applied and the child extracted
by them. If this cannot be accomplished, the child is to be
extracted by incision (of its head) as in the case of a dead
fetus.” He continued, “[I]f the head bone is big, o
up so the inside liquid flows out.” He was
describing hydrocephalus and craniotomy

The proposition that ibn Sina was the inventor of the
forceps has been corroborated by Dunn who reported a quote by Smellie “with regard to the fillet and
they have been alleged to be late inventions; yet we find
Avicenna recommending the use of both. The forceps
recommended by Avicenna is plainly intended to save
the fetus; for he says, if it cannot be extracted by this
instrument, the head must b
method used which he described in his chapter on the
delivery of dead fetuses.”31

Ibn Sina16 also described how to deliver a fetus that is
coming by janb (side) that is transverse presentation. He
described the procedure: “first by ma
podalic version), if unsuccessful, by use of
(hooks) and, if unsuccessful, by dividing it in pieces
(evisceration) as in the delivery of a dead fetus

Al-Razi described the procedure of internal podalic
version in the management of transverse lie
scholars discussed the management ofsome of the fetal
malpresentations, but it is a
detail, in chapters 75-78 of his book
malpresentations and described
delivery under each of these circumstances, such as
replacing the hand, internal podalic version, etc

Al -Zahrawi17 then stated, “If these
unsuccessful, one would resort to changing the position
of the parturient, shaking her,
seat, Valsalva manoeuvre.” Also
whole host of herbs.He would recommend mixing
mucilage of fenugreek, oil of fumary, and gum and
pounding them in a mortar and then anointing the
woman’s perineum and making her sit
water reaching to the ribs. Then he would make a
suppository of murrh and introduce it in the vagina and
after an hour make the woman stand. It would be
interesting to investigate the composition of these
materials and determine if they have

If all fails, al-Zahrawi17 will resort to the use of surgical
procedures such as cutting
using scissors in cases of shoulder dystocia, craniotomy
using a spike shaped scalpel
head using a mishdakh (cephalotribe), or evisceration
using hooks and scissors when the fetus cannot be
delivered otherwise or is already dead.

These instruments were among about 200 instruments
illustrated in his book (Figure
instruments were of his own design.
illustrations of the midfaa (thruster,
cranioclast) (Figure 2), mishdakh
(Figure 3), miqass (scissors) rod), hook(crotchet), mibdaa’ (scalpel)
(claws).17These instruments probably formed the basis of
the design for modern obstetric instruments.

It is noteworthy that there is no illustration of obstetric
forceps in al-Tasrif. While this may be an
could mean that al-Zahrawi was unaware or did not use
an instrument to extract a live fetus. This is noteworthy
based on our knowledge that ibn Sina, who was almost a
contemporary of al-Zahrawi, described the use of
obstetric forceps for the delivery of impacted fetal

Management of Obstructed Labour

Al-Zahrawi described in detail the management of the
different cases of obstructed labor.17. His detailed
description signifies his experience and clinical acumen

If the fetal head is large, and it is tightly
squeezed in exit, or if there is a collection of
fluid in the head (hydrocephalus), you should
introduce between your fingers a spike shaped
scalpel, a midfaa’(perforator) and split the head
to let the water out or you should smash
the instrument called mishdakh
cephalotribe), then you should draw out the
bones with forceps. If the head comes out and
the fetus is held up at the collar bones (shoulder
dystocia), an incision should be made
(cliedotomy).If the thorax is impacted, perforate
it to let out the humidity in it (hydrothorax), the
thorax will then shrink. But if it does not, then
you cut off pieces in any manner possible
(evisceration). If the lower belly is swollen or
dropsical (ascites) then you should make
opening to draw out all the fluid.
If the fetus presents by the feet, then the
extraction will be easy, and it will be a simple
matter to guide it to the maternal opening. If it is
stuck about the thorax or abdomen, then pull on
it with a cloth around your hand and cut an
opening in the abdomen or thorax to allow the
contents to flow out (evisceration).
If the fetus presents laterally (transverse) and it
is possible to reposition it (podalic version)
apply the manoeuvres for a living fetus, but if
this is not possible then the fetus should be cut
away piecemeal, then extracted.

If the vagina is closed on account of an abscess,
operative procedures should not be done. In
these cases, use infusions of grease and humid
herbs. The woman should sit in a bath of
softening and moisturizing waters

Extraction of a Dead Fetus

Ibn Sina16 discussed the management of the fetus that
there is no hope of being born alive, “labor lasting for
more than 4 days the fetus must be dead”. He advised
quick delivery, otherwise “the dead fetus will rot (swell)
andits extraction will become more
use ointments and grab the fetus manipulating it to be
extracted. If unsuccessful, he advised attaching hooks
and cutting the fetus into pieces (evisceration)

Al-Zahrawi17 described the operation to extract a dead
fetus. His detailed methodical description shows his
thoroughness and the effectiveness of his instructions to
the midwife:

You first examine the woman to see if she is
healthy or has a disease
life. Put the patient in the lithotomy position and
hold her down firmly. Then anoint your hand
with oil sand, mucilage of mallow sand
fenugreek with linseed and moisten the vaginal
opening. Gently introduce your hand into the
passages and locate the most suitable part of the
fetus to fix kooks into according to its
presentation. If it is the head, attach the hook to
the neck, mouth or beneath the chin, or if you
can, reach to beneath the ribs (probably in
oblique or transverse lies).
presenting, fix the hook to the pelvic region.
Hold the hook in the right hand and put the
curved part between the fingers of the left hand
and introduce the hook gently and fix the hook
as above. Then opposite it, let her (the midwife)
fix another or a third hook so as to give even
traction. Then she should pull evenly not just in
a straight line but with the fetus moved from
side to side so that its exit may be eased. From
time to time the tension must be relaxed, and if
any part of it be held up, the midwife must oil
some of her fingers to introduce them to one side
to manipulate the retained part. And if only a
part of the fetus comes away, she should shift
the hooks to other parts a little higher up and so
on until the whole of the fetus

Delivery of the Placenta

All these early scholars noted the need for complete
expulsion of placenta after delivery of the fetus and
discussed how to effect that. Al-Zahrawi specifically
stated “It is necessary that not a scrap of the afterb
left behind in the womb,”17astatement to which
completely ascribe. These scholars usually start by letting
the woman sneeze while closing her mouth and nose
(Valsalva maneuver). Then they will use vapors of
certain herbs introduced in the uterus while the woman is
sitting. If this fails, they will resort to its manual removal.
Al-Zahrawi stressed the importance of separating the
placenta from the uterine wall gently and then pulling it
from side to side, avoiding violent pulling
in rupture of the uterus or inqlab al rahim
inversion), a serious complication that may lead to
maternal death.17
A very thoughtful description that we follow now to
avoid these two very serious complications;
inversion of the uterus.

Al-Zahrawi realized that sometimes removal fails. We
now call this adherent placenta or placenta accreta.
was probably the first to describe this condition
circumstance, he injects tetrapharmacon ointment in the
uterus that will soften and dissolve or cause
“putrefaction” of the placenta in a few days. That will
loosen it, and it will come out.17

Extra-Uterine/Abdominal Pregnancy

Al-Zahrawi described a case of abdominal pregnancy.
The extra-uterine sac turned into an abscess which started
drainage with extrusion of the bones of the dead fetus.
With proper treatment (evacuation and dressing) the
woman survived in good health for a long time. His
description of the case demonstrated his clinical

Now I myself once saw a woman who h
become pregnant, and the foetus had then died
utero; then again, she conceived and the second
foetus also died; and after a long while she got a
swelling in the umbilicus which grew and
eventually it opened and began to produce pus. I
was called in to attend to her, and I treated her
for a long while, but the wound did not heal up.
So, I applied to it certain very strongly drawing
ointments, and then a bone came away from the
place; then a few days passed, and another bone
came out; and I was mightily astonished at this, seeing that the abdomen is a place where there
are no bones. I formed the opinion that these
were bones from a dead foetus. So, I
investigated the place and got out many bones
belonging to the head of the foetus. I continued
this procedure and got a great number of bones
out of her, continued the
dressing till it healed and
the best of health.17

Fetal and Infant Deformity

Ibn Sina16 discussed the causes of fetal and infant
deformity. He had the insight that some are caused by
inherent (genetic) factors. He stated that “some of these
agents (that cause the deformity)
beginning because of a defect in the formative power of
the sperm. “Other determinants of deformity “
force later in life — namely in parturition, during the act
of traversing the maternal passages. Others operate after
birth (tight binders and wrappings). Others operate in
infancy, before the limbs are hard enough to enable the
infant to walk”.


I would like to conclude by quoting Spink and Lewis
Attention is specially drawn to the
gynecological and obstetrical instruments
used by the “Arabian” doctors. It is shown
that in this branch at least, the “Arabians”
were by no means wholly
the classical writers.… [T]hey altered and
improved, out of recognition, the ideas they
received from classical sources.
Spink and Lewis continued
The speculum, the forceps, the lever and the
crotchet mark in a special way the original
Arab genius. It is also shown that the Arabs
had developed a clear practical idea of what
is normal, of what varieties of abnormality
were to be met with, and by no means least,
of prognosis, in obstetrical practice.


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