- How has obstetrical care changed, and how has it stayed the same?
- How were ethical principles of healthcare and research violated back then, and how are they violated today?
- What can we learn from the lessons of history?
Changing concepts in the management of labor” by Frederick C. Irving, MD, of Clearwater, Florida Am J Obstet & Gynec. 1954; 68(1): 224-227Dr. Irving reflected on the many changes in obstetrical care that happened between 1920 and 1950. Some of his most interesting observations are listed below: “A practitioner of 30 years ago might view the present frequent use of low forceps as somewhat radical, but results prove that given a reasonable amount of skill on the part of the operator it causes no more damage to the mother or infant than does normal delivery and it spares the integrity of the soft parts if accompanied by a suitable episiotomy. Moreover, it protects the infant from the cerebral damage that sometimes results from prolonged pressure against the pelvic floor.” “The same physician of an earlier era would probably be startled by the frequency with which at present labor is induced by rupture of the membranes, sometimes on good medical indications, sometimes to oblige the patient, but most often to suit the convenience of the doctor.” “Our elderly friend, with some justification, might well be critical of the frequency of cesarean section, which varies from 2 to 6%, depending on localities and clinics.” “The past 30 years have seen the extensive use of analgesic drugs, mostly the safer barbiturates, to assuage the pains of labor, and of an amnesic agent, scopolamine, to obliterate the memory of labor….On the other side of the picture is the so-called ‘natural childbirth’ of Grantly Dick Read and his disciples…there are no scientific data to prove that it establishes any special rapport between her and her infant or that she will love it any more deeply than if she were fast asleep when it was born….However, the method has aroused considerable enthusiasm among the women who have been delivered under it, and there certainly can be no argument against it if it makes them happy.” Other important changes that occurred between 1920 and 1950 were the transition of women giving birth in homes to almost exclusively in hospitals, the discovery of antibiotics, which drastically lowered maternal death rates from infection, and the development of safe blood transfusion, which reduced maternal deaths from postpartum hemorrhage.
“Forceps Delivery” by Arthur H. Bill, MD, from Cleveland, Ohio Am J Obstet & Gynec, 1954: 68(1): 245-249By 1954, the “high” forceps operation (when a baby was pulled out with forceps while it was still high up in the pelvis) had been almost completely eliminated. However, “mid-forceps” or “low forceps” deliveries were still used on most women. One of the most fascinating parts of this paper was when Dr. Bill justified the use of “prophylactic forceps.” Prophylactic forceps, or preventive use of “low” forceps, took place when the physician cut an episiotomy and used forceps to pull the baby out when it was crowning—not because anything was wrong, but just in case something might go wrong that could endanger the life of the child (Dr. Bill gave the example of cord prolapse, which is extremely rare—not to mention unlikely if the head is already coming out with no sign of cord). He states, “We believe that we are justified in anticipating the possible occurrence of such complications even though they are infrequent. The results of our long experience with this procedure definitely confirm our belief that the welfare of both mother and child are safeguarded.” The philosophy behind the use of prophylactic forceps is a great example of the “maximin” approach to obstetrics. The MaxiMin approach refers to the use of aggressive interventions to minimize the maximum potential losses. In other words, doctors used forceps and episiotomy during most deliveries in order to prevent very rare complications. However, only a very tiny percentage of women could possibly benefit from this approach. And unknown to most doctors until more recently, the routine use of forceps and episiotomy carried many potential harms for both women and infants.
“The use of intravenous and intramuscular injections of Demerol and scopolamine in labor and delivery.” By G.G. Passmore & Edgar W. Santa Cruz of San Antonio, TX. Am J Obstet & Gynecol 68(1): 998Dr. Passmore and Dr. Santa Cruz wanted to see if they could give women a quick and pleasant method of pain relief during labor—so they started giving Demerol and scopolamine together in the same syringe. The only harmful effects they observed were occasional nausea and vomiting (a “blessing in disguise” because it emptied the mom’s stomach), dizziness, sleepiness, and numbness. Babies did not need resuscitation any more frequently than other babies at the time (although they did not report the rate of babies who needed resuscitation). With their new routine, Dr. Passmore and Dr. Santa Cruz were able to keep their patients sleeping throughout labor. They stated, “About the only obvious signs of labor noted are deep respirations, in the first stage, and ‘bearing down’ involuntarily in the second stage. After delivery the patient lies quietly during episiotomy repair.” Based on 917 labors in which they used this routine, Dr. Passmore and Dr. Santa Cruz said that “without reservation, our experiences with it have been truly gratifying for us as well as for our patients. In the light of our statistics and the number of cases which we have handled, we feel that [this technique] offers little or no hazard to either mother or baby.” Dr. Passmore and Dr. Santa Cruz scoffed at anyone who would not want to use their technique, “Every day we see obstetrical patients who are frightened into resorting to such monstrosities as the so-called “natural childbirth” and other methods just as ridiculous in these modern times, all because sensational writers for the lay press, well-wishing relatives and friends, and even some physicians, who have little or no experience with good analgesia and sedation, force feed these unfortunate women with misinformation and nonsensical ideas concerning the use of drugs in labor and delivery. “They [mothers] are even hypnotized into believing that it is so wonderful, so satisfying, and so soothing to be awake in the delivery room, to hear that first little cry, which is more of a figment of a masochistic imagination than a reality. Most of the time it is downright disappointing to both patient and doctor for the patient to be conscious of what is going on in the delivery room… There are many couples who only have one child because of the discomfort and unhappy experiences they remember in having their first baby and more broken marriages from the resulting fear of pregnancy.” A couple of ethical issues come to light in Dr. Passmore and Dr. Santa Cruz’s article. The most obvious ethical problem is that these physicians were using an untested combination of drugs on laboring women without their knowledge or consent, and then collecting statistics to show that it was “safe and effective”—without ever comparing their patients to another group to see if it really was effective or safe. This was not research as we do it today—it was the unsystematic collection of clinical experiences to back up or “prove” pre-conceived notions. A research study such as this would never be approved by research ethics boards today. This “research study” was neither ethical nor safe for the participants, and it was so poorly designed, that it was basically putting mothers and infants at risk in order to publish junk science.
“Multiple Cesarean Sections” by Dr. James Bremner and Dr. James Dillon of Chicago, Illinois. Obstetrics & Gynecology. 1955; 6(1): 85-92.In most hospitals in the 1950’s, women were told that they must be sterilized after 2, 3, or 4 C-sections. The purpose of this paper was to describe what happens to uterine scars in women who had previous C-sections, in a setting where women were not sterilized after a C-section. This study was only possible because at Dr. Bremner’s and Dr. Dillon’s hospital, sterilizations were not allowed. The authors described 105 cases of repeat C-sections (1 woman had 7 C-sections, 2 women had 6, 9 women had 5, 29 women had 4, and 64 women had 3.) There were no maternal deaths, no sterilizations, no uterine ruptures, 1 hysterectomy due to a degenerating uterus, 2 newborn deaths (both born prematurely), and 2 stillbirths (1 uncontrolled diabetic mom and 1 stillbirth at 22 weeks). Based on their statistics, Dr. Bremner and Dr. Dillon felt that it was not necessary to require sterilization after 2 or more C-sections. They argued, “We feel that no definite limit may be placed on any given patient as to the number of cesareans she may have, but that the uterine scar in each instance must be evaluated individually… It is our belief that women who are subjected to sterilizing procedures and hysterectomies in their early years are deprived of a right which they desire, and to which they are entitled. As a result, they are subjected to demoralizing psychosomatic changes which might otherwise be avoided.”
Dr. Bremner and Dr. Dillon’s conclusion was honorable and respected the rights of childbearing women to make decision about their own fertility. Unfortunately, their conclusion was based on a sample size that was too small to determine the true risks of repeat Cesareans. But it’s interesting to read that women who had Cesareans in the 1950’s faced some of the same dilemmas as women who have Cesareans today: What are the risks of continuing to have children? Can you have a large family if you give birth by Cesarean? Should the family’s intended number of children influence delivery decisions in future pregnancies? “Maternal deaths from obstetric anesthesia and analgesia: Can they be eliminated?” By Stevenson, C. S. et al., from Detroit Michigan. Obstetrics & Gynecology. 1956: 8(1):88-98.In this paper, the authors examined 34 maternal deaths in Michigan during the years of 1950-1953 that were caused by obstetric anesthesia. Obstetric anesthesia was the 4th leading cause of maternal death at that time, behind hemorrhage (101 deaths), infection (43 deaths), and preeclampsia (63 deaths). How did these 34 women from Michigan die during childbirth? The majority of deaths were directly due to spinal anesthesia (20 deaths). Most of the women who died from spinal anesthesia were given excessive doses of medication (13 deaths) and/or received the spinal via improper technique (14 deaths). Six of these women should not have had spinal anesthesia because they had medical indications that prohibited its use (example = extremely low blood pressure). Importantly, one of the main factors behind these maternal deaths was the person who was administering the anesthetic. In fact, the individual in charge of delivering the anesthesia was far more important than the type of anesthesia or the drug being used. Unfortunately, during this time, trained anesthesiologists were not always available in the obstetric units. So anesthesia was frequently administered by residents or interns (7 deaths), obstetricians (13 deaths), nurses (8 deaths), or anesthesiologists who were not trained in giving anesthesia to pregnant women (2 deaths). It is interesting to see that many nurses on the labor and delivery role filled the role of “Nurse Anesthetists” back then. Although certified registered nurse anesthetists are well-trained today, most of the nurse anesthetists back then had no formal training in anesthesia. On labor and delivery units, nurses were often the ones responsible for giving inhalation anesthesia to patients. As the authors said, “These nurses are the faithful ‘day-and-night-duty’ representatives of the anesthesia department on the delivery floor in most hospitals, and it is they, aside from the medical anesthesiologists (who are kept busy in the surgical operating rooms), who are usually the most competent available person for the administration of obstetric inhalation anesthesia.” Unfortunately, these nurses sometimes made critical errors. In one case, a nurse gave a potent dose of Sodium Pentothal to a severely ill woman with preeclampsia who had delivered a few hours earlier. This patient, who was already extremely sedated, needed oxygen—not further suppression of her breathing—and she died within minutes of receiving this drug. The authors concluded that spinal anesthesia should only be given by care providers who have been specifically trained in the obstetrical use of these methods. Also, they stated that “no anesthetic is any better than the person giving it.” The researchers argued that at least 24 of these 34 deaths would have been prevented if the person delivering the anesthesia had been properly trained and experienced in giving anesthesia to pregnant women. The good news is that back in 1951, the authors who wrote this paper put into motion a plan to eliminate maternal deaths from anesthesia at their hospital (Herman Kiefer Hospital in Detroit, Michigan). Between 1951 and the publication of this paper in 1956, there were zero maternal deaths from anesthesia at their hospital, out of 20,650 deliveries. So to go back to their original question (which was also the title of their article), can we eliminate maternal deaths from obstetric anesthesia? In their opinion, the answer was yes—yes, we can. Rebecca’s Thoughts: Reading these articles was very eye-opening for me! I knew that twilight sleep was the norm during childbirth back in the 1950’s (my mother experienced it in the 1960’s), but I didn’t realize that so much of maternity care back then was based on little-to-no evidence. At best, the “evidence” supporting many interventions was shaky– and most of the time the evidence was non-existent. For example, I read one article where an obstetrician described how he manually removed the placenta out of every woman he took care of during childbirth. His rationale was that this was just the way it should be done. He “tracked” his statistics with hundreds of women, but his record-keeping was not scientific, and he did not provide any evidence that his way of managing the third stage of labor was safe. So many studies were conducted in extremely un-ethical ways that would never be approved by research boards today. (All research studies today must be approved by an “Institutional Review Board” to ensure that the rights of human subjects are protected.) Women were almost never informed that they were subjects of a research study. In one study, women were randomly assigned to 1 of 4 types of anesthesia during childbirth. One group was not allowed ANY pain relief during labor unless it became absolutely necessary. None of these women gave consent to be a research subject, and none of them were informed that they were assigned to a specific group. In other words, there was no informed consent or refusal. In another study on hyperemesis gravidum, women were randomly assigned to receive various drugs or placebo. One of the drugs that they gave to these women was methamphetamine or “meth.” The researchers gave meth to unknowing pregnant women to see if the psychological effects of this drug could alleviate nausea– because nausea during pregnancy was hypothesized to be psychological. Reading through these studies made me extremely grateful that research subjects today– especially pregnant women and children– have many protections. And yet– there were definitely shining pearls of family-centered care that I read here and there. In one of my favorite articles, several obstetricians described how, after they made the switch from twilight sleep to regional anesthesia, they convinced their hospital to allow men in the delivery room. The authors specifically referred to it as “letting men back in the delivery room,” because before the advent of hospital birth, most men had free access to attend the birth of their babies. Interestingly, the board of directors of the hospital (all fathers themselves) uniformly opposed letting men in the delivery room, because “we didn’t want to be in the delivery room, so certainly other men wouldn’t want to, either.” Nurses were afraid that men would faint and become patients themselves. The lawyers were afraid that there would be some kind of legal liability from allowing men in the delivery room. And the other physicians were worried that the men would mess up their sterile field. In the end, the OBs who were pushing for this change won– and lo and behold! The fathers did great! They didn’t mess up any sterile fields, they didn’t cause any extra work for the nurses, there were no lawsuits, and business boomed! Word of mouth spread, and soon this hospital became *the* most popular place to give birth in town. This family-centered change towards “allowing” fathers in the delivery room was actually quite advanced for its time, as most of the U.S. did not start to see this practice until the mid-1970’s. So what has changed since the 1950’s?
- Partners now routinely stay with the mother during the birth of the baby
- Twilight sleep became non-existent after research showed that it drugged babies for days after birth
- The C-section rate in the U.S. has risen from 2-6% to 32.8%
- Forceps and episiotomy use have become rare
- Women aren’t supposed to use meth during pregnancy anymore!
- Women are not “required” to be sterilized after several C-sections (although their future birth options are still limited because of the shortage of providers who support vaginal birth after Cesarean)
- The “maximin” approach is still common in obstetrics (for example, forbidding food during labor on the miniscule chance [less than being struck by lightning] that a woman might aspirate during an emergency Cesarean)
- Fear of legal liability, fear of change, fear of extra work, and fear of breaking the sterile field prohibit some hospitals from introducing family-friendly practices (such as allowing skin-to-skin in the operating room after a Cesarean)
- Procedures are frequently used on pregnant women without any high-quality evidence to back up their routine use (for example, requiring women to push on their backs), and sometimes even despite evidence showing that these procedures should NOT be routinely used (For example, requiring IV fluids instead of oral fluids, and recommending induction or elective C-section for suspected big babies).