Chapter 1 ~ A Time Traveler’s Perspective on Normal Childbirth  ~ copy WORD doc ~ savd Jan-17-2025

by faithgibson on January 17, 2025

in Contemporary Childbirth Politics

Word Count 8836 Jan 17, 2025

Note-to-self  Jan 2025 — Need to remove all unwanted spaces btw paragraphs

Note to self ~ Apparently I was editing two different version of Ch 1 without realizing it. This version has 8 pages of new material, but is too wide a scope of topics and too much detailed,  so I don’t think it’s better than the original

Chapter 1 ~A Time Traveler’s Perspective on Normal Childbirth  

I am a time and place traveler who watched the 20th-century history of childbirth practices in the United States unfold decade by decade. When I was 18 years old, I entered a hospital-based nursing school program immediately after graduating from high school. My first job after graduation was working nights in that same hospital’s labor and delivery unit.

There I experienced the uniquely aggressive style of American obstetrics first adopted in 1910 and so remarkably different from other wealthy industrialized countries. Most European countries use trained and highly experienced midwives to provide prenatal care and childbirth services to healthy women, with the full cooperation of MD general practitioners if the midwife has a question, there’s a problem or the laboring woman needs to be transferred to the hospitalized, which accounted for 70% to 85% of the childbearing population.

However, the standard of care in the US includes extremely interventive policies and practices that were used on healthy childbearing women as well as those with high-risk pregnancies or complications. When I came on the scene 50 years later (late 1960s and 1970s) these obstetrical interventions and invasive practices were virtually unchanged from their 1910 origin. As a result, my experience as an L&D nurse in 1970 was like working in a time warp, in which the way-back machine was set for the 1920s. I felt like I had fallen into Alice’s Wonderland, complete with the “off-with-her-head” queen, or in this case, the chief of the obstetrical department.

I’ve always been a naturally curious person with a lot of questions about what I saw. During my years of hospital nursing, I was particularly curious about the normal biology of childbirth, the vastly different ways women gave birth, and the divergent childbirth practices used by the obstetricians who delivered babies in the Southern hospitals where I began my career in maternity care.

First as a nursing student and then as L&D nurse in a racially-segregated southern hospital, I saw and directly participated in a smorgasbord of childbirth-related experiences. This included mothers who delivered precipitously and unassisted on an ER gurney, or sitting sideways in the wheelchair racing them up five floors in the elevator from the lobby. Other mothers arrived at the door of the L&D in such an advanced stage of labor that we had to cut their jeans off so the baby could be born. On the other end of the scale, I provided care to laboring women who suffered for days in an obviously painful but nonetheless ineffective labor that eventually ended in Cesarean surgery.

But there were nights when there weren’t any labor patients in the L&D unit. I took advantage of that as an opportunity to read the obstetrical textbooks that our older doctors brought in when they were retiring. Some were genuinely rare books, such as Dr. Joseph DeLee’s 1924 edition of Principles of Obstetrics. I read and continue to study every resource I could get my hands on about the history of maternity care, normal childbirth, and the practice of obstetrics through the ages.

I was particularly interested in how the US compared to other wealthy and industrialized countries. The answer was a shocker since everyone, including me, assumed that American had the best of everything medical, including our hospital-based obstetrical system. Boy was I wrong!

It turned out that historically the United State has one of the very highest maternal mortality rates of any developed country and that is still the case today. We are in 128th places Our country is one of the most unsafe places in the developed world to have a baby! American women would be safer having their babe in Uruguay, Tajikistan, Saudi Arabia, Russia, Iran, Albania, Bahrain, Chile, Hungary, Kuwait, Korea-South, Kazakhstan, Bulgaria, Bosnia-Herzegovina, Estonia, Qatar and, Croatia than in the United States.

Our high maternal mortality rate is not at all a new problem. In the early 1900, a well-known obstetrician of the day described the high mortality rate in the US as second only to Brazil.

My research into the dangers resulting from the routine use Twilight Sleep drugs, general anesthesia, obstetrical interventions and surgical deliveries forged a connection with other childbirth activists who also discover the truth about the standard American obstetrics desperately needed to be re-assessed and dramatically changed. What was sorely missing was a function distinction between childbirth services that were appropriate for the 70-to-80% of healthy women with normal term pregnancies who didn’t want to be routinely narcotized, anesthetized and didn’t need, medically-speaking, to be delivered by obstetrical forceps and the minority or about 25% of childbearing women who had high-risk pregnancies, were in premature labor, developed complications, or suffered an obstetrical emergency.

A quick history of the right and wrong uses obstetrics

Obstetrics in Western Europe was developed over several centuries that trace as far back as the 1600s. Its purpose and goal was to provide doctors with the ability to intervene when something went terribly wrong during pregnancy, childbirth and the immediate postpartum period.

This required accurate scientific knowledge of female reproductive anatomy, direct experience with normal labor and birth in healthy women and developing various manual “rescue” techniques to deliver a baby that for some reason was “stuck” or died in utero.

The very first obstetrical intervention in an attempt to save the mother’s life in obstructed laborwas “podalic version”. This required the doctor to insert his hand into the mother’s vagina, and up into her uterus and then grabbed hold of the baby’s feet and pulled it out.

Prior to this, the only treatment for obstructed was for doctors to wait until the unborn baby died, and then use sharp instruments inserted through the mother’s vagina to dismember its body and pull it out in pieces. However, often this was preceded by two or three days of continued fruitless labor before the baby finally died. During this time, the mother often got a raging infection that also killed her.

Whatever criticism any of us may have about the current overzealous use of obstetrical interventions, nobody ever wants to go back to the really, really “bad old days”!

Forceps were introduced in the 1600 century and according to the description in the original document “was later refined by historically famous(self-described “men-midwives”  like William Smellie”. Long before the professionalism of “obstetrics”, doctors who attended “cases of childbirth” were simply rerefered to as men-midwives” is – {vo78p00311.pdf}

In Victorian times, Simpson championed chloroform anesthesia, Lister pioneered antisepsis, and cesarean section was introduced as a last-ditch effort to save the baby’s life or in the case of a very recent maternal death, to possibly save the baby’s life.

In addition to different manual maneuvers, various obstetrical instruments were invented, the most famous being obstetrical forceps. Other types of “rescue operations” to treat obstrusticed labor were also developed, beginning with “podalic version”. This was a physical maneuver by the physician in which he push the unborn baby’s head back up into the mother’s uterus and then insert his hand into the uterus and after grabing the baby by it’s ankles,  pull the baby out of its mother’s body.

This obviously was very dangerous for many reasons but even when the baby lived and the other didn’t hemorrhage, living in the pre-antibiotic era make it very likely that the new mother or baby or both would die from a fatal infection that occurred when the doctor reached his bare hand up into her uterus.

As a result, obstetricians continued to search for less dangerous methods. This began with the invention of forceps by the Chamberlin family of doctors. Unfortunately, the use forceps risked unintentional harm to the mother’s uterus and the unborn baby, and the same risk of puerperal sepsis as a result of putting unsterile instruments up into the sterile body cavity of the mother’s uterus. Then in 1851 ether, the first non-lethal general anesthetic, was discovered and the most well-known of all emergency obstetrical procedures — Cesarean surgery – became possible. However, this still exposed mother and baby to the historic danger of untreatable fatal infection!

Over the four-hundred-year development of the art and science of modern obstetrics, a great many “trial and error” efforts were required before the effective use of obstetrical interventions and surgical instruments provided a reliable working process. But eventually, this knowledge base became a standard part of medical education and obstetrical practice in the Western Europe and the United States.

Giving birth on the right or wrong side of history

Childbearing women who lived during the many thousands of years before the modern era of obstetrical medicine found themselves giving birth on the wrong side of history. This enormous span of time was remarkable for our inability as a species to effectively treat the well-known complications associated with pregnancy and childbirth. For these unfortunate women and their families, the world was a cruel place

But for pregnant woman living in impoverished third-world countries without reliable access to modern maternity services, childbirth is still as dangerous in the 21st century as it was hundreds of years ago. The problem usually starts with extreme poverty and a general lack of education in combination with a misogynist dictator. His corrupt regime regularly redirects public funds that are suppose pay for a national healthcare service to him, his families and all his corrupt buddies.

In other circumstances the problem is religious zealotry. In that case pregnant women are not allowed to leave their homes or to be cared for by male physicians. In those cases, the modern world is just as cruel for childbearing women as it was during in pre-scientific times.

While not quite as extreme as undeveloped countries, pregnant woman living in the US in extremely poor areas still face many of the dangers pre-scientific times. Whether they live in a crime-ridden inner-city neighborhood or underserved rural community, they will have a hard time finding a doctor willing to provides obstetrical care under the federal Medicaid program. Eventually they will find a “Medicaid mill”, which typically is a professional group of OBs, usually 5 or 6 that practice that collectively to deliver thousands of babies every year.

When you do, its highly likely to be very inadequate, slap-dash care that starts with a burdensome and intrusive bureaucracy and over-worked and short-handed office staff. Between the one OB and two nurse-practitioners or midwives, they see as many of 150 OB patients a day. This means waiting an hour or longer to see a hurried and distracted doctor or nurse-practitioner for 5 or 6 minutes. This is prenatal care conducted like a speed dating event — remarkable for being too little, too late, and not meeting your basic biological, psychological and social needs, never mind developing a trusting relationship.

All these issues will be much more difficult if you also are a single mother, a woman of color, an immigrate without papers, and/or your English is not very good. The care provided to women in this category is most accurately described as “under treatment”.  This is bad medicine, bad for mothers and babies and bad for society. Legally it often constitutes obstetrical malpractice.

If as a pregnant woman you find yourself in “fortunate circumstances” – physically healthy with a normal pregnancy, well-housed in a safe neighborhood, well-fed, good job with a middle or upper class income, excellent health insurance, and the patient of a very popular obstetrician highly recommend by several of your friends. You would have every good reason to both believe and expect the care provide by your obstetrical team – your private OB and all the nurses working in the labor and delivery unit of the hospital where you will give birth — would provide the very best care available anywhere in the English-speaking world. Care provided during your labor and the baby’s birth would naturally be predicated on the latest scientific discoveries, most up-to-date technological equipment and hospital policies and protocols known as as “best practices”.

 

Such ‘best practices’ are arrived at by integrating the best scientific knowledge at the time with the most up-to-date supplies, equipment and electronic technologies and then combining all that with the formal recommendations provide by recently-published, peer-reviewed scientific studies. Since science and technology are constantly changing, the contemporary definition of obstetrical “best practices” also changes with the passage of time, economics, and other factors.

 

A hundred years ago, obstetrical “best practices” included the use of Twilight Sleep drugs during labor and putting women to sleep with general anesthesia, doing an episiotomy and delivering the baby with forceps. In contemporary times — third decade of the 21st century — ‘best practices’ for obstetrical care include elective induction of labor starting sometime during the 39th week and certainly inducing every mother-to-be by 40 weeks and 4 days of gestation. For reference, the “due date” given to new mothers is based on 40 full weeks as the normal or ‘term’ gestation for the human infant.

 

Women who go into labor spontaneously are admitted to the hospital’s L&D unit and connected to the hospital’s electronic fetal monitoring system. This includes two belts fitted with large electronic sensors (abt 2 ½ inches around) that encircle the pregnant woman’s abdomen and are connected to the computer via 2 long cables. One of the sensors calculates the fetal heart rate very two seconds and displays an average “beats per minute” (bpm) on the monitor’s screen. While this number changes often, but usually range is between 110 bpm to 160 bpm. The sensor in the second belt records the presence and length of uterine contractions.

 

Most hospitals now have central monitoring system that transmit the data coming from each labor room to a bank of fetal monitor displays at the Nurses’ desk in the hall. This is where the nursing staff and obstetricians sit and watch the displays so they can tell if the unborn baby is OK.

 

Most healthy women with a normal term pregnancy expect their labor to start on its own whenever the time is right. As a healthy pregnant woman, they typically assume that the many drugs and surgical procedures that obstetrical medicine uses to treat serious complications would never be used on them during unless they have an obstetrical emergency of some sort during their labor.

 

But in the typical American hospital, current “best practices” for healthy women with normal pregnancies includes medical and surgical interventions such as the universal use of continuous electronic monitoring and starting an IV as soon as the mother-to-be is admitted the L&D unit. IV Pitocin is routinely used to speed up labor and unplanned Cesarean for inadequate progress” or a fetal monitor strip that the staff or OB defines as “non-reassuring” or possible indications of fetal distress.

 

ChildbirthConnection.org, an organization founded by nurse-midwives in 1918 (originally the Maternity Care Association of NYC) conducted three separate surveys over a span of 11 years to identify the rate obstetrical interventions in American hospitals. By interviewing women who gave birth in American hospital within 15 months, they were able to identify the average rate obstetrical interventions in American hospitals. The first survey (?? date) was 93%, with an average of seven substantial interventions. Not counting artificial rupture of membranes, over 50% of American labor patients had one or more surgical procedures performed. This includes an episiotomy, vacuum extraction, forceps, manual removal of the placenta, Cesarean or emergency hysterectomy.

 

The Right and Wrong Use of Obstetrics in the US

 

The Making of a Childbirth Activist   

 

My journey to becoming a childbirth revolutionary began with my job as a hospital L&D over the course of a decade. The second and equally formative experience was the spontaneous and undisturbed birth of my first baby, a daughter born in the back seat of our family’s Renault as my husband turned in the hospital’s ER driveway. The next important milestone was my training as a Lamaze-certified childbirth instructor, which automatically made me an outspoken advocate for those who had chosen “the road less traveled”—“natural birth”.

 

Nonetheless, the cultural standards of the time assumed that the “doctor always knows best”, so the advice from the older more experieced women in the family insisted that first time childbearing women “just do what the doctor says”   never questioned their obstetrician or the “business as usual” practice of the obstetrical profession.  I was present on many occasions when the obstetrician provided information to a newly admitted labor patient, saying:

 

“Don’t worry, I left orders with the nurses to give you medicine so you won’t remember ever having had any labor pain and when the baby’s about to be born we’ll put you to sleep so you won’t feel anything.”

 

However, my Lamaze students were a radical group of pregnant women, many of whom had read “Our Bodies, Ourselves” by the Boston Women’s Collective and soundly rejected the ideology of “business as usual” obstetrics and the highly interventive “standard of practice” adopted by America obstetrician nearly in 8o years ago, a standard that was in direct conflict the historically non-interventive model of maternity services provided by professionally trained midwives used for centuries in Europe.

 

Instead, these women claimed their ethical right to say “no” to invasive or painful interventions such as episiotomy and forceps delivery that they didn’t need or want. They were planning to have an unmedicated, un-intervened with normal labors and births that did not include the routine use of  electronic fetal monitoring, narcotics, Twilight Sleep drugs, general anesthesia, episiotomies, forceps, manual removal of the placenta and all the other hospital protocols and obstetrical interventions they believed, and the scientific evidence fully affirmed, were not medically appropriate for healthy women with low-risk term pregnancies.

 

Unfortunate, the American obstetrical profession did not get the memo, and they just kept on using the model launch in 1910 by Dr. J. Whitridge Williams and his many associates and in essence, weaponized the process by simply giving “Doctors Orders “ to the L&D nursing staff that directed them, with or without the patient’s permission, to medicate all new admitted patients.

 

At that time, I was working in the L&D unit at Holiday Hospital in Orlando Florida, a newer and smaller hospital only a block away from Orange Memorial where I had trained. However, the same obstetricians had practice privileges at both hospitals, so Doctor’s Orders for medicating all our labor patients was the same – injections of 100 mgm of Demerol and 1/150 of a grain of scopolamine on admission, to be repeated q 2 to 3 hours until delivery.

 

This was a while before pharmaceutical companies began to use “single dose” packaging of drugs. In order give injections of Demerol and Twilight Sleep, the nurse began by taking the plunger out of the syringe and dropping the 1/150th tablet of scopolamine down the barrel.

 

At that time, the drug scopolamine was a very tiny white table the same size and shape as the newly available non-caloric sweetner “saccharine”. After dropping the tablet down into the barrel, the plunger of the syringe was replaced and about 1 cc/ml of sterile water was drawn into the syringe and shaken until the table was completely dissolved. Then a single dose glass ampule of 100 mgm of Demerol was snapped open and drawn up in the same syringe, and per Doctors’ Orders injected into each of our labor patients every 2 or 3 hours.

 

As a new graduate, my professional and personal experience with the different ways normal childbirth was managed in American hospitals did not stop there.

 

As childbearing woman myself, I was scheduled to give birth in the same hospital where I trained as a nurse and worked in the L&D. I knew I would be exposed to unnecessary, painful and risky interventions that had been baked into the obstetrical cake half a century before.

 

In an attempt to avoid the hated Twilight Sleep drugs, invasive obstetrical interventions, general anesthesia and unnecessary but routine surgical procedures, I delayed going to the hospital until the last minute. I hoped to be so far along in labor that my baby would be born before there was time to do any of these things. Nice idea but Mother Nature had other plans – something that sealed my fate, leading me away from L&D nursing and eventually to become a professional midwife.

 

That “something” was simple: I gave birth to my first baby in the back seat of our car just as my husband turned into the hospital’s ER driveway. I reach down as my baby’s head and the rest of her body slipped quietly into my hands and she made a meowing sound that meant she was breathing normally. I laid her wet warm body on my tummy and kept my hands on her to be sure so continued to breathe and help keep her warm. Compared to the world of sequential obstetrical interventions and invasive surgical procedures, this undisturbed normal birth was a profoundly “normal” (and normalizing) experience!

 

This was the first in becoming an advocate for normalizing normal childbirth in healthy women with term pregnancies. I’ve dedicated my life to making maternity care work for better for healthy childbearing women who don’t need of want the invasive obstetrical interventions, general already anesthetics and surgical procedures that had been the standard of care for the last 50-plus years and had no reason or desire to change courses.

 

Unfortunately, I was fired more than once for supporting the legal right of a healthy labor patient to decline “standard” obstetrical interventions. As a hospital employee, it was obvious to me that I would not be able to make any changes in this entrenched system. With regrets, I walked away from obstetrical nursing, which I really loved, and joined a domestic Peace Corps project in a small farming town in North Carolina.

 

As a Vista volunteer, I worked on several public development projects that included setting up a Farmer’s Market every Saturday morning. This was well received and we were able to successfully integrate by the black and white members of the community without incident. When my assignment ended, I was in my early forties and decided to move my family to the San Francisco Bay area. Soon after arriving I got involved with the tradition midwifery, which at the time was trying to get a direct-entry midwifery licensing law passed in California.

 

In the meantime, I cross-trained into traditional, non-nurse or “lay” midwifery by apprenticing with an extremely talented lay midwife – Donna Driscoll. Donna had been personally trained by a professional midwife (Katheryn Mathews) who’d been trained in the UK. She and her husband were temporarily living in student housing on the Stanford University Campus while her got his PhD.

 

This period of my professional life was extraordinarily important, even foundation to my future. During all the years of hospital L&D nursing, I knew the childbirth practices that had been the ‘standard of care’ since 1910 — Twilight Sleep drugs, general anesthesia followed by a series of surgical interventions that included episiotomies, dangerously forceful fundal pressure, forceps, manual removal of the placenta, etc. – were not biologically necessary. That was amply demonstrated by my experience in the hospital’s segregated black ward on 1-South.

 

These black mothers were unmedicated and their natural labors were neither hampered or augmented by the interventions routinely used on their white counterparts. Black mom delivered quickly, spontaneously and without incident, often as we wheeled on the stretcher into the elevator in an attempt to get them to the delivery rooms upstairs on 5-North before the baby was born. They didn’t have a single whiff of anesthesia or even one of the five routine surgical interventions though to be so essential; best of all, their babies breathed on their own and were perfectly healthy.

 

The “routines” used for the last 50 years on 5-North were considered by the obstetrical profession to be central to the 20th century practice of obstetrical medicine, therefore seen obstetricians as “best practices”. Nonetheless, this interventive and invasive model of obstetrics so model peculiar to the US was somehow missing the mark. I didn’t know how to magically correct this problem, but I am certain separating the wrong use of obstetrics from its appropriate use starts by telling the story of 20th century obstetrics in American. Only after this information becomes a core part of the public discourse would we be able to rehabilitate maternity care in the US.

 

With that in mind, I’ve dedicated the last phase of my professional life to telling what I describe as “the last and most important UNTOLD story of the 20th century”. That best-kept secret in modern times is how and why normal childbirth in a healthy population became the property of a surgical specialty and what the unproductive costs and negative consequences are, economically for the US health care system and personally for childbearing families.

 

Historically, obstetrics was developed in Western Europe over the last four centuries to provide life-saving medical and surgical interventions to women with high-risk pregnancies, those who developed a complication, or had an obstetrical emergency. But in early decades of the 20th century in the US, long before the concept of “evidenced-based medicine” was introduced, influential obstetricians theorized that childbirth could be made substantially safer by pre-emptively and routine using these obstetrical interventions during labor. The original 1910 version of this theory was not specific to the 10% or 20% of pregnant women who were at high risk of developing complications or having an emergency but applied equally to the 70% to 80% of healthy laboring women as well.

 

In today’s world, such a theory would result in a prospective clinical trial that would compare the two arms of the study group – the universal use of these medical, pharmaceutical and surgical interventions in a population of healthy childbearing women with a matched to a ‘control’ group of equally healthy women whose labors and births were managed physiologically. This means no routine interventions unless they become needed due to a complication or emergency.

 

Obviously, these studies didn’t were never done, and information from other sources that identified physiological management as the far safer choice for healthy women with normal pregnancies. Instead the routine use of drugs, medical treatments and invasive surgical procedures became the obstetrical model of care in the United States.

Due to these hundred-year-old decisions, there has always been a startling difference between the obstetrical profession own description of its practices and the reality as judged by objective criteria, such the mortality and morbidity rates for new mothers and babies in the US compared to similar wealthy and industrialized countries. In the US, the obstetrical profession has always insisted that normal childbirth was dangerous and the only way to make it safer was to lie routinely use of medical and surgical interventions makes childbirth for healthy women with normal pregnancies safer in the US – as contrasted with the reality.  When this interventive model is judged by the real-life consequences of these medical, pharmaceutical and surgical interventions in the lives of the healthy childbearing women. This starts with the dramatic spike in maternal deaths, both directly and indirectly, that are the result of systematically using these medical interventions and surgical procedures on healthy women with normal term pregnancies.

The best place for me to start this story is where it started for me: the life-changing experiences I had as an 18-year-old nursing student in a racially segregated hospital in the Deep South and after graduation,  working as a nurse in the labor & delivery room of that same segregated hospital. I characterize this as the ‘Dark Ages of the Deep South’. Due to an unequal, two-tiered system of medical apartheid, I got to closely observe and directly participate in two entirely different systems, side by side, in the same hospital, at the same time, with the same staff and the same type of patients but totally different management style and outcomes, different as day and night.

 

It was a naturally-occurring and one of a kind scientific study of two contrasting types of childbirth management. One was a profoundly interventionist model known as “knock’em out, drag’em out” obstetrics. These interventive and invasive obstetrical standard can be traced back to an obstetrical philosophy developed in the US in the late 19th and early 20th century. Professional spokesmen for the obstetrical profession defined normal biological childbirth as “nine-month disease” that required a “surgical cure”.

 

These interventionist policies increasingly influenced how obstetrics was practiced. By 1910, they began to dominate the practice of obstetrics. Then the special interest political process turned its attention to eliminating all non-obstetrician birth attendants who were not formally trained in obstetrical surgery. It began by getting rid of midwives but soon turned its attention of GPs as birth attendants.

 

This is highly interventive style of obstetrical management was originally introduced by Doctors DeLee and Williams in 1910 and was still being used on our white maternity patients 75 years later, with only minor modifications.

 

However, for black mothers in our racially-segregated system, the counterpoint to intense obstetrical intervention was a lazier-fair system designed by segregationist obstetrical department to provide as little care as possible to black mothers admitted a segregated ward in the basement of our hospital (Orange Memorial, more recently renamed Orlando Regional Medical Center). The unintended result was science-based physiological management as promoted the WHO and provided by family-practice physicians and midwives in other parts of the world.

 

In the 1960s and 1970s, the difference between the extremes of childbirth under “knock’em out, drag’em out” obstetrics versus the traditional use of physiological methods all depended on whether the mother-to-be was black or white.

 

Childbirth in Black and White

 

In our segregated southern hospital, Caucasian mothers were admitted to the all-white labor and delivery unit on Five-North. The only entrance was through two swinging door with big black letters that said: “No Admittance – Authorized Personnel Only”.  Before laboring women were admitted into the labor ward, nurses suggested that they kiss their husbands good-by. Once a laboring woman stepped thru these swinging double doors, she would be isolated from her family until after their baby was born and she had recovered from the anesthesia and been moved to her room on the postpartum floor.

 

As a part of the admission procedure, the laboring woman was asked to take everything off and we really meant everything — eyeglasses, weddings rings, other jewelry, dentures, braces, crutches, even an artificial limb — and put on a hospital gown. Then the mother’s clothing and other belongings were placed in a brown paper bag and taken out to her husband in the waiting room.

 

Husbands and other family members were never under any circumstances allowed to be in the labor and delivery area, which meant he would not be able to see his wife until after she gave birth. About-to-be new dads were told to take their wife’s clothing, wedding rings, eyeglasses, etc, go back home and just wait. He would be called by the doctor or one of the nurses after the baby was born. Sometimes this was as long as 36 to 72 hours.

 

Then newly admitted white patients were subjected to the traditional obstetrical ‘prep’. Because poor women in the early 1900s sometimes had public lice, hospital policy in the 1960s still required our white labor patients to have their public hair lathered up and shaved off. Because physicians in the early 1900s believed that infection following childbirth was sometimes the result of ‘autogenesis’ – that is, bacteria from the mother’s vagina or intestines — our labor patients were still being given a large soapsuds enema on admission. Sometimes this was repeated every 12 hours if they still were not in good labor. Once these admission rituals were all concluded, laboring women were given a double dose of the sleeping pill Seconal and put to bed.

 

As labor progressed, they were injected every 2-3 hours with a narcotic mixture known as “twilight sleep” – large and frequently repeated doses of morphine or Demerol, a tranquilizer drug and scopolamine. Scopolamine is a potent hallucinogenic drug that causes short-term memory loss and permanent amnesia of events occurring under its influence.

 

Women still felt the pain of uterine contractions, but under these powerful drugs some labor patients became temporarily psychotic and fought with the staff, often trying to bit or hit the labor room nurse. If left unattended, medicated patients often fell out of bed and could chip their teeth or break an arm. To keep drugged women from getting hurt, the hospital required a nurse to stay right at the bedside through out the entire labor.

 

However, the nurses were generally too busy to stay with each patient full time, so our white mothers were frequently put in four-point restraints, with arms and legs attached to the rails at the four corners of their bed. These were the same kind of heavy leather restraints used in the locked psychiatric wards of the hospital. They forced women to labor while lying flat on their back, a position that reduced blood flow to the uterus and placenta and made labor extremely painful and could cause fetal distress. Because labor was more painful when women were on lying on their back, the obstetricians in our area believed that labor was more effective when women were on their back, so they saw the use of leather restraints as an effective method for advancing the labor.

 

When the time came to give birth, our white mothers were moved by stretcher to an OR-type delivery room and immediately put to sleep with a general anesthetic. This is not a trivial detail, as the third leading cause of maternal deaths in the late 1950s and early 1960s were complications from obstetrical anesthesia.

 

As soon as the mother was unconscious, her legs were strapped in the obstetrical stirrups. If the delivering obstetrician was one of the older doctors, we also pulled her hips down until the buttocks hung free over the end of the OR table. Our older OBs said this prevented the laboring woman from bearing weight on her sacrum, which mechanically reduced the dimensions of her pelvis and could make delivery more difficult if her pelvis was small than average or her baby bigger than average.

 

At this point, the delivery room nurse began scrubbing the mother’s pubic region with germicidal soap, rinsed it with sterile water, and then painted her crotch with a Mercurochrome solution. The obstetrical resident or obstetrician began the surgical procedure of delivery by cutting a “generous” (!) episiotomy. Then he inserted each of the two blades of the forceps one at a time, and when they fit to his satisfaction, commenced to join the handles of two blades together until they locked into place.

 

Once the doctor was ready to precede with the forceps delivery, he instructed the delivery room nurse to stand on a 12” footstool by the side of the delivery table and use her full body weight to push laterally and downward as hard as she could on the top or “fundus” of the mother’s uterus. The idea was to use “fundal pressure” from above to mechanically press the baby further down into the birth canal while the obstetrician used forceps to pull from below and eventually to extract the baby.

 

After the birth, the doctor would put on a special surgeon’s glove that went up to his elbow and then inserted his gloved hand up into the mother’s vagina and then into her uterus and use his fingertips to remove to separate the placenta from the uterine wall and then pull the placenta out in his hand. Last but not least was suturing the episiotomy wound.

 

For white babies that arrived under the standard obstetrical management, respiratory depression was the inevitable result of the narcotic drugs, anesthesia, anti-gravitational positions for pushing, the use of a dangerously forceful type of fundal pressure and obstetrical forceps to extract the baby from the unconscious woman’s body. The well-known effect of narcotic drugs and anesthesia was to obliterate the newborn’s normal gag reflex (all general anesthesia has this effect).

 

In the early 1900s, giving general anesthesia for normal childbirth became the standard of care. It depressed respirations and obliterated the normal gag reflex which the newborn’s nose and throat were vigorously suctioned with a bulb syringe as soon as it was born.  This was repeated if there were any signs of choking or concern about the baby’s airway.

 

One of my jobs as a nurse in the all-white Five North delivery room was to resuscitate the many depressed babies who did not spontaneously breath at birth. Due to the use of general anesthesia and obstetrical instruments, combined with the depressive effects of narcotic drugs given the mother earlier in the labor, and traumatic effects of fundal pressure and forceps delivery, a significant number were never able to breathe on their own. For fundamentally healthy women with apparently normal pregnancies, the high mortality rate of the first half of the 20th century strongly reflected these iatrogenic factors.

 

For the obstetrician, routine care for white patients usually ended with the infamous “husband stitch”. Double entente comments often accompanied this, as the doctor added a few extra perineal sutures when repairing the episiotomy incision, just to be sure the mother’s vagina was tight as a virgin’s again for her husband. Doctors explained that sometimes new fathers complained that: “Ever since the baby was born, having sex with my wife is like walking into a warm room”. Our doctors apparently felt responsible for preventing this type of marital dissatisfaction.

 

After finishing his handiwork and removing his surgical garb, the obstetrician walked over to the waiting room and announced to the waiting family that: “It’s a boy!” or “It’s a girl”. He would congratulate the father with a handshake and bask briefly in the family’s appreciation of his skill in safely delivering their baby, then send the relatives over to the nursery window for their first look at the newest arrival.

 

For the new mother, obstetrical management on Five North ended by being wheeled, still unconscious from the effects of anesthesia, to the recovery area. There she would lie on a stretcher for a couple more hours, retching and vomiting her way back to a dim consciousness before she finally asked: “What did I have?”

 

The mother repeated this question, and answered many times by the nurse, before she was functionally conscious enough to realize the birth was over and keep the gender of her new baby fixed in her mind. Due to the use of general anesthesia, childbearing women were a non-person during the obstetricalized process of surgical delivery and always the last to know about their own birth.

 

The Other Half of the Story

 

As a young student nurse, my head was still swimming from all this when I rotated off Five North to One South, the all-black ward. Oddly enough, the maternity care for black mothers was remarkably simple, straightforward, non-interventive, and in my uninitiated 18-year-old opinion, infinitely more humane. It met the mother’s psychological needs and made right use of gravity. Biologically speaking, it was both safe and effective.

 

When factoring in the negative effect of narcotics on the mother’s labor and the respiratory efforts of her newborn, it was vastly safer than the medicalized version used on their Caucasian counterparts upstairs on Five North. The dramatic improvement between Five North and One South was a big relief. Being an agent for a process that was regularly harmful to mothers and babies had troubled me deeply.

 

All black patients — medical, surgical, maternity, pediatric and elderly — were admitted to One South, a segregated ward in the basement of our hospital. It was the oldest and most crowded wing in the sprawling hospital complex. Since it was originally built in the early 1900s, a huge institutional kitchen, an industrial-sized boiler room and the hospital laundry had been crowded in around the black wing, cutting off any view from the windows or access to open air.

 

For black mothers-to-be, One South had no labor ward and no labor room nurses, so black labor patients were admitted to their postpartum beds in an old-fashioned four-bed ward. Under a policy of benign neglect, there were no admission rituals, no sleeping pills, no drugs and no rules that said that black women had to stay in bed or labor on their backs.

 

In contrast to the restrictive protocols and tight control in the all-white labor ward on Five North, the labors of our black mothers were not accelerated with Pitocin or any other drugs. Nor were they given ‘twilight sleep’ (narcotics and scopolamine) or any other drugs for pain, because the two staff nurses were already responsible for 40-plus other patients. The skeleton crew assigned to One South had no time to labor-sit with drugged and combative women who were having hallucinations and trying to climb or fall out of bed.

 

In addition to staffing limitations, a segregated society doesn’t care what black women in labor wanted (or didn’t want). Their opinions and needs didn’t count. But no matter how reprehensible the motives, there were many unintended advantages to this system of purposeful neglect.

 

Left to fend for themselves, black labor patients moved around the big room, cheered on and cheered up by the older and more experienced women in the four-bed ward. This provided a useful source of encouragement and tips on how to cope with labor pain. Because they were undrugged and unencumbered, black mothers in labor were able to walk about freely, changing positions at will or taking themselves to the bathroom and sitting on the toilet as the baby descended in the pelvis and they began to feel pushy.

 

In particular, black mothers avoided lying down in bed, preferring to stand at the side of the bed and hold on to the bars as they swayed or squatted during contractions. As a naive student nurse, I remember asking one young black mom why she didn’t lie down in the bed so she would “be more comfortable”. She looked at me like I was a total idiot and in an irritated voice said: “…’cause it hurts too bad when you lay down!”

 

By an accident of race, these childbearing women were the beneficiaries of racial policies based in prejudice which co-incidentally shielded them from narcotics and artificial hormones to speed up labor or being forced to push in anti-gravitational positions. The labors of our black mothers were undisturbed and with rare exception, the physiological process unfolded as Mother Nature intended.

 

Eventually one of our black maternity patients would start to make deep-throated guttural noises — the unmistakable sounds of pushing. One of the two floor nurses would grab a stretcher and help the mother lay down on it. Then we raced the stork through the hall to the elevator, hoping to make it to the 5th floor delivery room before the baby made its entrance. It was my frequent pleasure, as an impressionable student nurse, to ‘catch’ the precipitously born babies of our black mothers in the elevators that traversed the vertical and political distance between One South and Five North.

 

These normal births were managed physiologically by nurses, which is to say, the mother gave birth spontaneously, pushing her baby out under her own powers. And wonder of wonder, these babies immediately breathed on their own, since their mothers had not been given narcotics or anesthesia and no artificial, forcible or mechanical means were used to accelerate the labor or pull the baby out.

 

In my experience, these unmedicated babies breathed spontaneously, had good Apgars and rarely needed help to clear their airway or other form of resuscitation. The mother had no painful episiotomy, no bleeding from a perineal incision, no fundal pressure, no tears in the muscles of her pelvic floor do to the use of forceps, no invasive removal of the placenta, no need to thrust a bulb syringe repeatedly down the baby’s throat. These lucky babies were enthusiastically embraced by their un-drugged and fully conscious new mothers, who beamed proudly and proclaimed in a happy and confident voice: “Look what I did

 

Racial prejudice and discrimination of the era institutionalized what now would be considered negligent treatment when judged by the legal standards of the era. When defined by the usual policies and protocols as set by the “community of physicians in each discipline, these black mothers were actually receiving substandard care. Yet, they clearly were getting the better end of the deal. The nurses just talked these black mothers through the last couple of pushes and their babies just slipped out with little fuss.

 

Had anyone in our hospital or our town or any researcher at the CDC been paying attention to this unofficial study of two diametrically opposed styles of birth management, the winner based on good outcomes would clearly been the black mothers and babies from One South. They enjoyed the safer, physiologically managed labors and normal spontaneous births, while being protected from the routine indignities and painful interventions that were the norm five floors above. Our black labor patients were not subjected to the labor-retarding effects of social isolation or immobilized on their backs in bed with four-point psychiatric restraints.

 

They did not have their memory erased by scopolamine or their labor slowed down by narcotics. No routine use of forceps damaged the mother’s pelvic floor or her baby’s cranium. The new mother was not debilitated by the slowly healing episiotomy that made it hard to sit and difficult to care for a new baby. Their babies were not exposed to intrauterine narcotics and the resulting fetal distress, nor did they need to be resuscitated. This no doubt contributed to increased IQ points and, according to three Scandinavian studies, a reduced the incidence of drug addiction as young adults.

 

After more than a half a century of watching both the right and the wrong use of obstetrics, It is  clear to me that Mother Nature knew what she was doing, and when we human helpers stayed respectfully out of her way, Mother Nature did a darn fine job the majority of the time. When the childbearing woman was healthy and her pregnancy was normal, the biology of childbirth was certainly better and safer than the “strict” or interventive model of obstetrics that conducts “the delivery” as a series of medical interventions and invasive surgical procedures “performed” on an unconscious mother-to-be.

 

A Practical Application of our Black-White Study – an “N” of one

 

When expecting my first baby, I took my lesson in childbirth out of the book of segregated childbirth and its extreme contrasts. In an attempt to avoid the detrimental effects of routine obstetrical intervention, I asked my obstetrician if I could have the same kind of care that our black mothers received – no drugs, able to walk around during labor, no anesthesia, no episiotomy, no forceps, just a boring un-intervened with spontaneous birth. He smiled and kindly suggested that I just stay out of the hospital until the baby was ready to be born because “that’s what hospitals are for — drugs and anesthesia”.

 

As a good and faithful nurse, I did exactly what my doctor said. I labored at home as long as possible, then left for the hospital with the hope of arriving just in time for a nice nurse-managed birth on a stretcher in that same elevator on the way up to the Five North delivery room. As luck would have it, I misjudged by a few block. While my husband drove the family car, I gave birth unattended in the back seat of our Renault to a lovely baby girl, just five blocks before we turned into the hospital driveway. It was the most surreal, most important moment in my life – the privilege of being the first person, after God, to welcome and hold my brand-new baby daughter.

 

ER personnel wheeled the stretcher holding me and my newborn daughter, umbilical cord still firmly attached, placenta in situ, into the elevator and up to Five-North. It was 11:15 on a cold January night. At the same time, the 3-11 shift of L&D nurses were getting off duty, waiting in the hallway for the elevator. Like the many black moms that preceded me with spontaneous births in that same elevator, I held up my tiny newborn up as the door opened and said to my surprised colleagues: “Look what I just did!” This could be called the “elevator effect”, but I shall always be convinced that it is an immutable right of childbearing women to feel proud and happy and confident as a result of giving birth normally, under their own steam. On the way to my unlikely career in midwifery, that was the second milestone of a very long journey.

 

My L&D Time Warp – 1910 to 1976:

 

Historically speaking, the policies and the process for providing obstetrical care to the white population of our hospital in the 1960s were pristinely unchanged since 1910, except for replacing the chipped white paint on the OR-style delivery table for shinny new chrome and (thank goodness!) substituting safer cyclopropane anesthesia for the much more dangerous chloroform and drip-ether.

 

The last day work that I worked in the L&D unit in August of 1976, the obstetrical protocols of our hospital still routinely confined the mother to bed, medicated her with narcotics and scopolamine during labor and gave general anesthesia for delivery. Normal birth was still conducted as a series surgical procedure that included episiotomy, forceps, forceful fundal pressure, manual removal of the placenta and suturing of the episiotomy incision. It still ended with the mandatory separation of mother and baby and the unconscious mother was still the last to know what she had.

 

As a L&D nurse, I worked to rectify the tension between the two opposing models of maternity care used by every hospital in our part of the state for my entire career as a hospital employee. Despite my best efforts, I was utterly unable to make the 1910 version of obstetrics move even a tiny millimeter towards the physiological model that served our black moms so well. I can say this with assurance as I was twice fired or transfer from my job in the L&D at the request of one or more obstetricians, citing my “interference” in their “business as usual”
abuse practices used routinely on unconscious childbearing women.

 

It finally became obvious that normal childbirth was permanently trapped on the wrong side of history, at least in Orlando, Florida. I threw in the towel and asked to be transferred to the ER, where I worked as emergency room nurse for the next several years. I too was traumatized by being the agent of the ‘new’ obstetrics to ever again be employed in a system that required me to do things I knew were harmful, humiliating and painful to mothers and babies as a normal aspect of my employment.

 

Relieved of these onerous duties, I was able to study the problem without so much emotional angst and to get a far better perspective on the right use of obstetrical interventions and the best form of care for healthy women. My conclusion was simple: no healthy woman should never be forced to choose between an obstetrician and a midwife or between a hospital and a planned home birth in order to get physiologically-managed maternity care, nor should any mother-to-be have to give birth unattended in order to avoid unwanted obstetrical interventions or mandatory but medically-unjustified Cesarean delivery.

 

What I discovered was heartening, as it provided logical reasons for why and how the ‘new’ obstetrics came to be at odds with the fundamental purpose of maternity care, which is to make normal childbirth safer and more satisfactory for healthy mothers and their unborn/newborn babies. My study provided insight in many areas of modern maternity care, and particularly trigger much sympathy for today’s obstetricians who are trapped by a medical malpractice system that really is out to get them. The obstetrical professions in the US is facing many more social, economic, political, and personal predicaments than most medical specialties.

 

I have identified a rational plan to address the immediate problems and a set of principles for restoring balance and rehabilitating our national maternity care policies. I am very hopeful and urge others to be encouraged.

 

A new non-surgical or “physiological” billing code for labor and birth services

 

         One of the simplest, and yet most important, is modernization of the billing code for physiological childbirth issues. Actually, there is not billing code for normal spontaneous childbirth. Since the 1930s childbirth, no matter how normal or spontaneous, has been billed as a surgical procedure. What we need is a physiological code would once again acknowledge that childbirth is a continuum. Continuity of care by the primary birth attendant during active labor, the birth and the first hour or two of the new baby’s life is a biological imperative for safe childbirth. Fair compensation for birth attendants, via a physiologic billing code, is an economic imperative for birth attendants and institutions and the lynch pin to making the maternity care system work for everyone – mothers, babies, doctors, nurses, midwives and hospitals.

Previous post:

Next post: