Note the very depressed baby being held in the doctor’s hands and the anestheiologist at the head of the table looking on. Obviously the mother had been rendered unconscious under chloroform or ether anesthesia
Word count ~ 2050 Jan 17, 2025
Chapter Six
Within just a few years, the promise of 1910 came to pass – organized medicine did train a large number of obstetrical surgeons to replace midwives, and these newly minted physicians took over the care of healthy childbearing women. We also have to admit that the obstetrical promise of complete control over the unpredictable nature of female biology is an enduring idea that continues to be enthusiastically embraced by both the medical profession and the lay public. And the claim that obstetrical management would vastly reduce (if not altogether prevent) childbirth-related disability and maternal-infant mortality is one the obstetrical profession sincerely believes to be a promise they delivered on.
Improved Outcomes, Difference of Opinion on Why
Simultaneously (or co-incidentally, depending on your perspective!) maternal infant outcomes did improve dramatically over the course of the 20th century. Both stillbirth and maternal deaths are way down as compared to 1910. However, medical anthropologists attribute this dramatic improvement not to obstetrical interventions but rather to social causes — rising economic and educational factors such as public sanitation and safe building codes, clean water, adequate nutrition, effective contraception, timely access to medical services when necessary, etc. But it comes as no surprise to hear that the obstetrical profession is not buying this explanation.
Birth as a Surgical Procedure Become the Standard of Care 1910 — 1980
According to the obstetrical profession, economic and public health factors were only a minor contributor to the vast improvement in maternal-infant outcome statistics during the first half of the 20th century. They remained convinced that childbearing was inherently dangerous and that it could only be made safe in a hospital as a surgical procedure, performed by a physician under sterile conditions.
Clearly, birth was indeed something the doctor (not the mother) did. From the perspective of organized medicine, medicalized childbearing fulfilled the obstetrical promise to prevent stillbirth, brain damage, cerebral palsy, and pelvic floor damage. While the cure was not yet a 100%, they had their eyes on the prize – a time when more and better obstetrical interventions would reduce ‘adverse events’ to the vanishing point.
With this kind of organized commitment and the momentum of both the lay public and the medical profession, more than 90% of childbearing women gave birth this way – full medicalized obstetrical management, narcotic drugs in labor, general anesthesia and “prophylactic use” of outlet forceps. The only good news was that the Cesarean rate was only about 1% for the first few decades of the 20th century.
If at first you don’t succeed, try, try again – 1930 to 1970
Despite the powerful control and massive manipulation of labor and birth, obstetrical problems continued to occur – labors didn’t go as planned, babies developed ‘fetal distress’ or were stillborn for no observable reason. Mothers continued to have massive hemorrhages after delivery and get serious, even fatal infections. Of additional concern were gynecological complications such as vaginal fistulas and incontinence. And the stubborn problem of ‘birth injuries – brain damage and cerebral palsy continued to defy their best efforts.
So they went back to the drawing board to come up with a new plan, a fresh start. The answer? Well obviously they were not using enough drugs or were not using them early enough. The 20th century obstetrical promise was a better birth for mothers and a perfect baby, every time. That meant it was the obstetrician’s role to make birth work and their profession’s reputation depended on their ability to bring that about.
And luckily for them, a whole host of new of drugs, equipment and methods arose serendipitously as a side-effect of the Second World War – antibiotics, blood typing, safer anesthesia agents, better surgical techniques, expanded diagnostic methods, etc. Obstetrical advances included the modern-day form of the labor stimulating hormone oxytocin (developed and marketed by Parke-Davis as ‘Pitocin’ in 1954), continuous caudal block in labor was first used, the first vacuum extractor for delivery was developed, and Dr Virginia Apgar invented the Apgar scoring system for assessing babies at one and five minutes after birth. Most notably, the prototype of ultrasound for obstetrical purposes – fetal heart rate monitoring and fetal pictures — first occurred between the years of 1958 and 1963.
However, standard obstetrical management did not change – labor was still managed as a medical condition. This included complete isolation from one family in a labor ward. Upon entering into the labor ward as a new patient, the scared young mother was greeted by a cacophony of distressing sounds from other women in labor who were under the influence of powerful drugs and cried out with every uterine contraction, moaning, shouting or swearing. Leaving no orifice unmolested, mothers-to-be were subjected to the standard OB prep (pubic shave) and large soapsuds enema, not allowed to eat or drink or get out of bed and had their water broken artificially.
Then they were given heavy doses of narcotics and amnesic drugs (they were probably grateful to forget what had just happened to them!). Birth was a surgical procedure was still the norm, which meant anesthesia, episiotomy, forceps, stitches, etc. But the new drugs of the 1940s did help obstetricians deal more successfully with the side-effects of these interventions – for example, antibiotics to treat infection from obstetrical manipulations (episiotomy and forceps) and blood transfusions to treat women hemorrhaging after the manual removal of the placenta. And doctors were finally able to reduce the high rate of maternal mortality and stillbirth of the preceding decades.
During this period forceps continued to be routine (90%), while Cesareans were being done more often (5%), as effective antibiotics, safe blood transfusion and safer anesthesia made such surgery less dangerous. Other problems that obstetrical management was suppose to prevent (such as pelvic floor damage) continued on unabated. Worse still, the obstetrical profession continued to stymied in their desire to banish brain damage and cerebral palsy, which seemed to be the same year after year. Doctors dreamed of a day when they understood what caused these heartbreaking problems so that they could banish them with the same success as puerperal sepsis and obstructed labors.
The Really BIG Guns — the Technological Fix — 1970 to 2000
Despite ever-increasing control and manipulation of labor and birth that had become routine during the 1960s, obstetricians at the end of that decade still could not predict or prevent labors that failed to progress, babies that developed ‘fetal distress’ for no observable reason and women who continued to have massive hemorrhages after delivery. New mothers sometimes got serious, even fatal infections, but antibiotics made this less of a worry. However, long-term gynecological complications such as pelvic floor damage, uterine prolapse and incontinence still persisted. The good news was that the stillbirth rate continued to drop. The bad news was that the stubborn problem of ‘birth injuries – brain damage and cerebral palsy – continued to plague them in spite of their best efforts.
But change was in the air, big changes. Over the next 30 years obstetrical practices would be dramatically different in six specific areas – regular use of Pitocin to start or speed up labor, epidural anesthesia, the presence of fathers and family members, the routine use of continuous electronic monitoring, a vastly increased Cesarean rate and the increasing role of the ‘malpractice crisis’ as the central organizing factor in obstetrical medicine.
Interestingly enough, these changes were not the result of new ‘medical miracles’, either drugs or technology, as there was little in the way of brand new inventions during these 30 years. Instead the period was remarkable for its refinement of earlier discoveries– primarily ultrasound and EFM. But the unquestioned lynch pin of the era was the further development and universal use of electronic fetal monitors (EFM) and its association with Cesarean section. More and more the Cesarean section was being seen a relatively safe rescue operation and, it was assumed, a valuable tool in the armamentarium of weapons against birth-related brain damage and cerebral palsy. In combination with an increasingly ‘litigious society’, the malpractice crisis fueled a propensity to use Cesarean section as the all purpose solution for every perceived problem.
Patient’s Rights as an Important, Modern-day Concept
The 1976 malpractice crisis occurred at the same time that the concept of “patients rights” underwent a major upgrade. This groundbreaking change was more substantial and far reaching than malpractice litigation, but it got little attention from the media. As a result most Americans were unaware of the ‘National Research Act’, passed in 1974 by the US Congress. This Act mandated the establishment of an 11-member National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Commission was “to identify the basic ethical principles that should underlie the conduct of biomedical and behavioral research involving human subjects and to develop guidelines that should be followed in such research.” [52]
Patient’s Rights is not a very exciting topic unless you also know that doctors in the US were not, up to that time, required by law to get voluntary participation and informed consent from patients before using them as test subjects in a medical experiment. This explains how something as reprehensible as the 40-year Tuskegee Syphilis Study could have occurred. It was not until July 1972 that a New York Times story brought this moral outrage to the public’s attention. The story, briefly stated, was that the United States Public Health Service conducted research from 1932 to 1972 on 600 black men in order to learn more about syphilis. There was no evidence that researchers informed these men that they were being used as subjects in a medical study.
These men were misled and not given the facts required to provide informed consent. Researchers told them they were being treated for “bad blood,” a local term used to describe several ailments, including syphilis, anemia, and fatigue. Withholding effective treatment caused needless pain and suffering. Even when penicillin became the drug of choice for syphilis in 1947 researchers did not offer it, nor were the men given the choice of quitting the study when this new, highly effective treatment became widely used. In July 1972 the New York Times story caused a public outcry that led the federal government to take a closer look at research involving human subjects and make changes to prevent such things from happening again.
Within a mere six years (still 46 years too late for the Tuskegee patients!) the National Commission for the Protection of Human Subjects published its recommendations in a document known as Belmont Report. In 1978 the patient’s right to voluntary participation thru “informed consent” (including the right to refuse or withdrew from treatment) was established at the federal level. The Commission’s recommendation mandated an ethical obligation on the part of doctors and other researchers to provide full information and obtain truly informed consent before any experimental treatment could be offered. Eventually this became a legal requirement.
National Commission for the Protection of Human Subjects
Were the medicalizing of labor for healthy women and/or the idea of normal childbirth as a surgical procedure that was introduced in the first decades of the 20th century to have occurred sixty years later, history would have been quite different for mothers, midwives and obstetrical surgeons. Under the mandates of the National Commission for the Protection of Human Subjects, the obstetrical profession would have been required to get approval from the hospital’s ethical research advisory board before embarking on an extended “medical experiment”. However, by the late 1970s, the original experimental nature of these ideas was lost to living memory and by then obstetrical intervention was considered to be the “norm”.
That said, the general necessity of obtaining fully informed consent was becoming much more developed and the idea of informed consent relative to obstetrical care gained a lot of traction in a short space of time. The ethics of ‘patient’s rights’, as defined by the Belmont Report, began leak into legal ideas of informed consent in medical care in general. Greater attention to informed consent in obstetrical practice was further spurred by fear of malpractice litigation. By the end of the 1970s the obstetrical profession insisted that childbearing woman were never subjected to interventions unless the labor patients (or her husband if she was under the influence of narcotic drugs) had been informed and given consent.
