Safety & Normal Birth: Part 1 ~ Turning a Bitter Historical Truth into a Win-Win Solution

Part 1

~ Safety & Normal Birth: Turning a Bitter Historical Truth into a Win-Win Solution and Brighter Future for all

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As a result of obstetrical medicine’s blind spot about midwifery — what I would characterized as “radio silence” — healthy childbearing women suddenly had no options other than to became the patients of a surgical specialty.

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For the last hundred years, the American-way-of-birth has been a highly-medicalized system that takes place in an acute-care hospital under the formal control of physician-surgeons.

This drastic alteration in childbirth practices represented two dramatic and simultaneous departures from all that went before.

The first big change was from the traditional medical practice of obstetrics by general practice doctors, which in 1910 was replaced by a newly-minted American surgical specialty. Officially it was a new combined profession of obstetrics and gynecology, but simply referred to as “the new obstetrics”by influential leaders in the field..

Second big change was a decision by this new surgical specialty to immediately and completely abandoned the 5,000 year-old tradition of supportive, non-interventive care by midwives bases on physiological principles.

Without having conducted any research to compare the two drasticaly different models (supportive, non-interventive midwifery, versus the pre-emptive use of  obstetrical interventions) and without having any other scientific evidence able to established, a priora,  the safety and effectiveness of the many new medical and surgical methods being proposed.

Nonetheless spokesmen for the ‘new obstetrics’ simply declared that henceforth care for normal childbirth in healthy women should be provided by surgical specialists under the sterile conditions of a hospital operating room (i.e. the ‘delivery’ room).

As medical doctors declared themselves to be ‘experts’ in childbirth, they insisted that the new ideas of medical science had rendered midwifery old-fashioned. In public they explained that the care provided by midwives (i.e. ‘physiological management’) — was  unscientific, therefore obsolete, dangerous, should be made illegal and gotten rid of as quickly as possible.

Starting with Pasteur’s discovery of “the germ theory” of infectious disease in 1881, the previous 30 years had seen many very important advances in the biological sciences. These formed the basis of our contemporary idea of  “modern medicine”, as contrasted with the type of medical care that precede it — bleeding, purging, ideas of the ‘four humors’ and many other now discredited treatments proven ineffective or harmful by standard scientific investigation.

Based on theoretical ideas of  ‘modern scientific research’, but not actually employing the scientific method in any way {which would  have required a hypothesis and the development of a research model testing out their theories which was never done or even contemplated) obstetricians boldly insisted that the traditional care of midwives had been found wanting.  As an outdated and inadequate form of care their ‘expert opinion’ was that everything about midwives belonged in the “dustbin of history”, to be dismissed from the mind of intelligent people, and talked about no more.

As a result of obstetrical medicine’s blind spot about midwifery — what I would characterized as “radio silence” — healthy childbearing women suddenly had no options other than to became the patients of a surgical specialty.

That also meant that normal childbirth became a surgical procedure conducted (only) by MDs.

Normal birth as a new surgical procedure included the routine use of:

• general anesthesia
• episiotomy
• forceps
• immediate clamping of the umbilical cord (to prevent the baby from getting more anesthesia)
• manual removal of the placenta
• suturing of the perinatal laceration
• separation of mother and baby during the  mother and baby’s recovery period (up to 12 hours)

Obviously this list of invasive surgical procedures could only be ‘performed’ by an obstetrically-trained surgeon on a properly prepared ‘surgical patient’, This required the laboring women to lay perfectly still on a narrow OR-type delivery table after she had been placed in gynecological stirrups and covered by a mountain of sterile drapes.

In order to protect the ‘sterile field’ and keep women in active 2nd stage labor (i.e. pushing) from falling off the OR table,  these mothers-to-be had their wrists restrained to the each side of the OR table with large leather cuffs. When the physician arrived and decided it was time to perform the surgical procedure of ‘delivery’, the laboring woman was put to sleep with general anesthesia.

The policies of the ‘new obstetrics’ as applied to healthy women having a normal labor and birth represented the most profound and far-reaching change in childbirth practices in the history of the human species.

Why didn’t anyone question these practices?

Laboring women were heavily medicated with “twilight sleep” drugs — narcotics and scopolamine, which produced hallucinations and amnesia and  completely unconscious during the delivery. Due to these drugs and the use of general anesthesia, laboring women had no memory or knowledge of the type of care they received. There was also no requirement that they be informed or give ‘consent’ to these treatments, nor were they told about any other options or alternatives.

Because the labor and delivery area of hospitals were restricted to “Authorized Personnel Only”, fathers, family members and the lay public were not allowed to be present during either the labor or the birth.  Except for hospital L&D nurses (like me), there were NO witnesses to the care provided to our insensate labor patients. The mother and her friends and family had absolutely NO idea what happened on the other side of those closed doors.

Why hasn’t this strange situation – allowing the surgical specialty of obstetrics to re-define normal childbirth in 1910 as a surgical procedure — been re-evaluated or questioned over the course of the last 100 years?

There is no good or easy answer but the consequences are clear – today, as was true in 1913, normal childbirth is still technically defined as a ‘surgical procedure’ and it continues to have a surgical billing code.

Likewise, there is no billing code for physiologic care as provided by non-obstetrician birth attendants (professional midwives and family practice physicians).

For reasons that are complicated and confusing, no public official – no policy maker, no no scientist, no legislator, no political leader – has ever objected to the use of interventionist obstetrics as the official standard of care in the United State for all laboring women, including those who are healthy, who have normal pregnancies and who do NOT want to be either medicalized or have their normal birth conducted as a surgical procedure.

Historical Background Material:

Historically, ‘obstetrics’ was a medical discipline that was taught to medical students as part of the general practice of medicine. It was expected that as a ‘family doctor’ they would provide care to maternity patients and so basic non-surgical obstetrical knowledge and associated technical skills would be normal part of their professional duties. This included training in the use of forceps for a slow or difficult birth, and manual removal of the placenta for PP hemorrhage.

While obstetrics at this time was a medical discipline – abet one that included the minor use of surgical techniques such as episiotomy and manual removal of the placenta — gynecology was clearly defined as a surgical discipline. This caused a lot of hard feelings between GPs who provided “normal” obstetrical care, and gynecologists who considered much of what they did as an unauthorized practice of surgery.

As surgeons protecting their turf, gynecologists believed that the slightest deviation from normal progress in a laboring woman should require the GP to call a gynecologist-surgeon to the bedside to take over the patient’s care.

Obstetrical practitioners retorted that they were no ‘merely midwives’ who had to refer their patients to doctors.

They insisted that as MD they had every right to handle all the common complications of labor, including those that required the use of forceps or a Cesarean.  Hadn’t they been taught to use forceps as a standard part of medical training? How dare these gynecologists claim that they had exclusive entitlement to the use of nearly all obstetrical skills!

However, the legal definition of a ‘surgical procedure’ is the use of any sterile instrument to severe or penetrate human tissue (except for the umbilical cord) or to insert a sterilized surgical instrument or medical devise into a sterile body cavity (such a forceps technique that went high up into the uterus). Clearly Cesarean sections were and high forceps were both surgical procedures.

The level of arguing and consternation between GP physicians and gynecology-surgeons during the late 19^th and early 20^th century was seen as distracting burden for both professions. As long as the professors of obstetrics were battling with the department of gynecology over which discipline should do what, and exactly what techniques could and should be taught to medical students, neither of their two disciplines could develop their full potential or ‘thrive’ in the market place.

To stop the self-defeating bickering between physicians who specialized in obstetrics (Dr. De Lee, Dr. Williams, etc) and gynecologists who represented their surgical specialty, leaders in the field of obstetrics decided that it was best rebrand obstetrics as itself a surgical specialty. No longer seen as medical discipline that was part of the general practice of medicine, they empowered themselves to perform forceps deliveries and Cesareans.

They also brought the surgical discipline of gynecology under their wing of to be a natural part of the newly-branded practice of “new” obstetrics. By rolling the medical and the surgical into one combined specialty, they created a super-specialty that had dominion over all the reproductive-related needs of the female gender.

This newly configured hybrid surgical specialty was referred to by its practitioners as “The New Obstetrics”. The unofficial leaders and promoters of this rebranding effort were Doctors J.Whitridge Williams and Joseph De Lee. Both men were both professors of obstetrics that history now refers to as the two Titians (of fathers) of American Obstetrics.

By 1910, they and other obstetrical professors were making references in professional journal articles and newspaper that introduced this new status as a ‘done deed’.

Dr. J. whitridge Williams famously declared to a large group of medical professionals in 1910 that:

“..care furnished during childbirth is now considered, in intelligent communities, a surgical procedure”.

A year later, he juxtaposition remarks about his grand vision for the ‘new’ obstetrics with his criticism of the medical profession’s prejudice against doctors who attended “cases of childbirth”:

“ … the ideal obstetrician is not a man-midwife, but a broad scientific man, with a surgical training, who is prepared to cope with the most serious clinical responsibilities, and at the same time is interested in extending our field of knowledge.

… No longer would we hear physicians say that they cannot understand how an intelligent man can take up obstetrics, which they regard as about as serious an occupation as a terrier dog sitting before a rat hole waiting for the rat to escape.”

Dr. Delee was also convinced that obstetrics was naturally a surgical discipline and he was clearly miffed when his conclusions were not enthusiastically embraced by other physicians and the public:

“… the treatment of labor should be regarded as surgical operation: it really is such, and the obstetrician is really a surgeon.

… The parturient suffers under the old prejudice that labor is a physiological act, … and the medical profession entertains the same prejudice, while as a matter of fact, obstetrics has great pathologic dignity — it is a major science, of the same rank as surgery”. [Dr. DeLee, 1915-C; p. 116]

“… The conduct of labor is not a simple matter, safely entrusted to everyone. Let the people know that having a child is an important affair, deserving of the deepest solicitation on the part of the friends, needs the watchful attention of a qualified practitioner and that the care of even a normal confinement is worthy the dignity of the greatest surgeon.” [DeLee textbook; p.  341]

Impressed with the ability of the obstetrical art to overcome the natural dangers in childbirth and convinced of that medical and surgical interventions were benignly beneficial in the hands of an properly trained obstetrical surgeon, they believed the new obstetrics had created a new world order.

A quote from the Boston Medical and Surgical Journal, February 23, 1911 sums up this point of view:

“We believe it to be the duty and privilege of the obstetricians of our country to safeguard the mother and child in the dangers of childbirth.

The obstetricians are the final authority to set the standard and lead the way to safety. They alone can properly educate the medical profession, the legislators and the public.”

excerpts from:

Twilight Sleep ~ A Simple Account of New Discoveries in Painless Childbirth
By Henry Smith Williams, B. Sc, MD, LLD ~ 1914 ~
Written in direct collaboration with Dr. J. Whitridge Williams, original author of “Williams Obstetrics”

“At present, gynecology and obstetrics are too sharply divided and are conducted upon too practical a basis to give ideal results.