Part 4 ~
Strike One ~ Autopsies, Anesthesia and Obstetrical Audacity
I describe this trilogy of historical events as a trifecta AAAs of iatrogenesis, so named after the three specific practices used during three different periods of history. The first was maternal autopsies in European hospital beginning in the 1830s; the second was use of general anesthesia in the US between 1910 and 1970s and the third and most fundamentally inexcusable is the audacity of corporate medicine in the US (with its fee-for-service profit stream that focuses on ‘billable units’ rather than genuine patient need), combined with institutionalizing obstetrical interventions — in particular routine use of EFM, elective induction of labor, normalization of epidural and preemptive or prophylactic use of Cesarean surgery.
This drastic change in the obstetrical professional’s relationship with Cesarean surgery went public in 1985. In this new world order, C-section was no longer seen as a treatment for serious complications — something reserved to rescue mother or baby when things go badly wrong — but instead Cesarean section began to be promoted as a newer and better standard for healthy women. In a paper published in the prestigious New England Journal of Medicine in 1985, two obstetricians make a statistical case for cesarean surgery as“saving” babies with only a little “excess maternal mortality”. (Prophylactic Cesarean Section at Term? George B. Feldman, MD, Jennie A. Friedman, MD; p. 1266-67….New England Journal of Medicine; 1985).
The preemptive use of Cesareans in a healthy population was proposed as a bold new strategy for reducing neonatal mortality of approximately 1 per 500 live births by replacing normal labor and vaginal birth with scheduled Cesareans for all. These authors described the “extra” maternal mortality of 5.3 per 100,000 associated with these elective surgeries as an acceptable trade-off and opined that saving babies at the “low cost of excess maternal mortality” of few more maternal deaths per 100K “may be” a price worth paying. The ideas promoted in this paper triggered no hue and cry from the medical professional. Lacking a public ‘smack down’ permitted its ideas to gradually become mainstream.
“….the number of extra women dying as a result of a complete shift to prophylactic cesarean section at term would be 5.3 per 100,000…. This may be the proper moment to recall that the number of fetuses expected to suffer a disaster after reaching lung maturity is between one in 50 to one in 500. … if it could save even a fraction of the babies at risk, these calculations would seem to raise the possibility that a shift toward prophylactic cesarean section at term might save a substantial number of potentially healthy infants at a relatively low cost of excess maternal mortality. We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10 or (as our calculations roughly suggest) as many as 36 or 360? …. Is there some ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure?
….is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery after fetal lung maturity has been reached?
If a patient considers the procedure and decides against [prophylactic Cesarean], must she then be required to sign a consent form for the attempted vaginal delivery?”
These shocking recommendations were made before the medical profession realized the link between Cesarean delivery and lethal placental abnormalities in subsequent pregnancies. Also a 6% rate of post-cesarean secondary infertility has since been confirmed. In addition to intra-operative and immediate post-operative complications (anesthetic reactions, surgical mistakes, hemorrhage, emergency hysterectomy, amniotic fluid embolism, pulmonary embolism and thrombophlebitis, and post-operative and/or MRSA infections), the authors of this NEJM paper did not taken into account the many delayed and downstream placenta-related complications of Cesarean surgery.
When the placenta implants on the lower half of the front wall of the uterus, the surgeon must cut through the still-functioning, still attached placenta in order to perform the Cesarean. This is a known cause of intra-operation hemorrhage, which is sometimes so unmanageable that an emergency hysterectomy must be performed. In post-cesarean pregnancies, a host of other placental abnormalities – previa, accreda or percreda — significantly increases the risk of mortality and morbidity to the childbearing woman. An increased perinatal mortality rate of 1:1, 000 puts unborn babies at risk in post-Cesarean pregnancies due to placental abruption during the 3rd trimester.
Strike One ~ 1830 to 1881
The first time that obstetrics went over to the dark side was during the era of Semmelweis (1830). This episode lasted for 5 decades and occurred during an era that had no understanding of the role of bacteria in contagious disease, no sterile exam gloves, no antibiotics and no scientific oversight from outside sources. During two previous centuries the medical profession acknowledged among themselves that aggregating childbearing together in an institution was directly associated with a drastic increase in number of cases and virulence of puerperal septicemia. Over the course of the previous century a small but substantial number of physicians all over the world – Doctor White in England, Dr. Gordon in Scotland, Dr. Cederskjšld in Sweden and our own Dr. Oliver Wendell Holmes in Boston — had all observed, studied and warned of the iatrogenic nature of childbed fever. In the published transcript of the 1880-1881 session of the Edinburgh Obstetrical Society, a Scottish professor of obstetrics acknowledged what he called “the old questions”:
“the old questions were long ago worked out by Sir J Simpson, Evory Kennedy and others of home versus hospital practice and of the greatly increased mortality of hospital as compared with home”.
In this regard, he identified the two-fold function of lying-in wards in European charity hospitals. One was to provide food, lodging and supportive medical care to homeless & indigent women during the last weeks of pregnancy, childbirth and the first weeks of their baby’s life. The second role of such hospitals was teaching medical students and providing clinical training. He noted that:
“maternity hospitals must exist, as much for the benefit of women at a time when they most need shelter and assistance, as for the clinical instruction which the medical student can receive there and there only.
The heart of the issue was the hospital-based practice of assigning medical students to perform autopsies everyday on all the newly delivered women who died of childbed fever (puerperal sepsis) and then sending these students and their professors to perform sequential vaginal exams (each ungloved student examined each laboring woman, one after another) without ever having disinfected their hands (or even washed them with soap and water) between their duties in the morgue and those in the labor ward or between each labor patient they examined. Once contaminated with streptococcal bacteria, a high percentage of newly delivered mothers developed a virulent septicemia that caused death within 72 hours postpartum.
In addition to students carrying contamination from autopsies to labor wards, there was also the new teaching practice of using the cadavers of women who died after childbirth as teaching mannequins. Before 1828 models of human anatomy were made from fabric, bone and other materials to teach childbirth practices and obstetrical skills to medical and midwifery students. These bio-safe mannequins allowed students to practice palpating the position of the baby’s head in relation to the bones of the maternal pelvis and to use forceps without harming any real live people.
However, the new is always more appealing than the old. What was new was an increasing use of cadaver dissection as a learning tool for medical students. As this became more common, obstetrical professors became convinced that the use of cadavers would provide a superior teaching situation and improved the ability of students to develop the necessary manual dexterity skills. Over the course of a decade (late 1820 & early 1830s) the traditional fabric mannequins were replaced with cadavers in many of the teaching hospitals of Western Europe.
Information gained from the use of maternal and infant cadavers permitted the obstetrical profession to measure the interior of the pelvis and birth canal in an actual body, one with its soft tissue, muscles and ligaments intact. This allowed obstetrical professors to develop a critical understanding of exactly how the baby came into the pelvis, transversed the mid-plane and exited the pelvic outlet. This provided the obstetrical profession with an accurate understanding of many important aspects of the physical birth process and to develop and teach the skills needed when babies didn’t fit or mothers couldn’t push. This exquisite and exacting detail could not have been gleaned from the skeletons of long dead bodies of women and babies, which had pelvic and cranial bones that were, as they describe it “unclothed” by bodily tissue and lacked the normal attachment of crucial ligaments. This was nearly many decades before the invention of x-rays and a full century-plus before MRIs and CAT scan and was not until 2011 that a woman gave birth for the first time in a special MRI in an effort to get a similar look at the relationship between passenger and passage.
However, the use of cadavers for obstetrical teaching purposes presented other problems. To prepare the deceased mother’s body for its novel function as a teaching mannequin her cadaver was first dissected at the waist. The upper end of the torso was discarded, and then the abdominal viscera, including the uterus, was removed from the bottom half of the deceased mother’s body. This cadaver-based teaching system also required a supply of cadaver newborns to be readily available, which were placed one at a time in the hollowed-out abdomen of the woman cadaver. This allowed students to reach up thru the deceased woman’s vagina to determine fetal position and practice performing forceps deliveries, podalic breech extractions as a second person pressed the neonatal cadaver down through the abdomen of its cadaver-mother. It also allowed students to learn how to ‘safely’ perform fetal destructive operations.
Unfortunately, the benefit of this body of knowledge and the greater skill that students gained from the use of teaching cadavers was offset by the infected organic material left on the hands and clothing of the students. Highly contaminated tissue and pus introduced potentially lethal bacteria to healthy hospitalized maternity patients, causing a mortality rate for both mothers and newborns that ranged from 5 to 50 persent, depending on the time of year.
Strike one of this obstetrical trifectawas therejection of antiseptic and aseptic techniques to disinfect the hands of physicians and medical students, surgical instruments and other supplies. They also rejected the use of other logical aseptic principles, such as not attending births on the same day that one performed autopsies or worked with teaching cadavers in the hospital morgue. These and associated iatrogenic practices lead to the death of untold hundreds of thousands of poor women and their babies, as they were forced by circumstances to give birth in the large charity hospitals of Europe.
Physicians were in the main offended by the idea of hand-washing. The all-male medical profession was drawn from the landed gentry. Coming from considerable wealth, doctors did not ‘work with their hands’ and therefore saw themselves as naturally cleaner than average people. Doctors stubbornly rejected to idea that their actions played a central role in contagion, insisting instead that they were “gentlemen and a gentleman’s hands could never harm anyone”. This unbecoming behavior continued unabated for 40 years. It told another 25 years before strict the aseptic principles were universally acknowledged by the medical profession as necessary and uniformly applied in institutional settings. The one shining exception to this was Sweden, which passed a national law in 1881 that required all physicians and midwives to use strict aseptic principles when attending cases of childbirth.
As we see in “Strike Two” reports, individual MDs were still ignoring the well-established principles of asepsis in the 1930 – a hundred years later.
