A brief excerpt post for Suzanne:
“How Childbirth Got Trapped
on the Wrong Side of History”
The Private and Personal Before the Political
Before returning to the big issues of organized medicine (AMA), obstetrics as an exclusive franchise (i.e. legal monopoly), and the racial politics of the Deep South during the legalized segregation of the 1960s, I’d like to briefly describe the complex world of healthcare in American hospitals – doctors and nurses, hospitals and patients, and the ruthless rules of reality regarding life and death and childbirth services.
The career of every healthcare professional starts with an idealized notion of the ability of modern science to eliminate all sorrow and suffering. It was no different for me, except I was younger and even more naive than most. I had a romantic notion of hospitals gleaned from the movies, especially the mystical, magical idea of labor and delivery. My fascination with childbirth was only slightly less worshipful than my attitude toward medicine, which I assumed had perfected the art of miracles.
The lesson that every physician, midwife, and nurse eventually learns is that Someone or Something is bigger than us as individuals and more powerful than anything medical science has to offer.
A Revealing Critique of American Hospitals
I am justifiable critical of medical politics as it’s been influenced over the last 125 years by the self-serving politics of the AMA.
I’m also very critical of the American obstetrical profession, which has had scandalously high rate of unnecessary Cesarean surgeries for decades. The American obstetrician profession continues to perform major surgery on one out of every three labor patients admitted to a hospital’s obstetrical department.
Unfortunately, there is no way to deliver a baby by Cesarean surgery without putting the mother’s life directly at risk during the surgery itself, the immediate aftermath, in future pregnancies and even years later as abdominal adhesions can cause a hard to diagnose bowel obstruction that can result in the mother’s death.
Once a woman has that kind of major abdominal surgry she will be vulnerable to a host delayed and downstream complications, especially in additional pregnancies. These numbers don’t lie and they don’t paint a pretty picture for any woman who wind up being delivered surgically.
Cesarean delivery is associated with a 13% increase in emergency hysterectomies during the C-section itself or complications following the operation. This also puts the new mother into a high-risk category for any future births (VBAC or “vaginal birth after Cesarean”).
The villain hiding in plain sight: Continuous EFM used in 85% of all labors in the US
This is a direct result of American hospitals purchasing the very expensive ($15,00 to $30,000) technology of continuous electronic fetal monitoring (EFM) beginning in the early 1970s. By 1980, the continuous of EFM on all labor patients had became the standard in virtually all American hospitals.
Unfortunately for all of us, EFM is actually a “failed technology”, in that it does not do what its manufacture claims. It is not safer or better than listening to the unborn baby’s heart rate and rhythm a convenient and inexpensive hand-held Doppler. This simple, reliable and very inexpensive method is known as auscultation (aus-cul-ta-tion). It has exactly the same ratio of good outcomes for babies as EFM but without dramatically increased Cesarean surgery rate. to listen and count the unborn baby’s heart rate and not its rhythm (regular vs irregular) every 30 minutes.
(85%)with than has dramatically increased rate of unplanned C-sections during based on spurious readings from the EFM.
EFM vs. Auscultation (aus-cul-ta-tion) with fetoscope or hand-held Doppler
Over the last 49 years — yes, you read that right — 49 YEARS — evidence-based studies on the continuous use of EFM during labor, which is has been found no to benefit mother or baby, while introducing many risks to the childbearing mother.
This can be easily and inexpensively avoid by simply using a that of itself does not make mother or babies any safer.
Unfortuntely, but its use is directly related with an increase in the number of Cesaerans performed , I also deficiencies of the healthcare system have to be balanced by recognizing what healthcare means to on the personal and private level as patients.
It is a hard job for everyone who provides some aspect of healthcare care to show up every day and do needed work as a caregiver.
My personal lesson in humility started when I was a brand new nursing student assigned to the whites-only labor and delivery ward on 5-North of Orange Memorial Hospital (now known “Orlando Regional”) in Orlando, Florida, 1960s.
Ground Zero ~ Day One, Birth One, Baby number One
As someone who had never seen a baby born, my first day as a student nurse in the Labor and Delivery Room started with a most unusual and, to me, exciting event. During the first hour of the first day of my L&D rotation, at exactly 7:25 in the morning, while I was still being oriented to the unit, a young “unwed” mother was wheeled through those swinging double doors that grace every delivery unit in the western world and are universally emblazoned with big black letters that say “NO ADMITTANCE – Authorized Personnel Only”.
The teenager was sitting crooked in the wheelchair, a dead give-away that something big was going on. When combined with the sounds of pushing, even I could figure out she was about to give birth. While I was excited, the unflappable older nurse merely grabbed the wall phone, dialed “O” and instructed the hospital operator to page the resident for a delivery. In the old day, before everyone carried personal pagers, this meant calling out over the hospital loud speaker: “OB resident – STAT to the Delivery Room, OB resident – STAT to delivery room!”
doctor was being paged as the charge nurse practically threw this mother-to-be on a gurney and raced down the hall and into a doublewide delivery room. The 1962 delivery rooms were typical of the era, which is to say, similar to the operating rooms you see on the TV show M.A.S.H. – a single large room equipped with two operating tables and two anesthesia machines separated by a standing three-panel screen placed in the middle so the patients on each OR table could not see one another. Doctors, nurses and nurse anesthetists routinely slipped back and forth between two simultaneous deliveries, proving assistance wherever it was needed most. This was one of the ways that babies sometimes got mixed up and given to the wrong parents.
On this particular day, another delivery was already in progress on the other side of the delivery room. As the stretcher came crashing into the empty side, the nurse anesthetist came around the screen and instantly sized up the situation. Obviously there was no time to move the mother to the OR-style delivery table or to observe the other protocols that went with childbirth as a surgical procedure.
Instead, the anesthetist just reached for the anesthesia mask, turned on the cyclopropane anesthetic gas and then stepped to the head of the gurney with the black anesthesia rubber facemask in hand. Her intention was to render this young mother unconscious, which was the way everyone gave birth at the time.
The laboring woman couldn’t see the anesthetist, who was behind and out of her line-of-sight. She was understandably shocked when an anesthesia mask seemed to fall from the sky and be pressed firmly over her mouth and nose, cutting off her air supply. This young woman – really just a girl of 16 — had probably never even been in a hospital before. So she grabbed the anesthetist’s wrist with one hand and clawed at the facemask with the other while shaking her head wildly from side to side. While the labor patient frantically tried to get the mask off her face so she could breathe, the nurse anesthetist chased her bobbing head around the stretcher, saying “Oh honey, you’ve got to have this, …. having a baby hurts too bad not to, …..you couldn’t stand it”
At this precise moment, the OB resident ran in the delivery room door. Standing at the foot of the stretcher out of breath and surveying the scene, he barked: “Oh, let her go, she’ll know better next time”. This comment seemed mean, if not punitive, like he was teaching her a lesson for not being a good patient, which is a lot to ask of someone in the middle of having her first baby.
My attention was drawn back to the teenage mother as the OB resident immediately started putting on the perquisite OR garb – cap, mask, shoe covers, sterile gown – all of which was in anticipation of his central role in ‘delivering’ the baby. However, Mother Nature had other ideas. While the doctor struggled into a pair of sterile gloves, this spunky teenager pushed again and the baby just quietly slipped out, unaided by anyone other than normal biology and the natural forces of its own mother.
With no fuss or effort or outward signs of pain or difficulty, this unmarried 16-year old gave birth totally under her own steam. I was amazed and speechless at my first lesson in the mechanics of normal birth – the answer to that age-old question of every 13-year-old girl: Exactly how does that great big thing get out of that little tiny place? Now that I had seen it with my own eyes, I could speak authoritatively.
Then my focus on the newly born baby was replaced by a crystal clear moment of cognitive dissidence, as my eyes and ears were assailed by two incongruous stories — if one of them was true, then other had to be false. But two seasoned professionals, a nurse anesthetist and OB resident, had both just equated normal childbirth with intolerable pain requiring general anesthesia and at least one of them alluded to extraordinary regret by the mother-to-be for being so “foolish” as to refuse their help.
Yet what I had just seen happen did not look at all like a train wreck or anything else that would require general anesthesia. The mother didn’t scream or yell or writhe in pain, there was no blood or gaping wound, nothing but the perfect miracle of that slippery little head peaking out timidly at first, instantly followed by the baby’s whole body, both feet, a big gush of pink amniotic fluid and the umbilical cord trailing along behind. Every detail of the moment was etched into my mind — how the cord glistened as the baby lay there in the pool of steamy amniotic fluid between the mother’s legs, a perfectly formed baby girl, weighing approximately 7 ½ pounds. Call the newspapers, stop the presses, let everyone know that something totally amazing and miraculous just happened on the 5th floor of OMH: Student Nurse Witnesses Her First Ever Normal Birth.
Forty years later this still is a moment outside of time, suspended in my memory. However, in the real world of healthcare, the clock was still ticking. The ‘birth’ was over but, the next act of this play – the product of that biological process, which is to say, a healthy baby — was not happening. As a green student nurse, I was so distracted by the sensory and mental overload that I failed to appreciate the significance of the umbilical cord’s quiescence. In a live baby, the umbilical cord is as big around as your thumb, intensely purple, spirals like a fat phone cord and pulses with every beat of the baby’s heart for several minutes after the birth.
For this baby, the cord was smooth, pale, slender and oh-so-still.
The umbilical cord was not the only thing that was too still and too quiet. The baby did not move, ….. did not cry, ……. did not try to breathe, …. did not have a heartbeat. Officially my first birth had been a stillbirth – mechanically normal but delivering a baby without any vital functions. After the shocked and grieving mother was moved out of the delivery room, still lying on the same stretcher that she had given birth on, I asked the older nurse “why?” What would cause this perfect little baby to be stillborn? She just shrugged her shoulders and quietly, without any particular emotion, said: “some babies just don’t make it, nobody knows why”. With that, the seasoned nurse turned and with a quiet dignity walked off to resume her duties as a handmaiden and faithful servant in the Church of Obstetrical Medicine.
I could only hope that someday I too would be privileged to serve the mystical process of childbirth as a highly qualified professional. But witnessing a stillbirth was a traumatic beginning that made me think of Mother Nature a cruel, even sadistic force. One burned, twice shy! When told by other professionals that the normal biology of childbirth was unreliable, a dangerous patho-physiology, I accepted that description as a self-evident fact. When the invasive obstetrical interventions used on every healthy woman were described as necessary and scientifically-sound, the only way to make childbirth reliably safe, I didn’t ask to see the data supporting that conclusion.
Over the next 17 years my understanding of hospitals and the healthcare system was completely upended. At the end of my nursing career I was much smarter, but only after a disturbing journey through a racial segregated health care system, a stint of working in the ER (and seeing how the other half of the medical profession lived!) and witnessing the pernicious influence of organized medicine, up-close and personal. As I came to know the actual risks of normal childbirth (versus the obstetrical profession’s perceived risks), I questioned the 20th century custom of having healthy women routinely cared for by the surgical specialty of obstetrics.
Childbirth in Black and White
In our segregated southern hospital, Caucasian mothers were sent to the all-white labor ward on
