Wrong Use of Obstetrics ~ Correcting the historical idea that physiological care is outdated and dangerous
Part One ~ Do NOT copy, distribute, or post on any publicly-accessible Internet site @@@
The Wrong Use of Obstetrics:
The most Profound Change in Normal Childbirth Practices
in the History of the Human Species
NOTE: This is an academic and synoptic version for
legal purposes and midwifery-related “insiders”
and not ready yet for the popular press
~ Correcting the historical idea that physiological care is outdated and dangerous
So far, I have mostly focused on the contemporary practice of obstetrics in the US. But it’s hard to understand the unique characteristics of American obstetrics without some knowing something of the history behind our aggressively interventive system.
The ten essays that follows this introduction and overview exposes and argues against the root problem introduced in 1910 by a small number of very influential American obstetricians. At that time, obstetricians genuinely believed their professional duty was to make childbirth safer by eliminating all physiological childbirth practices and replacing the supportive and non-interventive care previously provided by midwives and general practitioners with a strict interventionist obstetrical model.
This funneled the care of healthy childbearing women into the surgical specialty of obstetrics and gynecology. Its policies for managing normal childbirth were based on the idea of a “pre-emptive strike” that is, routinely using the same interventions and surgical procedures developed to treat serious obstetrical complications as a way to prevent those very same obstetrical complications.
For example, a small number of laboring women needed a forceps-assisted delivery, so forceps deliveries were done pre-emptively, without any indication of pelvic disproportion, signs of fetal distress or other problems. Since a small percentage of new mothers have a postpartum hemorrhage (PPH) due to a retained placenta, manually removing the placenta was done routinely as a strategy to prevent that particular cause of postpartum hemorrhage.
This also was a way to hurry the process up, since it meant the OB didn’t have to hang around waiting for the placenta to be expelled “naturally”. Instead, he could just put on an elbow-length sterile glove, reach up through the mother’s vagina to her uterus and then tease the attached placenta off the uterine wall and pull it out in his hand. This could be done in less than 5 minutes and assuming the mother didn’t immediately have a life-threatening torrential hemorrhage, the doctor could note that he was needed elsewhere and rush out the door.
Unfortunately, one of the most frequent triggers for PPH is manual extraction of the placenta. A 2019 study published in the Journal of Maternal Fetal Neonatal Medicine 2019 Feb [citation #3] doi: 10.1080/14767058.2017 “Risk factors and complications of manual placental removal after vaginal delivery – how common are additional invasive procedures?” concluded that:
Short-term complications included blood … transfusions and prolonged hospitalization. Invasive procedures for removal of [retain placental fragments] occurred in 12% of women in the study groups and in none of the women in the control group (p < .001).
Conclusions: Manual placental removal harbors short- and long-term complications, including a high likelihood of retained placental fragments necessitating further invasive procedures.
Literally hundreds of similarly negative studies have been published about the so-called “prophylactic” use of obstetrical forceps. None of these interventions served the childbearing woman by making her childbirth any “better” or any safer. Unfortunately, these are just a few examples from a very long list of iatrogenic complications that greatly exceeded their imagined benefits, but for whom the increased maternal mortality was not at all “imaginary”. Dead is dead.
The Only Logical Plan – Returning the surgical specialty of obstetrics to its historical role
As for universally reforming our highly-interventive obstetrical system, the only logical plan is to rehabilitate the discipline of obstetrics by returning this surgical specialty to its historically proper place. This describes providing much needed life-saving obstetrical care to women with high-risk pregnancies, those who develop complications, experience an obstetrical emergency, need an operative delivery or require going treatment for female reproductive issues.
This category also includes healthy childbearing women who have made an informed choice to have obstetrical interventions used routinely during their normal labors and births.
Obstetrics as a full-service provider or superior role as a surgical specialty
When the obstetrical professional decided to eliminate the practice of midwifery by midwives as independent professionals, they technically took the responsibility for providing direct support and guidance to healthy women experiencing the physiologically process of normal labor and birth. However, obstetricians didn’t see it that way. Instead of doctors making any effort to providing support for a normal labor, or hiring midwives or nurses trained to provide this hands-on midwifery care, and obstetricians denied they had any responsibility for providing any kind of “hands-on care”, or even being physically present during “the waiting period before the doctor arrives”. They just continued to claim that labor in human females was a pathophysiology.
Happily ensconced in the illusory ideology that normal labor was normally abnormal, the supposedly proper obstetrical response to labor (as defined by an obstetrician!) was social isolation and the semi-conscious state produced by Twilight Sleep drugs. This, of course, was based on the fact that obstetrics is a surgical specialty, obstetricians are trained to be surgeons and labor is seen as the “pre-op” period, which is to say, something properly relegated to auxiliary personal.
In hospital-ese, the conduct of surgery has three phases – pre-op, intra-operative and post-op. Care provided during the “pre-op” and “post-op” phase, which does not include any actual surgery, is considered by obstetrical surgeons to be an activity that should be done by the nursing staff. That means having nurses provide all necessary care in preparing the surgery patient for his or her operation, including a call to the MD if there is a question or problem, and as soon as the procedure is finished, all immediate post-op care again reverts to nurses, again with calls to the doctor if there are issues or complications.
When it comes to the delegation of duties between the economically-independent class of MDs and L&D nurses as hospital employees paid an hourly wage, this is a very unequal arrangement, since the nurse technically functions as a ‘physician extender’ during pre-op (i.e. labor) and post-op (postpartum) periods. Individual nurses take over a host of critically important and time-consuming tasks that save the physician’s “valuable time” by restricting his role to just the intra-operative period and to just those aspects and activities that requires one to be state licensed as an MD.
However, it’s obvious that when the “surgical event” is a normal vaginal birth, the ‘pre-op’ period of care is dramatically different situation. Instead of 5 to 50 minutes of preparing a patient for surgery, L&D nurses providing a “physician extender” service are routinely providing many hours of labor management. This is a critical service that is as important as the one provided by the OB who shows up just as the baby’s head starts crowning and barely gets their sterile gloves on before they manage to “catch” the baby.
At this point, the L&D nurses have provided 99.9% of the intrapartum care received by the mother who gave birth 60-seconds just after “her” OB entered the labor room. Quite obviously, these L&D nurses-as-physician extenders are not being economically compensated at a rate that is commiserate with value they provide to both the laboring patient and the obstetrician.
Eliminating the profession of midwifery by dividing it up between obstetricians and L&D nurses
Another strategy was to eliminate the independent practice of midwives was to divide up the professional duties of the midwife between physicians and nurses, like a piece of whole cloth taken from midwives and torn into two unequal pieces. The biggest piece, which high-paying end — independent practice for compensations –, went to doctors and the much smaller, subservient and low paying end went to the L&D nurses.
“Of the 3 professions—namely, the physician, the trained nurse and the midwife, there should be no attempt to perpetuate the last named (i.e. midwife) as a separate profession.
The midwife should never be regarded as a practitioner, since her only legitimate functions are those of a nurse, plus the attendance on normal deliveries when necessary.”
[1915-A; EdgarMD p. 104]
From the physician’s perspective, the bottom line was to maximize their per unit/patient profit by minimizing their per unit/patient time. This was to be achieved by having the nurses do everything related to the care of labor patients but catch the baby (or collect a representational share of the fee!). Here is how Dr. Ziegler, a very influential obstetricians of the 1920s, explains how doctor can: “get his money from small fees received from a much larger number of patients cared for under time-saving and strength-conserving conditions:
“The doctor must be enabled to get his money from small fees received from a much larger number of patients cared for under time-saving and strength-conserving conditions; he must do his work at the minimum expense to himself, and he must not be asked to do any work for which he is not paid the stipulated fee.
This means … the doctors must be relieved of all work that can be done by others —… nurses, social workers, and midwives.” [1922-A; Ziegler, MD, p. 412]
“The nurses should be trained to do all the antepartum and postpartum work, from both the doctors’ and nurses’ standpoint, with the doctors always available as consultants … when things go wrong;
…. the midwives should be trained to do the work of the so called “practical nurses,” acting as assistants to the regular nurses and under their immediate direction and supervision, and to act as assistant-attendants upon women in labor—conducting the labor during the waiting period or until the doctor arrives, and assisting him* during the delivery.” *Note the good doctor describes labor as “the waiting time before the doctor arrives” and when it come to helping, the midwife is assigned to “assisting him”, instead of the laboring woman [1922-A; ZieglerMD]
“In this plan, the work of the doctors would be limited to the delivery of patients [i.e., birth as a surgical procedure “performed” by the physician!] to consultants with the nurses, and … complete physical and obstetrical examinations. Under this arrangement, the doctors would have to work together in a cooperative association with an equitable distribution of the work and earnings.” [1922-A; ZieglerMD, p. 413]
Reference: https://former.collegeofmidwives.org/safety_issues01/rosenb4.htm
The protocols that organize the practice of surgery and how that applies to obstetrics
All aspects of surgery are organized around three specific time periods – the pre-op, intra-operative and post-operative period — and two different categories of personnel, which are doctors and not-doctors (i.e. nurses). “Pre-op” is a 5 to 50-minute period when the patient is being prepared for the surgery – name tags checked, IV started, etc. Since this doesn’t include any actual surgery, it’s classified as a nursing function carried out by nurses as hospital employees.
Next is the intra-operative period in which surgeons, who are independent practitioners (i.e. not hospital employees) actually “perform” the surgery, using the hospital’s surgical suite, hospital scrub nurses, other types of hospital staff and services, such as blood work or x-rays.
Last and least in the minds of most people is the “post-op” period – recovery from anesthesia and immediate care of the pos-op patient after he or she regains consciousness. Again, this does not include performance of surgery, so the post-op care is also carried out by nurses as hospital employees.
In world of obstetrics as a surgical specialty, labor is the “pre-op” period, and therefore it is the domain of the nursing staff. Unlike the 5 to 50 minutes typical for surgical pre-op, a labor patient can be under the care of L&D nurse for as long as three or even four days, which would be 12 shifts of nurses.
Obviously the “intra-operative period” as historically identified by obstetrical profession is the surgical procedure known as “the delivery”, which legally can only be performed by an MD trained in obstetrical surgery. “Delivery” consisted of series of surgical procedures that typically began rendering the patient unconscious under general anesthesia. Its surgical nature began with the OB “performing” (i.e. cutting) an episiotomy, followed by the use of obstetrical forceps to extract baby. Then doctor by inserted a gloved hand into the mother vagina and up into her uterus to detach and extracted the placenta. The ‘intra-operative’ period concluded with the physician suturing the episiotomy incision and turning the “post-op” patient’s care over to one of the L&D nurses. Like ‘pre-op’ care, the post-partum period is strictly the domain of the hospital nursing staff.
It’s easy to see why the obstetrical profession prefers and benefits from the formal designation of childbirth (the delivery) as a surgical service at the same time that they insist that labor is not a “surgical” or “intra-operative” period. This is to the advantage of the profession in two ways. By technically identifying it as a “pre-op” period, it eliminates any responsibility on the part of obstetrical surgeons to provide a supportive presence during labor, which is conveniently described as the “waiting period before the physician arrives” and therefore not one of the obstetrician’s professional duties.
Second, by defining childbirth i.e. “the delivery” as an intra-operative period, it restricts attendance at a normal birth to a “doctors only”. This technical definition of childbirth as an “intra-operative” period – i.e. something the ONLY a doctor could do – allowed state medical board to call for the arrest and criminal prosecution midwives for the “illegal practice of medicine”.
Using this technical designation as the basis for the legal theory of “illegal practice of medicine”, a professional-trained midwife who immigrated to the US from Scandinavian by the name of Hanna Porn (real name, not a typo), who was arrested in 1907. Then she was criminal prosecuted, found guilty and forbidden to attend births. The arrest and criminal prosecution of midwives continues to this day.
How this surgical definition of birth cheats childbearing women
By being defined as “obstetrical surgeons” obstetricians are not expected to be present during the mother’s labor. They also do not believe they have any professional obligation to make sure that physiologically based, one-on-one midwifery care is available to their labor patients. This “not-my-job“ attitude was clearly identified by an obstetricians who went so far as to publish this idea of “how it’s supposed to be for obstetricians”, saying:
“It is no longer feasible for individual physicians who have invested 12 years in training at a cost of hundreds of thousands of dollars to dedicate extended periods to observing one normal woman in labor.” American Journal of Obstetrics and Gynecology: Macer, J. A. 1992.
However, the mother’s personal experience during active labor – feeling supported and comforted instead of adrift in limbo — can make the difference between a normal vaginal birth or risky Cesarean surgery with downstream complications. By not taking any responsibility for how labor works for the laboring women, the obstetrical profession becomes complaisant in our disproportionately high maternal morbidity and mortality rate.
Notice this obstetrician-author does not talk about helping or supporting a woman during a normal labor. He only refers to the passive act of “observing” her, which then is officially identified as an inappropriate use of the obstetrician’s valuable time compared with the cost and length of his/her medical training.
I see something entirely different in Dr. Macer’s remark: “invested 12 years in training at a cost of hundreds of thousands of dollars to dedicate extended periods to observing one normal woman in labor”. I see this as the logical reason why professional midwives, whose formal training programs are typically 2 to 4 years, should be legally identified as the “appropriate” professional practitioners and birth attendants for healthy women with normal pregnancies.
But what is much bigger and more important than the on-going dust-off between obstetrics and midwifery is the public health issues of prevention – preventing childbirth-related complications, morbidity and preventable mortalities.
As judged by what they do, and NOT what they say, the American obstetrical profession has never valued prevention of complications equally with the treatment of complications.
If prevention of serious problems were appropriately valued by our obstetrical system, the science-based standard in every hospital and every obstetrical practice would be physiologically-based care for healthy childbearing women with normal pregnancies, with obstetrical interventions reserved for women with serious medical conditions, a high-risk pregnancy, develop a serious complication or have an obstetrical emergency.
A Very Small Change that would make such a Big Difference!
The way normal childbirth services have been reimbursed since the 1930s is to use a surgical billing code for the “surgical procedure” of “delivery”. A very small change in this would be enormously helpful at many different levels. A physiologically-based non-surgical billing code would fairly reimburse physicians for their professional time and attention during the mother’s active labor. This simple, and long-overdue modernization would provide better care during labor and help mothers avoid complications and operative deliveries, thus making it a “giant leap forward” for womankind!
Obstetrical Medicine & Midwifery as mutually respected & commentary disciplines
The early 20th century “either-or-thinking” by the American obstetrical system eliminated the idea of “both” – a mutually cooperative and comprehensive model that harmonized each profession’s different role in providing maternity care to an essentially healthy childbearing population. “Either-or” thinking was wrong then, and it is still wrong in the early 21st century.
As concerned citizens it is our job to promote a maternity care system in the United States that both acknowledges and honors the distinct differences and specific ‘gifts’ of each of these two models. They provide care to a different demographic of childbearing women under very different circumstances, but both of these professions are equally necessary. The benefit of all, including childbearing families, is best served by a reciprocal relationship of corporation and support between the two professions.
What would an integrated maternity care system look like?
Ultimately, all maternity care is judged by its results — the number of mothers and babies who graduate from its ministration as healthy, or healthier, than when they started.
Since the basic purpose of maternity care is to protect and preserve the health of already healthy women, mastery in normal childbirth services means bringing about a good outcome without introducing any unnecessary harm or unproductive expense.
This would promote a professional model that integrates the principles of physiological management as provided by midwives and family practice physicians with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women with normal term pregnancies, irrespective of the professional category of the practitioner.
Under this system, the individual management of pregnancy or childbirth would quite logically be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences.
This functional model of maternity care for healthy populations is consistent with recommendations by the W.H.O. This is the opposite of the system used in the US, which organizes the type of care by the occupational status of the birth attendant (i.e. obstetrician, family practice physician, or midwife), rather than the needs of the mother-to-be. Imagine taking your Toyota to a Ford dealership and having them put Ford parts in your engine instead of those designed and manufactured for your car’s model.
A Simple Goal: A system that works for everyone
The goal is simple: Healthy childbearing women who do not want or need a medicalized labor should have unfettered access to a professional birth attendant who is trained and experience in the physiologic management of normal labor and birth in both hospital and community settings. This practitioner needs to be physically present during the active phases of labor (1st, 2nd and 3rd stages), as well as the first hour or two of the immediate postpartum-neonatal period.
This kind of high-quality, evidence-based, supportive and non-interventive care must be universally available to these women. This would be irrespective of the category of professional birth attendant that was providing care — obstetrician, family practice physician or professional midwife – and irrespective of the planned place of birth – hospital, independent (OOH) birth center, or planned home birth.
When providing maternity to healthy women, all American practitioners help us to reverse and eliminate the many harmful decisions made in the 20th century. This means replacing this outmoded surgically-based obstetrical system with a modern 21st century mother-baby-friendly, family-centered form of care. This cost-effective system would normalize childbirth in healthy women and provide routine access to physiological childbirth practices.
Historically and our modern world, the only professional discipline professionally educated and clinically trained in the use of physiologic support is midwifery. As an independent discipline, it’s time for the American midwifery profession to take its rightful place as a normal part of our mainstream maternity care system.
This will not only benefit healthy childbearing families, but also allow the obstetrical profession to do what it does best — making childbirth safer for women with high risk pregnancies. A newly configured 21st century practice of obstetrics that is no longer at war with physiologic principles or fighting against the right use of gravity, obstetricians will be free to really practice obstetrics.
As trained surgeons, I imagine they would appreciate using their life-saving skills and technical abilities on a daily basis to assuage unnecessary suffering, treat complications, respond to obstetrical emergencies, perform operative deliveries, and treat women with reproductive issues.
This would clearly be a win-win for obstetricians, midwives, childbearing women and their babies and the America taxpayer!
Next ~ Chapter 1: Viewing American Obstetrics through the Lens of History
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