Word count 2701 Jan 2025
Chapter 11 ~ Common Sense
The conduct normal childbirth in hospitals under conditions of surgical sterility was originally done because it was the only method available in the last 1800s to prevent the epidemic of puerperal sepsis in institutional settings. Even though it was obvious that aggregating women in an institutional setting was a basic part of the problem, the medical profession concluded that hospitalization for birth was necessary as the only way to make clinical training available to medical students. It is a fluke of history that we got caught in the cross hairs of that singular event, which so influenced and defined the subsequent development of maternity care for healthy women in the US.
Unfortunately it resulted in a maternity care system organized around hospitals and obstetrical surgeons and was accompanied by an ever expanding appetite for labor stimulating drugs, electronic fetal monitoring, narcotic use, anesthesia, episiotomy, forceps, manual exploration of the uterus after delivery, suturing, antibiotics, and the liberal use of Cesareans. And finally — a mere 90 years after the 1910 Flexner Report — this run-away process has concluded with the ‘elective’ use of Cesarean, now promoted as the Rolls Royce of childbirth. At this moment we stand at the cusp of what many in the obstetrical profession hope will lead to ‘patient-choice’ Cesarean as the “standard of care” for childbirth in the US.
This is the obvious conclusion to a system that has refused to teach, learn or utilize physiological management for nearly a hundred years.
Someone is asleep at the switch . . .
Overwhelming scientific evidence informs us that this ‘Alice in Wonderland” story about Cesarean as ‘better and safer’ is just the most recent wrong turn in a four-hundred year old history of wrong turns. Obviously these conclusions are not science-based, not helpful, incredibly expensive and, in many instance, harmful. Why do they prevail in the 21st century spite of all this evidence? I believe it is because someone is asleep at the switch.
We could blame doctors, we could be angry at organized medicine, we could bemoan the obvious sexism of the situation. But I question the usefulness of those reactions. Having been intimately engaged in this controversy for 40 years, I have done (or seen done) all of the responses listed. Believe me, none of them has been helpful so far.
The “someone” who is asleep at the switch is us, all of us, the American public. We are the ones who are loosing by snoozing. The entity that is responsibility for the organization of society is society – our mainstream culture — with a particular burden of responsibility going to the scientific community and investigative journalism. Some of us are members of those groups, the rest of us are the people who zoned out, went south, thought that if we weren’t pregnant or planning to get pregnant the problem didn’t concern us, that this issue was just gender politics and if we weren’t female the issue didn’t matter. So we didn’t speak up, we did speak truth to power, we didn’t state the obvious – the Emperor’s Clothing is, politely stated, threadbare. We didn’t demand of ourselves, or others, that action be taken and the problem rectified. We didn’t make a commitment to do whatever was necessary, for as long as it takes, until science-based maternity care for healthy women becomes the foremost standard of care in the US, one used by all maternity care providers, (physicians and midwives alike) and regardless of the setting for childbirth (hospital, home, independent birth center).
The explanations and excuses are endless and actually don’t matter much, since no one can steer a car down the highway of life by looking in the review mirror. We need a new orientation, we need to change our focus from the “Why are they doing that to us” perspective to one that looks squarely at the problem from the obstetrician’s viewpoint.
“To Run with Endurance the Race Marked Out for Us” – biblical verse
I believe that the practice of obstetrics is not easy, not very satisfying, not ‘safe’ in regard to the issues of malpractice litigation. The obstetrical profession needs our help to facilitate the great effort it will take to untangle the Gordian Knot that obstetrics has become after 4 centuries of racing down a tunnel with no cheese at the end. The original reasons for institutionalizing childbirth in a surgical model no longer apply – we no longer need to stop an epidemic of puerperal sepsis, house indigent pregnant women for months in a hospital setting or cannibalize the client-based of midwives in order to provide ‘clinical material’ to med students.
The sky’s the limit, but so far, imagination has been lacking.
A 21st Century World Trapped in a 19th century Mechanical Model of Childbirth
Contemporary obstetrical practices are a direct reflection of a vastly different era, one that saw the human body as a machine. In the mechanical model of the very early 20th century, the biology of childbearing is imagined to be like the engine of a 1910 Model T Ford. The engine of a car was something under the hood (normally hidden from view) that often broke down and needed to be fixed. In this mechanistic view, the mother is like the body of the car – an inanimate object whose ‘permission’ is not need before “looking under the hood”. And like the car, the mother herself plays no active part in the activities of the physician/mechanic to ‘fix’ her recalcitrant uterus, which either won’t start, stalls out, or doesn’t have what it takes to get up to speed or it can’t make it over the hill.
In this analogy, the pregnant uterus is seen as very similar to a carburetor — it runs to rich or too lean or gets stuck with its chock open. The mother’s primary role is to spread her legs so her OB can get to the source of the problem. The job of her OB is that of a ‘uterine mechanic’ who must constantly tinker with this uterus-carburetor to keep the labor going. This often means changing the fuel (Vitamin “P” or Pitocin induction) or the richness of the mixture of gas to air (giving the mother oxygen), resetting the idle speed and if it thinks get too kinky, doing an “ectomy” — when in doubt, take it out.
After a hundred years of working under the hood, bent over with all eyes on that one same little part — the uterus-carburetor – the job has gotten boring and its limitations outweigh its opportunities by a good bit. The rest of the field of medicine has been transformed in the last 100 years, while obstetrics is doing just what it did in 1920, but with better toys.
Certainly there are many reasons why childbearing women should find this mechanical model discouraging. As a method for protecting and preserving normalcy, it is a scientifically bankrupt process that inadvertently exposes them and their babies to high levels of iatrogenic complications. However, the reasons why obstetricians should want to change it are not so immediately apparent. But the case for the obstetrical profession is every bit as compelling as that for childbearing women. Being trapped in and by a 19th century model is to be deprived on the wonders of the 20th and 21st century. It is to be segregated off from the mainstream of medical science. It means to get stuck with a profession defined not by other obstetrical professionals but by hospital lawyers promoting risk reduction activities – the “You can’t be too careful” school of thought. And yes Virginia, you CAN be too careful, so risk adverse that the very activities of being ‘careful’ actually, regularly, trip up the system.
Malpractice and physician-centric risk reduction generates caution instead of curiosity (can’t be too careful!) and stifles scientific discovery and inventiveness for fear that any obstetricians that does anything “different’ may be acquired of negligent or substandard care. This has locked obstetrics at the very lowest level, permitting it to grow stale, become increasingly inbred and for many physicians, to be boring. It takes a good emergency CS to spices thinks up and convince yourself that it was worth going to school for 14 years to become an obstetrician.
The rest of the world has been moving on!
Its interesting to contrast the frozen-in-time nature of obstetrics with the up, up and away course of science and society in general. Without the millstone of obstetrical orthodoxy, the rest of the medical and scientific world has actively embraced the 20th century with creative innovation.”.
Being stuck in the 19th century, battling phantom epidemics of the 16th, 17th and 18th century takes the fun out of things, mutes the satisfaction, stifles creativity and makes everyone march in locked step, tied up in the straight jacket of learning more and more about less and less. After a hundred years of increasingly “surgical” methods to conduct childbirth, could there possibly be any room left for innovation? The extreme end of the tunnel has got to lead to Cesarean as the “surgeon’s choice” and sure enough, that has come true. What now?
Since there is no where to go after C-sections become the “state of the art”, lets instead explore the possibility of what obstetrics could be come if it got out of the 19th century rut and its inappropriate and singular focus on surgical delivery.
21st Century Obstetrics ~ holistic practice, technologically enhanced teaching
Missing for the last century has been opportunities for genuine research and inventiveness to advance the ability of maternity care provides to support physiological process of pregnancy and birth. While that provides a host of wonderful possibilities, it’s clear that what childbearing women need most but find most glaringly absent, is the psychological aspect of maternity care. One of the most important 20th century revolutions is the scientific recognition of the “mind-body” connection and the big part that psychology plays in preventive and therapeutic medicine. During the last 30 years everyone – professional and lay public alike – has become mindful of how the mind influences the body and the advantage of working within this paradigm to promote wellness and prevent illness.
Unfortunately obstetrics completely missed the mind-body revolution. So far obstetricians have been stuck thinking of the pregnant or laboring uterus as a carburetor that needs to be tinkered with through out eternity. Officially ACOG doesn’t believe that psychology – mental and emotional processes — has anything to do with the conduct of normal childbirth or with perinatal outcomes. In general obstetricians think the touchy-feely stuff is twice suspect, since it is (somehow) “unmanly” AND associated with midwives and other icky weirdoes.
“Pregnancy makes a mother as well as a baby” … Judith Rook, Midwifery In America
Equally important is the general topic of the childbearing woman’s psychological status, her emotional experience, the social aspect of pregnancy, birth and new motherhood, which also has been missed by the profession of obstetrics, at least if the table of contents of obstetrical textbooks is any indication of what is being taught to medical students. Pregnancy makes a mother as well as a baby. Of course this wider focus on social and psychological components opens the door to issues such postpartum depression and other places the current practice of obstetrics can’t or won’t go. This is not necessarily because the individual OB doesn’t want to or isn’t interested, but because the straight jacket of “standard of care” doesn’t permit it. Obstetricians are trapped by the risk reduction process, which organizes everything around the likelihood of litigation.
21st Century Medical Education — Computer Games, Technological Teaching Manikins
It would be the first time in a hundred years that medical training would include the principles of physiological childbirth and the associated skill sets. Adding physiological management to the curriculum would create an opportunity to bring 21st century technology into obstetrical education and permit obstetricians to achieve mastery.
For example, contemporary medical students have being playing computer games for decades. This type of learning ‘in the round’ has already been developed in technical areas such as surgery and dissection. What better way to develop the basic understanding and judgment skills for physiological management than using the computer game model, which allows student to learn didactic information and acquire skills in virtual time and try out alternative strategies for management. Using actual case histories of spontaneous labors and normal births to construct teaching cases would help students learn judgment skills without having to fight anyone over the “scarcity of clinical material”.
Better yet, it would be fun and a far more interesting way to learn. The game model permits the student to try out different approaches and see if they bring him or her closer or farther away from the goal. Take psychological needs into account, factor in the mothers need for privacy, make right use of gravity and rack up the points, put the mother to bed on her back, start some Pitocin and watch things heat up as the labor goes south and signs of fetal distress get worse and worse. If you have to do a CS to rescue the baby, the program can determine whether it was due to iatrogenic causes, in which case, you loose.
The New Generation of Technological Teaching Manikins
Another, even more sophisticated, 21st century technology is the new generation of technological teaching manikins. Already there are medical centers in different parts of the country that have special labs set up like flight simulators for anesthesia and surgical residents, which uses a life-like wired manikin developed for simulated surgery as a learning activity. The techy manikins ‘breathe’, have a heart beat that can be programmed to speedup or slow down and, ‘bleed’ and the pupil of their eyes can dilate or constrict. If you give them the wrong medicine, go into anaphylactic shock, if you use the wrong surgical technique, they hemorrhage and go into shock. If the residents don’t respond to the shock properly, they “die”. If the resuscitative measures are timely and done properly, the heart starts to beat again and everyone in the room cheers! The remarkable part of this new educational opportunity is that it can be repeated and over and over again until everyone the medical team becomes experienced and highly skilled, and yet is like no one is harm
In a system that values physiological management, this type of medical simulator would be applied to childbirth. In an obstetrical manikin with an anatomically correct reproductive tract, the ‘j’ shape of the childbearing pelvis, the mobility of the sacrum, the influence of gravity — whether right use or wrong use of it — would be instantly observable. This would permit OB residents an opportunity to see what worked and what didn’t from a mechanical standpoint (for example, what happens when you make wrong use of gravity!), without worrying about being sued for any perceived failure to provide the standard obstetrical management. It would also provide instant feedback between the mother’s position (prone vs. upright) and blood flow to the placenta and fetus, thus making the dynamics of fetal distress directly observable.
Web Sites, Web Logs (Blogs) and Pod-Casting Lead to New Teaching-Learning Communities
The new technologies of the “wired” age really do open up new ways to reunite us thru shared information and shared experience. Learning is no longer restricted to a university classroom and teaching is no longer restricted to professors of medicine. This helps us take down the “Berlin Wall” that has grown up over the last four centuries between the medical and the midwifery profession. It also permits up to remove the artificial barriers between care providers and those who receive care. Web sites, web logs (blogs) and pod-casting permit medical students and obstetrical residents to form unofficial teaching-learning communities that allow the sharing of knowledge among themselves and also facilitates access to the world of childbearing women and midwives. If doctors would take the time, they would find that childbearing women themselves are the best teachers of what women need and want during pregnancy, labor and birth. Those who had bad experiences with ‘conventional’ obstetrics can become spokespersons promoting necessary corrections.
Understanding all these vital issues from the inside out will permit obstetrics to become an integrated discipline that leaves no one out and leaves no one behind.