Background Reading ~ Part 1
The History of Obstetrics in America
and why these historic facts still matter in 2022
The “new” American Obstetrics as a surgical specialty, circa 1910
turned normal childbirth upside down in the healthy population (75%) of woman, which paved the way for the NEJM paper 74 years later, claiming that vaginal birth was so dangerous it should be replaced by scheduled cesarean as safer for babies, while acknowledging but
disregarding the consequence of “excess” maternal deaths
Over the last half-century, I’ve been a hospital-based L&D nurse, given birth spontaneously and without any obstetrical procedures to three healthy children, and after cross-training into midwifery, provided home birth services to several hundred healthy women with normal term pregnancies.
It was both my privilege and my burden to have been an up-close and personal witness to childbirth practices under a variety of very different and at times shocking circumstances. I was also able to participate directly as a professional midwife in a much safer childbirth practices in which women were not subjected to any unnecessary obstetrical interventions and gave birth spontaneously to unmedicated babies that were able to breathe on their own.
As I described in a short publication (“A Time-traveler’s Perspective on Normal Childbirth”; BIRTH, September 2011), my clinical training as a student nurse in a hospital in Orlando, Florida and my first job as a new graduate was in a racially-segregated hospital during a by-gone era best described as the “Dark Ages of the Deep South”. At that time, our hospital had two totally separate and totally different models for providing childbirth services, depending on whether the labor patient was white or black.
All White 5 North L&D
The white obstetrical unit was upstairs on the fifth floor, where our healthy white labor patients were medicated on admission with “Twilight Sleep” drugs. This protocol required L&D nurses to give large and frequently repeated injections of the narcotic Demerol and the amnesic and hallucinogenic drug scopolamine. Under the influence of narcotics and psycho-active drugs, our white labor patients became semi-comatosed and thus were confined to their hospital beds as a matter of hospital policy.
Unfortunately, the drug scopolamine caused some labor patients to become extremely agitated. In addition to trying to crawl out of bed, these women became combative, hitting and biting the nurses. To keep them from falling out of bed and knocking out a tooth or breaking their arm, the nursing staff had to use “four-point restraints” – large leather cuffs that were attached their wrists and ankles and then tied to the four corners of their hospital bed. This forced these laboring women to lay spread eagle on their back while they labored, a position much more painful for the mother and one biology that restricts blood flow to the placenta, which sometimes results in fetal distress.
When it was time for the baby to be born, these healthy mothers were taken by stretcher to one of our obstetrical operating rooms and put to sleep with general anesthesia. The protocols for surgical “delivery” included several surgical procedures, starting with a “generous” episiotomy. Then the doctor instructed the L&D nurse to provide an extremely forceful and dangerous form of “fundal pressure” in combination with the doctor’s use of forceps to extract the baby. Obstetrical “delivery” ended with the manual removal of the placenta and suturing of the episiotomy incision.
Unfortunately, the narcotics and anesthetic gases given to laboring women, combined with the physical trauma of extremely forceful fundal pressure and a forceps delivery, resulted a profound respiratory depression for many normal newborns born to healthy white women and did not breathe after being born.
1 South ~ African-American ward in the basement, next to the laundry, the morgue, and the industrial kitchen
Our hospital didn’t have a separate L&D unit for black labor patients, so these about-to-be mothers were admitted to the all-black 40-bed medical, surgical, and pediatric ward on 1 South and assigned to a bed in a four-bed ward. Black mothers were never given any narcotics or any other pain medication, so they were not forced to stay in their beds during labor. Instead they walked around freely, and as their labor got more active, they held on to the foot of their bed, swaying between contraction and squatting with each contraction. The only specific labor-related care these patients got was to be told to notify one of the nurses when they felt like pushing.
When we heard the classic sounds of pushing, we grabbed a stretcher and had the mother “hop up” on it and covered her with a sheet. Then we raced down the hall to the elevator that connected 1 South to 5 North, which was where all the hospital’s 2 delivery rooms were. However, many of our black labor patients had given birth many times before and often delivered precipitously in the elevator before we reached 5 North. In these instances, the nurse or me as a student nurse, just “caught” the baby as it came out and instigated a “U-turn” by handing the baby up to its mother’s waiting arms. Equally remarkable was the enthusiasm these newly-delivered mothers expressed, greeting their babies with sweet words and obvious affection.
The most extraordinary thing about these spontaneous births was how unmedicated women gave birth without undo fuss or other signs of “unbearable” pain, and wonder of wonders, these babies just breathed on their own without needing to be resuscitated. This all seems like a genuine miracle to me!
In fact, the most notable thing about the births of our black mothers is what didn’t happen – no Twilight sleep drugs, no need for 4-point restraints to keep drugged labor patients from getting out of bed, no general anesthesia, episiotomy, dangerous fundal pressure, forceps extraction of the baby or manual removal of the placenta, and no need to suture an episiotomy incision.
Even as an inexperienced student nurse, the stark and startling difference between these two models of care could not have been more stunning – a long list of interventions that included narcotics, anesthetics and multiple surgical procedures — visited on healthy white mothers, coupled with the disturbing propensity of their newborn babies to not breathe on their own. All this was in such an extreme contrast with the mother-managed and undisturbed nature of a normal labor and birth in our black mothers and propensity of these babies to be healthy, vigorous, and able to breathe on their own.
While I understood (but did not agree with) race-segregation, I still could not account for the obstetrical profession’s use of two such different models – a total lack of interventions in the labors of one set of healthy women who happened to be not be African American, while throwing everything including the kitchen sink, hallucinogenic drugs and forceps at a demographically identical set of healthy laboring women who in this case were being subjected to many painful, dangerous and invasive interventions because they happened to be Caucasian.
Lots of questions, very few answers
This ‘disconnect’ between the ‘story’ of why there were two different forms of obstetrical care for a biologically identical demographic of childbearing women caused me to question the “business as usual” obstetrical culture and everything it did.
This started with the big historical questions, the most imponderable being why normal childbirth on 5 North was conducted as a series of “surgical procedures” (and billable as such), while black mom had a normal spontaneous birth, that is, they just pushed their baby out with their last labor contraction?
Why didn’t obstetricians allow the placenta to be expelled normally instead of putting on an elbow-length sterile glove and reaching up through the newly-delivered mother’s vagina and into the sterile interior of her uterus?
Trained as Ob-Gyn, these doctors surely knew that the vagina is not a sterile part of the human body, which means the bacteria normally present in the mother’s vaginia would be carried up into her uterus on the surgeon’s gloved hand. The process of using his fingers to pry the attached placenta off the uterine wall would in essence rub the bacteria on his gloved fingers into the open blood vessels that feed the placenta during the months of pregnancy. This was the perfect circumstance for introducing puerperal sepsis (childbed fever or “septicemia”) into the mother’s blood stream.
Septicemia is often referred to as “blood poisoning” because the sickness producing germs are in the person’s blood, being carried to all the body’s organs and tissues. Before the discovery of sulfa drugs, penicillin and other antibiotics, this potentially-fatal infection killed 10,000 new mothers every year in the United States. But even after the availability of antibiotic drugs (1945), a labor patient who was in poor health or had an impaired immune still got septicemia and died as a result of the medically-unnecessary surgical intervention of manually removing the placenta as a “normal” part of attending a “normal” birth.
Unanswered questions that are more relevant to contemporary times is the continuing inability of the obstetrical profession to officially acknowledge that the needs of healthy childbearing women are distinctly different than women with serious medical conditions or high-risk pregnancies and that the use of interventions developed to treat complicated pregnancies are not only unnecessary but iatrogenic, that is, capable of causing harm when used during the labors of healthy women.
This includes routine use of ultrasounds during prenatal visits, electively scheduled induction of labor before the due date, continuous electronic fetal monitoring (EFM) during labor. Another iatrogenic form of care includes forcing women with breech babies, twins or have had a previous Cesarean section to have a repeat C-section based on “hospital protocols” instead of the health needs of mother or baby.
The type of maternity care that is the most appropriate and the safest for healthy women with normal pregnancies is distantly different from the obstetrical model. The general medical maxim is simple: Treatments that are life-saving when they are provided to patients with a life-threatening condition (ex. a given a patient who is hemorrhaging a blood transfusion). When life-saving treatment are used on patients that do not have life-threatening condition, those treatments can themselves be life-threatening.
Then there is the strange idea that once a laboring woman was admitted to the L&D unit, all her physical activities would have first to be approved by the obstetrical and nursing staff, who would decide what she was or wasn’t “allowed” or “permitted” her to do. And why, as a matter of course, weren’t laboring women provided with one-on-one labor support by family members and the staff? Why doesn’t the L&D staff routinely include professional midwives who routinely provide one-on-one care?
Of this long list of the inexplicables and imponderables I wondered why institutional obstetrics uniformly puts and keeps laboring women in bed, instead of “allowing” them (better yet, encouraging them!) to walk around and move freely, and “permit” them stay hydrated and energized by drinking freely and eating lightly?
Why weren’t laboring patients “allowed” to do the other things that we know help women tolerate the intense pains of labor, such as touch-relaxation as provided by partner or spending time in a warm shower or getting into a deep-water tub? Why does the “system” not make “right use of gravity”? Instead of upright and mobile positions, laboring women in second stage, especially those who have epidurals, wind up laying their back, a biological position that forces the woman to push her 8-pound baby uphill (toward the ceiling) and around 60-degree angle (Curve of Carus) in the bony pelvis?
As a result of these experiences as an L&D nurse, I was no longer just an ordinary hospital employee working in obstetrics, someone who goes home at the end of her shift and doesn’t think of her job again until it’s time to go back to work.
I wanted an answer to the big and very fundamental question: Why two such different models of care for the same medical category of healthy childbearing women with normal term pregnancies? I wanted to know why such an extreme difference between the care received by biologically identical demographics? How did they justify the routine use of risky, potentially dangerous interventions – drugs, general anesthesia, forceps, etc — in the labors and birth of essentially healthy women?
So, I became a detective, delving into the professional history of midwifery and obstetrics. I started with 5,000-year-old history of traditional childbirth practices that include the care of trained midwives as recorded in ancient Egyptian hieroglyphics and childbirth practices, hen moved on to Western Europe and the United States. I read various kinds of historical records and mortality reports, as well as two-hundred year-old obstetrical textbooks and contemporary textbooks and other professional publications of various kinds.
I contrasted that wealth of information with standard maternity practices in wealthy developed countries where normal childbirth services provided by midwives trained in State-sponsored midwifery schools in western Europe. I was especially interested the systems used England, Scotland, Scandinavia and the Netherlands, were the history of professional midwifery is more than two centuries old and the maternal mortality rate is three times lower than in the US.
But I was particularly interested in the history of the particular obstetrical interventions that were originally developed to treat potentially life-threatening complications, such as anesthesia, episiotomy, forceps and manually removing placentas, and why came to be used routinely in the US during the labors and births of healthy women with normal term pregnancies. However, my plan was dramatically impacted when my husband, who had been stationed overseas for a year and a half came home and I soon by discovered that I was pregnant with my first child.
My personal experience of American obstetrics ~ giving birth to my first child
While my own pregnancy and childbirth meant this research project on the back burner, my personal experience with our hospital’s obstetrical the system was extremely helpful. The obstetrician I chose — Dr. Louis Pohlman — attended births our hospital. I worked with him from time to time and knew he was familiar with its racially-segregated system. A few weeks before my due date, I told him I wanted to give birth the way our black moms did – no drugs, anesthesia, episiotomy, forceps, or manual removal of the placenta. Dr. Pohlman actually did pat my knee, and said:
“Why don’t you just have the baby before you get to the hospitals, because that is what hospitals are for, drugs and anesthesia”.
His comment wasn’t meant to be sarcastic; he was just stating the obvious: Our hospital’s obstetrical “system” drugged all its white labor patients and conducted all its deliveries under general anesthesia and that was that. Neither the doctor nor the patient had any control over this system. As a white labor patient, the only way to get around such set-in-stone protocols was to delay going to the hospital as long as possible and arrive when it was too late for drugs and all the others labor and birth-related interventions. Actually, this was required an extraordinary feat of timing, especially since we lived 50 miles from Orlando, on the east coast of central Florida in Cape Canaveral.
Irrespective of my intentions to arrive “just in the nick of time”, Mother Nature has other plans. We were still about 20 miles away I started pushing, which husband, who’d listened to my daily accounts of “you won’t believe what happened at the hospital today” currently interpreted as great likelihood that the baby was about to be born. It just so happened that the only other car on that lonely road between the east coast and central Florida was a Florida State Trooper. He kept flashing his lights until the officers pulled over on the side of the road. The conversation was very brief: he informed them that his wife was about to give birth in the back seat of the car, and they said, “so sorry, but we are transporting prisoners and can’t help you. However, we will radio head and have a squad car met you at the Orlando city limits and escort you to Orange Memorial.
Aware that pushing probably meant the baby was going to be born in the car in the middle of nowhere, my husband started urging me not to push. My daily accounts of L&D nursing included my effort to delay the birth so the doctor could make his appearance before the baby. That required repeatedly telling these women to “pant like a puppy dog” with their overwhelming urges to push. So my husband keep saying “pant like a puppy dog”, to which I snarled: “I’d darn will push if I wanted to” and so I did.
So I gave birth “unassisted” in the back seat of our family car, just as my husband turned into the hospital driveway in our little 2-door Renault. After rolling to a stop at the entrance to the emergency department, one of our OB looked in the back window of the car, and noting that I was holding a baby, said is a pissy voice: If she’s already had the baby, I don’t want to have anything to do with it” and walked off. Then a nurse from the ER came out and gave me a blanket to keep the baby warm, followed by Dr. Wilson, who was as OB that I worked with and liked. He said the staff was still trying to figure how to get me and my baby daughter, whose umbilical cord still intact, out of the back seat of a 2-door car.
As he turned and walked back into the ER, I slipped on my sandals on with one hand while holding my newborn daughter and her blanket against my body with the other hand. Then I just scooted out of the back seat of the car thru the open passenger-side door, walked over to the waiting stretcher, and baby firmly in hand, I hopped up and laid down. After covering us with a sheet, the orderly took the two of us to that same elevator and up the five floors to the all-white L&D unit.
The next day I heard Dr. Pohlman and his OB partner in the hall talking to each other just before they entered my postpartum hospital room. One of them said: “She gave birth in the back seat of a little 2-door foreign car and the staff couldn’t figure out how to get her and the baby out of its back seat, so she just got out of the car herself, with the baby in her arms, and walked over to the stretcher! Can you imagine!”
What was so remarkable about that brief exchanged is not that I could walk immediately after giving birth, but that every newly-delivered mother seen by these 50-year old doctors had been a heavily drugged labor patient being pushed around on a stretcher by the staff. Since they experienced childbirth as a surgical procedure, a fully conscious and physically able new mother was unimaginable, like an anesthetized patient hopping off the operating room table after major surgery and walking away under her own steam.
