Copy of first 7 chapters for “Whole Enchilada” post
Reminder to me — this is only the first 58 pages of a document Whole Enchilda that is 138 page long.
Chapters Five through the rest of the document
20th Century Birth ~ An Unofficial Medical Experiment with a 100-year run
The 20th century medicalization of labor and birth in the US was remarkable more for scale than substance. It systemized the complete loss of physiological management and eliminated important attributes such as ‘patience with nature’ and ‘right use of gravity’. Implementing this form of obstetrical management as the ‘standard of care’ triggered the most dramatic changes in the history of normal childbearing during the 20th century. For women with complicated pregnancies these changes were often positive. For the 70% of women who were healthy, normal pregnancies, the change was not good. The thesis of this medical experiment was the idea (more correctly a hypothesis) that medicalized childbirth would eliminate dysfunctional labor, obstructed birth, perinatal deaths and cerebral palsy.
However, there was no solid evidence to support this hypothesis. The high level of very serious intervention was further complicated by the suddenness of it all. The really accelerated curve for taking over the “obstetrical material” of midwives and reconfiguring them as obstetrical patients was from 1910 to 1920. That is a very short time to work out the bug of something so big and complicated as eradicating the biology of normal childbirth. But the obstetrical profession rose to the occasion by developing a variety of methods they hoped would reduce these problems including the routine use of anesthesia, episiotomy, forceps, manual removal of the placenta, perineal suturing and drugs to treat hemorrhage and eventually, drugs for infection.
What this meant to the childbearing population was that they were no longer cared for at home by their midwife or family physician but instead admitted to hospitals where their labors were managed by professional nurses (whom they did not know) as a ‘medical’ condition. Normal birth was no longer a process of biology belonging to the laboring women, for which she engaged the help of others to assist her, but which was clearly her own accomplishment. Instead birth was now something accomplished by doctors and nurses, a commodity or a product of the medical profession — something you couldn’t do yourself. It was like engaging the services of a surgeon to remove your appendix, only now doctors took you to the delivery room to “remove” your baby. Had you asked to see the studies on this new ‘surgical procedure’, you’d have found out that medicalized childbirth was a ‘hypothesis’ still in the ‘experimental phase’.
That said, it is only fair to also acknowledge the many important new discoveries and inventions during the first forty years of the 20th century as the science of obstetrics. Ways to artificially induce labor, such as balloons or ‘boogies’ inserted into the cervix to pry it open and drugs injected into the mother to start or speed up labor were developed and used. The design of forceps was improved (several times), the fetascope for listening to heart tones was invented and became indispensable, the basic understanding of the effects of labor on fetal heart rates (which eventually lead to the invention of the electronic fetal monitoring in 1960s) was published by Dr DeLee in 1924, ‘twilight sleep’ was introduced (narcotic and amnesiac drugs) and first use of a crude form of oxytocin (labor-stimulating hormone) and ergotamine occurred. Surgical techniques and anesthesia administration were improved, making Cesareans many time safer that before. However, C-sections were still only performed as a ‘last resort’ because of the risk of serious complications from anesthesia, hemorrhage and infection.
As for the experience of laboring women, that was not improved. Mothers-to-be were kept in bed, heavily medicated with narcotics and isolated from family members. Normal childbirth (now called ‘the delivery’) was to be conducted by a physician as a surgical procedure, ‘performed’ in a sterile operating room on an unconscious women. Of course, fathers (or other family members) were not allowed. This style of medicalized management resulted in a host of difficult labors, including failure to progress and the need to narcotize mothers since the pain of laboring in bed on one’s back was too great to tolerate without medication. For no apparent reason newly delivered mothers suffered massive hemorrhages and some still got fatal infections or infected episiotomy incisions. Other unexpected difficulties included babies that appeared to develop ‘fetal distress’ for no discernable reason, who were stillborn or so depressed at birth they required resuscitation.
Despite what it appeared to be powerful tools to control labor and birth, there was in the background the really dark side of everyone’s worse fears – babies inexplicably born with permanent neurological damage, cerebral palsy and other severe mental and physical problems sometimes referred to as ‘birth injuries’.
All these interventions were a valiant and well-meaning attempt to eliminate the tragic complications of childbirth including stillbirth, brain damage, cerebral palsy and damage to the mother’s pelvic floor. Doctors did not intervene to be mean or out of a disregard for the health of their patients. They were good people who had high hopes, they believed in what they were doing. The question (both unanswered and unasked) was could the medical model delivery on its promise?
The Fix is a Failure
Unfortunately for obstetricians, the same measures of safety that lead to the original condemnation of medical education in 1910 — poor outcome statistics and a high level of maternal and infant mortality and morbidity — revealed the ‘fix’ to be a miserable failure. One physician of the era (Dr. Bolt) identified an increase in maternal deaths of 15% per year for more than a decade and a 44% rise in birth injuries during exactly the same period (1910 to 1935) that coincided with the displacement of midwives by physicians and healthy women became obstetrical patients.
According to a contemporary paper entitled “The Elimination of Midwifery in the United States — 1900 through 1935” by Dr. Neal DeVitt :
‘“The Committee on Maternal Welfare of the Philadelphia County Medical Society (1934) expressed concern over the rate of deaths of infants from birth injuries increased 62% from 1920 to 1929. This was simultaneous with the decline of midwife-attended birth and the increase in routine obstetrical interventions, due in part to the influence of operative deliveries.”
In 1937 Dr Guttmacher pointed out the problem with the following comments about maternal-infant mortality in the US:
“Let us compare the operative rates of these relatively dangerous countries (USA, Scotland) with those of the countries which are safer. In Sweden the [operative] interference rate is 3.2 percent, in Denmark it is 4.5, while in Holland …. it is under 1 percent.” “What is responsible for this vast difference in operative rates? … Analgesics [narcotic drugs] and anesthetics, which unquestionably retard labor and increase the necessity for operative interference, are almost never used by them in normal cases; and more than 90 percent of their deliveries are done by midwives unassisted. And midwives are trained to look upon birth as a natural function which rarely requires artificial aid from steel or brawn. [emphasis added, 1937-A]
NOTE –> The problem was that physicians took over the practice of midwifery without any idea of the philosophy, principles or techniques required for the practice of midwifery — the ‘social’ or physiological model of birth.
They coulnd not bring themselves to acknowledge the psychological and social needs of laboring women or appreciate the greater safety and other benefits afforded by respect for and strict adherence to physiological management. Most important of all, they had no understanding of the dangers introduced by medical interference and surgical interventions.
Instead physicians saw the care of healthy childbearing women primarily as an educational opportunity for them to develop better skills in interventive obstetrics. This was done by routinely using chloroform, episiotomy, forceps and manual removal of the placenta at every normal birth. This reflected the idea that medical students needed to learn these surgical techniques and graduate physicians needed to keep current on these skills, so that when forceps were actually necessary, they would be proficient. The lay public doesn’t appreciate how hard it is to use any instrument of force in the “J” shaped birth canal of a childbearing woman. Since babies don’t come out like a train comes out of a tunnel, you can’t just “pull” them out with the medical equivalent of tongs or a toilet plunger. Learning how to navigate that 60-degree angle, officially called the “curve of Carus” after professor of anatomy and obstetrician Carl Gustav Carus who first described it as the “parturient axis” in 1789, is a difficult skill.
Much of obstetrics is the story of how hard it is to fool (or fool with!) ‘Mother Nature’. The history of forceps is the record of the various ways the medical profession has tried to “work around” the problems caused by that 60-degree angle. In particular, how hard it is to get an undamaged baby out of the unconscious, anesthetized (or numb) body of a laboring woman who can’t push her baby out (perhaps because of the anesthesia) or for whom the anti-gravitational position and weight-bearing on the pelvis works directly against the natural (and necessary) characteristics of pelvic mobility.
Hard as it is for a mother lying on her back to push her baby uphill around a 60-degee angle, consider how much more difficult it would be for the doctor to accomplished the same things by pulling on the fragile skull of an unborn baby “from below” (standing on the floor in front of the pelvis), with enough force to get the baby to go around the corner and emerge at an uphill angle (i.e., baby’s head pointing towards the ceiling). The many bad maternal-infant outcome statistics of the era reflected the poor outcomes that resulted from pulling heavily narcotized babies out from below with forceps.
The Obstetrical Profession Confuses ‘Cause’ and ‘Effect’
In a systemized effort to “fool” Mother Nature, anesthesia, episiotomy, forceps, manual removal of the placenta and stitching up the episiotomy not only became ‘routine’ but quickly also became the “standard of care”. Unfortunately, anesthetic deaths, postpartum hemorrhage, infection, newborn brain damage, stillbirth and long-term gynecological complications associated with the use of forceps (such as incontinence) followed in the wake of this ill-conceived and unscientific model of care.
Equally sad for the obstetrical profession, the actual cause of these poor outcome statistics turned out to be the very thing that the obstetrical profession considered to be the ‘big deal’, the brightest hope of its profession, its best talent, its raison d’etre – the ‘creative’ and prophylactic use of drugs, anesthesia and surgical interventions. However, the interpretation by medical professionals was an exactly inverted opinion. In their minds the bad outcome statistics only proved that birth was even more pathological than they already imagined. They were (and remain) convinced that what was (and is) needed to correct the problem was (is) ever more drastic interventions, done sooner and applied to more and more cases of otherwise healthy pregnancies or normal labor.
(When I retired from L&D nursing in 1976, this was still the obstetrical standard of care, except that general anesthesia was slowly being replaced by spinals or epidural anesthesia)
Chapter Six
Within just a few years, the promise of 1910 came to pass – organized medicine did train a large number of obstetrical surgeons to replace midwives, and these newly minted physicians took over the care of healthy childbearing women. We also have to admit that the obstetrical promise of complete control over the unpredictable nature of female biology is an enduring idea that continues to be enthusiastically embraced by both the medical profession and the lay public. And the claim that obstetrical management would vastly reduce (if not altogether prevent) childbirth-related disability and maternal-infant mortality is one the obstetrical profession sincerely believes to be a promise they delivered on.
Improved Outcomes, Difference of Opinion on Why
Simultaneously (or co-incidentally, depending on your perspective!) maternal infant outcomes did improve dramatically over the course of the 20th century. Both stillbirth and maternal deaths are way down as compared to 1910. However, medical anthropologists attribute this dramatic improvement not to obstetrical interventions but rather to social causes — rising economic and educational factors such as public sanitation and safe building codes, clean water, adequate nutrition, effective contraception, timely access to medical services when necessary, etc. But it comes as no surprise to hear that the obstetrical profession is not buying this explanation.
Birth as a Surgical Procedure Become the Standard of Care 1910 — 1980
According to the obstetrical profession, economic and public health factors were only a minor contributor to the vast improvement in maternal-infant outcome statistics during the first half of the 20th century. They remained convinced that childbearing was inherently dangerous and that it could only be made safe in a hospital as a surgical procedure, performed by a physician under sterile conditions. Clearly, birth was indeed something the doctor (not the mother) did. From the perspective of organized medicine, medicalized childbearing fulfilled the obstetrical promise to prevent stillbirth, brain damage, cerebral palsy, and pelvic floor damage. While the cure was not yet a 100%, they had their eyes on the prize – a time when more and better obstetrical interventions would reduce ‘adverse events’ to the vanishing point. With this kind of organized commitment and the momentum of both the lay public and the medical profession, more than 90% of childbearing women gave birth this way – full medicalized obstetrical management, narcotic drugs in labor, general anesthesia and “prophylactic use” of outlet forceps. The only good news was that the Cesarean rate was only about 1% for the first few decades of the 20th century.
If at first you don’t succeed, try, try again – 1930 to 1970
Despite the powerful control and massive manipulation of labor and birth, obstetrical problems continued to occur – labors didn’t go as planned, babies developed ‘fetal distress’ or were stillborn for no observable reason. Mothers continued to have massive hemorrhages after delivery and get serious, even fatal infections. Of additional concern were gynecological complications such as vaginal fistulas and incontinence. And the stubborn problem of ‘birth injuries – brain damage and cerebral palsy continued to defy their best efforts.
So they went back to the drawing board to come up with a new plan, a fresh start. The answer? Well obviously they were not using enough drugs or were not using them early enough. The 20th century obstetrical promise was a better birth for mothers and a perfect baby, every time. That meant it was the obstetrician’s role to make birth work and their profession’s reputation depended on their ability to bring that about.
And luckily for them, a whole host of new of drugs, equipment and methods arose serendipitously as a side-effect of the Second World War – antibiotics, blood typing, safer anesthesia agents, better surgical techniques, expanded diagnostic methods, etc. Obstetrical advances included the modern-day form of the labor stimulating hormone oxytocin (developed and marketed by Parke-Davis as ‘Pitocin’ in 1954), continuous caudal block in labor was first used, the first vacuum extractor for delivery was developed, and Dr Virginia Apgar invented the Apgar scoring system for assessing babies at one and five minutes after birth. Most notably, the prototype of ultrasound for obstetrical purposes – fetal heart rate monitoring and fetal pictures — first occurred between the years of 1958 and 1963.
However, standard obstetrical management did not change – labor was still managed as a medical condition. This included complete isolation from one family in a labor ward. Upon entering into the labor ward as a new patient, the scared young mother was greeted by a cacophony of distressing sounds from other women in labor who were under the influence of powerful drugs and cried out with every uterine contraction, moaning, shouting or swearing. Leaving no orifice unmolested, mothers-to-be were subjected to the standard OB prep (pubic shave) and large soapsuds enema, not allowed to eat or drink or get out of bed and had their water broken artificially.
Then they were given heavy doses of narcotics and amnesic drugs (they were probably grateful to forget what had just happened to them!). Birth was a surgical procedure was still the norm, which meant anesthesia, episiotomy, forceps, stitches, etc. But the new drugs of the 1940s did help obstetricians deal more successfully with the side-effects of these interventions – for example, antibiotics to treat infection from obstetrical manipulations (episiotomy and forceps) and blood transfusions to treat women hemorrhaging after the manual removal of the placenta. And doctors were finally able to reduce the high rate of maternal mortality and stillbirth of the preceding decades.
During this period forceps continued to be routine (90%), while Cesareans were being done more often (5%), as effective antibiotics, safe blood transfusion and safer anesthesia made such surgery less dangerous. Other problems that obstetrical management was suppose to prevent (such as pelvic floor damage) continued on unabated. Worse still, the obstetrical profession continued to stymied in their desire to banish brain damage and cerebral palsy, which seemed to be the same year after year. Doctors dreamed of a day when they understood what caused these heartbreaking problems so that they could banish them with the same success as puerperal sepsis and obstructed labors.
The Really BIG Guns — the Technological Fix — 1970 to 2000
Despite ever-increasing control and manipulation of labor and birth that had become routine during the 1960s, obstetricians at the end of that decade still could not predict or prevent labors that failed to progress, babies that developed ‘fetal distress’ for no observable reason and women who continued to have massive hemorrhages after delivery. New mothers sometimes got serious, even fatal infections, but antibiotics made this less of a worry. However, long-term gynecological complications such as pelvic floor damage, uterine prolapse and incontinence still persisted. The good news was that the stillbirth rate continued to drop. The bad news was that the stubborn problem of ‘birth injuries – brain damage and cerebral palsy – continued to plague them in spite of their best efforts.
But change was in the air, big changes. Over the next 30 years obstetrical practices would be dramatically different in six specific areas – regular use of Pitocin to start or speed up labor, epidural anesthesia, the presence of fathers and family members, the routine use of continuous electronic monitoring, a vastly increased Cesarean rate and the increasing role of the ‘malpractice crisis’ as the central organizing factor in obstetrical medicine.
Interestingly enough, these changes were not the result of new ‘medical miracles’, either drugs or technology, as there was little in the way of brand new inventions during these 30 years. Instead the period was remarkable for its refinement of earlier discoveries– primarily ultrasound and EFM. But the unquestioned lynch pin of the era was the further development and universal use of electronic fetal monitors (EFM) and its association with Cesarean section. More and more the Cesarean section was being seen a relatively safe rescue operation and, it was assumed, a valuable tool in the armamentarium of weapons against birth-related brain damage and cerebral palsy. In combination with an increasingly ‘litigious society’, the malpractice crisis fueled a propensity to use Cesarean section as the all purpose solution for every perceived problem.
Patient’s Rights as an Important, Modern-day Concept
The 1976 malpractice crisis occurred at the same time that the concept of “patients rights” underwent a major upgrade. This groundbreaking change was more substantial and far reaching than malpractice litigation, but it got little attention from the media. As a result most Americans were unaware of the ‘National Research Act’, passed in 1974 by the US Congress. This Act mandated the establishment of an 11-member National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Commission was “to identify the basic ethical principles that should underlie the conduct of biomedical and behavioral research involving human subjects and to develop guidelines that should be followed in such research.” [52]
Patient’s Rights is not a very exciting topic unless you also know that doctors in the US were not, up to that time, required by law to get voluntary participation and informed consent from patients before using them as test subjects in a medical experiment. This explains how something as reprehensible as the 40-year Tuskegee Syphilis Study could have occurred. It was not until July 1972 that a New York Times story brought this moral outrage to the public’s attention. The story, briefly stated, was that the United States Public Health Service conducted research from 1932 to 1972 on 600 black men in order to learn more about syphilis. There was no evidence that researchers informed these men that they were being used as subjects in a medical study.
These men were misled and not given the facts required to provide informed consent. Researchers told them they were being treated for “bad blood,” a local term used to describe several ailments, including syphilis, anemia, and fatigue. Withholding effective treatment caused needless pain and suffering. Even when penicillin became the drug of choice for syphilis in 1947 researchers did not offer it, nor were the men given the choice of quitting the study when this new, highly effective treatment became widely used. In July 1972 the New York Times story caused a public outcry that led the federal government to take a closer look at research involving human subjects and make changes to prevent such things from happening again.
Within a mere six years (still 46 years too late for the Tuskegee patients!) the National Commission for the Protection of Human Subjects published its recommendations in a document known as Belmont Report. In 1978 the patient’s right to voluntary participation thru “informed consent” (including the right to refuse or withdrew from treatment) was established at the federal level. The Commission’s recommendation mandated an ethical obligation on the part of doctors and other researchers to provide full information and obtain truly informed consent before any experimental treatment could be offered. Eventually this became a legal requirement.
National Commission for the Protection of Human Subjects
Were the medicalizing of labor for healthy women and/or the idea of normal childbirth as a surgical procedure that was introduced in the first decades of the 20th century to have occurred sixty years later, history would have been quite different for mothers, midwives and obstetrical surgeons. Under the mandates of the National Commission for the Protection of Human Subjects, the obstetrical profession would have been required to get approval from the hospital’s ethical research advisory board before embarking on an extended “medical experiment”. However, by the late 1970s, the original experimental nature of these ideas was lost to living memory and by then obstetrical intervention was considered to be the “norm”.
That said, the general necessity of obtaining fully informed consent was becoming much more developed and the idea of informed consent relative to obstetrical care gained a lot of traction in a short space of time. The ethics of ‘patient’s rights’, as defined by the Belmont Report, began leak into legal ideas of informed consent in medical care in general. Greater attention to informed consent in obstetrical practice was further spurred by fear of malpractice litigation. By the end of the 1970s the obstetrical profession insisted that childbearing woman were never subjected to interventions unless the labor patients (or her husband if she was under the influence of narcotic drugs) had been informed and given consent.
Chapter Seven — last chapter copied to this file
The Seventies – paradigm shift par excellence!
To make it easier to follow the events of this 30-year era, lets considered the story decade-by-decade, beginning with 1970s.
In the early 1970s there were no less than three new kids on the block — electronic fetal monitoring, epidural anesthesia and the malpractice “crisis”. The biggest and most obstetrically influential was continuous electronic fetal monitoring (EFM), which was tightly paired with that familiar obstetrical staple – surgical birth as either forceps or Cesarean section. However, women were most impressed with epidural anesthesia, which permitted they to be “awake and aware” and have their husband with them. As for the malpractice crisis, lawyers and hospital administrators were zoned in on that.
Electronic Fetal Monitoring
EFM was billed as the answer to every obstetrician (and every family’s) prayer – the magic bullet, the ‘cure’ for birth-related brain injuries. It was believed that the use of continuous EFM could detect fetal distress before it caused any permanent damage. The nifty trick was to catch potential brain damage before it happened and rescue the baby via emergency CS.
Its promise was simple but profound – the marriage of EFM and liberal use of CS was to virtually eliminate birth-related brain damage and cerebral palsy. EFM made maternity care out side of the acute care hospital unthinkable. As the use of EFM became more common, there was increasing pressure for Cesareans to be employed whenever continuous EFM indicated a possible abnormality or fetal distress. It was this idea that gave rise to the obstetrical slogan of “When it doubt, cut it out”.
Very quickly the obstetrical standard of care expanded to include the routine use of continuous EFM, in combination with immediate access to and liberal use of Cesarean surgery. It was suppose to be so easy – just hook every mother up continuously electronic fetal monitoring and sit back and watch the strip scroll by. However there were a few unexpected problems, which doctors, for the most part, kept to themselves.
As with any new technology, there were bugs and unintended consequences. Interpreting EFM tracing was not as straight forward as first assumed. There were many widely differing opinions on just what was and was not a ‘normal’ versus ‘abnormal’ as recorded on the EFM printout. As a result, the emergency CS rate shot thru the roof as obstetricians mistook the many normal variations of FHR pattern as potentially “ominous”. For the first 20 years, the EFM machines were very finicky and the mother had to lie real still, preferably on her back, to get a good reading. It was not widely recognized at the time or, at least not admitted to, but the technology to detect fetal distress also created or contributed to fetal distress.
But still it seem that EFM was the beginning of something great. After a futile search by generations of obstetricians for a way to prevent brain damage and cerebral palsy, obstetricians were convinced that they had finally achieved this most admirable goal. EFM would, finally, categorically and for all time, eliminate these newborn tragedies and the obstetrician’s anxiety of being wrongly accused by the parents or the hospital for some perceived mismanagement of the labor or birth.
Unfortunately, celebration over this perceived victory of the brutish forces of nature was muted by the gathering storm and long-term fallout of the 1976 malpractice crisis.
Epidural Anesthesia
Women and their families were not as impressed with EFM as they were the change to “awake and aware” labor and birth practices and the ability to have their loved ones present during the birth. There were two specific reasons for relaxed hospital policies. Fear of puerperal sepsis had been cured by access to effective antibiotics, so the isolation of maternity patients no longer legally mandated by state laws.
Second, the use of spinal and epidural (instead of general) anesthesia made it more sensible for fathers to be present. Both of these substantive changes happily coincided with the non-obstetrical phenomenon of childbirth education classes and the resulting demand of childbearing women to have their husbands involved in their labor. A very small number of women even managed to have a ‘natural’ birth in this medicalized environment, but this rare oddity did little to influence obstetrical customs.
Malpractice Litigation
Last in our trilogy is the ‘bad humbre’ — the malpractice crisis of 1976. Over the last three decades, the issue of ‘risk reduction’ had begun to organize all medical care around preventing malpractice litigation.
Characterizing EFM as the “big gun” of obstetrics is more metaphorically accurate than one might suppose, as EFM and the malpractice crisis both landed right in the middle of the 1970s. EFM, marketed as the cure-all, made obstetricians uniquely vulnerable to litigation as it left a paper trail that could be subpoenaed and argued over in court by competing and diametrically-opposed ‘expert witnesses’.
The combination of hard-copy ‘evidence’ and the wide variation of professional interpretation was a particularly deadly mix. EFM became like a double-barreled shoot gun with one barrel cocked at the culprit of brain damage and cerebral palsy, ready to shoot to kill, and the other barrel twisted backwards, with the obstetrician dead center in his own sight. The very thing that was seen to ‘save’ the reputation of the obstetrician was also capable of killing it off.
Labor and Birth, 1970-style
Unfortunately, the experience of the ‘awake and aware’ labor patient was not as different as people imagined. Aside from the change to epidural anesthesia and the presence of father (and if they were lucky, maybe one or two other family members) obstetrical management by the end of the 1970s was pretty much the same as the 1930s. Even though infection was no longer the central and organizing problem in hospital childbirth, labor was still organized around its cure, which was to say that birth was still being conducted as a surgical procedure.
Pregnant women were still admitted to hospitals to have their labors managed by nurses as a medical condition. Mothers were still kept in bed, still had no control over what happened to them, still had their water broken, still had their public hair shaved off, still given enemas, still required to be NPO (no food or drink), with the exception of ice chips.
Only now, in addition to the already substitive list, they also had IVs going, an epidural catheter in their back, blood pressure cuffs permanently affixed to their arm, and the ubiquitous EFM leads wrapped around their middle. All this was accompanied by the beep-beep of the electronic fetal monitor, which is the first thing everyone looked at when they entered the room and the last thing they glanced at as the left.
In fact, the EFM got far more attention than the mother. Right use of gravity was not a part of this picture.
More of an issue was that these ‘improvements’ were not as dramatically effective as obstetricians first imagined. The decade of the 1970s ended with a whimper rather than a roar. In spite of having the best control and manipulation of labor, birth and unborn baby in the history of the world, obstetricians at the end of that decade still could not predict or prevent labors that failed to progress, babies that developed ‘fetal distress’ with no explanation and women who continued to have massive hemorrhages after an apparently normal delivery.
New mothers sometimes got infections, which were quickly treated by antibiotics, but occasionally there still was a maternal death. The same long-term gynecological complications such as pelvic floor damage and incontinence persisted. The only good news was that the stillbirth rate continued to drop. But the unexpected bad news was that the stubborn problem of ‘birth injuries – brain damage and cerebral palsy – continued to plague them even with intrapartum use of continuous EFM.
The Eighties
The most remarkable characteristic of the 1980s was the inventive combining and clustering of the newer or upgraded technologies – genetic testing, EFM & ultrasound, improved techniques and equipment for epidural anesthesia, a big increase in labor induction and augmentation, prostaglandins for cervical ripening, accompanied by an ever expanding list of reasons to induce labor and a CS rate around 25 %, primarily due to false-positive reading from the EFM.
Induction – Baby on Demand
Inducting or speeding up labor with Pitocin became much more popular in the late 1970s and early 1980s. A big contributor to this was the development and aggressive marketing of the easier to use angio-cath, which was a replacement for the metal IV needle. This plastic catheter meant the patients no loner had to have their arms tied down to an “IV board” for fear that if they accidently bent their elbow, the IV needle would go straith thru their arm. This was a creepy enough thought that patients and nurses alike were far happier with the new none-needle needles. This made the IV administration of Pitocin more acceptable.
In the 1980s the development of the IV pumps, which help to ‘titrate’ or carefully measure out an exact dose, make the use of Pitocin a bit less risky, at least from the standpoint of hospital staff error. However, Pitocin is a powerful drug and there is no way to tell ahead of time if a laboring women is overly sensitive to it.
The product insert by Parke-Davis pharmaceutical company that ships with every package of Pitocin lists no less than 11 serious or fatal “adverse reactions” (i.e., complications or death) for mothers and 7 for unborn or newborn babies, including a tetonic contraction lasting up to 10 minutes, fetal distress, amniotic fluid embolism, placental abruption, uterine rupture, death and permanent neurological damage for either mother or baby.
VBAC – A Long Over-due Reversal of an Outdated Policy
The high Cesarean rate triggered the reversal of a long-standing obstetrical tradition – the idea that ‘once a Cesarean, always a Cesarean’ came under questions after 50 years of automatic repeat CSs. With a CS rate of 25 %, about 20% of women were having a second pregnancy after a Cesarean.
A modest number of these women were so disturbed by the original CS, or so distraught at the thought of another one and/or so committed to having a normal vaginal birth, that they refuse to sign up for a repeat CS and convinced midwives to let them give birth at home.
That got the attention of the obstetrical profession. After these doctors regained consciousness (many fainted when they heard the news!), there was a long-overdue reassessment. After publishing a few positive studies on VBAC (vaginal birth after cesarean), it was determined that the risk was relatively minor and so hospital VBAC became the standard of care for the obstetrical profession.
“For the first time, the technology of ultrasound allows the fetus to be the primary patient of the obstetrician” Preface of Williams obstetrical textbook, published in early 1980s [emphasis added]
However, the hot new technology of the eighties was prenatal evaluation and genetic testing. Before the decade was over, the combination of ultrasound and genetic testing (such as alpha-feto-protein and amniocentesis) had become the new standard for prenatal care. This made targeted termination of pregnancy possible when it was clear the baby had a serious congenital anomaly.
A side effect of genetic testing was that the number of fragile fetuses who would have became distressed in labor or would have been stillborn was significantly reduced, which improved outcome statistics for live births in all industrialized countries.
Another major area of change was hospital economics. During the 1970s and 80s old charity hospitals were rapidly being improved and converting to ‘for profit’ institutions. A concerted effort to liberalize the social aspect of hospitalization was brought on by economic competition with other hospitals (and the threat of home birth!).
Improvements included new LDRs (labor-delivery-recovery rooms), which architecturally healed the artificial split between ‘labor’ and ‘delivery’. An LDR is basically a controlled and equipped surgical environment (same as a delivery room) that has been modified to accommodate the pre-birth activities of labor, the surgical procedure of ‘delivery and immediate recovery for both new mom and new baby.
LDR standards are the same as any OR and so the bed, floors, ceiling height were all built to surgical specifications and all surfaces were scrubbed and disinfected between each patient.
The normal delivery room equipment and surgical instruments were hidden in cupboards with attractive wooden doors. Equally important was a special (and especially expensive) motorized labor bed that quickly turns, at the press of a button, into a waist-high delivery “table”, complete with stirrups.
Instead of putting women on stretchers and moving them down the hall to the delivery room (which left dad behind), they brought the delivery room and OR table to both mom and dad. This was part of an industry-wide effort by the hospital PR folks to be perceived as family friendly, which included a sprucing up the LDR with flowered bedspreads and other window dressings, moving in a rocking chair and maybe a daybed for dad. This was not an idea that obstetricians had much affection for, but the public really embraced them whole heartedly.
Labor and Birth, Eighties-style:
As for what the fashion conscious, ‘awake and aware’ labor patient of the 80s should wear to have a baby, it was still an ugly and immodest hospital gown. Proper accessories for an UHG (ugly hospital gown), were EFM straps in attractive shades of baby pink and power blue. The medical management in 1980 was, well, even more medical than before. By 1980s threat of malpractice litigation had heated up and was making everyone paranoid. Risk reduction was ‘hot’, physiological management was definitely not.
In fact obstetrical interventions were on an ascending course — ever-increasing in number and invasiveness, with ever widening and relaxed criteria for surgical interventions. Mothers were still required to be NPO (no food or drink) with the exception of ice chips. On a brighter note, many hospitals changed the full public shave to the less invasive “Poodle clip” and exchanged the big soapsuds enema for a small disposable “Fleets” enema. Obviously the idea that the rectum should properly be an ‘exit-only orifice’ had not yet come into its time.
In theory laboring women were ‘allowed’ to walk around, but in practice, as labor progressed they were eventually hooked up to a half dozen medical devices – two electronic fetal monitoring leads, IV and Pitocin administration equipment, epidural anesthesia catheter and administration pump, automatic blood pressure cuff, pulse oximetry, Foley catheter with urine bag hanging on the bed rail. Needless to say, all this ‘stuff’ held them hostage in bed for at least 98% of the total labor.
As if they was not already wired for sound, another ‘refinement’ of the period was the increasing use of the internal fetal monitor lead (which screwed into the unborn baby’s head with a tiny little medal corkscrew) and the intrauterine pressure catheter or ‘IUP’. The IUP required a water-filled tube to be inserted up into the laboring uterus, with the other end hooked up to a complicated hydraulic pressure gauge mounted to the bed at exactly the same height as the mother’s uterus when she was lying down (and cautioned to stay still so as not to screw up the equipment!).
Of course both these invasive forms of EFM required the mother’s membranes to be artificially broken, so these leads and tubes could be inserted up inside them. And sadly, for many, this tangle of tubes and wires was topped of by an oxygen mask when the inevitable signs of fetal distress were noted, a frequent result of a supine position (lying on the back) and the depressive effect of multiple doses of narcotic drugs.
Obviously maternal mobility, right use of gravity and other aspects of physiological management were still not a recognized part of obstetrical care. Nor were meeting the social and psychological needs of the mother acknowledged to be important or contribute to safe, satisfying and non-surgical outcomes.
More than a century had pasted since obstetricians recommended that childbearing be conducted as a surgical procedure to protect women from the epidemic infections of hospitalized childbirth. A hundred years later, that custom that continued to be the organizing principle of obstetrics and the central billing unit of maternity care. Forceps were being used less and less, primarily due to concerns of malpractice liability.
Of course, this meant that Cesareans were being done far more often and with less good reason. Induction of labor and scheduled or ‘elective’ Cesareans were now being recommended with increasing frequency for unusual or “risky” situations: Breech, twins, big baby, premie baby, older mom, hypertension, diabetic, etc.
By now the background rate of CS was about 20%, with some years going as high as 25%. Episiotomy was about 75% for first time mothers and about 50% for multips. Forceps were used in about 30% of births. Unfortunately, many of the problems that strict obstetrical management was suppose to prevent – brain damage, cerebral palsy, pelvic floor damage – continued to occur, in spite of ultrasound evaluation of fetal position and size, NSTs and increasing inductions of labor, continuous EFM, internal EFM leads and expanded reasons for Cesarean delivery.
Obstetricians despaired!
The Nineties
1990 – 2000 ~ The nineties were discouraging to many who had spent the previous decades working towards the liberalization of obstetrical policies and reduction of surgical births. For those who longed for a reversal of the run-away medicalization, it was depressing to see that virtually every healthy labor woman was being harpooned to the bed in a tangled twisted web of electronic wires, tubes and catheters, with the ubiquitous machine that goes “bing” droning on and on in the corner, the center of everyone’s attention.
However, there seemed to be a confluence of patient anxiety with obstetrician anxiety. Women stopped complaining about the restrictions of medicalization and started asking for more – more tests, more inductions, more assurance their baby was OK, even if it meant twice weekly trips to the doctor for NSTs during pregnancy and being arc-welded to the electronic fetal monitor during labor.
But the biggest difference was that more women were asking for more and earlier epidural anesthesia. It was now ‘in’ to have an epidural, so much so that women who voiced a desire for a ‘natural’ birth were told by other women that they would be nuts to even try. The advice was blunt “Get your epidural in the parking lot”.
By the end of the decade, many hospitals had a 95% epidural rate. In fact, the obstetrical profession had been so successful at marketing epidural anesthesia as the “Cadillac of childbirth”, that a new medical profession arose to meet the growing need – OB anesthesia is now a separate sub-specialty for anesthesiologists.
The pernicious influence of run-away malpractice litigation, increasing in number and in amount of jury awards, thoroughly poisoned the water that obstetrician swam in. Psychologically-speaking, the operative words were tight, tighter and tightest – everything in OB was tightly organized around malpractice risk reduction. The astute reader will no doubt be able to predict what comes next – MORE of everything, with a few new bells and whistles.
Obstetrical technology was still king, but for the most part, the ‘cutting’ edge’ was still refining machines and methodologies already in use – color and 3-D ultrasound, telemetry leads for continuous EFM and toward the end of the decade, the first prototype of a fetal pulse oximetry, which is an electronic devise that monitors the oxygen saturation of the unborn baby’s blood. Like the intrauterine pressure catheter, it is yet another tube that is pushed up into the laboring uterus and hooked to a read-out devise.
Between 1990 and the year 2000, greater medical scrutiny was focused on prenatal testing for Group B Strep (GBS) and Gestational Diabetes (GDM) and treatment for these conditions became the ‘standard of care’. Routinely stripping membranes weekly to prevent post-dates became popular as well as the regular induction of labor for all women who had not delivered by 41 weeks.
In addition to prostaglandin gels to ripen the cervix for induction, the off-label use of Cytotec (a drug manufactured for stomach ulcers which caused miscarriages in pregnant women) was considered by many obstetricians to be a miracle drug to kick-start an induction. Some women delivered in an hour after it was inserted into their vagina and it only cost 27 cents a pill (it was described by one OB as “ungodly cheap”).
The Reversal of a Reversal
And another unusual reversal occurred – a reversal of a reversal if you will. The VBAC issue was turned on its head by the end of the millennium and the hot new policy for the year 2000 was the same old policy of “once a Cesarean, always a Cesarean” of the 1930s. This was a curious turn of events, with a ‘multi-factorial basis’, as the say in scientific circles.
There was one part the hubris of more than a decade of treating post cesarean labors as “no different” than any other labor, which was to say, the same extreme medicalization with the same misuse of Cytotec, induction, lack of physiological process, counter-productive management, wrong use of gravity, etc and (no surprise!), there were more uterine ruptures (up to 15 times as many) than spontaneous labors.
Another factor was a totally unjustified change from the classical two-layer suturing technique for cesarean incisions to a single layer technique that was suppose to be faster, use less suture material (cheaper) and reduce the risk to the doctor of finger sticks (an issue if the mother was HIV positive). However, rupture rates are 2 to 5 times greater with single layer closure. Then there was the malpractice crisis – according to lawyers, a VBAC rupture case is a lawsuit on steroids. And in 1998 ACOG changed its official policy so that doctors were required to actually be in the hospital during the entire labor. This was a real disincentive and began to slowly reverse the engines, reducing the number of VBACs and increasing the number of repeat CS.
As for cutting edge techy-toys in the 1990s, many of the new idea were embarrassingly low tech. Amnio-infusion was to prevent respiratory problems for babies associated with meconium. It used a tube to run warm water up into the uterus to wash out the meconium (the sterile contents of the unborn baby’s intestine which is irritating to the lungs and can cause a chemical pneumonia). IV antibiotics were routinely given to GBS+ mothers during labor. Perhaps the only bright spot was that many hospital stopped shaving off the pubic hair of women in labor and dropped the compulsory labor enema. But in every other way, it was more and more and more intervention. The CS rate was about 24 %, forceps about 12%, episiotomy somewhere between 35 and 75%, induction about 20%.
And so we ended the 20th century where we began – labor as a medical condition, birth as a surgical procedure, the classical promise of obstetrics unfulfilled. The total elimination of all childbirth-related complications and the guarantee of a perfect baby every time did not come about as hoped. In spite of having the best level of control over labor, birth and the unborn baby ever to occur in the history of the human species, obstetricians at the end of the 20th century still could not predict or prevent labors that failed to progress, babies that developed ‘fetal distress’ with no explanation and women who continued to have massive hemorrhages after an apparently normal delivery. New mothers sometimes got infections, which were quickly treated by antibiotics, but occasionally there still was a maternal death. The same long-term gynecological complications such as pelvic floor damage and incontinence persisted.
When your best still isn’t good enough ….
And that old nemesis – the triade of brain damage, cerebral palsy, pelvic floor damage – all continued to happen in spite of the ability of ultrasound to evaluation of fetal size and position, non-stress testing, increased inductions of labor, intrapartum IV antibiotics, amnio-infusion, continuous EFM, internal EFM leads, fetal pulse oximetry and massively expanded reasons for Cesarean delivery.
Despair was an inadequate concept to describe the frustration of the obstetrical profession.
