Mayday! Mayday! Chapter 2 ~ Calling all Americans to fix a problem that’s wasting millions of healthcare dollars & results in preventable maternal deaths

by faithgibson on May 2, 2019

in Contemporary Childbirth Politics

Easy link for sharing ~https://tinyurl.com/y5gsetf6

Chapter 2

How did obstetrics in America stray so far from its foundations?

Before addressing this complex question, it’s helpful to step back and look at the big picture from an historical perspective.

A little trip in the Way-Back Machine

This Mayday series is a search for answers. One of the questions is “How did such a great idea as obstetrics go so far off track in modern America?”

In our journey to find answers, we need to fully understand the relationship that the discipline of obstetrics has with modern technologies, particularly the universal use of c-EFM as the obstetrical standard of care in healthy low-risk labor patients.

19th century Doctor’s Black Bag – Note the two small glass bottles to the left of the doctor’s bag — one is ether and the other chloroform. Before forceps were used, the mother would be rendered unconscious with general anesthesia.

To do that, we first need to know much more about the development of modern medical science in general, and the early history obstetrics in the US in particular.

The advancing course of medical discoveries and obstetrical medicine ~ 1850 to 1950

The historic purpose of obstetrical medicine was to safeguard the life and wellbeing of laboring women and their unborn babies.

As we think of it today, modern medical science began with the universal development of the biological sciences. The first big road marker in that journey was the discovery of ether — the first general anesthetic — in 1850. The scientification of Western medicine developed at an ever quickening pace over the last half of the 19th and first half of the 20th century.

‘Wee Beasties’ and other fun facts about bacteria ~ 1673

The microscopic world of bacteria were originally discovered in 1673 by a Dutch self-made scientist, who was an ordinary trades man with little schooling, but he did such extraordinary things that he’s now regarded as having invented the ‘scientific method’ of verifying facts thru controlled and repeatable experimentation, and rightfully considered to be the Father of Microbiology. Using a microscope of his own invention, Antony van Leeuwenhoek was the first person to see the tiny wiggly creatures that he referred to as his  “wee beasties“.

The Germ Theory of Infectious Disease and Contagion ~ 1881

French Chemist Louis Pasteur, inventor of ‘pasteurization, father of the Germ Theory of Infectious Diseases and contagion (1881)

It wasn’t until 1881 that the French chemist, Louis Pasteur, had satisfactorily proven that particular strains of bacteria (ex. streptococcus, staphylococcus, etc) were the cause infectious disease and epidemics.

Pasteur was already well known for having invented a simple process that cost nothing, did not need any specialized equipment and could be used by ordinary people to kill TB germs in raw cows’ milk by heating it to 180 degrees for several minutes.  This process made it safe for children to drink and less likely to spoil. Pasteurization obviously bore the name of its inventor.

During Pasteur’s presentation at the French Institute of Medicine in Paris in 1881, he described his Germ Theory of (Infectious) Disease, followed by an announcement that puerperal sepsis (childbed fever), which was the single largest cause of maternal death, was caused by a very specific bacteria.

Then he drew the outline of several streptococcus bacteria on a chalkboard — they looked like round railroad tanker car lined up on a train track. Pointing at this drawing, he said:

And that gentlemen is what is killing these women“.

The Medical Profession’s 1st Holy War between Assumptions and Evidence ~ 1840-1881

During that era, the majority of the medical profession worldwide rejected the claims by Pasteur and several others who were convinced they’d identified the role of bacteria in putrefaction and infection. The list of Pasteur’s predecessors began with Dr. Semmelweis of Vienna.

As an assistant professor of obstetrics at the huge general hospital in Vienna, he did the first scientific study that identified puerperal sepsis to be a contagious disease caused by some unknown, invisible substance spread on the hands of doctors and medical students.

His carefully crafted study identified the critical chain of events as originating with medical students and their obstetrical professor who perform daily post-mortem dissection as a part of their medical studies, using the cadavers of the two or more new mothers and newborns that died of puerperal sepsis each day (70o-plus a year).

Before continuing, I must emphasis that these events occurred at a time and place where no one — not even the most highly respected professors of obstetric — had knowledge of germs or understood the relationship between invisible bacteria and infection. While this true account is shocking, it must be seen from the perspective of its historical period, and not judged by our modern standards or sensibilities.

These events occurred in a world without latex exam gloves, knowledge of microscopic pathogens, or access to antibiotics. For medical students of that time and place, the traditions associated with their clinical training were bizarre by today’s standards. Medical students have always been at the bottom of the social ladder and their professor expected to do what they were told them without question.

One of those customs decreed that doctors and their students wipe their bloody their hands on their lab coat after doing surgery or dissections. At that point in history, a blood-stained coat was a mark of professional prestige. It was a long time ago and things were very different.

Clinical training at the Allgemeines Krankenhaus (Austria’s largest and most famous hospital ) called for students to spend each morning in the morgue, doing autopsies and dissections on the dead bodies of obstetrical patients, the vast majority of whom had died of sepsis.

Then these junior doctors and their professor would dutifully wiped the blood from the last body they dissected on their lab coats, rinsed their hands under the cold water spigot from the pump in the court yard, and then walk together down a short hall to a labor ward brimming with patients.

The students watched respectfully as their professor did a vaginal exam on each laboring woman, followed by each medical student or intern repeating the invasive  exam, until all the women on the ward had been examined 5, 6 or 7 times, while the students stood around asking questions and discussing their findings with their professor.

Neither doctor nor students washed their hands before or between patients. The maternal mortality rate for the obstetrical department of the Allgemeines Krankenhaus wavered between a rare low of 5% and a high of 50%. The wonder is that it was not 100%.

Just as Semmelweis’s work preceded Pasteur, he also had physician-supporters who shared his basic conclusions (if the not all the details) that infection was a contagious disease spread by something that couldn’t be seen with the naked eye. These included Dr. White of Aberdeen, Scotland, also an obstetrician, and the American physician (soon-to-be Supreme Court Justice) Oliver Wendell Holmes.

Unfortunately, the herd mentality won out and doctors continued to clump together and ridicule the “crackpot” idea that van Leeuwenhoek’ invisible wee beasties were responsible for the infections that indiscriminately and in large numbers killed newly delivered mothers and surgical patients. In their mind, anyone who associated with such nonsense was either an idiot or a charlatan and certainly not worthy of their respect or their time!

Thankfully, this animosity among doctors of opposing views was a two-way street.  In 1843, the American doctor O. W. Holmes delivered his own the zinger on the origins of  puerperal sepsis, and theory versus commonsense:

“…. it does appear a singular coincidence that one man or woman (i.e. doctor or midwife) should have 10, 20, 30 or 70 cases of this rare disease following his or her footsteps, with the keenness of a beagle, through the streets and lanes of a crowded city, while the scores [of other doctors] that cross the same paths on the same errands know it only by name” (i.e., they have no cases whatsoever of puerperal sepsis in their own practice).

Then he got real serious and dropped the big bombshell:

“The time has come when the existence of a private pestilence in the sphere of a single physician should be looked upon not as a misfortune, but as a crime.”

Dr. Joseph Lister,  Father of Modern Surgery ~ 1865

Physician and US Supreme Court Justice, the Honorable Oliver Wendell Holmes, Esq

Like many other discoveries and inventions, this story is not uniformly linear.

In 1864 — 15 years before Pasteur’s Germ Theory — Sir Joseph Lister, Royal Surgeon to Queen Victoria, and pioneer of antiseptic surgery, read all the studies by Louis Pasteur on bacterial pathogens and was impressed.

Unlike Pasteur, who was chemist and not a doctor, Lister had the ability to put Pasteur’s theories to the test in a clinical setting. Even though he had no personal knowledge of microbes, and was flying mostly by the seat of his pants, he decided to do just that.

Dr. Lister accepted Pasteur’s theory that some type of biological entity — a bug that was too small to be seen with the naked eye — was responsible for the virulent post-operative infections that at times killed as many as 90% of his post-op patients.

And not wanting to take any chances with Queen Victoria’s health, Lister decided to implement Pasteur’s theories by using another new idea — that of sterilization, the goal being to kill of 1005 of these unseen pathogen. His method was to submerge all of his surgical instruments after each use for several minutes in boiling water. Without touching the sterilized instruments, he wrapped them in clean cloth squares sterilized earlier with a hot iron.

After finding the heat of boiling water to be so effective at killing germs, Dr Lister created the first “sterilizer”. This was a pressurized machine (i.e. a pressure cooker) that used scalding steam to sterilize his surgical instruments, cloth drapes and all the medical equipment that came in contact with his patients during surgery. Post-operative deaths from infection dropped to less than 5%.

Then Lister went on to develop the general principles of asepsis that we live by today. This included scrupulous hand-washing between patients (w/close attention to fingernail beds), and the daily scrubbing of hospital floors, walls and other equipment with a germicidal solution.

Equally important, he invented the principle of ‘surgical sterility‘ or ‘sterile technique‘ that continues to be used by surgeons and obstetricians, as well as other medical and healthcare professionals all over the world.

For this reason, Dr. Lister is still referred to as the Father of Modern Surgery and his name is rightly associated with the ‘germ-killing’ mouthwash “Listerine” and other such products.

 


Stainless Steel Pickup Forceps, typically about 8 to 10″ long

An aside for the curious reader:  The trick of handling but not touching sterilized instruments is pulled off by including an extra pair of ‘pickup forceps’ in each batch of instruments to be sterilized.

After they cool, you carefully take the forceps out by their handles w/o touching any other instrument or gripping end of the forceps. The sterile end of the pickup forceps is then used to carefully remove the remainder of the sterile instruments, placing each on its sterile wrapper. This way they can be handled and packaged without compromising their “surgical sterility”.

This kind of arcane knowledge comes from being a nurse in the days before sterile plastic disposables from China.  This isn’t my only “back-in-the-day” story, but will have to do for now.


The very first medical technologies and wonder drugs ~ 1895 to 1945

The first x-ray machine was built in 1895. Blood typing, which is critical to maken blood transfusions safe, was first used in 1907. Penicillin, the first antibiotic, and sulfa, the first chemical antiseptic drug, were discovered in 1928 and 1932 respectively. This category of pharmaceuticals were widely talked about as “wonder drugs” or a ‘magic bullet’.

However, penicillin was not used to treat an American patient until March 14, 1942 and then only because the patient, woman dying from puerperal sepsis, was a special test case.  This ‘wonder drug’ was not available to the general population until the end of WWII (1945).

That was the very first time the critical elements of modern obstetric medicine were all present and accessible at the same time and in the same place — the obstetrical department of the average American hospital.

Modern scientific obstetrics had finally come of age.

Obstetrics — Before and after the rise of modern medical science

Scientific obstetrics remains one of the most important medical miracles of all times.

But before we had access to modern obstetrical medicine and modern hospitals, simply being a childbearing woman was a terribly dangerous job, one that too often ended in tragedy. The reasons were many, some related to maternal health and others to the low standard of living and the socio-economic hardships that regularly afflicted most Americans, especially for ethnic minorities and new immigrants. Being poor and a childbearing woman doubled your chances of dying prematurely, often as a result of your gender-related biology. 

Continue ~ Chapter 3: The Bad Old Days: before medical science & the discovery of antibiotics

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