1. How to tell the last and most important untold story of the 20th Century ~ interventive obstetrical care for healthy women w/ normal pregnancies

by faithgibson on July 1, 2007

in Historical Childbirth Politics 1820-1980, OB Interventions: Dubious or Detrimental, Scientific Literature

Reading time ~ 11 minutes

Telling the last
and most important
untold story of the 20th Century

A “perfect storm” of unnecessary obstetrical interventions
turned healthy women into the patients of a
surgical specialty, and turned
normal childbirth into a
surgical procedure

This was the most profound change in
childbirth practices in the history
of the human species

August 9th, 2007 ~

My name is faith Gibson.

I’m a daughter, sister, wife, and mother of three adult children and have two  grandsons, and a former ER and L&D nurse.  I also been a childbirth activist, Lamaze teacher, and grassroots lobbyist who worked with the state legislature to get the Licensed Midwifery Practice Act of 1993 passed.

Since then, I work with legislature to pass 3 amendments to the LMPA. SB 1479, SB 1950, and SB 1638 make the practice of midwifery work better for professional midwives and childbearing families.

I’m currently a professionally midwife with a small home birth practice. I was appointed by the Medical Board of California to Chair of the Midwifery Advisory Council this year (2007) and elected as its Chair.

I’m looking for an experienced editor or co-author to collaborate with me on a variety of fiction and nonfiction writing projects.

This series of posts is an online repository for that material. The purpose of these posts are to help organize the large mass of materials — historical documents and synoptic essays of this material that I and others will use to tell this extremely important untold 20th Century story of American obstetrics as a new surgical speciality.

Obstetrics as a hospital-based surgical discipline that was routinely providing highly interventive care healthy women represents the most profound change in childbirth practices in the history of the human species. The result was a perfect storm that turned healthy women into the patients of a surgical specialty and normal childbirth into a surgical procedure

Goals of my research and publication of that information

The purpose of my writing projects is to rehabilitate our national maternity care policies and demedicalize childbirth for the healthy 70% of our childbearing population.  The goal of individual writing projects is to educate individuals, inform professional and consumer groups, interest investigative journalists, engage the broadcast media and ultimately stimulate a robust public debate.

This public discourse should call into question the century-long custom in the US of routinely using highly interventionist obstetrics as the primary source of care for healthy women with normal pregnancies.

This unfortunate practice is particularly well documented by two surveys of healthy childbearing women done by Maternity Center Association of New York City in 2002 and 2006 1, which identified an average of seven (or more) significant medical or surgical interventions being routinely used in every birth conducted under obstetrical management.  The medical intervention rate for this healthy population is 99% and surgical procedure rate is approximately 70%.

Typical labor room scene with the mother ensconced in a hospital bed, surrounded by an astonishing amount of medical and electronic equipment and the all-important continuous electronic fetal monitor (EFM)

Despite a daunting list of surgical complications, the US Cesarean section rate is over 30% — 1.3 million C-sections. It is the most frequently performed hospital procedure in the US 2, equal to the total number of students that graduate from American colleges each year. The cost of Cesareans surgeries in 2005 3 was 14.6 billion (with a “b”).

The obstetrical profession expects the Cesarean section rate to be over 50% in another decade. In anticipation of permanently increasing rates, some hospitals 4 have started building more operating rooms as a replacement for their labor suites.

Many within the obstetrical profession are promoting the idea of electively scheduled Cesarean for healthy women as the new 21st century standard of care 5. This is in the wake of paper published in the New England Journal of Medicine in 1985 “Prophylactic Cesarean Section at Term?”  Its authors made a strong case for the routine use of “prophylactic” Cesarean at term (later to be referred to by the obstetrical profession as “vaginal bypass surgery”) as an effective way for the obstetrical profession to permanently eliminate the danger that vaginal birth can at times pose to the unborn and newborn baby.

The authors claimed this method for providing safer births to babies would entail only a small increase in the number of “excessmaternal deaths and “extra maternal mortality”. (p. 1266)

“….the number of extra women dying as a result of a complete shift to prophylactic cesarean section at term would be 5.3 per 100,000… [emphasis added]

… if it could save even a fraction of the babies at risk, these calculations would seem to raise the possibility that a shift toward prophylactic cesarean section at term might save a substantial number of healthy infants at a relatively low cost of excess maternal mortality.” [emphasis added]

We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10 ….

Is there some ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure? [emphasis added]

….is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery after fetal lung maturity has been reached? [emphasis added]

If a patient considers the procedure (i.e. routine CS @ term) and decides against it, must she then be required to sign a consent form for the attempted vaginal delivery?” p. 1267 [emphasis added]

The statement that strikes me as most absurd is the “probably” in this sentence:

“We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10…? ”.

Replacing normal low-risk biology with scheduled abdominal surgery is being promoted as better, safer and cheaper than normal birth and the ultimate expression of a woman’s “right to choose”. 6 Unfortunately, these claims of improved safety or lowered cost do not square with the facts, as elective or non-medical use of Cesarean surgery increases maternal mortality by 3.5 times 7 and results in increased mortality and morbidity for newborns 8.

Photo of a high-tech operating room with a staff of 14 and cutting-edge interventionist radiology equipment. It’s designed for doing cesarean deliveries on women who have an abnormally implanted placenta, a dangerous complication frequently associated with having had one or more previous C-section and one that generally requires an emergency hysterectomy after the baby is delivered.

Currently, 17% of our national medical budget is funneled into maternity care 9   that  includes expensive, and often medically-unnecessary interventions in the labors of a healthy population, thus reducing resources available to those with genuine medical needs. This unproductive use of medical resources makes it increasingly hard for the US to be competitive in the global economy. To compete successfully, the US needs to develop a cost effective maternity care system similar to what is used in the European Union and elsewhere around the world.10,11,12  That system relies on physiologic practices for management of normal birth in a healthy population and enjoys much better maternal-infant outcomes at much less expense.13, 14, 15

My Philosophy & Motives   

While I myself am a community midwife, I must that the issue is not midwifery or planned place of birth, it is not a turf war or ideological split between obstetricians and midwives. I have the greatest respect and gratitude for the ability of obstetrical medicine to save lives and reduce suffering. I like obstetricians as individuals and believe that they are often victims of forces beyond their control or even comprehension.

The classic role of a midwife is to help childbearing women do something that is very important to them but also very hard and frequently painful, something that in the moment they don’t necessarily want to do. However, normal birth is a path that they have chosen for themselves. New mothers are inevitably happy afterwards for having accomplished these important goals and grateful for the help they received. Personally, I feel fortunate to have such rewarding work. I also believe that the verbs of ‘midwifing’ – that is, to facilitate important and necessary changes that may not initially be welcomed but are overall beneficial — are helpful to society in the larger political sense.

My Professional Background 

I started my professional life in 1961 as an 18 year-old nursing student and then as a graduate nurse working in the Labor & Delivery Room of what I now characterize as the ‘Dark Ages of the Deep South’ — a time and place that still had a racially segregated, two-tiered (unequal) system. I got to closely observe and directly participate in two oppositional systems, side by side in the same hospital, at the same time, with the same staff and the same type of patients, but totally different management style and outcomes, different as day and night.

This could be thought of as a unique and naturally-occurring study of two contrasting types of childbirth management. One method was a profoundly interventionist model characterized as “knock’em out, drag’em out” obstetrics. This referred to the same style of obstetrical interventions that had been used since the 1920’s.

The other was a lazier-fair system that resulted in, ipso facto, classic physiologically-managed care of the type now provided by family-practice physicians and midwives in other parts of the world. In the 1960s of the Deep South, everything depended on whether the mother was black or white. For Caucasian patients, the policies of the ‘new obstetrics’ prevailed, while our black mothers were excluded from this interventionist style of obstetrical management.

For white women, it began by being isolated from their family as soon as they were admitted to the labor ward; fathers were not allowed to be present during the labor or birth. The list of routine obstetrical interventions started with repeated doses of powerful narcotics, amnesic drugs and laboring in bed on their back, often in four-point leather restraints, which were necessary to keep profoundly drugged mothers from falling out of bed.

For birth, mothers were moved by stretcher to the delivery room, put in stirrups and given general anesthesia. A “generous” (!) episiotomy was done, accompanied by the inevitable stream of blood running like an open facet and splashing loudly into the stainless steel bucket on the floor between the mother’s legs. Then the doctor extracted the baby with obstetrical forceps, followed by the manual removal of the placenta and suturing of the episiotomy wound.

For babies that arrived under the standard obstetrical management, respiratory depression was the inevitable result of the narcotic drugs, anesthesia, anti-gravitational positions for pushing and the use of forceps. For narcotized and anesthetized newborns, life usually started by being resuscitated by the delivery room nurse. Many babies born under these circumstances were never able to breathe on their own.

For the obstetrician, routine care usually ended with the infamous “husband stitch”, which was often accomplished with a flourish and much loose talk as the doctor added a few extra perineal sutures, to make sure the new mother’s vagina was tight as a virgin’s again for her husband. In our small town, the new dad might well have been a golfing buddy of the obstetrician. Wouldn’t want the father complaining that “ever since the baby was born, having sex with my wife is like walking into a warm room”.

 After finishing his handiwork and removing his gown and gloves, the obstetrician would go over to the waiting room and announce to the family that “It’s a boy! (or a girl)”. After congratulating the father with a handshake and basking briefly in the family’s gratitude to him for his skill in safely delivering their baby, the doctor sent the relatives over to the nursery window for their first look at the newest arrival.

For the new mother, obstetrical management ended by being wheeled, still under the effects of anesthesia, to the recovery room. There she would lie on a stretcher for a couple more hours, retching and vomiting her way back to a dim consciousness before she finally asked “What did I have?”  The mother was always the least important person in this obstetrical process and the last to know about her own birth.

Historically speaking, the policies and the process for delivering obstetrical care to the white population of our hospital in the 1960s were pristinely unchanged since 1910, except for replacing the chipped white paint on the OR-style delivery table for shinny new chrome and substituting cyclopropane anesthesia for the much more dangerous chloroform and drip-ether. All in all, it was a happy time for obstetricians but a dangerous time for our Caucasian mothers and babies.

However, our black mothers were the accidental beneficiaries of the prevailing racial prejudice of the time. Black women in labor were admitted to their postpartum beds in a segregated ward in the basement of the hospital and then ignored. This accident of racial politics meant that they had physiologically-managed labors without narcotics for pain or any drugs to speed up labor or other obstetrical interventions such as being forced to push in anti-gravitational positions. Instead, they walked around in labor, cheered on and cheered up by other, often older and more experienced women in the ward.

Our black moms routinely delivered precipitously while being transported up the five floors to the delivery room in the white part of the hospital. It was my frequent pleasure, as an impressionable student nurse, to ‘catch’ their spontaneously born babies in the elevators that traversed the vertical and political distance between One South and Five North. These lucky babies greatly benefited by being free from narcotics and anesthetic gases. They cried immediately, breathed without artificial assistance and were enthusiastically embraced by their conscious and proudly beaming new mothers, who also benefited by not having a gaping episiotomy wound.

A Time Traveler Talks about Maternity Care in the 21st Century

You see, I am a time and place traveler who watched the 20th century history of childbirth unfold, decade by decade, while reading everything that came into my hands on the historical practice of obstetrics. Sixteen years ago, legal events of a political nature required that I do extensive academic research in the medical libraries of Stanford University. As is said of one’s impending execution, arrest and criminal prosecution are also wonderfully effective at focusing the mind! As a result, I became an Idiot Savant in my field and ultimately prevailed in the legal system.

 Now, at 64 years of age, I have committed the final decade of my professional life to telling what I describe as “the last and most important untold story of the 20th century”. The best kept secret in modern times is how and why normal childbirth in a healthy population became the property of a surgical specialty and what the current costs and consequences of that are.

Normal maternity care in America has been defined, for nearly a hundred years, by the politics of organized medicine instead of the scientific and common-sense principles of normal biology. The problem is the application of emergency interventions to the non-emergency circumstances of normal labor and birth. While the obstetrical profession publicly espouses a zeal for safety, this impulse has not translated into enlightened policies in many important ways. In these policy areas, obstetrical medicine has allowed true science to devolve into a pseudo-science — a partial knowledge that corrupts rather than guides. Data that is convenient or fits with pre-ordained plans is embraced and elevated, while the inconvenient truths are ignored or disputed.

Another part of that ‘best-kept secret’ is that the scientific basis for maternity care for healthy childbearing women is not medical management but physiological management. A consensus of the scientific literature supports physiological management of normal childbirth as the evidence-based model of maternity care for a healthy population. The primary purpose of maternity care has always been to preserve the health of already healthy mothers and babies. Approximately 70% of pregnant women in the United States are healthy and have normal pregnancies, which is about 3 million normal births annually.

Normal Care for Normal Birth ~ Physiological Management

The scientific method most appropriate for a healthy population is physiological management – “…in accord with, or characteristic of, the normal functioning of a living organism”. This traditionally non-medical form of maternity care is the most ‘efficacious’, that is, the safest and most cost-effectiveness. As a matter of principle, physiologic management is a commitment not to disturb the natural process.

Physiologically-based care is actually protective for both mothers and babies and results in a dramatic reduction in the number of obstetrical interventions by a factor of two to ten times. The C-section rate for healthy women who chose physiological management is under 5%, while preserving the same level of maternal-infant wellbeing. Episiotomy and operative delivery rates (and their associated complications) drop from over 70% to less than 10%, with the same or slightly reduced perinatal mortality rate. When it comes to complications, less is best.

These protective and preventive methods depend on continuity of care, patience with nature, the full-time presence of the primary caregiver during active labor, one-on-one social and emotional support, non-drug methods of pain relief and the right use of gravity. Obstetrical intervention is reserved for complications or if the mother requests medical interventions.

The Cesarean section rate for community midwives (which includes all hospital transfers) is under 4% [British Medical Journal, June 2005]. For example, I attend about 20 planned home births (PHB) a year. Eighty-seven percent of the mothers we serve deliver normally at home without incident or medical sequelae. The maternal and infant mortality rate for our practice is zero; our Cesarean section rate is 5% (current rate in California is 34%).

Historically, this was called ‘midwifery’, which referred to the formal discipline of non-surgical maternity care for healthy women, regardless of the gender or status of the practitioner. Until the late 1800s, doctors who provided birth services were called ‘man-midwives’. As late as 1955, textbooks for doctors published in the UK referred to the minimal-intervention care for normal birth as ‘midwifery’ and used the term “Midwifery” in their title. This form of maternity care is still provided around the world by both midwives and general practice physicians.

As a physiologic process, normal birth is managed as an “aseptic” event. Aseptic technique entails the use of materials and supplies that are guaranteed clean, dry and free of pathogens. Nothing ever touches the mother that has ever come into contact with any source of contamination – the body fluids of others or sources of ordinary dirt.

Under aseptic conditions, sterile supplies are used anytime an instrument or gloved hand must enter into a sterile body cavity or touch tissues that have been cut or lacerated. Whether normal birth care is being provided in hospitals, birth centers or homes, the necessary sterile supplies are simple — a pair of sterile gloves, a sterile scissor to cut the cord, a sterile clamp to tie it off and a suitable sterile surface (sterile towel) upon which to set these instruments. Accompanying this short list of sterile supplies is the liberal use of clean linens, plastic-backed disposable under pads, paper towels, disposable diapers, sanitary napkins and appropriate trash receptacles.

The doctor or midwife does not have to be “gowned and masked”, the mother does not have to be in a ‘surgical’ environment, nor does she have to lie still or be unable to touch any thing. Wherever the mother is being cared for, the conditions for aseptic technique do not overshadow the mother’s psychological and social needs. The family, including other children, can be present. Normal childbirth as an aseptic event is orders of magnitude less expensive than surgical sterility. There is also no reason for it to be billed under a surgical billing code as a surgical procedure, thus dramatically reducing the cost of providing care for normal childbirth.

For this healthy population, physiological management and routine use of aseptic technique should be the universal standard used by all types of professional caregivers (family physicians, obstetricians and midwives) and in all settings (hospital, birth centers and home).

 Continued ~ Part II

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