The first act of the industrial childbirth revolution was the invention of obstetrical forceps in 1650.
According to historians, the first functional pair of forceps was due to the ingenuity of an English family of doctors – patriarch William Chamberlen, sons Peter I and Peter II and grandson, Peter III. It was William Chamberlen’s accurate knowledge of the bony pelvis and his understanding of the mechanics of normal childbirth that permitted him to design the first obstetrical instrument that would permit a physician to forcibly extract a living baby out without causing it permanent harm or death.
For centuries physicians had been looking for a method or instrument that would permit them to extract the baby in cases of obstructed or ineffective labor. The obvious question is why it took so long to design something like forceps and why didn’t anybody come up with alternative methods until the vacuum extraction was developed in the 1970s? What is so special about the anatomy of the childbearing pelvis? Unfortunately, the use of force to get an undamaged baby out is very much harder than it looks. In order to understand what was so remarkable about the Chamberlen intervention, readers refer back that primer in the bony anatomy of childbirth and the simple physiology of normal childbirth earlier in this essay and entries on this blog.
In general, the successful extraction of a live baby from the birth canal without hurting either mother or baby required a functional understanding of the “J” shape of the pelvic canal and the simple fact that when a mother is lying down, a physician using any form of physical and mechanical force (root of the word “forceps”) would have to be pull the baby around the 60 degree angle of the pelvis. In order to accomplish this, the angle of the pull is straight up towards the ceiling. Unless the doctor is suspended from the ceiling, this would be a very difficult maneuver. The 60-degree angle and the need to exert force going upward are just two issues that the design of obstetrical forceps had to overcome.
Using William Chamberlen’s original pair of forceps as a push-off point, successive generations of the Chamberlen family developed and refined their designs over the next century. It should be noted again that the operative word in forceps is ‘force’. Whether the use of force is a blessing or a curse depends on many factors.
While obstetrical forceps are potentially a life-saving technology, their history is a disturbing story marked by intrigue, unbridled competition, ego-centricisim, personality cults, gender politics and old-fashioned greed. William Chamberlen’s life-saving invention was kept as a family secret for more than a hundred years.
The surreptitious use of the forceps was accomplished by tying one end of a bed sheet around the neck of the doctor and covering the lower half of the mother’s body with the other end. The box containing the forceps was slipped under this visual tent and the forceps taken out and inserted into the mother vagina by “touch”. No one in the room, not even the mother, knew what they looked like or exactly how they worked.
The invention of forceps was the first time in the history of obstetrics that a manufactured instrument became the personal or ‘intellectual’ property of its doctor-developer. Unfortunately, this proprietary relationship with an obstetrical invention led to a host of abuses. Due to the unwillingness of the Chamberlens to make their discovery available to the public, it is conservatively that estimated that during the 17th and 18th century hundreds of thousands of babies who could have been successfully delivered by forceps (had the technology been in the public domain) instead died as a result of obstructed labors. After 4 to 6 days of useless labor, the baby would die and the mother was often left with severe and permanent damage to the tissue of her pelvis (fistulas) and life-long incontinence.
While forceps were designed to rescue babies that otherwise would have been permanently damaged or died, the use of instrumental delivery by the medical profession gradually become more and more indiscriminate, based on obstetrical fashion instead of medical need. In particular, forceps were used excessively on wealthy patients who didn’t need them while being withheld from maternity patients whose babies would die with help, all because the family could not pay the large professional fee.
Forceps in the 20th Century
In early 20th century American, this enthusiasm turned into an irrational exuberance, as forceps become central to the routine practice of obstetrics. Normal birth was characterized as a dangerous mistake of Mother Nature, whereas forceps were portrayed as making birth safer and better. This was the forerunner of today’s identical claim by the obstetrical profession that Cesarean section being better and safer than normal birth. As they say, ‘the more things changes, the more they stay the same’.
In the early years of the 20th century, a famous obstetrician of that era (Dr. Joseph DeLee) was infamous for defining the biology of birth as a patho-physiology — no more ‘normal’ for the mother’s perineum than “falling on a pitchfork”. Even worse, the poor baby’s head was being used as a “battering ram on the mother’s iron perineum”. His solution was the routine use of episiotomy (incidentally giving rise to an entire century of unnecessary episiotomies!) and forceps to save the mother and baby from what he defined as the pathological effects of normal birth.
From 1910 to the 1940s, they were routinely used at all physician-attended births. As late as the 1970s, low or “outlet” forceps deliveries were still the norm in the South and more rural parts of the US. They were used routinely where I worked in the L&D as last as 1976 (Orange Memorial Hospital and Holiday Hospital in Orlando, Florida).
Ultimately, forceps changed the nature of maternity care, tipping it away from physiological management by midwives and general practice physicians and towards the male-dominated profession of obstetrics. The use of forceps became the single most important element of obstetrical practice and virtually eliminated physiologically-based maternity care, since instrumental delivery must be accompanied by the use of anesthesia and episiotomy.
Traditionally, maternity care had been a personal service between two people of the same social status who had an on-going relationship and lived in geographically proximity. But midwives were not permitted to use forceps, which was a restricted practice of medicine. Thus the idea of ‘market share’ was introduced, making obstetrics into an economic adventure shaped and dominated by market forces.
The obstetrical profession took on the mantle of being the source of all knowledge about normal reproduction and the only credible source of wisdom about proper care during childbirth. To their way of thinking, this equated to a medical version of “manifest destiny”. Newspapers and women’s magazines picked up this drum beat and soon the lay public was socialize to the idea that more intervention in birth was, well, more better. The manifest destiny of industrialized childbirth in the US had been born. Within a single generation, virtually all childbirth services were reorganized around hospitals, physicians, obstetrical interventions, with forceps at the top of the list.
Intellectual Property Versus the Normal Anatomy of Childbearing
For mothers who are too tired to push or for whom the baby is in distress, the use of obstetrical forceps to extract the baby can be life-saving. That puts the invention and use of forceps in the pantheon of modern medicine, both as a humanitarian advance and as an aspect of the ‘industrialization’ of maternity care. Unfortunately, the thing that has distinguished the use of obstetrical forceps was not any form of humanitarian concern.
I could not possibly improve on the historical account of the invention, the politics and the lasting consequences than to simply provide the original words of obstetrical historians.
Before providing the test of these historical excerpts, I must mention that ‘obstetrics’ is a 20th century word. From the time of the Ancients until the last 1900s, the word midwifery was almost synonymous with the idea of maternity care, regardless of the gender or status of the practitioner – midwife or physician.
The obstetric forceps: a short history and descriptive catalogue
by BRYAN M. HIBBARD,
The introduction of forceps into obstetric practice is variously described as one of the great advances in obstetric care, or alternatively as an example of the brutal use of new instruments whose only purpose was to advance the cause of man-midwifery.
The latter view was held by many eighteenth-century midwives who saw their business slipping into the hands of medical practitioners, and sometimes by modern historians reacting against what they see as the subsequent domination of childbirth by men, with their persistent tendency to intervene unnecessarily in a physiological process.
…any obstetrician worth his salt had to have a pair of forceps to his name. Witowski, whose Histoire des accouchments was published in Paris in 1887, described mid-nineteenth-century obstetricians as “possessed with an incredible ardour for inventing instruments sometimes dangerous, often useless, but always ingenious”.
If you had your name attached to an instrument, you were tempted to use it whenever it was necessary and often when it was not; and your students learnt to do the same.
“Give me a pair of Kiellands and a pair of Wrigleys and I am content” was, as I remember it, the received obstetric wisdom in the 1950s,….
The past proliferation of forceps does, however, provide an important clue to past practice. The massive intervention in normal or slightly delayed labours, which was such a feature of obstetric practice from the mid-nineteenth century to the 1930s, stimulated the production of new designs. In the hands of an experienced practitioner, forceps could relieve an enormous amount of distress and save maternal and infant lives. Their misuse, which admittedly occurred on a grand scale
BRYAN M. HIBBARD, The obstetric forceps: a short history and descriptive catalogue of the forceps in the Museum of the Royal College of Obstetricians and Gynaecologists, London, Royal College of Obstetricians and Gynaecologists [27 Sussex Place, London NWl 4RG], 1988, 8vo, pp. iii, 69, £2.00.
The Dirty Secret of the Doctors Chamberlen:
The use of forceps to deliver babies has had a long twisted history. As far back as the twelfth century there were instruments described in such a way as to only be useful in removing babies that had died. The use of obstetrical forceps to effect delivery to save the child didn’t come into prominence until the mid eighteenth century. Over a century later than it should have.
Power, fame, and greed all played a role in keeping this instrument a secret, so that those with the knowledge [of forceps] could claim that they alone could deliver patients when everyone else had failed. But before we condemn the foul secrecy that was used for personal gain, the secret of omission that was responsible for countless of thousands of babies’ deaths for over a hundred years.
In 1813, a woman found an old hidden trunk which described and contained the invention of the Chamberlen family–the obstetrical forceps. In this trunk was evidence indicating that Peter Chamberlen, who died in 1631, was the first to use the technique. In fact, he claimed to be the one who could handle the impossible cases.
Along with his brother, they became prominent practitioners with the secret, and used their success to control the instruction of midwifery in England. Peter’s nephew, also named Peter, was the first Chamberlen to actually become a doctor. He maintained the secrecy, assuring his success and prominence, and was the attendant at births of the royal family, who alone benefitted from his solution for difficult births.
Had any of the future monarchs died at their deliveries, like the “little people,” because of not using forceps, history might be vastly different
Dr. Chamberlen, armed with his secret, issued his own “Cry of Women and Children as Echoed Forth in the Compassions of Peter Chamberlen.” After his death, his son, Hugh, tried to sell the family secret to a French physician, Mauriceau, claiming he could deliver even the most difficult cases in minutes. Mauriceau tested him by assigning him a woman in labor who was a dwarf, and he failed.
Hugh Chamberlen translated Mauriceau’s book into English, he wrote in the preface of how, “My father, brothers, and myself (though none else in Europe as I know) have by God’s blessing and our own industry attained to and long practiced a way to deliver women…without (harm) to them or their infants.”
He later sold his secret in Holland, where the Medical-Pharmaceutical College of Amsterdam was given the sole privilege of licensing physicians, for a huge amount of money, to use the secret technique of the Chamberlens. Finally, someone with scruples bought the privilege and went public, but it seems he himself was sold only one part of the forceps pair, meaning that either he was defrauded by the Medical College or Chamberlen had done it to them. Meanwhile, babies suffered the consequences of this thievery.
Hugh Chamberlen’s son, also named Hugh, was a friend of the Duke of Buckingham, and because of this his statue stands today in Westminster Abbey. He’s the one who finally freed the obstetrical forceps for general use at the beginning of the eighteenth century, ending the countless needless infant deaths that his family’s secret had caused. About the same time, a Dr. De la Motte addressed the Paris Academy of Medicine, [and] stated how he felt about anyone who might invent a successful instrument like that, and what should happen to him should he keep it secret for is own profit:
“He deserved to be tied to a barren rock and have his vitals plucked out by vultures.”
End of historical text
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No doubt the development of forceps were as exciting to the medical profession in the 17th and 18th century as our contemporary enthusiasm for computer technology and the Internet have been to us in the 20th century. It is human nature to embrace technologies that allow us to control the here-to-fore uncontrollable, and it is particularly sweet when it gives us a personal or economic advantage over everyone else.
For the last century however, the concept of ‘balance’ between the needs of maternity patients and the obstetrical profession has been largely ignored in the US, a time when the use of obstetrically-managed childbirth care became the social norm. There are approximately 4 million births each year, more than 90% of which are obstetrically managed.
And yet, there has been little public debate, no public oversight based, no scientific monitoring of the large pantheon of obstetrical interventions and technologies. We have no objective scientific body that can provide evidence-based guidance to develop cost-effective national maternity care policies. It seems that the practical needs of childbearing mothers and the system for providing maternity care to healthy women have both fallen into a cultural blind spot.
Like many areas of modern life, maternity care for healthy women can be organized in two diametrically opposed ways. One is sustainable, socially–conscious, cost-efficient and has a small carbon footprint. The other, refereed to by Dr G. as the ‘obstetrical package’ — is associated with a large carbon footprint and ever-increasing economic, ecological, and humanitarian burden.
Unfortuantely, the current obstetrical status quo is unsustainable — industrialized childbirth for a healthy population fails the cost-benefit test. The status quo is also unacceptable in that it fails to meet the practical needs of the childbearing population. But the good news is that unlike war, terrorism, global warming and many other ills facing America today, we do know what to do about this problem. It’s called physiological management. The use of its prinicples can be of benefit to all categories of childbearing women, even those with high-risk pregnancies. It can be used by all categories of birth attendants – obstetricians, family practice physicians and midwives. It works wherever the mother wants or needs to be – home, hospital or independent birth center.
The missing link is YOU!
For more on “Green Maternity Care”, visit http://www.normalbirth.org/.
Part Three:
The Next Wave of Industrialization – 18th century Medical School and Clinical Training
