Ten Slippery Steps into Hell Beginning Obstetrics, Ending Normal Birth MIDWIFERY

1. Ten Slippery Steps into Hell Beginning Obstetrics, Ending Normal Birth MIDWIFERY The historical term for non-surgical maternity care for healthy women as provided by doctors or midwives

2. Childbearing body as a Teaching Device for Medical Students When patients are objectified as ‘clinical material’ or teaching cases, they are reduced to the status of a living manikin. Maternity care for normal birth reflects the artificial needs of medical educationI nstead of the normal biology of childbirth.

3. Theme one Living women are reduced to reproductive machines which the professor uses to teach and the student uses to “practice” the art of obstetrics.

4. Childbed Fever as an Iatrogenic Disease Theme Two Through out history, a few women became ill after birth with a potentially fatal infection -- haemolytic streptococcus. This infection was called ‘childbed fever’ by the lay public and ‘puerperal sepsis’ or ‘septicemia’ by the medical profession. Before normal childbirth became institutionalized by the medical profession, maternal & infant death from infection was a rare and isolated event.

5. Childbed Fever as an Iatrogenic Disease After hospitals became a place to the training of medical students and interns, septicemia became an epidemic cause of death in hospitalized women. Because large numbers of women died of infection under the care of physicians, in spite of being hospitalized, it became easy for doctors to assume and lay people to be convinced that childbirth itself was dangerous. This created a negative feed-back loop. The more mothers and babies that were harmed by medical and surgical intervention, the more people believed that normal birth itself was to blame – and NOT the interventionist care doctors.

6. Ten Slippery Steps into Childbirth Hell • Problem One ~ 1600 to 1800 -No “clinical material” (i.e., teaching cases) for medical training in midwifery/normal birth • Physicians always provided routine midwifery care as part of general practice of medicine – it was good for business • Medical training in normal midwifery and in operative obstetrics didactic only – book learning

7. Ten Slippery Steps into Childbirth Hell • No clinical or ‘hands on teaching’ in medical schools – “see one, do one” • Clinical teaching of technical skills required a steady stream of pregnant patients Problem However, childbearing women all attended in own homes by midwives and doctors Home birth could not provide the volume of clinical experience to educate large number of medical students.

8. Ten Slippery Steps into Childbirth Hell • Fix Number one ~ 1800s: • Institutionalize childbirth to meet the needsof obstetrical education • Charity hospitals already offered ‘hospitality’ to destitute and homeless pregnant women, including ‘fallen women’ -- prostitutes living on the street • Women lived in early hospital during the last 2 months of pregnancy, were cared for by midwives during labor and birth

9. Ten Slippery Steps into Childbirth Hell • Fix Number one ~ 1800s:Continued • Medical educators turned this pool of institutionalized women into a steady stream of clinical material to teach obstetrical medicine • Required medical students to perform frequent & invasive pelvic exams on laboring women to learn about female biology and normal childbirth. • Clinical skills and manual dexterity also associated with the liberal use of medical and surgical interventions as aspect of training

10. Ten Slippery Steps into Childbirth Hell • Students learned pathology of female reproduction by performing autopsies on pregnant women who died during or after giving birth Hundred years before germ theory of infection understood Long before the invention of sterile exam gloves • Went from the autopsy room to delivery room --without disinfecting their ungloved hands doctors and med students went from dissecting room -- where performed autopsies on patients who died of hospital acquired infections -- to the labor wards

11. Ten Slippery Steps into Childbirth Hell • Went from bed to bed doing internal exams, unintentionally spreading the germs of a lethal infection to all the women in labor that day • The fix for medical education ‘problem’ – lack of clinical experience – created problem #2 – deadly epidemics of puerperal sepsis

12. Ten Slippery Steps into Childbirth Hell • Problem #2 ~ 1830: • Assembly line process of obstetrical education made iatrogentic infection the norm for hospitalized women • Routine use of obstetrical practices central to educational process – but never before been a part of normal birth -- resulted in hospital-based epidemics of childbed fever. • Concentrating labor patients together in institution exposed healthy women to contaminated bedding, environmental sources of infection, invasive exams, use of surgery, forceps, etc • Doctors recognized that aggregating childbearing women in institutional settings drastically increases mortality – but didn’t understood why some died and other didn’t..

13. Ten Slippery Steps into Childbirth Hell • Indigent women who gave birth on the doorsteps of the hospital, prior to admission, were usually free from infection, as were their newborn babies – Indicated that hospitalization causal • Five to 50 % of women and babies delivered in hospitals died • The public began to associate hospital childbirth with dying -- put pressure on doctors to find cause or redirect the blame! • The 1830s Problem -- deaths from iatrogenic infection -- generated the 1830s Fix – perform post-mortem dissections on every woman who died from septicemia to understand what is killing them.

14. Ten Slippery Steps into Childbirth Hell • The 1830s Fix: • Concentrating thousands of women in contaminated, highly-contagious hospital environments caused lethal problems not understand at the time. • Obstetrical professors convinced only better training could bring an end to these problems, • Confused cause and effect, thought ‘more’ was ‘better’ when it came to dissection and that traditional methods were ‘inadequate’

15. Ten Slippery Steps into Childbirth Hell • The 1830s Fix:Continued • Traditional 19th century teaching hospitals depended on a sophisticated teaching manikin developed by the French midwife to King Louis the XV. • Life-size teaching dolls had anatomically correct pelvis, pregnant uterus occupied by realistic fetal doll, amniotic fluid, a placenta, umbilical cord and access to the pregnant uterus thru a working genital tract • Biologically safe teaching devise used to teach midwifery skills to student midwives, instrumental and manipulative obstetrics to medical students. • As dissection became more important part of medical school education, the obstetrical manikin fell out of favor all across Europe.

16. Ten Slippery Steps into Childbirth Hell • Imagination of obstetrical educators captured by new, cutting-edge idea -- use of cadavers of women and babies to teach manual dexterity skills • Use of teaching cadavers assumed to improve technical skills, reduce mortality rate, prevent long labor via use of forceps • Bio-safe manikinreplaced by bio-hazardous cadavers of women who died in childbirth -- assumed to result in a superior education. • Newly deceased woman prepared by cutting body in half, removing abdominal organs, placing deceased baby inside the pelvic cavity.

17. Ten Slippery Steps into Childbirth Hell • By passing a series of newborn cadavers down thru the pelvis of a recently deceased childbearing woman, a professor of obstetrics could: • control the learning experience • assist his medical students to could carry out vaginal exams • determine fetal lie and position • apply obstetrical forceps • practice fetal destructive operations • learn life-saving maneuvers for obstructed births • Technically speaking, this was ‘fix’ a successful educational strategy, except that it gave rise to the new problem of a more dramatically increase the maternal and infant death rate.

18. Ten Slippery Steps into Childbirth Hell Problem #3 ~ 1840s: Pandemic across hospital of Europe of a virulent septicemia that caused death within 72 hours, often killed more than half the women who came under the misguided care of physicians Teaching cadavers made an already bad situation worse. It virtually guaranteed that highly-contaminated organic material would be carried into the labor wards on the hands of medical students Even more undelivered mothers became contaminated with the haemolytic streptococcal bacteria and developed a virulent septicemia that caused their death Out of 3,000 deliveries annually at University hospital of Vienna, 700 died each year -- two or more mothers and babies each and every day.

19. The 1840sFix ~ Story of Dr. Joseph Semmelweis • At university hospital in Vienna, associate professor of ‘midwifery’ -- Dr. Joseph Semmelweis -- questioned common practices of obstetrical staff and students. • Dr Semmelweis employed the true spirit of scientific investigation -- eventually identified the iatrogenic nature of childbed fever. • Common knowledge that infection rate of women delivered in the midwifery wards (Division Two) or gave birth at home, was only a fraction of the rate for medical wards -- Division One. • Dr Semmelweis was convinced something doctors doing in Division One responsible for excess mortality in obstetrical patients Ten Slippery Steps into Childbirth Hell

20. Ten Slippery Steps into Childbirth Hell • The 1840sFix ~ Story of Dr. Joseph Semmelweis • Began to conduct experiments find out why some large groups of women nearly always contracted puerperal fever and other groups did not. • Eventually he demonstrated that personal cleanliness on the part of physicians could prevent the disease, though he did not know why • Conducted an experiment insisted that students wash their hands between patients – the women stopped dying • In his own words Dr. Semmelweis concluded: “puerperal fever is caused by the examining physician himself, by the manual introduction of cadaveric particles into bruised genitalia”

21. Ten Slippery Steps into Childbirth Hell • Dr. Semmelweis reformed these iatrogenic practices by introducing prophylactic hand washing in chlorine of lime solution and banned examining labor patient if performed an autopsy on the same day. • Like a sudden overnight miracle, maternal deaths in his institution fell from 18.27% to 0.19% in the eight months between April and December of 1847. • Devoted his entire career to preventing unnecessary maternal deaths by teaching and preaching the use of aseptic principles. • No Good Deed Goes Unpunished, especially in medical science

22. Ten Slippery Steps into Childbirth Hell • Unfortunately, these ‘radical’ life-saving ideas were ridiculed and dismissed as absurd by other doctors. • Doctors thought it inconceivable that healing hands a physician (or his instruments) could ever, under any circumstances, be a vector for contagious fatal illness • For his trouble Dr. Semmelweis lost his prestigious post • Lost his reputation and eventually his profession • He died shortly afterwards leaving a wife and several young children.

23. Ten Slippery Steps into Childbirth Hell • Problem # 4 ~ the 1880s: • Simple but effective solution to iatrogenic septicemia was ignored by Semmelweis contemporaries, who could not accept something so unglamorous and straightforward as hand washing. • Education-based obstetrical practices (meeting need of students at the expense of the mothers and babies) continued unexamined and unabated, as did the high level of maternal mortality associated with hospital delivery. • Over the course of a hundred years, small number of astute physicians publicly identified the epidemic levels of maternal-infant mortality as iatrogenic.

24. Ten Slippery Steps into Childbirth Hell • Problem # 4 ~ the 1880s: • Growing criticism all over the world observed repeated virulent epidemics of puerperal sepsis virtually absent in places that: • midwives (who did not use instruments) managed normal birth instead of doctors (who did) and • where autopsies or dissections were not being done by the same practitioners who attended deliveries.

25. Ten Slippery Steps into Childbirth Hell • One well known doctor was Oliver Wendell Holmes • identified the contagious nature of birth-related septicemia • agreed that the disease was often transmitted, via an unknown agent, by both physicians and nurses. • published findings in the New England Journal of Medicine and Surgery in 1843, entitled ‘The Contagiousness of Puerperal Fever’. • Obstetricians discussions among themselves the vastly higher death rate for hospital births versus “private practice” -- women attended in their own homes.

26. Ten Slippery Steps into Childbirth Hell • A renowned professor of obstetrics from Edinburgh lamented in 1881 that in his institution: “…maternal deaths during childbed – death occurring within four weeks after delivery -- have been shown to be striking in their frequency”“The present Maternity Hospital, being a necessity, and puerperal fever having been shown to exist there, [is known] to have been the direct cause of death in 1 out of every 32 women ….

27. Ten Slippery Steps into Childbirth Hell • Despite high mortality associated with the hospitalization of maternity patients, the conclusion by medical professionals was that hospital birth was absolutely necessity. • Only place to house indigent pregnant women • Absolutely necessary to medical education • Educators concluded high quality clinical instruction vital to medical education could only be provided in a hospital environment. • Again we see the solution to one problem, a problem framed by leaders of the medical profession, giving rise to yet another problem.

28. Ten Slippery Steps into Childbirth Hell • The Fix ~ 1881: • It was not until 1881 that a French physician, the now famous Dr. Louis Pasteur, established the central role of microbes -- commonly known as ‘germs’ or ‘pathogens’-- in causing illness and infection. • On a chalk board at a prestigious medical meeting Dr. Pasteur drew a graphic representation of what the streptococcus bacteria looked like under a microscope:-- rectangular microbes that resembled a string of box cars on a train track -- and said “This, gentlemen, is the cause of Childbed Fever”.

29. Ten Slippery Steps into Childbirth Hell • The Fix ~ 1881: • With this discovery, Dr. Pasteur delivered the fatal blow to the erroneous theory ‘spontaneous generation’ • a dangerous doctrine that for the previous 2000 years insisted that life could arise spontaneouslyin organic material. • To preserve hospital birth as an educational necessity while simultaneously eliminating iatrogenic cases of childbirth septicemia, the obstetrical profession threw itself into the development of new aseptic practices for maternity care.

30. Over the next 30 years childbirth was changed from a normal biological process (women giving birth) into a surgical procedure ‘performed’ by physicians under general anesthesia in an operating or “delivery room” • The Plan to Protect Hospital-based Obstetrical Education: • Forbid autopsies and dissections to be done in the same building and by the same practitioners as attended cases of childbirth • Forced bathing and pubic shaving of women on admission to the labor ward (in case they had bed bugs or pubic lice!), • Meticulous attention by the housekeeping department to disinfecting bed linens Ten Slippery Steps into Childbirth Hell

31. Ten Slippery Steps into Childbirth Hell • In 1880s, doctors thought the immediate postpartum -- the first 24 hours after the birth – was the period of greatest vulnerability • Aseptic techniques included scrupulous hand washing and a procedure called ‘panning’ used in American hospitals until 1960s. • Panning consisted of placing the newly delivered woman over a sterile bedpan in order to wash the mother’s labia and perineum with a series of sterile cotton balls wet with antiseptic soap.

32. Ten Slippery Steps into Childbirth Hell • In 1880s, doctors thought the immediate postpartum -- the first 24 hours after the birth – was the period of greatest vulnerability • Required a special pair of sterile of tongs (pickup forceps) so that the mother’s body was never touched by the nurse’s fingers • Done every four hours as well as every time the mother needed to urinate or change her perineal pads (i.e. ‘Kotex’ napkins). • In 1880s panning followed by the very unpleasant practice of soaking perineal pads in a strong antiseptic solution

33. The consistent habit of medical profession to propose ‘solutions’ in places that that did not acknowledge or correct the actual problem. • Main source of childbirth septicemia was physician intervention • Main responses was panning and perineal pads saturated with harsh chemicals • Did nothing to prevent iatrogenic infection • Could not make up for blood loss during a severe hemorrhage • Did nothing to stop an infection already acquired during in labor Ten Slippery Steps into Childbirth Hell

34. Ten Slippery Steps into Childbirth Hell • Beginning of the So-Called “Modern Era” • Debunking the idea of ‘spontaneous regeneration’ and replacing it with the germ theory ushered in the real beginning of what we now call “Modern Medicine” as an applied science. • Scientific understanding of microbiology and the improved antiseptic practices dramatically lowered maternal & infant mortality rates.

35. Ten Slippery Steps into Childbirth Hell • Beginning of the So-Called “Modern Era” • However, the story of iatrogenesis was not yet over. • Concentrating large numbers of childbearing women in hospitals still resulted in fatal infections and other iatrogenic complications • In spite of all improvements, teaching hospitals still had much higher rate of maternal mortality than expected or could be explained. • The problem – the first 30 years of this initial “fix” – aseptic technique -- was a failure. The answer --Try Harder + Yankee Ingenuity

36. Ten Slippery Steps into Childbirth Hell • Problem # 5 ~ circa 1910: • In 1910, science had not yet come to obstetrics in the United States. Doctoring did not have a particularly good reputation, especially when it came to normal childbirth for healthy women. • Major reason was septicemia or birth-related infections • People couldn’t figure out why they should pay much high fees of a doctor -- instead of a midwife -- since physician-attended birth was associated with a higher mortality rate for both mothers and babies.

37. Ten Slippery Steps into Childbirth Hell • Problem # 5 ~ circa 1910: • Medical science could not dependably address many of the complications that might arise during normal birth --Even when it could fix the original problem, the mother might still die later on from septicemia • This situation frustrated the obstetrical profession on many levels. About 90% of the ‘miracles’ of modern medicine had yet to be invented in 1910: • No antibiotics, safe blood transfusion, safe anesthetics • Safer surgical techniques not yet developed

38. Ten Slippery Steps into Childbirth Hell • The Fix ~ circa 1910 • The obstetrical profession’s attempt to eradicate the infectious diseases of childbirth and simultaneously improve their professional reputation predicated on three inter-related ideas: • First they redefined the biology of childbirth as basically defective and pathological. • In their eyes, problem was the nature of birth itself -- not the quality of obstetrical care provided by doctors

39. Ten Slippery Steps into Childbirth Hell • The Fix ~ circa 1910 • It was the “God made junk” theory -- a variation on Freud’s idea that biology was destiny and women got the short end of the stick. • Doctors insisted that birth was abnormal because it was associated with damage to the mother’s vaginal tissues. • Breaks in the skin of the mother’s genitals and birth canal -- fairly frequent occurrence during vaginal birth -- permitted deadly bacteria to gain entrance to her blood stream and sometimes caused her and baby to both die

40. Ten Slippery Steps into Childbirth Hell Second, obstetricians believed that conducting normal birth under conditions of surgical sterility could, for the first time in history, totally eliminate infectious pathogens, and thus make up for the faulty biology of Mother Nature.

41. Ten Slippery Steps into Childbirth Hell • Childbearing separated into two halves • Care of the laboring women was divided between two professions • Labor was defined as a medical condition to be managed by hospital nurses.

42. Birth was renamed the ‘delivery’, • Defined as an operative procedure that could only be performed by a physician-surgeon under circumstances of surgical sterility Ten Slippery Steps into Childbirth Hell

43. In order to guarantee the continuing sterility of the operative field, it was necessary to put the mother to sleep with general anesthesia. Ten Slippery Steps into Childbirth Hell

44. Even though anesthetic complications sometimes caused a mother’s death, childbirth under anesthesia seen as part of the process of protecting women from lethal infections. • Anesthesia was the only dependable way to be sure that laboring women – in the throws of great physical effort associated with pushing a baby out: • Would lie quietly on their backs with legs in obstetrical stirrups • Stay perfectly still during obstetrical manipulations. • General anesthesia also prevented women from accidentally touching the doctor with their “unsterile” fingers or • their own genitals • ‘contaminating’ sterile linens and drapes • the doctor’s sterile gloves • sterile instruments 1956

45. 1956

46. Ten Slippery Steps into Childbirth Hell • However, general anesthesia required the mother to be in an anti-gravitational position on her back and unconscious. As a result she was no longer able to push effectively, a problem that was fixed via: • A generous episiotomy was routinely performed

47. Ten Slippery Steps into Childbirth Hell • Forceps were used to pull the baby out • Manual removal of placenta, exploration of uterus • Repair of episiotomy incision with sutures

48. Ten Slippery Steps into Childbirth Hell • Obstetricians saw episiotomy (a ‘nice’ straight cut in mother’s perineum with scissors) and forceps as another advantage of birth as a surgical procedure. • Episiotomy thought to spare the mother’s tissues --as well as the delicate tissue of the baby’ brain – from damage sometimes associated with normal birth

49. Ten Slippery Steps into Childbirth Hell • Physicians believed that episiotomy, was necessary to preserve the integrity of her pelvic muscles. • Forceps and episiotomy was assumed to also protect the baby’s head from being battered against the mother’s “iron perineum”.

50. Ten Slippery Steps into Childbirth Hell The third and final part of the obstetrical plan wasto eliminate all other forms of maternity care, which they defined as inferior. 1915 “Of the 3 professions---namely, the physician, the nurse and the midwife, there should be no attempt to perpetuate the last named [i.e. midwife], as a separate profession.” [Edgar MD p. 104]