The Historical Move to Re-define Childbirth as a
Surgical Procedure
Part 1 ~
The original medical definition
of “surgery” was to “sever or penetrate human tissue”. Since the
discovery of microbes and the development of the germ theory of disease,
this definition was expanded to include the use of sterile techniques or
entering into a sterile body cavity through a natural body orifice. The
mouth, nose, ear, vagina and rectum are not normally ‘sterile’ and thus
excluded from that definition. Only three sterile organs can be accessed
thru a natural body orifice -- the lungs, the bladder and the uterus.
A medical treatment is functionally a “surgical procedure” if it
occurs under general or regional anesthesia and utilizes “sterile”
technique. This would apply to changing burn dressings in the OR or
inserting a bronchoscope into the lungs. In the
early years of the 20th century, surgical sterility and
anesthesia was also applied to “normal vaginal birth”.
The
idea of surgical ‘sterility’ itself is little more than a 100 years old.
It was not until 1881 that a French physician, Dr. Louis Pasterur,
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 “Gentlemen, this is the cause of Childbed Fever”. With this
discovery, Dr. Pasteur delivered the fatal blow to the erroneous and
dangerous doctrine of ‘spontaneous generation’ -- the theory held
for 2000 years that life could arise spontaneously in organic materials.
This was a natural conclusion for Louis Pasteur as his father was a vintner and techniques to achieve bacteria-free surfaces are basic to
wine making. In order to prevent mold from growing on the fermenting wine,
the bottles must be sterilized by boiling and their sterility maintained
until filled with wine and sealed. Dr Pasteur also developed
"pasteurization", a process by which harmful microbes in
perishable food products are destroyed using heat, without destroying the
food.
It
was not until the discovery of anesthesia in the 1840s to control the
inevitable pain of surgery and then 40 years later, the germ theory of
disease and use of sterile technique to control the infection that surgery
became a reasonably effective form of medical treatment.
According to history, the first-ever obstetrical operation -- a
Cesarean -- was done in first century Rome to extract a living child from
its dead or dying mother. Anesthesia made it possible to do Cesareans on
living women and sterile technique made it possible for women to survive the
operation. Other obstetrical surgeries such as episiotomy and the use of
forceps were greatly enhanced by anesthesia and sterile technique. It did
not take long for operative obstetrics to become the new “wave of the
future” – for the decade of 1900 to 1910, operative deliveries in one
famous NYC hospital were already up to 20% or one out of five births.
By
the early 1900s, “enlightened” obstetrical care was based on the idea
that surgical interventions provided a superior form of care. One of the
titans of the obstetrical world in the first decade of the 20th century was
Dr. Joseph DeLee. Dr DeLee was famous (or perhaps infamous!) for insisting
that childbirth, from the mother’s standpoint, was about as “natural”
as falling on a pitchfork. He
likewise insisted that every baby’s head was subjected to pathological
forces during even the most normal labor by being repeated bashed into the
mother’s unyielding (“iron”) perineum. The take-home message in 1910
was that a “generous” episiotomy saved both mother and baby from the
malevolent forces of her “iron” (i.e., intact) perineum and that the
routine use of forceps ‘saved’ the baby from being battered and bruised
as it was pushed down thru an intrinsically dangerous birth canal by
unpredictable forces of nature.
For
these reasons it was natural to obstetricians of the early 1900s that
childbirth should henceforth be considered a surgical procedure.
Technically-speaking, childbirth is considered “operative” delivery when
forceps (& now vacuum extraction) are used or a Cesarean section
performed. Strangely, an episiotomy, which impacts only the mother, is not
statistically categorized as operative.
By 1910 it was considered “standard” to utilize sterile
technique, anesthesia, episiotomies and outlet forceps at every birth, to
manually remove the placenta (this required the doctor to reach up inside
the uterus and sheer the placenta off the uterine wall with is fingers) and
then suture the perineal wound. These surgical procedures and operative
techniques were routinely used 95% of the time and quickly equated to the
formal obstetrical “standard of care”.
Doctors
also assumed that childbirth conducted under these sterile operating room
conditions would eliminate the great killer of childbearing women and
newborns -- a fatal streptococcal infection of the blood stream known as
puerperal sepsis or ‘childbed fever’. It was the streptococcal bacteria
which caused septicemia after childbirth that Dr Pasteur used as an example
of the germ theory of disease on that famous day in 1881. In the minds of
obstetricians 2 decades later, surgical techniques represented a permanent
cure for this scourge, one so important to public health that it called for
100% hospitalization and 100% care of childbearing women by obstetrical
surgeons.
While
their intentions were good, the idea that normal childbirth should be
abandoned and replaced by the routine use of surgical procedures was
actually an experimental hypothesis, that is an "theory"
instead of a proven fact. The application of any unproven hypothesis would
be considered, under the ethical guidelines for scientific
"discoveries", to be a medical experiment. The
obstetrical profession was proposing that thousands of years physiological
management be abandoned and replaced by the hospitalization of healthy women
under surgical conditions and the interventionist care of obstetrical
surgeons. This massive change was purported by the obstetrical profession to
make childbirth 'safer'. Normally it would be up to the group that is
proposing such a dramatic change to establish that their theoretical basis
was accurate and the new methods it generated were safe and effective.
However, this most central aspect of good science, which is to put new
theories to test in a well-conducted research phase, was skipped
entirely in the rush to medicalized normal birth. Instead the obstetrical
profession went straight to the whole-sale implementation of this
untested experimental model, which was turned directly into a
wide-spread clinical practice within a single decade and without a
single study to verify its efficacy.
The
reason that no studies and no vital statistics could validate to the
superiority of normal birth as a surgical procedure was because it was
associated with a dramatic increase in complications, which at times
were fatal to childbearing women. Unfortunately the frequent pelvic exams associated with laboring in a hospital, combined
with episiotomy, forceps, manual removal of placenta and suturing of the perineum,
created the ideal conditions to carry virulent hospital pathogens up into the sterile
cavity of the uterus where the raw surface of the recently delivered
placenta offered bacteria the perfect pathway into the mother’s blood
stream.
The
stress of anesthesia and the added blood loss associated with episiotomy,
operative delivery and manual removal of the placenta all weakened the
mother’s immune system and made her more vulnerable to this lethal
infection. The lack of effective antibiotics sealed her fate in all too many
cases -- in 1918 there were 23,000 maternal deaths, the majority cause by or
complicated by streptococcal septicemia. Unfortunately for the childbearing
women of the era, surgical birth vastly increased the rate of puerperal
sepsis and the rate of maternal deaths.
Other Unintended Consequences
But
this 20th century convention of birth as a surgical procedure
influenced more that just the way the baby was delivered and went far beyond
the singular experience for any one childbearing woman, more even than
the sum total of fatalities from surgical complications. There was an
impressive and exhaustive list of special arrangements that had to precede
the wholesale provision of childbirth as a surgical service. For the last
100 years these special arrangements have molded and eventually defined the
institutions of society in regard to maternity care.
More
influential than the 30 minutes surgical procedure of “delivery” were
the many other areas this new concept impacted -- public opinion, medical
education, the design of hospital maternity wards, the
rigid, gender-based roles of health care professionals and the dramatically
increased professional fees charged for this type
of medicalized maternity care. These social changes molded public opinion
and national policies for health care so even if an individual woman never
personally gave birth under “surgical” conditions, her choices in regard
to normal childbearing (i.e., physiological management and non-medicalized
birth) were eclipsed by this historical turn of events.
First
off, birth as a ‘surgical procedure’ changed both the public and the
medical profession’s fundamental relationship to childbearing. Doctor,
nurse, mother, husband, lay person -- status didn’t matter, as everyone
began to see a sharp (if artificial) split between ‘labor’ and
‘delivery’ -- the mother labored and the doctor “delivered”.
Attention was directed away from the mother and her labor and instead shined
a spotlight on the artificially created, very brief event of “delivery”,
during which the obstetrician, instead of the mother, becomes the most
essential person in the room and the one credited with bringing about the
birth of the baby. Birth as a surgical procedure was (and is) divorced from
labor, which was historically characterized by the obstetrical profession as
merely the “waiting period”. All
of this resulted in a very different expectation of where and how to give
birth, and what the proper roles of the participants were -- the mother and
her family, the doctor and his assistants. It also promoted a drastically
different type of hospital architecture that isolated the mother and the
events of childbirth from all forms of social oversight and accountability. (See Hx
Addendum)
Maternity Care ~ on a Metaphoric ‘San Andreas
Fault’ after the “Big One”
With
childbirth redefined as a surgical procedure performed by physicians, the
hospital quickly replaced the home, the nurse displaced both family and
midwifery care during labor, the doctor displaced the midwife during the
birth/delivery and his surgical skills displaced the mother’s spontaneous
efforts. Under ‘surgical’ conditions, the mother’s central role was
reduced to a passive, usually unconscious vessel, out of which a baby was
extracted by the physician who then received the accolade of the father for
having ‘safely’ delivered his wife of the longed-for son or daughter.
While the doctor was giving the good news to the family in hospital waiting
room and they were admiring the baby in the nursery window while handing out
cigars to passing strangers, the mother was vomiting her way out of the fog
of anesthesia in the “No-Admittance” labor ward.
Birth
as a surgical procedure also leads to an entirely different focus in medical
education. Medical students “observed” deliveries -- not labors. They
studied interventions, not normal biological processes. They practiced
surgical techniques, not methods to avoid the necessity of their use. They
dissected cadavers and performed autopsies, which required them (in
emotional self-defense) to distance themselves, and objectify the ‘body’
as an inert and unemotional machine.
The
fashion of surgical dominance spilled over into other areas and influenced
nursing school education, which now taught students nurses a surgical style
for childbirth and prepared them to be good technicians who carefully served
the hospital system and faithfully carried out the doctor’s
orders. While the ratio of midwifery caregiver to mother has always been
(and remains) one midwife to one mother, the ratio of nurse to
laboring patients (that is patients plural) is one nurse to several
labor patients – anywhere from two to six women in all stages of labor,
plus new admissions, emergency surgeries and covering for other nurses while
they take meal breaks. This made labor room nursing a very different entity
from the traditions of midwifery care. Nurses primarily administered potent
drugs while “waiting” for the mother to be completely dilated so she
could be prepared for ‘delivery’ and of course, the nurse assisted the
doctor during the surgically conducted procedure of childbirth. The
obstetrical care system itself, that is the needs of the doctors and the
hospital, were the central focus of L&D nursing.
The
Surgical System ~ a galaxy light-years away in its own orbit
Labor
and delivery was organized around ideas of surgical sterility which first
required admission to an acute care hospital and second required isolation
of the “patient” within the hospital. Laboring women were hidden way
behind those ubiquitous swinging doors with a sign that read “No
Admittance -- Authorized Personnel Only” in big black letters.
Surgical procedures required special preparations of the mother’s body
(pubic shaving and enemas) and administration of sleeping pills, narcotics
and other drugs that altered her consciousness. As a ‘pre-op” patient
she was NPO – non per os or ‘nothing by mouth’, no food or
water. In some hospitals, IV fluids were given if the labor was unusually
long. The narcotic and amnesic drugs, combined with the L&D protocols,
restricted her to lying horizontal a hospital bed, listening to other women
in the labor ward moan and cry out with each contraction. She was isolated
her from friends and family and prevented from walking about or socializing
during labor. Under these circumstances the drugs were a blessing, even
though they depressed newborn respirations. Needles to say, virtually all of
the standard techniques of midwifery care, such as psychological support,
walking and right use of gravity, were impossible in this medialized
environment devoted to assembly-line childbirth.
Birth
as a surgical procedure also required a specially trained professional
staff, special clothing for the staff and special arrangements for changing
clothes -- a place where doctors and nurses could exchange street clothes
for special OR clothing. It required a variety of other special preparations
and rituals for the staff such as a surgical cap to hide the hair, shoe
covers to hide the feet, a surgical mask to block exhaled air and a
prolonged form of hand washing called a “surgical scrub”.
The OR team (surgeon and scrub nurse) were all required to perform a
ritualized cleaning of nails and scrubbing of fingers, hands and forearms
for 5 full minutes with a special antibacterial soap, rinsing hands with
fingers pointing up so that the water (and germs from skin) flowed off the
fingers and hands and water dripped off the elbows. Then the scrubbed hands
and arms must be dried with a sterile towel while being held in this
fingers-up, elbows down position.
The
last steps in this particular ritual were special techniques for physicians
and scrub nurses to don sterile OR gowns and gloves without ‘breaking
technique’ -- that is, scrubbed and dried hands must be kept directly in
front of the body, in sight and above waist level at all times, and touch
nothing that isn’t itself sterile, all surfaces must be keep dry, etc.
With hands in this stilted position, the doctor and scrub nurse must each
don a sterile “doctor’s” gown and surgical gloves (while
the circulating nurse tied their gowns, as scrubbed hands can’t go
behind the body or out of sight).
One
of the most “special” aspects of birth as a surgical procedure was the
special location designed for the surgical procedure of “delivery” -- an
operating or ‘delivery’ room itself. The operating room of an acute care
hospital functions under special rules, which included restricted access and
the ability to maintain sterility of the environment (no cloth or other type
of porous surfaces, sealed flooring, etc) and non-sparking electrical
equipment. It also required very special furnishings -- stretcher, operating
table, operating room lights, instrument table, surgical instruments, drugs,
equipment cabinets, oxygen, anesthesia machine, etc.
Next
was the need for a special OR staff -- circulating nurse and “scrub”
nurse, other assistants and on occasion, specially trained nursery nurses
and the most “special people” of all -- licensed physician-surgeons as
obstetrician, anesthesiologist and sometimes a pediatrician. Physicians and
physician-extenders (Physician Assistants or certified nurse midwives acting
under the authority of an MD) were (and still are) the only people with the
special technical skills and legal authority to provide surgical procedures
of any kind, including normal childbirth defined as a surgical event.
The
special role for the mother relative to a surgical ‘delivery’ was to be
especially passive, compliant, horizontal, pushed thru space on a conveyance
such as a stretcher or special type of intensive care bed. In order for the
doctor to properly perform the ‘delivery’ the mother had to be
positioned on a operating room table (or specially equipped bed) in
lithotomy stirrups. She would be naked from the waist down, with her
buttocks hanging slightly off the table over empty space. This unstable
position on the delivery table required special restraints -- the mother’s
arms were confined by leather cuffs at each side so she wouldn’t fall off
the high narrow delivery table or touch any of the sterile drapes, her legs
were strapped into the lithotomy stirrup on each side of the table.
Since
these all these surgical functions were strictly segregated from the public,
the very architectural design of the hospital was deeply changed by this
re-defining of care for normal childbirth. Birth as a surgical procedure
meant that women labored in a different setting and under different
conditions than they “delivered”, hence the now familiar expression
“the Labor and Delivery Room”. What had been an integrated maternity
ward (with mother’s laboring, giving birth and recovering in the same
place) was now divided into four separate classifications – (1) labor
room, (2) operating/delivery room, (3) postpartum hospital room for the new
mother, (4) nursery care for the new baby.
The
childbearing woman (and eventually her baby) experienced musical beds and
conveyances as she went by wheelchair from hospital admitting desk to her
labor bed, then by stretcher to the delivery table, by stretcher again to a
recovery room or temporary holding area until she regained consciousness and
then she was rolled out via stretcher to her to postpartum bed. During this
time her baby had already been sent to the nursery to reside for several
days in a cot (or incubator).
Needless
to say, this plethora of specialty arrangements added greatly to hospital
overhead and thus greatly increased the basic cost of maternity care.
Patients (or third party payors) were billed for the special staff and
surgical environment by the quarter hour and for the patient room and
nursery by the day. These special services also provide an excellent
opportunity for professionals to charge a very handsome fee for the advanced
technical skills associated with the surgical procedure of ‘delivery’.
Fast Forward à
Childbirth in the Year 2003
While the use of twilight sleep and general anesthesia
is rare today, the contemporary obstetrical standard in the United States is
still a surgical model for normal childbirth, with a philosophy and a style
of care remarkably faithful to the 1910 model, only now days we usually
bring the delivery room to the mother through surgically equipped LDR rooms
that have special (and especially expensive) motorized labor beds which turn
into a waist-high delivery “table” with stirrups at the press of a
button.
Epidurals have replaced general anesthesia but
childbearing women are still required to be NPO (no food or drink) with the
exception of ice chips and they are still immobilized in bed during labor.
The 21st century woman is now held hostage in bed by the ½ dozen
(or more) the medical devices that she is hooked up to -- IV fluids and
Pitocin administration equipment, 2 continuous electronic fetal monitoring
leads, epidural anesthesia catheter and administration pump, automatic blood
pressure cuff, Foley catheter, pulse oximetry, and for many, an oxygen mask
when the inevitable signs of fetal distress are noted, the frequent result
of a supine position and the depressive effect of multiple drugs.
Obviously maternal mobility, right use of gravity and
other aspects of physiological management are still not a recognized part of
obstetrical care. Meeting the social and psychological needs of the mother
are still not acknowledged to have any real importance in regard to safe,
satisfying and non-surgical outcomes.
The physician is still the “captain of the ship”
and the nurse is still a “borrowed servant”, loaned to the physician by
the hospital as his assistant. She is out of the labor room 79% of the time,
serving the “system” instead of the mother. According to this study of
L&D nursing, only 6% of the nurse’s time is devoted to the
personalized care of the mother.
Normal childbirth is still conducted as a ‘surgical
procedure’ (complete with a surgical billing code that charges by the
quarter hour) that must be performed by and billed for by a licensed
physician (or physician extender). It is still the nurse’s job to keep the
mother from pushing so that the baby will not be born spontaneously before
the physician arrives, as the doctor can’t bill for the surgical procedure
of ‘delivery’ if he wasn’t scrubbed in and the hospital can’t bill
for the nurse’s services as a birth attendant since she is not a licensed
practitioner. This makes an “easy” birth a big problem for everyone but
the new mother.
Unless her baby is born precipitously, the mother is
still expected to be prone and passive during delivery, which is assumed to
be accomplished by the doctor while the mother lies on her back in
some version of a lithotomy position. The physician will still be
“scrubbed in” and wearing a surgical gown, scrub cap, shoe covers and
face mask (with splash guard), with ready access to an array of gleaming
surgical instruments at his side. And the mother still assumes, for the most
part, that she could not have ‘done it’ without the physician’s
advanced technical skills and thus is grateful to the doctor for
‘delivering’ her. And as soon as the physician puts in the last stitch,
his/her official duties as a surgeon are completed and the mother’s
“post-op” recovery will be assigned to the nursing staff.