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Monday
Aug111986

Grandaddy's Obstetrics

[Unpublished; written Summer 1986]

My grandfather lived to be ninety-six, and in many ways he was like a birch tree: small but springy and bright, with light filling his blue eyes. For over 60 years he signed his name George Frederick Oetjen, M.D. and (although he told his daughters that “M.D.” really stood for “My Daddy”) being a doctor was the joy of his life.

Many of those years he was an obstetrician, and once I had a chance to ask him about his obstetrical training. There was a reason for my curiosity. I had just gone through my third “natural” birth, and I had been teaching the subject to pregnant women for years. But what did I really know about childbirth? Everything I believed was colored by a narrow range of experience: modern, middle-class, American birth practices. What had this experience been like for other women in other eras? What did my grandfather know that I didn’t?

Of course, I had a sneaking suspicion of what his reply would be. I figured he ‘d say in a kindly tone, but with unmistakable condescension, that women are weak, birth-giving is dangerous, and the most important thing is to obey the wise (and presumably male) obstetrician. I expected one whose medical training began before World War I to be steeped in such thinking.

Was I wrong.

Grandaddy looked away, as if recalling a classroom of almost a century before.  “I can remember my old professor of obstetrics,” he said, “telling us about the Indians and how they would march along.” The what? I thought. He went on, “When an Indian woman went into labor she would step outside the line and give birth. After the baby was born the others would slow down, so she could catch up with them and go on. It was as easy as that. My professor told us that story, then said, ‘If you men keep in mind that it’s just a normal physiological event, and keep your hands off, and just let nature take its course, you’ll get a normal baby and a normal delivery.’ And I still believe it.”

I was surprised to hear such “natural birth” sentiments being recalled from a Georgia classroom of 1917. While the story about Native American birth practice might indicate cultural naivete, it indicated something else as well: a conviction that birth was an essentially healthy process. Far from relegating women to helpless passivity, or elevating obstetricians to god-like control, there was an expectation that women were strong and competent to give birth with minimal assistance.

Obviously there was a lot I didn’t know about the obstetrics of the time. When I got a chance, I scanned his bookshelves until I found it: a red volume stamped in gold Obstetrics—Williams.  William’ s Obstetrics is still the standard textbook for obstetricians-in-training, though today’ s students enjoy a fresher version; my grandfather’s was the 4th edition, published in 1917.

Leafing through I discovered aged sheets of paper slipped between the pages, containing notes he had made about obstetric cases under his care. One included the ominous words, “Puer Sepsis”  —the dreaded ‘childbed fever” that claimed so many lives before sterile technique was fully understood. Another scrap of paper was headed “Final Exam” and listed numbered essay questions. It struck me that the questions could appear unchanged on an exam of today (for example, “What is your conduct of the third stage of normal labor?”), but the correct answers would be dramatically different.

As I read through the textbook I saw there gradually emerge a portrait of a very different time, and a very different approach to birthing. For example, today pregnant women are expected to go for early and regular prenatal exams. At the turn of the century, however, care consisted of monthly urinalysis and not much more. The woman would be physically examined only once, and even that one exam was not easy for the obstetrician to get, in that adamantly modest era.

J. Whitridge Williams wrote regarding prenatal care: “In private practice it is not necessary to examine the pregnant woman in the early months of pregnancy unless symptoms indicative of some abnormality occur…On the other hand, a careful and thorough examination is indispensable about six weeks before the expected date of confinement, and to neglect in this respect can be attributed the deaths of untold numbers of women and children. Usually this can be made much more conveniently with the patient in her own home and in bed than at the physician’s office…Unless the physician fully appreciates the importance of this examination, and has learned to look upon the making of it as a bounden duty, he may sometimes be deterred by feeling that it is repugnant to the patient, and that she may object to it or even refuse it. My experience, however, has always been that a few words of kindly explanation soon smooth away all such difficulties…If, however, despite the exercise of the greatest tact on the part of the physician, and his insistence that such an examination is a necessity for her own sake, the patient persists in her refusal, the former has no alternative but to decline absolutely to attend the case.”

As I continued reading, I discovered other ways the treatment of labor has changed. Many hospitals are cautious about letting women out of bed in labor; the attachment of fetal heart monitor and IV drip make this complicated, and epidural anesthesia makes it impossible. The toll may be in slowed labor; when the woman is allowed to move around as she likes, the process tends to pick up.

Eighty years ago obstetricians were taught to let laboring women set their own pace: “During the first stage of labor the patient usually prefers to move about her room, and frequently is more comfortable when occupying a sitting position. During this period, therefore, she should not be compelled to take to her bed unless she feels so inclined.” The obstetrician’s role in a birth like this was essentially that of a life guard, standing by in case of an emergency.

Occasionally such a situation did arise, but transfer to a hospital was not a necessity, particularly for minor “operations” such as the use of forceps. Nevertheless, it’s startling to imagine the settings in which our foremothers gave birth: “For the performance of an operation, it is advisable, even in private practice, to place the patient upon a narrow table. One that will answer the purpose quite satisfactorily is usually to be found in every kitchen, but, if a suitable table is not available, a satisfactory makeshift may be improvised by unscrewing the mirror from a bedroom bureau.”

Much of my work as a childbirth educator had been aimed at helping women use natural pain-relief techniques to avoid medication. Medication for childbirth had been introduced with some controversy in the mid 19th century; some felt that it was contrary to Scripture (“In pain you shall bring forth children,” Genesis 3:16) and others warned that only childbed pain induced a mother to love her child. Gradually anesthesia won acceptance, particularly after it was used by Queen Victoria.

But the medications available then were of a very different kind from the epidural anesthesia available now. “The most popular anesthetics are ether and chloroform,” Dr. Williams wrote. “…Generally speaking, chloroform is preferable in normal labor, for by its use obstetrical anesthesia can be rapidly and safely produced. I believe that it is practically devoid of danger when properly administered, and should be used whenever there is time for its administration, unless the patient has conscientious objections to its employment.”

These must be those women who felt pain to be somehow necessary or redemptive. I and the women I taught didn’t share that point of view, but just wanted to control and experience our births more fully by using drug-free methods to reduce pain. As I taught my students, the worst pain of labor is late second stage, just before you begin to push. But it certainly won’ t look that way; it looks like the worst part comes later, at the moment of birthing the baby’s head. For many women this is painless, or provokes an intense but brief burning sensation; it certainly isn’t  the time for anesthesia if you’ve avoided it so far.

Dr. Williams gave opposite instructions, however. “The choice of the time for its administration, however, is of great importance, nor should it be used before the latter part of the second stage, when the head becomes palpable through the perineum… When properly administered, the patient experiences marked relief after a few inhalations, but retains consciousness and is generally able to talk rationally. When the distention of the vulva is at its maximum, obstetrical anesthesia is not sufficient to abolish the pain, and it is my practice at that time to render the patient completely unconscious by increasing the dose of the drug.”

At the time this edition of Williams’ Obstetrics was being written, feminists and social leaders like Mrs. John Jacob Astor were touting a new form of anesthesia called Twilight Sleep. This combined the previous method (ether or chloroform) with scopolamine, a drug that induced hallucinations and amnesia. It didn’t reduce pain, necessarily, but it eliminated the memory of pain, and the memory of shameful exposure (at least the conscious memory of these; bizarre dreams and nightmares were not uncommon postpartum effects). After decades of widespread popularity, this artificial and purposeless drug cocktail was gradually rejected. Dr. Williams predicted as much decades before it reached its ascendance: “The method is not ideal, and it is my belief that it will gradually fall into desuetude, or at least that its use will be restricted to a small group of neurotic patients.”

Should the doctor make an incision in the vagina to enlarge its circumference for birth? Natural-birth enthusiasts frown on routine episiotomy, believing that such an incision is not always necessary, and that natural tears are likely to be smaller than the one the doctor would inflict. Dr. Williams agrees: “Personally, I see no advantage in the procedure, as my experience is that ordinary perineal tears will heal almost uniformly if properly sutured and care for.”

The rate of Cesarean delivery is cause for concern now as it was then. The female body is designed to give birth, and we all are descended from a long line of birthgiving women; the need for the radical intervention of Cesarean section should be miniscule. Yet a fourth or more of births each year are Cesarean, a figure caused by many factors including the litigious and malpractice suit-prone society we inhabit.

Dr. Williams opposed the increasing reliance on the procedure: “There seems to be a growing tendency to regard cesarean section as the simplest means of coping with obstetric difficulties. At the present time I consider that the operation is being abused, and that not a few patients are sacrificed to the furor operativus of obstetricians and general surgeons who are ignorant of the fundamental principles of the obstetric art.”

Of course, in 1917 Cesarean delivery was still an extremely risky operation, due to the danger of deadly infection; Dr. Williams warned that 10% of Cesarean patients would die. He recommended alternatives that could be highly damaging, but were less likely to be fatal: forceps thrust high into the uterus, an incision through the cervix and lower uterine segment, reaching into the uterus to turn the child by hand, forcible dilation of the cervix, and cutting through the pubic bone.

Dr. Williams’ opposition to unnecessary Cesareans was matched with a belief the procedure should not be unnecessarily repeated; vaginal birth after Cesarean was quite possible, even though there were some cases in which the previous incision had ruptured. “Certain authors consider it so real a danger that they have laid down the dictum, ‘Once a cesarean, always a cesarean.’ This is an exaggeration, as the accident is likely to occur only when the wound has been improperly sutured, or its healing has been complicated by infection.”

I was surprised to see such a generally favorable approach to natural birth in a textbook from so long ago. But as I read on, the advice on caring for mother and child after the birth perplexed me. Dr. Williams wrote: “It is a time-honored custom to allow the puerperal woman to sit up on the tenth day. This rule, however, should not be slavishly followed, and every patient should be kept in bed until the fundus of the uterus has disappeared behind the symphysis pubis. This frequently occurs by the tenth day, occasionally a day or so earlier, but very often not until some days later. Generally speaking, a two week’s rest in bed is not excessive.” As someone who had always been up and about the day after birth, it certainly sounded excessive to me.

Dr. Williams agreed with contemporary thinking regarding the high value of breastfeeding: “The ideal food for the newly born child is the milk of its mother, and, unless lactation be contra-indicated by some physical defect, it is the physician’s duty to insist that every woman should at least attempt to suckle her child.” But the procedure he recommended sounded bizarre, to say the least. “Bathe the nipples with saturated boracic solution before and after each nursing…Until the milk appears, nurse three times a day, and don’t give any other food unless otherwise directed.”

Dr. Williams went on to prescribe a regimen of military precision: “After the milk appears, let the child suckle, except after its bath, every three hours by the clock, from 6:00 or 7:00 A.M. to 10:00 or 11:00 P.M. Time one feeding so that it will come directly after the bath after which the child may be allowed to sleep as long as it will. Feed only once, or not at all, between bedtime and 6:00 or 7:00 A.M. As soon as the milk appears, write out a schedule for nursing and adhere to it, awakening the child at each feeding time if necessary. Before each nursing wash out the child’s mouth with boric acid solution. After the first three weeks increase the intervals between feedings to four hours.”

In fact, regulating the child and insuring its compliance with the household schedule was of utmost importance. “As soon as the child is taken from the breast it should be placed in bed and not disturbed. It should not be allowed to sleep at its mother’s breast, nor should it be rocked or fondled after feeding. If these regulations be persisted in, the child will usually go to sleep within a few minutes after being put to bed, and if it wakens before the next feeding is due it will remain quiet. The importance of following these directions cannot be overestimated, for it is only by rigid adherence to such details that the child can be given regular habits, and its care prevented from becoming a strain upon all concerned.”

Of course, the most taxing element of baby care is diaper changes, and Dr. Williams had no doubt that this could be regulated as well. “The physician should impress upon the mother and nurse the necessity of attempting to train the child to regular habits as to urination and defecation, and it is surprising how soon these may be formed if proper care is taken. For this purpose the napkins should be changed before each feeding, and after the first few weeks the child should be held over a small chamber at these times.”

As I closed the bulky red volume I felt that I had travelled to a strange time: a time when home birth was the norm, but homebirthing women were rendered unconscious at delivery: a time when breastfeeding was almost compulsory, but the infant was not allowed to sleep at its mother’s breast; a time when doctors hesitated to do a hasty Cesarean, sometimes preferring to saw through the woman’s pubic bone.

I went back to my grandfather with a question: as this training was seasoned by experience, how did he come to see the art of obstetrics? What was the most important part of assisting at the birth of a child? “Patience and prayer,” he said, “just remember that: patience and prayer. You can’t rush childbirth; that’s when you get into trouble. Just trust in nature to do a good job and don’t interfere unless you’re sure it’s necessary.” 

He paused and looked off again, as if envisioning himself about to go in to deliver one more baby. “At old St. Luke’s Hospital, there was a prayer framed over the scrub sink,” he said, “and the last line of it always stayed with me. It read, ‘For without Thy help we can do nothing.’ It didn’t say ‘Without Thy help we can do a little bit’ —it said ‘nothing.’ I always thought about that every time before I went in to a delivery. Young doctors today should just remember three things: you’re there to help at an essentially normal process, keep your hands off; and keep praying—and you’ll have a happy birth.”

There didn’t seem to be anything I could add to that but “Amen.”

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