Dennis M. O'Connor. MD
Why consider the history of obstetrics at all? There are two very good reasons:
1) Many of the procedures and instruments in use today were developed by individuals whose names are synonymous with fundamental obstetric principles.
2) One is hard pressed to find a like specialty in medicine where a decision in management, or an invasive procedure could change the course of history. In regards to the latter, the following patient presentation will serve as evidence.
(*) The patient was a white 21 yo G1PO with an estimated date of confinement given as October 21. Her prenatal course was benign, with the exception of three episodes of vaginal bleeding. She had premature rupture of membranes at approximately 43 weeks, with clear fluid. Examination at this time showed the cervix to be 1 cm and 0 station. Estimated fetal weight was 4000 grams. Labor soon began spontaneously, but contractions were weak, at 8-10 minutes apart. (*) Reexamination after 16 hours of labor revealed the cervix to be 3-4 cm dilated and 0 station. The contractions were still irregular, but now somewhat stronger and becoming more painful. (*) Twenty-six hours later, the head was quite low and the cervix "a rim," but the pains were "once again weak".
Were this the present, an obstetrician would admit that her labor represents a protraction disorder. At the very least, assessment for cephalopelvic disorder is required. Consideration might be given to augmentation of her labor with oxytocin.
Well, the time happens to be November 1817, the patient being presented is the Princess Charlotte Augusta of Wales the obstetrician is the capable Dr. Richard Croft, who was trained by, and was the son-in-law of the great Sir Thomas Denman. Incidentally, the baby in question was to be the future heir to the throne of England. We would therefore today classify this as "a premium pregnancy.”
(*) In any event, she became completely dilated a few hours later, beginning the second stage. After five hours of pushing, however, the fluid became meconium stained. An associate, a Dr. Sims, was consulted, but, without examining the patient, advised against forceps delivery. His comment: "The women was still able to push."
(*) After 24 hours of the second stage she spontaneously delivered a nine pound stillborn male. The baby appeared to have been dead for several hours. Vigorous attempts at resuscitation were unsuccessful.
(*) The patient began hemorrhaging during the third stage, and the placenta was manually extracted from the uterus, but left in the vagina. It was removed several hours later due to the patient's persistent complaints. Some hours after this, the patient became agitated and short of breath' She was given Laudanum, opiates, cordials, and nourishment. (*) Eventually, however, her pulse became irregular, and the Princess Charlotte died approximately seven hours after delivery.
A footnote in history, perhaps, except that, due to the deaths of the only male heir to the English throne and the woman who could produce that individual, there was a rash of marriages between English and German royalty. One of these was the marriage of the Duke of Kent to Mary Louise Victoria. Their daughter was also named Victoria, whose reign as Queen of England would span the 19th century, see new heights of English expansion, and henceforth be known as "The Victorian Age."
You are probably wondering what happened to the
obstetrician, Dr. Croft. He had another woman in labor three months later whom he managed the same way, and unfortunately, he had the same result. Despondent, he shot himself. An so from the loss of the child, the mother and the physician, this case is known as "The Triple Obstetric Tragedy."
You see, the management of this case was entirely correct, according to the dictates of the times. To see how this came to be, it is best to start at the beginning.
(*) This is a representation of a birth scene carved in stone by a people who lived in caves near Laussel, France from 32,000-15,000 BC, one of the earliest representations of the phenomenon of birth.
(*) In ancient Egypt, if a woman of wealth began labor, she would call numerous attendants to her, and retire to a room in a specially designated birthhouse, or temple. (*) She would also take images of Bes, an ugly god to ward off evil spirits (to which she unfortunately was susceptible to during labor) (*) and Theoris the protectoress of pregnant women. The goddess was usually in human or hippopotamus form. Of interest is the symbol between the goddess' legs. The object appears to represent a uterus and vagina, but is also the ankh, or hieroglyph for life. Although the prior slide is a representation of the Egyptian queen Sen-Het giving birth in a chair, other not-so-affluent Egyptian women in labor used caves as their birth houses, and squatted on bricks, or stones. (*) The Egyptian hieroglyph for birth was synonymous with "to squat or sit on stones."
(*) In ancient Greece, it had been determined that birth occurred after approximately 280 days. It was also felt that the fetus, by breaking the bag of waters, would initiate labor. This would be a belief that would last until the 18th Century.
The woman gave birth sitting in a birth chair, attended by midwives. These were elderly women beyond reproductive years. These women had vast experience, usually from their own births. There is evidence that some of these ladies were associated with the medical school founded by Hippocrates in the 5th century BC.
(*) This is a portion of a freeze found in a Pompeian bathhouse depicting a Roman birth. For the first time males now appear as attendants or obstetrix at deliveries. Most prominent physicians during the late Republic and Empire were Greek. One of these was Soranus of Ephesus, whose text "On Gynecology, or
the Treatment of Diseases in Women" was written in the 2nd century AD. In it, he described the use of a three-bladed vaginal speculum. He was also the first to describe a method to expedite difficult deliveries by turning the fetus in utero, grabbing the feet, and then delivering the fetus as a breech. A procedure we now know as "version and extraction."
(*) Moving on, there is a passage written by Justinian in his work, the Digesta, which is here in the original Latin. Translated loosely. It reads: "It is the rule of kings that forbids the burial of pregnant women before the young is excised from their bodies…” This Lex Regia, or Law of Kings, is attributed to Numa Pompilius, a legendary king of Rome during the eight century BC. The Lex Regia became the Lex Caesaria under the emperors. And so we have a possible entomologic origin for the term caesarean section. Another possibility of its origin is the Latin word caedere, which means, "to cut."
Legend has it that those individuals born this way had almost supernatural powers of leadership. Pliny writes that the great legates, or generals, Scipio Africanus, Marius and the Dictator Julius Caesar were delivered abdominally.
(*) This is the earliest known illustration of the operation, a medieval woodcut from a print of Seutonius' "Lives of the Twelve Caesars," published in 1490. In reality, Caesar was not delivered this way, as evidenced by the fact that his mother Aurelia lived at least until Caesar's marriage of his first wife at age 14. It is also of interest to note that Soranus, for all of his extensive writings concerning complicated deliveries, never once mentioned this type of delivery.
(*) Here is a set of obstetric and gynecologic instruments also found in the ruins of Pompeii. While many may represent destructive instruments, the Amnihook is no different in design from the ones in use today.
(*) This is another look at a vaginal delivery from ancient Rome. Of note is the instrument held in the male attendant's hand-very similar to the modern-day forceps. There is, however, some question as to the authenticity of this freeze, which was found in Northern Italy during the early 1950s.
(*) Which brings us to the Middle Ages. A typical birth taking place during this time would look like the following: the parturient is sitting on a birth stool aided by two attendants. The midwife is performing the delivery under various dresses and petticoats, as was common practice. A pitcher and basin for cleansing the newborn are in the foreground. An astrologer is in the background to predict the newborn's future.
(*) A 15th Century German birthing stool, a fine example of Teutonic simplicity and functionality. Note the wheels for portability.
(*) Protracted labor, due to uterine inertia, has always been a problem. This is an example of the usage of coriander seed for augmentation. It was suggested that the seed be removed promptly, "lest the entrails be expelled with the fetus."
(*) The mainstay of medieval and early Renaissance obstetrics was the French accoucheur, the German heb-amme, or the English midwife. An excellent example of a 16th century midwife was Louise Bourgeois Boursier (1563-1636), who served as midwife to the French royal family. Unfortunately her popularity, as well as her head, fell quickly when the Princess Marie de Bourbon
Monpensiere died of puerperal sepsis. (*) The title page from her textbook, one of the first written by a midwife, for midwives. In it, she described the induction of premature labor for contracted pelves, and a description, and plan of management for a face presentation. (*) A contemporary of Boursier was the German heb-amme Justien Dietrich Singemunden. (*) This is an illustration from her text demonstrating her method of version and extraction.
For the males, however, midwifery was an unpopular profession: (*) "Haec ars viros dedecit" (This art is unsuitable for men) wrote Roderigo A' Castro in 1594.
During the Renaissance, the first man-midwives were mainly barber-surgeons. Some examples are (*) Ambrose Pare, a French military surgeon who published voluminously on various trauma cases, including pregnancy. He was one of the first to recommend caesarean section on the living, a totally unheard of, outlandish idea. A pupil of Pare was (*) Jacques Guillemeau, who first described a technique for delivery of the after-coming head in a breech by (from his original text), "...turning the infant upside down, such that the face is downward. With the index finger inserted in the infants mouth it is easy to extract the baby from the mother's body." The name for that maneuver, however, is however given to this man: (*) Francois Mauriceau, who lived from 1637-1709, and who became one of the dominant figures in obstetrics in the 17th century. His text "The Treatment of Diseases of Pregnancy" was translated into English, Dutch, German, Italian, Latin, and Flemish (the must-have obstetric text of its time). In it, he advocated amniotomy for placenta previa,
suturing of perineal lacerations, and delivery in bed to ease performance of operative procedures.
(*) Another English male midwife of the late Renaissance was this particular gentleman. His name was Dr. Peter Chamberlain, also known as "The Younger," the son of a Huguenot refugee who fled to England in 1596. The family Chamberlain developed and refined a device that would revolutionize obstetrics, as it was practiced at the time.
(*) A photograph of the original forceps as they were found in the attic of the Chamberlain house in Essex, England. The instruments were passed from father to son, but for reasons of prestige, monetary, or whatever, they were kept a family secret for over 100 years. The secret was almost released to the European world when one of the later sons, Hugh Senior, traveled to Paris and attempted to sell the secret to Mauriceau and the French Court for 50,000 livers, stating that he could accomplish the most difficult delivery in the matter of minutes. Mauriceau, somewhat reticent, presented him with a rachitic dwarf who had been in labor for eight days. After three hours of attempting delivery, Hugh Chamberlain admitted defeat, and the deal was off. And so the forceps remained an instrument reserved only for the Chamberlains for a number of succeeding years.
(*) Multiple births in the Middle Ages were felt to be due to some sort of supernatural event, and they were usually greeted with proclamations, or testimonials. This is a famous woodcut from 1566. Translated from the German, the inscription reads: "...on the 22nd and 23rd day of December, in the 65th year just passed, in a village between Augsburg and Dillingen, Anna Rise, the wife of a poor peasant, gave birth and was delivered of 5 living infants, four girls and 1 boy, who were entirely complete, and possessed of all members." (The infants eventually died).
(*) There is also the story of the countess of Henneberg, who mocked a woman burdened with a multiple gestation, saying that it was impossible that they could have been conceived by the same man. She was then cursed by the poor woman, to "bear one child for each day of the year." This apparently eventually occurred, with 365 little children delivered at the same time. The little babies were separated into basins, the boys christened John, and the girls baptized Elizabeth. This was probably one of the earliest recorded accounts of a hydatidiform mole.
(*) Caesarean section, as a whole, was still widely discouraged, and reserved only for dead, or dying mothers. The mortality rate was about 100%, and, as Mauriceau wrote, "any survivors were in the imagination of the surgeon."
(*) An example of the surgery may have been like the following. The patient is restrained by two attendants: The barber-surgeon is about to make his pre-marked left paramedian incision, which was popular during that time (17th century). Anesthesia and asepsis, as you can see, was unknown. The minister in the background is reciting prayers.
It is said that the Lady Jane Seymour, the third wife of Henry VIII, delivered Edward IV, his only son, by caesarean section. She had apparently failed to progress in labor, and the doctor, a man named Owen, was told by the future father, to "deliver me a boy at any cost, for I can always get me another wife." The actual method of delivery was never recorded, but numerous ballads written at the time attest to the possibility of a caesarean.
(*) An example:
"0 doctor, 0 doctor, if doctor ye be
You'll open my left side, and save my babie,
They churched her, they churched her, they dug her a grave,
They buried her body, and christened her babe…”
Mainly due to the morbid fear of caesarean section, the 18th century would see obstetrics rise to new heights of operative technique. The general feeling at the time was "preservation of the mother's life at the expense of the fetus." Thus, if the infant could not be delivered by conservative means, then it had to be mutilated. This called for techniques that would cause as little damage to the mother as possible, but usually mean (*) destruction for the fetus.
(*) As we move into the 18th century, this is an example of a late 17th century delivery, from an etching by Abraham Bosse. The parturient is now in a semi-recumbent position, with the father in attendance.
(*) An example of an 18th century birth chair, somewhat more luxurious than the previous one shown. These were, by this time, adjustable, and could be converted into a table.
(*) Into this background emerged William Smellie. Born in Lanark, Scotland. In 1697, he received his MD degree from Glasgow University. He then migrated to London, where his practice was mainly in the Holborn and St Giles district in London, where conditions were so appalling that only one in five children usually lived to reach the age of six. He thus had no trouble attracting teaching cases for his students, who paid five guineas to (quoting Smellie) "attend all courses and labours, and have the opportunity to see and participate in difficult cases." Each student also paid 6 shillings for support of the patients, so all benefited from the experience.
(*) His most famous work is The Treatise and Sett of Anatomical Tables, first published in 1752. In it, he described a method of measuring the diagonal conjugate of the pelvis, again described the method of delivery of the aftercoming head in the breech popularized by the French and a description on the physiology of labor, as related to contractions of the uterus.
(*) Some of the instruments illustrated in his treatise, including boring scissors and crochet, (*) blunt hook, and straight forceps. Note the lock, now known as an English lock, which is the standard lock for forceps in use today.
(*) The usage of these instruments could be best exemplified by the following example, a case (collection #34, case 7) from his Observations of Midwifery. "During the first year of my practice I was called to many lingering cases, often occasioned by imprudent methods used by unskillful midwives.
From Smellie's description, one acquires a sense of the brutality of operative obstetrics at the time. Nevertheless, the skills required were extreme, and the physical exertion was almost beyond our comprehension, in the hopes of reaching a happy outcome: "The woman behaved with great courage weakened as such by the flooding she endured, and eventually recovered... The case so fatigued me that I was obliged to be carried home in a chair, and go to bed. My hands were so swelled that I could only use my fingers like a gouty person for a day or two…”
(*) As could be imagined, the midwives of the era, particularly the most prominent, Elizabeth Nihill, were violently opposed to male obstetricians. Smellie and his students were labeled as "broken barbers, tailors, and pork butchers.
(*) The bitterness came to a head when the book "Man-Midwife Dissected" was written by John Blunt, in 1753. He wrote, "Man-midwifery is a personal, domestic, and a national evil..." This illustration from his text reads "A man-midwife, or newly discovered animal, not known in Buffoon's time."
Nevertheless, males began soon to infiltrate the specialty in large numbers.
(*) A French man-midwife, Jean Louis Baudelocque, who popularized the (*) art of measuring the female pelvis in the mid 18th century by designing various pelvimeters. (*) From his book, “The Art of Obstetrics" we have this illustration of a pair of forceps, a popular French design by Andre Levret, applied to a breech. This is one of the earliest illustrations of this method, still in use today.
After the retirement of Smellie, many of his successors misused the hooks and forceps, usually with disastrous results.
This lead to an avocation by many early 19th century obstetricians of an ultra conservative approach to delivery, a practice that lasted almost 50 years.
(*) One of the major champions of this conservatism was Sir Thomas Denman, a name you may recognize from the beginning of this presentation. His text, "An Introduction to the Practice of Midwifery," became the definitive obstetric text of the time. A passage from this book required obstetricians to delay application of any forceps until waiting at least six hours, even though labor had stopped. This could lead to disastrous results for the fetus, as we have seen
(*) In 1828, Ferdinand August Maria Franz Von Ritgen described a method by which the perineum might be spared of laceration, a major problem before episiotomy, by pressing on the perineum for support, and flexing the head. He later modified this procedure by the improvement of extending the head, and hence, we have the technique now called "the modified Ritgen Maneuver" for spontaneous delivery of the fetal head,
(*) In 1848, James Young Simpson exhibited his new invention at a meeting of the Edinburgh Obstetrical Society - A device that henceforth would be known as Simpson's forceps, the most common forceps in use today. (*) Simpson's original publication shows what he felt was the correct application; "The correct application could be determined by noticing the forceps' marks over the baby's face.
(*) Simpson is also credited with the invention of the first vacuum extractor. He apparently obtained the idea from observing Scottish children playing a street game, whereby they would pick up stones by using leather cups. The device here was also made of leather, and, after being greased with lard, it was applied to the baby's head. Suction was obtained by pulling on the handle on the other end. The idea did not catch on, and he abandoned it in favor of his forceps.
Perhaps the greatest contribution that Simpson made to obstetrics occurred on January 19, 1847, when he administered ether to a parturient with a contracted pelvis, to aid in version and extraction. This practice soon came under heavy attack, from both his colleagues, and the clergy, who had previously called the pain of labor "… healthy and physiologic." Simpson countered these attacks by searching for a better agent by sniffing various gases himself. Finally settling on chloroform as a substitute for ether.
In 1853, John Snow, the first full-time physician-anesthetist, gave chloroform to Queen Victoria during the birth of Prince Leopold, her eighth child; She was extremely grateful and lavish in her praise of the agent. This ended all opposition to obstetric anesthesia, and lead to its widespread usage.
Anesthesia brought about the end of conservatism which had permeated obstetrics up to this time, unfortunately it brought about a rash of inventions to aid in obstetric manipulations, most of which were useless, and some of which were downright dangerous.
(*) Bags, balloons, and animal bladders for the induction of labor
(*) The sericeps of Jules Poullet. How this instrument could be used to deliver a liveborn fetus I'll never know.
(*) Numerous devices to stop postpartum hemorrhage, which was usually successful, except for lower extremity sloughing.
As the 19th Century continued, important concepts were being advanced.
(*) In 1851, Friedrich Scanzoni described a technique for rotation a posterior fetal head and reapplication of the forceps, which we now call "The Scanzoni maneuver." He also advocated pelvic application of the forceps to avoid the fetal face, which put him at odds with his contemporary Simpson.
(*) In 1860, John Braxton Hicks described the presence of contractions in the uterus during the second, and third trimester, henceforth known as "Braxton-Hicks contractions."
(*) About this time, it was also noted that numerous vaginal exams during labor increased the possibility of puerperal sepsis. To avoid this, Gerhard Leopold introduced (*) his four maneuvers in 1890. Although no longer used in labor, the "Leopold maneuvers" are common practice during antepartum patient visits.
The advent of anesthesia and attempts at infection control also renewed interest into Caesarean section. However, because of postpartum hemorrhage, death was still the usual outcome for the patient. One method to circumvent this was, interestingly, caesarean hysterectomy.
(*) The first major successful operation of this type was performed by an Italian, Eduardo Porro, on a rachitic dwarf named Julia Cavallini. After it had been determined that vaginal delivery would be impossible, the plan was presented to the patient, who accepted. Porro and the patient then retired to the church to pray together. (*) When the surgery was begun, the uterus and adnexa were removed in toto using the uterine snare designed by Cintrat. The lower uterine segment and snare were pulled through the abdomen into the lower portion of the incision. The post-op course was complicated by suppuration of the wound, vaginitis, decubiti of the sacrum and urinary tract infections, (*) all of which were considered minor, as Julia Cavallini survived. It would be for Max Sanger to advocate closure of the uterus to control hemorrhage and Wilhelm
Latzko to refine the extra-peritoneal method of caesarian section to help control infection to reduce the need for caesarian hysterectomy, which, in may sites is still known as a "Porro-section."
(*) As we now reach the 20th Century, the forceps would undergo numerous modifications, to the point that now there are over 300 different types in the obstetrician's armamentarium.
Two significant developments in forceps design include the introduction of a rotatory forceps by Christian Kielland in 1914. (*) This illustration from his original publication shows the reverse application of these forceps, now known as the classical application for these forceps. (*) And, lastly, Piper's introduction of a specially designed forceps for an after-coming head, in 1929.
After World War I, the New York Academy of Medicine decided to determine the cause of the stationary maternal mortality rate, while the death rates from all other causes were declining. It was shown retrospectively that 60% of all maternal deaths were due to lack of judgement, or inability on the part of the midwives, who were still doing the majority of the deliveries in a home setting. This study would have ramifications throughout the entire country, as the number of midwives would become less and less, and more deliveries would be performed on obstetric maternity wards. Only recently has this trend reversed, as patients are asking for delivery in a less technically dominant setting, and midwives are becoming accepted again.
Which brings me to the point where I think, in the interest of time, its best to that our little journey comes to a close. The use of fetal monitoring, fetoscopy, ultrasound, fetal scalp sampling, fetal transfusions, and fetal surgery are all recent developments that could in themselves be the subject of a future presentation.
I would like to finish with this thought in mind. We now have a considerable amount of computer-driven electronic wizardry that can be, in some instances, invaluable to the practice of obstetrics. Nevertheless it is not unusual to find a patient buried in a mass of tubes, monitors, catheters, etc. such that she may get lost.
(*) But take a moment and look at an illustration of "A midwife going to a labor". These individuals had so little to offer compared to today, but they always had compassion for the patient and concern for her welfare.
It is to these people that all obstetricians owe an awful lot. And so, for their sake, think about how it used to be, be thankful it's not quite that way today, and always keep the patient foremost in your mind.
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