Women's Health

Already we are saving newborn infants who are born with a trouble, caused by the much publicized Rh factor that is called erythryblastosis. This practically means that they do not have good red blood cells. They are jaundiced and have other troubles. The cause is now known and naturally young parents have been disturbed, especially when they think that their two types of blood might cause this difficulty in their baby’s blood.
It is not an easy matter to understand the different types of blood, and the Rh factor is an especially complicated part of the whole story. When the blood from different species of animals is mixed, one blood destroys the cells of the other. Thus attempts in the past to help men by putting in their veins the blood of sheep, for instance, have been worthless. When bloods from individuals of the same species have been mixed (man, of course, is the species that we are interested in), the results at times have been very bad.
Evidently there are substances in some bloods which are hostile to others. We speak of bloods as being of different types and we know that there are many types in humans. Hence before mixing two bloods it must be determined to what type each belongs. If they may be mixed with safety, they are said to be compatible.
Dr. Karl Landsteiner, of the Rockefeller Institute, was a leader in the study of these types. Some years ago he and Dr. Alexander S. Wiener were studying a blood reaction which sometimes makes trouble for the unborn or newborn child. In the course of their experiments they, with that mysteriously reasonable curiosity which guides geniuses, put the blood of a rhesus monkey into a rabbit. After several injections the rabbit’s blood developed a substance that, when injected into the monkey, would cause the latter’s blood to form in clumps and be destroyed. The same sad result would happen to 85 per cent of humans. Evidently the monkey and most humans had something in their blood which caused this reaction. Dr. Landsteiner as a great compliment to the rhesus monkey, which had been so helpful, called this substance the Rh factor. So everybody knows of the Rh factor but few know of the modest Dr. Landsteiner.
Those persons who have the factor are said to be Rh positive; those who do not are Rh negative. If a father is Rh positive, he usually transmits it to his child. Sometimes some of the child’s blood leaks through the placenta and into the mother’s blood. If she is Rh negative, she then forms some of the substance which reacts against the child’s blood. This substance is called an antibody and is a part of an elaborate system for protection against materials which might do harm. In this particular situation it is hard to see how it is anything but a nuisance and danger. When it gets back into the child, it attacks his blood. Usually with the first pregnancy it does not make serious trouble, but in subsequent pregnancies more antibodies may be formed with increased potency.
The fact is, though, that only in a small proportion of cases where there is an Rh positive father and an Rh negative mother does trouble arise. Not all positive fathers transmit the factor to their children; not always does the blood from the positive baby get into the mother; not always does a negative mother react. At one large hospital there have been about twenty-five cases of erythroblastosis in seven thousand deliveries. The other hazards of pregnancy are greater. As an experienced and wise physician connected with this hospital said: “This factor is nothing of recent origin. It has always been with the race; and the dangers of childbirth, including this one, have certainly not increased. Quite the contrary, but the identity of this Rh menace has recently been established and dramatically publicized.” Infants severely injured by the Rh factor are now being saved by blood transfusions.
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WOMEN’S HEALTH

Lots of women must feel that way: A survey of doctors by the American College of Obstetricians and Gynecologists shows that in 1970 only 2.2 percent of women who’d had cesareans later delivered vaginally. By 1991, that figure had leaped to more than 25 percent. Dr. Richard Porreco, director of the perinatal program at Presbyterian-St. Lukes Medical Center in Denver, says, “To get cesareans below 10 percent, you need to give almost every woman who has had a C-section the chance to go into labor.”
No single cause explains the burgeoning of surgical births. As noted earlier, profit is one motive. So is fear.
Fearful doctors mean more cesareans: They want neither to be blamed nor to have to blame themselves for damaging an infant by letting labor continue if either baby or mother is in danger. Sometimes the problems are genetic, not medical. John J. Bower, a New York lawyer who has been trying malpractice cases for four decades, says, “People think the doctor is delivering a product, and they want a perfect product. But in medicine, the doctor isn’t always in control. Even with the best techniques, things can go wrong.”
The fear of malpractice suits seems justified. A 1992 survey conducted by the American College of Obstetricians and Gynecologists showed that 80 percent of obstetricians had been sued at least once. One-fourth of those doctors said that they reduced the number of high-risk patients they cared for. In some states their malpractice insurance cost more than 100,000 dollars a year. Small wonder that in 1992 more than 12 percent quit the profession.
Some women get C-sections because they need them, some because they want -and can afford -them. Dr. Jeffrey B. Gould, chief of a program for maternal and child care at the University of California at Berkeley, says, “Affluent women are better at telling doctors what they want.” It’s the private hospital that might end up with as many as one in two born under the knife. In public hospitals, cesareans are more likely to meet the ideal rate of 12 percent, because the uninsured poor can’t demand such costly elective services.
Why would women demand cesareans? Some want to avoid labor or ensure a convenient time for the birth. (Doctors, anxious to keep their patronage, don’t refuse.) Still others are attracted to C-sections by the anesthesiologists’ epidural “spinal block.” With it, the mother is awake during childbirth, yet she feels no pain.
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WOMEN’S HEALTH

Until recent times midwives have had entire charge of women in labor, and there have been advantages as well as disadvantages in this custom. In the past much meddlesome obstetrics has been done, but, on the whole, modern obstetrics has been increasingly triumphant. The first great advance was the invention of the obstetrical forceps by the Chamberlen family nearly three hundred years ago. This family, contrary to the ethics which good medical men like to practice, kept the secret for several generations. Forceps are used when the mother cannot expel the baby by her own exertions. There are various reasons for this use: the baby may be too large in relation to the mother’s dimensions; the mother, because of prolonged labor or other reasons, may be too exhausted to furnish the proper propulsive force; the baby may be lying in the wrong position. Modern forceps consist of two pieces of metal curved so as to fit both the baby’s and the mother’s anatomy. They lock firmly after they have been placed in position. A handle allows the obstetrician to manipulate the forceps and pull the baby down at the speed and in the direction that he wishes.
When the forceps became generally used, they were, of course, abused. The “high forceps” of a generation ago was brutal. In such an operation, the forceps were applied to the child’s head while was still far up in the pelvis and had not been moulded by the force of labor into a shape which would allow it to come down easily. The pulling of this great head usually resulted in much damage to the mother’s tissues. Our ability to remove the baby by operation (the so-called Caesarean section) in a simpler, safer manner has outmoded this danger.
The good modern obstetrician exercises, in the words of one of my former teachers, “scientific apprehensive expectancy.” He should let most mothers deliver themselves, but he should understand when things are not going well, and he now has many clever ways in which to help out the mothers.
The baby, while in the womb, is out of reach of our direct interference. The child is absolutely under the control of the mother. If nothing abnormal occurs with her, all should go well with the child. Obstetricians realizing this have for many years now given great attention to pre-natal care. This has paid excellent dividends. One authority tells us that in his state six times as many women died in childbirth fifteen years ago as do now. The death rate for babies has been similarly declining. One hopeful aspect of this problem is that we are beginning to appreciate some of the reasons for the deaths and malformations of these infants, and we can see that it is not just chance. A few years ago we knew nothing of the effects of virus diseases of the mother during pregnancy; of conditions causing the baby to get insufficient oxygen; of the Rh factor. So far we have not taken great advantage of our glimmerings of new knowledge but we are bound to get more light and see our way to saving more and more babies.
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WOMEN’S HEALTH

Nearly one in four American babies is exposed to its first light in an operating room, with masked doctors and nurses peering into its mother’s womb as a surgeon cuts open the uterus to remove the baby.
Although often lifesaving for both mother and child, surgical delivery – also called a cesarean section or C-section – has become a multi-billion-dollar business for both doctors and hospitals. The fee is higher for surgery than for a vaginal birth. Hospital bills are higher too: the mother stays longer and requires more services and drugs.
Public Citizen’s’ Health Research Group, consumer advocates in Washington, D.C., analyzed the cesarean situation. Since 1970, they report, C-sections have surged from 6 percent to almost 25 percent of all births. The group found 56 hospitals nationwide with more than 40 percent C-sections; some hospitals exceeded 50 percent. The Abrom Kaplan Memorial Hospital in Kaplan, Louisiana, topped the list, with a cesarean rate of 57 percent. The Health Insurance Association of America says the average cost for a cesarean in this nation in 1991 was 7,826 dollars, compared to 4,720 dollars for a vaginal delivery. More than 7 billion dollars was spent in the United States on nearly a million cesareans. Public Citizen’s Health Research Group estimates that half of these surgeries were unnecessary.
There is a rising clamor within and outside the medical community for doctors and hospitals to reject surgery as the first answer to birth problems.
In an interview shortly before he died, Dr. Mortimer Rosen, chief of obstetrics at Columbia-Presbyterian Medical Center in New York City, called the cesarean explosion a dangerous national scandal. He was a leader in the effort to reduce birth surgeries. “Cesareans are costly, dangerous, and painful,” Dr. Rosen told me. “This is not a neat, simple procedure. It is big-time, major surgery. The floor of the operating room is covered with blood and fluids. A woman loses two units of blood, undergoes anesthesia. She is scarred internally and externally.”
A C-section can be a lifesaver, however. Liz Baldwin, 41, of Miami, says she is sure surgery saved the life of her firstborn son, David. Labor contractions were lowering David’s blood supply in the womb by pushing against his defective birth cord. A cesarean was performed, and David was saved. Still, Mrs. Baldwin recalls the aftereffects: “For 2 to 3 weeks, I had the most horrible pain.” She was determined that her next baby would have a vaginal birth. But her first doctor said that a vaginal birth after a cesarean would endanger the baby’s life and hers also.
Many obstetricians maintain that a surgically scarred uterus can rupture under the pressure of labor contractions. However, Dr. Bruce Flamm, of Kaiser Permanente Medical Center in Riverside, California, says the risk of rupture is less than 1 percent. Dr. Flamm led the research for a 5-year study on the risk of uterine rupture after C-section. The study, involving 5,733 women, ended in 1988.
Mrs. Baldwin found another doctor and, 4 years later, had Billy by vaginal birth. “It was the most wonderful experience,” she says. “I wept tears of joy for 3 months, just thinking of it.”
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WOMEN’S HEALTH

Labor is a normal physiological process. Throughout time immemorial the overwhelming proportion of cases have delivered without help. This is the basis for the modern “natural childbirth.” It is founded, of course, on Rousseau’s hypothesis that the savage in a state of nature is the perfect man, but man (and woman) has assumed the upright posture and the changes incident to this have not facilitated childbirth. Numerous observers amongst savage tribes have testified that savage women have possibly as much difficulty as the civilized women.

The biblical statement still holds with some women: “In sorrow shalt thou bring forth children. . . .” But these are exceptions. On the Lewis and Clark expedition, an Indian and his squaw dropped out from the line of march. A day later, they had joined again with a newborn baby. At the turn of this century, my mother’s washerwoman had a baby while no one else was in the house, took entire care of it, and was doing a washing the next day. Now that lying-in hospitals are getting crowded, obstetricians have found that new mothers can go home almost as promptly as this.
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Women’s health