DEFINITION OF OBSTETRICS
Obstetrics is the branch of medicine that concerns management of women during pregnancy, child birth and the puerperium.
Historical Evolution
History gives an account of the changes that have taken place in obstetrics in many centuries. Hence, obstetrics is as old as mankind.
The development of obstetrics possibly started in the Indus valley about 5 million years ago. Figures of women giving birth in sitting and kneeling positions are seen with a figure of the goddess of fertility. The husband was called to cut the cord (husbands still do this in Brazil) but no other male is allowed in, especially in Egypt and the Middle East.
Drawings of 6000 to 1200 BC show women squatted on the ground or on bricks to deliver. Labour stimulants like salt, onions, oil, mint, incense, wine and even ground up scarabs and tortoise shells were used. The first cry of the neonate had a great significance and the cord was cut only after the midwife had washed the baby. Breastfeeding was universal. Pregnancy was diagnosed by the woman urinating on a mixture of wheat and barley seeds with dates and sand. It was believed that if the grains sprouted she pregnant. If only barley grows, a girl would be born but if only wheat sprouted, a boy was in the womb.
A variety of goddesses were thought to protect and help the woman in labour. In India, during 1000 BC to 500 AD, women had a high position. Their physical health was treated as being as important as that of the men (500 BC-500 AD). It is possible that obstetrics started in India and gradually moved to the West reaching Greece, Italy and then Rome. Soranus wrote his Gynaecology in Greek. This book was quoted by Muscio (or Mustio) around 300–500 AD and had a portion for midwives. There are various illustrated positions of the foetus in Temkin's edition of Soranus Gynaecology. Soranus knew that the foetus can take up various positions in the uterus and he described them all. He prescribed the qualities needed for a good midwife, like she had to have a good memory, love for her work, be respectable to her patients, be sound of limbs, robust and endowed with long slim fingers and short nails. She should be free from superstitions.
There are records of birthing stools, made of wood, in the old Testament. The front of the seat was hollowed out into a semicircle and two upright wooden rods were affixed on each corner of the front so that the woman could grasp them, when pushing, in the second stage of labour while the midwife stood in front.
Oribasius (325–403 AD) of Pergamum had a high reputation as an Obstetrician in Byzantium.
In Baghdad, the book Liber Helchavy written by Rhazes (850–923 AD) was devoted mainly to 4midwifery. Over the next few centuries European medicine gradually re-emerged until 1316 AD.
The knowledge of anatomy was based on that of the pig. Mundinus at Bologna wrote a book on human dissection. He wrote that the uterus contains several cells but rejected the old Greek concept of wandering uterus.
Dissection was performed, particularly by Gabrielis Fallopio (1523–1562) and published as the anatomical work. He described the fallopian tubes, connecting the ovaries to the uterus. (In the eleventh century, Trotula wrote a book which was translated into English in the fifteenth century. This book showed abnormal foetal positions. Richard of Salerno, in thirteenth century, wrote a book showing some pictures of female anatomy. Albert Magnus, a Dominican monk [1193–1280 AD] produced the first printed work in gynaecology, giving comments on the secrets of women). De Graaf (1641–1673) was able to describe ovaries with follicles. In 1513 Eucharius Rosslin produced a book the ‘Rose Garden’ which was translated to English by Richard Jonas as, ‘The Byrth of Mankynde’ in 1540. It remained the most popular textbook of midwifery till late seventeenth century. Ambroise Pare (1510–1590) of Paris was a greatly acknowledged obstetrician. He revitalised the idea of podalic version (internal). Hotel Dieu in Paris started by Ambroise Pare, in fifteenth century became the most famous maternity unit in Europe and the world. It is still functional.
In England, Henry VIII in 1512, formed an Act to regularise midwifery practice. Obstetric forceps were developed but kept a secret for 150 years by the Chamberlain family in 1598. Many other varieties of forceps were developed by Jacob Rediff Paltyne, Doughlas and others. During this period, the understanding of embryology and reproductive anatomy was enhanced because of the advent of the the microscope. Other instruments to deliver the dead foetus also developed, e.g. various forms of hooks, vectis and different bandages of soft leather, linen, muslin, etc. for application of traction on breech. Eighteenth century saw the beginning of scientific obstetrics. William Smellie (1697–1763) introduced varieties of the obstetrics forceps besides studying the effect of rickets on the pelvis. He also studied pelvic soft tissues.
William Harvey, of blood circulation fame, wrote on labour in De Partu (De Generation Animalium). This is the first original English book on Obstetrics in which he advised against unnecessary interference.
Francois Mauriceau (1637–1709), a renowed Obstetrician of Paris, investigated the mechanism of labour and devised a method for delivery of the after coming head in breech. He also described brow presentation. He was, perhaps the first, to advocate delivery in bed rather than on a birth stool. He emphasized greatly on hygiene in his book.
Hendrik van Deventer (1651–1727) of Hague wrote about obstructed labour and deformed pelvis. Dutchmen, Hendrik Van Roenhuyze (1625–1672) advocated caesarean section in obstructed labour to prevent vesico vaginal fistula.
In nineteenth century James Young Simpson (1811–1870) of Edinburg started obstetrical anaesthesia. Parro's Caesarean hysterectomy (subtotal) saved many lives (1876). In 1882 Adolph Kechrer, closed the uterine wound and laid the foundation of modern caesarean operation. Symphysectomy (division of symphysis pubis) was known to be practiced in Ireland. In Paris Sigault (1777) is said to have performed the first symphysectomy on a living woman. William Hunter (1718–1783) studied anatomy of the pregnant and non-pregnant uterus and the embryo.
Charles White (1728–1813) of Manchester emphasised the need for cleanliness to prevent puerperal sepsis. Soranus of Ephesus (at the coat of Turkey) provided the first anatomical description of the ovaries (98–138 AD). Leanardo da Vinci (1452–1519) drew the anatomy of the uterus and ovaries (Andre Levret).
Fielding Ould (1710–1789) was considered the first important teacher in Obstetrics in Ireland. He introduced the left lateral position for delivery. Lying-in wards were added in the hospital building in 1773. The hospital was later rechristened as the Queen Charlotte's hospital.
Thomas Bull wrote the first book on antenatal care in the nineteenth century. It sold 25 editions between 1837–1877. Dr A Pinard of France was one of the first to advocate antenatal examination of the abdomen (1895). He favoured induction of labour. He also designed the foetal stethoscope. The first antenatal 5patient hospital, was made by Madame Becquet of Vienne (France) in 1892 in Hotel Dieu. It had less space hence two patients used to share a bed (as is seen in government hospitals in resource poor countries, like in our hospital, i.e. Safdarjung Hospital).
The term puerperal fever was given by Edward Strother in 1716. Oliver Wendell Holmes (1809–1894) in 1843 pointed out that the disease was carried to the patient by her physician or nurse. Development of antiseptics and discovery of antibiotics, besides the all important ‘hand washing’ helped reduce the maternal morbidity and mortality. Florence Nightingale (1820–1910) emphasized the importance of a good ventilation system. Gustav A Michealus (1798–1848) discovered true conjugate measurement.
Friedrich Trendelenberg (1899–1925) introduced the position of the patient which is now named after him. James Methew Duncan (1826–1886) helped formulate management of antepartum haemorrhage. Crede (1819–1892) of Leipzid introduced a method of separation of placenta. John Braxton Hicks (1825–1893) noted rhythmic uterine contractions of pregnancy. Aschheim and Zondek described pregnancy test in 1927. Voge introduced detection of pregnancy by the flocculation pregnancy test in 1926.
Nearly all breeches were delivered from below. Rhesus factor was discovered in 1940 by Landsteiner and Wiener. Though Hofbauer advocated pituitary extract in 1918, it was introduced very late in practice.
Antenatal care is attributed to J W Bellantyne. In 1901 Royal Maternity and Simpson Memorial Hospital endowed one bed for the purpose. In USA it was started in 1911 and in 1912 in Sydney.
Though John Charles in 1811 discovered the relation of proteinuria with eclampsia, it didn't receive much attention at that time. The invention of the stethoscope was done in 1819 by Rene Laennec (1781–1826) and his student Kergaradec. Hearing the foetal heart by applying his instrument to the abdomen was a great step forward. In 1896 the sphygmomanometer was perfected by Scipione Riva-Rocci and the relation of high blood pressure and eclampsia was established. However, blood pressure was not often taken in antenatal checkups. Stronganuff in 1909 introduced anticonvulsants and their combination with antihypertensive started in 1960.
Fig. 1.1: Dr. Krishna Menon with the Department of Obstetrics and Gynaecology. Banaras Hindu University, India, February 1976.
Krishna Menon's regime was in vogue for a long to treat eclampsia thus lowering the maternal mortality drastically. During 1932–1944 Macafee's regime helped many patients suffering from antepartum haemorrhage and their neonates.
Caesarean section by 1931 was not considered a dangerous operation and it saved many patients with placenta praevia. The technique of ultrasound introduced by Ian Donald in 1958 replaced all other invasive methods of diagnosis of placenta praevia.
The abandoning of high forceps and difficult vaginal deliveries, reduced the incidence of birth trauma and the morbidity significantly. The uterus and its contractions were investigated for long by Alvarez and Calderyro- Barcia in 1950.
In 1970 para-sympathomimetic agents were introduced, thus preventing neonatal deaths. The categorisation of antenatal mothers into low-risk and high-risk helped the mothers and neonates immensely. Foetoplacental function tests developed in 1961, greatly improved our insight into the foetal condition.
Tremendous changes occurred in the understanding and management of labour, its induction and active management of the third stage of labour in the twentieth century. There is a gradual trend of increasing hospital deliveries. Artificial rupture of membranes became popular at the end of the nineteenth century. Quinine for the induction of labour (Porak in 1878) was popular till 1930. Oxytocin induction was started by Theobald in 1952. Pelvic scoring system was devised by Bishop in 1964. The use of prostaglandins, as a cervical ripening agent, was introduced by Karim and his associates in 1968. Titration of oxytocin infusion by Turnbull and Anderson was started around the same time. Incompetence of cervix was investigated by Lash and Lash in 1950, Palmer and Shirodkar in 1953 and McDonald in 1957.
O' Driscoll and Meqagher of the National Maternity Hospital Dublin, revolutionised the active management of labour with the use of the partogram introduced by Philpott of Rhodesia, which helped them to intervene before the mother and foetus were exhausted. Analgesia and regional anaesthesia is becoming popular. Caudal anaesthesia was replaced by epidural analgesia by mid 1970. Caesarean delivery was performed in less than 2 per cent of labour in the beginning of twentieth century. But by 1990, it was about 12 per cent. The practice of episiotomy with or without instruments became common in 1950. Introduction of vacuum was a great achievement.
The crude foetal kick counting was introduced by Sadovsky and his associates in 1976. Biophysical assessment of the foetus introduced by Frank Manning and Larry Platt in the early 1980, still continues to be life saving for the foetus.
Electronic foetal monitoring of high-risk cases combined with Saling's technique of foetal scalp pH monitoring, is still of considerable value. Genetic counselling and determination of genetic defects has helped a lot. Maternal mortality review and audit of maternal care during antenatal, natal and postnatal period, according to evidence-based protocol and practices is now improving the maternal care to a great extent.
In this chapter we have had a brief glimpse of the journey of the primitive art of obstetrics conducted by natives to the midwives and now by qualified obstetricians. It has gradually become a scientific venture from ovulation to conception, from the development of the foetus to delivery.
BIBLIOGRAPHY
- Chamberlain G, Turnbull A. The continuum of obstetrics. In Turnbull's Obstetrics, A, Chamberlain G and Steer PJ (Eds): 3rd edition page 1–7 Churchill Livingstone 2001.
- Colebrook L. Puerperal infection. In Munro Kerr JM, Johnston RW, Philips MH (Eds). Historical Review of Obstetrics and Gynaecology (1800–1950) 203–25,1954.