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Society, Women, Epidurals - Part Two

Tracing Factors Bringing Us to Where we are Today, PART TWO

 

Adapted from DELIVER ME FROM PAIN: Anesthesia & Birth in America by Jacqueline Wolf

 

By the late 20th century, sectioned births and epidurals had come to characterize “normal” birth in the U.S.; together they seemed to highlight the risk and excruciating pain seen as inherent in vaginal birth

 

The contemporary popularity of epidural anesthesia cannot fully be understood without also examining the normalization of cesarean delivery. Public and medical acceptance of epidurals and of a high cesarean rate stemmed from the same impulse - the longtime desire of physicians and mothers to maximize comfort and safety during birth. The introduction of the electronic fetal monitor in the late 1960s, with its high false-positive rate for fetal hypoxia, raised the cesarean rate and also made physicians less wary of the epidural . . . . the increasing c-section rate ensured that anesthesiologists would be more readily available in maternity wards (when rates of 20% became common, anesthesia coverage became mandatory in labor and delivery. Prior to this time, nurse-anesthetists and OBs were administering anesthesia).

 

The rise in cesarean birth beginning in the 1960s was steep and swift. Between 1965 and 1987, birth by c-section in the United States increased 455%  (italics mine), from 4.5% to nearly 25% of births. In 2009, 32.9% of births were abdominal deliveries.

 

An obstetrician recalling her residency at Chicago’s Cook County Hospital in 1940 recalled that during her tenure, although there were 1500 births monthly (among a high-risk population), if a resident did more than 4 cesarean sections a month, case reviews and serious scolding ensued. Supervisors painstakingly reassessed the need for every section, teaching residents every possible way to avoid it.  Even the most highly interventive obstetric chief (anesthesia, forceps, episiotomies) “felt that a cesarean rate of about 2% was about right.”

 

In 1928 the only “absolute indication” for a sectioned delivery was “contracted pelvis,” with several other conditions (cord prolapse, multiple previous stillbirths) listed as “subjective” and “potential justifications.” By 1951 the same text (DeLee’s Principles and Practices of Obstetrics) listed 17 indications, and each indication was qualified: “definite” disproportion, ”total” placenta previa, “severe” abruption, “extreme” narrowing of pelvic outlet, breech presentation “in first time mothers older than forty.”  By the time the c-section rate began its precipitous rise in the 1960s, obstetricians had broadened the definition of dystocia to also include “failure to progress” during labor, a diagnosis that increased in coming years, and was criticized as “vague” and “catch-all.”

 

The higher rates horrified the older obstetricians whose careers were ending in the early 1980s. These physicians had come of age during the gas-inhalation, pre-blood banking, pre-antibiotic era, when the risks associated with c-section were enormous. When these doctors trained, a low section rate was a sign of skill; a high rate (normally defined as anything approaching 4%) signaled incompetence. (italics mine). The most experienced doctors tended to be the most critical of the high rate. Dismayed and appalled, they predicted that young obstetricians were relying so heavily on sections that soon they would have no skills in emergencies, forceps, or breech deliveries. A former ACOG president warned the Obstetrical Society that doctors should never point to technology to justify the unwarranted assumption that it had become unnecessary to hone their hands-on clinical skills.

 

Ironically, the increase was most precipitous between 1970 and 1981, when natural childbirth was at its zenith of popularity. Thus, for a time, two diametrically opposed attitudes toward birth and medical treatment prevailed....Not until the late 1970s, as the c-section rate reached 16%, did the government, the medical community, and the lay press begin to examine and criticize the trend.

 

 

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