Obstetrical Forceps: History, Mystery, and Morality

The history of obstetrical forceps has almost always been one cloaked in controversy after a long history of being shrouded in mystery. Forceps have a long history and have evolved from facilitating the delivery of dead fetuses to aiding in the delivery and survival of live babies. In the middle of all of this arises the story of the Chamberlain family whose contribution was enormous but whose behaviors pushed at the envelope of (at least) our present-day concepts of medical ethics. This lecture traces an interesting story that spans a millennium.

Two Obstetrical Heresies

Dr. Silas F. Starley deplores what he considered errors generally taught and accepted in the late 19th century in Two Obstetrical Heresies . “The first is the part that membranes containing the amniotic fluid and the foetus play in effecting dilation of the os uteri in the first stage of labor.The second is the supposed necessity for waiting for their rupture and the escape of the waters before applying the forceps, in every case, without exception.” Silas F. Starley (1823-1887) was born in Alabama and moved to Texas with his family in 1837. He graduated from the University of Louisville School of Medicine in 1854 and spent his professional career in Texas, ending his career in Corsicana. He was President of the State Medical Association of Texas (Texas Medical Association) in 1883 and wrote articles in Texas medical journals on various topics including obstetrics, vascular tumor, and pneumonia. Texas State Historical Association, http://www.tshaonline.org/handbook/online/articles/sat05 , accessed 10/16/2012. Texas Physicians Historical Biographical Database, http://www4.utsouthwestern.edu/library/doctors/doctors.cfm?DoctorID=16809 , accessed 10/16/12.

Intensive care for extreme prematurity--moving beyond gestational age.

BACKGROUND: Decisions regarding whether to administer intensive care to extremely premature infants are often based on gestational age alone. However, other factors also affect the prognosis for these patients. METHODS: We prospectively studied a cohort of 4446 infants born at 22 to 25 weeks' gestation (determined on the basis of the best obstetrical estimate) in the Neonatal Research Network of the National Institute of Child Health and Human Development to relate risk factors assessable at or before birth to the likelihood of survival, survival without profound neurodevelopmental impairment, and survival without neurodevelopmental impairment at a corrected age of 18 to 22 months. RESULTS: Among study infants, 3702 (83%) received intensive care in the form of mechanical ventilation. Among the 4192 study infants (94%) for whom outcomes were determined at 18 to 22 months, 49% died, 61% died or had profound impairment, and 73% died or had impairment. In multivariable analyses of infants who received intensive care, exposure to antenatal corticosteroids, female sex, singleton birth, and higher birth weight (per each 100-g increment) were each associated with reductions in the risk of death and the risk of death or profound or any neurodevelopmental impairment; these reductions were similar to those associated with a 1-week increase in gestational age. At the same estimated likelihood of a favorable outcome, girls were less likely than boys to receive intensive care. The outcomes for infants who underwent ventilation were better predicted with the use of the above factors than with use of gestational age alone. CONCLUSIONS: The likelihood of a favorable outcome with intensive care can be better estimated by consideration of four factors in addition to gestational age: sex, exposure or nonexposure to antenatal corticosteroids, whether single or multiple birth, and birth weight. (ClinicalTrials.gov numbers, NCT00063063 [ClinicalTrials.gov] and NCT00009633 [ClinicalTrials.gov].).

Certified nurse midwives effects on catecholamine levels and maternal anxiety during labor

Studies of nurse midwifery care in the last twenty one years have reported excellent birth outcomes (Levy, Wilkenson and Marine, 1971; Platt et al. 1985; Stone et al. 1976). These outcomes are frequently attributed to the special support offered during labor and delivery by nurse midwives. This supportive style is thought to decrease catecholamine levels by reducing maternal anxiety. This prospective observational study evaluated catecholamine levels, anxiety levels, in-hospital costs, obstetrical practices and outcomes between low risk, term, labor and delivery primigravida patients managed by obstetrical residents (n = 55) or by certified nurse-midwives CNM (n = 59). The two groups were similar with regard to obstetrical risk factors present at admission. Each group was selected over the same period of time between March 23, 1994 and November 2, 1994. Specific catecholamines evaluated were epinephrine and norepinephrine. Obstetrical and newborn characteristics were also compared. This study did not prove that there is a decreased level in stress as indicated by lower levels of epinephrine and norepinephrine in nurse-midwife patients compared to obstetrical resident patients after adjusting for the use of epidural anesthesia. There was also no difference found in the perceived anxiety levels between the two groups. This study did confirm that nurse-midwives and obstetrical residents have different practice styles. Nurse-midwife patients had fewer augmented deliveries, fewer operative deliveries, less blood loss, fewer episiotomies and fewer third and fourth degree lacerations. The physician's choice to utilize more interventions such as continuous fetal monitoring and epidural anesthesia did not improve outcomes. The hospital cost of the nurse-midwife patients in this study was 35 percent lower than the physician patients. ^

Hepatitis B vaccination of high risk pregnant women: A clinical trial at Parkland Memorial Hospital

Hepatitis B infection is a major public health problem of global proportions. It is estimated that 2 billion people worldwide are infected by the Hepatitis B virus (HBV) at some point, and 350 million are chronic carriers. The Centers for Disease Control and Prevention (CDC) report an incidence in the United States of 140,000–320,000 infections each year (asymptomatic and symptomatic), and estimate 1–1.25 million people are chronically infected. Hepatitis B and its chronic complications (cirrhosis of the liver, liver failure, hepatocellular carcinoma) responsible for 4,000–5,000 deaths in America each year. ^ One quarter of those who become chronic carriers develop progressive liver disease, and chronic HBV infection is thought to be responsible for 60 million cases of cirrhosis worldwide, surpassing alcohol as a cause of liver disease. Since there are few treatment options for the person chronically infected with Hepatitis B, and what is available is expensive, prevention is clearly best strategy for combating this disease. ^ Since the approval of the Hepatitis B vaccine in 1981, national and international vaccination campaigns have been undertaken for the prevention of Hepatitis B. Despite encouraging results, however, studies indicate that prevalence rates of Hepatitis B infection have not been significantly reduced in certain high risk populations because vaccination campaigns targeting those groups do not exist and opportunities for vaccination by individual physicians in clinical settings are often missed. Many of the high-risk individuals who go unvaccinated are women of childbearing age, and a significant proportion of these women become infected with the Hepatitis B virus (HBV) during pregnancy. Though these women are often seen annually or for prenatal care (because of the close spacing of their children and their high rate of fertility), the Hepatitis B vaccine series is seldom recommended by their health care provider. In 1993, ACOG issued a statement recommending Hepatitis B vaccination of pregnant women who were defined as high-risk by diagnosis of a sexually transmitted disease. ^ Hepatitis B vaccine has been extensively studied in the non-pregnant population. The overall efficacy of the vaccine in infants, children and adults is greater than 90%. In the small clinical trials to date, the vaccine seemed to be effective in those pregnant women receiving 3 doses; however, by using the usual 0, 1 and 6 month regimen, most pregnant women were unable to complete a full series during pregnancy. There is data now available supporting the use of an "accelerated" dosing schedule at 0, 1 and 4 months. This has not been evaluated in pregnant women. A clinical trial proving the efficacy of the 0, 1, 4 schedule and its feasibility in this population would add significantly to the body of research in this area, and would have implications for public health policy. Such a trial was undertaken in the Parkland Memorial Hospital Obstetrical Infectious Diseases clinic. In this study, the vaccine was very well tolerated with no major adverse events reported, 90% of fully vaccinated patients achieved immunity, and only Body Mass Index (BMI) was found to be a significant factor affecting efficacy. This thesis will report the results of the trial and compare it to previous trials, and will discuss barriers to implementation, lessons learned and implications for future trials. ^

A comparison of labor and delivery management activities in two settings

Similarities and differences in management activities and patient health outcomes between a traditional physician staffed labor and delivery setting and a certified nurse-midwife staffed Birth Center within the same hospital were described. The 950 study subjects, low income, minority women, were classified as low obstetrical risk by a POPRAS score of 25 points or less at time of admission for labor and delivery. The study subjects were similar in demographic, antepartum and intrapartum characteristics; the labor course was problem free for the majority in both settings. There were no remarkable differences in health outcomes between the groups. Management activities varied between settings; these variations were policy related rather than health related. The POPRAS rating system was an accurate predictor for 93% of BC subjects and 85% of LDU subjects. Charge for service was approximately $600 less for BC women; length of stay did not contribute to the difference in charge. Overall, BC respondents to the attitude survey were more satisfied with their labor and delivery experience than L\&DU women. ^

OUT-OF-HOSPITAL CHILDBEARING CENTERS IN THE UNITED STATES: A DESCRIPTIVE STUDY OF THE DEMOGRAPHIC AND MEDICAL-OBSTETRIC CHARACTERISTICS OF WOMEN BEGINNING LABOR THEREIN 1972-1979

There is currently much interest in the appropriate use of obstetrical technology, cost containment and meeting consumers' needs for safe and satisfying maternity care. At the same time, there has been an increase in professionally unattended home births. In response, a new type of service, the out-of-hospital childbearing center (CBC) has been developed which is administratively and structurally separate from the hospital. In the CBC, maternity care is provided by certified nurse-midwives to carefully screened low risk childbearing families in conjunction with physician and hospital back-up.^ It was the purpose of this study to accomplish the following objectives: (1) To describe in a historical prospective study the demographic and medical-obstetric characteristics of patients laboring in eleven selected out-of-hospital childbearing centers in the United States from May 1, 1972, to December 15, 1979. Labor is defined as the onset of regular contractions as determined by the patient. (2) To describe any differences between those patients who require transfer to a back-up hospital and those who do not. (3) To describe administrative and service characteristics of eleven selected out-of-hospital childbearing centers in the United States. (4) To compare the demographic and medical-obstetric characteristics of women laboring in eleven selected out-of-hospital childbearing centers with a national sample of women of similar obstetric risk who according to birth certificates delivered legitimate infants in a hospital setting in the United States in 1972.^ Research concerning CBCs and supportive to the development of CBCs including studies which identified factors associated with fetal and perinatal morbidity and mortality, obstetrical risk screening, and the progress of technological development in obstetrics were reviewed. Information concerning the organization and delivery of care at each selected CBC was also collected and analyzed.^ A stratified, systematic sample of 1938 low risk women who began labor in a selected CBC were included in the study. These women were not unlike those described previously in small single center studies reported in the literature. The mean age was 25 years. Sixty-three per cent were white, 34 per cent Hispanic, 88 per cent married, 45 per cent had completed at least two years of college, nearly one-third were professionals and over a third were housewives. . . . (Author's abstract exceeds stipulated maximum length. Discontinued here with permission of school.) UMI ^

Black/white disparities in infant mortality rates in the U.S.: A quality of care perspective

The infant mortality rate for non-Hispanic Black infants in the U.S. is 13.63 deaths per 1,000 live births while the IMR for non-Hispanic White persons in the U.S. is 5.76 deaths per 1,000 live births. Black women are 2 times as likely as White women to deliver preterm infants and Black women are 2 times as likely as White women to deliver low birth weight infants (weighing less than 2,500 grams at birth). Differential underlying risk factors among mothers of different racial/ethnic groups for delivering pre-term and low birth weight infants have been historically accepted as the cause of racial disparities in IMRs. However, differential underlying risk status may not be the only major causative factor. Differential or unequal access to and provision of care is widely speculated to be a leading contributing factor to the wide racial disparity in infant mortality.2 This paper conducts a systematic review of existing literature investigating racial disparities in obstetrical care provided by healthcare practitioners to evaluate whether inequities in healthcare services provided to pregnant mothers and their neonates exist. The search terms "racial disparities obstetrical care," "racial differences quality of prenatal care," and "infant mortality racial disparities" were entered into the EBSCO Medline, Ovid Medline, PubMed, and Academic Search Complete databases, and articles between years 1990–2011 were selected for abstract review. The only articles included were those that used statistical methods to assess whether racial inequalities were present in the obstetrical services provided to pregnant women. My literature search returned 5 articles. Four of the five studies yielded significant racial differences in obstetrical care. However, the one study that used a large, nationally representative valid sample did not represent significant differences. Thus, this review provides initial evidence for racial disparities in obstetrical care, but concludes that more studies are needed in this area. Not all of the studies reviewed were consistent in the use and measurement of services, and not all studies were significant. The policy and public health implications of possible racial disparities in obstetrical care include the need to develop standard of care protocols for ALL obstetrical patients across the United States to minimize and/or eliminate the inequities and differences in obstetrical services provided.^

Cary's Illustrated and Priced Catalogue: Surgical Instruments, Physicians, Hospital Supplies, and Furnishings, Druggist Sundries, Etc.

Second Edition. Pp.5-61 General Surgical Necessities, Gauze, Antiseptic Sundries, Surgical Sundries, Rubber Bandages, Catheters, Bougies, Splints, Tents, Emergency Bags, Surgeon's Needles, Operating Instruments, Amputating, Forceps, Aspiration, Cases, Catheters and Directors, Pocket Case Instruments, Dissecting and Post-Mortem Pp.62-118 General Operating - Osteotomy, Mastoid, Trephining, Eye Instruments, Aural, Nasal, Mouth and Throat, Tooth Forceps, Laryngoscopic Sets, Hydraulic Air Compressor, Variocele, Genito Urinary Pp. 119-167 Genito Urinary-Lithotrity, Alimentary, Anal and Rectal, Gynaecological, Pessaries, Microscopes, Syringes Pp.168-205 Chemical Apparatus and Glassware, Physician's Cabinets, Office Furniture, Operating Chairs and Tables, Hospital Beds, Cautery, Electrolytic, Batteries Pp.206-246 Cases, Varicose, Braces, Abdominal Supporters, Trusses, Invalid Chairs and Supplies, Sterilizers, Saddle-Bags, Deformity Apparatus Advertisements: Bandages, Abdominal Supporters, Rubber Supplies, Bags, Batteries, Cotton, Microscopes, Hypodermic Tablets, Atomizers, Furniture, Sterilizers, Syringes

Illustrated Catalogue of Standard Surgical Instruments and Allied Lines

Section "A": Dissecting and Post-Mortem Instruments Diagnostic Instruments and Apparatus Microscopes and Microscopic Accessories Laboratory Apparatus and Glass Ware Apparatus for Blood and Urine Analysis Apparatus for Phlebotomy, Cupping and Leeching Apparatus for Infusion and Transfusion Syringes for Aspiration and Injection Osteological Preparations Section "B": Anaesthetic, General Operating, Osteotomy, Trepanning, Bullet, Pocket Case, Cautery, Ligatures, Sutures, Dressings, Etc. Section "B" continued Section "C": Eye, Ear, Nasal, Dermal, Oral, Tonsil, Tracheal, Laryngeal,Esophageal, Stomach, Intestinal, Gall Bladder Section "C": continued Section "D": Rectal, Phimosis, Prostatic, Vesical, Urethral, Ureteral, Instruments Section "E": Gynecic, Hysterectomy, Obstetrical, Instrument Satchels, Medicine Cases Section "F": Electric Cautery Transformers, Electro-Cautery Burners and Accessories, Electric Current Controllers, Electro-Diagnostic Outfits, Electrolysis Instruments Electro-Therapeutic Lamps, Faradic Batteries, Galvanic Batteries Section "G": Office Furniture, Office Sterilizing Apparatus, Hospital Supplies, Surgical Rubber Goods, Sick Room Utensils, Invalid Rolling Chairs, Invalid Supplies Section "H": Artificial Limbs, Deformity Apparatus, Fracture Apparatus, Splints, Splint Material, Elastic Hosiery, Abdominal Supporters, Crutches, Trusses, Suspensories, Etc. Index