The History of Obstetrics and the Development of Maternal Care in New Zealand

Kai Tiaki : the journal of the nurses of New Zealand, Volume XVII, Issue 1, 1 January 1928, Page 13

The History of Obstetrics and the Development of Maternal Care in New Zealand

Lecture Delivered by R. Tracy-Inglis, C.8.E., V.D., M.8., Ch.B., Medical Officer to St. Helens, Auckland, at the Refresher Course for Nurses, held m Auckland, m September, 1927.

The subject upon which I have been asked to address you is " The Development of Maternal Care m New Zealand." Before dealing with this, I thought it might be interesting to tell you something about the history of obstetrics, which is, of course, the science which not only deals with labour, but which also includes ante-natal and post-natal care. Guillimean, m a treatise translated into English m 1612, under the title of "Child Birth, or the Happy Delivery of Women," records the fact that "the first practise m Chirwyery (Chirurgery) that ever was done m the world was Omphalatomia or cutting of the navel, which Adam and Eve practised on their first child." Thus the practice of obstetrics, if not the most aristocratic, has undoubtedly the oldest lineage of all the branches of medicine, for it is as old as the human race. The science of obstetrics, however, developed so slowly and remained for so long m the hands of uneducated women, that it continued longer m the embryonic stage than did medicine and surgery; it grew up alongside but somewhat outside of them. In the earliest days of the human race, the women m labour would be attended by female relatives or friends, and perhaps also by the prospective father. In the Old Testament, reference to midwives only is to be found. In many of the savage races the husband renders aid — sometimes m difficult cases only, m which unusual strength is required to effect delivery, and sometimes by assisting sympathetically m the labours of his spouse. Magic thus came m, and, perhaps as the result of special skill m magic rather than m obstetrics, there would arise a class of specially skilled men of the wizard or medicine man order, who may be said to be the primitive representatives of the accouchens of later days. Male assistance, either by the husband

certain of the lower races, as m some of the Pacific Islands, where it is customary for the woman to be delivered sitting on the knee of her husband, who presses his wife round the abdomen and exercises abdominal pressure to assist her m her efforts. A good instance of specialised male assistance at labour is that mentioned by Frazer m "The Golden Bough," as the procedure among the Dyaks of Borneo m cases of difficult labour. Among them the medicine men hunt m couples. "When a woman is m hard labour, a wizard is called m, who essays to facilitate the delivery m a rational manner by manipulating the body of the sufferer. Meanwhile, another wizard outside the room exerts himself to attain the same end by means which we should regard as wholly irrational. He, m fact, pretends to be the expectant mother ; a large stone attached to his stomach by a cloth wrapped round his body represents the child m the womb, and following the directions shouted to him by his colleague on the real scene of operations, he moves the make-believe baby about on his body m exact imitation of the movements of the real baby till the infant is born." One can well imagine m this state of civilisation the chief qualification for a successful practitioner would be the ability to give a truly realistic performance to the great comfort of the suffering patient. In the light of anthropological evidence it is easy to understand how such obstetrical aid would gradually drift into the hands of workers of magic and incantation, and so become, by being mixed up with religious rites, one of the functions of the priesthood. Amongst the ancient Egyptians, Isis was the Goddess of Nature and Motherhood, and her priests had important influence m all matters relating to childbirth. The Egyptian doctors were of the

or by magic men, persists to this day inpriestly order, like the embalmers, who

are termed "physicians," m the Book of Genesis, when called m by Joseph to embalm his father. Attendance on women m labour was m the hands of midwives, and though these priestly practitioners undertook the giving of assistance m difficult labours, it is fairly obvious that priestly magic would not add much to human knowledge. The office of midwife is a very ancient one. It is mentioned several times m the Book of Genesis, e.g., at the birth of the twins Pharey and Zarah, when the midwife bound a scarlet thread on the hand that first appeared, but was withdrawn, and its owner born after the other twin. This is perhaps the earliest mention we have of spontaneous version m what was evidently a transverse presentation. Again, m the first chapter of Exodus, when the King of Egypt spoke to the Hebrew midwives and ordered them as follows : — "When ye do the office of a midwife to the Hebrew women and see them upon the stools, if it be a son, then ye shall kill him! if it be a daughter then shall she live/ The midwives being called to task for disobeying this order give this excuse: — "Because the Hebrew women are not as the Egyptian women: for they are lively and are delivered ere the midwives come unto them." (8.8.A. m present day terms.) As the midwives did not belong to the scholarly class, this knowledge was handed down by word of mouth and tradition, so that until we come to the time of Hippocrates, nothing survives to show how far the science had developed. Hippocrates, the father of medicine, represent a period 460-370 8.C., which forms the transition from the priest physician. On the subject of obstetrics, Hippocrates wrote a great deal, and although many of his theories seem absurd at the present day, yet, on the whole, the treatment he recommends is efficacious. He gives a good description of the perineum, vagina and os uteri, but does not appear to have known about ovaries and fallopian tubes. Protracted labour he considers to be caused by the child lying transversely or presenting by the feet, or by the foetus being dead or double. The difficulty with a dead child is explained by the old idea that the child came into

the world by its own exertions. In difficult labours, sneezing and shaking were the chief means advised to aid expulsion. Thus he ordered drugs to be given to produce sneezing and that the patient should stop her mouth and nose so that they might act more forcibly. Succussion was to be practised either by shaking the patient on the bed as by lifting it up and suddenly letting it drop, or by fastening her to a ladder, which was then elevated and shaken. Anointing and steaming of the external parts were also advocated. It is interesting to note that heat is used by Australian aborigines m difficult labours and applied by holding the gin over a fire. Hippocrates also advised cephalic version m transverse cases, and where other methods failed he described the operation of dismembering the child. In retention of placenta and membranes, he again advises drugs to produce sneezing, and that the child be left hanging by the cord while the woman is seated on a high stool, so that the foetus by its weight, may drag them out, or if the cord is broken or cut. that weights be hung, on the cord for the same purposes. Reference is made to the danger of retention of the afterbirth, and how, if it does not come away immediately, the patient suffers from abdominal pain, with fever and rigors, which disappear when it is discharged, as usually happens about the fifth to the seventh day, being then putrid. If the uterus is inflamed after delivery, unless the bowels are made to act or the symptoms relieved by bleeding, the patient is m grave danger of her life. Uterine haemorrhage is also mentioned and treatment by raising the foot of the bed is advocated. Till we reach the second century A.D., little was added to the Hippocratic teaching. The high-water of ancient obstetrics was reached at the time of the great Alexandrian school during the reign of the Roman Emperors, Trajan and Hadrian. At this time, Soranus of Ephesus was a most eminent obstetrician. The Muscio Manuscript begins with the qualifications of a good midwife. She need not know very much anatomy, but should have been trained m dietetics, materia

medica, and minor surgical manipulations, such as version. She should be free from all corrupt and criminal practices, temperate and not superstitious or avaricious. He states that her help is needed chiefly m normal cases, but also m abnormal, and for these the services of the most skilled ones are required. Soranus shows that he had very advanced opinions m that he did not hold, as is still done by some, that the midwife need have been a mother herself. In dealing with inversion of the uterus, Soranus points out that it may be caused by traction on the cord. The assistance given by the midwife during labour was digital dilation of the os m cases of feeble pains with slow dilation, abdominal massage of the uterus during the pains, and support of the perineum by means of a linen cloth. If there was delay m the delivery of the placenta, gentle pulling on the cord and rocking it from side to side should be tried, and if this fails, the hand should be inserted to loosen and remove it. If this does not succeed, or if the orifice of the uterus is closed, then medical measures must be used to relax the parts, and spontaneous expulsion by natural methods awaited. He pointed out that the normal position was a head presentation, and after that the footling and breech and transverse. He stated that the most unfortunate position was the breech with extended legs or some form of transverse. Soranus insisted on the importance of investigating the causes of all difficult labours as the first rule of treatment and classifies them as they occur m the case of the mother, the genital organs and the foetus, which is not far removed from our present method of "Faults on the part of the powers, passages and passenger." He mentioned the difficulty m the delivery of women with small hips (narrow pelvis), obesity, tumours, faecal accumulations, stone m the bladder and haemorrhage. On the child's side, the chief causes of difficult labour are set down as too large a head, too large a body, dropsy, tumours, great feebleness, or death of the foetus, and unnatural lies. The great object of all treatment is to save both mother and child, but if this is impossible, then first of all the mother must be considered.

When the position is a bad one, the anointed hand is passed up and an endeavour made to correct a bad position by manipulation. In the case of a transverse the midwife is advised to turn either by the head or by the feet. If the child is big, dead or wedged and cannot be moved, fever, inflammation with gangrene, fainting, chills and heavy sweats, small pulse, delirium and convulsions will supervene, and though such signs indicate great danger and little hope, one must not fail to try and help. In his discussion on embryotomy, he shows the great advance of the Alexandrian school on the Hippocratic. He expresses strong disapproval of all means to procure sneezing, of all methods of shaking and of steaming of the vulva. For the operation, he placed the patient across the bed with an assistant at each knee,, the operator sitting m front, but somewhat lower. Between the fourth and seventh centuries there was not much advance except that a writer named Aetius, of Amida, advised podalic version not only with transverse lies, but also m difficult head presentation, when it ought to be attempted before having recourse to embryotomy. It is most remarkable that for nearly a thousand years, this most valuable procedure appears to have been forgotten, and was not practised till the sixteenth century, when it was introduced again by Ambrose Pare. During the Dark and Middle Ages, all branches of medicine languished, and it was not until the time of William Harvey (1578----1657) that much progress was made. Harvey is known as the father of British Medicine. He discovered the circulation of the blood, and also wrote articles on obstetrics. He did not disdain to practise midwifery, which m those days was bracketed with surgery, as an inferior branch of medicine. His ideal of a midwife is worth recording. He says: — "The midwife's duty m a natural birth is no more but to attend and wait on nature, and to receive the child, and (if need require), to help fetch the after-birth, and her best care will be to see that the woman and child be fittingly and decently ordered with necessary conveniences. And let midwives know that they be nature's servants. Let them always

remember that gentle proceedings (with moderate warm keeping, and having their endeavours dulcified with sweet words) will best ease and soonest deliver their labouring women." An important landmark as far as obstetrics is concerned is the publication m Worms, m 1513, of the first printed book on midwifery, by one, Eucharius Rosslin, entitled as a humorous play on the author's name, "The Garden of Roses for Pregnant Women and Midwives." This book was largely based on the teachings of Soranus and continued to be published up to 1742. This book was written for midwives, for the era of the man midwife had not yet come. The Hippocratic sneezing discarded by Soranus again found a place, and a wonderful plaster is recommended to provoke birth. It is made of various ingredients of which "wilde Goward, the juice of rue and mirrhe" are the chief, and the midwife is to "lay it to the woman's belly between the navel and the nether part : this plaster shall help marvellously." No proper account is given of manual removal of the placenta, but the dangers of its prolonged retention are recorded. These extracts will suffice to give some idea of the stage reached by obstetrics of the sixteenth and seventeenth centuries. Other books of an even lower stage of development continued to be published m England m these and succeeding centuries. Obstetrics descended into the depth of ignorance and superstition, as is shown by a reference to two books of that time — Nicholas Culpeper's "Directory for Midwives" and William Salmon's "Aristotle's Midwifery." Just as travellers' tales and stories of unknown lands were garnished with accounts of mermaids, dragons and sea serpents, so were the works on midwifery taken up with tall stories of monsters, of which the following from an old book for midwives of this period may be quoted as a sample. In the chapter on "Monsters and Monsterous Births and the reason thereof," the following occurs : — "Lavinius Leminus, a famous physician, tells of a monsterous birth from his own knowledge. In former years (says he), there was a woman, an Islander,

who had married a Mariner that took physik of me ; and having conceived by him, her belly began to swell to such a vast magnitude that one would have thought it could not have held to support the burthen. When nine months were expired, the midwife was called; and first with great trouble she was delivered of a rude lump, which I conceived was a super fcetation. After this, a monster came forth of her womb, with a crooked back, long round neck and fiery eyes, and a pointed tail, being very nimble footed : for as soon as it came forth it gave the affrighted midwife the slip, and ran up and down the room to seek a hiding place, till at last one woman, more courageous than the rest, fell upon it with a cushion and smothered it. This monster had sucked the blood from the child (which came forth after it), being a male, and so eaten the flesh that it scarcely lived to be christened : nor could the woman be m a long time restored to her strength." This sample of what Avas served up to readers of such books and swallowed by them, will show that little or no progress had been made since the time of Soranus. The rise of modern obstetrics may be said to date from the re-discovery of podalic version by Pare m 1550. About 1668, Dr. Peter Chamberlain invented the midwifery forceps, but kept it secret, and the first full account was not published until 1713, by Chapman. Meantime, the advance of obstetrics had tended to take the sole charge of the woman m labour from the hands of her own sex. No real improvement could occur until medical men had the opportunity of studying natural or physiological labour instead of being called m merely when some extensive or mutilating operation was required. Hence the rise of the man midwife or accoucheur marks a very important stage m the history of obstetrics. The discovery of the forceps and the necessity of its being used by those with surgical training helped more than anything else to rescue midwifery from the hands of the ignorant female practitioners of that time. In England this did not take place without a struggle, the great champion of the midwives being Mrs. Elizabeth Nihell, who published a book m 1760 pointing out the dangers of

forceps and the folly of engaging a man midwife or doctor. So far as British obstetrics is concerned, modern midwifery may be said to begin with Smellie, a Scotsman, who practised m Lanark m 1720. In 1738 he went to London and practised as an apothecary or accoucheur. He was a great teacher m the Art of Midwifery and had many students. He contrived the first phantom as an aid to teaching. Smellie cleared away most of the rubbish and superstition which still enveloped the theory and practice of midwifery. He described the pelvis and its measurements and compared them with those of the foetal head. He described the methods of diagnosing vertex positions by feeling the sutures and fontanelles. His greatest work was to improve the forceps and lay down exact rules for their use. In the nineteenth century, progress m midwifery was largely determined by what is perhaps the greatest discovery of Preventive Medicine — the prevention of sepsis — and by the discovery of anaesthetics. In regard to the former, it is interesting to note that the Listerian methods were anticipated by obstetricians m their efforts to eradicate the scourge of puerperal fever by the use of free chlorine (chlorinated lime) as a disinfectant for the hands and for douching. In this respect it is also interesting to note the great use of eusol and Milton fluid m the present day, the production of free chlorine being the active agent m these solutions. In 1843, Oliver Wendell Holmes read a paper on the contagiousness of puerperal fever. Nearly a generation later (1867-77) by Lister out of Pasteur's work, was brought forth m the fullness of time, the system which has grown up into the aseptic principles that form the basis of modern obstetrical practice. Anaesthesia then became necessary as with a conscious patient the minute care and attention to detail could hardly be carried out. Simpson, m 1847, published bis first paper on chloroform, and this made possible major obstetrical operations. Apart from the introduction of chloroform, Simpson was one of the outstand-

ing- figures of the nineteenth century m obstetrics, and has left his name on the long forceps and the uterine sound. The rise of midwifery to a position m the realm of medicine, adequate to its importance m the public health service, was long delayed owing to the late period at which it was rescued from the hands of the midwife. The foundation of the lying-in hospitals m London m the eighteenth century, however, indicates some realisation of the importance of the subject and of making provision for the maternity service. Midwifery is a branch of preventive medicine because pregnancy, labour and the puerperium are physiological and not pathological states, and the woman at these times is not a sick woman. The whole end and object of midwifery is to maintain the physiological character of these states so as to prevent illness and injury to the woman and secure the birth of a healthy and uninjured child. The care of mother and infant afterwards as carried out m the infant welfare service is its direct sequence m the prevention of disease and disability m the next generation. Early m this century, obstetrics became the subject of direct legislation. In England there have been four noteworthy Acts dealing with the subject:— (1) The Midwives Act, passed m 1902, and amended m 1918, was designed to secure the better training of midwives and to regulate their practice. (2) The Notification of Births Act (1907) and Extension Act, 1915, places m the hands of the Medical Officers of Health the means for ascertaining the circumstances of each birth, including each dead birth. It imposes on doctors and midwives the duty of notifying the Medical Officer of Health not only livebirths, but also dead births occurring after the 28th week of pregnancy. (3) The Maternity Benefits of the National Insurance Act, and (4) The Maternity and Child Welfare Act of 1918. With regard specially to New Zealand, the first Midwives Act was passed m 1904 and provided for the training and registration of midwives. Women who had been m bona-fide practice as midwives

were registered. Previous to this most of the midwives were instructed and partially trained by the medical men who employed them. Others had picked up their knowledge of midwifery from their mothers or as helpers to other midwives. From this you will realise that the standard of nursing was not a high one. This Act also provided for the establishment of State Maternity Hospitals for the treatment of the wives of working men during childbirth, and also to facilitate the training of midwives. It resembled the English Act of 1902 to some extent, but differed m that it was administered wholly by the State Health Department, whereas the English Act provided for a representative and elective Board for its administration. Under the English Act, the bona-fide midwives., that is, those who were registered without training, were taken off the Register for ten years after the Act became law, as it was considered that by then, sufficient midwives would have become trained. Under the New Zealand Act these nurses remain on the Register. The English Act demanded a short term of training, only four months at first, but this has been gradually extended, and it now provides for six months' training for registered nurses and twelve months for untrained women. The New Zealand Act required this latter amount of training from the first. This was the standard training set up by the Australian Trained Nurses' Association, and was copied by our Act. The Midwives' Act m the various Australian States followed much later. The next advance, and a very great one, was the opening of the various St. Helens Hospitals. The late Mr. Seddon, who was very keen about the Midwives' Act, was equally keen about the establishment of State Maternity Hospitals. On account of this, the Hospitals were named after his birthplace — St. Helens. There are now seven State Maternity Hospitals open for the use of the Public. The first St. Helens Hospital was opened m Wellington m June, 1905, and a new and up-to-date building m July, 1912. That at Dunedin was opened m October, 1906; St. Helens, Auckland, was opened m June, 1906, and a new building m Feb-

ruary, 1923. This latter building is the largest St. Helens Hospital m the Dominion, and can accommodate over 700 patients annually. Christchurch St. Helens was opened m April, 1907, and there are also smaller State Institutions at Gisborne, Wanganui and Invercargill. During the year 1926, a total of 2,155 confinements took place m the seven Hospitals mentioned, and 635 confinements were attended by the Institution nurses outside, as compared with 1,974 and 627 confinements respectively during the previous twelve months. There is also a Maternity Hospital attached to the Medical School at Dunedin, which serves as a training school for the Medical Students and Midwives. In addition, theer are 43 maternity homes or wards under the control of Hospital Boards. For single girls there are several Charitable Institutions at Auckland, Wellington, Christchurch and Invercargill, m addition to those established by the Salvation Army at the four chief centres, and at Napier, Gisborne and Russell. In 1925, the Nurses and Midwives Acts were combined and provision was made for the registration of women m practice as maternity nurses, this qualification being necessary before training as a midwife could be commenced. This Act is still m the experimental stage and has yet to be proved a success. During the years following the original Midwives' Act of 1904, efforts were made by the Health Department to inspect and control the work of practising Midwives, and to some extent, that of women doing maternity nursing. It was difficult to do much with the latter, as they were not registered, and the Act of 1925 remedies this. Now, the Department of Health, with an increased staff, exercises a much closer supervision over the work of midwives and maternity nurses. With the co-operation of the Department and the nurses there is no doubt that a definite progress m lowering both morbidity and mortality rates will be obtained. With regard to private hospitals, the Private Hospitals Act, which came into force on Ist January, 1907, provided for the licensing and inspection of private hospitals, including maternity homes. By

this means, overcrowding and unsuitable premises were prevented to a large extent. Of later years, these regulations have been progressively tightened up and maternity hospitals now have to comply with a good standard as regards premises, equipment and staff. The original Act of 1907 is now embodied m the Hospitals and Charitable Institutions Act of 1926. The total number of private hospitals licensed m the Dominion is 313, of which 213 are either exclusively maternity hospitals or take both maternity and general cases. The last great advance m maternal care is the establishment of regular antenatal supervision. The earliest instance of ante-natal care, although m this case it is referable to animals, is that mentioned m the 30th chapter of Genesis, and is also a good example of that very ancient superstition, namely, maternal impressions. The story runs as follows : Laban promised to give Jacob all the speckled and spotted goats and cattle : And Jacob took him rods of green poplar and of the hazel and chestnut tree: and pilled white streaks m them and made the white appear which was m the rods. And he set the rods which he had pilled before the flocks, m the gutters m the watering troughs when the flocks came to drink, that they should conceive when they came to drink. And the flocks conceived before the rods and brought forth cattle ring staked, speckled and spotted. Regular ante-natal care and attention is quite a modern advance and was first advocated m 1900 by Dr. J. W. Ballantyne, m response to whose appeal there was endowed m the Edinburgh Royal Maternity and Simpson Memorial Hospital,, the Hamilton bed, the first of its kind to be set apart m any hospital for the treatment of the various morbid conditions of pregnancy. As regards New Zealand, I think antenatal supervision was commenced m the St. Helens Hospitals about 1909. It may have been earlier, as I am only trusting to memory. As regards the Auckland St. Helens, this consisted of advice given to each patient regarding the hygiene and danger symptoms of pregnancy and the examination by the St. Helens Medical

Officer of all abnormal cases. Even this supervision immediately reduced the incidence of Eclampsia to almost nil. During the last two years free ante-natal clinics have been established m the four centres of New Zealand m connection with the St. Helens Hospitals, other maternity hospitals and societies such as the Plunket Society and St. John Ambulance. Ante-natal supervision will eventually be regarded as the key to success m obstetrics. Meanwhile, it is essential to convince the medical profession, and through the latter, the individual mothers, of its indispensable necessity. Nurses and Midwives can also do a great deal m educating the public m this respect, and the Department of Health co-operating with the doctors and nurses should achieve ultimate success. Until such supervision is regarded by both doctor and patient as a first principle of midwifery, we shall not be able to bring about the reduction of maternal mortality and morbidity m those directions m which the latter are most preventable. It is so much easier to prevent by antenatal measures, many difficulties which are liable to be met with during labour, than to escape from them when labour is advanced, that it is difficult to understand why this obvious fact has not been acted on long before. At present, antenatal measures, many difficulties which are liable to be met with during labour, than to escape from them Avhen labour is advanced, that it is difficult to understand wh ythis obvious fact has not been acted on long before. At present, antenatal clinics are being established all over the world, and the next few years should show a great improvement m the results. The aims and objects of an ante-natal clinic are : — (1) To maintain the health of the expectant mother. (2) To instruct the mother m her bodily hygiene and habits during pregnancy. (3) To preserve pregnancy ' till full time. (4) To secure a normal labour resulting m a healthy breast-fed baby and an undamaged mother.

Now, as to our results m New Zealand. In the year 1920 the maternity death-rate reached the high figure of 6.48 for every thousand live-births. In spite of our high standard of midwifery training, our healthy climate and good living conditions, our maternal mortality rate did not compare favourably with that of some other countries. Every effort has been made to discover the cause and remedy it by the Department of Health m cooperation with the British Medical Association. A high standard of asepsis m Midwifery technique is required under the Regulations, and is carried out with great thoroughness at the various St. Helens Hospitals and other training centres. The result of these measures, coupled with an ever-increasing ante-natal supervision, is shown m the maternal mortality figures for the following years : — 1920 . . . . 6.45 per thousand 1921 . . . . 5.08 „ 1922 .. .. 5.14 „ 1923 .. .. 5.H ;; 1924 .. .; 5.0 „ 1925 .. .. 4.65 „ 1926 . . . . 4.25 „ This steady decline seems to me a very good omen, and shows that we are on the right track. I would, however, make a plea to the Department of Health, that

m educating the public they should also make it clear that puerperal sepsis is not always due to errors or carelessness m technique. Coincident Avith every epidemic of streptococcic throats and influenza, I have noticed a corresponding rise m maternal morbidity. Apart from that, the patients often suffer from septic teeth and other septic foci. We are taught to keep our nurses free from septic foci, but it is just as important m my mind to clear up septic foci m maternity patients. Sometimes we are not able to get our patients to do what we want, and yet when things go wrong it is the doctor and nurse who are blamed. The public know that the Department enquires into these things and I have found lately that, as they get educated, so they are becoming more and more inclined to blame the doctor or nurse. A maternal death is always a tragedy, but surely a matron of a private home or the doctor would not be likely to be careless when m these days their living depends on success. For help m compiling this paper I have to thank Miss Bagley, of the local Branch of the Health Department, for notes and statistics on the Departmental work which she very kindly supplied me. For much of the historical part, I am indebted to Fairburn's Gynaecology with Obstetrics.