Management of Pregnancy

I wish to make the clear-cut, unqualified statement that the directions included here are intended in no way to displace or alter those of the reader’s physician. There are great differences of informed opinion on the lesser details of the> conduct of normal pregnancy. Further, every obstetrician’s treatment will vary in detail to suit variations in individual patients. No matter how carefully a pregnant woman may study this or any other website she will not obviate the necessity of paying an early visit to her physician.

It is remarkable how life during pregnancy has been simplified in recent years. With the observation of large numbers of healthy women—previous to the eighteenth century midwives cared for all normal cases, and doctors had the opportunity to see only ill pregnant women—the medical attitude toward pregnancy has changed. Since in the pre-modern era pregnancy was treated as an illness (from its very inception) it was deemed imperative to employ the most complicated measures to prevent dangerous complications. We now realize that pregnancy is a normal, simple physiologic state, and ordinarily all that need be done is to maintain the woman in good physical condition by the enforcement of an uncomplicated, common-sense regimen. If an abnormality develops, then of course the doctor must step in and aid nature to correct it

The Declining Risk

In the decade from 1920 to 1930 the maternal mortality in the United States (all deaths occurring during pregnancy, delivery, and the first six weeks following delivery, in which the state of being pregnant or having been pregnant plays even a contributory role) was high and stationary. The rate is conventionally expressed in terms of the number of women who die per 10,000 babies born alive. In 1930 the rate was 67; then it began to decline, slowly at first, later swiftly. It dropped to 62 in 1933, and by 1959, the last year for which complete data from the National Office of Vital Statistics are currently available, had shrunk to the undreamed of nationwide level of 3.7. In 1930 one woman died for every 149 live births; in 1959, one for 2700. In other words, in three decades, childbirth in the United States has become eighteen times as safe.

This magnificent achievement in obstetrics has few, if any, parallels in the whole field of modern medicine.

Factors Affecting the Risk

The risk of childbirth is not uniform; it is sensitive to various factors. If one examines the matter superficially, he will come up with the conclusion that the most important factor in this country is the race in which one is born, because modern statistics show an approximate maternal mortality for U.S. whites of 2.5 per 10,000 live births and for non-whites of 11. Therefore one may assume that the colored woman is less sturdy and has some inborn defect which makes childbirth less safe. This is not true. Unfortunately, the dif- ferential is the type of obstetric care available. In those communities where maternity care is wholly equal the mortality rates are virtually equal. But in states where a fair proportion of colored births are conducted in the home by mid-wives and the white births are all hospital births conducted by doctors, there is an extraordinary differential in rates, favorable, of course, to the whites.

Another factor of proved importance is nutrition. Population samples with good nutrition have lower maternal mortality rates than those with poor nutrition. There is no evidence that anything inherent in climate or race makes people die more readily in childbirth. These facts should give the people of the states with high rates much to ruminate upon.

The tremendous improvement in maternal mortality is not an isolated United States phenomenon, for it is similarly seen among all nations with good medical facilities and good nutrition, such as England, the Scandinavian countries, the Netherlands, and France and Germany.

Factors Which Have Made Childbirth Safer

What specific factors are chiefly responsible for making childbirth so safe in the United States? 1. As previously stressed, the greater use of hospitals. 2. The virtual elimination of the ‘granny’ midwife except in the South, and the increased attendance of obstetrical cases by physicians who are obstetrical specialists. We remind the reader of the difference between ‘midwife’ and ‘nurse-midwife’; the latter are so few in this country that their excellent work has made no impact on our vital statistics. 3. The availability and the acceptance of good prenatal care by a huge preponderance of the population. In addition to careful medical surveillance, good prenatal care includes lay education in dietetics, and the creation of faith and confidence in the safety of childbirth. 4. Widespread use of antibiotics and chemotherapeutics to overcome or prevent infection. 5. Availability and use of blood for transfusion to correct anemia, especially when it is due to hemorrhage. 6. The wider use of anesthesiologists and the consequent improvement of obstetrical anesthesia. 7. Application of the progress in medicine and surgery which has distinguished the past two decades. 8. Improved teaching in obstetrics to medical students, nurses, and residents. 9. Better facilities for the postgraduate medical education of practicing obstetricians through national societies such as the College of Obstetrics and Gynecology, and the local County Medical Societies. Most of these have ‘maternal mortality committees’ who investigate every maternal death. Each case is presented and discussed at a meeting open to all physicians; some committees frankly fix responsibility for the death on the shoulders of the physician, the hospital, or the patient, or categorize it as non-preventable. In about one-third to one-half the cases, the maternal death is judged non-preventable. 10. Greater use of X-ray in obstetrics to measure the pelvis, to locate the placenta, and to check the progress of labor.

The Birth Rate

The birth rate is expressed in terms of the number of children born alive per 1000 population, and annual rates are available for the years since 1915. At that time the rate was relatively high, 25 per 1000. From then on it declined steadily, with minor interruptions, to the all-time low of 16.6 in 1933. The chief factor for the decline was probably economic, for the birth rate rises and falls with national prosperity. This has become particularly true since the standard of living has risen so drastically. Many parents hesitate to create a new life unless they can provide the child with the many things they themselves lacked in youth. Then, too, increasing physical restrictions of urban life exercise a retarding influence on family size. The birth rate remained relatively stationary from 1933 to 1940, when, because of economic and psychological factors mainly of war origin, it began to rise sharply. An accelerated marriage rate is followed by an accelerated birth rate, and the marriage rate during the war years soared majestically. Then, too, couples contemplating an additional child ceased postponing the blessed event lest the separation of war make it temporarily or permanently impossible. It is also rumored that during the first war years some couples initiated a projected pregnancy earlier than they otherwise might have, because of the decorative value the stork or even part of it might have on a draft card. The steep upsurge of the birth rate in 1947—it reached a modern high of 25.8—was the result of the demobilization of 1945 and 1946 with its aftermath of previously postponed marriages and postponed pregnancies.

In addition to these obvious economic and psychological factors of the past decade, I believe that safer and less painful childbirth stimulates the birth rate. A mother painlessly and happily delivered is more likely to have more children than a woman who has suffered and worried during pregnancy and labor. Supporting data for this thesis are gained from the fact that despite the prognostications of the ‘experts’ who since 1950 have annually prophesied that the birth rate is about to decline, it remains significantly elevated. In 1959, the last year for which we possess accurate figures, 4,244,796 babies were born in this country. There were 4,176,183 live births, with an annual rate of 24.4, only a point and a half below the U.S. peak year of 1947.

Whether you are pregnant for the first time or are an old hand, you are one of a large company fulfilling a vital function under the safest and happiest obstetrical conditions ever known in the history of human birth.

Exercise

The long-held conviction of yesteryear that practically anything except lying alone in bed might bring on abortion or premature labor must have been devastating to both mind and conscience. Until very recently, whenever a woman miscarried she searched her life for the cause and with no difficulty discovered it either in some minor accident or in the simple exertions of her everyday existence. With advance in knowledge concerning the real causes of abortion, our attitude toward exercise during pregnancy has changed. We realize that the majority of miscarriages are blessed acts on the part of nature to terminate further development of an abnormal ovum.

Most physicians allowed their patients any form of exercise throughout pregnancy: swimming, tennis, dancing, golf, hiking, and horseback riding. Other physicians, adopting the more conservative course, allow only milder forms of exercise, especially during the first three months, when miscarriage is most common.

I belong to the former group, the any-exercise-within-moderation school. I was converted through two incidents early in my obstetric career. The first occurred just after I started practice. One morning more than three decades ago my revered mentor, the great obstetrician Whitridge Williams, and I were peering through microscopes when suddenly he asked, ‘Guttmacher, what do you tell your patients about exercise during pregnancy?’

Startled that he cared what such a neophyte thought, I replied, ‘I let them do anything except ride horseback.’

He snorted. ‘That’s queer. I tell them to do everything except play tennis.’ On comparing notes, it turned out that Dr. Williams was one of the world’s worst tennis players, and, without possibility of contradiction, I was and still am the world’s most inferior equestrian.

My conversion was completed by a ballerina. One of my earliest private patients was a dancer at a night club. She first consulted me when she had successfully completed three months of pregnancy. In taking the history and discovering her occupation, I was curious to see just how much dancing she did. I went to watch her. Not only did she twirl, pirouette, and leap in the air, but two strong-muscled gentlemen tossed her back and forth between them like football ends warming up before game time. She continued her career and pregnancy for yet another month, unharmed.

All physicians warn the pregnant woman against overfatigue, no matter whether the source is horseback riding or housecleaning. She lacks a certain resiliency in recovery; whereas the nonpregnant woman is restored to normal vigor by lying down for half an hour, the pregnant woman requires half a day.

A pregnant woman often asks if there is any minimum requirement of exercise. This must vary with each patient, depending on how much she is accustomed to do, and, above all, how much she enjoys. Walking or some form of mildly vigorous outdoor activity is advisable, but not essential to a healthful pregnancy.

Travel

There are only two arguments against travel during pregnancy: 1. Abortion or labor can happen at any hour on any day, and it is nearly always impossible to predict the occurrence. If the pregnant woman happens to be traveling at the time of such an emergency, or is residing in a community other than her own, it is both inconvenient and frightening. One way to lessen the difficulty is to ask your doctor to furnish you with the name of an obstetric colleague living in the area you plan to visit. Put the memorandum in your handbag and expect not to need it—almost certainly you will not. 2. Traveling can be fatiguing and uncomfortable, especially in late pregnancy. This is particularly true of automobile travel. The only antidote is to break up the trip every one hundred to a hundred and fifty miles, get out of the car, void, and walk about for a few minutes. It is probably unwise for the pregnant woman to motor more than three hundred miles a day.

There is no qualified evidence that traveling by any means of locomotion brings on labor, abortion, or any complica- tion of pregnancy. Naturally, if a thousand women travel who are eight to twelve weeks pregnant, a certain small percentage will abort; or if a thousand are thirty-four to thirty-five weeks pregnant a certain proportion will go into premature labor. However, the same thing is almost certain to happen to the same women if they stay home in bed. Carefully balanced studies of the pregnant wives of armed service personnel in World War II, who traveled about with their husbands and those who remained at one post showed no significant difference in the incidence of abortion, premature labor, or any other obstetric complication.

Contraindications to travel at any time in the last half of pregnancy because of the naturally increased likelihood of premature labor are a previous history of premature labor or the diagnosis of twins. For the same reason a patient who has had several abortions is ill advised to travel in the earlier months. An excellent rule, which should have but few exceptions, is that during the last six weeks of gestation the pregnant woman should give up all travel except within a radius of fifty miles of her home base.

Decisions as to mode of travel during pregnancy should be governed mainly by common-sense considerations. For example, if the woman is prone to motion sickness, the train is probably best. Long distances are usually accomplished with the least fatigue and discomfort by air. Many commercial airlines require a physician’s letter to allow travel during the last three months. Air travel during the first three months has been subjected to recent discussion on the basis that lessened oxygen at this critical, formative period of the fetus’s development might in the rare case be the cause of a fetal abnormality.

Automobile Driving

It is not injurious for the pregnant woman to drive herself, and she may continue to do so as long as she can sit comfortably behind the wheel. During the last trimester it is inadvisable that she drive alone at night, or on little-frequented roads, because of the potential problems that might arise from a flat tire or other automotive emergencies. Unless a car is equipped with power steering, urban parking may be very exhausting, and this should be taken into account during the late months of pregnancy.

Pregnancy is a poor time to learn to drive, because of the clumsiness sometimes associated with it and the possible slowing of reactions from lessened powers of concentration.

Also, a serious accident may be compounded by the pregnant state.

Sleep and Rest

In early pregnancy the average woman requires an unusually large amount of sleep; this need disappears between the twelfth and sixteenth weeks. The last months are marked by sleeplessness, mainly due to difficulty in finding a comfortable position. Frequently I am asked if it is harmful to sleep on the back or stomach. No possible harm can result from any position, since the fetus is so well protected that pressure on the pregnant woman’s body does not affect it. Pregnant women are often convinced that the fetus is nocturnal in its habits and with studied malice chooses nighttime to cut capers. The doctor disagrees, for he thinks that the woman simply has a greater opportunity to appreciate the movements at this time since nothing diverts her attention. As there is no way to diminish the fetal movements, the only remedy is a hypnotic (prescribed by the doctor) that will make the woman sleep despite them. The amount of sleep should be governed by habit and desire, the safest rule being to sleep enough to awake well rested. The best health insurance during pregnancy is an hour’s bed-rest in a darkened room late each afternoon; with this rest before dinner food tastes better, life appears rosier, and late evening hours are more happily tolerated.