Obstetrical Operations

The Marked Increase in Operative Births A significant trend in modern childbirth is the increase in the incidence of operative deliveries, causing a sharp decrease in the number of babies arriving unassisted. In this section I shall attempt to unearth the factors responsible for this rise in operative births.

One reason is that the constantly greater use of hospitals, antiseptics, and anesthetics has created an aura of surgical confidence, making an obstetrical operation not nearly so momentous a matter as it was twenty years ago.

A second factor is a subtle shift of values in the importance of the infant’s life when compared to the life and health of its mother. Until recently, except to one religious group, the life and health of each mother were inestimably more important than those of her child; today the pendulum has veered a long way toward dead center. I have tried to discover the explanation for this shift in values. It is in part due to three things: the smaller number of children, the more careful planning of pregnancies, and the improvement in infant mortality rate. In the case of the smaller families of this generation, the product of each pregnancy gains in importance, whereas when a woman already had ten children her eleventh was not so exciting. Then, too, most of today’s pregnancies are planned pregnancies; they usually don’t just happen. When a couple carefully plans to have a child and the result is a fetal death, there is a sense of deep frustration which the loss of an unplanned baby perhaps may not elicit. And with the decrease in infant deaths there is the feeling that, if the child is only born alive, it is certain to be reared. This was not true in 1668, when Mauriceau wrote: ‘We see daily about half of the young children die, before they are two or three years old.’ With the change in attitude, operative interference is often resorted to in order to save the baby, even if it is prejudicial to the best interests of the mother.

A third source of the increase in operative obstetrics is modern woman’s insistence on short, relatively painless labors. I am not castigating her, for I dare say if I were metamorphosed into a laboring woman, I should probably join the chorus of, ‘Don’t let me stay in labor too long, and be sure it doesn’t hurt.’ As is obvious to the reader from earlier discussions, several of the current techniques of pain relief require a forceps delivery; for heavy analgesia, and caudal as well as spinal anesthesia deprive the patient of her usual urge to bear down and spontaneously expel the baby. This increase in forceps deliveries is an increase in only the simplest type, the low or outlet forceps, an operation which carries no additional risk to mother or baby.

Good obstetrics cannot condone operative procedures done solely to shorten labor, for under these circumstances delivery is carried out before the patient is ready, substituting a needless and dangerous procedure for one which would be simple and safe minutes or hours later. The obstetrician whose inexperience or excessive sympathy prompts him to make undue haste because of the importunings of an overanxious family or patient has frequent cause for regret.

It is impossible to fix the optimum obstetrical operative rate, for it depends on many variables. The type of clientele a particular doctor or hospital draws affects it; the greater the reputation of either, the larger the proportion of problem cases. As previously stated, analgesia and anesthesia are also important factors, as is parity (the number of previous deliveries). More important than the gross operative rate are the types of operations and particularly the obstetrical end result. Are the mothers left healthy and well, with future childbearing unprejudiced? Are the babies vigorous and uninjured?