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Friday
May132011

1906 Placenta Previa Treatment

I have the most wonderful book, the 1906, "Obstetrics, Volume V of the Practical Medicine Series" by none other than Dr. Joseph B. De Lee (he spelled it separated). One of the moms that reads on the Navelgazing Midwife Facebook page has Placenta Previa and is scheduled for a cesarean in three days. It was her "case" that sent me looking at the old text, to see how they dealt with previa back in the olden days. Here, I'll write it out for you all.

"R. Warren summarizes a series of 94 cases of placenta previa with a mortality of 6 mothers, 6.3 percent; and of the 93 infants, 49 died, or 52 per cent. None of the primipara mentioned in the series died, although mortality in such cases is considerable. Twin labors occurred twice, three of the children and one mother dying. Prolapse of the cord occurred in 3 cases out of 54 in which de Ribes bag was not used and in 4 cases out of 40 where it was used. Postpartum hemorrhage occurred in 14 cases; in 4 the placenta was adherent, in 2 there was atony uteri. These last two mothers died. As regards treatment, in 27 cases watchful expectancy was followed in conjunction with various minor methods of treatment. Twenty-one cases were treated by internal version or extraction by the breech in podalic presentations. Of these, 5 mothers died; of the 22 children, 14 died. Forty cases were treated by the insertion of the de Ribes bag. None of the mothers died, but 25 children were lost. There was no case of complete previa in the series."

The book goes on discussing complete previas (Placenta Previa Centralis), Missed Labor with Placenta Previa Centralis, where the author gives the case study of a woman having labor then it completely stopped, re-starting two months later where she gave birth to an 11-pound stillbirth.

The standard of care was "tamponing," putting some sort of material (it doesn't say anywhere I can find) inside the vagina to put pressure on the presenting placenta until the mom is dilated completely, then the placenta and baby come out together once the mom is completely dilated.

"When the placenta is located over the os it is better to loosen it at one side until the edge is felt and then rupture the membranes than to bore through the placeta."

Eek!

Cesareans were extremely rare... unless they were vaginal cesareans. Yes, you read right. That will be the next post from this book. It's rather amazing. And looks horrid!

Reading about how many mothers and babies died at the doctor's hands... as they obviously practiced on women... just ghastly. I thank goodness for today's mortality rate; wish it was better, of course! But oh so glad it isn't like it was in 1906.

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Reader Comments (12)

The two medical advances that made C/S feasible [unless you were willing to sacrifice the mother] were general anesthesia, available from roughly 1850 onwards [although largely rejected for use in childbirth, as it was felt that unless the mother "suffered" in labor, as mandated in the Bible, she wouldn't love her child], and antibiotics, which weren't generally available until the end of WWII. The differences in maternal mortality figures before and after 1946 reflect this dramatically: the statistics changed to give mortality per 10,000 births, rather than per 1000, since it wasn't even 1 in 1000 with the advent of safe C/S.

My favorite [if you can call it that] obstetrical horror story caused two world wars. Queen Victoria's daughter Vicky, married at 17 to Frederick of Prussia, was in labor for three full days, and close to death, when the Prussian doctors "remembered" that her mother had sent her own physician and he was called in. Diagnosing a complete placenta previa and breech presentation, he rolled up his sleeves [no gloves in the 1870s], rammed his hand into the vagina and cervix, through the placenta, using it as a tamponade, grabbed the baby's buttocks and pulled with all his strength and extracted the future Kaiser Wilhelm out before Vickie could hemorrhage to death. The birth was so traumatic that the brachial nerve in his left arm was severed, leading to atrophy and paralysis and a massive inferiority complex which made him behave aggressively and become obsessed with Germany's "rightful" dominance over other European nations. And Vickie? 18 months later she gave birth again, without complication.

That's the way it was -- and why, in a lot of old family Bibles, we see that Grandfather or Great-Grandfather married two or three wives during his life, the first [or maybe several] not surviving childbirth. How easily we forget!

May 14, 2011 | Unregistered CommenterAntigonos

The mortality rate was high all around but I think this data is skewed in that most moms where still delivering at home in the the 1900s. So Dr. De Lee saw those that failed homebirth obviously those mothers were already at higher risk for death and neonatal death. I bet that book is a very interesting read. From my Grandmother's description her third birth was a previa. She says the afterbirth was coming before the baby. Baby survived and is nearing 60 now. She also talks about her first birth when they gve her an enema and set her on a bedpan in a rocking chair in labor. Can you even imagine?! Then no one would listen to her when she said the baby was coming because it was her first and she had hours to go... She nearly delivered in said bedpan!

I love talking to other generations, cultures about birth experiences.

Rachael

May 14, 2011 | Unregistered CommenterRachael

I don't think "skewed" is the right way to see this. If they saw the failed homebirths, they still dealt with them... AND the homebirth midwives did. The death rate, no matter *who* started or ended the care, was atrocious.

May 14, 2011 | Registered CommenterNavelgazing Midwife

From what I remember of the history of the Rotunda Maternity Hospital in Dublin, which was established in the 1700's, the MMR was approx. 1/100 and the neonatal MR (until the mother left the hospital) was about 1/10. Shocking figures, and most from puerperal fever. The alterations made to the building in an effort to prevent the "miasma" from spreading are laughable now, but v serious then.

The wealthy women, of course, would have had their babies at home.

May 14, 2011 | Unregistered CommenterQoB

those poor women died for so many reasons, rickets, corset induced pelvic deformity, superstition, lack of education. Its why women in the developing world still die in large numbers Home birth is not in and of itself a cure. Educated,(whether formally or through apprenticeship) midwives are the answer, and healthy moms. and thank goddess for c sections in the case of previa, and transverse lie(and other truly life threatening situations)

May 14, 2011 | Unregistered Commentertabitha

This makes me feel sick. There was a lot of stuff in Tina Cassidy's book that still haunts me - the thing where they would cut through the pubic bone (is that your vaginal cesarean?), craniotomy. *Shudder*

May 14, 2011 | Unregistered Commenterchingona

No, cutting through the pubic bone is called a symphysiotomy, The vaginal cesarean goes through the vagina, opening the cervix and the cutting into the lower segment of the uterus to get the baby out.

This book has a section on removal of the decapitated baby. I skipped that part.

May 14, 2011 | Registered CommenterNavelgazing Midwife

I am currently reading 'Obstetrics for the General Practitioner' , 1936 , by someone who studied with De Lee. By then, with strict asepsis, C section is considered survivable and is recommended for placenta previa. Most other difficult situations are handled either with forceps, or with breech extraction. The infant mortality rate cited in this book is 5/100.

While women were having babies at home, this wasn't home birth as we understand it. Women are lying on their backs, they are medicated and sedated, they are too exhausted to push out babies, they all have episiotomies, and after the baby is born they are sedated, and the baby should not be brought into the mother's room sooner than eight hours after the birth.

Clearly when we are trying to achieve the ideal of safety with the ideal of avoiding unnecessary intervention, we aren't looking back to some golden age in the past. It doesn't exist.

Susan Peterson

May 14, 2011 | Unregistered CommenterSusan Peterson

Fascinating, thanks for sharing.

@ Susan - "Clearly when we are trying to achieve the ideal of safety with the ideal of avoiding unnecessary intervention, we aren't looking back to some golden age in the past. It doesn't exist." - Bravo!!! Well said.

May 14, 2011 | Unregistered CommenterMegan

Yes, mortality used to be a lot higher than it is now. Most folks in our privied society are not as thankful as they should be for clean water, the knowledge of the need for aseptic technique, proper shelter, proper clothing, antibiotics, the invention of engine-powered farming equipment which allowed mass-produce of food and livestock, selectively breed crops and (there are natural versions..) pesticides, safer surgeries (of all types), generally how the knowledge we have gained has saved lives etc. among many other things..

If you are just paying homage to how much knowledge we have gained.. and how we've changed in reflection of that knowledge, and how you are glad we are at a better point than we were in yesteryear.. then alright, reflection on the past to be thankful for CHANGE is good.. but do not forget that we are just another timestamp... looking to the past (even very recent past... ) should also tell you that we have our own informational and knowledge gaps, and our own severe injustices. Knowledge will change more.. it will continue to change.. do not grow comfortable in your knowledge as a care provider, or even as a person, because tomorrow is a new day.. and a new lesson. The future and even ourselves will look back and judge us, and we should all want to be forward-thinking and not get stuck marveling at how wonderful we've become whilst we commit the terribly human but sadly typical act of being sublimely ignorant.

This is not to say I am not guilty of all of the above (said not being thankful enough, said ignorance and said focusing on what I think I know and not on what I should be striving to know) but I like to point out flaws in myself in others because it helps me to want to be better, if that, makes any sense at all.

May 14, 2011 | Unregistered CommenterElElRi

I could *never* presume we are in an enlightened, we-can't-evolve-more-than-this place seeing the changes in maternity care in just the last 30 years! In the next 100, our great-great granddaughters will cringe/laugh/scoff at how stupid/ignorant/blind we were when it came to <fill in the blank>. In my own little birth world, I've watched shaving and enemas go away, caudal and pudendal blocks all but vanish, episiotomies wane and now waxing again... all sorts of technology introduced, then yanked back when it was found useless, or worse, dangerous to a mom or baby. And I am barely IN the medical world! I am 100% aware we are merely on a spectrum and, at the moment, on an okay part (for most things). We *always* have a long way to go. Always.

May 15, 2011 | Registered CommenterNavelgazing Midwife

You didn't mention paracervical blocks. And I wonder why they went away. I know that there was some danger of a drop in blood pressure...just as there is with epidural. It seems to me that some novocaine in the cervix is much less scary than putting something similar in the epidural space. And it didn't decrease one's ability to move around. I am not saying that they were without drawbacks, but from my limited perspective, those drawbacks seem less than those of epidurals. I had a pudental block for my midforceps rotation delivery. I certainly was better off in the long run for having a paracervical block , a pudental block, and a forceps delivery, than the epidural and C section I would almost certainly have had with that baby now. (In the short run it was a rather painful recovery from the midforceps rotation.)
But anyway, why did those local blocks go into oblivion?
The caudal was a low spinal and made no sense to me at all as they were giving them to women for the actual birth only, at least if that is what was called a "saddle block" back then. I can see why that was abandoned.

Anyone know though why paracervical blocks disappeared?

I wonder if it isn't because the OB's did them rather than anesthesiologists, which meant the OB had to be around earlier on in labor...AND that they weren't throwing jucy business to the anesthesiologists. But perhaps I am too cynical.

And by the way, I was not at all congratulating us on how far we have come. I think the state of things now is not very good at all for women, or for babies. Except perhaps for those who would have died; for them what we have now is better. But, is there really no other way of achieving that than what we have now?

Susan Peterson

May 16, 2011 | Unregistered CommenterSusan Peterson

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