This feature is part of a year-long series of excerpts and special commentaries celebrating AFP's 50th year of publication. Excerpts from the two 1950 volumes of GP, AFP's predecessor, appear along with highlights of 50 years of family medicine.
This feature contains excerpts from the article “Office Obstetrics in Rural Practice,” by David G. Miller, Jr., M.D., and Blanche H. Miller, R.N., published in the December 1950 issue of GP, and commentary by Barbara S. Apgar, M.D., M.S., associate editor of AFP.
During the 12 years I have spent in the general practice of medicine in a rural area, the last five in close contact with medical students and young physicians as a lecturer in general practice at a medical school, and as a preceptor for beginning physicians, it has become increasingly apparent to me that hospital obstetrics is one of the best taught branches of modern medicine. This applies not only to the classroom and didactic lectures but to the practical experience obtained by the student and intern. But putting this obstetric knowledge into practice in a rural area is a different matter. Good obstetrics can be done in the rural homes at an enormous cost of time and energy on the part of the physician and his assistant, quite often his wife.
During the war years when I was the only active physician in our county, and more and more demands were made upon my time, most of my obstetrics was done in two small general hospitals, one 26 miles and the other 32 miles from our office. From the physician's viewpoint, this type of obstetrics is ideal, in that there are no worries about sterile supplies and drugs; the hospital's nurses follow the progress of labor, attempting to call the physician only when delivery is imminent. The time consumed in driving to the hospitals over paved roads is often less than that required to reach the homes of patients, especially before jeeps were available and the home visit often included walking, horseback, or wagon rides. The only defect in hospital obstetrics from my standpoint was that the usual fees for labor and delivery rooms plus a few days in the hospital and an ambulance trip home left little or nothing with which the accoucheur might be paid.
The patients and their families objected to the hospital deliveries because the nonmedical fees usually approached $60 (labor and delivery room and three days in a ward bed $45, and ambulance $5 to $15, averaging 40 cents a mile). They hated also to have the mother out of the home during the puerperium.
Disadvantages of Home Deliveries
My wife and I were very reluctant to begin home deliveries because we well remembered the long trips over poor or nonexistent roads, often time after time when the labor was long; the long hours spent in a lamp-lit home, with a flickering log fire that barely warmed our shins and left our backs freezing. Often it seemed better to wait than to make the trip home and back again, discounting the chance of a precipitate delivery. We also wished to avoid the domestic chores that frequently fell to our lot, when the father had neglected to obtain a suitable practical nurse or even a hired girl, or had been unable to get any help. Often we had been forced to change the mother's gown and bed and to improvise diapers, bands, and clothing for the baby who had already been greased (with lard until we learned to carry baby oil in the “Ob” bag). We had even cooked and served meals to the mother, as well as the older children. Often we had been forced to remain at the home for hours until the father returned with the “girl” he had engaged for the puerperium. We wished to avoid the constant and real threat of bedbugs, fleas, and other insect pests which we had brought home in our bags, topclothing, and soiled linens. A bedbug at 2 a.m. is a minor calamity even in these days of DDT.
A short period of hospital obstetrics had taught us that there were times when additional supplies, too bulky or too infrequently used to be carried in the bags, were urgently needed in home deliveries. More than supplies, we missed consultations and additional personnel when emergencies arose, and the accoucheur and the one assistant were busy with the mother, leaving no one but untrained relatives or neighbors to see to the resuscitation of the baby. We vividly remember a few times when competent consultation might have saved the mother or the baby. Today we would not care to isolate ourselves for lack of telephones in the country home. We do not want to carry out obstetric procedures under surroundings comparable to those of kitchen surgery.
Setting Up an Office Delivery Room
We decided to provide complete delivery-room facilities, and to give adequate care with analgesia in our office during the labor. One room in a semi-isolated portion of the office had already been set aside for patients who required more attention or a longer stay than usual. This room had a table, larger than the ordinary examining table and equipped with a comfortable sponge-rubber mattress covered with a waterproof slip. We were already using this room for basal metabolism determinations, electrocardiograms, intravenous administrations of glucose, saline, plasma, and occasionally transfusions. This room was adjacent to my private office, readily accessible from the rear office or front office entrances, but far enough from the more frequently used examination and treatment rooms that a parturient there would give a minimum disturbance to the other patients, and in turn, be quiet enough for the woman to doze between pains.
Since we were 26 miles from the nearest hospital, it was necessary for us to provide space and equipment for emergency traumatic surgery. This room had been set aside for clean surgery and we decided to equip it for obstetrics. In addition to prohibiting work on all dirty or even potentially infectious patients in this room we banned routine dressing of even clean cases and the examination of patients for other ills, as when the other rooms were full. We instituted additional care in scrubbing the tables, walls, and floors and we used ultraviolet light for air sterilization, soon after each delivery.
For years we had used a pressure-cooker-type autoclave to sterilize obstetric packs, towels, gloves, flats, solutions, and all supplies that we did not wish to boil. We replaced this with a war surplus, gasoline burner, field-type, autoclave for approximately $45. For less than $50 more it was converted to burn bottle gas, and connected to the water supply and drain. This is easier to operate than the pressure-cooker type and has a capacity equal to the autoclave used by many small hospitals.
The Need for Avoiding Haste
We repeat an oft-voiced thesis when we again state that most obstetric errors are caused by haste on the part of the attending physician. Usually this haste is the result of anxiety to return home to bed or a desire to rush back to an office full of patients whom the physicians knows (or fears) are waiting for him. We find that having the woman in labor come to the office allows regular office hours to be held with little or no disturbance of the usual work.
When the labor takes place at night and the first examination reveals that several hours will elapse before delivery, perineal toilet and enema are delayed for a while, and if the bladder is emptying properly, 100 mg. of Demerol is given intramuscularly and the patient is urged to try to sleep. The member of the family who has accompanied her is shown how to use the dial phone to call us. She is shown where the water and soft drinks are to be found, and instructed to call us if the discomfort becomes severe or there seems to be a marked change in the character of labor. This means that one can sleep from 4 to 6 hours at home, and later in naps of 1 to 2 hours in the office as labor progresses. Waiting for labor to progress is much less tedious when one is at home than when one is in an alien environment.
Preparations for Delivery
When each patient arrives at the office, regardless of the last prenatal visit, she is immediately examined. First the blood pressure is obtained and a voided urine checked for albumin. If this is positive, a catheterized specimen is immediately obtained; if not, a later specimen of catheterized urine is examined. The abdomen is carefully examined by inspection and palpation to determine the degree of emptiness of the bladder, the position of the fetus, and the degree of descent and engagement of the head. The fetal heart is listened to, and the condition of the fetus determined by the rate and regularity of the beat. The size, and especially the weight of the fetus, are estimated to determine prematurity. The location of the placenta is noted and one looks particularly for evidence of placenta previa. A rectal examination is then made and the presentation and position rechecked. The degree of effacement and dilatation are then determined, and if we can be certain, the patient is followed with a minimum of rectal examinations. If the results of a rectal examination do not seem clear-cut, we do sterile vaginal examinations, first preparing the patient. If there is the slightest question of disproportion, or a fetal position that is not easily diagnosed we immediately resort to x-ray films, ranging from scout films to radiographic pelvimetry. Throughout labor we try to follow the patient with rectal examinations, but we do not hesitate to employ a sterile vaginal examination when the rectals are uncertain, or if the patient has so many hemorrhoids that rectals are unduly painful.
While we do not fully subscribe to the principles of “natural childbirth” we do feel that the parturient is helped both mentally and in the progress of labor if she is kept informed about her true condition and constantly reassured. Frequent explanations help her to relax, and we find that most often the patient who needs the most “vocal analgesia” is the woman who has had a difficult delivery before without adequate analgesia and obstetric assistance, rather than the primipara who trusts and relies upon us to call for additional assistance or consultation if it is indicated.
We do not rupture the membranes routinely when we feel that the cervix is “ripe” and this procedure will induce labor at a time more convenient for us, but do not hesitate to employ this procedure when we think it will shorten labor without harm to the mother or child. We definitely feel that the patient should not be allowed to be up wandering about town or pursuing her usual household duties after the membranes are ruptured. While rupture of the membranes is carried out under strict asepsis, we do not transfer these women to the delivery room, but perform this simple act in the labor room while the patient is on a bedpan.
Care During Labor
During labor the parturient is encouraged to drink water freely, and if it appears that the time of delivery is 6 or more hours away, she is allowed a light diet. If she is nauseated or vomiting and the fluid intake is low or if she appears to be dehydrated, we administer 10 percent dextrose in saline plus B complex. Fruit juices and the semisolid foods allowed are purchased at one of the restaurants by members of the family and brought by them to the patient.
When it appears that delivery will occur in 1 or 2 hours, depending upon the discomfort of the patient, the delivery table is wheeled into the labor room and the woman is transferred to the delivery room. Using the table in this manner eliminates the need for a wheeled stretcher, and permits short turns and narrow doors to be safely traversed.
In the delivery room we place the parturient's legs in the Bierhof crutches and have her grasp the hand-holds on the table. We rarely use restraints in the delivery room, realizing that no one likes the feeling of “being tied down” and that restraints give rise to a feeling of animosity which is not present in the woman who feels free and therefore cooperates more fully. Occasionally hysteria or the need for deep inhalation anesthesia requires restraints.
Second Stage of Labor
Immediately following delivery of the head, 1 cc. of Pitocin is administered intramuscularly. When the posterior shoulder is delivered, 1 cc. of Ergotrate is given intravenously. We find this conserves blood, although it may prolong the third stage. When the baby is removed from the mother's abdomen the uterus is pushed up into the abdomen and massged by an assistant whose hand is kept between the symphysis and the body of the uterus. During the third stage, we carefully watch for bleeding and definitely feel that maternal blood should be conserved by any reasonable procedure. Ergotrate and Pitocin are repeated if blood loss approaches 200 to 300 cc. If during the third stage one edge of the placenta separated with more bleeding than we like, or if the placenta is caught in the cervix, we do not hesitate to invade the uterus for its manual removal. Extreme care is used in inspecting the placenta and membranes in an effort to insure complete expression of the entire decidua.
It is impossible to make statistical observations about this group of patients who were delivered in the office, but some results stand out in our experiences with approximately 50 office deliveries. There has been no maternal death. None of the more than 20 episiotomies has broken down or failed to heal per primum, and to my knowledge only one patient had a post-partum temperature of above 100°F. This patient bled rather profusely from the lower uterine segment as she had done several times before, and the cervix and vagina were packed to control this bleeding She was not given penicillin and sulfonamide until the third day when she had a chill. This was due to an oversight. When penicillin, sulfonamide, and aureomycin were used, none of the other 6 patients who were similarly packed had fever.—DAVID G. MILLER, Jr., M.D., BLANCHE H. MILLER, R.N.
Fifty years ago, David G. Miller, M.D., and his nurse (and wife) Blanche practiced in a rural area of Kentucky. During the 12 years he spent in general practice, he was invested in providing his patients with quality obstetric care. Although he believed that hospital obstetrics is one of the best taught branches of modern medicine, he pondered returning to the home delivery care he had once offered. But the memory of “long trips over poor or nonexistent roads,” “the constant and real threat of bedbugs, fleas and other insect pests” and the lack of “competent consultation that might have saved the mother or the baby” drew him to another style of practice.
He decided to “provide delivery-room facilities, and to give adequate care with analgesia in our office during the labor.” His decision to set up an office obstetric station was based on the principles of doing what was best for the patient but also doing what was best to achieve a balance in his life. Having women labor in his office allowed him to continue to serve the needs of his ambulatory care patients. The comfort of the mother and family were high priorities. He planned for “emergency traumatic surgery” because he was 26 miles from the nearest hospital. He set aside a “clean surgery” room and equipped it for delivery. He set up the delivery table, a cabinet with supplies, a “pressure-cooker-type” autoclave and infant resuscitation equipment and incubator.
Before delivery, patients were given instructions on how to prepare for the delivery and what would occur during the process. He felt that most obstetric errors are caused by haste on the part of the attending physician. At nighttime, he encouraged mothers to labor in the office while attended by a family member, so the physician could stay at home for as long as possible, because “waiting for labor to progress is much less tedious when one is at home than when one is in an alien environment.”
When the patient arrived at the office, he performed a sterile vaginal examination, “first preparing the patient” by letting her know what to expect. He felt that the mother “is helped both mentally and in the progress of labor if she is kept informed about her true condition and constantly reassured.” Women were encouraged to drink water freely during labor. Amniotomy was perfomed if “it will shorten labor without harm to mother or child.” Once delivery was imminent, “the delivery table was wheeled into the labor room,” avoiding unnecessary transport of the mother. Restraints were rarely used because they “give rise to a feeling of animosity which is not present in the woman who feels free and therefore co-operates more fully.”
Delivery was usually done under pudendal block. An episiotomy was usually performed. “Immediately following delivery of the head, 1 cc of Pitocin” is given, followed by 1 cc of Ergotrate. He estimated that about 15 of 50 patients had postpartum hemorrhages in the past three years. The baby remained on the mother's abdomen “until the cord has ceased to pulsate.” He stresses two points about the newborn care: “the cord be doubly tied” and “the respiratory tract is freed from as much aspirated” material as possible.
Dr. Miller reports on his observations of 50 office deliveries. There were no maternal deaths. There were no episiotomy complications. There was one patient with postpartum fever. There was no occurrence of venous thrombosis or emboli. All of the infants lived and were normal. In the conclusion of the article, he cites the outcomes that point to successful practice: “The physician has the personal satisfaction of knowing that his obstetrics is of the type done in good hospitals.”“The family life is not disturbed by going to a hospital.”“The patient likes office obstetrics because of the financial saving.” One patient commented, “Dr. Miller, why in the world didn't you and Blanche think to do this sooner?” Compassionate and rational care is good care whether it is rendered in 1950 or 2000.—BARBARA S. APGAR, M.D., M.S.