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Chapter Four Assessing Risk 1950s–1970s By the ­ middle of the twentieth ­ century, the long-­ running disagreements among obstetricians had ended in a victory for the operator camp. Just as Joseph DeLee had suggested in 1920, the physicians practicing in American hospitals­ were treating childbirth as “a decidedly pathological pro­ cess.” ­ Every treatment DeLee had called for, and more, had become a component of maternity ward protocol. Obstetricians shaved pubic hair and administered an enema, a ritual known as “the prep”; they induced or augmented contractions by puncturing the amniotic sac and/or administering Pitocin subcutaneously or intravenously; they dispensed assorted analgesics throughout first-­stage ­labor; they administered general , pudendal-­ block, or saddle-­ block anesthesia throughout second-­ stage ­ labor; and they performed an episiotomy. By the 1950s, forceps had become mandatory in virtually ­every birth; ­mothers ­were too heavi­ly drugged to push. In short, birth in US hospitals in the 1950s and ’60s was a prescribed, industrialized pro­ cess governed wholly by the physician.1 A new focus on the fetus helped drive the protocol. As one retired obstetrician said of the medical culture when he first trained, “we ­ didn’t ­ really think a ­ whole lot, when I was a resident, about the outcome for the baby. We ­ were focused more on the ­ mother ­ because that was right at the end of the period where we ­ were getting to where maternal mortality was way down.” Only ­ after the maternal death rate dropped “tremendously,” he explained, did obstetricians “become more and more focused on protecting the baby and making sure he or she is safe and healthy.”2 Assessing Risk   99 With the well-­ being of the fetus now on a par with concern for ­ mothers, physicians developed diagnostic tools to help them detect and prevent trou­ble. Three of the tools, developed in the 1950s and ’60s to identify and mitigate risk during childbirth—­ the Friedman curve, the Bishop score, and the Apgar score—­ heightened obstetricians’ perception of the risks of childbirth. Other developments amplified the public’s perception of risk—­ namely, the horrifying birth defects that resulted from the use of thalidomide by pregnant ­women during their first trimester followed quickly by a German measles epidemic, both against the backdrop of a March of Dimes campaign against birth defects. The medical and lay views of risk ­ shaped by ­ these events would eventually help stoke the unpre­ ce­ dented increase in the cesarean rate that began in the early 1970s. Laboring on the Friedman Curve As hospital-­based residencies in obstetrics and gynecol­ogy became the primary training ground for obstetricians, sitting by ­ women’s bedsides throughout ­ labor became a significant component of residents’ training. Both laboring ­women and obstetric residents benefited from the practice. ­ Women enjoyed constant companionship in an era when their husbands and friends ­ were barred from ­ labor and delivery, while obstetricians-­ in-­ training ­ were afforded many opportunities to witness the rhythms of ­ labor. As one observer said approvingly in the 1930s: “They watch ­ every ­ mother from beginning to end of her ordeal . . . ​ no ­ matter how long or seemingly uneventful the travail. . . . ​ So our young medicos and nurses have an unparalleled chance to learn the natu­ ral history of childbirth.” An obstetrician trained in the 1950s recalled how his constant presence also helped ease ­ mothers’ fear and pain as they labored. “The doctor in the room,” he quickly learned, “[was] worth 100 milligrams of Demerol.”3 Emanuel Friedman was an obstetric resident in the 1950s, when this practice was in its heyday. He based his eponymous curve, a depiction of the average length of first-­time ­labors in the form of a sigmoid curve, on 100 births, data he prob­ably collected as he labor-­ sat. Quickly and widely ­ adopted, the Friedman curve prompted the notion that if a first-­ time ­ mother labored longer than the curve indicated was within the range of “normal,” she and her baby ­ were at heightened risk. The more a ­ labor veered from the curve, the greater the risk.4 The longest portion of the curve represented the average number of hours spent by ­ women in the first stage of ­ labor, that is, from their initial contractions to full cervical dilation. Friedman then subdivided the first stage into four phases. He found that phase one, the “latent period,” before appreciable cervical dilation 100  Cesarean Section occurred, lasted from 1.7 to 15 hours—­ a mean 7.3 hours. During the latent phase, the cervix softened, effaced, and dilated about 2 centimeters...


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