The family physician as an obstetrician.
T. D. HOLLINGSWORTH, M.D., AKRON, OHIO
It is difficult to write a paper on the subject of obstetrics and cover only one phase.
There seems to be a return to the family doctor for treatment along many lines that in recent times were thought to be the exclusive domain of the specialist. Perhaps the economic feature has had more to do with the change than other factors; however, the results obtained in the average case seems to justify the return to the family doctor.
In obstetrics, if we can rely on statistics, the mortality rate is lower in the home under the family physician than in the hospitals of the United States. It is claimed that 70 per cent. of the obstetrics is done by the family doctor. The higher death rate in the hospitals may come from the fact that so many difficult and abnormal labors after being started in the home are transferred to the hospitals for operative or instrumental delivery.
The patient in the home does not come in contact with bacteria foreign to her environment. She has built up at least a practical immunity to the bacteria in her home. (Hear, hear!—MM)
There is more danger of infection in a general hospital from pus cases and other sources unless the maternity patients are in a separate building or the maternity floors have no communication with other parts of the hospital and are served by their own diet kitchen, sterilizing outfits, and other facilities.
Public hospitals get all kinds of patients, some almost moribund on admission. Here we would expect a higher death rate than in an institution that gets a different class of patients.
The statement has been made that 50 per cent. of the maternal deaths are largely preventable. Toxemias should be classed among preventable diseases.
There is a class of writers in some of our popular magazines and also in some books that seem to want to discredit the medical profession of the United States in the practice of obstetrics by claiming this nation ranks fourteenth or lower among the civilized nations of the earth in our maternal death rate. It has been proven that the percentages given and the figures quoted do not give a true picture of conditions, as many of the other countries do not include all the causes of maternal deaths as given in the U. S. All deaths in the three stages, pregnancy, parturation, and lactation, are included in the maternal mortality figures in the United States, and not in all the other countries keeping statistics.
Some interests that want to turn the maternity work over to the mid-wives in the U. S. claim their death rate is lower than the physician's. It can not be proven, as all abnormal and instrumental deliveries are done by physicians, then if anything happens the death certificate is signed by the physician. The chances are that the patient would have recovered had she been under a doctor's care during her pregnancy and at the beginning of labor.
We will admit the death rate is too high in maternity cases in the U. S., and that it has not been lowered by the methods employed in the modern maternity hospital. The claim is made by some specialists that the death rate is increased in certain hospitals because any physician can take his patient there and deliver her, that she does not receive expert treatment, and that poor judgment is used in the choice of methods employed in abnormal cases. There may be other reasons not mentioned, but the fact remains that there is a lower maternal death rate among women confined at home.
The American women are receiving better prenatal care than formerly and there have been improvements in the technique of delivery, still our death rate has not been lowered nearly as much as it should be.
Women who show no signs of any organic or functional diseases may develop some serious lesion from the added strain of pregnancy. A careful periodic examination of these patients will give time to correct conditions before they become dangerous. By watching the diet we can ease the strain on the kidneys. By supplying calcium, we can save the teeth and the bony structures. There are indicated remedies that may be given to quiet the nerves, induce sleep, relieve the annoying uterine cramps, correct constipation if diet alone will not do it.
No drastic cathartic should be used during pregnancy, only mild laxatives. Corpus luteum will control the uncomplicated cases of morning sickness. One ampule every day or every second day for a few days will stop the vomiting and control the nausea. Calcium carbonate serves a double purpose by supplying calcium for the foetus and also correcting sour stomach. Pulsatilla macrotys, caulophyllum, and black haw are often indicated during gestation. I could supply a longer list of drugs that are useful at times, but as you are familiar with them I will not repeat them here.
There are two lives at stake in each delivery, and the infant should receive consideration as well as the mother. The modern obstetrician wants to get the case over on time and if uterine contractions do not begin on the day set, measures are taken to start the pains. This may not harm the mother at all, but sometimes it does the child no good, if it does not actual injury. There are times when such interference is justified as when a contracted or deformed pelvis or larger infant makes it difficult or impossible to give birth via natural passage, a Cesarean section should be performed before actual labor begins. By so doing there is less danger of infection.
Obstetrics does not stand on as high a plane in the eyes of the majority of physicians as surgery, and less time is spent teaching this important subject in the average medical school than should be given to it. When obstetrics is given more attention in the course and women are educated to the importance of putting themselves under the care of a competent physician early in pregnancy and follows his advice, we will have fewer deaths from preventable causes.
There is no one more competent to give advice and care to the average pregnant woman than her family doctor, since he knows her history, her family, its surroundings, and her physical condition. He is in a position to watch over her and detect any trouble that might develop from the extra load carried by the heart, kidneys, and other organs during pregnancy. He can help correct conditions as they arise.
I do not desire to leave the impression that a specialist would do less for the patient, but the average expectant mother can not afford to pay the fee demanded by the specialist.
No physician should accept confinement cases unless he has enough interest in the work to give them proper prenatal care, and to watch them after confinement until the generative organs have returned to normal.
We can not have the same degree of asepsis in the home that is imperative in the hospital, yet we can have all instruments, bed coverings, and dressings coming in contact with the patient sterile. It is much more important to have surgical cleanliness in the hospital delivery room to avoid infection being carried from one patient to another. The worst infection I have had in my own practice occurred in a patient delivered in a hospital. It would not be fair to claim the infection was contracted in the institution as she had a slight elevation of temperature when admitted.
Statistics prove there is a greater mortality rate among women confined in hospitals. It is my opinion that there may be a smaller infant mortality rate among babies born in hospitals as they have better equipment to resuscitate infants than can be carried by the physician to the homes.
There are certain things that need to be done to reduce the maternal death rate. The most important of these is education. Educate the mothers to seek medical supervision at the beginning of pregnancy. Educate medical students as thoroughly in obstetrics as in other lines. Place service in obstetrics on an equality with other services in the hospital. Educate the family physician to the necessity of giving better service to maternity patients. When these things are done there will be less cause for complaint, and many of the preventable causes of death in obstetrics will have been removed.