In early times women in labor were attended by relatives or

uneducated midwives. Some Greek and Roman physicians taught

midwifery, but doctors, being men, were excluded from attending
childbirth until the 16th century. The first book on midwifery was
printed in 1513 in Germany. Ambroise Paré, a French military surgeon,
founded a school for midwives in Paris. In 1572 a French Huguenot
family, the Chamberlens, fled to England with the forerunners of
modern obstetric forceps, which were their family secret.

Accoucheurs (male midwives) became fashionable in France in the

17th century. A surgeon attended a mistress of Louis XIV in 1663 and
an accoucheur, Mauriccau, published a treatise on midwifery in 1668.

In England in the 18th century the secret of the obstetric forceps

became public, although their use remained controversial. The first
British school of midwifery was founded in 1725 in London, and the
first chair of midwifery in Edinburgh in 1726. Queen Charlotte's
Hospital, Britain's first maternity hospital, was founded in 1739. In that
year William Smellie, a Scottish doctor, set up a school of midwifery in
London, and in 1752 he published his Treatise on the theory and
practice of midwifery. Smellie, ‘the master of British midwifery’, was a
man of humanity and common sense but was violently opposed by
some local midwives. One of his pupils, William Hunter, a fellow-Scot
and older brother of the famous surgeon John, became very popular
and by the latter part of the 18th century accoucheurs were
fashionable in England.

In the 19th century labor was still dangerous. Among the poor, rickets
caused pelvic deformities. In maternity hospitals many women died of
puerperal fever, whose contagious nature was recognized by Alexander
Gordon of Aberdeen in 1795 and Oliver Wendell Holmes in the USA in
1843. In 1861 Semmelweiss in Vienna reduced deaths from puerperal
fever by reducing cross-infection with methods such as hand-washing.

Midwifery became a compulsory subject for medical students in 1833

in Scotland and 1866 in England. In 1847 James Young Simpson,
professor of midwifery in Edinburgh, used chloroform to relieve labor
pain. He met strong opposition from doctors and clergy until Queen
Victoria requested it at the birth of her seventh child.

Obstetrics was limited to childbirth itself until the 20th century, when
antenatal care was introduced. In 1901 R. W. Ballantyne set aside a
bed for antenatal patients in Edinburgh Royal Infirmary. Antenatal
clinics were opened in Boston, Sydney, and Edinburgh in 1911, 1912,
and 1915, respectively. Obstetrics remained a branch of surgery until
1929, when the Royal College of Obstetricians and Gynecologists was
founded.

The history of obstetrics is closely linked with that of midwifery.

Midwives were mostly illiterate ‘Sairey Gamps’ until the 19th century,
when several European countries introduced regulations for their
training and control. Attempts to do the same in Britain failed, but in
1872 the Obstetrical Society of London began issuing certificates of
competence to midwives. The Midwives Institute was set up in 1881. At
last, in 1902, the Midwives Act made state registration compulsory and
set up a Central Midwives Board to regulate midwifery. The Midwives
Institute became the College of Midwives in 1941, the prefix ‘Royal’
being added in 1947.

Maternal mortality
Throughout history, childbirth has been dangerous for women, but
after 1930 there was a remarkable improvement in Britain. The
maternal mortality rate — the number of women dying per 100 000
deliveries — in Britain until 1935 was around 500, but nowadays it is
only 8. The mortality rate remains high in many developing countries,
and in parts of Africa it is still around 500. The reasons for the fall in
Britain are numerous. The health of the population has improved but
the fall is probably due more to specific measures. For example,
infection may now be treated with antibiotics, and bleeding by blood
transfusion. Legalization of abortion in 1967 eliminated criminal
abortion as a cause of maternal death.

Since 1952 in Britain a national Confidential Enquiry into Maternal

Deaths has examined each death and issued regular reports with
recommendations for improvements. Hemorrhage and infection are
now relatively rare causes: in recent years the commonest causes have
been venous thrombosis and raised blood pressure. Death due to
anesthesia is now extremely rare.

Perinatal mortality

Childbirth is 100 times more dangerous for the baby than the mother.
The perinatal mortality rate is the number of stillbirths and deaths in
the first week of life per 1000 deliveries. In 1935 in England and Wales
it was 70, and in 1990 it was 8.3. The three main causes of perinatal
mortality — low birth weight, lack of oxygen in utero, and congenital
abnormalities — are discussed below.

Obstetric techniques
Obstetric forceps were first used on living babies by the Chamberlens.
They were modified during the 18th and 19th centuries but the forceps
in use today are similar to those designed by Simpson 150 years ago.
Most forceps require the baby's head to be facing towards the mother's
back, but in 1916 Kjelland, a Norwegian obstetrician, designed forceps
for use when the baby's head is facing to the side or to the front.

The vacuum extractor (or ventouse), invented by Malmström of

Sweden in the 1950s, has a suction cup which is applied to the baby's
head. After recent improvements, studies have shown that it causes
less trauma to the mother than forceps delivery, although the baby
may suffer mild ill-effects from bruising of the scalp.

cesarean section got its name from the Lex Caesarea, a law dating
from the 7th century bc that if a pregnant woman died, the baby
should be removed and buried separately. The procedure was not done
with any regularity until the 1880s, at which time ‘classical’ cesarean
section involved a lengthwise incision in the uterus. This does not heal
well and may rupture in subsequent labor. In 1906 the modern ‘lower
segment’ operation was introduced, in which the incision is in the
fibrous lower part of the uterus.

Antenatal care

The emphasis in modern obstetrics is on preventing problems. The

purposes of antenatal care are to treat symptoms during pregnancy, to
screen for maternal and fetal complications, and to help prepare a
couple for childbirth and childrearing.

At a prepregnancy clinic, checks are made on a woman's health,

obstetric history, and immune status (for example, to rubella). Women
with a history of genetic disease may receive counseling and, if
necessary, diagnostic tests. Those with pre-existing disease such as
diabetes may need to alter their treatment.

The pattern of antenatal clinic visits varies among countries but in

Britain a woman usually attends first around the 12th week of
pregnancy, monthly until the 28th week, fortnightly until the 36th
week, and weekly thereafter. The midwife, general practitioner, and
hospital clinic share the care, depending on local arrangements and
individual risk factors. The trend nowadays, for low-risk women, is
towards fewer visits and less hospital care.

Investigations at booking (the first visit) include tests for anemia,

syphilis, rubella, and blood grouping. If a woman's blood group is
Rhesus negative and her baby is Rhesus positive, she may develop
antibodies against the baby's red blood cells, leading to fetal anemia,
which may be lethal. Such Rhesus isoimmunization has been almost
eliminated by a national prevention program: Rhesus-negative women
are injected with a small amount of antibody to destroy fetal cells in
the mother's blood before they stimulate an immune reaction.

Prenatal diagnosis

Around 2% of babies have major congenital abnormalities, such as

Down's syndrome or spina bifida. The risk of some of these can be
reduced. Women planning a pregnancy are now advised to take
supplements of folic acid to prevent spina bifida, but for the remainder
all we can do is make the diagnosis as early as possible, when the
woman can be offered the option of terminating the pregnancy.

In chromosomal abnormalities, the baby's cells contain abnormal

genetic material owing to failure of the chromosomes to distribute
themselves correctly at conception. Most cause miscarriage but a few
are compatible with life, such as Down's syndrome, in which there is an
extra chromosome 21. Chromosome abnormalities may be diagnosed
in various ways. Pre-implantation diagnosis can be performed after in
vitro fertilization: in the laboratory one cell is removed from an early
embryo; the chromosomes are examined and if they are normal the
embryo may be placed in the womb. Chorion villus sampling may be
done from the eighth week of pregnancy: a sample of placental tissue
is removed via a needle inserted through either the vagina or the
abdominal wall. Chromosomes from these rapidly dividing cells can be
examined directly by microscopy. Amniocentesis involves removing
some amniotic fluid via a needle through the abdominal wall. Cells
shed from the fetus may be cultured and examined, which takes longer
than direct examination after chorion villus sampling. Amniocentesis,
formerly restricted to the 15th week of pregnancy or later, can now be
done as early as the 10th week.

Anatomical abnormalities may occur in fetuses with normal or

abnormal chromosomes. The most common types are abnormalities of
the nervous system (such as spina bifida) or the heart: others include
cleft palate or club foot. They are present from the early weeks or
embryonic life but become detectable only when the structures are
large enough to be seen on ultrasound scans.

Obstetric ultrasound
During the Second World War, echoes from high-frequency sound
waves were used to detect submarines. In the 1950s in Glasgow,
Professor Ian Donald modified the technique to make measurements
on the fetus in the amniotic fluid. In the early days a single beam of
ultrasound produced blips on an oscilloscope screen, but today's
machines give detailed moving images, allowing diagnosis of
anatomical abnormalities and accurate assessment of fetal growth and
of the position of the placenta. Ultrasound has transformed obstetrics
and is now widely used in gynecology and other specialties.

Complications of pregnancy

At each antenatal visit the size of the uterus is assessed. A large uterus
may mean multiple pregnancy, excess amniotic fluid, or a large baby,
and a small uterus may mean the baby is failing to grow. This may be
checked by ultrasound. Checks are also made on the woman's blood
pressure and urine for signs of pre-eclampsia — a condition in which
the blood pressure rises and protein appears in the urine and which,
untreated, may progress to eclampsia (convulsions). In the later weeks
checks are made for breech presentation, which occurs at the end of
4% of pregnancies.

Care in labor

About 600 000 babies are born in Britain every year, most in hospital.
The move towards total hospital deliveries accelerated in the 1960s as
doctors and women perceived hospital as safer for the baby. There is
now concern that home delivery should remain as an option for women
who want it, although hospitals are becoming less institutional to strike
a better balance between safety and a relaxed environment.

Normal labor

Labor has three stages, the first lasting from the onset until the uterine
cervix is fully open. During the second stage (which ends at delivery of
the baby), the woman feels the urge to push. The third stage is from
delivery of the baby to delivery of the placenta. In Britain women in
labor are cared for mainly by midwives, who as independent
practitioners are not required to seek medical help unless they feel this
is necessary.

Pain relief in labor

There is much variation in the amount of pain experienced during labor

and much debate about the best form of pain relief. Methods include
psychoprophylaxis, and painkilling drugs such as pethidine, inhaled
gases, and epidural analgesia. General anesthesia is nowadays rarely
used for instrumental delivery and many cesarean sections are carried
out using epidural block. General and epidural anesthesia are
administered by specially trained anesthetists.

For epidural analgesia a fine catheter is inserted between the

vertebrae and a painkilling drug is infiltrated around the roots of the
nerves leading from the uterus. This may give complete freedom from
pain but may interfere with the second stage of labor by abolishing the
urge to push, and therefore this increases the chance of an
instrumental delivery.

Fetal monitoring

The simplest way to monitor the baby's condition during labor is by the
midwife listening to its heartbeat through a stethoscope. Electronic
monitoring of the fetal heart rate became widespread in the 1970s.
During labor uterine contractions may reduce blood flow to the
placenta, interfering with the baby's oxygen supply and altering its
heart rate, but abnormalities may have no sinister cause and an
electronic monitor (cardiotocograph) can cause unnecessary concern.
Cardiotocograph abnormalities can be checked by taking a sample of
fetal blood for measurement of oxygen levels but this facility is not
available in all hospitals.

Active management of labor also became widespread in the 1970s and

1980s. Often a woman's first labor is slow because the uterus does not
contract strongly, although subsequent labors are usually much more
efficient. ‘Active management’ of a first labor involves early diagnosis
of slow progress and the use of oxytocin, a natural hormone, to
strengthen the contractions. It reduces the need for instrumental
delivery or cesarean section, but oxytocin has to be given by
intravenous drip and some women see active management as
excessive medical intervention.

Complications of labor

Some complications such as malpresentation (for example, breech

presentation) may be anticipated in the antenatal clinic, but some are
unpredictable. For example, rarely the umbilical cord may drop into the
vagina when the waters break, or more commonly heavy bleeding may
occur immediately after delivery (postpartum hemorrhage). The most
common indications for intervention nowadays are fetal distress or
failure to progress.

Fetal distress means the baby shows signs of lack of oxygen, such as a
slow heartbeat or the passage of meconium (bowel contents). These
signs may occur, however, when the baby's oxygen levels are normal.
Failure to progress in labor means the cervix fails to dilate beyond a
certain point, owing either to poor contractions or to the baby being
too big for vaginal delivery. ‘Slow progress’, however, may be a
subjective diagnosis. Thus both these indications may be arbitrary.

If delivery is necessary in the first stage of labor, cesarean section is

required. In the second stage vaginal delivery may be assisted by
forceps or vacuum extraction, but cesarean section may be preferred
to a potentially difficult instrumental delivery. Rates of cesarean
section have risen steadily in many developed countries. In Britain in
the 1950s, 5% of babies were born by cesarean section but by 1990–91
the rate had risen to 13%. In the USA the rate has risen to 25%. The
rise has been blamed on overenthusiastic obstetricians, but recent
research shows that women are unwilling to accept even a low risk to
their baby, and many prefer cesarean section when a mild
complication is detected.

The puerperium

This refers to the time from delivery until the woman's genital tract
returns to normal, usually around 6 weeks later. In the early days after
delivery emotional lability is usual but true puerperal psychosis is
uncommon. Infection of the womb, the cause of the once-dreaded
puerperal fever, is now infrequent and can be treated with antibiotics.
In Britain fewer than half of women breast-feed, although hospitals are
now having some success in increasing this figure.

Future trends

There is a stark contrast between the obstetric needs of countries such

as Britain and those of developing countries, where the maternal
mortality rate is high and many women suffer complications such as
vesicovaginal fistula (bladder damage during labor). The World Health
Organization estimates that world-wide half a million women die every
year as a result of pregnancy, one a minute. Reducing this total will not
be easy. This will mean not only improving maternity services but also
raising the status of women in some cultures, and providing easy
access to cheap contraception.

In Britain, by contrast, the trend is towards reducing medical

intervention without compromising safety. Research studies to
distinguish useful from unnecessary intervention involve large
numbers of women and complex statistical analysis, and several
studies may have to be combined to obtain clear answers. Obstetric
and midwifery practice is increasingly being guided by such research.
At the same time, women have high expectations and any adverse
outcome of pregnancy may lead to litigation. Huge awards have been
made to ‘brain-damaged’ babies, but it is now recognized that only a
small proportion of cases of cerebral palsy are due to obstetric causes.