Joseph Bolivar DeLee and the Prophylactic Forceps Operation
In 1920, Joseph Bolivar DeLee, a Chicago-area doctor presented his infamous paper, “The Prophylactic Forceps Operation,” which redefined childbirth as pathogenic in nature. DeLee wrote the article after his reputation had already been established and his textbooks accepted as required reading for students.
DeLee’s procedure, which became widely adopted, began with sedation of the woman with scopolamine when labor started. Her cervix was allowed to dilate on its own and she was given ether during the second stage. The doctor would then perform a generous episiotomy, and extract the baby with forceps. Removal of the placenta followed, as did a dose of ergot to help the uterus contract, and the perineal cut was stitched restoring what DeLee called “virginal conditions.”
Wrote Judith Leavitt in her 1988 American Journal of Public Health article, “Joseph B. DeLee and the Practice of Preventive Obstetrics”:
DeLee changed the focus of action from a response to a specific perceived problem to intervening prophylactically and routinely. DeLee did not want to wait until the course of labor indicated women were in trouble and needed interventions; he wanted instead to prevent any problems from developing by intervening first, by explicitly directing the course of labor and delivery.
From the viewpoint of doctors, this new procedure was so successful that the rate of forceps deliveries between 1946 and 1951 at the Chicago Lying-In Hospital, where DeLee first practiced, was 68.2 per cent.
Joseph DeLee had good reason to redefine childbirth as pathogenic event that required specialists: respect. As he wrote in 1923, “The fundamental reason why obstetrics is on such a low plane in the opinion of the profession… is just because pregnancy and labor are considered normal, and therefore anybody, a medical student, a midwife, or even a neighbor, knows enough to take care of such a function.”
The article is long so I’ve emphasized sentences of interest.
THE PROPHYLACTIC FORCEPS OPERATION
The time is not yet ripe for the recommendation of the procedure to be described in this paper, yet, as obstetric specialists, we must lead the way in improvements of our art—and this is still capable of improvement. The public is demanding, with a voice that becomes louder and more insistent each year, relief from the dangers of child-birth for the child-bearing woman. As regards the pain, the rapid spread of the twilight sleep craze will show the demand. That tokophobia is spreading among woman is a fact.
If we study our cases carefully the conclusion is inevitable that while we have decidedly improved the maternal mortality and morbidity, and have reduced fetal deaths somewhat, labor is still a painful and terrifying experience, still retains much morbidity that leaves permanent invalidism. The latter statement is also applicable to the child. Many efforts are being made to ease the travail of the woman and to better the lot of the infant. What follows is another such effort. Experience alone can decide is it accomplishes its purpose.
The prophylactic forceps operation is the routine delivery of the child in head presentation when the head has come to rest on the pelvic floor and the early removal of the placenta. Primiparous labors, and those in which the condition of the soft parts approximates a first labor, are treated by this method, which really comprises more than the actual delivery of the child. It is a rounded technic for the conduct of the whole labor, with the defined purpose of relieving pain, supplementing and anticipating the efforts of nature, reducing the hemorrhage and preventing and repairing the damage.
It is not a complete reversal of the watchful expectancy that is universally taught, but I cannot deny that it interferes much with Nature’s process. Were not the results so gratifying I myself would call it meddlesome midwifery.
A typical case is treated as follows: As soon as the pains are well established and the cervix opened to 2 to 3 cm. the parturient is given 1/6 grain morphin and 1/200th scopolamine. After one hour 1/400 gr. scopolamin is given and in one or two hours occasionally a third dose of the same size. The room is darkened and suggestion used as much as possible to aid the medicines. This is really a modified twilight sleep and usually the cervix dilates and the head comes down on the perineum without the necessity of further drugs. Occasionally 15 gr. Chloral and 40 gr. Sodium bromide are given per rectum to aid the morphin at the end of the first stage, or gas and oxygen are administered by an expert. It is important to obtain complete spontaneous dilation of the cervix, and the slower the better. The importance attached to the point, the natural dilation of the cervix and the slow retraction of the pericervical connective tissues cannot be exaggerated. We are unable to imitate this by art.
When the head has passed the cervix and rests between the pillars of the levator ani, and has begun to part them and to stretch the fascia between them—a matter that is easily determined by rectal examinations—the patient is put to sleep with ether and a typical perineotomy (soon to be described) is performed. Under the minutest possible control of the fetal heart tones—either the operator listening frequently every minute, with a head stethoscope, or an assistant doing it—the forceps are applied and delivery accomplished. This is surprisingly easy. As soon as the child’s head is born, 1 c.c. of Burroughs & Wellcome pituglandol is injected into the deltoid muscle. A nurse stands ready with 1 c.c. of aseptic ergot, and this is injected into the outer thigh muscles as soon as the placenta is visible in the vulva. If there is hemorrhage the placenta is removed at once; if not, we wait five to ten minutes. The operator either changes his gloves or disinfects them with antiseptics and inserts the left hand into the lower uterine segment, palm up, while with the outside hand the hard (pituitrin) uterus is pushed down on the already descended placenta. The placenta slides down the hand like a heel slides along a shoehorn. We call his method of expression of the placenta the “shoehorn maneuver,” and it is the rare exception that the placental delivery needs more help than light pressure on the contracted uterus from above. Should there be any undue bleeding another ampoule of pituitrin is injected directly into the uterine muscle through the abdominal wall. Uterine tamponade is almost never needed.
A woman is not given ¼ gram of morphin and 1/200 gr. scopolamin to reduce the amount of ether required for the repair work, to prolong the narcosis for many hours post-partum and to abolish the memory of labor as much as possible. If the pains are strong, perineotomy without forceps may suffice for the easy delivery.
It is surprising how bloodless the operative field, especially the cervix, has become. The cervix is pulled down with the specially constructed ring forceps and all tears immediately repaired. I have thus gained a large experience in cervical tears and find it necessary to revise my previous notions of their anatomy. The cervix tears often even in spontaneous deliveries. The body of the cervix often tears, leaving mucosa internal and external intact. Later such cervices show all the evidences of laceration, chronic inflammation, eversion, erosion, etc. Those lacerations which are open also show the separation of the muscle of the cervix at the sides, and the deep retracted portions of the wound must be pulled out and united, preferably with buried sutures. Our previous failures in cervical repair were, I believe, due to non-recognition of this fact.
THE PERINEOTOMY. This is one of the most important steps of the procedure—its making and repair. It is essential to have clear notions of the normal anatomy of the pelvic floor and how the structures are changed during delivery. The models are intended to show these things: he head advancing through the hiatus genitalis (1) stretches the vagina radially and longitudinally—it also, sometimes, wipes the vagina off its fascial anchorings, sliding it downward and outward. (2) The head stretched the pelvic fascia over the lavatory ani, and between the rectum and vagina and the layer behind the rectum, also radially and longitudinally, and this also permits the rectum to be wiped downward and slid off its fascial attachments to the levator ani. (3) The head often tears or overstretches the fascia over the levator ani, especially in those bundles which hold the pillars of the muscle in position at the sides of the rectum, spanning the hiatus genitalis, and permits the pillars to separate—a real diastasis of the levator pillars resulting, and the pathology is similar to that of the diastasis recti abdominales. This diastasis of the levator pillars and wiping or sliding of the rectum and vagina downward and outward are the essential features of most pelvic-floor injuries, and have been, to my mind, the least noticed by current writers. (4) The tears in the levator ani muscle are usually due to improper treatment, and they occur, least commonly, near the insertion of the muscle on the pubic ramus (usually due to cutting by the forceps) and more commonly at the sides of the rectum, behind, near the raphe. (5) Labor always ruptures the urogenital septum, tearing it in all directions, and also from its ramifications with the endopelvic fascia, both above and below the levator ani. (6) The fascia between the vagina and bladder is also stretched or torn, also radially and in a downward direction, tearing the vagina and bladder off its anchoring to the upper surface of the endopelvic fascia over the levator ani and the posterior surface of the pubis.
It is thus evident that most of the damage resulting from labor is due to injury, rupture, distraction and displacement of the fascia and less to tearing of the muscles.
Prevention, therefore, aims to preserve the fascia in its normal position throughout the parturient canal, and when the overstretching or rupture cannot be avoided, to incise the structure at a spot where it can be repaired by suture.
We cannot do anything directly to save the pericervical connective tissues from radial and longitudinal overstretching and tears—we can, indirectly, by avoiding all interference with natural processes of dilation of the cervix and restraining the natural powers if they are too violent. This means the avoidance of bags to hasten dilation, of manual stretchings, of urging the parturient to bear down before the head passed the cervical barrier and especially avoiding pituitrin before complete opening of the cervix.
We can take direct action to save the fascial and muscular structures of the pelvic floor, in addition to practicing the measures just mentioned for preserving the connective tissues of the upper pelvis. By incising the fascia at its most vulnerable point, and reuniting it after delivery, we are almost always, not invariably, able to eliminate all damage to the pelvic floor. The first incision is through the skin and urogenital septum, exposing the pillar of the levator ani covered with the fascia endopelvina. Next the vagina is incised and with it the upper layer of the levator ani fascia exposing the rectum, which is seen at the bottom of the wound covered with its fascia propria. Next the fibers of the fascia communicating with the urogenital septum are cut, which allows the perineal body with the sphincter ani and rectum to fall to the side opposite the cut. Simpleepisiotomy will not prevent injuries to the pelvic fascia. When the disproportion between the head and the pelvic floor is great, the muscular belly of the levator ani is also incised at a right angle to the fibers’ length. The models show these incisions better than descriptions.
Sometimes during the delivery the fascia tears and stretches more than we wish, but never so much that we lose the advantages of the preliminary incisions. By slow extraction we reduce this possibility very much. The repair is done ith catgut, layer by layer, vagina, muscle, fascia, urogenital septum, subcutaneous fat and fascia and skin, all in anatomico-surgical fashion. Primary union is the rule and examination later shows that virginal conditions are usually restored.
Now, should virginal conditions be restored? Did not nature intend women should be dilated in the first labor so that subsequent children will come easily? Are not the lacerations normal?
Labor has been called and still is believed by many to be a normal function. It always strikes physicians as well as laymen as bizarre, to call labor and abnormal function, a disease, and yet it is a decidedly pathologic process. Everything, of course, depends on what we define as normal. If a woman falls on a pitchfork, and drives the handle through her perineum, we call that pathologic, abnormal, but if a large baby is driven through the pelvic floor we say that is natural and therefore normal. If a baby were to have its head caught in a door very lightly, but enough to cause cerebral hemorrhage, we would say that it is decidedly pathologic, but when a baby’s head is crushed against a tight pelvic floor, and a hemorrhage in the brain kills it, we call this normal, at least we say that the function is natural, not pathogenic.
In both cases, the cause of the damage—the fall on the pitchfork and the crushing of the door—is pathogenic—that is, disease-producing, and in the same sense labor is pathogenic—disease-producing, and anything pathogenic is pathologic or abnormal.
Now you will say that the function of labor is normal that only those cases which result in disease may be called abnormal. Granted, but how many labor cases, measured by modern standards, may be so classified? Sir J.Y. Simpson, said that labor, in the intention of nature, should be normal, but that in a large proportion of cases it was not so. If the proportion was large in Simpson’s days the middle of the last century it amounts to a majority today. In fact, only a small minority of women escape damage during labor, while 4 per cent of the babies are killed and a large indeterminable number are more or less injured by the direct action of the natural process itself. So frequent are these bad effects that I have often wondered if nature did not deliberately intend women should be used up in the process of reproduction in a manner analogous to that of the salmon, which dies after spawning? Perhaps laceration, prolapse and all the evils soon to be mentioned are, in fact, natural to labor and therefore normal, in the same way as the death of the mother salmon and the death of the male bee in copulation are natural and normal. If you adopt this view I have no ground to stand on, but if you believe that a woman after delivery should be as healthy, as well, as anatomically perfect as she was before and that child should be undamaged, then you will have to agree with me that labor is pathogenic because experience has proved such ideal results are excessively rare.
What are the factors that render labor so pathogenic? Dangers, immediate and remote, threaten both mother and child throughout.
First for the mother. Infection is always a threat, even under the most ideal conditions. Virulent streptococci inhabit a large percentage of vaginae, and it the second stage becomes too prolonged, if the bruising of the parts is too extensive, if a woman’s resistance is worn down by too much suffering or by hemorrhage, they may invade the organism and prove fatal. The death may occur in fashion that hides the cause from the unobservant accoucheur, e.g., a very mild sepsis or even a single rise in temperature is shown, and, in the second week, death occurs from embolism.
Exhaustion is not infrequent in a second stage that may not be too long for a healthy woman, but in one whose nerve reserve is low exhaustion may lead to immediate nervous shock, and, later, pronounced neurasthenia. If the twilight sleep propaganda taought us anything it showed us the actual value of preserving the nervous strength of the parturient.
Of greatest importance, because of greatest frequency, is the damage to the pelvic floor and perineum; next comes the injury to the vesicovaginal fascia and then the lacerations of the cervix and the connective-tissue supports of the uterus, the so-called uterine ligaments. It has not been necessary before a society of this kind to enumerate the immediate and remote effects of these destructions of tissue.
The dangers of the second stage of labor to the child are much greater than one who has not studied the matter thinks. It may surprise some present to know that the following injuries have been caused by the forces of natural spontaneous labor: Fracture of the skull; rupture of the tentorium cerebelli; intracranial hemorrhage (numerous minute and large ones); retinal hemorrhage, abruption retinae, dislocation of the lens, facial paralysis, Erb’s paralysis; rupture of the sternocleidomastoid muscle, already diseased, resulting in wryneck, fracture of all the long bones of all the extremities, rupture of the cord, tearing of the cord from the bell, etc.
The most common dangers, however, and therefore the most important are asphyxia from abruption placentae or prolonged compression of the brain and intracranial hemorrhages. Brothers, of New York, found that 5 per cent of children had died during labor. Holt and Babbier, of New York, 4.4 per cent; Schutz 5 per cent and 1.5 per cent in twenty four hours from the trauma of labor; Kerness, of Munich, found 5.2 per cent, and Potter, of Buffalo, had 4 per cent fetal mortality. A certain portion of these deaths occurs in natural unassisted labor. How many babies are hurt and damaged in operative delivery cannot be determined, but their number is legion—and the same must be said of the effects of natural labor. Anyone who has thoughtfully studied the head of a chld molded by strong pains through the tight pelvis of a primipara will agree with me that the brain has been exposed to much injury. The long, sausage-shaped head means that the brain has been dislocated; the overlapping bones indicate that the sinuses have been compressed with resulting cerebral congestion; the caput succedaneum evidences the pressure to which the brain was subjected. If there is a caput on the outside of the skull, what of the inside? The punctuate hemorrhages in the skin confirm the last mentioned finding; the subconjuctival ecchymoses show us the possibility of hemorrhage in the retina. From outward visible evidences, therefore, we can deduce that this brain has suffered distortion, congestion, edema, compression and hemorrhages, but we need not rely on deduction alone. Clinically, if you listen continuously to the fetal heart tones you will be convinced that the child is suffering, and autopsies bring the final proof of the above assertions. Neurologists for many year have pointed out the connection between epilepsy, idiocy, imbecility, cerebral palsies and prolonged hard labors. Observant obstetricians have known this for so long that it is an accepted fact. In 1917, Arthur Stein, of New York, reviewed the literature on the subject; he studied 5562 cases in various homes for feebleminded children and comes to the conclusion given above. Indeed, although statistics are meager they seem to show that instrumental delivery is safer than prolonged, hard, unassisted labor. Stein’s article is well worth reading, as it quotes numerous accoucheurs and neurologists of scientific standing who support this view. One may well ask himself whether the short, and moderate in amount, compression of the head in a skillfully performed forceps operation is not less dangerous to the integrity of the brain than the prolonged pounding and congestion it suffers from a hard spontaneous delivery. If a late forceps operation is done on a head and a brain already infiltrated with small hemorrhages the results are worse, compounded.
Anoxemia (anaerosis—the beginning of asphyxia) of the child in the second stage is a not uncommon condition, but fortunately most children are born before the asphyxia becomes fatal. In the Chicago Lying-In Hospital hardly a month goes by but that one or more infants die from this cause. Either the child is stillborn or dies a few minutes after birth or dies within the week from atelectasis. Most so-called blue babies are simply atelectic. The asphyxia may be primary—from separation of the placenta, pressure on the cord, tetanic action of the uterus, etc., or it may be secondary to cerebral compression or hemorrhage. Its beginning and progress may readily and easily be determined by means of the stethoscope, industriously applied during the second stage. Another result of asphyxia in labor is infection of the fetus. In gasping for air the child inspires vaginal mucus and later develops pneumonia or intestinal sepsis.
Among the late effects of prolonged labor on the child must be mentioned permanent disorders of the special senses, sight and hearing, due to hemorrhages into the nerve endings, the nerve itself or its nuclei. Fetal deaths and all the complications are more frequent in primiparae, as would be expected, even if the statistics and the history of primogeniture did not bear out the truth of the statement.
If we review all these things, and if we admit that they occur even in so-called normal labor, we must ask ourselves, Are we today doing all that our refined obstetric art permits to prevent damage and avoid disease of both mother and child? In other words, shall we depart from our old trusty, time-honored “watchful expectancy,” i.e., waiting for distinct signs of distress on the part of the mother or babe before interfering—or should we anticipate these dangers, and, as routine, make the first stage of labor less painful and shorter and eliminate the second stage by a surgical delivery?
For the first stage, as stated before, we can do nothing safely except give narcotics, recommended in the form of twilight sleep—unless we perform Cesarean section. It is surprising to me to receive requests from women for this method of saving them from the pain of this part of labor. The most radical apostle of early surgical delivery is Potter, of Buffalo. In all cases, as soon as the cervix is fully opened (and oftentimes before), he completes the preparation of the soft parts manually and performs podalic version followed by immediate extraction. This practice has, and in my judgment, justly, evoked a storm of disapproval. In Potter’s hands (perhaps) the operation is safe, but in less skilful hands there will undoubtedly be a long train of dead and damaged babies, ruptured uteri and torn soft parts. The same may be said, though with considerably less force, to what I recommend for the obstetric specialist—the operation of “prophylactic forceps.”
The radical interference with the mechanism of the third stage is intended to reduce the amount of blood lost, shorten the anesthetic period and reduce the danger of infection from retained blood-clots, membranes and insufficient uterine contraction.
Now the writer freely admits that this method of treating labor is a revolutionary departure from time-honored custom and must have really sound scientific basis for recommendation. This it has.
1. It saves the woman the debilitating effects of the suffering in the first stage and the physical labor of a prolonged second stage, and in the modern nervous inefficient product of civilization this is becoming more frequently necessary. The saving of blood, already referred to, has much to do with the quick and smooth recoveries I have observed in my cases. In the combination with morphin and scopolamin in the first stage, gas or ether in the second stage and operative delivery, we have robbed labor of most of its horrors and terrors, and we ought to thus favor the increase of the population.
2. It undoubtedly preserves the integrity of the pelvic floor and introitus vulvae and forestalls uterine prolapse, rupture of the vesicovaginal septum and the long train of sequels, previously referred to. Virginal conditions are often restored.
3. It saves the babies’ brains from injury and from the immediate and remote effects of prolonged compression. Incision in the soft parts not alone allows us to shorten the second stage; it also relieves the pressure on the brain and will reduce the amount of idiocy, epilepsy, etc. The easy and speedy delivery also prevents asphyxia, both its immediate effects and its remote influence on the early life of the infant.
There are three objections to the innovation and one is a real one, but it will be, let us hope, only temporary. Prophylactic forceps will be made an excuse by unskilled, conscienceless accoucheurs for the hasty termination of labor, not in the interests of the mother or babe, but for their own selfish ends. I fear there are already too many forceps operations, and, therefore, I hesitated long before I decided to publish this method. But I have always felt that we must not bring the ideals of obstetrics down to the level of the general, the occasional practitioner—we must bring the general practice of obstetrics up to the level of that of the specialist. Let us trust each man to do honestly according to his limitations. For the one, watchful expectancy; for the other, prophylactic forceps.
The other two objections are the possibility of infection and the dangers to the child from an improperly performed forceps delivery, brain injury and compression of the cord. If the woman has an evident infection or if there is a suspicious leucorrhea the operation is contraindicated. In clean cases the matter of infection should not deter us. We practise a technic as painstaking as for laparotomy and have no fear of the results.
As for the forceps operation—in skilful hands the danger is nil. By means of the head stethoscope we are able to recognize danger to the infant from asphyxia, and since the resistances of the soft parts are gone, there is no compression on the child’s brain. We should not blame the operation for faults made in its performance.
The results of this new method of treating labor are all that one could wish for. As yet no mother or baby has died and there has been no case of infection or cerebral hemorrhage. The babies have thriven; the mothers have not shown the exhaustion and anemia of olden days. The restoration of the parturient canal has been almost perfect—indeed, perhaps too near perfect. I have gotten the impression that involution is quicker and more complete; that retroversion of the uterus is rarer, and, all in all, the recovery much more rapid and satisfactory than with the older treatment.
Cassidy, T., (2006). Birth. Boston: Atlantic Monthly Press.
Murphy-Lawless, J., (1998). Reading Birth and Death. Bloomington: Indiana University Press.
Leavitt JW., Joseph B. DeLee and the practice of preventive obstetrics. Am J Public Health 1988; 78:1353-1360.
Photo credit: Time.com