An excerpt from Fifty Years a Doctor: The Journey of Sickness and Health, Four Plagues and the Pandemic.
I went to medical school for four years.
I was a medical intern for one year and a surgical resident for one year. And finally, an otolaryngology resident for three years.
My medical license permits me to practice medicine and surgery as a general practitioner.
I never lost interest in general medicine or the history, biology, and science underpinning modern medicine.
I was originally attracted to OB/GYN as a specialty. But at that time, it was all-solo practice, being on call for deliveries day and night — that did not appeal to me.
My extensive medical school experience in OB/GYN, with sleepless nights, turned me from this field.
How was I to know that within a few years, a stressful OB/GYN routine would turn into a group practice with well-defined schedules for the doctors? But I never forgot my extensive obstetrical experiences in medical school with the 50 deliveries I performed.
Helping bring life into the world was different from treating sickness and dealing with death. But some things troubled me from those hospital deliveries that were still in my mind. I would find myself thinking about them at times, trying to figure them out.
For example, after the delivery of the newborn, there was a great rush to clamp and cut the umbilical cord. I was surprised at how difficult it was to clamp that turgid, pumping cord, and this is from a young man not far from the days when he weight-lifted loaded barbells and still had a very strong grip. After the cord was clamped, it was cut, and the baby was handed to a nurse who rushed the infant to a separate area to be analyzed for the Apgar score, which measured how strong and healthy the baby was immediately after delivery.
The Apgar score came from a pediatric anesthesiologist named Virginia Apgar and stands for appearance, pulse, grimace, activity, and respiration.
If a newborn did not get the normal score, the pediatrician would start various treatments to improve the newborn’s chance of healthy survival.
I wondered why so many newborns were in medical danger soon after birth. But when I was working in obstetrics, I didn’t even have time to walk over to talk with the pediatrician assessing the newborn’s health because there was an immediate urgent need to deliver the placenta.
The placenta is commonly called afterbirth since it is delivered after the infant’s birth.
The crisis we had to deal with at this moment was to get the placenta delivered as quickly as possible. This involved putting large amounts of pressure on the mother’s abdomen to push the placenta out of the uterus without leaving any fragments behind. This could cause serious bleeding or later infection that might necessitate a hysterectomy.
You can imagine how uncomfortable and painful the strong pressure applied to the mother’s abdomen was right after the struggle of delivery.
Often, a slim nurse would climb onto the mother’s abdomen to push even harder. And with all this pushing, the placenta was delivered with a large amount of bleeding since there was still lots of blood in the placenta backed up from the immediate clamping of the umbilical cord while it was still delivering blood to the baby, as well as bleeding from violent tearing of the placenta from its uterine attachments because of all the pressure applied to the abdomen.
If there was a chance that some parts of the placenta were not delivered, then the obstetrician would need to do a wiping of the uterus with a gauze pad at the end of a large forceps, which caused even more discomfort to the young mother, who had just gone through labor and delivery.
I knew from my biology studies that almost all mammals are placental. In humans, they support the developing animal with nutrients and oxygen through an umbilical cord. It is hard to imagine that any other mammal, for example, a horse, cow, dog, or cat, would turn around during birthing to bite and sever the umbilical cord while it was still delivering essential blood to its progeny.
Why were humans different? Was there some medical advantage to depriving the newborn of all the blood in the placenta? This was what I would ponder at various times.
And then there was when I had a delivery experience with a private obstetrician in Brooklyn.
The attending doctor wanted to further our education and let us, the medical students; deliver the babies of his private patients without the permission or knowledge of the patient, which sounds unbelievable in the present era but was considered normal teaching in that era.
The patient would have sedation and possibly spinal anesthesia. A blindfold was placed over the patient’s eyes as she was told that this might prevent a spinal headache. Then I switched places with the private attending doctor to sit in the doctor’s delivery chair opposite the patient’s vagina. In contrast, the private doctor kept talking to the patient. I smiled at the young attending obstetrician, and he smiled back at me.
The delivery was smooth without needing an episiotomy, a surgery to widen the vaginal space to avoid an irregular and uncontrolled tearing of the vagina as the baby’s head stretches the vagina.
The patient was relaxed in a twilight anesthesia state, with an anesthesiologist administering small doses of medication to reduce pain and create a mild amnesia of the birthing process and its pain.
Of course, now I realize that the potent sedatives and anesthetics given to the woman in labor, even in small doses, also seeped into the placenta and all other bodily tissues and thus into the infant, interfering with breathing and other essential activities. This was why we had to get the infant delivered quickly, immediately cut the cord, transfer the baby to the waiting pediatrician for evaluation, get an Apgar score, then get the infant to the nursery where a trained obstetrical staff of obstetrical nurses would oversee the newborn’s condition.
If the infant was drowsy but breathing well, this would affect its ability to nurse and be fed by the mother, another disruption of the natural course of childbirth and maternal bonding, in addition to missing the excellent nutrition and immune transfers from the first breast milk, called colostrum, loaded with important immune particles.
Now we also know that the last blood from the placenta has many important stem cells that can help support the baby’s health, possibly even into adulthood.
After World War II, there was a movement to use baby formula instead of breast milk, at least for those who could afford it. The sterile formula was considered more hygienic than having a baby put its mouth on the mother’s skin, which was obviously not sterilized!
It seems that in medicine and most other fields as well, we humans tend to think we are smarter than nature.
But I had a chance to see how childbirth should be done when I did home deliveries just as a midwife would, without sedation and with a normal squatting birthing position.
I arrived at the home of one laboring woman and was greeted by her parents and taken into the living room, where she was reclining comfortably with lots of pillows and towels.
She smiled, and we greeted each other. I examined her several times as part of her prenatal evaluation. We had discussions about hospital delivery vs. home delivery and possible risks. She was totally dedicated to having her baby as naturally as possible.
Then I met her husband, who was completely nude, sitting on the floor directly in front of her. This being the ’60s era, although the calendar said ’70s, “back to the earth,” no shame, etc., I was not bothered by this.
I spoke to my patient, and she told me she was moving along nicely with regular contractions and that she had not yet” broken her water,” which to me was always an awkward way to say the amniotic sac had opened with the release of amniotic fluid which usually led to a quick delivery.
I continued to talk to the patient and family while the husband was rocking slowly in front of his wife. Suddenly, without warning, a veritable tsunami of greenish water splashed all over the husband, who gave a loud gasp. We all started laughing at what had just happened, including the husband’s wife and then the husband as he was handed towels to wipe the greenish amniotic fluid from his body.
And sure enough, within ten minutes, the pregnant woman was squatting and “pushing,” and the baby’s head appeared at the vaginal opening. A few “grunts” later by the laboring woman had the infant “crowning” at the vagina. I supported the head and allowed a slow delivery of the head and then the rest of the body.
The newborn was immediately alert and breathing normally and moving. I helped the mom get her baby and bring him to her breast, where he quickly searched and found a nipple and started sucking, all while still attached to an actively pumping umbilical cord.
The cord didn’t have to be stretched since it was long enough for the distance from the mother’s lower abdomen to her breast.
Everyone was so happy. The question of who would cut the cord came up. I explained we would cut it when it was no longer pulsating and had shriveled, which took a few more minutes. I let the dried-off husband do that. There was no need to clamp the lifeless cord since it was like old cellophane, and the cutting was bloodless. There was no blood from the vagina either and in a few more minutes the new mother said she had a cramp and a small, bloodless placenta. The “afterbirth” was delivered effortlessly without a drop of blood from the vagina.
My work was done, and I told them to call me the next day. This happy, sucking newborn would get the highest Apgar score possible.
The next day, I heard from the new mom, who thanked me so much for helping her have a wonderful birth experience. She laughed and brought up the funny explosion of amniotic fluid all over her husband, and I laughed, too.
The next delivery I attended was a little more complicated.
I arrived at the apartment where the couple lived and was greeted by the husband, whom I had never met before, and he said he was glad that I had come because his wife was having some problems.
I went into the living room with him and saw her propped up on the floor over a few towels. She quickly told me that she had been “pushing” for an hour and had no progress.
I examined her, felt a normal pulse and heart and lungs, and then palpated her abdomen using the Leopold maneuvers to find out if the fetus was positioned properly with his head downward. I also felt the fetus moving.
I asked her how often her contractions were coming. She said she wasn’t sure. She was pushing all the time. She hadn’t felt any progress.
I thought that something was blocking her cervix from dilating. I told her I would do an internal exam. I put a sterile glove on, examined her, and noted that the cervix was very edematous and spongy, probably from all of her straining against an undilated cervix.
She told me that her water “broke” about an hour ago, and she had read that the baby should be coming out quickly after that happened.
I explained that wasn’t always the case and that all of her straining had caused swelling around her cervix. I felt that if we waited, her normal labor would soon begin, and the cervix would dilate.
I got her and her husband to relax. I asked her to tell me when she got a contraction.
Within 15 minutes, she had a contraction. Others came in a regular pattern and then some very strong contractions. I told her to try pushing with the next one. She said she felt the baby moving. As the strong contractions continued, we started to see signs of her dilated vagina and the baby’s head.
Within 10 minutes, the head was crowned. I put gentle pressure on the head to prevent an uncontrolled “popping” of the head through the vagina and allowed for a gentle advancement of the baby until he was fully delivered.
I gave the baby to his mom and told her to put him on her chest. This newborn quickly shook his head in search of a nipple, got one, and started sucking greedily.
The parents were very happy now and relaxed. Then a smaller contraction occurred, and the small afterbirth (placenta) was delivered.
The question of cutting the umbilical cord came up. I said we would do this when all the blood was transferred from the cord. Within a few more minutes, we cut the shrunken cord with no need to clamp it first since its function was over — it was empty of blood and totally collapsed.
Seeing an unsedated young mom with her unsedated, active newborn was wonderful.
I told them to keep the baby warm and to call me in the morning or sooner if needed.
As I left, I noted that there was not one drop of blood on the white towels she had been lying on.
My younger sister was also my obstetrical patient more than 20 years later.
She and her husband were living in our house. She wanted a natural childbirth. She had one child several years earlier when she was living in a California commune, “the Source Family.” She did that with two other Source women who had experience with childbirth, so I knew she was capable of uncomplicated vaginal birth, and I agreed. Her pregnancy was well advanced when she arrived at my house. When she was near her due date, I examined her abdomen manually and felt the fetal head in the correct downward position.
A couple of weeks later, she told me that her water had broken, and she was starting to have contractions.
I said we should all go to bed and rest because she would probably have the baby at night or in the morning.
When I awoke early in the morning, I went to see her. She told me her contractions didn’t seem right.
She removed her blanket. I immediately saw an abnormal abdominal shape. On palpation, the fetus was lying crosswise, a transverse presentation — there was no way that I would deliver her at home.
We went to the local general hospital, where I knew all the doctors and called the chief of obstetrics. He responded quickly and said the obvious.
“Let’s get her ready for a C-section.” Later that morning, she had her newborn son at her breast.
My friend, the obstetrician, never charged her for the delivery, and neither did the hospital. That was how old-fashioned professional courtesy worked in that era.
Ronald Halweil is an otolaryngologist and author of Fifty Years a Doctor: The Journey of Sickness and Health, Four Plagues and the Pandemic.