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Martha's Vineyard Times is a weekly publication.
April 28 - May 4, 2005 Edition
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North Road April 28, 2005 There is no new Off North Road column. Revolution in delivery April 21, 2005 By Russell Hoxsie, M.D. See Part II Part I A group of women and I sat in my kitchen sometime in the fall of 1970 to discuss their hopes for a new approach to pregnancy, labor, and delivery at the Martha's Vineyard Hospital. Those who have grown up after the 1960s and 70s must have difficulty understanding the fire and determination women had then for changes in the practice of hospital obstetrics. I can remember walking through a typical labor room in a large municipal hospital of that era. The area was like a stable with five or more beds off to each side of a central aisle. Each cubicle had a drapery to separate it from the next and, if properly drawn, from the central aisle.
However, that walk through the labor room was often horrendous, everyone in advanced labor screaming their disorientation, in danger of catapulting out of bed if not restrained. When a woman needed to be moved to delivery, a great eruption of activity occurred: “Hurry, I can see the head,” “She's bulging,” or “Her water's broken.” Gurneys would fly through the curtains and head for the exit, privacy a nuisance and patients left exposed. Not a pretty picture and this filtered down to many women after their amnesia wore off and they talked with nurses and some women who had been lucky enough to avoid the same drugs. Everyone who was admitted routinely was shaved over the birth outlet, most had enemas, which might be expelled during delivery. Husbands, corralled in a fathers' waiting room well away from the pandemonium of labor, waited and waited until a nurse appeared to tell daddy the result of it all. Most of the men then paced outside the large nursery windows waiting for a glimpse of their progeny in the altogether as nurses got babies diapered, and swaddled. “No more surprises in the waiting room today,” obstetrician Pat Donegan told me when I talked with him recently about current programs for delivery at our Vineyard hospital. “No unexpected twins at the last minute.” A month ago some of the 1970 group - Lee Fierro, Peg Goodale and Fran Finnegan - sat with me in Lee's kitchen to reminisce about the old days. These women were part of a group of Vineyarders exposed in the 1950s and 60s to Grantley Dick Reid's “Natural Childbirth” and F. Lamaze's “Childbirth without Fear.” Lee had had five children, one at home, without drugs after prenatal childbirth education. “It was a mish-mash,” she says now. “No one particular system.” Peg had given birth under the Lamaze program and brought “scads” of materials to the group. This material became the women's policy manual. They formed “Education for Childbirth.” Gradually other young pregnant women learned of the group and several of my patients enlisted. Most of these early arrivals became teachers and birthing coaches for the new movement. They taught two separate classes, 8 weeks and 6 weeks, in anatomy, physiology, and exercise. Lee told the patients to train as if they were competing for the Olympics. They alternated [on duty] in two groups, 8 weeks on and 8 weeks off. Lee remembers, “We came to Dr. Hoxsie's house and talked about [our hopes and plans for] the whole subject of [childbirth, including] going into the labor and delivery rooms. I remember [he] said, 'You're going to have a fight with the doctors but go ahead; I'll support you.' I remember several nurses were supportive. Dr. Rappaport was the only doctor who came to one of our sessions to see…what was going on.… He was very interested and asked a lot of questions.… I felt grateful he came….” Peg said, “No one had ever been allowed into the OR to watch a C. section. When it finally happened it was a triumph for forward motion.” [ca 1972] Fran began her story. “I was pregnant that winter living in California in various informal places. We were just a young couple and up till that time it never occurred to me … [that I wouldn't just] some day wake up with a baby. I'm a fruitcake you know…camping, hiking.… We moved to the Vineyard. [It] then was a great shock, rolled up the sidewalks, nothing to do…awful. I saw a movie, 'River Run,' or something like that, and heard mention of a childbirth book by Lamaze. I went to the Bunch of Grapes and asked if they had it. The woman in the store said that was strange; I was the second person to ask for the same book that week. She gave me the woman's name and phone number. Elizabeth and I began reading the book together, trading back and forth…between Chappaquiddick and Chilmark. “On my first appointment with Dr. Hoxsie I said, 'Here's what I want to do,' showing him the Lamaze book. 'I don't know how much experience you've had with this before…no episiotomy, no shave, husband present…. Dr. Hoxsie said he'd go along with it. I felt great….” She described a later delivery. “I have a photo of Dr. Hoxsie holding my kid up by his ankles and slapping him on the bottoms of his feet. I said I was going to get him on that one. He's not going to get away with holding my baby upside down and slapping him on the feet.” Lee added, “We were pushing the envelope all the time.” The group's response was clearly stated. It was all grass roots. They didn't want drugs or episiotomies unless they had to…. They wanted the labor to go naturally. They made such a difference to the mothers and the fathers, particularly during long labors; nurses changed shifts; doctor was in and out. “We always stayed no matter how long it went. All the doctors went along…. It took time to be accepted by the staff…. we were all women with children of our own who were sitting in with a woman throughout her whole labor and delivery. I can't help thinking the doctors and nurses were relieved and grateful.” “I was a grateful doctor,” I told the group. “You took over some responsibilities from me. I stopped worrying so much about each patient. It was quite a change.” Lee interrupted, “I didn't realize we relieved responsibility from you, Russ.” “That's right,” I replied. “You [thought you] were all depending on me.” Much laughter followed. The long, lonely hours in the labor room with only one nurse and the patient present were gone and my sense of “attending a delivery” was engendered while the sense of “delivering the baby” was modified, despite frequent lapses in language to the contrary. Fran continued her first natural birth story. “Pretty close to dilating, I deliberately stayed home; the longer I stayed home the less they could interfere with my labor. Michael was a nine-pound baby born on Christmas. I didn't tear and went home the next day. Everybody in the hospital came to see the woman who had given birth without medicines or anesthetic - a freak. It was quiet, unrushed, stayed overnight. And such a big baby. Elizabeth's was born next month the same way.” I remember my mixed feelings attending this birth and wondered if we had gone a step too far in changing the order of things. Coming to the Island to practice obstetrics was an unsettling experience. No longer with in-house support of a large hospital, the thought of serious hemorrhage or ruptured uterus was unthinkable. With no blood bank on-Island in the early days, I carried phone numbers of a dozen new friends with Type O, Rh negative blood who agreed to come to the hospital for emergency blood donation. Fortunately I never needed them. A specialist's help was a couple of hours away. Emergency evacuation off-Island was then in the pre-helicopter stage. However, when Fran's wonderful baby, Michael, gushed forth with mother panting and pushing under total control, father at her head and sharing every labor contraction, I knew that we were onto something too long delayed. Not a dry eye in the room survived and there were hugs all around. Lee remembered our first conversation at my kitchen table 35 years ago. “It went much like this today…. [It] seems like a bookend.” Part II of this article will appear on April 21, illustrating some of the highlights of obstetrical practice on Martha's Vineyard in the new century culled from my conversation with Dr. Patrick Donegan about his obstetrical practice at Martha's Vineyard Hospital. Part II Part I of this two-part article described the natural childbirth movement on Martha's Vineyard, some of the changes which it wrought and the people who were involved. I regret omitting Elizabeth Depperman and Bronwyn Hill from the “1970s” group of pioneers. Part II jumps ahead 35 years to present-day obstetrics at the Martha's Vineyard Hospital.The revolution described in the previous article was one of velvet gloves over tight fists, civil yet confrontational. Those pioneer Vineyard women remain curiously puzzled about where the movement went and ended. It seemed to melt away. I discontinued my obstetrical practice in 1977, but I was convinced that the natural childbirth movement was no flash in the pan. Enthusiastic and innovative, the women directing its course changed significantly the way doctors and hospitals treated their women patients. The Vineyard had seen nothing like it here before and my feeling was that it would not simply evaporate. In the intervening 30 years, the idea of preserving as much of a natural process as possible thrived under two other obstetricians, Susan McCoy and Jason Lew. The hospital itself “went into competition,” as the original group of women remarked, by starting prenatal classes in the doctors' waiting room. The physicians without exception gave their blessing and several of the obstetrical nurses conducted the prenatal sessions. In the mid-seventies our first full- time anesthesiologist, Malcolm Dunkley, arrived from Canada. From that time on, anesthesia in the form of epidurals became a much sought-after procedure for abolishing pain during active labor. Many women who conscientiously had followed “the program” were disappointed to discover pain continued to be a disagreeable problem. However, with instruction beforehand and a cooperative staff in making the whole process more humane and individualized, delivery became a cooperative process among patient, family, anesthesiologist, nurses, and physician. I sat down recently with Patrick Donegan, obstetrician-gynecologist at Martha's Vineyard Hospital since September 2003, to see how present-day obstetrics was practiced on Martha's Vineyard. Dr. Donegan is a graduate of the University of Missouri, the Medical Center of Kansas City, and a progressive obstetrical program at Boston University Medical Center. He worked with midwives from the outset. Boston Medical Center, he explained, “was…well integrated in natural childbirth…with six neighborhood health centers which fed in prenatal patients to Boston City Hospital. Nurse-midwives rotated through the obstetrical service where an aggressive program prevailed to keep things 'natural.' We used no anesthesia except intravenous narcotics…even then [we had] a feeling that rest and less medicine were better for labor progress. “Common preparations for a woman in labor [which the 1970s group on the Island was so adamantly against] had been uncommon for so long that no one anticipated they would be done. Episiotomies were never done routinely … only when they were needed to avoid a tear. [Shaving and enemas were things of the past. Anxious fathers no longer paced up and down in distant waiting rooms.] We looked up the medical literature; there was never any evidence that justified the use of masks and gowns. Later in the AIDS era, protocol changed, more for the protection of the health provider than the patient. “Here in the Vineyard hospital Kathy Chase, nurse-midwife, and I actually manage a joint practice without a clear line between doctor and midwife. We try to co-manage each patient and we both are aware of every labor as it comes along; each of us sees the patient at regular intervals in the prenatal period. If a patient wants to see one of us exclusively we can do that too. Few do. Some patients consider Kathy as their primary care giver and call her Dr. Chase. “That's fine with me; we have the best of both worlds. Kathy is very experienced and our practice styles mesh entirely - no disagreements. Part of this is my having always worked with nurse midwives and Martha's Vineyard is small enough to [so that we can] give a very personalized experience. Fifty percent of the time both of us are at delivery, half the time one or the other. I really like it here. “Some women remain convinced that quality of care is higher at the Brigham and Women's in Boston. Quality is equal here except, of course, for the extreme complications. If I could have had this experience with my four kids I'd have changed it for this, just because the environment and culture are different. The tendency [in large hospitals] is to move on to the next patient, move on to the next crisis. We have so little of that here we have time to tend to the patient. A few patients have gone off-Island for a delivery, and then had a [subsequent] delivery at our hospital and were amazed at the care they got here. Sometimes it's hard to get over this concept: we are so close to Boston [hospitals] with their international reputation. Personal attention you get here is unmatched by any other hospital that I'm aware of and I've been in quite a few. It's impressive.” Dr. Donegan sees the evolution of hospital obstetric practice away from a hospital-doctor orientation to a patient oriented one. The women's movement and natural childbirth gave women a sense of power and ability to ask for and obtain the kind of obstetrical care they wanted. At my reunion meeting a month ago with the 1970s women, Lee's “bookend” may have closed the first chapter of a revolution in delivery on Martha's Vineyard but the movement did anything but fade away. It paved the way for a standard of care that will continue to adapt to needs of women and their families as long as mothers don those velvet gloves. |
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