Obstetrics Midwifery

Pre-maternity supervision is in its infancy, but with experience of its working much more will be possible in the way of preven tion. Many of its problems have scarcely begun to be worked out and an example of one of the most outstanding of them is worth a little consideration as an example of the problems that obstetrics has to face.

A Widened Outlook.

When these wider questions are looked into, there is little ground for complacency among those respon sible for the obstetric practice of the country. There has been no reduction in maternal mortality equivalent to the drop in the general death-rate or to the remarkable fall in the infantile mor tality, which has been halved since the beginning of this century. Further analysis of the registrar-general's figures in England and Wales shows that septicaemia, a form of blood-poisoning prac tically eliminated from general surgery by the antiseptic and aseptic technique, is still too prevalent and still causes (as puerperal sepsis) about a third of the deaths in childbearing. The annual rate of maternal deaths per 1,000 live births registered in England and Wales is a little under f our. In the bad years im mediately after the War, the rate was over four per ',coo. In the United States (192o) the rate was 7.99 per thousand. This may not appear large but means that about 3,00o women in the prime of life die in childbearing with the loss of their ma ternal care to many more young children, and of these mothers over i,000 die from puerperal sepsis, a preventable disease. Its prevention is a more complicated matter than, and a somewhat different problem from, that of surgical sepsis, because septic organisms may be present in the lower genital tract and spread upwards and into the blood stream, apart from any question of failure of aseptic technique on the part of the attendant.

The statistics of all maternity hospitals show that fever in childbed increases with all complications and difficulties calling for internal manipulation, all of which tend to the introduction or upward spread of infective organisms. The more prolonged and the higher up the tract the manipulation, the greater is the incidence of fever. By far the commonest operative interference is delivery by the forceps because it is advocated by many merely in order to shorten the patient's suffering. Instead of trying to

secure natural delivery in cases of weak uterine action, a sub stitute for the uterine power is adopted in the shape of the muscular power of the attendant exerted through the obstetric forceps. The causes of weak uterine power are difficult to de termine and often impossible to foresee, but here is a direction in which investigation is necessary.

Particularly calling for solution are the questions, how far mod ern social conditions have lessened the power of the woman of to-day to stand the hardship, fatigue and mental and physical strain of child-birth and rendered her less capable of completing the expulsion of the child naturally than the mothers in the days before anaesthesia and frequent forceps delivery ; what are the factors tending to produce this lessened capacity; and, how far are they removable? The obstetrical centre of gravity has thus been shifted back wards from the care of labour to the supervision of pregnancy and a wider outlook over the reproductive cycle is taken so that the part played by obstetrics is seen as but part of the wider subject that is concerned with securing the health of the new generation at the minimum of cost to the old. The pre-maternity supervision looks forward to the nursing of the child and the rearing of the family. It anticipates the natural feeding of the infant by removing all causes that may interfere with breast feeding. It has an educational side and endeavours to inculcate sound principles of hygiene in the preparation for, and the care of, the babe when born, because success in this direction will mean a better start for the new generation. The observation of the de veloping child falls to paediatrics and the two subjects, as ma ternity and child welfare, have become a duty and charge to local health authorities, and as such are well known to the public.

In conclusion a tribute should be paid to the late Dr. Bal• lantyne of Edinburgh, as the advocate of pre-maternity super vision and the pioneer of the antenatal clinic, which more than anything else has served to further the permeation of obstetrics by the spirit of preventive medicine. See J. S. Fairbairn, Gynae cology with Obstetrics (1926). ( J. S. FA.)