Obstetrics (Lat. obstetrix, 'a midwife,' from obsto, 'I stand before,' thus literally 'a woman who stands before or beside another'), called also MIDWIFERY (A.S. mid, 'together with,' and wif, 'a woman'). As a branch of medical science and practice obstetrics is concerned with the study and care of women during the processes of pregnancy, parturition, and the puerperium, or lying-in. As a department of medical study it embraces the anatomy and physiology of the female organs of generation, the phenomena of conception and pregnancy, of labour, normal and abnormal, and of the puerperium and the return of the organs to their non-pregnant condition. Strictly speaking, these processes are normal and physiological, and in perfectly natural conditions require little or no skilled help or assistance. But, while theoretically this may be so, it is still the case that these processes each produce an effect on the female organism which results in great modifications of the ordinary vital functions, so that the condition is one of continued physiological tension, which at any moment may pass into a pathological or abnormal condition in which skilled assistance is of the utmost importance. There can further be no doubt that many influences at work in states of civilisation tend greatly to increase the dangers of the reproductive process, so that the members of highly civilised communities are peculiarly liable to disaster; but at the same time the rudest savages are by no means free from these risks, and the care which most of them take of their women during pregnancy and parturition amply proves how conscious they are of this fact (but see COUVADE). The dangers with which the reproductive process is associated may be in some measure realised when it is understood that during pregnancy women are liable to be affected by many of the ordinary diseases in an aggravated form, which may give rise to premature expulsion of the ovum—abortion—a process in itself attended by grave dangers; that during parturition the child may present by some part of the body other than the head, causing increased difficulty, often impossibility of spontaneous delivery; that there may be some disproportion between the size of the child's head and the pelvis, due to disease or deformity; that from disease or exhaustion the uterus may be incapable of expelling its contents; that after the birth of the child the natural processes for checking hemorrhage from the site of the placenta may be at fault, or again the retention of a blood-clot or fragments of placenta may expose the patient to the risks of septicæmia or blood-poisoning. These are but a tithe of the dangers which surround the reproductive process, but they give an ample explanation of the existence of a science and art of obstetrics by which these and similar dangers may be obviated. With regard to parturition itself it may be noted that the great majority of labours (95 per cent.) are natural—i.e. the head presents, and they are spontaneously accomplished within twenty-four hours. But in civilised countries, and under the best practice, it is estimated that one in 120 women dies within a fortnight after labour. It would be out of place in a work of this kind to enter into the details of this science, but a sketch of the history of its origin and development may be of interest.
Until about the beginning of the 16th century the practice of obstetrics was mainly empirical. It was founded on experience and superstition, and was in great measure destitute of an anatomical or physiological foundation. Such practice is seen in the present day among uncivilised races, and we find procedures described as employed by the Egyptians, Jews, Greeks, and Romans in vogue among the North American Indians and negroes at the present time. During the empirical period we find, as we might expect, that the ordinary practice was wholly in the hands of women. At first female friends and neighbours would perform what kindly offices they could, but soon a distinct class of midwives arose, whose experiences or special aptitude fitted them for the duty. All ordinary labours were attended by them, and they did not yield up a difficult case to the surgeon or physician until they had exhausted a code of practice partly reasonable as founded on experience, partly superstitious, but often very elaborate. When these resources failed, the aid of the male practitioner, who combined the offices of priest and physician, was usually invoked. At first the aid yielded by these was largely based on superstition, consisting in charms, incantations, and invocation of special deities. Eilithyia among the Greeks and Lucina among the Romans were the chief deities presiding over childbirth, though among the Romans particularly a number of minor deities were regarded as specially available for special complications. With the growth of medical knowledge the purely religious office of the priest became detached from that of the physician, and among the Egyptians in quite early times the physician became a separate functionary and rendered much more practical aid. The ignorance of the anatomy of the organs involved greatly limited their practice, and cases of difficult or delayed labour were usually treated by Cæsarean (q.v.) section, or later by some form of embryotomy.
The writings of Hippocrates (400 B.C.) contain the earliest attempt to formulate a practice of obstetrics. While his writings on this subject show keen observation and shrewd judgment, yet his imperfect anatomical knowledge led him into grave errors. The presentation of the head was the only way by which he considered it possible that delivery could be effected, and then cephalic turning was enjoined by him in all cases where the head did not come first. When this was found to be impossible, as in many cases it must have been, embryotomy or Cæsarean section were the only alternatives. For over 300 years the teaching of Hippocrates was practically unquestioned, until the study of anatomy in Alexandria, under the Ptolemies, served to clear up many of his errors, and so advance the art. To the knowledge of anatomy gained here is due the great advance in obstetrics shown by the Greek physicians who practised in Rome about the beginning of the Christian era. Chief among these is Soranus (98-137 A.D.), who published a work 'on the diseases of women,' which shows a wonderful advance in the knowledge of the anatomy of the female organs of generation. He further showed a knowledge of obstetrics which is a long way ahead of Hippocrates. He insisted upon the safety of foot and breech presentations, and recommended and described the operation of podalic turning. He showed the importance of posture in favouring difficult labours, and gave careful instruction for the performance of various destructive operations. After Soranus came Galen (born 130 A.D.), who gave an account of obstetric art as it existed at that time, but whose anatomy was very defective as compared with that of Soranus. His teaching and opinions seem to have largely influenced the Persians, and through them the Arabs, for their practice all through the middle ages seems to have been founded on Galen. Probably about the 4th century a remarkable book was published by Moschion, Peri tōn Gunaikeiōn Pathōn, which is sometimes, though not quite correctly, called the first obstetric work published. It is based on Soranus, and shows a much sounder anatomical knowledge than Galen possessed. Three hundred years later Paulus Æginetus published a work on this subject which is really a compilation from previous authors, and shows no advance on Moschion. From this time until the beginning of the 16th century it may be said that obstetrics made no progress. Indeed, with the fall of the Roman empire this, like other arts and sciences, fell on evil days, and the knowledge was in great measure lost and its practice degenerated, gradually passing into the hands of the lowest and most degraded women. All trace of the earlier teaching was lost with the knowledge of the anatomical principles on which it rested; practice was regulated by the grossest superstition and ignorance, and the male practitioner was never allowed to enter a lying-in room save as a last resort. Indeed, the practice of midwifery by men was for many centuries in Europe regarded as a crime and an offence against morals, and so late as 1522 Wertt of Hamburg, who donned female attire in order to permit his attending and studying a case of labour, was detected and publicly burned at the stake. And a hundred years later a Dr Willughby, an Englishman, whose daughter was a midwife, crawled into a darkened room on his hands and knees in order to assist her at a difficult labour! Nothing could have been more deplorable than the state of obstetric practice during this period, and the suffering and mortality resulting from this condition of affairs could not be easily estimated.
The first indication of a new order of affairs is found in the training of midwives in the medical school
of Salerno about the beginning of the 16th century. Some time previously this school had inaugurated the study of anatomy, and the light shed thereby had its influence on the dark and degraded practice of obstetrics. Progress was, however, slow, and its practice still largely remained in the hands of women, to whom clung the superstition of the dark ages. Yet in the hands of anatomists like Vesalius, Fallopius, Berengarius, and surgeons such as Paré, a scientific basis was again being laid, and the knowledge of Soranus and Moschion being rediscovered. And, while all ordinary labours were managed by women, the surgeons were called in to assist when a difficulty arose. By them turning was rediscovered, and embryotomy, Cæsarean section, &c. were restored and developed on more scientific principles. By-and-by, especially in France, the practice of obstetrics by surgeons gradually gained ground, though there, and still more elsewhere, its practice by men lay under a reproach. The invention of the obstetric forceps by the Chamberlens, about the beginning of the 17th century, gave a great impulse to the art. In 1668 Mauriceau published his Treatise, which ran through seven editions, and was for long the standard work on the subject. It was translated into English by Hugh Chamberlen in 1672, and it seems to be about this time that men began generally to engage in the practice of midwifery: Harvey, the Chamberlens, and others took it up in England; whilst La Vallière, the mistress of Louis XIV., by employing Julian Clement, a surgeon of high eminence, in her first confinement in 1663, did much to establish the practice in France.
Since the revival of the study of anatomy and physiology the progress of scientific obstetrics has been steady and sure. The reproach under which its practice so long lay has been entirely removed, and the colleges of physicians, which at one time refused their fellowships to any one engaged in obstetric practice, now receive them on the same terms as other physicians, and all medical licensing bodies demand an adequate knowledge of its theory and practice from every candidate for their diplomas. The science and practice have been built up by a host of workers, the mere mention of whose names here space precludes. But it may be of use to indicate some of the great advances and discoveries on which the art rests.
(1) The Rediscovery of Podalic Version or Turning.—In 1550 Paré described this operation, whose value had been recognised and its method described in the 1st century by Soranus. This had been lost to practice since the 7th century. Paré showed how it could be performed, and pointed out its advantages in saving fetal life; and it is certain many children were delivered safely by this means whose lives could not have been otherwise saved. The operation has been extended and modified in various ways since, but that described by Paré is at the present day the one most usually performed.
(2) The Invention of the Forceps.—About the end of the 16th or beginning of the 17th century, the forceps were invented by Dr Peter Chamberlen, a son of a William Chamberlen, a Huguenot refugee, living in England (see FORCEPS). The secret, long kept, ultimately leaked out, and by 1747 the instrument was generally known and employed. The original instrument was modified by Levret of Paris, Smellie and Simpson in Great Britain; and, more recently, its construction has been elaborated by Tarnier of Paris on what is called the 'axis-traction' principle. It may safely be said that no single invention has been more successful in saving life and relieving suffering.
(3) The Employment of Anaesthetics.—In 1847 Sir James Simpson first employed chloroform anaesthesia to relieve the pain of labour, and this certainly marks one of the most beneficent advances in the history of obstetrics—probably the greatest since the invention of the forceps. Besides relieving and abolishing untold suffering in ordinary labour, it permits the performance of many operations and the correction of untoward conditions which previously were impossible or irremediable. It should be added that Hypnotism (q.v.) has within recent years been employed on the Continent for the same purpose.
(4) The Employment of Antiseptics and the Prevention of Puerperal Fever.—Till 1870 the great scourge of maternity hospitals, and also a frequent cause of disaster in private practice, was the prevalence of outbreaks of puerperal fever or septicæmia. In that year the teaching of Lister began to influence obstetric practice, and since then rigorous antiseptics are the rule in all maternity hospitals. Thus a mortality reaching in many instances to 6 per cent. of all cases has been reduced almost to zero, and this opprobrium of obstetric practice has been removed.
The teaching of midwifery is provided for in the curricula of all the medical schools of the United Kingdom. In most a three months' course of lectures with attendance on a certain number of cases is demanded of each student. The Scottish universities require attendance on a six months' course of 100 lectures, besides practical training by the bedside. As has been said, the licensing bodies demand an adequate knowledge of midwifery from every candidate for a license to practise; and further, at every maternity hospital the training of nurses by lectures and demonstration is regularly carried on. The ignorant midwife of the past is thus being replaced by trained women, who are competent to undertake the management of all ordinary cases of labour. There is, however, considerable room for improvement in the training and certification of these midwives. In recent years, in Great Britain and elsewhere, the facilities offered to women to obtain a full medical training are being greatly increased, and it is not unlikely that in course of time a very large part of the practice in this department, at the present undertaken by men, may be transferred to women. And that properly educated women are capable of undertaking all the responsibilities of this department of practice is shown by such cases as those of Mesdames Boivin and Lachapelle, who (in the words of Velpeau), 'although the pupils of Baudelocque, were not afraid to shake off, to a certain extent, the yoke of his scientific authority, and whose high position and dignity form the starting-point of a new era for the science of obstetrics in Paris.'
See amongst English works on the subject those of Playfair and Barnes; American, those of Lusk and Parvin, and the American System of Obstetrics; the French treatise by Tarnier and Budin; and German works by Schroeder, Spiegelberg, and Winckel (all of which have been translated). See also articles in this work on ABORTION, CESAREAN OPERATION, FÆTUS, FORCEPS, PREGNANCY, &c.