Prenatal Care in 1981 and 1998
(Dated article hasn't lost anything since 1998)
Recently at my Mandeville Ob-Gyn office I saw a woman newly pregnant. Of course this is commonplace with what I do, but what was unusual was that her last baby was born in 1981. After I saw her that day, I began considering just how different prenatal care was back then compared to now. Even though 1981 is still considered by many to be in "modern times," I know the contrast between two different protocols of prenatal care separated by 17 years is remarkable.
In 1981, surprise stillbirths still haunted obstetricians frequently. Of all the things since then that has made an impact in decreasing these tragedies, routine screening for gestational diabetes and third trimester fetal surveillance with a simple fetal heart monitor have had the biggest influence. Currently, stillbirth is a rarity, usually victimizing those mothers who sought no prenatal care at all. With almost 10% of all pregnant women testing positive for otherwise silent gestational diabetes, we now know the people we need to watch more carefully during pregnancy. The non-stress test has proven a lifesaver in selecting out high-risk patients who may need earlier delivery to save a baby at extreme risk.
In 1981 amniocentesis was used, as it is now, to determine fetal lung maturity in those babies that needed to be delivered earlier than term. Whether fetal jeopardy from diabetes, growth retardation from hypertension or smoking, or imminent danger from unknown reasons, the amniocentesis eliminated the worry of lung immaturity in making the decision to deliver early. Back then, the tests were cruder; today our tests can give a rapid (same day) yes or no as to whether the baby would be worse off outside the womb than inside.
In 1981 a patient presenting late in pregnancy with bleeding had to suffer the risk of the "double set-up." This was a test wherein the woman was placed in the C-section room for a vaginal exam. All of the surgery instruments were opened and a team was ready to carry out immediate C-section should the simple vaginal exam (one set-up) inadvertently place an examining finger into a low-lying placenta. This bad surprise would often cause instant life-threatening hemorrhage for both the mother and baby, and somehow the C-section preparations (the other set-up) didn't reduce any of the anxiety. But today of course we have simple non- invasive ultrasound. Thank goodness.
In 1981, over half of the patients that underwent C-section at Charity Hospital ended up in the "Septic Ward," experiencing serious post-operative infections. But now we're into second and third generation antibiotics. We also have antibiotics that cross the placental barrier safely to treat infections in the womb, which has single-handedly added weeks onto the gestations of babies of mothers with premature rupture of membranes. It is not uncommon in such a catastrophe at 28 weeks gestation (12 weeks early) for these drugs to allow progress to 32 weeks.
Premature delivery is still the biggest cause of complications to children. Back in 1981, a drug called ritodrine was just replacing the powerful alcohol drip to stop contractions. This was a huge advance if you ever saw a woman on IV alcohol, which was a pretty horrible adventure into nausea, vomiting, delirious seizures, and proven risk to the baby. Terbutaline, about ten times cheaper and just as effective and safe as ritodrine, is now used ubiquitously in private practice. There are even medical companies that can set a patient up with a terbutaline pump she can go home with, allowing her to stay away from the hospital until delivery. Home uterine monitoring can allow a patient to send information from her home to avoid having to go to a hospital every time she wondered whether premature labor was beginning. A new test, SalEst, is a mere collection of saliva that can indicate who might go into labor within a couple of weeks.
Routine ultrasound, often under attack for not being cost effective, is extremely cost effective to the baby where something is discovered that normally would remain undiagnosed. The number of ultrasounds in private physicians' offices has made ultrasound an accepted standard for most obstetricians. Besides the medical benefit, the intangible benefits of maternal (and paternal) bonding occur much earlier when the expecting parents see their child months before the birth.
Isn't this what having a child is all about? Ultrasound has made relating to the product of a couple's love easier and earlier. Today, we have satisfactory screens for chlamydia and other infections which can be silent until causing premature labor.
We have colposcopy in common use, allowing us to evaluate an abnormal pap smear in the office instead of doing the potentially destructive cone biopsy to a woman's cervix-- the one thing holding the baby in until maturity. For Rh negative mothers, RhoGam is now given before delivery as well as after, reducing the fatal disease of hemolytic disease of the newborn to mere thousandths of the original incidence. In hospitals we have computer programs that can transmit fetal heart monitor recordings to screens in our offices as they're being recorded. Nurses have central monitoring at the nurses' station, allowing them to see the recordings on all of the babies and labors at once, signaling alarms at the first sign of fetal distress.
In 1981, monitors weren't always used, and when they were, they sat in the labor room often unobserved by the labor nurses charting at their desk. It's often said that total knowledge is doubled each cycle in half the amount of time it did the previous time span. I know this is certainly true in obstetrics. In 1998 the level of prenatal care is so much higher than in "modern" 1981 that a current obstetrician would be very uncomfortable indeed using standards from back then to render care.
Uncomfortable? Frightening might be a better word.