Chapter V: Maternal Mortality and Diseases Affected by Pregnancy (2)

“The children of nephritics are usually puny and pale.” P. 497.

Both mother and child are seriously jeopardized by chronic nephritis, the mortalities being about 30% respectively. P. 497.

Women with chronic nephritis should not marry, and if married, should not conceive. P. 498.

Diabetes. Sterility is common. Abortion and premature labor occur in 33% of the pregnancies. The children, if the pregnancy goes to term, often die shortly after birth, the total mortality being 66%. P. 502.

True diabetes has a very bad diagnosis. Offergold found over 50% mortality. Of the children 51% were still born, 10% died within a few days after birth, and 5% more before six months. P. 503.

If a woman comes under treatment with a history of diabetes it is best to terminate the pregnancy at once. P. 503.

_THE PRACTICE OF OBSTETRICS. Designed for the use of Students and
Practitioners of Medicine. J. Clifton Edgar. Professor of
Obstetrical and Clinical Midwifery in the Cornell University
Medical College; Visiting Obstetrician to Bellevue Hospital, New
York City; Surgeon to the Manhattan Maternity Dispensary;
Consulting Obstetrician to the New York Maternity and Jewish
Hospitals. 5th Edition, Revised. P. Blakiston’s & Co.,
Philadelphia._

Statistics appear to show that labors in these women, (diabetes) are quite apt to end unfavorably, in one or another way. When diabetic women become pregnant their disease usually takes a turn for the worse. According to Lecorche, true diabetes who become pregnant, usually succumb to the disease within a short time after delivery. P. 305.

ECLAMPSIA

_THE PRINCIPLES AND PRACTICE OF OBSTETRICS. By Joseph B. De Lee, M.D._

Over 20% of women with eclampsia die and statistics show that 10% of such cases developed in the maternities. For the child the chances are not good, nearly one half of the children dying as a result, that is, due to: prematurity, toxemia, asphyxiation by repeated convulsions of the mother, drugs administered to the mother, and injuries sustained during birth, especially forced delivery. Eclampsia is more easily developed in a pregnant woman because the kidneys are carrying an increased burden, and too often diseased through the pregnancy changes. The cause of eclampsia are unknown but in 20% of cases the convulsions begin during pregnancy, in 60% during labor, and in 20% after delivery. Page 365.

The treatment is to stop the gestation at a point before either mother or child, or both, are in danger either to life or to health. Page 1041.

_MATERNAL MORTALITY. Grace L. Meigs, M.D., U. S. Department of Labor.
1917._

Puerperal albuminuria and convulsions, called also eclampsia, or toxemia of pregnancy, is a disease which occurs most frequently during pregnancy but may occur at or following confinement. It is a relatively frequent complication among women bearing their first children. When fully established its chief symptoms are convulsions and unconsciousness. In the early stages of the disease the symptoms are slight puffiness of the face, hands, and feet; headache; albumen in the urine; and usually a rise in blood pressure. Very often proper treatment and diet at the beginning of such early symptoms may prevent the development of the disease; but in many cases where the disease is well established before the physician is consulted, the woman and baby can not be saved by any treatment. In the prevention of deaths from this cause it is essential, therefore, that each woman, especially each woman bearing her first child, should know what she can do, by proper hygiene and diet, to prevent the disease; that she should know the meaning of these early symptoms if they arise, so that she may seek at once the advice of her doctor; and that she should have regular supervision during pregnancy, with examination of the urine at intervals.

DIABETES

_THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Joseph B. De Lee, M.D.
Page 514._

Without doubt pregnancy has a bad effect on the course of this disease. It may develop a latent diabetes, there being cases where severe symptoms appeared only during successive pregnancies, and others where the disease grew progressively worse each time. Coma occurs in 30% of the cases and is almost always fatal. It may be brought on by a slight shock in pregnancy, but more often during and just after labor. Delivery seems to have a worse effect than most surgical operations, causing collapse, coma, or sudden death. Bronchitis has been noted in the puerperium, and this has been found to eventuate in tuberculosis. True diabetes has a very bad prognosis, authorities finding over 50% mortality, of which 30% died in coma, within two and one half years, and too often the child dies in utero.

PELVIC DEFORMITIES

_MATERNAL MORTALITY. Grace L. Meigs, M.D., U. S. Department of Labor,
1917._

Some obstruction to labor in the small size or abnormal shape of the pelvic canal causes many deaths of mothers included in the class “other accidents of labor” and also many stillbirths. If such difficulty is discovered before labor, proper treatment will in almost all cases insure the life of mother and child; if it is not discovered until labor has begun, or perhaps until it has continued for many hours, the danger to both is greatly increased. Every woman, therefore, should have during pregnancy—and above all during her first pregnancy—an examination in which measurements are made to enable the physician to judge whether or not there will be any obstruction to labor. A case in which a complication of this kind is found requires the greatest skill and experience in treatment, but with such treatment the life and health of the mother are almost always safe.

_PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.,
Professor of Obstetrics at the Northwestern University Medical
School; Obstetrician to the Chicago Lying-in-Hospital and
Dispensary, and to Wesley and Mercy Hospitals, etc. W. B. Saunders
Co. 1913._

No subject in medicine presents greater difficulties in all its aspects than this one, (treatment of contracted pelves) and none demands such art or practical skill. Science aids little here. P. 709.

Outside factors must also be considered: 1—The environment, whether the parturient is in a squalid tenement, in the country, in a home where every appliance is attainable, or in a well equipped maternity. 2—Whether in the hands of a general practitioner or a trained specialist. 3—If the patient is a Catholic, all medically indicated procedures not being permitted. 4—The age of the parturient, and the probability of her having more children. Even with these enumerations, the possible factors which might influence a labor, or our decision regarding the course to pursue have not all been mentioned. P. 709.

_THE PRACTICE OF OBSTETRICS. Designed for the use of Practitioners and
Students of Medicine. J. Clifton Edgar, Professor of Obstetrics
and Clinical Midwifery in the Cornell University Medical College.
Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon
to the Manhattan Maternity Dispensary; Consulting obstetrician to
the New York Maternity and Jewish Maternity Hospitals. 5th
Edition, Revised. P. Blakiston’s & Co., Phila._

A knowledge of the female bony pelvis is the very alphabet of obstetrical science, and the foundation of obstetrical art. This structure is most important since it is from the disproportion between its size and that of the fetus, or from its abnormal shape that many of the difficulties of labor arise.

_PRACTICAL OBSTETRICS. Thos. Watts Eden. Obstetrician; Physician and
Lecturer on Midwifery and Gynecology, Charing Cross Hospital;
Consulting Physician to Queen Charlotte’s Lying-in-Hospital;
Surgeon to In-Patient Chelsea Hospital for Women. 4th Edition. C.
V. Mosby Co. 1915._

The general course of labor is modified by pelvic contractions in various ways. 1—Abnormal presentations are three or four times commoner in contracted than in normal pelves. 2—Prolapse of the cord is much commoner than in normal pelves. 3—When natural delivery occurs labor is prolonged and the mechanism is modified. 4—Unless the true conjugate is at least 3¼ inches, even with artificial aid the survival of the child is seriously jeopardized. 5—The maternal risks are increased by the greater length and difficulty of the labor and by the frequent necessity of employing artificial methods of delivery. 6—The fetal risks are increased in natural delivery by severe compression of the head during its passage through the narrow pelvis, and other circumstances by the operations required to effect delivery, some of which involve the destruction of the fetus. P. 409.

_THE PRACTICE OF OBSTETRICS. In Original Contributions by American
authors. Edited by Reuben Peterson, A.B., M.D. Lea Bros. & Co.,
Phil. and New York. 1907._

Labor complicated by anomalies of the Bony Pelvis. John F. Moran, M.D.

The frequency with which pelvic contraction occurs can only be determined with relative accuracy. There is in existence a comparatively large amount of statistical data on this subject, but the reports of different investigators vary within wide limits, and these variations are naturally not to be explained entirely on the assumption of racial conditions, or geographic distribution. Between these wide limits are arrayed the figures of about 20 modern observers in different parts of the civilized world who have reported statistics of cases. The combined figures of 19 observers include a total of over 150,000 cases examined for pelvic contraction. In these cases the average of contraction is found to be about 10%. Williams concludes that contracted pelves occur in from 7% to 8% of the white women of this country. P. 658–659.

HEART DISEASE

_THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
HYGIENIC ASPECTS. E. Heinrich Kisch, M.D. Professor of the German
Medical faculty of the University of Prague; Physician to the
Hospital and Spa of Marienbad; Member of the Board of Health, etc.
Translated by M. Eden Paul, M.D. Rebman Co., New York._

These are cases (severe heart disease) in which, in my opinion, it is the physician’s duty to concern himself with the subject of the use of preventive measures, and having regard for the preservation of a woman’s life, and uninfluenced by any false delicacy, but with simple earnestness to inform his patient with respect to the needful prophylactic measures. The artificial termination of pregnancy, which unquestionably is often justified in women suffering from heart disease, but which unfortunately is apt to have very unfavorable results, will rarely need to be discussed if by the proper employment of preventive measures care is taken that pregnancy does not recur too frequently. P. 255.

_OBSTETRICS. A Text Book for the use of Students and Practitioners.
Whitridge Williams, Professor of Obstetrics, Johns Hopkins
University; Obstetrician in Chief to the Johns Hopkins Hospital;
Gynecologist to the Union Protestant Infirmary, Baltimore, Md. D.
Appleton & Co., 1912._

Some authorities recommend that women suffering from heart lesions should be dissuaded from marriage, or if married, from becoming pregnant. This, however, appears to be an extreme view, though of course when the lesion is serious and the compensation faulty the dangers of child-bearing should be carefully explained. P. 498.

_THE PRACTICE OF OBSTETRICS. In Original Contributions by American
authors. Edited by Reuben Peterson, A.B., M.D., Professor of
Obstetrics and Gynecology in the University of Michigan, Ann
Arbor, Mich.; Obstetrician and Gynecologist-in-Chief to the
University of Michigan Hospital. Lea Bros. & Co., Phil. and New
York. 1907. Chapter XIX._

“Leyden claims that about 40% of all women with serious heart lesions meet their death in connection with childbirth. Still greater than the demands upon the heart during pregnancy are those made by labor. The strain, mental excitement, and especially the sudden changes in the blood pressure, conditions which are well recognized as extremely harmful to every patient with a chronic heart lesion, and which cannot be avoided in the course of labor, make the situation extremely dangerous.” (Hugo Ehrenfest, M.D.) P. 357.

“The prognosis for the fetus is unfavorable. Fellner, whose figures undoubtedly are low, places the frequency of premature, spontaneous interruption of pregnancy as 20%, other writers at from 40% to 60%.” P. 358.

“No marriage for the unmarried, no pregnancy for the married, no nursing for the confined,” is a statement which has been made by a French author, and has been accepted by many writers. It is incompatible with the results of recent investigations. It would be too harsh and unjustifiable to deny marriage to a woman who has a well compensated valvular lesion. She should be informed of the risks of impregnation, but should be warned against marriage only where there exist distinct evidences of incompensation, especially in cases of mitral stenosis. P. 359.

_A TEXT BOOK OF OBSTETRICS. Barton Cooke Hirst, M.D.; Professor of
Obstetrics in the University of Pennsylvania; Gynecologist to the
Howard and Orthopaedic, and the Philadelphia Hospitals, etc. 7th
Edition. W. B. Saunders Co., Philadelphia and London. 1912._

Abortion is induced in about 25% of all cases, as the result of placental apoplexies, or of the stimulation of the uterus to contraction by the accumulation of carbondioxid gas in the blood. Pregnancy distinctly increases the danger of the heart lesion. In 58 serious cases, 23 died after premature delivery of the child. In milder cases prognosis is not grave, yet the woman’s condition is by no means free from danger. If the disease be of long standing and serious in character, it appears from statistical studies that about half the women die. P. 423.

_PRINCIPLES AND PRACTICE OF OBSTETRICS. Jos. B. De Lee, M.D.;
Professor of Obstetrics at the Northwestern University Medical
School; Obstetrician to the Chicago Lying-in-Hospital, and to
Wesley and Mercy Hospitals, etc. W. B. Saunders Co. 1913._

Abortion and premature labor, especially the latter, occur in cases of dis-compensation, in from 20% to 40%, and stillbirth in 29% to 70%, giving figures collected from various sources by Fellner. P. 489.

_THE PRACTICE OF OBSTETRICS. Designed for the use of Students and
Practitioners of Medicine. J. Clifton Edgar, Professor of
Obstetrics and clinical midwifery in the Cornell University
Medical School; Visiting Obstetrician to Bellevue Hospital, New
York City; Surgeon to the Manhattan Maternity and Dispensary;
Consulting Obstetrician to the New York Maternity and Jewish
Maternity Hospitals. 5th Edition, Revised. P. Blakiston’s & Co.,
Philadelphia._

Acute Endocarditis not only has an injurious influence upon pregnancy, but it is also apt itself to become extremely grave. Regarding treatment, induced labor will be demanded. P. 310.

TOO FREQUENT PREGNANCIES

_BEING WELL BORN. An Introduction to Eugenics. Michael F. Guyer,
Ph.D., Professor of Zoology, University of Wisconsin.
Bobbs-Merrill Co. Indianapolis. 1916._

Too short an interval between childbirths would also seem to be an infringement on the rights of the child as well as of the mother. Thus Dr. R. J. Ewart, (“The Influence of Parental Age on Offspring,” _Eugenic Review_, Oct., 1911) finds that children born at intervals of less than two years after the birth of the previous child still show at the age of six a notable deficiency in height, weight and intelligence, when compared with the children born after a longer interval, or even with first-born children. P. 166.

_FREQUENT PREGNANCIES. The Contributions of Demography to Eugenics.
Dr. Corrado Gini, Professor of Statistics at the Royal University
of Cagliari, Italy._

If the possibility of generation at any season of the year cannot, as has been shown, have any deleterious effect on the vitality of human offspring, it can none the less have indirect deleterious consequences, in so far as it allows pregnancies to succeed each other at too short intervals. P. 323.

“The deleterious consequences which too short a period after the preceding birth have upon the vitality of the child are indisputable, at least during the first year of life.” P. 323.

_THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, BIOLOGICAL AND
HYGIENIC ASPECTS. E. Heinrich Kisch. Rebman Co., N. Y._

“Frequently recurring pregnancies and childbirth, according to Kronig, act as the predisposing cause in the production of neurasthenia.” P. 257.

_NEO-MALTHUSIANISM AND RACE HYGIENE, IN “PROBLEMS IN EUGENICS.” Vol.
2. Dr. Alfred Ploetz, President of the International Society for
Race Hygiene. London, 1913._

Malthusianism further affects the quality of the offspring by increasing the intervals between single births. In families in which the parents intend to have only a few children, the mother is usually exempt from so frequent child-bearing, and she has ample time for regaining her strength. The greater interval between births has evidently a favorable effect upon the expectation of life of the children that are born. Westergard has stated that in 21,000 births, if the interval between birth is:—

The percentage of deaths before five years of age is Less than one year 20% One to two years 14% More than two years 12%

That means a difference in the mortality between first and last class of 40% in favor of the longer interval. P. 186.

_THE LIFE INSURANCE EXAMINER. A Practical Treatise by Charles F.
Stillman, M.S., M.D., Medical Examiner for the Mutual Life
Insurance Co.; Clinical Professor of Orthopaedic Surgery in the
Women’s Medical College of the N. Y. Infirmary; Orthopaedic
Surgeon to the N. Y. Infant Asylum; Member of the Am. Orthopaedic
Association; Permanent member of the American Medical Association;
Fellow N. Y. Academy of Medicine, etc. 3rd Edition. Spectator Co.,
N. Y., 1890._

“Postpone (as dangerous insurance risks) all cases of pregnancy; all instances where the mother seems, in the judgment of the Examiner, to have been bearing children too fast.” P. 186.

_RASSENVERBESSERUNG. Translated from the Dutch of Dr. J. Rutgers. 2nd
Edition. Dresden, 1911._

The combatting of self-induced abortion is one of the problems of Sexual Hygiene. The two causes of most weight in this situation are syphilis and too frequent pregnancy. It is quite evident that both of these causes would be favorably influenced by the use of contraceptive measures. P. 81.

_THE MALTHUSIAN, May 15, 1914. Sexual Ethics. A Study of Borderland
Questions. Robert Michels, (Review)._

Prof. Michels perceives that race control has two aspects; it may be an urgent duty, and it is in any case an inalienable human right. It may be regarded as a duty to actual or potential children, in view of either bad economic conditions,—such as affect the bulk of all European populations,—or defective heredity, and it may also be considered as an obligation of humanity towards the wife and mother. Prof. Michels here speaks with no uncertain voice: “The type of woman continually engaged in child-bearing is a primitive one, out of harmony with the needs and ideas of modern civilized life. Even as few as six pregnancies that go to full term rob a woman of about ten years of her life, and these the best. It is evidently far easier to provide a clear-sighted affection and a wisely conceived and individualized upbringing for two or three children than it is for eight or nine.”

_MR. SIDNEY WEBB, in The Times of October 16, 1906._

Assuming, as I think we may, that no injury to physical health is necessarily involved (in the volitional regulation of the marriage state); aware, on the contrary, that the result is to spare the wife from an onerous and even dangerous illness for which in the vast majority of homes no adequate provision in the way of medical attendance, nursing, privacy, rest, and freedom from worry can possibly be made, it is, to say the least of it, difficult on any rationalist morality to formulate any blame of a married couple for the deliberate regulation of their family according to their means and opportunities.

PERNICIOUS VOMITING

_THE PRINCIPLES AND PRACTICE OF OBSTETRICS. By Joseph B. De Lee, M.D._

Among diseases incidental to pregnancy must be counted pernicious vomiting. Page 370.

Statistics are uncertain, but out of 118 cases there were 46 deaths. Page 357.

The keynote of treatment is to stop the gestation at a point before either mother or child, or both, are in danger to life or to health. Page 1041.

_THE PRACTICE OF OBSTETRICS. By J. Clifton Edgar, M.D., Professor of
Obstetrics and Clinical Midwifery in the Cornell University
Medical College; Visiting Obstetrician to Bellevue Hospital, New
York City; Surgeon to the Manhattan Maternity and Dispensary;
Consulting Obstetrician of the New York Maternity and Jewish
Maternity Hospitals, New York City._

Under certain circumstances labor may be much disturbed by pernicious vomiting. The causes comprise actual organic disease of the stomach and functional disturbances from errors in diet. The determining cause of a paroxysm of vomiting is a severe labor pain. The coincidence of labor and vomiting is not unusual in anemic primiparae. Mental emotion is also a cause. As this vomiting may presage the development of eclampsia or some other affection it is best to terminate labor at once. Page 648.