On many occasions I text a junior partner in our practice at a dreaded hour and tell him or her to rush to the hospital to join me for an impending birth. Sure, that may not sound unusual as obstetricians should be accustomed to unscheduled 3 a.m. hospital runs. What is unusual is that I text them even if they are not on call and should be afforded a well-deserved, peaceful night of sleep. More curious, when awoken to a text stating “breech delivery—get here asap,” they happily jump out of bed and hurriedly drive to labor and delivery. The motivation is to learn skills that are not emphasized and definitely not mastered, even in the most prestigious academic obstetrical residencies. My colleagues understand that the only way to attain experience in natural twin deliveries, forceps deliveries and breech births is to make themselves available when the opportunity arises. Joining a practice that specializes in difficult pregnancies and avoiding cesarean sections, they are afforded the opportunity to learn and sharpen skills that are hard to come by.
As recently as 40 years ago the use of obstetrical forceps or the art of breech delivery was fundamental knowledge for all practicing obstetricians. Unfortunately, with the ease and availability of cesarean section and today’s harsh medical-legal climate, skilled vaginal delivery is rapidly becoming a lost art. The vast majority of practicing OB-GYNs do not have the experience, or many times, the desire to involve themselves in difficult deliveries. With fewer and fewer old-school obstetricians available to teach the younger generation, it is no surprise that every year fewer obstetricians are well versed in these arts.
On occasion when mentoring my partner in the proper application and use of forceps I contemplate the irony of how the art of obstetrical forceps has come full circle. It was once proprietary; it evolved into general medical knowledge and widespread use; and now is reverting back to a proprietary skill. Let me explain what I mean with a short history lesson.
The Chamberlens, a family of surgeons and man-midwives (as obstetricians were called at the time) lived in London from the late 16th century. Peter Chamberlen “the elder” invented a crude device designed to extract the fetal head from the pelvis of women in protracted labor. These were metal “tongs” that were designed to fit around the baby’s head, allowing the obstetrician to pull the baby out after proper placement. The Chamberlens were known to have a “secret” instrument that allowed delivery of the baby in cases where intact delivery seemed hopeless. A succession of father and son Chamberlens were recognized as leaders in their field and served as the obstetricians to the royal family.
Obstetrical forceps remained a Chamberlen family secret for close to 150 years and the family went to fantastic lengths to keep it so. They would arrive at the house of the patient in a special carriage. A large gilded box was brought from the carriage into the laboring woman’s house. The room was cleared of all people except the Chamberlens and the patient, who was blindfolded. The terrified relatives heard peculiar noises such as ringing bells—sounds manufactured to confuse and misguide the curious listeners on the far side of the door. The instrument was again stowed in the oversized chest by the time the doors were unlocked.
Hence, initially the use of forceps was extremely proprietary with only one family knowing the secret. The lengths the Chamberlens went to prevent others from learning their methods was not unusual or considered selfish at the time. Before the modern age, the practice of medicine, like many professions, was proprietary. Fathers taught sons; mentors schooled their proteges. The techniques learned or developed were what set one professional apart from the competition. It would have been foolhardy to divulge secrets that defined and provided your livelihood. After the Chamberlens’ secret eventually leaked to the general medical community, the 19th and 20th centuries saw forceps go through widespread use and dozens of iterations. The skill was part of any decent obstetrician’s repertoire.
Sadly, today it has reverted back to being a proprietary tool, one only learned and mastered by a more experienced physician motivated to teach a protege. Of course as an advocate of vaginal delivery who is disappointed to see the ever-climbing cesarean section rate, I desire to keep these obstetrical skills alive. Furthermore, many of my mentors have generously spent time imparting these skills and I feel a moral obligation to carry on the tradition of teaching. However, I suspect that part of my motivation is a little less selfless. I dream of a future where my partner will independently deliver a breech or use forceps, and I do not receive that dreaded text at 3 a.m.
Dr. Yaakov Abdelhak is a board-certified OB/GYN who also completed an additional fellowship in perinatology (high-risk obstetrics) and has been a maternal-fetal medicine doctor since 2002. He is a firm supporter of natural and vaginal birth whenever safe for the mother and baby. He is the founder of Maternal Resources, a thriving boutique-style practice, with offices in Hackensack, Jersey City, Hoboken, Howell and NYC.
