"Conservatism in Obstetrics" (1916), by Edwin B. Cragin
In 1916 Edwin B. Cragin in the United States published "Conservatism in Obstetrics," in which he discussed medical practices and techniques to preserve the vitality of pregnant women and their fetuses. Cragin argued that women who give birth via cesarean section, the surgical act of making an incision through both the abdomen and uterus to remove the fetus from a pregnant woman's womb, must rely on that method for future births. That claim was later coined the Dictum of Cragin. In "Conservatism in Obstetrics," Cragin described obstetric techniques to maintain healthy births for women and fetuses. Cragin's article outlined the best practices for obstetricians in the early twentieth century, and publicized the claim that if a woman delivers a newborn via cesarean section, she should deliver any future newborn via the same method, a theory that persisted throughout the century.
Cragin practiced obstetrics and gynecology in New York City, New York, throughout the late 1800s and early 1900s. He also taught at the Columbia University College of Physicians and Surgeons in New York City. Cragin published "Conservatism of Obstetrics" in the New York Journal of Medicine for their weekly review of medicine column.
Throughout the article, Cragin describes many improvements, techniques, and attitudes that he argues should be adopted to provide the best medical care for a pregnant woman. He offers what he believes are the best medical practices for vaginal examination, vaginal delivery, and cesarean sections. Cragin first discusses how caesarean sections have low mortality rates in the twentieth century. He argues that the fundamentals of obstetrics are being neglected and forgotten.
In "Conservatism of Obstetrics," Cragin begins by addressing pelvimetry, a technique used to measure the opening of the pelvis as a means of determining whether a woman can or cannot give vaginal birth. He reports that pelvimetry is not the only way of determining an appropriate method of delivery. However, pelvimetry in combination with the patient's medical history, condition, and a vaginal exam helps doctors determine the necessity of a cesarean section. Cragin says that those other factors play a role in whether a woman can deliver vaginally. He goes on to argue that doctors should not solely rely on pelvimetry to determine if the pelvis is large enough for vaginal birth. For example, he explains that although a woman's pelvis may seem large enough to pass the fetus through the vaginal canal, the position of the fetus against the sacrum, the area of the spine that connects both sides of the pelvis, may not allow for easy delivery.
Cragin goes on to explain that if physicians use pelvimetry during the beginnings of labors, they may better determine if a cesarean section is necessary. He notes that if a physician measured the top and bottom portions of a woman's pelvis throughout her pregnancy while also comparing the size of the fetus to the size of the pelvic opening, those measurements could detect if the pelvis is wide enough to allow the fetus to emerge. According to Cragin, if a physician did not measure the pelvis, the patient may become exhausted from pushing during labor, and both the fetus and the woman could be injured. If the physician does not measure the vaginal opening prior to the beginning of labor, the physician may find that the head of the fetus is too large to pass through the vagina. If opening is too small the life of the fetus and mother may be compromised.
Next Cragin discusses toxemia, which he also calls eclampsia, a disorder resulting from high blood pressure that if left untreated results in fetal and maternal death. In his article, Cragin notes that early toxemia symptoms can be observed by analyzing the blood pressure and urine of the pregnant woman. Cragin explains that doctors should test the urine of a pregnant woman every two weeks throughout pregnancy to detect abnormalities in their urine. Later researchers found that protein in the urine of a pregnant woman indicates that her blood pressure is elevated causing kidney failure. With the high blood pressure, the blood vessels in the kidneys stretch and enable large protein molecules to pass through, eventually ending up in the urine. Cragin stresses the use of urinalysis to diagnose toxemia.
In addition to performing a urinalysis to detect toxemia, Cragin notes that the blood pressure, the force of the blood on the vessel walls, of pregnant women should be monitored. By monitoring the blood pressure, doctors can tell if the patients' blood pressure levels are too high. Cragin says that high blood pressure can also indicate toxemia. Cragin explains the importance of checking for the presence of edema, the excess fluid and swelling in tissues, another sign of toxemia. If doctors do not catch toxemia early, the pregnant woman and fetus could potentially suffer from life threatening symptoms or death.
After discussing conditions that can occur during pregnancy, Craign discusses delivery techniques. Throughout "Conservatism in Obstetrics," Cragin regards infection prevention as an important component of obstetrical practice. He mentions puerperal fever when discussing the use of antisepsis techniques. Though not explained in Cragin's discussion of antisepsis, puerperal fever was an illness that women prior to the 1900s commonly faced due to infection often transmitted from the physician during delivery. Prior to the early 1900s, physicians did not wash their hands after performing autopsies on cadavers and before treating pregnant women in labor. They transmitted the infection from their hands into the vaginal opening of the birthing woman.
Cragin makes recommendations about antiseptic techniques during vaginal examinations, births, and cesarean sections. Cragin states that any physician who does not take all precautions necessary to protect their patients from any external infection is not looking out for the well being of his patients and will lose the support of his fellow colleagues. Cragin says that sterile gloves and a sterile gown are important measures to take when performing obstetric procedures. He explains that the use of sterile methods decreases the physician's risks of transmitting an infection to patients. Cragin reports that by wearing sterile gloves and a sterile gown, the patient and the physician will be protected against any infection.
Cragin goes on to explain his notion of conservatism in the obstetrics field. He states that being conservative does not mean an opposition to progress or innovation. Rather, Cragin argues that progress is slow to ensure the well being of pregnant women and fetuses. He explains that the two crucial techniques to ensure the wellbeing of pregnant women and fetuses are frequent vaginal exams and fetal heartbeat monitoring. He explains that doctors should perform those exams regularly and before they use other invasive techniques, including the use of forceps or caesarean sections.
In the last part of the article, Cragin notes that while caesarean sections have low mortality rates, doctors should adopt a conservative approach to the technique. Cragin argues that once a woman gives birth to a child via a cesarean section, all subsequent children must also be delivered via cesarean section. Cragin states that if a woman had a vaginal birth after delivering an infant via a cesarean, the uterus might rupture, unable to withstand the contractions. Cragin ends his article by reiterating the risks of vaginal births after cesarean sections. Additionally, he notes that cesarean sections should not be performed unless absolutely necessary.
The claim that all subsequent births following an initial cesarean section must be delivered through cesarean section later became called the Dictum of Cragin. The Dictum became the standard of care for many physicians due to the fear of potential risks in vaginal births after cesarean sections. In the 1980s, the US National Institutes of Health in Bethesda, Maryland, began to question the validity of the Dictum of Cragin after noticing a drastic increase in cesarean sections throughout the twentieth century. Discussions at the 1980 American Congress of Clinical Obstetrics and Gynecology in New Orleans, Louisiana, led to a change in recommendations that a woman with one previous cesarean section can give birth via a vaginal delivery. However, in a 1981 statement on cesarean sections, the National Institutes of Health advised that women who have had two or more cesarean sections avoid vaginal births. Into the twenty first century, the Dictum of Cragin influenced obstetricians.
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