From classical obstetrics to modern industrial technologies

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In the world bellowing:

Glory to the coming!

What whispers in me:

Glory to the gone be!

Marina Tsvetaeva

The decision to publish this article was inspired by the lively response from my peers to my recent speaking on women’s, children’s, and population health in Russia. The concerns raised in the above speeches have obviously been occupying our obstetrics gynecology community for a long time, and is The article was also motivated the opinions some colleagues who had a different understanding the problems under discussion, but considered it important keep them on the current deliberations.

At the recent conference “From Classical Obstetrics and Gynecology to Modern Perinatal and Reproductive Technologies” held at the Altai State Medical University, I was delighted to see how strongly the of classical achievements in the basis for the of modern obstetrics conveyed in the Altai Territory, far from Moscow and St. Petersburg. Why have I decided to discuss this? It has been over three decades since classical obstetrics has been mentioned at any conference in Russia. Naturally, this was the result the intervention Western missionaries, who largely destroyed our science and education in 1990s, which eventually paved way for closure the Russian Academy Medical Sciences, the adoption the Bologna system and Unified State Examination, replacement national classifications, etc. Westernism has become deeply entrenched, adapting our mentality to prioritize Western values. Concurrently, a number Russian obstetric specialists declared that the age classical obstetrics, with its violence inherited from late Middle Ages, had ended with arrival perinatal obstetrics. This assertion is completely misleading because classical obstetrics has always rejected violence during childbirth. Furthermore, the historical period of midwifery preceding the 19th century has not been defined as classical [1].

The concept classical originated in Europe in early 19th century, marking the development classical obstetrics. It is to distinguish between classical obstetrics and medieval midwifery.

Ernst Bumm is widely acknowledged as the father classical obstetrics in Western Europe. In Russia, Eduard-Anton Y. Krassovsky became the leader and founder of scientific classical obstetrics in the same period. Significant to his legacy was foundation first Russian Society Obstetricians and Gynecologists in St. Petersburg (1886) and Journal of Obstetrics and Women’s Diseases (1887). the end 19th century, Russia, with France, the home obstetrics, and Germany, constituted top three obstetrical centers, in no way outranking any of It is noteworthy that the of classicism and classical implied focus on Renaissance, not only in the sciences, but also in arts.

Vesalius’s (1514–1569) human anatomy, Harvey’s (1578–1657) discovery of of the of stethoscope and of childbirth, Semmelweis’s and Lister’s antiseptics, Simpson’s and of of antibiotics sulfonamides, and many other advances laid cornerstone for development fundamental, scientific, and essentially classical obstetrics. This is likewise true for cesarean section (CS) surgery, which has also evolved from the so-called classical CS to lower-segment CS. This is evidence that obstetrics is an excellency based on scientific achievements [1].

The discovery of the by academician Aleksey A. Ukhtomskiy in this context [2]. Professor Ivan I. Yakovlev further extended this concept to obstetrics, which resulted in deeper understanding of and dominant childbirth. These phenomena are associated with the biological preparation a woman’s body and soft part her birth canal for childbirth. Wouldn’t we say that this is classical obstetrics, which largely determines the physician’s strategy during labor and delivery? It is crucial this context acknowledge that fundamental principles and approaches classical obstetrics are based on the concept that pregnancy and childbirth are physiological processes that have evolved over centuries and have adapted to basic vital needs population.

In their efforts to meticulously safeguard physiological processes parturient women, distinguished practitioners midwifery care have consistently adhered the principle classical obstetrics: “to help, or at least to do no harm.” The argument some obstetricians that classical obstetrics has become outdated with advent perinatal obstetrics and increasing prevalence CS rates completely ill-founded. This viewpoint may be detrimental, as it is associated with inability curtail epidemic-like growth CS rates in Russia (25%), where one CS operation for every four births (and one for every three in big cities) perceived as normal. The underlying causes this phenomenon are widely recognized, with one salient factor being the decline professional standards. Should the upward trend in CS rates persist, it will precipitate an evolution in the way childbirth is performed, from natural to cesarean delivery. The attempt justify increase in CS rates reducing perinatal mortality inconclusive and may have been relevant, but only in past. Contemporary evidence indicates that the primary factors contributing decline in perinatal mortality are the advent new, highly effective institutional and diagnostic technologies, launch perinatal centers, provision maternity wards with latest equipment, increased use prenatal diagnostics, treatment extragenital diseases, etc.

It is hard agree with those who advocate CS and believe that classical obstetrics based on recognition the unconditional priority of mother’s interests over those the fetus. This idea, often attributed romantic writers, has long history, although it hardly represents real situation. As early as the 1920s, after the Great October Revolution, the first obstetrical and by Nikolay A. Semashko, the first People’s Commissar of the A Healthy Child for and for a Child.” It is significant to mention that the fetal well-being was never disregarded and it was not the prevailing attitudes that considered the fetus as something expendable. The high incidence perinatal and infant mortality was largely attributable limited resources and expertise available in obstetrics, pediatrics, and general medicine during that period.

It is not one single CS surgery that can solve all problems obstetrics like a sword cutting Gordian knot. The myth of CS safety has long been dispelled. It must be acknowledged that the incidence CS-related complications is 25-fold higher than that natural childbirth.

It is ignore recent studies that have demonstrated that during CS surgery, i.e. when the child does not come into contact with the and the child receives hospital infection strains and experiences a of the mother’s vaginal and intestinal microbiome, which reduces the strength of and increases the of a variety diseases, including infections and inflammatory diseases.

Individuals aspiring to establish career in obstetrics must acknowledge the reality that without scientific, fundamental, and therefore classical obstetrics, they will not be able to reach apices professional excellence. It is also crucial to be aware of the fact that the concept of classical is strongly associated in the public minds with the concepts of eternal and inviolable.

Following the shift in obstetric practice to a perinatal model, which acknowledged the fetus as a patient alongside the mother, there was a notable increase in the prevalence of CS surgery. This increase exceeded the reasonable, standard guidelines. Concurrently, the fetus has come be regarded as patient in context transpersonal psychology [3].

Transpersonal psychology is a relatively new field human sciences. It recognizes existence long-term prenatal fetal memory during pregnancy and birth and also considers process childbirth as key in formation human mentality and consciousness. The prevailing views in this field are summarized the American scientist Harris based on the idea that the by the fetus at the the birth trauma are recorded and brain in some form. These stored memories, similar to a dormant gene, are later released and contribute the of various neuroses psychosomatic diseases. Furthermore, Harris’s theory suggests that the fetus’ memory imprinted with feeling fear death when mother seeks abortion. The child will remember this event as an attempted murder, and in such cases, mothers later have difficulty in trusting contact with their child. Contemporary research has unveiled additional insights into the intricate details fetal life.

The human mentality and consciousness are based on Grof matrices, stable functional structures that provide the foundation for many of person’s mental and physical reactions throughout his or her life. They are formed during pregnancy and childbirth: first matrix, towards end pregnancy; second matrix, with increased uterine contractions during first stage labor; third matrix, during second stage labor; and fourth matrix, at time childbirth. CS surgery excludes the second and third stages of labor and the development of the third and fourth matrices in the fetus, depriving the child of the experience of his or her own birth, the incentive and challenge to collide with an obstacle, and the possibility of a triumphant escape from a shrinking space. Perinatal psychologists believe that this reduces the newborn’s stress tolerance and adaptability. Initial studies have demonstrated that children delivered by CS surgery have certain psychological features and often psychosomatic disorders requiring intervention by various medical professionals. The very incomplete list of problems associated with CS surgery demonstrates that medical community has to face a serious medical and social challenge. It is evident that the time has come reconsider place CS surgery in modern obstetrics, and thus time to the and conferences aimed at solving the accumulating problems. Anyway, it is time adopt paradigm returning to natural, high-quality childbirth, because it is the quality childbirth that is the lifetime resource for the

As is the case with surgery, obstetrics has often found itself a crossroads and has followed various paths, including wrong ones, thereby dragging along certain groups of obstetricians who had not yet gained a foothold in the profession. Erroneous decisions and a perverse commitment to false path are still being followed today [4]. the controlled cord traction during the postpartum period, a practice intended to prevent bleeding, contravenes Alfred’s “hands off uterus” inviolable pathogenetic principle.

Revising the time limits recommended by the World Health Organization for resuscitation of children with low and extremely low body weight at 22 weeks of gestation should not be ignored. It is noteworthy that nearly all countries worldwide, with the exception three, including Russia, have changed the time limits for neonatal resuscitation to 24–25 weeks gestation. In this regard, it is worth mentioning quote from the of Gynecology Obstetrics: “The risk of fatal outcomes after neonatal resuscitation in infants weighing 500 g is 75%–80%, and for the survivors, risk developmental disorders brain, endocrine and other systems is approximately 80%.” In light these findings, it seems reasonable legally establish requirement for full neonatal resuscitation from 24–25 weeks gestation. However, observing the principles biomedical ethics, obstetricians cannot and should not deprive >22 weeks’ gestation newborns the necessary palliative care (care, warmth, nutrition). This approach will help significant number obstetricians and pediatricians resolve emerging ethical, economic, social, and legal issues.

The idea of “newborns any cost” is manifestation pseudo-humanism that does nothing to improve demographic situation. Conversely, it is associated with considerable financial and social burdens.

The suggested method of hypotonic hemorrhage control by “elastic” bandaging of the uterus, which has not received expert approval, but has been included in the the of Health, is quite surprising. It is barely advisable delay surgical hemostasis for 30 minutes (the minimum time bandaging) in favor bandaging in case continuing bleeding. Furthermore, the degree compression the uterine tissues cannot be uniformly dosed with a bandage, which may lead to microcirculation disorders of uterine tissues during hypoxia, which will not help to improve organ health. It would be also interesting to know how to combine uterine bandaging with an intrauterine balloon (while seeking emergency aid as stated in the clinical guidelines of the Russian Ministry of Health), which is also unsuccessful in the case of hypotonic bleeding [5, 6].

It is hard to agree with the proposed method of controlling postpartum hemorrhage by placing a chitosan hemostatic dressing for external use into the uterine cavity after both natural childbirth and CS surgery. This approach fails to contribute to primary objective hypotension, which is to induce uterine contractions, however creates favorable conditions ascending infection. The suggestion that the use a hemostatic bandage for hypotonic bleeding leads to thrombosis throughout the is unsupported, speculative, and ignores the decrease in smooth muscle tone and excitability in hypotension, not only of the uterus, but also of the myometrial vessel walls, which are essential contributors to thrombosis. According to the International Federation Obstetricians and of efficacy. The era colpeurysis, metreurysis, applications, uterine balloon tamponade, and other anachronistic obstetrician procedures has passed into oblivion. The control of early postpartum hypotonic bleeding should be based not on mechanistic approach, but on the assessment and of uterine tone and excitability, which govern its contractile activity, knowledge of the female genital blood circulation and blood coagulation system [5, 6].

Reports of hypotonic hemorrhage typically contain a small number observations, whereas the conclusions are always positive. There is no doubt that without clinical trials in hospitals and research institutes, and at least short-term multicenter studies their efficacy and safety, absolutely impossible propose new methods treatment a wide range practitioners. It is in this way that validity a particular method can be established and it can be suggested for use in practice.

The suggestion not to remove invaded part the placenta and uterus for placenta accreta, but to wait the of placental tissue within 2–3 months by is controversial. The centuries-old scientific and of the postpartum period, based on the of of the uterus, remains firmly in And this is not dogma, but paradigm. It is evident that comprehensive discussion potential risks associated with inflammation and bleeding in conservative management postoperative period in cases involving the retention the placenta in the uterus is the

It is noteworthy that, as reported in the publications, almost the majority very rare cases placental retention in uterus result in delayed hysterectomy with onset complications. The conservative management of placenta accrete (the most common practice) may be beneficial for intraoperative detection of placenta accrete when the obstetrician does not have experience with the method uterine extirpation and the hospital does not have the for state-of-the-art treatment of profuse hemorrhage. In such extraordinary circumstances, it is imperative initiate surgical intervention (e.g., metroplasty or uterine extirpation) expeditiously, however, without trying to separate placenta immediately after CS surgery, whether through immediate external assistance or subsequent urgent transfer to tertiary care facility [7, 8].

This is time for scientific surgery and scientific obstetrics. The era pure empiricism in medicine has passed. It is therefore important not rely on impressions based on unrepresentative data, but on research based on fundamental science and the findings obtained in clinical and laboratory settings pathologists, physiologists, pharmacologists, and other medical professionals. It is always the case that any new suggestion raises a lot assumptions and questions. Particularly when complex biological problems are solved mechanistically, it’s not easy to have confidence in them. As these considerations are discussed, I must say that I am not one of uncompromising opponents clinical experiments. However, these high-risk experiments must be thoroughly justified by the for and for patient safety. It is a successful clinical experiment may often be associated with immediate and delayed unfavorable outcomes.

The motivation behind this essay is as follows. I a medical practitioner and university lecturer with 60 years experience, who has been involved in and its establishment for many years. Recognizing that numerous obstetricians and gynecologists in this country will probably read this article, I once again appeal to younger colleagues, our future, to remain committed classical obstetrics, to be critical, to have their own dignity, and not fall prey new fashion in obstetrics.

An obstetrician-gynecologist’s role is more than just to watch over the of and her unborn child; it is also to remain a and interpreter of medical science of a of present, and, of course, a dreamer of the future.

Additional information

Author contributions. E.K. Ailamazyan, conceptualization, original draft preparation, review and editing. The author approved the manuscript (the version to be published) and agreed to be responsible for all aspects of the accuracy or integrity of any part of it are appropriately reviewed and resolved.

Funding sources. No funding.

Disclosure of interests. The author declares that he has no relationships, activities or interests for the last three years related with for-profit or not-for-profit third parties whose interests may be affected by the content of the article.

About the authors

Eduard K. Ailamazyan

Author for correspondence.
Email: ailamazyan@icloud.com
ORCID iD: 0000-0002-9848-0860
SPIN-code: 9911-1160

MD, Dr. Sci. (Medicine), Professor, Academician of the Russian Academy of Sciences, Honored Scientist of the Russian Federation

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