Flat Tires and Other Deflations

And for myself I am fully convinced that there does exist, in Nature, means of Selection, always in action and of which the perfection cannot be exaggerated. —Charles Darwin, On the Origin of Species by Means of Natural Selection, 1859 There is no better evidence of the Western medical tradition's medieval roots than postmodern childbirth “management.” A sequence of traditions, from Aristotle through Galen, the memorably named Soranus of Ephesus (AD 78–117), and the Bible led to the idea that men and women had similar physiology but superior and inferior versions (1). The uterus was envisioned as an inverted penis, stuck inside the body. The female body was believed to be more labile and unformed, with openings and leakages. Menstruation was thought to be the same phenomenon as more irregular and infrequent male epistaxis. By 1400 women were believed to be naturally flawed, unstable and crooked in judgment. The etymology of hysteria reflects these perceptions. From Soranus' Roman obstetric compendium it took fourteen centuries for Eucharius Roslin to produce his German text Rosengarten (c 1513) and Thomas Raynalde to translate it into English via a Latin intermediate edition as The Byrth of Mankynde (c 1540). That first English language obstetric text lasted through 13 editions to the last one published in 1654, suggesting that the speed of evolution of obstetric thinking was not exactly blinding. And “It was a fact generally acknowledged by all but the most contumnaceous spirits at the beginning of the seventeenth century that woman was the weaker vessel; weaker than man, that is” (2). Five centuries later, in Margaret Thatcher's words, “It's (still) a funny old world.” According to contemporary best evidence, our species' ancestors began to walk on the ground six to seven million years ago in the African savannah, leading to a “cascade of adaptations” (3). About two million years ago our predecessors' brains began to expand, and along with that growth came gradual heightening of consciousness and ability to make new tools. And 30,000 to 40,000 years ago, humans began to make awls, chisels, and blades. As our brains became the part of humanity that diverged most rapidly from the tree of life, we created science and learned how to make evolution and the processes described by Darwin work faster for us than any other species, except perhaps bacteria (3). After a few million years of evolution, unless one can stipulate why what Darwin identified in other species does not apply to us, it seems reasonable to presume that women and their uteri would have birth fairly well organized. Indeed, the term uterus refers to the most powerful muscle in the human body, male or female. But strangely, its “competence” remains in question, and the search continues for devices to help what is so often presumed to need help. Could that explain why approximately 37 percent of North American births now receive some form of operative intervention, or why one-fifth to one-fourth of infants on this continent are rescued from the presumably faulty towers of labour? I don't know, I am just asking. However, I was puzzled to read about a “A Labor Assister System,” a commercially manufactured “inflatable obstetric belt” and a randomized trial testing its worth or lack thereof (4, 5). According to the trial, this thing “did not significantly reduce operative delivery rates when used in this clinical setting in the second stage of labour,” but that is not what I found noteworthy. If there were a contest for the wackiest obstetric device patented, the Labor Assister System would deserve mention. Inevitably, it would lose to the Blonsky centrifugal force apparatus (6). But one of the most influential biases in evidence acquisition is choice of the question, and the best evidence in answer to the wrong question is useless. Various cultures in Finland, northern India, South and Mesoamerica have used encircling abdominal bindings to garrotte the pregnant belly in the belief that doing so assists the birth process, and I admit that there is a paucity of randomized trials on which one can base conclusions about those methods. The Mexican rebozo, a Mayan childbirth method descendant, is still used to try to gently rock malpresentations into a better attitude and is used after birth as a garment and infant carrier. But to me, inflating and deflating a belt every 30 seconds in second stage seems, well, something less than Darwinian. Someone may reply that if we had been meant to drive, we would have evolved wheels and tires instead of feet and toes, but that is too simplistic. And that riposte would not address the two questions about this device that perplex me, which are why “five hundred nulliparae with a singleton cephalic pregnancy at term and with an epidural in labour … recruited during the first stage and randomised at full dilatation” would agree to test this strange medieval device, and what was said to them to convince them to do so?

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