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Betty Burroughs was the first patient in Tennessee to undergo a new minimally invasive heart valve replacement surgery available at VUMC. photo by Dana Johnson

Special to The Reporter: "Modern Obstetrics Comes to Vanderbilt: A Personal Historical Perspective"

BY: FRANK BOEHM, M.D.

12/10/2004 - Having a baby today in this country is a relatively safe event. While there may be serious complications and problems for both mother and child, each year the vast majority of the four million American pregnant women deliver safely and their babies live long and healthy lives. Until relatively recently, however, this was not the case.

While life expectancy for women today is approximately 80 years, during the 1500s, a woman's life expectancy was only 24. A young girl usually married soon after reaching puberty and was often given a piece of fine cloth to be made into a wedding dress. Soon thereafter, that same cloth would be used as a funeral shroud. Death was most commonly the result of childbirth complications.

Over centuries, although advances in the care of pregnant women led to an overall decrease in the number of women dying during childbirth, the national maternal mortality rate by 1930 was 670 maternal deaths per 100,000 live births, a figure still considered too high. With the gradual introduction of sterile techniques, antibiotics, blood transfusions, improved surgical techniques and in-hospital deliveries, annual maternal mortality rates finally reached a record low of 7.5 maternal deaths per 100,000 live births by 1982, and has essentially remained at this level.

Perinatal mortality, defined as babies dying before birth or within the first 6 days of life, also witnessed a huge decrease, from 60 per 1000 live births in 1940 (the year I was born), to 41 per 1000 in 1965 and finally to 7 per 1000 today. Infant mortality, children dying during the first full year of life, has also dropped dramatically over the years. In 1940, infant mortality was at a level of 47 per 1000 live births and by 1997 had reached a level of less than 8 deaths per 1000 births. While the medical profession will never be satisfied with these figures and continues to attempt to reduce them, it is safe to say that we have come a long way in improving the health of pregnant women and their newborn children. This accomplishment, however, did not come easily or without considerable controversy.

The process leading to significant improvements in the care and outcome of pregnant women and their babies had its birth in the late 1960s and became fully developed in the 1970s. In many ways that process can be labeled as the birth of modern obstetrics. The modern obstetrics era is best defined as that time when Obstetricians throughout the United States began utilizing advanced technology available for improved diagnoses and treatment of pregnant women and their unborn children.

What follows here is the story of modern obstetrics as it unfolded at Vanderbilt University Hospital, where I began to make my home in 1972 at the completion of my training and military service. It is a story that describes the ups and downs that occurred during the past 32 years I spent as a faculty member of the Vanderbilt Department of Obstetrics and Gynecology.

During my fourth and final year at Vanderbilt Medical School in 1965, finding the right residency program for my post-graduate education and training in Obstetrics and Gynecology became, in many ways, an obsession. While I traveled to many hospitals across the country, it was not until I got off the New York City to New Haven train that I knew I had found the place I wanted to spend the next five years. Yale New Haven Hospital felt comfortable and inviting and the doctor who interviewed me and showed me the facility was warm and encouraging. What I did not realize when I was accepted as an intern at Yale New Haven Hospital, was that Yale professors in Obstetrics and Gynecology, Pediatrics and Anesthesiology were hard at work perfecting new medical technologies that would revolutionalize the care of pregnant women and their newly born babies. Yale New Haven Hospital became the birth-place of modern obstetrics and I was fortunate to have a front row seat in witnessing the many changes that resulted.

The father of continuous electronic fetal heart rate monitoring, Dr. Edward Hon and his associates, were just beginning to bring to the labor and delivery floor at Yale New Haven hospital a new invention to continuously monitor the fetal heart rate of women in labor. Dr. Ernest Kohorn was attempting to bring ultrasound to the bedside of pregnant patients with his ongoing research on viewing the unborn using high frequency sound waves. At the same time, Dr. Louis Gluck was perfecting the ability to determine fetal lung maturity by performing an amniocentesis to test amniotic fluid's content of certain lipid compounds, in hopes of reducing newborn complications caused by premature deliveries. In addition, Yale professors were in the early stages of inserting needles guided by x-ray equipment into an unborn's abdomen in an effort to transfuse a fetus affected by severe Rh disease thus preventing many fetal deaths.

I learned much more during my years as an Ob/Gyn resident that would introduce me to new ways of taking care of pregnant patients, such as genetic advances in available information and testing, the collegial relationship between doctor and midwife that was possible as well as productive, and the use of epidural anesthesia for continuous pain relief during labor and delivery, an evolving technology that was to revolutionalize pain management in labor.

What I did not know then, however, was that I was one of only a few residents in this country who was getting this type of training, making me and my fellow residents highly sought after by teaching centers across the United States following completion of our training.

While several teaching centers expressed an interest in my joining their faculty, it was Vanderbilt Medical Center that made the best case for me to begin my work to introduce modern obstetrics in Nashville. In part, my decision to accept a position as Assistant Professor in Vanderbilt's Department of Obstetrics and Gynecology was related to the fact that I was born and raised in Nashville and, as an only-child, had considerable pressure placed on me by my parents to return home.

And so it was that on July 1, 1972, I walked into my small office on the second floor of what is now Vanderbilt Medical Center North to begin the arduous task of introducing the many new obstetrical technologies that I had been taught during my resident training years to Vanderbilt residents, medical and nursing students, as well as, my new Ob/Gyn colleagues.

Obstacles, however, were everywhere. In order to introduce continuous electronic fetal heart rate monitoring to our patients in labor, it was necessary to purchase at least five fetal monitors and a blood gas analyzer. When I approached the medical administration at Vanderbilt to purchase this needed equipment, I was told that money necessary for this purchase was not available and that I should write grants and submit my requests to national organizations. Unfortunately, because I was young and had little experience, I was unable to secure funds to introduce the new and exciting technology of fetal heart rate monitoring to laboring patients on Vanderbilt Hospital's labor and delivery floor.

Determined to succeed in my mission, I turned to my father's cousin, “Uncle Arthur” for help. Arthur Frank was a wealthy New York lawyer who graduated from Vanderbilt University in 1905 and someone with whom I had a close and nurturing relationship. When I asked him to make a $50,000 contribution to Vanderbilt Hospital in order for us to purchase the necessary equipment, he agreed. Within one year, the fetal monitors and other supportive equipment had been purchased and the labor and delivery area was dedicated to Arthur Frank and renamed the Fetal Intensive Care Unit (Figure 1). Ongoing educational sessions were immediately begun on our delivery floor to adequately train our doctors and nurses on the new fetal monitoring equipment that had been brought to the bedside of pregnant patients.

The renaming of labor and delivery had an important purpose. Labor and delivery nurses at Vanderbilt were significantly underpaid, resulting in a less than ideal staff. In order to attract a committed, highly trained and competent staff, it was necessary to find a way to increase salaries for nurses working in labor and delivery. I had been told that nurses working in an intensive care unit were paid at a higher rate so it seemed practical to rename our labor and delivery suite, the Fetal Intensive Care Unit. I could then ask Vanderbilt's administration to remunerate labor and delivery nurses as they would any nurse working in an intensive care unit environment. After all, we were intensively monitoring the laboring patient and her unborn child with technical monitoring devices.

Our plan worked! Vanderbilt's administration agreed that because our unit was now an intensive care unit, its nurses should be paid higher wages. Within a relatively short time, the caliber of nurses taking care of our pregnant patients was of the finest quality. The environment for pregnant patients at Vanderbilt had changed and we were now poised to usher in an era of modern obstetrics. There existed, however, another serious problem.

After joining the faculty at Vanderbilt, I realized that few patients were delivering their babies at Vanderbilt Hospital. Only approximately 60 patients delivered in our newly created Fetal Intensive Care Unit each month and most had few, if any, obstetric problems. While our new mission was to care for the most complicated pregnancies, we were taking care of a very small number of normal uncomplicated pregnancies. If we were to become an actual intensive care unit taking care of complicated pregnancies, something had to change.

That change was made possible by a new and exciting process called Perinatal Regionalization. In 1971, the American Medical Association adopted a position supporting the regionalization of perinatal care and, in 1972, both organizations representing Obstetricians and Pediatricians developed guidelines on how this process was to evolve.

Perinatal Regionalization involved the transfer of high-risk newborns from smaller hospitals to larger, better-equipped and staffed neonatal intensive care units for their care following delivery. It also involved the transfer of high-risk pregnant women to tertiary hospitals, like Vanderbilt, prior to delivery, so they could receive the most sophisticated and advanced treatments available. Ideally, it was recommended that whenever possible, pregnant mothers should be transferred before delivery, so as to provide the unborn child with the best incubator (the mother's uterus) during transfer. It was determined that delivery in a hospital appropriately staffed and equipped for all problems that might arise would result in better outcomes.

Regionalization of perinatal health care required the organization of a region, (in our case, middle Tennessee), in which there were defined levels of perinatal care consisting of at least one tertiary care (Level 3) hospital, whose primary concerns were education, consultation, transportation and a high level of care. Level 1 care hospitals (small rural hospitals throughout the 39 counties of middle Tennessee), described care given to normal obstetric patients and normal newborns while Level 2 care described care given for somewhat more complicated pregnancies and newborn illnesses (Murfreesboro, Clarksville, Columbia, Cookeville Hospitals). Being a tertiary care facility, Vanderbilt University Hospital was able to provide the Level 3 care required for the most complicated and sick pregnant patients and their newborns. Important aspects of the regionalization process was the prevention of expensive duplication of health care services and staff as well as to provide the most sophisticated and technologically advanced care by highly trained health care providers.

The process of regionalization was to play a major role in improving the outcome for mothers and their newborns throughout the United States. For example, perinatal mortality (babies dying around the time of birth) in Tennessee, which was 31.2 babies per 1000 births in 1970, steadily declined to 15.8 by 1983. Maternal mortality (mothers dying because of pregnancy complications) also declined during this time, from 2.9 pregnant patients per 10,000 pregnancies to 1.3. Other states reported similar positive results with the introduction of Perinatal Regionalization.

The task for Vanderbilt was to convince doctors and administrators in small rural hospitals throughout surrounding counties of Nashville, to send to Vanderbilt Hospital their sick newborns, as well as their complicated pregnancies, so that improved outcomes could materialize. As I was to discover, this was no easy task.

Initial telephone calls to practicing Obstetricians in some of the hospitals around Nashville to explain the benefits of Perinatal Regionalization were not productive. I soon realized that convincing physicians to transfer care of their patients (and income) to Vanderbilt Hospital would take a face-to-face encounter in their office, as well as a visit to the administrator of the hospital who would also be affected by a loss of patient care dollars. If we were to reduce morbidity and mortality of mothers and babies, doctors and hospital administrators across middle Tennessee would need to be convinced that Perinatal Regionalization was the way to achieve this goal.

Visiting each of the over three dozen hospitals and the doctors that practiced in them, would take time and money. With that in mind, I paid a visit to Dr. Eugene Fowinkle, the then Tennessee State Commissioner of Health, to ask for his support. I explained the importance of Perinatal Regionalization and how this process would not only save lives, but would also save considerable duplication of equipment and personnel in hospitals throughout the state. Dr. Fowinkle did not hesitate. He instructed me to write a proposal outlining the costs and said he would do what he could.

Three months later, the State of Tennessee awarded Vanderbilt's Ob/Gyn Department $20,000 a year for two years thus allowing me to travel to each hospital in middle Tennessee in hopes of convincing doctors to send their high risk pregnant patients to Vanderbilt rather than trying to care for them in their local community hospitals.

Although born and raised in Nashville, I had never visited the many surrounding cities, which made up the region of middle Tennessee. For the next two years, each Friday morning a member of our nursing staff and I drove to each of the hospitals throughout middle Tennessee, experiencing the incredible beauty of our state. Getting off interstate highways and moving down country roads along rolling hills and bucolic landscapes, I was truly impressed with what I saw. Convincing doctors to accept Perinatal Regionalization once I arrived in their picturesque cities, however, was not as pretty.

Local doctors resented Vanderbilt Hospital for the way some of its staff had treated them whenever they attempted to call for a consult or when they sent a critically ill patient to Vanderbilt for special care. Many referring doctors explained how physicians at Vanderbilt were often condescending or arrogant when asked their advice. Being treated as doctors who did not understand how to take care of complicated patients; these middle Tennessee physicians developed a sense of hostility towards Vanderbilt Hospital personnel.

In addition, I was told that when these local doctors did refer patients to Vanderbilt, their patient were lost to follow up. No one at Vanderbilt, it seemed, made an attempt to inform referring physicians as to what had happened to their patients. To add insult to injury, I was told of patients having returned home following treatment at Vanderbilt, telling their local doctors of disparaging comments made by Vanderbilt staff about the care they had received prior to transfer. To say the least, Perinatal Regionalization was not an easy sell. What I thought could be done in one visit to each hospital eventually required two and sometimes three visits to convince physicians throughout middle Tennessee that Vanderbilt staff would respond to their complaints and that their patient's outcome would be improved.

It was with this in mind that we began to stress to the many doctors and nurses in the department of Ob/Gyn at Vanderbilt, the importance of our relationships with referring doctors throughout middle Tennessee. Insisting on direct Vanderbilt attending physician to referring physician consultation, we were able to gain control of our communication with physicians in middle Tennessee and slowly began to change opinions of our referral base of doctors.

Putting into place a system that emphasized rapid verbal and written communication to keep referring doctors updated on their patients after transport to Vanderbilt, as well as making certain that none of our staff made negative comments concerning care patients had received prior to transfer, was helpful in beginning a process whereby doctors began feeling comfortable referring their complicated pregnant patients to Vanderbilt Hospital for specialized care. Unfortunately, not everyone was pleased with our attempts to regionalize the care of pregnant patients.

Soon after our weekly travels throughout middle Tennessee began, I received anonymous and threatening postcards. The first arrived at my home in 1976 and read, “Do you really think regionalization of perinatal care will make your job more secure?” (Figure 2). That post card was followed by a more sinister message, “BAA BAA BLACKSHEEP, BYE BYE BIRDIE, BYE BYE BOEHM” (Figure 3). Not long thereafter I was told, “Have U Missed me? You need to move on” (Figure 4).

Somewhat disturbed by these threatening messages, I contacted the local FBI and met with special agents who informed me after studying the messages that there was little the agency could do. To this day, I do not know who sent these messages. One thing I did understand, however, was that there were some health care providers around middle Tennessee who were unhappy with my attempts to regionalize perinatal care. To them, regionalization was government intrusion into the care of their patients. Some physicians obviously felt that no one should be telling them that they needed to transfer patients to doctors at a large teaching center in Nashville.

Slowly and steadily, however, the number of high-risk obstetric patient referral for in-patient care began coming to Vanderbilt Medical Center with numbers reaching as high as 700 each year. Physicians taking care of pregnant patients throughout middle Tennessee, southern Kentucky and northern Alabama were soon convinced that Perinatal Regionalization was a positive step forward in the care of pregnant patients as well as their newborns. As early as 1981, Vanderbilt was able to report that survival of very small infants born at Vanderbilt Medical Center had doubled during the years 1975 and 1980, while there were no similar survival changes in those babies continuing to be born in outlying smaller hospitals. Clearly, the process of regionalization was working.

Because of an increase in the number of high-risk pregnant patients being admitted to our facility, we also began receiving an even larger number of outpatient referrals to the Vanderbilt Clinics. Patients were being sent to our clinics for consultations on how to manage their complicated pregnancies. Patients requesting genetic counseling and testing increased rapidly as was our need for ultrasound examinations of pregnant women.

During this time there did not seem to be anyone in our Vanderbilt Radiology Department who was interested in the new and very exciting technology of ultrasonography. Ultrasound technology made it possible for us to view the world of the fetus. With its ability to use high frequency sound waves to make pictures of the unborn child while providing important other information, ultrasound studies would literally change the way pregnant women were treated. We needed someone at Vanderbilt to step forward and help bring this technology to the bedside.

That someone did appear. It was, however, not a faculty member, but rather a very junior resident, Dr. Arthur Fleischer who came to my office one day to tell me that he understood the capabilities and possibilities of ultrasound. He said he was interested in this new technology and wanted to begin research on its use as well as bring it to our high risk pregnant patients. (Dr. Fleischer has gone on to become one of the most prestigious and important contributors to the field of Obstetric and Gynecological ultrasound in the world.) I was overjoyed! We were now able to put together a team of doctors that included perinatologists (high-risk obstetric specialists), neonatologists (high-risk newborn specialists), radiologists, anestheologists and nurses, who would bring modern obstetrics to Vanderbilt and middle Tennessee.

Realizing that doctors and nurses in the many hospitals around Nashville were beginning to use fetal monitors to monitor the heartbeats of babies during the labor process, we began offering educational seminars at Vanderbilt Hospital on the use of this new technology. While many did avail themselves of this education, it became obvious that most doctors and nurses needed an on-going educational process that would involve on-site education on a regular basis. We needed a team of educators who would travel to hospitals around Nashville to provide education on the use and interpretation of fetal monitoring.

Our department turned to the March of Dimes and requested money to hire a nurse specialist who would be able to spend her days traveling throughout middle Tennessee in order to teach nurses the art and science of fetal monitoring. We also requested enough money to purchase Xerox telecopiers for each hospital as well as one for our labor and delivery suite and my home, thereby allowing physicians to transmit strips of their patient's fetal heart rate tracings for rapid consultation (Figures 5,6). Impressed with our request, the March of Dimes stepped forward and awarded us seed money to begin our project.

Vanderbilt Hospital's process of introducing a fetal intensive care unit, fetal monitoring and Perinatal Regionalization to middle Tennessee resulted in numerous publications on the achievement of our efforts. The first publication, entitled The Xerox Telecopier and the Fetal Monitor, appeared in 1973, followed by The Fetal Intensive Care Unit: an Evolving Concept which was published in 1974. Other publications followed, including: Regionalization of a Fetal Monitoring System (1975), a Statewide Program to Teach Nurses the use of Fetal Monitors (1978), Maternal Transport: an Evolving Concept (1979), Xerox Telecopier Transmission of Fetal Monitor Tracings: a Four Year Experience (1979), and Perinatal Nursing Education in Tennessee: a Regional Approach (1981). These and other publications brought Vanderbilt Medical Center regional and national attention as a forerunner in the field of modern obstetrics.

While our newly developed Division of Maternal Fetal Medicine was fulfilling its mission of providing highly technical care to laboring patients, we were also aware that many of our patients were interested in maintaining a less technological approach to child bearing. Lamaze classes were becoming very popular and many of our patients were requesting labor without anesthesia and in an environment whereby the father could be involved in the delivery event. These couples wanted to be delivered in their labor room and not be taken to the sterile environment of a delivery room without any family member. They were also requesting a more home like environment for the birthing process.

This desire to deliver a baby in a home like atmosphere was becoming quite popular in many cities around the country. To keep up with this growing demand our obstetric staff requested the hospital administration to open birthing rooms (also called labor, delivery and recovery rooms (LDR)) on our newly constructed labor and delivery floor in the new 11 floor Hospital, which was scheduled to open in the fall of 1980.

Despite what seemed a reasonable request, opposition surfaced. Members of the anesthesia department were expressing concern that LDR rooms might impose an increased risk for laboring patients. Anestheologists, providing pain relief for our laboring patients stated that any patient placed in one of the newly built LDR rooms should not have epidural anesthesia nor be given oxytocin (a labor stimulant) during labor and should not be allowed to have the father of the baby attend the delivery without undergoing an educational process and signing an agreement to abide by a number of rules of behavior. These restrictions were requested in an attempt to balance the need for close technological monitoring of the labor process with the more natural hands- off approach that many of our patients were requesting.

Fortunately, over time, with the help of print and electronic media, as well as continued pressure from patients, consumer groups and practicing obstetricians, Obstetric Anesthesiologists were convinced that the LDR process was a safe and rewarding experience and all of the once placed restrictions on patients wanting a birthing room experience were lifted.

Today, family centered births occur as a routine in all labor and delivery rooms at Vanderbilt, side by side with advanced technology of modern obstetrics. Our patients undergo continuous electronic fetal monitoring with epidural anesthesia and often with oxytocin stimulation even as they labor in a birthing room environment with their family in attendance. While we certainly had come a long way, there was more that needed to be done.

Another significant obstacle to advancing the concept of modern obstetrics was our inability to care for obstetric patients in our labor and delivery rooms who were critically ill. Many of our pregnant patients required medical intensive care, including placing patients on ventilators (breathing machines) and placing tubes into their hearts for proper monitoring of life threatening conditions. Patients requiring such care were routinely sent to one of the intensive care units on other floors remote from convenient operating rooms, where we would have to turn over care of our obstetric patients to non-obstetric doctors and nurses.

What we needed was the ability to provide this same type of medical intensive care to our pregnant patients on labor and delivery where highly trained obstetric doctors and nurses could continuously provide simultaneous modern obstetric technology with the technology of medical intensive care usually provided in surgical and medical intensive care units in other parts of the hospital. If these extremely ill patients could be cared for on our labor and delivery floor, we could more rapidly respond to the need for emergency cesarean sections and avoid delay in managing prolonged fetal or maternal distress that occasionally occurred.

With this in mind, I asked one of our first year Maternal Fetal Medicine fellows, Dr. Connie Graves if she would be interested in learning the art and science of medical and surgical intensive care and help us set up an intensive care unit for critically ill obstetric patients on the labor and delivery floor. After an enthusiastic yes, Dr. Graves began a three month rotation in Vanderbilt's surgical intensive care unit, under the supervision of its Director, Dr. John Morris.

What was also needed, however were obstetric nurses who had interest and skill to also care of these extremely complicated patients. One of our nurses, Nan Troiano, had an interest in this type of intensive care and began the task of selecting a group of obstetric nurses for intensive care training. Ms Troiano, along with Dr. Graves, trained nurses as well as Ob/Gyn residents on how to properly take care of pregnant women requiring intensive care monitoring and treatment. Thus began one of the countries first Obstetric Intensive Care Units providing care for critically ill pregnant women on a labor and delivery floor.

Dr. Connie Graves and Nan Troiano became Directors of our Obstetric Intensive Care Unit and began taking care of approximately 50 patients a year. The labor and delivery area of Vanderbilt Hospital was now able to care for our sickest patients and provide safe and sophisticated care to a pregnant population requiring medical as well as obstetric intensive care. However, more needed to be done to complete the task of bringing new and innovative procedures to our pregnant population.

One significant change that came from the specialization of high-risk obstetrics was that perinatologists were being trained to care for pregnant patients who also had diabetic mellitus and other serious chronic medical conditions usually cared for by medical internists. Most pregnant patients with diabetes had to visit their obstetrician as well as their internist. In addition, they were being sent to perinatologists for ultrasound exams as well as other specialized tests to ascertain fetal well -being during the third trimester of pregnancy. What was needed was a clinic that could take care of all of the needs of a pregnant diabetic patient thereby eliminating the need for fractionated care.

In 1976, the Vanderbilt Obstetric Diabetic Clinic was created to administer comprehensive and inclusive care for diabetic pregnant patients. Our patients no longer had to make several visits to different doctors to obtain the care they needed while pregnant. Perinatologists, (and in the beginning years, along with Internist and diabetic specialist, Dr. Alan Graber), perinatal nurse specialists, nutritionists, social workers and ultrasound specialists provided the sophisticated care required of pregnant diabetics in one weekly visit. Over the past 28 years the Obstetric Diabetic Clinic has cared for thousands of patients and is recognized as one of the outstanding care facilities for diabetic pregnant patients. This same concept was employed years later when the number of pregnant patients infected with HIV/AIDS began to grow and a need for centralized care for these patients was also required.

Numerous other exciting programs began to surface at Vanderbilt Hospital as a result of the introduction of modern obstetrics. In 1982, the Department of Obstetrics and Gynecology received a grant to participate in a multicenter preterm birth prevention project. Statistics in the early 1980s revealed that approximately 10% of babies born in the United States were born too early. It was noted that 75% of all serious illness and death in American newborns was the result of preterm birth. The multicenter project introduced an early warning system which included a combination of risk screening, special prenatal care, (which included home uterine contraction monitoring), and patient and staff education. Since the initiation of this project Vanderbilt has made numerous contributions to the scientific literature concerning prevention as well as treatment of premature labor and delivery.

Certain unborn babies become severely anemic because of Rh disease and may die as a result. Previous attempts to transfuse these fetuses using x-ray equipment were difficult and frequently unsuccessful. In 1986, Vanderbilt doctors were able to directly transfuse a fetus while still in its mother's uterus. Real time ultrasound technology allowed doctors to direct a needle into the unborn's umbilical cord and directly transfuse blood into the anemic child with considerable success. In what was to become a frequently performed procedure, Dr. Dinesh Shah and I, with the aid of Dr. Arthur Fleischer, were able to insert a needle into the umbilical vein of Jocelyn Terry, who was suffering from extreme anemia and close to death. What resulted was the first of several successful transfusions, and eventual delivery of a healthy non anemic child (Figure 7). More exciting events were to follow.

In January 1987, a Hendersonville, Tennessee woman, Darlene Hawkins, gave birth at Vanderbilt Medical Center to the first quintuplets ever born in Tennessee (Figure 8). The delivery came 24 weeks into the pregnancy with the babies weighing about 1 1/3 pounds each. News of this rare event was projected to the entire nation when reporters attended daily press conferences. Tragically, only the first born, Stephen, survived, yet the event catapulted Vanderbilt's Obstetric and Newborn services to a national audience. We have kept in touch with the Hawkins family and, 16 years after his birth, Vanderbilt's labor and delivery staff gave Stephen a birthday party at the hospital. Today he is a healthy and delightful young man.

The introduction of a new method for early prenatal testing called CVS (chorionic villi sampling) made Vanderbilt a pioneer in the field of early prenatal testing. CVS was capable of diagnosing chromosomal abnormalities and certain metabolic conditions of the fetus in the first trimester of pregnancy (10-13 weeks), and was an alternative to amniocentesis (which cannot be performed until the 15th week of pregnancy). CVS is performed by passing a thin catheter through the cervix and into the placenta under ultrasound guidance to obtain a biopsy of the chorionic villi contained in the placenta and which possesses the same genetic material as the baby. It can also be performed by passing a needle into the placenta through the mother's abdomen.

I had read about this new procedure being performed in Europe as well as at a few teaching centers in this country. We were unwilling, however, to perform CVS on pregnant patients without first gaining experience. We therefore, requested that Planned Parenthood of Nashville allow us to perform this procedure on women who were to undergo an abortion. Fifty patients at Planned Parenthood accepted a monetary gift allowing us the opportunity to perform and perfect this new and innovative procedure. Following the CVS procedure, they underwent their already scheduled abortion. I am grateful to these women who allowed us the opportunity to become skilled at a somewhat difficult procedure to perform.

In 1987 our Obstetric Division began offering CVS to pregnant patients. Since those early days, patients have come to Vanderbilt Medical Center from all parts of Tennessee and surrounding states and we have performed over 3,000 CVS procedures. Our published results indicate a safe and reliable early prenatal testing process for pregnant patients at risk for fetal abnormalities.

If you think it was difficult to convince doctors and nurses that siblings should also be allowed in the room when their mother was delivering their brother or sister, you are right. However, in 1987, the Vanderbilt Perinatal Parent Education Program began formal classes to help children understand pregnancy so they could be prepared to witness the birth of a sibling. Many parents told us that watching siblings being born would be a learning experience for their children and would enhance the feeling of being a part of an important family and life cycle event.

Despite restrictions on allowing young children to attend a delivery, we were able to put together a process by which siblings could join in the birth process. Many of our patients took advantage of this opportunity and to this day, having siblings attend the birth of their brother or sister has been a positive event (Figure 9). Vanderbilt Medical Center had taken another step towards bringing advanced technology together with a family centered atmosphere.

In 1990, doctors at Vanderbilt Medical Center performed a surgical procedure called a cerclage on a patient who had just delivered an extremely premature twin. This was the first time such an operation, under these circumstances, had been performed in the United States and it saved the life of a middle Tennessee newborn. I had read about this procedure, which had been performed twice in Europe, but not yet in this country, and I was interested in using it when the time became suitable.

That time came after the extreme premature birth and death of Jolin McKoin's first twin at 23 weeks of pregnancy. The result was the successful birth of Henry, born 27 days after the birth of his sibling. Following delivery of the first twin, we placed a stitch around the cervix (cerclage), to stop Jolin from delivering Henry, her second twin. With the use of effective medicine to inhibit contractions and antibiotics to avoid infection, we were able to gain a critical additional 27 days in-utero. Allowing the second twin to remain in the uterus for those additional days saved Henry's life.

Henry's mother still sends updated pictures of her “miracle birth” (Figure 10). Since that first cerlage to stop the delivery of a second twin, the procedure has been performed in similar situations at Vanderbilt and around the country.

Vanderbilt's Obstetric staff continues to pursue advances in technology to provide an improvement in outcome for mother and baby. In 1990, the Maternal Fetal Medicine Division recruited Dr. Joseph Bruner to Vanderbilt Medical Center in order for him to develop a fetal surgery program. In-utero surgery of the unborn was becoming technologically feasible and a number of birth defects were amenable to surgical correction while the fetus remained in its mother's uterus. Fetal surgery was becoming an exciting prospect. Within seven years, Dr. Bruner and Pediatric Neurosurgeon, Dr. Noel Tulipan, performed the first in-utero surgical repair of fetal spina-bifida (open spine defect). This historic event was followed by 178 fetal surgical repairs of spina-bifida at Vanderbilt Medical Center resulting in the publication of several landmark scientific publications pointing to some improvement in outcome for the newborn. The National Institutes of Medicine is now funding and sponsoring a randomized research project along with two other major teaching centers, to ascertain the evidence based scientific value of such a procedure based on rigid research criteria. This study is now in progress.

Dr. Bruner also directs a Fetal Diagnostic and Procedure section of our Maternal Fetal Medicine Division that concentrates its resources in the diagnosis and treatment of babies with other serious birth defects. Other more recent advances introduced to Vanderbilt Medical Center and middle Tennessee include; pulse oximetry technology which directly measures oxygenation of the fetus during labor, thereby avoiding numerous unnecessary Cesarean Sections; centralized management of pregnant women infected with the human immunosuppressive virus (HIV) and delivering 130 babies not infected with the AIDS virus during the past 5 years; one of the first Certified Nurse Midwife programs in the area delivering approximately 40 babies each month at Vanderbilt.

With an increasing need for physicians and nurses to be educated and updated on a regular basis on the many new obstetric technological advances as well as research providing information on how best to care for the many complicating factors surrounding pregnancy, Vanderbilt's Division of Maternal Fetal Medicine began in 1975 a yearly two day seminar called the High Risk Obstetric Conference. The conference, held on the Vanderbilt Medical Center campus each December, has become the longest running as well as the most attended post graduate Obstetric course in America. This year marks our 30th year and will have over 500 doctors and nurses from all parts of Tennessee and the south east. The annual High Risk Obstetric Conference has played a significant role in continuously improving the care Tennessee doctors and nurses provide for their pregnant patients as well as improving overall outcomes.

Helping usher in the era of modern obstetrics at Vanderbilt and middle Tennessee has been hard work but also extremely rewarding. Bringing about change in any field is difficult, and introducing modern technology into Obstetrics was no exception. As a result of hard and dedicated work by many doctors and nurses involved in obstetric care, Vanderbilt's Department of Obstetrics and Gynecology has been named in the top 20 best Departments in America for the past five years.

Modern obstetrics has improved the lives of countless mothers and babies over the past 32 years. I am confident that in the future, the staff at Vanderbilt Medical Center will continue to combine modern technology with a humane, family oriented approach to childbirth in an attempt to bring and maintain excellence and safety to the process of giving birth.

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