Twilight sleep (English translation of the German word ) is an amnesic state characterized by insensitivity to pain without loss of consciousness, induced by an injection of morphine and scopolamine, with the purpose of pain management during childbirth. The obstetric method originated in Germany and gained large popularity in New York City in the early 20th century.
Effects and usage
In the Freiburg technique, considered the gold standard of twilight birth, patients were first given an intramuscular injection of of scopolamine and of morphine. Forty five minutes later, a second scopolamine injection of the same dosage was administered. A memory test was then given, and subsequent smaller doses of scopolamine were given based on the individual's performance on the memory tests. When performed properly, the drug combination caused a drowsy state and relieved the pain only partially, whilst creating amnesia such that the woman giving birth sometimes would not remember any pain, although these results were variable. Because of how variable the scopolamine dosages are between patients, and the need for accurate assessment of performance on the memory test, the twilight sleep method required skillful, well-trained practitioners for proper execution.
To effectively keep women in an amnesic state, sensory isolation was necessary. Women gave birth in a darkened room, and the birth attendants wore uniforms designed to minimize noise. Women were sometimes blind-folded, had their ears plugged with oil-soaked cotton, or were tied to padded beds with leather straps to "promote sleep." Sensory deprivation also prevented delirium, one of the adverse side effects of scopolamine.
History
Pain management in labor
Prior to the 20th century, childbirth predominantly happened in the home, without access to any medical interventions for pain management. Childbirth was a leading cause of death for women, largely due to the movement of childbirth from the home to hospitals in the early 20th century. Doctors (primarily, if not all men) were now managing the vast majority of childbirths as opposed to midwives or Doulas. Many women were fearful of the process of giving birth, creating a large desire for pain management. But despite the demands of female patients, little relief was offered before the mid-19th century. Chemical anesthesia during labor was first introduced in 1847, receiving support from women and reluctance from physicians. The legacy of the Bible in the Anglo-American medical community was clear. While pain relief was seen as a necessary part of surgery, many physicians viewed painful childbirth as a natural, divinely ordained punishment for Eve’s behavior in the Garden of Eden. Anesthesia's use was popularized in 1853 by Queen Victoria’s decision to use chloroform for pain relief during the birth of her eighth child.
Germany
In 1899, a Dr Schneiderlin recommended the use of hyoscine and morphine for surgical anesthesia, and it began to be used as such sporadically. The use of this combination to ease birth was first proposed by Austrian physician Richard von Steinbuchel in 1902, before being picked up and further developed by Carl Gauss and Bernhardt Kronig in Freiburg, Germany, beginning in 1903. The method came to be known as ("twilight sleep") or the "Freiburg method" when performed according to Gauss and Kronig's specific technique. Gauss and Kronig's research showed that the use of scopolamine during childbirth resulted in fewer complications and a faster recovery. The two presented their findings on the use of scopolamine during childbirth at the 1906 National Obstetrics Conference in Berlin, Germany. They recorded preferred dosages and adverse side effects of scopolamine, which included slowed pulse, bradypnea, delirium, dilated pupils, flushed skin, and thirst.
Its usage spread slowly, and different clinics experimented with different dosages and ingredients. By 1907, Gauss was performing the Freiburg method on all of his pregnant patients, and wealthy German women began to travel to Freiburg for childbirth to receive Kronig and Gauss's twilight sleep method. The Women's Clinic of the State University of Baden, where Gauss was a physician, had the city's lowest rates of maternal and neonatal mortality, further increasing the procedure's popularity. Eventually, wealthy pregnant women from the United States began traveling to Germany to receive twilight sleep during childbirth.