HHH Column: Empress Marie Louise’s difficult delivery: a test case of lost skills in obstetrics by Jan Bosteels

The HHH column is a monthly blog in which History, Health & Healing members share their thoughts on research, current affairs, or anything to do with medical history. Each edition is written by a different member – in due time, we hope to offer everybody a chance to publish a contribution. This month, the floor is for Jan Bosteels, head of department Obstetrics-Gynaecology AZ Imelda Bonheiden, and visiting professor in OB-GYN at the University of Ghent. He is currently writing a biography of obstetrician Antoine Dubois. In this column Jan discusses Empress Marie Louise’s difficult delivery as a test case confirming a loss of skills in present day obstetrics.

Empress Marie Louise’s difficult delivery: a test case of lost skills in obstetrics

Jan Bosteels

On the 3^rd of February 1818, Napoleon Bonaparte had a conversation with his Irish physician, Barry O’Meara. The former Emperor of the French in exile had just heard news of the tragic death of Crown-Princess Charlotte of England on the 6^th of November 1817. Her obstetrician Sir Richard Croft had diagnosed that her baby was in an abnormal position during labour. Nevertheless, he had favoured spontaneous evolution rather than active management. After 50 hours of painful labour, the unfortunate Charlotte delivered a stillborn nine-pound baby (4080g), had a severe bleeding, and died six hours after giving birth. Three months later Sir Richard Croft took his own life. 

The ‘triple obstetric tragedy’ reminded Napoleon of the difficult childbirth of his second wife, the Empress Marie Louise on March 20^th, 1811: “Dubois, the accoucheur, came to me while I was reclining on the sofa, ‘with great alarm painted on his countenance, and said, ” that the empress was in a state of great danger, that there was a wrong presentation. I asked him if he had ever seen anything of the kind before. Dubois replied, ‘ that he had but very rarely, perhaps not one in a thousand, and that it was very afflicting to him that so extraordinary a case should happen with the empress. Forget,” said I, “that she is empress, and treat her as you would the wife of a little shopkeeper in the Rue St. Denis. This is the only favour I ask of you. Dubois then asked, if it were necessary that one should be sacrificed, which should he save, the mother or the child?? The mother certainly, ” I replied, “it is her right.” I then accompanied Dubois to the bedside, encouraged and tranquillized the empress as much as possible, and held her while the forceps were applied. The child was apparently dead when born, but by frictions and other means he was restored to life..”

History has paid little attention to the difficult childbirth of Marie Louise. Most historians are convinced that the obstetrician Antoine Dubois (1756-1837) was overwhelmed by the huge responsibility. The baby was in a breech position, and Dubois refused to proceed with the delivery unless Napoleon’s personal physician was present. In his own words the emperor ‘saved the day’ by severely reprimanding Dubois. The obstetrician then used the ‘irons’ (forceps) to deliver the baby.

Dubois became the chirurgien-accoucheur of Marie Louise after the death of Jean-Louis Baudelocque, the obstetrician who had delivered several members of the Imperial family. What happened on that fateful 20^th March 1811? Unfortunately, we have no first-hand, written account from Dubois. However, a letter written by Napoleon to Emperor Francis of Austria, the father of Marie Louise, very likely echoes Dubois’s exact words: « Ce matin, à huit heures, l’accoucheur entra chez moi, fort affairé, me fit connaître que l’enfant se présentait par le côté, que l’accouchement serait difficile, et qu’il y aurait le plus grand danger pour la vie de l’enfant ».^[1] Most historians agree that the baby was lying feet-first (a breech position) but ‘L’art des Accouchements’, the reference French handbook on obstetrics published by Baudelocque, classifies a breech delivery as a natural way of giving birth. In other words, a physician should not intervene. Additional evidence supporting this diagnosis can be found in Napoleon’s memoirs: «Il n’y avait pas longtemps que l’Empereur était dans le bain, que les douleurs reprirent, et que l’accoucheur vint, la tête perdu, lui dire qu’il était le plus malheureux des hommes, que sur mille couches qui arrivaient dans Paris, il ne s’en présentait pas de plus difficile ».^[2] This strongly supports the diagnosis of a transverse lie of the child, most likely a presentation of the hip. Firstly, this is the correct and literal interpretation of the French words par le côté, and secondly, a transverse lie occurs rarely (0.1%) compared to a breech position (3%). According to Baudelocque’s handbook, a hip presentation is almost impossible to diagnose before the rupture of the membranes.^[3] This explains why Antoine Dubois did not suspect the abnormal position until after the membranes had ruptured. This sheds new light on the state of mind of Antoine Dubois: the obstetrician was agitated (affairé in Napoleon’s words) and extremely unhappy (malheureux) not because he was very stressed, but because he realized that he had missed a crucial opportunity. If he had made the diagnosis before the rupture of the membranes, he could have advised to reposition the mother to facilitate the conversion of the position of the baby from an unnatural position (transverse) to a natural position (breech), as recommended by Baudelocque.^[4]   

Despite Napoleon’s exhortations, Dubois refused to intervene unless Jean- Nicolas Corvisart (1755-1821) was present.“Sire, je ne puis rien faire qu’en présence de Corvisart”. Historians have attributed this alleged hesitancy of Dubois to his desire to have Napoleon’s personal physician stand by as an expert witness. During the first 10 years of his professorship, the 54-year-old Dubois had supervised 23 800 deliveries at the Maternité de Port-Royal. He was a highly experienced obstetrician who knew perfectly well how to perform the next step, a hazardous intervention called internal podalic version. The Baudelocque handbook advised the obstetrician to grasp one or both feet of the child and to pull the baby out of the birth canal. Dubois performed this manoeuvre skilfully, but the head of the child could not pass the mother’s pelvis: it became entrapped above the pelvic brim. Baudelocque had observed four different positions of an entrapped fetal head. When stuck above the inlet of the female pelvis, the head of the baby most often faced to the left or right side of the pelvis.^[5] A present-day obstetrician would do a caesarean section. Even the most skilled obstetricians would acknowledge that it is impossible to apply a forceps in this position. 

But the history of medicine presents a strong case that the present-day generation of obstetricians suffers from a loss of skills. The handbook of Baudelocque meticulously describes how to apply the irons in this situation. We have tested the practicability of this manoeuvre using the guidance of the 19^th century obstetrical handbook, a Levret-type forceps, and an anatomical model. Our experiment has confirmed the feasibility of this complex manoeuvre and the duration of 26 minutes to have the head of the baby delivered as reported in several key witness accounts. Moreover, the obstetrician performing the extraction needed both hands throughout the procedure, so assistance by a skilled co-operator was paramount. Our simulation sheds new light on the words of Dubois: he wanted Corvisart by his side, not as a witness for medicolegal reasons but to assist him during the delivery. The Medizinhistoriches Museum Wien, also known as the Josephinum, displays a wax model of a delivery of a child with an entrapped head using applied forceps. This serves as additional scientific proof that obstetricians in 18^th– and 19^th century Europe acknowledged that the entrapment of the fetal head above the pelvic inlet was an exceptional clinical problem. The wax model was used to instruct obstetricians on how to manage this difficult situation: these men knew how to deal with this exceptionally hazardous problem at a time when a caesarean section was a death sentence for the mother.

Definitive proof that the scenario actually happened as presented, cannot be given because there are no written first-hand accounts by Dubois. Our hypothesis sheds a new light on several historical facts reported by those present at the events of March 20^th, 1811. Moreover, as a test case it should make present day obstetricians humble because, despite scientific progress, we have without a doubt lost the skill to perform an instrumental delivery in case of a foetal malposition. 

This column is based on the article “Baron Antoine Dubois and the difficult childbirth of Napoleon I’s
second wife the Empress Marie Louise on 20 March 1811” in Acta Chirurgica Belgica.

REFERENCES

[1] PIERREFITTE-SUR-SEINE, Archives Nationales, AF IV 889, mars 1811, n°293 [C 17496]. 

“This morning, at eight o’clock, the obstetrician suddenly rushed into my bathroom, totally upset, and informed me that the child was lying transversely, that the delivery would be difficult, and that there would be the greatest danger to the child’s life.”

[2] T. LENTZ e.a., Le mémorial de Sainte-Hélène, Le manuscrit original retrouvé, 360-361.

“The Emperor had not been long in his bath, when the pains resumed, and the obstetrician came in, out of his mind, shouting that he was the most unfortunate of men, that out of a thousand deliveries in in Paris, there was none more difficult.”

[3] BAUDELOCQUE, L’Art des accouchements, I, 689. §1582.

[4] BAUDELOCQUE, L’Art des accouchements, I, 691. §1590

[5] BAUDELOCQUE, L’Art des accouchements, II, 202-210. §1873-1885.