Father of Perinatology

Roberta Speyer: This is Roberta Speyer reporting for OBGYN.net. I have the distinct pleasure to be here at the World Congress of Perinatal Medicine with THE father of perinatal medicine, Professor Emeritus Erich Saling.

Professor, when they say you are the father of perinatal medicine, that really mean you are the one who coined the term, are you not, and started the society?

Professor Emeritus Erich Saling: Yes, the term has been fixed up, it was 1967 in a German paper. When the British editors did a run of diseases of childhood they brought that editorial, but now with our access to the fetus, it started fetal medicine and I recommended, “No, it would better to call it perinatal medicine”. And this was the start of the terminus of the name but we started with our approach to the fetus much earlier, it was in June 1960. So for the first time we took, during labor, blood samples from the unborn and examined them in different directions, for instance serological directions, hematological directions, and a little bit later for acid-based balance and blood _______. This was so far a breakthrough as up to now nobody could diagnose the state of the unborn baby correctly. There had been only very rough impressions by, for instance, auscultation of the heart beats of the fetus, but they can be so misleading. They can be sometimes very slow and the obstetricians had the experience that when they are very slow mostly they have to operate to terminate the labor.
But we took blood samples and we could measure directly what is the oxygen content in the blood of the fetus, and we could draw much better and more exactly the right state of the respiratory state of the fetus, and also when the heart beats have been very slow when we took a sample and the acid base was normal, we said, “No, no, nothing happened, we can wait. We can expect a normal continuation of the birth”. This was a breakthrough.
Then we developed an additional method to examine the amniotic fluid in the last weeks of pregnancy by looking into the cervix and the membranes. They are translucent, this means we can look through the membranes, and we could examine the color of the amniotic fluid because we know that fetuses who are chronically endangered, this means the supply from the mother is reused, they eliminate the meconium, and the amniotic fluid is green because it is polluted. We have known that in all cases where the amniotic fluid is green, the risk of the fetus is increased. In such cases we have to look how strong the fetus is or induce labor to prevent more complications.

So, it was at that time a very good and reliable method in late pregnancy but now we have much better, ultrasonography and so on. But in those years it was a real breakthrough and the fetus became within a very short period of time a real patient.

Roberta Speyer:  Yes, this is the beginning.

Professor Emeritus Erich Saling:  Because up to now I have shown a presentation with slides how it was at the beginning of the 1960's. There have been very extensive textbooks with only a few pages about the fetus, about the condition of the fetus because not much more was known. We started with this and within a few years, eight years, I edited the first book about the infant in the field of obstetrics. This is the first document where the fetus became a patient. Then afterwards it was a revolutionary development in many, many directions. Today we have textbooks; the last edition is 7.2 kgs and 2,220 pages.

Roberta Speyer:  The perfect birth weight! Just take us back a little bit before. You are talking around 1960 when you start doing these things. But take us back to the 1950's and take us back a little earlier. What occurred to you, what happened, that made you see that this was possible; to start looking at the world in a way that no one had ever looked at it before, instead of just the mother but the fetus as a patient?

Professor Emeritus Erich Saling:  The fetus was a     ________right; it was not an individual because we didn't know much about the fetus. We could only listen to the heart activity and that was all. When there was a delivery we stood on the delivery bed, and we have expected and oh, we have been surprised at the condition the fetus is, as we never could know that it must be in a good condition. Or how endangered the fetus is. This was suddenly, when we started to take blood samples; we have known. We can expect that the fetus is not endangered, and really we have seen that this fetus is vigorous, it takes its first breath, it is crying and so on, and you want that. This was a right "sezur" as we say in German. It was a sudden broken line.

Roberta Speyer:  So, it was a change, a complete change in the way things were done.

Professor Emeritus Erich Saling:  Yes, a complete change.

Roberta Speyer:  So, because of your work, the world changed, and everyone then starting working in different fields and ways to look at the fetus, through monitoring, electronically, even now to do surgery on the fetus while it is still in utero.

Professor Emeritus Erich Saling:  This was very much later. To diagnose the fetal heart activity, it's much, much older. The first publications have been in 1880. They deduced that there is a sound and this is the fetus. For the modern electronic monitoring the first steps have been done by Professor Caldeyro-Barcia out of Uruguay. He put a harpoon electrode in anencephalic fetus. Through the abdominal wall he punctured the buttock of a fetus, and he took the first electronic signals. But this was everything in a very elementary experimental stage. So they needed, and he developed, the monitor, the monitor was like a wall, a computer like a whole wall. So they started very early.

But for clinical use, for routine use, it was eight years later after we started with the direct blood examination the cardiotocography. This was a German, Konrad Hammacher, he developed it together with Hewlett-Packard. The first equipment, which was suitable for broad routine work. This was an invasion in all high-level departments.

Roberta Speyer: And people were able to have this in regular hospitals.

Professor Emeritus Erich Saling:  Yes, and they thought they could do everything now with electronic monitoring of the heart rate. Then we came and compared it with our biochemical examination with fetal blood sampling. We demonstrated that the electronic monitored fetuses are also more than 50 percent misleading. I compared the cardiotocograms, the records, with monkeys in a jungle, because monkeys in a jungle they are very sensitive, and if there is any suspicion of noise they give alarm. But in more than half the cases the alarm is caused by very harmless and not dangerous reasons. And only in about 40 percent it is justified, it’s right, so it is with a cardiotocogram. This is what we compared. Now our method, the biochemical, is more or less a gold standard to know much better in what condition the fetus is.

But there are so many others; ultrasonography, it was a revolution because for the first time we could see inside the uterus.

Roberta Speyer: See the baby. Now with 3D you can even see all the features.

Professor Emeritus Erich Saling:  Yes, to see the baby. Of course the first have been very primitive but later on it was so that today you can have 3D dimension, you can see that there I have a slide in which there are the faces of the fetuses compared with the same fetuses later, directly after birth. So you see it here ultrasonography picture and here you see a real photo picture. They are so similar.

Roberta Speyer: It’s amazing. What do you predict with all your years of experience, and the things you have seen, what do you predict going forward in the future 20 – 25 years? Will there be operations? Will there be more treatment do you think of the fetus as a patient while it is still in utero?

Professor Emeritus Erich Saling:  I think we will be much better, diagnose much earlier, when there is any aberration from the normal course of labor, so that we know very early in which cases we should operate, which we should terminate or what can we do to start a pathological event in the labor to normal again. I think using all the techniques that are now available and probably with new techniques in the future, we will have much better in our hands to have a safe birth process for the mother and for the fetus.

Roberta Speyer: I want to mention before we close that there is an award, an award in your name that is given by the Society, the Saling Award. Could you tell us who receives this award and what is the purpose of it?

Professor Emeritus Erich Saling:  They are very prominent colleagues. The first was Professor Nicholaides from London. The second was Professor Romero, he is an outstanding colleague. The third was Professor Holzgrafe from Basel, Switzerland. The last time was Professor Jose Carreras from Barcelona and Professor Frank Chervenak from New York. All have done a lot for the progress of perinatal medicine.

And now, the prize had been awarded to Professor Dudenhausen, who is the president of this congress. He is my pupil, he worked with me for about 18 years.

Roberta Speyer: He turned out okay.

Professor Emeritus Erich Saling:  Ja! I’m very happy about this that I am still alive and I can present to him this prize, and Professor Anne Greenough, the first candidate from neonatology and the first lady. Up to now only men have got the prizes. So I was particularly happy we have now the first woman in our group.

Roberta Speyer: Well that’s good. I’m glad it’s a girl. Well Professor, I am so happy we had this chance to interview you for OBGYN.net, the Father of Perinatal Medicine, Professor Emeritus Erich Saling, thank you very much.