A very interesting article about childbirth that surveys the changes in the field of obstetrics and the transformation of childbirth from an art to a standardized procedure. Highlighting the importance of the Apgar score and the prevalance of Cesarean sections
Around the world, virtually every child born in a hospital had an Apgar score recorded at one minute after birth and at five minutes after birth. It quickly became clear that a baby with a terrible Apgar score at one minute could often be resuscitated�with measures like oxygen and warming�to an excellent score at five minutes. Spinal and then epidural anesthesia were found to produce babies with better scores than general anesthesia. Neonatal intensive-care units sprang into existence. Prenatal ultrasound came into use to detect problems for deliveries in advance. Fetal heart monitors became standard. Over the years, hundreds of adjustments in care were made, resulting in what�s sometimes called �the obstetrics package.� And that package has produced dramatic results. In the United States today, a full-term baby dies in just one out of five hundred childbirths, and a mother dies in one in ten thousand. If the statistics of 1940 had persisted, fifteen thousand mothers would have died last year (instead of fewer than five hundred)�and a hundred and twenty thousand newborns (instead of one-sixth that number).
There�s a paradox here. Ask most research physicians how a profession can advance, and they will talk about the model of �evidence-based medicine��the idea that nothing ought to be introduced into practice unless it has been properly tested and proved effective by research centers, preferably through a double-blind, randomized controlled trial. But, in a 1978 ranking of medical specialties according to their use of hard evidence from randomized clinical trials, obstetrics came in last. Obstetricians did few randomized trials, and when they did they ignored the results. Careful studies have found that fetal heart monitors provide no added benefit over having nurses simply listen to the baby�s heart rate hourly. In fact, their use seems to increase unnecessary Cesarean sections, because slight abnormalities in the tracings make everyone nervous about waiting for vaginal delivery. Nonetheless, they are used in nearly all hospital deliveries. Forceps have virtually disappeared from the delivery wards, even though several studies have compared forceps delivery to Cesarean section and found no advantage for Cesarean section. (A few found that mothers actually did better with forceps.)
Doctors in other fields have always looked down their masked noses on their obstetrical colleagues. Obstetricians used to have trouble attracting the top medical students to their specialty, and there seemed little science or sophistication to what they did. Yet almost nothing else in medicine has saved lives on the scale that obstetrics has. Yes, there have been dazzling changes in what we can do to treat disease and improve people�s lives. We now have drugs to stop strokes and to treat cancers; we have coronary-artery stents, artificial joints, and mechanical respirators. But those of us in other fields of medicine don�t use these measures anywhere near as reliably and as safely as obstetricians use theirs. . . .
. . . In obstetrics, meanwhile, if a strategy seemed worth trying doctors did not wait for research trials to tell them if it was all right. They just went ahead and tried it, then looked to see if results improved. Obstetrics went about improving the same way Toyota and General Electric did: on the fly, but always paying attention to the results and trying to better them. And it worked. Whether all the adjustments and innovations of the obstetrics package are necessary and beneficial may remain unclear�routine fetal heart monitoring is still controversial, for example. But the package as a whole has made child delivery demonstrably safer and safer, and it has done so despite the increasing age, obesity, and consequent health problems of pregnant mothers.
The Apgar score changed everything. It was practical and easy to calculate, and it gave clinicians at the bedside immediate information on how they were doing. In the rest of medicine, we measure dozens of specific things: blood counts, electrolyte levels, heart rates, viral titers. But we have no measure that puts them together to grade how the patient as a whole is faring. It�s like knowing, during a basketball game, how many blocked shots and assists and free throws you have had, but not whether you are actually winning. We have only an impression of how we�re performing�and sometimes not even that. At the end of an operation, have I given my patient a one-in-fifty chance of death, or a one-in-five-hundred chance? I don�t know. I have no feel for the difference along the way. �How did the surgery go?� the patient�s family will ask me. �Fine,� I can only say. . . .
. . . The Apgar effect wasn�t just a matter of giving clinicians a quick objective read of how they had done. The score also changed the choices they made about how to do better. When chiefs of obstetrics services began poring over the Apgar results of their doctors and midwives, they started to think like a bread-factory manager taking stock of how many loaves the bakers burned. They both want solutions that will lift the results of every employee, from the novice to the most experienced. That means sometimes choosing reliability over the possibility of occasional perfection. . . .
. . .The question facing obstetrics was this: Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills�the Woods corkscrew maneuver for the baby with a shoulder stuck, the Lovset maneuver for the breech baby, the feel of a forceps for a baby whose head is too big. You do research to find new techniques. You accept that things will not always work out in everyone�s hands.
But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques. You notice the steady reports of terrible forceps injuries to babies and mothers, despite the training that clinicians have received. After Apgar, obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section. . . .
. . . And yet there�s something disquieting about the fact that childbirth is becoming so readily surgical. Some hospitals are already doing Cesarean sections in more than half of child deliveries. It is not mere nostalgia to find this disturbing. We are losing our connection to yet another natural process of life. And we are seeing the waning of the art of childbirth. The skill required to bring a child in trouble safely through a vaginal delivery, however unevenly distributed, has been nurtured over centuries. In the medical mainstream, it will soon be lost.
Skeptics have noted that Cesarean delivery is suspiciously convenient for obstetricians� schedules and, hour for hour, is paid more handsomely than vaginal birth. Obstetricians say that fear of malpractice suits pushes them to do C-sections more frequently than even they consider necessary. Putting so many mothers through surgery is hardly cause for celebration. But our deep-seated desire to limit risk to babies is the biggest force behind its prevalence; it is the price exacted by the reliability we aspire to. . . .
via Fructis Ventris
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