Authors: Atul Gawande
The two reports brought modern obstetrics to a critical turning point. Specialists in the field had shown extraordinary ingenuity. They had developed the knowledge and instrumentation to solve many problems of child delivery. Yet knowledge and instrumentation had proved grossly insufficient. If obstetrics wasn't to go the way of phrenology or trepanning, it had to discover a different kind of ingenuity. It had to figure out how to standardize childbirth.
Three-quarters of a century later, the degree to which birth has been transformed by medicine is astounding and, for some, alarming. Today, electronic fetal heart-rate monitoring is used in more than 90 percent of deliveries, intravenous fluids in more than 80 percent, epidural anesthesia in three-quarters, medicines to speed up labor (the drug of choice is no
longer ergot but Pitocin, a synthetic form of the natural hormone that drives contractions) in at least half. Thirty percent of American deliveries are now by Cesarean section, and that proportion continues to rise. The field of obstetrics has changed--and, perhaps irreversibly, so has childbirth itself.
A
N ADMITTING CLERK
led Elizabeth Rourke and her husband into a small triage room. A nurse midwife timed her contractions--they were indeed five minutes apart--and then did a pelvic examination to see how dilated Rourke was. After twelve hours of regular, painful contractions, Rourke figured that she might be at seven or eight centimeters. Instead, she was at two.
It was disheartening news: her labor was only just starting. The nurse practitioner thought about sending her home but eventually decided to admit her. The labor floor was a horseshoe of twelve patient rooms strung around a nurses' station. For hospitals, deliveries are a good business. If mothers have a positive experience, they stay loyal to the hospital for years. So the rooms are made to seem as warm and inviting as possible for what is, essentially, a procedure room. Each has recessed lighting, decorator window curtains, comfortable chairs for the family, individualized climate control. Rourke's even had a Jacuzzi. She spent the next several hours soaking in the tub, sitting on a rubber birthing ball, or walking the halls--stopping to brace herself with each contraction.
By 10:30 that night, the contractions had sped up, coming every two minutes. The doctor on duty for her obstetrician's group performed a pelvic examination. Her cervix was still
only two centimeters dilated: the labor had stalled, if it had ever really started.
The doctor gave her two options. She could have active labor induced with Pitocin. Or she could go home, rest, and wait for true active labor to begin. Rourke did not like the idea of using the drug. So at midnight she and her husband went home.
No sooner was she home than she realized that she had made a mistake. The pain was too much. Chris had conked out on the bed, and she couldn't get through this on her own. She held out for another two and a half hours, just to avoid looking foolish, and then got Chris to drive her back. At 2:43 a.m., the nurse scanned her in again--she was still wearing her bar-coded hospital identification bracelet. The obstetrician reexamined her. Rourke was nearly four centimeters dilated. She had progressed to active labor.
Rourke began to feel her will fading, however. She had been having regular contractions for twenty-two hours and was exhausted from sleeplessness and pain. She tried a narcotic called Nubain to dull the pain, and when that didn't work, she broke down and asked for an epidural. An anesthesiologist came in and had her sit on the side of the bed with her back to him. She felt a cold, wet swipe of antiseptic along her spine, the pressure of a needle, and a twinge that shot down her leg; the epidural catheter was in. The doctor gave a bolus of local anesthetic into the tubing, and the pain of the contractions melted away into numbness. Then her blood pressure dropped--a known side effect of epidural injections. The team poured fluids into her intravenously and gave injections of ephedrine to increase her--and her baby's--blood pressure.
It took fifteen minutes to stabilize her blood pressure. But the monitor showed that the baby's heart rate remained normal the whole time, about 150 beats a minute. The team dispersed and around 4:00 a.m., Rourke fell asleep.
At 6:00 a.m., the obstetrician returned and, to Rourke's dismay, found her still just four centimeters dilated. Her determination to avoid medical interventions ebbed further, and a Pitocin drip was started. The contractions surged. At 7:30 a.m., she was six centimeters dilated. This was real progress. Rourke was elated. She rested some more. She felt her strength coming back. She readied herself to start pushing in a few hours.
Dr. Alessandra Peccei took over with the new day and looked at the whiteboard behind the nursing station where the hourly progress of the mother in each room is recorded. In a typical morning, a mother in one room might have been pushing while a mother in another was having her labor induced with medication; in still another, a mother might be just waiting, her cervix only partially dilated and the baby still high. Rourke was a "G2P0 41.2 wks pit+ 6/100/-2" on the whiteboard--a mother with two gestations, zero born (Rourke had had a previous miscarriage), forty-one weeks and two days pregnant. She was on Pitocin. Her cervix was six centimeters dilated and 100 percent effaced. The baby was at negative-two station, which is about seven centimeters from crowning, that is, from becoming visible at the vaginal orifice.
Peccei went into Rourke's room and introduced herself as the attending obstetrician. Peccei, who was forty-two years old and had delivered more than two thousand newborns, projected a comforting combination of competence and
friendliness. She had given birth to her own children with a midwife. Rourke felt that they understood each other.
Peccei waited three hours to allow Rourke's labor to progress. At 10:30 a.m., she reexamined her and frowned. The cervix was unchanged, still six centimeters dilated. The baby had not come down any further. Peccei felt along the top of the baby's head for the soft spot in back to get a sense of which way it was facing and found it facing sideways. The baby was stuck.
Sometimes increasing the strength of the contractions can turn the baby's head in the right direction and push it along. So, using a gloved finger, Peccei punctured the bulging membrane of Rourke's amniotic sac. The waters burst out, and immediately the contractions picked up strength and speed. The baby did not budge, however. Worse, on the monitor, its heart rate began to drop with each contraction--120, 100, 80, it went, taking almost a minute before recovering to normal. It's not always clear what dips like these mean. Malpractice lawyers like to say that they are a baby's "cry for help." In some cases, they are. An abnormal tracing can signal that a baby is getting an inadequate supply of oxygen or blood--the baby's cord might be wrapped around its neck or getting squeezed off altogether. But usually, even when the baby's heart rate takes a prolonged dive, lasting well past the end of a contraction, the baby is fine. A drop in heart rate is often simply what happens when a baby's head is squeezed really hard.
Dr. Peccei couldn't be sure which was the case. So she turned off the Pitocin drip, to reduce the strength of the contractions. She gave Rourke, and therefore the baby, extra oxygen by nasal prong. She scratched at the baby's scalp to irritate
it and make sure the baby's heart rate responded. The heart rate continued to drop during contractions, but it never failed to recover. After twenty-five minutes, the decelerations finally disappeared. The baby's heart rate was back to being steadily normal.
Now what? Rourke had not dilated any further in five hours. The baby's head was stuck sideways. She'd been in labor for thirty hours to this point, and her baby didn't seem to be going anywhere.
T
HERE ARE 130,000,000
births around the world each year, more than
4,000,000
of them in the United States. No matter what is done, some percentage are going to end badly. All the same, physicians have had an abiding faith that they could step in and at least reduce that percentage. When the national reports of the 1930s proved that obstetrics had failed to do so and that incompetence was an important reason, the medical profession turned to a strategy of instituting strict regulations on individual practice. Training requirements were established for physicians delivering babies. Hospitals set firm rules about who could do deliveries, what steps they had to follow, and whether they would be permitted to use forceps and other risky interventions. Hospital and state authorities investigated maternal deaths for aberrations from basic standards.
Having these standards reduced maternal deaths substantially. In the mid-1930s, delivering a child had been the single most dangerous event in a woman's life: one in 150 pregnancies ended in the death of the mother. By the 1950s, owing
in part to the tighter standards and in part to the discovery of penicillin and other antibiotics, the risk of death for a mother had fallen more than 90 percent, to just one in two thousand.
But the situation wasn't so encouraging for newborns: one in thirty still died at birth--odds that were scarcely better than they were a century before--and it wasn't clear how that could be changed. Then a doctor named Virginia Apgar, who was working in New York, had an idea. It was a ridiculously simple idea, but it transformed childbirth and the care of the newly born. Apgar was an unlikely revolutionary for obstetrics. For starters, she had never delivered a baby--not as a doctor and not even as a mother.
Apgar was one of the first women to be admitted to the surgical residency at Columbia University College of Physicians and Surgeons, in 1933. The daughter of a Westfield, New Jersey, insurance executive, she was tall and would have been imposing if not for her horn-rimmed glasses and bobby pins. She had a combination of fearlessness, warmth, and natural enthusiasm that drew people to her. When anyone was having troubles, she would sit down and say, "Tell Momma all about it." At the same time, she was exacting about everything she did. She wasn't just a talented violinist; she also made her own instruments. She began flying single-engine planes at the age of fifty-nine. When she was a resident, a patient she had operated on died after surgery. "Virginia worried and worried that she might have clamped a small but essential artery," Stanley James, a colleague of hers, later recalled. "No autopsy permit could be obtained. So she secretly went to the morgue and opened the operative incision to find the cause. That small
artery had been clamped. She immediately told the surgeon. She never tried to cover a mistake. She had to know the truth no matter what the cost."
At the end of her surgical residency, her chairman told her that, however good she was, a female surgeon had little chance of attracting patients. He persuaded her to join Columbia's faculty as an anesthesiologist, which was then a position of far lesser status. She threw herself into the job, becoming the second woman in the country to be board certified in anesthesiology. She established anesthesia as its own division at Columbia and, eventually, as its own department, on an equal footing with surgery. She administered anesthesia to more than twenty thousand patients during her career. She even carried a scalpel and a length of tubing in her purse, in case a passerby needed an emergency airway--and apparently employed them successfully more than a dozen times. "Do what is right and do it now," she used to say.
Throughout her career, the work she loved most was providing anesthesia for child deliveries. She loved the renewal of a new child's coming into the world. But she was appalled by the care that many newborns received. Babies who were born malformed or too small or just blue and not breathing well were listed as stillborn, placed out of sight, and left to die. They were believed to be too sick to live. Apgar believed otherwise, but she had no authority to challenge the conventions. She was not an obstetrician, and she was a female in a male world. So she took a less direct but ultimately more powerful approach: she devised a score.
The Apgar score, as it became universally known, allowed nurses to rate the condition of babies at birth on a scale
from zero to ten. An infant got two points if it was pink all over, two for crying, two for taking good, vigorous breaths, two for moving all four limbs, and two if its heart rate was over a hundred. Ten points meant a child born in perfect condition. Four points or less meant a blue, limp baby.
Published in 1953 to revolutionary effect, the score turned an intangible and impressionistic clinical concept--the condition of new babies--into numbers that people could collect and compare. Using it required more careful observation and documentation of the true condition of every baby. Moreover, even if only because doctors are competitive, it drove them to want to produce better scores--and therefore better outcomes--for the newborns they delivered.
Around the world, virtually every child born in a hospital came to have 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. Neonatal intensive care units sprang into existence. The score also began to alter how childbirth itself was managed. Spinal and then epidural anesthesia were found to produce babies with better scores than general anesthesia. Prenatal ultrasound came into use to detect problems for deliveries in advance. Fetal heart monitors became standard. Over the years, hundreds of adjustments and innovations 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 childbirth out of five hundred, and a mother dies in less than one in ten thousand. If the statistics of
1930 had persisted, 27,000 mothers would have died last year (instead of fewer than five hundred)--and 160,000 newborns (instead of one-eighth that number).
T
HERE'S A PARADOX
here. Ask most research physicians how a profession can advance, and they will tell you 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 largely ignored the results. Take fetal heart monitors. Careful studies have found that they provide no added benefit in routine labors over having nurses simply listen to the baby's heart rate hourly. In fact, the use of monitors 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 child deliveries. Or consider the virtual disappearance of forceps in 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.)