Better (21 page)

Doctors in other fields have always looked down their masked noses on their obstetrical colleagues. They didn't think they were very smart--obstetricians long had 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, mechanical joints, and artificial respirators. But do those of us in other fields of medicine use these measures anywhere near as reliably and as safely as obstetricians use theirs? We don't come close.

Ordinary pneumonia, for instance, remains the fourth most common cause of death in affluent countries, and the death rate has actually worsened in the past quarter century. That's in part because pneumonias have become more severe, but it's also because we doctors haven't performed all that well. Elegant research trials have shown us the best antibiotics to use and that patients needing hospitalization are less likely to die if the antibiotics are started within four hours of arrival. But we pay little attention to what actually happens in practice. A recent study has concluded that 40 percent of pneumonia patients do not get the antibiotics on time. When we do give the antibiotics, 20 percent of patients get the wrong kind.

In obstetrics, meanwhile, if a new 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 went about improving: on the fly, but always paying attention to the results and trying to better them. And that approach 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 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 feedback on how effective their care was. In the rest of medicine, we are used to measuring dozens of specific things: blood counts, electrolyte levels, heart rates, viral titers. But we have no routine measure that puts the data together to grade how the patient as a whole is faring. We have only an impression of how we're performing--and sometimes not even that. At the end of a difficult operation, have I given my patient a one in fifty chance of death, or one in five hundred? I cannot say. 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. Chiefs of obstetrics services began poring over the Apgar results of their doctors and midwives, and by doing so they became no different from the bread factory floor manager taking stock of how many loaves the bakers burned. They both want solutions that will lift the results of every employee, from the most novice to the most experienced. That means sometimes choosing reliability over the possibility of occasional perfection.

The fate of the forceps is a revealing example. I spoke to Watson Bowes Jr., the University of North Carolina emeritus professor of obstetrics, about what happened to the forceps.
In addition to his studies on the care of premature babies, he was the author of a widely read textbook chapter on forceps technique. He had also practiced in the 1960s, when less than 5 percent of deliveries were by C-section and more than 40 percent were with forceps. Yes, he said, many studies showed fabulous results for forceps. But they only showed how well forceps deliveries could go in the hands of very experienced obstetricians at large hospitals. Meanwhile, the profession was being held responsible for improving Apgar scores and mortality rates for newborns everywhere--at hospitals small and large, with doctors of all levels of experience.

"Forceps deliveries are very difficult to teach--much more difficult than a C-section," Bowes said. "With a C-section, you stand across from the learner. You can see exactly what they're doing. You can say, 'Not there.
There.
' With the forceps, though, there is a feel that is very hard to teach."

Just putting the forceps on a baby's head is tricky. You have to choose the right type for the shape of the mother's pelvis and the size of the child's head--and there are at least half a dozen types of forceps. You have to slide the blades symmetrically along the sides, traveling exactly in the space between the ears and the eyes and over the cheekbones. "For most residents, it took two or three years of training to get this consistently right," he said. Then a doctor must apply forces of both traction and compression--pulling, Bowes's chapter explained, with an average of forty to seventy pounds of axial force and five pounds of fetal skull compression. "When you put tension on the forceps, you should have some sense that there is movement," he said. Too much force and skin can tear, the skull can fracture, a fatal brain hemorrhage may
result. "Some residents had a real feel for it," Bowes said. "Others didn't."

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 some four million babies a year in the United States alone, then a new understanding is required. The focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the Unites States could really safely master all these techniques. You notice the steady reports of terrible forceps injuries to babies and mothers, despite all the training that clinicians 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.

J
UST AFTER 7:30 P.M.,
in the thirty-ninth hour of her labor, Elizabeth Rourke underwent surgery to deliver her baby. Peccei had offered her the option of a Cesarean eight hours before, but Rourke refused. She hadn't been ready to give up on pushing her little baby out into the world, and, though the doctor doubted Rourke's efforts would succeed, the baby was doing fine on the heart monitor. There was no harm in Rourke's
continuing to try. The doctor increased the Pitocin dose slightly, to as high as the baby's heart rate seemed to allow. Despite the epidural, the contractions became fiercely painful. And there was progress: by 3:00 p.m., Rourke's cervix had dilated to nearly nine centimeters. The contractions had pushed the baby forward two centimeters. Even Peccei began to think Rourke might make this delivery happen.

After three more hours, however, the baby's head was no lower and was still sideways; Rourke's cervix hadn't dilated any further. Rourke finally admitted to herself that her baby wasn't coming out. When Peccei offered her a Cesarean again, she said yes.

The Pitocin drip was turned off. The contraction monitor was removed. There was just the swift tock-tock-tock of the fetal heart monitor. Peccei introduced a colleague who would do the operation--Rourke had been in labor so long, she'd gone through three shifts of obstetricians. She was wheeled to a spacious, white-tiled operating room down the hall. Her husband, Chris, struggled to put on the green scrubs, tie-on mask, bouffant surgical cap, and blue booties over his shoes. He took a chair next to her at the head of the operating table and placed his hand on her shoulder. The anesthesiologist put extra medication in her epidural and pricked at the skin of her belly to make sure that the band of numbness was wide enough. The nurse painted her skin with a yellow-brown antiseptic. Then the cutting began.

The Cesarean section is among the strangest operations I have seen. It is also one of the most straightforward. You press a No. 10 blade down through the flesh, along a side-to-side line low on the bulging abdomen. You divide the skin and golden
fat with clean, broad strokes. Using a white gauze pad, you stanch the bleeding points that appear like red blossoms. You slice through the fascia covering the abdominal muscle, a husklike fibrous sheath, and lift it to reveal the beefy red muscle underneath. The rectus abdominis muscle lies in two vertical belts that you part in the middle like a curtain, metal retractors pulling left and right. You cut through the peritoneum, a thin, almost translucent membrane. And the uterus--plum-colored, thick, and muscular--gapes into view. You make a small, initial opening in the uterus with the scalpel, and then you switch to bandage scissors to open it more swiftly and easily. It's as if you're cutting open a tough, leathery fruit.

Then comes what still seems surreal to me. You reach in, and instead of finding a tumor or some other abnormality, as surgeons usually do when we go into someone's belly, you find five tiny wiggling toes, a knee, a whole leg. And suddenly you realize you have a new human being struggling in your hands. You almost forget the mother on the table. The infant can sometimes be hard to get out. If the head is deep in the birth canal, you have to grab around the waist, stand up tall, and
pulllll
. Sometimes you have to have someone push on the baby's head from below. Then the umbilical cord is cut. The baby is swaddled. The nurse records the Apgar score.

After the next uterine contraction, you deliver the placenta through the wound. With a fresh gauze pad, you wipe the inside of the mother's uterus clean of clots and debris. You sew it closed with two baseball-stitched layers of stout absorbable suture. You sew the muscle fascia back together with another suture, then sew the skin. And you are done.

This procedure, once a rarity, is now commonplace. Where before obstetricians learned one technique for a foot dangling out, another for a breech with its arms above its head, yet another for a baby with its head jammed inside the pelvis, all tricky in their own individual ways, now the solution is the same almost regardless of the problem: the C-section. Every obstetrician today is comfortable doing C-sections. Small hospitals have no difficulty keeping in practice. The procedure is performed with impressive consistency.

As straightforward as these operations are, they can go wrong. The child can be lacerated. If the placenta separates and the head doesn't come free quickly, the baby can asphyxiate. The mother faces significant risks, too. As a surgeon, I have been called in to help repair bowel that was torn and wounds that split open. Bleeding can be severe. Wound infections are common. There are increased risks of blood clots and pneumonia. Even without any complication, the recovery is weeks longer and more painful than with vaginal delivery. And, in future pregnancies, mothers can face serious difficulties. The uterine scar has a one in two hundred chance of rupturing in an attempted vaginal delivery. There's a similar risk that the scar could attach itself to a new baby's placenta and cause difficult bleeding problems. C-sections are surgery. There is no getting around it.

Yet there's also no getting around C-sections. We have reached the point that, when there's any question of delivery risk, the Cesarean is what clinicians turn to--it's simply the most reliable option. If a mother is carrying a baby more than ten pounds in size, if she's had a C-section before, if the baby is lying sideways or in a breech position, if she has twins, if any
number of potentially difficult situations for delivery arise--the standard of care requires that a midwife or an obstetrician at least offer a Cesarean section. Clinicians are increasingly reluctant to take a risk, however small, and try laboring through.

I asked Bowes how he would have handled obstructed deliveries like Rourke's back in the sixties. His first recourse, as you'd expect, would have included the forceps.
*
He had delivered more than a thousand babies with forceps, he said, with a rate of neonatal injury as good as or better than with Cesarean sections, and a far faster recovery for the mothers. Had Rourke been under his care back then, the odds are excellent that she could have delivered safely without surgery. But Bowes is a virtuoso of a difficult instrument. When the protocols of his profession changed, he changed with them. "As a professor, you have to be a role model. You don't want to be the cowboy who goes in to do something that your residents are not going to be able to do," he told me. "And there was always uncertainty." Even he had to worry that, someday, his judgment and skill would fail him.

These were the rules of the factory floor. To discourage the inexpert from using forceps--along with all those eponymous maneuvers--obstetrics had to discourage everyone from using them. When Bowes finished his career, in 1999, he had a 24 percent Cesarean rate, just like the rest of his colleagues. He has little doubt he'd be approaching 30 percent, like his colleagues today, if he were still practicing.

A measure of how safe Cesareans have become is that there is a ferocious but genuine debate about whether a mother in the thirty-ninth week of pregnancy with no special risks should be offered a Cesarean delivery as an alternative to waiting for labor. The idea seems the worst kind of hubris. How could a Cesarean delivery be considered without even trying a natural one? Surgeons don't suggest that healthy people get their appendixes taken out or that artificial hips might be stronger than the standard-issue ones. Our complication rates for even simple procedures remain unflatteringly high. Yet, in the next decade or so, the industrial revolution in obstetrics could well make Cesarean delivery consistently safer than the birth process that evolution gave us.