by Atul Gawande
These situations are dangerous. When a baby is stuck, the umbilical cord, the only source of fetal blood and oxygen, eventually becomes trapped or compressed, causing the baby to asphyxiate. Mothers have sometimes labored for astonishing lengths of time, unable to deliver, and died with their child in the process. In 1817, for example, Princess Charlotte of Wales, King George IV's twenty-one-year-old daughter, spent four days in labor. Her nine-pound boy was in a sideways position with a head too large for Charlotte's pelvis. Only after the fiftieth hour of active labor did he finally emerge--stillborn. Six hours later, Charlotte herself died, from hemorrhagic shock. As she was George's only child, the throne passed to his brother instead of her, then to his niece--which is how Victoria became queen.
Midwives and doctors long sought ways out of such disasters, and the history of ingenuity in obstetrics is the history of these efforts. The first reliably lifesaving invention for mothers was called a crochet, or, in another variation, a cranioclast: a long, sharply pointed instrument, often with clawlike hooks, which birth attendants used in desperate situations to perforate and crush a fetus's skull, extract the fetus, and save, at least, the mother's life.
Many obstetricians and midwives made their names by devising ways to get both a mother and baby through obstructed deliveries. There is, for example, the Lovset maneuver for a breech baby with its arms trapped above the head: you take the baby by the hips and turn it sideways, then reach in, take an upper arm, and sweep it down over the chest and out. If a breech baby's arms are out but the head is trapped, you have the Mariceau-Smellie-Veit maneuver: you place your finger in the baby's mouth, which allows you to pull forcefully while still controlling the head.
The child with its head out but a shoulder stuck--a "shoulder dystocia"--will asphyxiate within five to seven minutes unless it is freed and delivered. Sometimes sharp downward pressure with a fist just above the mother's pubic bone can dislodge the shoulder; if not, there is the Woods corkscrew maneuver, in which you reach in, grab the baby's posterior shoulder, and push it backward to free the child. There's also the Rubin maneuver (you grab the stuck, anterior shoulder and push it forward toward the baby's chest to release it) and the McRoberts maneuver (sharply flex the mother's legs up onto her abdomen and so lift her pubic bone off the baby's shoulder). Finally, there is the maneuver that no one wanted to put his name to but that has saved many babies' lives through history: you fracture the clavicles--the collar bones--and pull the baby out.
There are dozens of these maneuvers, and, though they have saved the lives of countless babies, each has a significant failure rate. Surgery has been known since ancient times as a way to save an entrapped baby. Roman law in the seventh century b.c. forbade burial of an undelivered woman until the child had been cut out, in the hope that the child would survive. In 1614, Pope Paul V issued a similar edict, ordering that the child be baptized if it was still alive. But Cesarean section on a living mother was considered criminal for much of history, because it almost always killed the mother--through hemorrhage and infection--and her life took precedence over that of the child. (The name "Cesarean" section may have arisen from the tale that Caesar was born of his mother, Aurelia, by an abdominal delivery, but historians regard the story as a myth, since Aurelia lived long after his birth.) Only after the development, in the late nineteenth century, of anesthesia and antisepsis and, in the early twentieth century, of a double-layer suturing technique that could stop an opened uterus from hemorrhaging, did Cesarean section become a real option. Even then, it was held in low repute. And that was because a better option was around: the obstetrical forceps.
The story of the forceps is both extraordinary and disturbing, because it is the story of a lifesaving idea that was kept secret for more than century. The instrument was developed by Peter Chamberlen (1575-1628), the first of a long line of French Huguenots who delivered babies in London. It looked like a pair of big metal salad tongs, with two blades shaped to fit snugly around a baby's head and handles that locked together with a single screw in the middle. It let doctors more or less yank stuck babies out and, carefully applied, was the first technique that could save both the baby and the mother. The Chamberlens knew they were onto something, and they resolved to keep the device a family secret. Whenever they were called in to help with a mother in obstructed labor, they ushered everyone else out of the room and covered the mother's lower half with a sheet or a blanket so that even she couldn't see what was going on. They kept the secret of the forceps for three generations. In 1670, Hugh Chamberlen, in the third generation, tried and failed to sell the design to the French government. Late in his life, he divulged it to an Amsterdam-based obstetrician, Roger Roonhuysen, who kept the technique within his own family for sixty more years. The secret did not get out until the mid-eighteenth century. Once it did, it gained wide acceptance. At the time of Princess Charlotte's failed delivery in 1817, her obstetrician, Sir Richard Croft, was widely reviled for failing to use forceps to assist. In remorse for her death, he shot himself to death not long afterward.
By the early twentieth century, the problems of human birth seemed to have been largely solved. Doctors could avail themselves of a range of measures to ensure a safe delivery: antiseptics, the forceps, blood transfusions, a drug (ergot) that could induce labor and contract the uterus after delivery to stop bleeding, and even, in desperate situations, Cesarean section. By the 1930s, most urban mothers had shifted from midwife deliveries at home to physician deliveries in the hospital.
But in 1933 the New York Academy of Medicine published a shocking study of 2,041 maternal deaths in childbirth in New York City. At least two-thirds, the investigators found, were preventable. There had been no improvement in death rates for mothers in the preceding two decades; death rates for newborns had actually increased. Hospital care brought no advantages; mothers were better off delivering at home. The investigators were appalled to find that many physicians simply didn't know what they were doing: they missed clear signs of hemorrhagic shock and other treatable conditions, violated basic antiseptic standards, tore and infected women with misapplied forceps. The White House followed with a similar national report. Doctors may have had the right tools, but midwives without them did better.
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.
AN 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.
THERE 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.