The Score

May 31, 2019 9:31 AM

In the mid-thirties, delivering a child had been the single most dangerous event in a woman’s life. By the fifties.... the risk of death for a mother had fallen more than 90%, 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 those of the 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 obstetrics and the nature of childbirth. sl New Yorker, by Atul Gawande
posted by Cozybee (10 comments total)

There is a lot in this essay. But I was struck by a few things:

> In 1614, Pope Paul V issued a similar edict, and ordered 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.

...it makes me depressed that this appears to no longer be the case, see: ectopic pregnancy and the latest abortion laws

>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, then a position of far lesser status. She threw herself into the job, and became 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.

Apgar sounds incredibly kick-ass and I would read her biography/watch a movie based on her


Studies vs real life was a super interesting point:

> 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.)
> I spoke to Dr. Watson Bowes, Jr., an emeritus professor of obstetrics at the University of North Carolina and the author of a widely read textbook chapter on forceps technique. He started practicing in the nineteen-sixties, when fewer than five per cent of deliveries were by C-section and more than forty per cent were with forceps. Yes, he said, many studies did show fabulous results for forceps. But they only showed how well forceps deliveries could go in the hands of highly experienced obstetricians at large hospitals. Meanwhile, the profession was being held responsible for improving Apgar scores and mortality rates for new-borns everywhere—at hospitals small and large, with doctors of all levels of experience.

And finally, the petition to have something equivalent to the apgar for all patients (including mothers), which fits with gawande's recurring theme of improving the medical field....
posted by Cozybee at 9:35 AM on May 31, 2019 [9 favorites]

That's what I've heard about forceps -- that in the hands of an expert, they are better than nearly anything. But the issue is it takes a lot of time to get to that level, and they can do terrible damage if badly wielded. When it was the only option, it was worth using even if you hurt the infant -- at least the mother would live and the child still had a chance. But when you had the more reliable (since it just required general surgery skills) option of a Cesarean it couldn't really be justified.
posted by tavella at 9:55 AM on May 31, 2019 [3 favorites]

Fascinating article!

Since the actual details of the Apgar Score aren’t mentioned until considerably late in the article:

The Apgar score, as it became known universally, 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.

The score was published in 1953, and it transformed child delivery. It turned an intangible and impressionistic clinical concept—the condition of a newly born baby—into a number that people could collect and compare. Using it required 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 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.

posted by darkstar at 9:59 AM on May 31, 2019 [8 favorites]

This is an oldie but a goodie. No comment on the article, except to note that it is collected in one of Gawande's books, Better, which I found fantastic. If you enjoyed this article, you'd probably like the book! Complications, which is an earlier collection of his writing, is also fantastic, and contains what is perhaps my all time favorite essay-The Case of the Red Leg.
posted by HighTechUnderpants at 10:09 AM on May 31, 2019 [7 favorites]

I had no idea the Apgar score was named for a person. I always assumed it was some kind of arcane medical acronym.
posted by Thorzdad at 11:04 AM on May 31, 2019 [12 favorites]

It's both! APGAR is the rare eponymous polylingual double-backronym: One acronym being the scoring elements (Appearance, Pulse, Grimace, Activity, Respiration) which has been translated into other languages; the other acronym being a generalized name for the test (American Pediatric Gross Assessment Record).
posted by ardgedee at 12:10 PM on May 31, 2019 [28 favorites]

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.

I've just been reading a bunch of stuff about Toyota-style industry vs. GM-style industry - and the problems that Toyota started encountering when it decided to scale its methods to become the biggest automaker in the world - so this is doing weird things with my head.

Fascinating article.
posted by clawsoon at 1:53 PM on May 31, 2019 [1 favorite]

One thing that struck me about Atul Gawande's article was how at the end Elizabeth Rourke got stuck in a narrative of having failed, until she challenged that narrative and reframed the events of her child's birth into a positive story. Now, I'm a writer, so storytelling is what I think about, but I do think that people process life-altering events, like births, as stories. It's best when they can tell a story that makes sense of it to them in a positive way.

It's also interesting to me that the article didn't mention vacuum extraction, which is how my son was delivered four years ago in Finland. This might be more common in the Nordic countries than elsewhere, given that the modern technique was pioneered in Sweden.

Finland has much lower percentage of caesarean births than the US (less than half). My wife's labor was very long but a C-section was never seriously considered by midwives or doctors because there was never any danger, it was just slow. We've talked about since, that even though it was exhausting, and looooong, it wasn't traumatizing, because there never was a feeling of danger, nor of any kind of heightened tension. Even by the end when there were more midwives and doctors in the room than we expected to see, and they decided to use the suction cup, it all felt like a logical conclusion.

I'm pretty sure that in most other countries than Finland, our son would've been born via C-section, and we would've had a different story to tell, but the institutional preference here for vacuum extraction shaped the story of my son's birth. The child that's due two and a half weeks from now will get its own story. Hopefully a quicker birth, too.
posted by Kattullus at 3:29 PM on May 31, 2019 [6 favorites]

It's a very interesting article which makes me grateful to the hospital at which we had our first. My wife was in labor for about two and a half days, and when my oldest's head finally started to appear, she had so much hair that vacuum extraction was not an option. I do remember the nurses and doctors having a low-key battle (which I don't think we were supposed to be able to pick up on) about when they would push for a C-section (the doctor on duty had, by her own admission, delivered 5 babies in her 12 hour shift, and was exhausted, but our nurse insisted that everything was progressing, just very slowly). Finally they brought in two steel-haired ladies: a doctor and a midwife, who exuded absolute competence. They suggested a forceps delivery, which was successful. I had no idea how much training forceps required, but if there was anybody who I would have immediately trusted with them, it was that doctor. (Technically she placed the forceps then guided a young trainee doctor's hands on them.)

I've often thought that another hospital would have called it 'failure to progress' much earlier. It was lucky, I think, that I was working at a university in a fancy-pants area so we went to a hospital used to dealing with fancy-pants people. This article made me realize that if they hadn't had that doctor on staff ...
posted by Comrade_robot at 1:49 AM on June 1, 2019 [3 favorites]

I don't know if this is a bit of a derail but I was curious about how delivery methods compared to the UK. I couldn't find stats for the UK as a whole but NHS England publishes monthly reports on a bunch of different childbirth-related stuff. So for England Feb 2019 there's the following:

Of the births that had a recorded delivery method, 57 per cent were spontaneous vaginal births, 11 per cent had instrumental assistance, 14 per cent were elective caesarean sections and 16 per cent were emergency caesarean sections.

Overall that's a caesarean rate of 30% although a substantial number of those are planned rather than emergency C-sections, and instrument-assisted deliveries (forceps, ventouse) are still somewhat common.

The article itself was fascinating - I've ordered a copy of Better and am looking forward to reading it.
posted by the cat's pyjamas at 5:10 AM on June 1, 2019 [2 favorites]