Baby, baby, baby

A history of obstetrics — and how the impulse for standardized reliability means that C-sections continue to grow in popularity.

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.

[…] This procedure, once a rarity, is now commonplace. Whereas 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 a C-section. The procedure is performed with impressive consistency.

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 bowels that were 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 a new baby’s placenta could attach itself to the scar and cause serious 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, with natural childbirth.

And part of what’s interesting in this is the growing sense (or claim) that C-sections may always be safer than natural childbirth (despite their own risks).

Currently, one out of five hundred babies who are healthy and kicking at thirty-nine weeks dies before or during childbirth—a historically low rate, but obstetricians have reason to believe that scheduled C-sections could avert at least some of these deaths. Many argue that the results for mothers are safe, too. Scheduled C-sections are certainly far less risky than emergency C-sections—procedures done quickly, in dire circumstances, for mothers and babies already in distress. One recent American study has raised
concerns about the safety of scheduled C-sections, but two studies, one in Britain and one in Israel, actually found scheduled C-sections to have lower maternal mortality than vaginal delivery. Mothers who undergo planned C-sections may also (though this remains largely speculation) have fewer problems later in life with incontinence and uterine prolapse.

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 kottke)