Modern Medicine and Pregnancy

Atul Gawande is a working surgeon, and yet he also finds time to write some of the best medical journalism around. His latest article on the "industrialization of childbirth" is a real gem.

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 ninety per cent of deliveries; intravenous fluids in more than eighty per cent; epidural or spinal 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 half. Thirty per cent of American deliveries are now by Cesarean section, and that proportion continues to rise. Something has happened to the field of obstetrics--and, perhaps irreversibly, to childbirth itself.

Gawande traces the beginning of this "industrialization" to the introduction of the Apgar score for newborns, which gave nurses a quick way of making a precise medical evaluation. But this simple measurement had widespread side-effects, and led obstetricians to completely re-think the modern delivery:

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.