A surgeon looks at the pros and cons of forceps, Cesarean sections, epidural anesthesia, fetal heart monitors and other fixtures of modern delivery rooms
Better: A Surgeon’s Notes on Performance. By Atul Gawande. Holt/Metropolitan, 273 pp., $24.95.
By Janice Harayda
Last year the New York Times published an article on a remarkable medical study that found that – contrary to a near-universal belief – pushing during labor helps neither the mother nor the baby. The study also found that women who were told to push may have more urinary problems after the delivery. One of the doctors who did the survey, published in the American Journal of Obstetrics and Gynecology, said that the research did not mean that women should never push. Instead, he said, they should do “what feels natural to do – and for some women that would be no pushing.”
I had two reactions to this news. First, if I were pregnant, I would ask my obstetrician if he or she planned to tell me to push and, if so, why, given there seems to be no benefit to doing this during every birth. Second, why didn’t we know this news sooner? Why have doctors for so long inflicted the needless agony of pushing on women? I had no idea what the answer to the second question might be until I came across a striking fact in the chapter on childbirth in Atul Gawande’s Better: Most doctors pay lip service to the idea that nothing should be used in medicine unless it has been properly tested and shown to be effective by a respected research center, preferably through a double-blind, randomized trial.
“But in a 1978 ranking of medical specialties according to their use of hard evidence from clinical trials, obstetrics came in last,” Gawande writes. “Obstetricians did few randomized trials, and when they did they largely ignored the results.”
That observation helps to explain why Gawande, a surgeon and writer for The New Yorker, may be our most important medical writer. Unlike many others working in the field, he doesn’t write mainly about the latest developments in medicine. He digs deeper, looking for the “why” behind the “what,” while taking on extraordinarily complex topics. But his writing is rarely harder to understand than in his lines about the 1978 survey of medical specialties. He seems to make a grail not just of accuracy but of clarity.
The chapter on childbirth in Better shows his work at its finest. It deals largely with why so many women have Cesarean deliveries, which account for about 30 percent of American births. Many people explain the statistic by saying that Cesareans are more convenient and lucrative for doctors than vaginal births. Gawande argues persuasively that there is a larger reason for the pattern. And part of it has to do with the virtual disappearance of forceps from delivery rooms.
In the 1960s fewer than 5 percent of deliveries were Cesareans and more than 40 percent involved forceps. And those numbers are related. Gawande makes a strong case that in the hands of experts, forceps are safe (according to some research, safer for mothers than Cesareans). But forceps are hard to learn to use properly – a process that can take two years. And if forceps are used by inexpert doctors, the results can be disastrous. Cesareans are easier to master. And this has led hospitals to phase out forceps and, in many cases, do C-sections instead. To discourage the inexpert from using forceps, Gawande says, “obstetrics had to discourage everyone from using them.” This change has come at a cost. Gawande notes that, as straightforward as Cesarean deliveries can be, they can go wrong. The baby can be lacerated. If the head doesn’t come free quickly, the child can asphyxiate. The mother also faces risks:
“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.”
With all of this, Gawande isn’t trying to frighten women away from having Cesareans or bring forceps back to every community hospital. He is instead trying to show the trade-offs that medicine involves. And this is only a small part of what he says in his chapter on childbirth, “The Score,” which also covers such delivery-room fixtures as fetal heart monitors, epidural anesthesia and the labor-inducing drug Pitocin. It is an even smaller part of what he has to say in the 11 chapters of Better that deal with subjects other than childbirth, including advances in military medicine and the need for doctors to wash their hands more often.
Women who are pregnant may reach for books like What to Expect When You’re Expecting and The Girlfriends’ Guide to Pregnancy. And patients who are facing surgery may turn to guides to their illnesses. But both groups could benefit from also reading this fine collection of essays. For some of them, Better may just be better.
Best line: Gawande writes about the Apgar score, which rates a newborn’s health: “In a sense, there is a tyranny to the score. While we rate the newborn child’s health, the mother’s pain and blood loss and length of recovery seem to count for little. We have no score for how the mother does, beyond asking whether she lived or not – no measure to prod us to improve results for her, too. Yet this imbalance, at least, can surely be righted. If the child’s well-being can be measured, why not the mother’s, too?”
Worst line: None.
Editor: Sara Bershtel
Published: April 2007
Furthermore: The New York Times article on pushing during labor, “Rethinking the Big Push During Contractions, appeared on Jan. 3, 2006, page F8. I can’t link directly to it, but here’s a link to a similar reprint in its sister publication, The International Herald Tribune. When you click on the following link, you will reach a page that says “Multiple Choices” and see another link that looks just like it (below the phrase “Available Documents”). You have to click on that one, too, to read the story (which appears below an article on “lazy eye”): www.iht.com/articles/2006/01/04/healthscience/snvital/php/php.
Links: Gawande has posted many of his articles on medicine at www.gawande.com.
© 2007 Janice Harayda. All rights reserved.