Writer and physician Atul Gawande, reminds us in his book, BETTER, that much of modern medicine did not just happen—it came to be through trial and error, through the deaths of others, the mistakes and triumphs that IS the history of medicine. In BETTER, a surgeon’s notes on performance, we meet Elizabeth Rourke in the chapter, THE SCORE.
OUR PREGNANT PATIENT
Rourke is forty-one weeks pregnant, having contractions. She’s an internist, on staff at Mass General. Her contractions are 7 minutes part. She reports this to her obstetrician at 8:30 am. She is told not to go to the hospital until her contractions are 5 minutes apart. Standard protocol. (this book was published in 2007). In medical school, Rourke has seen fifty births, delivered 4, and watched one in a hospital parking lot. It was winter, the baby was blue, crying. They covered the infant, raced back into the hospital. With that memory, Rourke finished packing her bag and her husband drives her to the hospital.
Gawande then relates some history of pregnancy and birth that has been recorded. He writes of 21-year-old Princess Charlotte of Wales, in 1817, four days in labor, struggling to deliver a nine-pound boy in a sideways position, his head too large for her pelvis. When he finally emerges, he is stillborn. Charlotte dies six hours later from hemorrhagic shock. Gawande relates that her physician was reviled for not using forceps. In remorse for her death, he shot himself.
Gawande relates other statistical history of births—that 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 of those deaths investigators found to be preventable, that many physicians simply did not know what they were doing. They missed signs, symptoms, incorrectly used forceps and spread infection. Midwives did better.
UPDATE ON OUR PATIENT, ROURKE
Her pain has increased, thinks she must be 7-8 centimeters. She is at 2. Her labor has stalled. Then at 2:43 AM she is at four centimeters. It’s been twenty-two hours. They give Rourke an epidural. This is not a simple procedure. Gawande goes through the steps, explaining the risks, one being the mother’s heart rate dropping and the necessity for a bolus of fluid injections and ephedrine to increase and stabilize hers and the baby’s blood pressure. The baby’s heart rate is being monitored constantly, showing decelerations during contractions and then recovering. When necessary, Rourke (and thus the baby) are given extra oxygen by a nasal prong.
At 6 AM Rourke is a 4 centimeters. At 7:30 Dr. Alessandra Peccei comes on duty. Rourke is 6 centimeters dilated and 100% effaced. Baby is seven centimeters from crowning, head becoming visible at the opening to the vagina. As the hours progress, Dr. Peccei punctures the membrane of Rourke’s amniotic sac. Waters flow, contractions pick up, the baby does not move and the heart rate begins to drop. 120, 100, 80. When the doctor stimulates the baby’s scalp, the heart rate responds.
SEGWAY to: VIRGINA APGAR, the APGAR SCORE
Virginia Apgar was a doctor working in New York, a doctor who had an idea, one that Gawande states is “ridiculously simple.” It transformed childbirth and the care of newborns. And as Gawande states, she was an unlikely revolutionary for obstetrics, had never delivered a baby, not as a doctor, not even as a mother. But she would often sit down with someone having trouble and say, “Tell Momma all about it.” She was a surgeon, but joined Columbia’s faculty as an anesthesiologist. She became the second woman in the country to be board certified in anesthesiology, helping the practice to have its own division, on equal footing with surgery. Gawande writes that Apgar was appalled by the care 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. She had not authority….She was not an obstetrician. She was a female in a male world. Gawande: “So she took a less direct but ultimately more powerful approach: she devised a score.”
The Apgar score—as it is now universally known, allowed nurses to rate the constitution 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 the heart rate was over a hundred. Ten points meant a child born in perfect condition. Four points or less meant a blue, limp baby.
Throughout the world, virtually every child born in a hospital came to have an Apgar score at one minute after birth and then again at five minutes after birth. It became clear that a baby with a bad Apgar score at one minute could often be resuscitated, with doctors, nurses providing warmth, physical touch and oxygen, to help the baby gain an excellent score at five minutes.
The results: neo-natal units! The score also affected the management of childbirth. Spinal and epidural anesthesia were found to birth babies with better scores than general anesthesia.
Prenatal ultrasound became a regular process used to detect problems for delivery in advance.
Fetal heart monitors became standard. All these changes, these procedures have produced amazing results. Gawande writes: “In the US today, a full-term baby dies in just one childbirth out of 500, and a mother dies in less than one in 10,000.”
FINAL THOUGHTS How did Dr. Apgar’s work make doctors BETTER?
The Apgar Score changed everything, being a practical way to calculate and give doctors an immediate feedback as to how effective their care had been.
The Score also changed the choices that doctors made concerning how to do better! They poured over the Apgar results, wanting to encourage results that would make every doctor, nurse, from the most experienced to the novice, a better practitioner.
And our patient, Elizabeth Rourke? She had almost 40 hours of labor and finally a Cesarean section. Katherine Anne was born at seven pounds, fifteen ounces, brown hair, blue-gray eyes, and soft purple welts where her head had been wedged sideway deep inside her mother’s pelvis. Her Apgars: 8 at one minutes, 9 at five minutes—nearly perfect.
MORE TO READ: Find more wonderful information about Health Care in Gawande’s books: BETTER: A Surgeon’s Notes on Performance, COMPLICATIONS: A Surgeon’s Notes on an Imperfect Science, BEING MORTAL: Medicine and What Matters in the End, THE CHECKLIST MANIFESTO: How to Get Things Right
I’ve read them all.