Les Jones

Science > History of Obstetrics and the Apgar Score

Incredible New Yorker article on the history of the Apgar Score for newborns, told in the sweep of obstetrics history. Via a Marginal Revolutions thread pondering why much of medicine is art rather than science.

Among other things the article offers another reason for the increasing number of C-sections:

“Forceps deliveries are very difficult to teach—much more difficult than a C-section,” Bowes said. “With a C-section, you stand across from the learner. You can see exactly what the person is doing. You can say, ‘Not there. There.’ With the forceps, though, there is a feel that is very hard to teach.” Just putting the forceps on a baby’s head is tricky. You have to choose the right one for the shape of the mother’s pelvis and the size of the child’s head—and there are at least half a dozen types of forceps. You have to slide the blades symmetrically along the sides, travelling exactly in the space between the ears and the eyes and over the cheekbones. “For most residents, it took two or three years of training to get this consistently right,” he said. Then a doctor must apply forces of both traction and compression—pulling, his chapter explained, with an average of forty to seventy pounds of axial force and five pounds of fetal skull compression. “When you put tension on the forceps, you should have some sense that there is movement.” Too much force, and skin can tear, the skull can fracture, a fatal brain hemorrhage may result. “Some residents had a real feel for it,” Bowes said. “Others didn’t.”

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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.

Incidentally, when we had Natalie, she wouldn't come out the last little bit. We were faced with having another C-section (which we were trying to avoid) and forceps (which we were afraid of). We chose a third option. The doctor put a rubber cap over the crown of the baby's head, drew suction on the cap, and pulled Natalie out that way without any complications. In talking to my mother while we were making the decision, I learned my brother had been delivered with the same technique.

Another P.S. The first part of the article reminds me of the time I helped deliver a calf at Sunlight Gardens. The calf's leg was bent and its knee caught on the mother's pelvis, so that one leg was protruding less than the other. Taking telephone instructions from the vet we tied a rope around the short leg and pulled it straight. Then we re-tied the rope around both legs and two of us pulled the calf out of the mother, literally leaned back on our heels. Mom and calf both did just fine. They named the calf Jones.

Person I'm thinking of as I post this: Katie Allison-Granju, who is expecting a baby with her new husband. Congrats, you two.