Friday, April 13, 2007

The Score: How childbirth went industrial by Atul Gawande (New Yorker)

In a sense, there is a tyranny to the score. Against the score for a newborn child, 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? Indeed, we need an Apgar score for everyone who encounters medicine: the psychiatry patient, the patient on the hospital ward, the person going through an operation, and the mother in childbirth. My research group recently came up with a surgical Apgar score—a ten-point surgical rating based on the amount of blood loss, the lowest heart rate, and the lowest blood pressure that a patient experiences during an operation. We still don't know if it's perfect. But all patients deserve a simple measure that indicates how well or badly they have come through—and that pushes the rest of us to innovate.
"I watched, you know," Rourke says. "I could see the whole thing in the surgical lights. I saw her head come out!" Katherine Anne was seven pounds, fifteen ounces at birth, with brown hair, blue-gray eyes, and soft purple welts where her head had been wedged sideways deep inside her mother's pelvis. Her Apgar score was eight at one minute and nine at five minutes—nearly perfect.
Her mother had a harder time. "I was a wreck," Rourke says. "I was so exhausted I was basically stuporous. And I had unbearable pain." She'd gone through almost forty hours of labor and a Cesarean section. Dr. Peccei told her the next morning, "You got whipped two ways, and you are going to be a mess." She was so debilitated that her milk did not come in.
"I felt like a complete failure, like everything I had set out to do I failed to do," Rourke says. "I didn't want the epidural and then I begged for the epidural. I didn't want a C-section, and I consented to a C-section. I wanted to breast-feed the baby, and I utterly failed to breast-feed." She was miserable for a week. "Then one day I realized, 'You know what? This is a stupid thing to think. You have a totally gorgeous little child and it's time to pay more attention to your totally gorgeous little child.' Somehow she let me put all my regrets behind me."

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