The Story of an Almost

Lena Waithe Explains the Significance of Cutting Her Hair (video)

A Two-Year-Old’s Solution to the Trolley Problem

At about 10.5% of births, caesareans were far less common in the United States in 1976 than they are today, when almost one in three births is by caesarean section. The steepest increase in the surgery occurred between 1965 and 1987, when caesareans rose 455% — from 4.5% to 25% of births. Doctors have long debated which factors contributed to that precipitous rise. Was it the malpractice climate? Changes in the training of obstetricians? An epidemic of maternal obesity? Women delaying childbearing? Or perhaps the culture of scheduled, “hurry-up” births? Almost always missing from the list is the effect of the electronic fetal monitor on obstetricians’ decision-making. As the mother learned in 1976, the monitor increased the likelihood that a physician would tell a laboring woman that she needed a caesarean section.

Although used routinely by American hospitals today, the electronic fetal monitor has a fraught history. The device first appeared in select hospitals in 1969. The value of the technology seemed so obvious that no one tested it for efficacy before its release. Most obstetricians were certain that continually monitoring the fetal heartbeat during labor would help ensure good outcomes by immediately alerting doctors to fetal distress. A timely caesarean could follow. Physicians predicted that the monitor would reduce by half fetal deaths during labor, “mental retardation” and cerebral palsy.

In fact, perinatal mortality did decrease. However, public health officials pointed out that hospitals not employing monitors were seeing the same effect thanks to a revolution in pediatrics that paralleled the use of the fetal monitor. New subspecialties of neonatology and perinatology had improved prenatal care, maternal nutrition and newborn care.

Most obstetricians nevertheless continued to believe that the electronic fetal monitor deserved the lion’s share of credit for the improvement in infant health. By 1976, American doctors were so bullish on the monitor that they employed it in half of all hospital births. An even greater tip-off that the monitor would become a linchpin of maternity care was a 1976 survey indicating that all but one of the country’s obstetric residency programs employed the technology.

In 1976, researchers also performed the first randomized, controlled trial of the device. Before the advent of the monitor, physicians checked the fetal heart rate with a special stethoscope every 30 minutes or so during labor. The 1976 trial assigned the use of the monitor to one group of laboring women and the “fetoscope” to the other group.

According to the study, the monitor didn’t change outcomes. Apgar scores, rates of neurological disability, admissions to neonatal intensive care units, stillbirths, and neonatal and perinatal deaths were effectively identical in both groups. The sole difference was that 16.5% of the electronically monitored women gave birth by caesarean, and only 6.8% of the intermittently fetoscoped mothers did. Subsequent studies saw similar results.

Under the perpetual gaze of the machine, fetal distress, once an infrequent diagnosis, had become commonplace. Edward Hon, the Yale University obstetrician who invented the monitor, complained that colleagues across the country were “dropping the knife with each drop in the fetal heart rate.” Before electronic monitoring, no one had continually observed the fetal heartbeat throughout labor, and its accelerations and decelerations in response to contractions were perplexing. Misinterpretations were common. Hospitals were seeing false positive rates for fetal hypoxia (lack of oxygen) of 40%. And doctors responded by erring on the side of caution, performing emergency caesareans.

Physicians, mothers and health insurers have good reason to be concerned about this phenomenon. A caesarean section is major abdominal surgery and comes with its attendant risks: infection, hemorrhage and potentially fatal placental anomalies in subsequent pregnancies caused by a scarred uterus. Surgical birth comes with risks for newborns too. The lungs of all fetuses are filled with amniotic fluid in utero, the trip through the birth canal squeezes out that fluid. Babies delivered by caesarean section, on the other hand, are born with wet lungs, making them more likely than their vaginally born counterparts to spend time in the neonatal intensive care unit and to suffer from asthma.

Although a caesarean section can be necessary and even life-saving, the World Health Organization advises that the optimal caesarean rate is between 10% and 15% of births. A rate higher than 10% is not associated with improved maternal or neonatal outcomes, and a rate over 15% does more harm than good. In other words, most caesareans performed in the United States today are unnecessary and therefore unjustifiably risky.

This was the crossword puzzle in the New York Times yesterday. 

Tausig’s crossword is a so-called Schrödinger puzzle, named for the physicist’s hypothetical cat that is at once both alive and dead. In a Schrödinger puzzle, select squares have more than one correct letter answer: They exist in two states at once. “Black Halloween animal,” for example, could be both BAT or CAT, yielding two different but perfectly correct puzzles. Only 10 such puzzles have now been published in Times history.

It’s the theme of Tausig’s puzzle, though, that makes it special. Four entries in Thursday’s crossword can include either an “F” or an “M.” Both are correct; neither is wrong. For example, “Part of a house” can be either ROOF or ROOM. The long “revealer” answer, tying those select entries together and spanning 11 squares smack-dab in the middle of the puzzle, is GENDER FLUID.