Thinking Beyond Science

Cesarean section on a living mother was considered criminal for much of history, because it almost always killed the mother–through hemorrhage and infection–and her life took precedence over that of the child. (The name “Cesarean” section may have arisen from the tale that Caesar was born of his mother, Aurelia, by an abdominal delivery, but historians regard the story as a myth, since Aurelia lived long after his birth.) Only after the development, in the late nineteenth century, of anesthesia and antisepsis and, in the early twentieth century, of a double-layer suturing technique that could stop an opened uterus from hemorrhaging, did Cesarean section become a real option. Even then, it was held in low repute. And that was because a better option was around: the obstetrical forceps.

A measure of how safe Cesareans have become is that there is a ferocious but genuine debate about whether a mother in the thirty-ninth week of pregnancy with no special risks should be offered a Cesarean delivery as an alternative to waiting for labor. The idea seems the worst kind of hubris. How could a Cesarean delivery be considered without even trying a natural one? Surgeons don’t suggest that healthy people get their appendixes taken out or that artificial hips might be stronger than the standard-issue ones. Our complication rates for even simple procedures remain unflatteringly high. Yet, in the next decade or so, the industrial revolution in obstetrics could well make Cesarean delivery consistently safer than the birth process that evolution gave us.

Many argue that the results for mothers are safe, too. Scheduled C-sections are certainly far less risky than emergency C-sections–procedures done quickly, in dire circumstances, for mothers and babies already in distress. One recent American study has raised concerns about whether scheduled C-sections are safe enough or not, but a study in Britain and one in Israel actually found that scheduled C-sections had lower maternal mortality than vaginal delivery. Mothers who undergo planned C-sections may also (though this remains largely speculation) have fewer problems later in life with incontinence and uterine prolapse.

Yet there is something disquieting about the idea that childbirth is becoming so readily surgical. Some hospitals across the country are doing Cesarean sections in more than half of child deliveries. It is not merely nostalgic to find this disturbing. We are losing our connection to yet another natural process of life. And we are seeing the waning of the art of childbirth, too. The skill to bring a child in trouble safely through a vaginal delivery, however inconsistent and unevenly distributed, has been nurtured over centuries.

Skeptics have noted that Cesarean delivery is suspiciously convenient for obstetrician’s schedules and, hour for hour, is paid more handsomely than vaginal birth. Obstetricians say that fear of malpractice suits pushes them to do C-sections more readily than even they consider necessary. Putting so many mothers through surgery is hardly cause for celebration. But our deep-seated desire to limit risk to babies is the biggest force behind its prevalence; it is the price extracted by the reliability we aspire to.

Cystic fibrosis is a genetic disease. Only a thousand American children per year are diagnosed as having it. Some ten million people in the United States carry the defective gene, but the disorder is recessive: a child will develop the condition only if both parents are carriers and both pass on a copy. The gene which was discovered, in 1989, sitting out on the long arm of chromosome No. 7-produces a mutant protein that interferes with cells’ ability to manage chloride. This is what makes sweat from people with CF so salty. (Salt is sodium chloride, after all.) The chloride defect thickens secretions throughout the body, turning them dry and gluey. In the ducts of the pancreas, the flow of digestive enzymes becomes blocked, making a child less and less able to absorb food. This was the reason Annie had all but stopped growing. The effects on the lungs, however, are what make the disease lethal. Thickened mucus slowly fills the small airways and hardens, shrinking lung capacity. Over time, the disease leaves a child with the equivalent of just one functioning lung. Then half a lung. Then none at all.

You will find, however, that many respond –because they are polite, or friendly, or perhaps in need of human contact. When this happens, try seeing if you can keep the conversation going for more than two sentences. Listen. Make note of what you learn. This is not a forty-six-year-old male with a right inguinal hernia. This is a forty-six-year-old former mortician who hated the funeral business with a right inguinal hernia. One can of course do this with people other than patients.

Source : Better: A Surgeon’s Notes on Performance by Atul Gawande

Goodreads : https://www.goodreads.com/book/show/213233.Better

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