Last OREX Day — August 2009
By Lucy Ogbu, OREXer ’08-09
Today’s lecture by Dr. Harken was one of the most surprising and enlightening discussions I have ever heard. Dr. Harken presented a study done by some major hospital regarding the effects of socioeconomic status on a patient’s ability to get through serious illnesses. He stated that the evidence showed that you can predict the outcome risk for a patient based on their socioeconomic status. Those patients on a higher level were able to survive procedures and illnesses when compared to others of a lower status with the exact same condition. I do not fully understand the science behind it but it’s still rather shocking all the same.
Today’s procedures were much of some of I have already observed, however the highlight of my day came in an unexpected delivery. Usually at Highland, the deliveries do not take place on the 5th level operating room department, however they had a caesarian birth randomly scheduled on the OR floor that day. I was very excited because I have never seen a live caesarian and I knew I had to witness this. I found out that the mother already had three previous C-sections and thus was not a likely candidate for VBAC—Vaginal Birth After Caesarian. When a woman has had two or more C-sections, it is usually not likely that her physician will prescribe a vaginal birth because they could risk uterine rupture and other potentially fatal complications for the mother and child. So with this particular case, it was a clear-cut option for her to undergo her fourth caesarian.
As the room was being prepped for the procedure, there was a certain element of excitement in the air because there was a sense of freshness to it all, as they do not usually partake in a birth and there was an anticipatory mood all around. When the mother arrived to the O.R., I took the chance to ask her a little bit about how she was feeling and she said she was nervous and apprehensive. This is definitely understandable because as it is her 4th, there are certain risks attached that are higher for women undergoing subsequent caesarians. In fact, historically, caesarians were considered criminal and held in such low repute because it almost always killed the mother—through hemorrhage and infection. 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 open uterus from hemorrhaging, did caesarian section become a more viable and common option.
As the procedure began, I was so focused on the experience because childbirth to me is an astonishing phenomenon, the entire process and all that it entailed and just the simple idea of bringing another human being to the world literally humbles me. So I stood there and watched as the obstetrician, took a No.10 blade down through the flesh horizontally low on the bulging stomach. She cut through the yellow golden fat with clean and broad strokes, as she wiped away the blood that seeped out with each cut. As she sliced through the fascia covering the abdominal muscle, I can see from my peripheral view the nurses readying and preparing the room for the newborn’s arrival. She then reached the peritoneum—thin, fragile and almost transparent membrane—cut through it and there it was; the uterus! It hit me in that particular moment that I am looking at a human uterus—plum-colored and thick—that contained another being just on the other side of it. The surgeon makes a small opening in the uterus with the scalpel and then she switched to a thicker scissors—to cut it open more efficiently. Then all of sudden, water just started pouring out of her stomach—like a mini-fountain—and there is a bit of a scuttle in the room as the time is getting nearer. She then reached in—this moment is still absolutely surreal to me—and swiftly, with a strong grip pulled out a new human being—with five tiny wiggling toes, a knee a whole leg…an entire person! This is so unlike every other procedure I have observed in the O.R. in which the surgeon reaches inside abdomen and pulls out a tumor or some other abnormality. After the umbilical cord is cut, the baby is swaddled and the nurse recorded the baby’s Apgar score. The Apgar score, developed by a physician, Virginia Apgar, is the universally utilized methods in which nurses rate the condition of newborns on a scale of zero to ten. An infant gets two points if it was pink all over, two for crying, two for taking good, strong breaths, two for moving all four limbs and two if the heart rate is over a hundred. Thus ten points signifies a newborn in perfect condition and four points or less meant a blue, limp baby. Fortunately for us, our baby had a perfect Apgar score of ten points, a great way to make an entrance into the world! I watched as the next uterine contraction occurred and the placenta was delivered through the same open wound. The surgeon then wiped the inside of the uterus clean of clots and debris and then sewed it shut with an absorbable suture.
As I researched the Apgar score following this procedure, I was presented with some interesting questions. While the Apgar score is a useful and innovative way to measure a newborn’s health, what comparative score or measure is there for the mother, to prod doctors to improve results for her too? In all essence, the Apgar effect was not just about giving clinicians a quick objective read of how they had done, it also changed the choices they made about how to do better.Indeed, it seems to me then that we need an Apgar score for every patient who encounters medicine: from the psychiatry patient to the patient undergoing an operation. In my research, I came across a surgery research headed by Dr. Gawande in Massachusetts, that came up with a surgical Apgar score—a ten-point rating based on the amount of blood loss, the lowest heart rate, and the lowest blood pressure a patient experiences during a given operation. They found that those with a score of nine or ten, had a less than 4 percent chance of complications and there were no deaths; those with a score less than five had a greater than 50 percent chance of complications and a 14 percent chance of death. This simply illustrates and emphasizes how all patients deserve a simple measure that indicates how well or badly they have come through and that pushes clinicians to innovate and work harder but more importantly work better to improve the lives and outcomes of all patients.