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Chapter Five Inflating Risk 1960s–1980s News stories in the 1960s related to pregnancy and childbirth—­including stories about thalidomide and the March of Dimes campaign—­ alarmed the public. Although childbirth was measurably safer than it had ever been in the United States (maternal mortality had plummeted from a high of 670 deaths per 100,000 live births in the 1930s to 10 deaths per 100,000 live births by the 1970s), anx­ i­ eties surrounding childbirth ­ were as power­ ful as ever—­ a byproduct of both a better-­ informed populace and the high hopes for medical treatment that came with the antibiotic age. Ex­ pec­ tant parents had come to believe that medicine offered guarantees; one effect of their faith was the ac­ cep­ tance of diagnostic tools that seemed to mitigate the perceived risks of childbirth.1 The obstetricians’ diagnostic arsenal, which included the Friedman curve and Apgar score by the early 1950s, and the Bishop score by the early 1960s, was soon augmented by machines. Ultrasound equipment changed the experience of pregnancy; obstetricians and parents could now view the previously invisible fetus. And just as sonography changed the experience of pregnancy, the electronic fetal monitor changed the experience of ­labor. Obstetricians and ­mothers had been primed to accept the monitor by the ongoing news about threats to the fetus, including a 1967 article in Newsweek describing ­ labor as “the most perilous hours in an infant’s life.” A year ­ later, the fetal monitor appeared to keep constant watch over the beleaguered fetus as a ­ mother labored. Hospitals quickly­ adopted the device.2 124  Cesarean Section While ultrasound equipment and fetal monitors alleviated medical and lay anxiety by ostensibly placing childbirth ­ under medical control in previously unimagined ways, the machines also had their downsides. Ultrasound weakened obstetricians’ hands-on skills. ­ After describing the once-­ essential art of externally palpating a pregnant ­woman’s belly to gather vital information, an obstetrician trained in the early 1970s lamented, “Oh, that art is gone . . . ​ in ­ labor and delivery now routinely, on ­ every patient who comes into ­ labor, residents do an ultrasound to make sure the baby is headfirst.” Another obstetrician, trained in the early 1990s, marveled that the obstetrician who mentored her during her residency “could tell twins’ positions just by hands on. And it was a very impressive ­thing to watch his clinical skills.” She, on the other hand, is typical of more recently trained obstetricians—­ “reluctant to rely on my hands-on if the ultrasound is right ­ there and I can know for sure. ­ Because I ­ wouldn’t want to put this patient at risk.”3 The electronic fetal monitor likewise came with unanticipated downsides, most notably an increase in the cesarean rate. The immobility imposed by the monitor made ­ labors longer, leading to more diagnoses of dystocia to be remedied by cesarean surgery. And in a particularly frustrating development, the machine’s messages ­ were so difficult to interpret that false positives for fetal hypoxia became epidemic nationwide, prompting the largest spike in c-­ sections yet. As obstetric residents shifted their attention from ­mother to machine, the monitor substituted for frequent physician-­ patient contact and greatly diminished the amount of time residents spent with laboring ­women. Spurred by the ­women’s rights movement, a vocal group of ­ mothers, including many who proved ­ adept at garnering the attention of mass media, began to object to what they viewed as an inhumane, mechanical, isolating approach to birth. Once again, childbirth was in the news. This time, however, rather than celebrate the latest medical innovations, newspapers and magazines offered a view on American birth practices through the eyes of angry ­ mothers. The ­ great irony of the nationwide crusade for a more humane , “natu­ ral” approach to birth, however, was that just as feminist activists­ were seeing the most positive, concrete responses to their demands for birth reform , the cesarean section rate was seeing its most precipitous rise. Ultrasound Makes an Appearance In the 1970s, as the nascent birth reform movement came to public attention, ultrasound equipment was making its first appearance in the United States. Developed in Glasgow beginning in 1956, the machine was in use throughout the British hospital system by the mid-1970s, almost a de­cade before its firm establish- Inflating Risk   125 ment in the United States. To gain a foothold in the lucrative American market, one ultrasound manufacturer, Advanced Diagnostic Research Corporation (ADR), pitched the equipment directly to obstetricians, to virtually no avail. American doctors saw ­little...


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