Monday, February 4, 2013

On That Episode of Downton Abbey (Spoilers)

If you've seen it, you know the one I'm talking about. If you haven't, stop reading NOW. I was grateful no one spoiled me for this one, and I'd hate to inadvertently spoil anyone else. This is Episode 5 of Season 3, which aired January 27, 2013 in the United States. (I'm trying to write enough that the preview of this post will not show any spoilers.)

This episode was fascinating to me, for obvious reasons. Birth in 1920 wasn't handled all that differently from today, except considerably fewer births took place in the hospital. I'm reminded of reading Cheaper by the Dozen when I was in sixth grade, which takes place around the same time. The mother decided to try having one of her babies at the hospital, though all her other babies were born at home. A few hours there, and she came traipsing back home, saying that a hospital was no place to have a baby. At the time, I had no idea that babies sometimes weren't born in hospitals, and I had no idea that there was such a thing as a "home birth."

It's funny to think that now, less than 100 years later, giving birth at home is the unusual way.  Times change.

And yet.

If you watch the episode from the point of view of birth advocacy or knowledge of birth, watching the two doctors argue over the best course of action was eerily similar to what happens today. Watching Lord and Lady Grantham disagree over which doctor to listen to, watching poor Tom's distress over his wife's potential fate, watching the sisters try to understand what was going on - well, those kinds of panicked discussions happen just as much today, when the doctor raises the question of fetal distress or other potential birth emergency that may necessitate a cesarean or other intervention.

Dr. Clarkson, the beloved village doctor, wanted to take her to the hospital for a cesarean. There was no way to know, of course, whether it might already have been too late. (And, of course, this is all fiction, so the writers could have taken this in whatever direction they wanted. But let's pretend Lady Sybil, Dr. Clarkson, and Sir Philip were real people, just for the sake of discussion.) There was no way to know whether the cesarean itself would be more risky than allowing labor to continue. They didn't have the option of Pitocin to move things along, or magnesium sulfate to prevent seizures, or fetal monitoring to see how the baby was doing. But they had seen toxemia (preeclampsia) before, and they had seen eclampsia before, and how painful it must be to see those seizures begin and know the patient is going to die and know there's nothing you can do. Eclampsia is still a major cause of maternal death, and it is still unknown what causes an otherwise healthy woman to have a spike in blood pressure, organ failure, and seizures leading to death. It is known that the only way to prevent it is to deliver the baby before the pre-eclampsia becomes eclampsia.

Dr. Clarkson's recommendation to attempt a cesarean section in hopes of saving Lady Sybil's life was not made lightly. He knew the only way to avoid eclampsia was to deliver the baby as quickly as possible. He also knew that a cesarean section was extremely dangerous, a last resort. Until the 1970s, c-sections were performed extremely rarely (4% or fewer of cases). It was known that the risk of infection to the mother was high for surgery performed in a public hospital. Obstetrician-to-the-nobility, Sir Philip, who Lord Grantham hired because he wanted his daughter to be in the best of hands, was aghast that Dr. Clarkson would even suggest such a thing. He felt the risks associated with a cesarean section were higher than the risk of eclampsia. It's possible professional pride prevented him from admitting that he, too, saw the signs of toxemia. It's also possible that he felt labor was progressing well enough that no intervention was required. When the baby was delivered healthy and Lady Sybil appeared to be fine, it looked as though Sir Philip had indeed been correct. Unfortunately, hours later, we learned that Dr. Clarkson's dire prediction was to be borne out.

A case like Lady Sybil's today would probably have been a no-brainer. She would have been taken in for an emergency c-section, and very likely both she and the baby would have been fine. By the end of pregnancy, a woman receiving regular prenatal care would be seeing her doctor or midwife weekly. Her blood pressure would be monitored, and if there was any suspicion that her blood pressure may be rising or that she may be at risk of preeclampsia, she would be told to watch for symptoms such as those described by Lady Sybil - sudden swelling of the ankles and hands, headache, disorientation, visual disturbances.

With both my first and second sons, my blood pressure rose toward the end of my pregnancy, and I was given weekly or even twice-weekly reminders to call my doctor immediately if I should experience any of these symptoms. As it happened, though I was not diagnosed with preeclampsia, my blood pressure was high enough, and stayed high enough, at my 37-week appointment with my second son, that the decision was made to deliver him to protect both of us. Fortunately, a Pitocin induction, in my case, worked perfectly, and my son was born healthy and full-term, and I was fine. My blood pressure came down immediately upon delivery and I experienced no further symptoms that would suggest preeclampsia.

As with any medical decision, decisions regarding birth and interventions during labor require a weighing of the risks and benefits of action or inaction. Sometimes the safest route really is to simply wait and see. Other times, an emergent situation changes the balance in favor of intervention, up to and including immediate surgery. As the helpless viewer of Downton Abbey, we could yell and scream at the TV to go do the cesarean, or that no, she'll be fine, or however we felt, but we couldn't affect the outcome. I could see they were leading up to something when Sybil complained to Mary about the swollen ankles and headache she was experiencing a few days before she went into labor. I was puzzled that Dr. Clarkson didn't mention anything about her blood pressure at that point, since they specifically showed him taking a measurement. I don't know enough about 1920's medicine to comment on his knowledge of the significance of blood pressure in pregnancy. In any case, as committed as I am to allowing labor to take its course in most cases, it became clear that we were supposed to root for Dr. Clarkson's proposal and to be angry at Lord Grantham for agreeing with Sir Philip.

In 2013, a c-section is a relatively safe option in a first-world hospital setting. However, as with any medical or surgical procedure, it carries risks, including infection and complications. The issue, as always, is whether those risks outweigh the benefits of performing the procedure. When the life of the mother or baby is clearly in immediate danger, the benefit of mother and child surviving is obviously greater than the risk of infection, for example. It is important to know what the risks are to both mother and baby of performing a c-section under various conditions and to consider whether the benefits truly make those risks worth taking.

Of course in Lady Sybil's case, the risks of c-section were considerably higher than they would be today in a modern hospital setting, so the decision was nowhere near as clear-cut.

There's a lot of discussion these days about encouraging doctors and hospitals to be more hands-off during birth, to allow nature to take its course, to trust in the birth process. The issue of eclampsia and other life-threatening complications of pregnancy are a stark reminder that modern medical practices during birth also save lives, and that there is definitely a time and place for these interventions. We can hope that, in the future, there will be a better balance between the use of interventions when necessary and relaxing and letting things progress normally when appropriate.

As a side note, I did spend quite a few minutes wondering who is feeding the baby?! when everyone was tending to Sybil and the baby was nowhere to be seen. I was glad when they mentioned that they'd found a nurse for her, though it seemed a throwaway line just to cover that detail. That was the main option for a family of means when the mother died in childbirth. Today, the idea of wet-nursing seems odd, but they didn't have the fancy formulas we do today. Though rudimentary formulas and other infant-feeding options did exist, including simply feeding sheep's or goat's or cow's milk directly, a wet-nurse, if the family could afford and find one, was a better option.

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