Late Preterm Birth - Patient and Provider Education is Still Needed
Monday, November 26, 2007
Kenneth F. Trofatter, Jr., MD, PhD
The primary concern expressed by the skeptics relates to the patient’s unacceptance of its truth. I was not entirely surprised by this observation because its prevalence is a daily reality in our own practice. The cacophony resounds in the valley of the shadows of perceptions: “I had my last baby at 36 weeks and it did just fine.” “My mother had me at 8 months and I turned out okay.” “I’m really starting to feel awful and believe you should take my baby now.” “If you won’t deliver me when I want to be delivered, then I will find another doctor who will.” “We can’t take our (15 year old) daughter’s whining any more, she’s suffering so much, you must deliver her.” Basically, the same patient comments were reiterated at every place I have spoken.
It is clear if this campaign in the wilderness is to be successful, women must be educated about its importance and proactively question the ways of the recent past. Induction rates at many hospitials exceed 40% and I am aware of some that exceed 80%. It has been clearly established that inducing labor, or even worse, performing an elective cesarean section, before 39 weeks without medical indication is associated with more risks than benefits for both mothers and babies. So, if you are a pregnant woman, be aware of the following facts, and if you are a provider, please be sure your patients are aware of them as well:
• Inductions with an unfavorable cervix require more medical intervention, are usually more uncomfortable, and can be prolonged
• Induction increases the risk of having a cesarean section, particularly in women having their first babies and an unfavorable cervix
• Prolonged inductions increase the risk for infection, intrapartum and postpartum, and postpartum hemorrhage
• As a consequence of the above, there is an increased need for parenteral antibiotics and transfusion
• Babies born between 34-38 weeks have a greater risk for respiratory problems, hyperbilirubinemia, hypoglycemia, infection, thermal instability, feeding problems, prolonged hospitalizations, admissions to the neonatal intensive care unit, readmissions following discharge from the hospital, long-term morbidity and even death
• Babies risks are increased for all the above even further if delivered by cesarean section, especially if the cesarean is done in the absence of labor
• ALL the above can result in longer hospitalizations, risk for unexpected complications, and increase the cost of medical care
Remember, before there was exogenous pitocin (prostaglandins, laminaria, foley bulbs, and combinations of all), women often went into labor by themselves at “term!” Although we have not sorted out all the mechanisms of spontaneous labor, generally, at term labor is signaled and accompanied by fetal “maturity” with lungs, brain, liver, and immune system ready to face the cold cruel world. Often times, the mother’s cervix is also more “ripe” by that point as well. There is no higher liability risk to providers if uncomplicated patients are watched until the onset of labor at least up to 41 weeks and with careful monitoring, even longer.
Labels: induction of labor, Late preterm birth
10 Comments:
At Tue Nov 27, 03:50:00 AM 2007,
Anonymous said…
i had a caesarian section with my first child due to having a rise in my blood pressure at my 8 month checkup. she has grownup with asthma attacks all her life, which is probably due to delivering her early. so i agree patient education with their provider i still needed because my daughter was born 33 years ago and i wasn't informed then what the compications could be. debbie
At Thu Nov 29, 11:34:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Debbie Nov 27: But don't kick yourself over that Debbie. 33 years ago, doctors were very reluctant to deliver you early unless there was a good medical indication. In your case, you probably had preeclampsia and that's nothing you or your doctors could have prevented and waiting might have caused more harm for you and your baby than taking the chance on delivering you early. Thank you for sharing your story. Dr T
At Wed Dec 05, 03:36:00 PM 2007,
Anonymous said…
Many of the issues you raise are related to inducing labor. Do you feel as strongly about c-sections?
My toddler was born at 36 weeks. She didn't spend any time in NICU or get sick during her 1st year. We did confirm her lungs were mature via amnio. She does have some motor processing issues. We chose to go ahead w the C-section largely because I didn't care for the drs on call for the next several days. We also liked the idea of the surgery being when the dr is rested etc rather than in the middle of the night as an emergency. (She was breech and placenta previa and I was bleeding some.)
At Fri Dec 14, 12:28:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Dec 5: I feel especially strongly about c/sections! Normal babies (as a group) delivered by elective c/sections do worse than babies delivered vaginally at every week prior to term with regard to the complications mentioned. Labor and vaginal delivery help the baby mobilize fluid from the lungs and stimulate maturation of other organ systems as well. But, in your case, you clearly HAD a medical indication for delivery and you had MATURE fetal lung studies. The problem is that MOST babies delivered a few weeks early will do well, but just because someone does well with one pregnancy does not mean that will be the case the next time around or that the next patient will be as lucky. That's where BOTH patients and providers get trapped. I am glad things turned out well for you and thanks so much for reading! Dr T
At Sun Dec 30, 04:08:00 AM 2007,
Anonymous said…
I had a baby at 34 weeks (5.3 lbs, 20"), naturally, no problems with her at all, after 9 days on drugs to stop labor (that didn't work) and bed rest. I also had steroid shots to develop her lungs and a level 3 ultrasound to check on the development of her organs. Where can I get more information about how to deal with my second pregnancy? I really feel that she was ready to come, and if she had been any bigger, I would have had an emergency C-section.
At Wed Jan 02, 01:14:00 PM 2008,
Anonymous said…
Dear Dr T,
My first baby was stillborn after she stopped moving at about 35 weeks. I am now 14 1/2 weeks with my second. I have read that many women are induced early in subsequent pregnancies after stillbirth, particularly the pregnancy immediately following. What is your view on this - is the mere fact of a previous stillbirth sufficient medical indication? Post mortem results showed a "hypercoiled" umbilical cord which had developed a clot, mild "assymetric" growth restriction and an enlarged placenta. Labour was induced and lasted 3 hours - there were no complications with delivery.
At Thu Jan 17, 11:25:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Dec 30: Even if the baby was 'ready to come', you still delivered 6 weeks early and by your history of preterm labor, re at much greater risk for delivering early again - perhaps even earlier than last time. I know the last baby did well, but you might not be quite so lucky the next time. Preterm birth is a big problem in the U.S. and I would recommend that you go on the internet to the March of Dimes website to get some more information about why I am so concerned. Thanks for reading. Dr T
At Thu Jan 17, 11:32:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Jan 2: Forgive the delay in my response to your questions. First, I am so sorry for your loss. Hypercoiled cords are associated with otherwise unexplained fetal losses for reasons that sre not entirely clear. You also are at greater risk for similar complications in another pregnancy. However, with careful follow-up, ultrasound evaluation of the fetal growth, Dopplers, and well-being, coupled with regular antepartum fetal heart rate testing starting in the month before you lost your previous baby, odds are in your favor that things will go better this time. If you do get to 39 weeks successfully, I also think it is very reasonable to undergo an induction at that time. If your doctors want to deliver you electively before 39 weeks, I suggest that you have an amniocentesis to assess fetal lung maturity first, so that you don't end up with another tragedy resulting this time from iatrogenic prematurity. Best wishes to you and please let me know how things turn out. I hope this finds you well. Dr T
At Tue Feb 19, 06:53:00 PM 2008,
Anonymous said…
Dr. T,
I have gotten great information from you on another occassion, not for myself but for a friend of mine, and it really helped her. She really appreciated the information you provided, as it was much more than what her doctor was willing to give.
However, now I have another question, this time about preterm births.
Could a fall that occurred 4.5 months prior be the cause of a 6 week preterm birth of she landed on her stomach? At the time of her accident, she did not think she was injured, but she has had two prior children, neither of which were born early.
Do you think her fall could be the cause of her daughter being born early?
Josh
At Thu Feb 28, 06:01:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Josh Feb 19: Hello again, Josh. It is unlikely that the fall caused the premature birth, unless she actually had a partial separation of the placenta (placental abruption) at that time, and lost some of the placental function. Over time, if the baby 'outgrows' the amount of placenta it has to keep it healthy, mother's will often develop preeclampsia or go into early labor. When babies gets 'unhappy' inside, sometimes they figure out a way to take their chances in the cold cruel world rather than dying in utero! Thanks again for reading. Dr T
Post a Comment
<< Home