Elective Late Preterm Birth – Why Aren’t Patients and Providers Listening?
Saturday, April 05, 2008
Kenneth F. Trofatter, Jr., MD, PhD
Ignoring the message is foolish, is associated with increased morbidity for otherwise healthy babies (usually in hospital settings not prepared to handle the unexpected – further increasing the risk of morbidity, mostly respiratory distress), and has gotten to the point where it is indefensible from a medical-legal standpoint. Late preterm birth now constitutes about three-quarters of all preterm deliveries. This amounts to more than 300,000 deliveries per year! Many of these deliveries are by elective cesarean section and many others result from cesarean section as a consequence of failed labor induction when the mother’s cervix is ‘unfavorable.’ Indeed, 50% or more of late preterm inductions end up as cesarean sections. The real tragedy is not in the delivery for appropriate medical indications that results in a baby with complications of prematurity, but the ‘iatrogenic’ prematurity resulting from inaccurate pregnancy dating or marginal medical indications such as “the baby was getting awfully big, her blood pressure was up a little at her last visit, she’s getting a lot of swelling…” and, unfortunately, as many as one-third of all late preterm births are the result of iatrogenic prematurity.
Several recently published articles contribute to the growing body of evidence supporting the concerns related to late preterm birth – whether spontaneous, medically indicated, or iatrogenic. McIntire and Leveno (Obstet Gynecol 2008; 111:35-41) evaluated neonatal outcomes at 34, 35, and 36 weeks of gestation compared with births at 39 weeks. At their institution, late preterm singleton live births accounted for 76% of all preterm births, 45% the result of the late of ‘preterm labor’ and found that ”mortality rates per 1,000 live births were 1.1, 1.5, and 0.5 at 34, 35, and 36 weeks, respectively, compared with 0.2 at 39 weeks (P<.001).” Neonatal morbidity was significantly increased at 34, 35, and 36 weeks, including respiratory distress requiring ventilator support, intraventricular hemorrhage (grades 1 and 2), need for invasive sepsis work-ups, culture-proven sepsis, hyperbilirubinemia, and necrotizing enterocolitis. Shapiro-Mendoza and colleagues (Pediatrics 2008;121:223-32) compared 26,170 infants born late preterm to 377,638 born at term and found that the late-preterm infants were 7 times (22% vs 3%) more likely to have newborn morbidity than term infants. “The newborn morbidity rate doubled in infants for each gestational week earlier than 38 weeks. Maternal medical conditions, especially, maternal hypertensive disorders and hemorrhage increased the vulnerability of the late preterm infants. Yoder and colleagues (Obstet Gynecol 2008;111:814-22) also demonstrated the gestational age-related risk for morbidity and confirmed previous observations that infants delivered by cesarean section fared worse than those delivered vaginally. The article immediately following this one by Yee and colleagues (Obstet Gynecol 2008;111:823-28) supported the relationship of elective cesarean delivery and respiratory complications and also pointed out the increased risk of male infants compared to females born prior to term.
So, what got me off on this tirade today? Well, recently, I visited our neonatal intensive care unit, and there, laid out on a bed designed for the smallest of premature babies, was another 10 lb infant, born at an outside hospital by elective cesarean section at a well-documented “38 weeks.” The baby was clearly macrosomic, had profound hypoglycemia and appeared to be the product of a diabetic mother (although that diagnosis had not been suspected during the pregnancy), was male, and had severe respiratory distress syndrome – indeed, there were real concerns that he might not survive. The sad thing about the case was that the obstetrician had called me about this pregnancy the day before the delivery and asked if it was “alright just to get her delivered by cesarean section because the baby is so big, the patient is miserable, and is begging to be delivered” and I had clearly suggested that an amniocentesis to assess fetal lung maturity be performed first in the absence of any other indication for delivery. It wasn’t done, and I do not know if my recommendation was even mentioned to the patient. I said a little prayer for the baby and, selfishly, for myself, as I left hoping that I would not be called to testify if the outcome was poor in the end….
Labels: Late preterm birth
8 Comments:
At Sat Apr 05, 06:05:00 PM 2008,
Anonymous said…
This might be a dumb question, but do steroids help mature a baby's lungs at term? Do they work after birth, or only before?
At Sun Apr 06, 06:53:00 AM 2008,
PE Mommy said…
I totally agree with you!!! I had two babies delivered preterm for medical conditions. The first was delivered by emergency induction due to severe preeclampsia and partial hellp syndrome. I could not have a csection due to the fact my blood was not clotting. She was norn at 36 weeks on the nose. She is now 9 years old. For the first 5 years of her life she was labeled failure to thrive. Then at 6 she just started growing. She has caught up in the weight aspect now. She also was very sick as a little girl with asthma. She has had trouble with her digestive system.
My second was born at 35 weeks 5 days due to severe pih and she had decels on the nst at the peri's office. With her, my peri wanted to do an amnio. She scheduled it. When she talked to my ob, he nixed it because there was no point. They were going to have to deliver, it was just a question of when. On the day I delivered (same day that the amnio had been scheduled ironically), I ran 160/120-130 bp on strict bedrest on 2000mg of Aldomet and 60mg of procardia a day. My ob didn't know about the 130 that I had gotten the day before. He did know about the 120 though. We were all thoroughly freaked. That's why she was delivered. She hasn't been failure to thrive. She does have asthma, and she had severe jaundice requiring hospitalization at 4 days of age. She also had trouble with the sucking reflex as did my first. When my second has gotten sick, she has gotten REALLY sick.
I am not for preterm births unless absolutely medically necessary. What I would give to actually make it to 37 weeks +. My chances of that is probably slim to none according to my peri. She and my ob have said count on bedrest by 26weeks and to count on delivering between 35-36 weeks. PEople )even medical personnel) refer to the 34-36 week babies as full term. They are not full term. They need that time in the womb and it is crucial. I correct people (and medical personnel) who refer to my girls as full term. They are not. They were early and still had problems. Yes, their likihood of living is greater than 90%, but it wasn't an easy road with either of them when they were born. I can't stand when people tell me how lucky I was to never go through the last month.
Unfortunately it is a hard lesson for that mom in the NICU right now.
At Mon Apr 07, 07:13:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 5: It is NOT a dumb question at all. In fact, now that we recognize that babies can have respiratory complications, and other problems realted to prematurity, the logical question is should we consider corticosteroids at 34-37 weeks if delivery is expected to be early. There may not be an indication for delaying delivery under those circumstances in women who are in 'late preterm labor' because the risks may outweigh the benefits, but the possibility of steroids in selected cases is going to have to be properly evaluated. At some point I will probably devote a full blog to this questionlooking at potential risks and benefits. There is little doubt the greatest benefits are seen in babies delivered before34 weeks. Thanks for the "dumb" question, and I hope you have more in the future. Dr T
At Mon Apr 07, 07:14:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To PE mommy: Thanks for the comment. I hope other readers take the time to look at it. Dr T
At Tue Sep 16, 07:47:00 PM 2008,
Anonymous said…
Thanks for this article!
I am 34 weeks with gestational diabetes and too much fluid, profoundly uncomfortable and wondering how much longer is necessary.
If more mothers knew the risks of delivering early, I think we would all "tough it out" a little longer without complaint.
Is it safer to induce delivery of a macrosomic baby once the cervix has softened naturally (my last 2 induced successfully at 38-39 wks), or to let the baby grow as long as possible knowing that a C-section will be the likely outcome?
Meredith
At Tue Sep 23, 07:07:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
Meredith: Quite honestly I am not sure that the growth of the baby during the last two weeks of pregnancy is going to make or break your risk for c/section. The best thing you going for you is your previous pregnancy history! Good luck and let us know how things turn out. Dr T
At Thu Oct 09, 10:00:00 PM 2008,
Tubo Family said…
I so appreciate a provider speaking out on this issue. Pre-term birth is a health risk! Both my babies were pre-term, due to pre-term labor (not induction, not c-section), and I do not agree when people tell me I was "lucky" to not go full term. The oldest was 36.5 weeks and less then 6 lbs with terribly uncoordinated suck-swallow-breath reflexes. Neither the hospital nor health care providers seemed aware of the potential issues for pre-termers so poor feeding and failure to thrive were the result. Luckily, for second baby he stayed in a little longer (37.5 weeks) and heavier (7 lbs 1 oz) AND was also born at a different hospital (Sutter Davis in the Sacramento, CA metro area deserves accolades) that was much more alert to the risks for pre-term babies and encouraged us to stay at hospital until he was nursing well and otherwise proven to have settled in. Of course pre-term C-sections can be life-saving but there is more to be done for pre-term babies. Alison Tubo
At Fri Oct 31, 06:43:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To alison Tubo: Thank you so much for your comments. It sometimes means so much more to certain readers if they hear these things directly from women who have had the experiences that you have had. I appreciate your sharing very much! Kind regards, Dr T
Post a Comment
<< Home