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Fruit of the Womb
Fruit of the Womb

Late Preterm Birth - Patient and Provider Education is Still Needed

I have spent much of the last year preaching the gospel of “Thou shalt not deliver before 39 weeks, unless thou hast a good indication.” In general, the “word” has been well-received by providers, although many have voiced skepticism of its divine origin. Many were not aware of the short- and long-term morbidity of “Late Preterm” or “Near Term” deliveries and appreciated the information; many expressed concern about a “bad experience” and didn’t “want to take the chance” of not delivering a woman early for certain conditions; others were so tied to their patients or unhappy with their own “cross-coverage” that they routinely delivered patients on their schedules, “even if it is just a little bit early”; others were afraid of losing their patients to other providers; and, many were not aware of the recommendations of the American College of Obstetricians and Gynecologists decrying elective delivery before 39 weeks without medical indication or assessment of fetal lung maturity. Most physicians agreed that if they could get their local colleagues to stand firm on the issue, and resist “temptation” they too could see the light and adhere to the guidelines.

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.
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