Changing early delivery approach gives hope for healthier babies
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BY MARK ANDERSEN / Lincoln Journal Star
Britt Otte, 34, knows things will be different with baby No. 3, due in September.
Her first two, a 6-year-old girl and a 4-year-old boy, were delivered at 38 weeks. This time she won’t have that as a choice.
While schedules, the mother’s comfort and the convenience of relatives coming to help with the new baby have been common reasons for inducing labor both locally and nationally, Lincoln hospitals recently adopted policies of not inducing for nonmedical reasons before 39 weeks’ gestation.
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Increasing numbers of cesarean delivery appear to be only marginally related to elective inductions.
Locally, cesareans are approaching a third of all births. In Lancaster County, babies delivered by cesarean section grew from two in 10 during the mid-1990s to three in 10 in 2005, according to the National Center for Health Statistics.
The center says the numbers are driven both by an increase in first-time cesareans and a sharp increase among women with previous cesareans.
A jump five years ago, said Lincoln Dr. George Hansen, occurred after new guidelines recommended against attempting vaginal delivery after a cesarean unless a physician was immediately available during labor. The reality of physician schedules almost guarantees another cesarean delivery.
According to studies, the increase in first-time cesareans has not occurred due to a change in the health status of mother or baby.
The issue really is in the discussion stages, said Debbie Chambers, director of the Family Birth Center at Saint Elizabeth. There’s been no determination of the what the trend means or how to respond, she said.
Setting the guideline
Salt Lake City-based Intermountain Healthcare, delivering close to 30,000 babies yearly, helped develop the 39-week guideline.
Historical data showed when babies were electively induced at 37 weeks of gestational age, 8.85 percent were admitted to a neonatal intensive care unit. That fell to 3.34 percent at 39 weeks.
Of babies electively induced at 37 weeks, 1.92 percent struggled with respiratory distress syndrome. At 39 weeks, 0.42 percent did.
After the hospital initiated a 39-week guideline, elective labor inductions performed before 39 weeks fell from 28 percent in 1999 to 3.4 percent in 2006. Afterward, Intermountain saw a 90-minute drop in the average length of labor among electively induced patients.
Medically necessary
New 39-week restrictions in Lincoln on induced labor deal only with elective procedures - defined as occurring for a reason other than to protect the health of mother or child. There has been no change in local physicians’ ability to induce labor for medical reasons.
According to the American College of Obstetricians and Gynecologists, labor may be induced whenever it is more risky for a woman’s baby to remain inside her.
Common medical reasons for induction:
* Two or more weeks past due
* Placental abruption
* Infection of the membranes
* Ruptured membranes
* Preeclampsia.
Other acceptable reasons include an expectant mother living far from her hospital and risk of rapid delivery.
The change has paid dividends.
* Fewer cesareans due to induced labor failures.
* Quicker deliveries.
* Less stress on newborns.
Otte, a labor and delivery nurse at Saint Elizabeth Regional Medical Center, said she made the choice to deliver her first two babies early.
“It was mostly me,” she said.
Both times, uncomfortably pregnant and still working 12-hour shifts, she went to her doctor with early contractions.
“My doctor said, ‘You know, we could get this done today.’”
“Yes, please, let’s do.”
Both babies were born with jaundice, one of the risks of a preterm delivery, but no other problems.
Otte worries a little bit about what lies ahead with No. 3 since the policy change.
“I know how difficult it is at the very end to stay comfortable and to stay at work,” she said.
But like most mothers who have been told of the risks of early inducement, she’s OK with playing it safe.
“Sometimes when you’re in that situation, you think, ‘It’s not going to happen to me,’ but it very well could,” Otte said.
“If your body can do it on it’s own, it’s much easier to go naturally, and it (labor) progresses so much better.”
Hospital officials hear a lot of reasons for scheduling births.
Grandma’s flying into Lincoln Sunday for the arrival of her first grandbaby. The pregnancy is almost full-term, and it would be convenient for her if the delivery was Tuesday.
A first-time mom is a tax accountant and wants to deliver in time to be back at work for crunch time.
The mom’s younger brother is getting married, and it would be great if she could deliver early and make it to the wedding.
Saint Elizabeth Regional Medical Center and BryanLGH Medical Center still may bend some rules for very rural mothers and soldiers shipping overseas, but not by much.
Since hospital officials implemented a trial run of the policy last summer, they say they’ve seen fewer incidents of newborn harm.
Both hospitals withheld data for competitive reasons, but they say fewer induced babies are winding up in neonatal intensive care, there’s been a drop in the number of cesarean sections after inducement and there’s been a decline in low Apgar scores — a measure of newborn health.
The declines are small in absolute terms but significant over time and in large populations, especially since problems in giving birth can result in a lifetime of trouble.
The 39-week policy, part of a larger standardization of labor and delivery procedures, has gained wide acceptance among local caregivers.
“I used to get calls in my office from grandmothers,” said Debbie Chambers, director of Saint Elizabeth Family Birth Center. They’d say, “‘I’m flying in from Minneapolis. …’”
Everyone felt the pressure.
When she toured local clinics last summer to explain the change in rules, she said, staff reaction was: “‘Oh, thank you, thank you.’”
They encounter mothers at the end of pregnancy who can’t sleep, can’t get comfortable — and they want it to end.
Staff worry they can’t see the forest for the trees.
Studies show that when babies are induced before 39 weeks’ gestation, labor and hospital stays are long, interventions and costs increase, as do bad outcomes.
Benjamin Pennell wondered why Jaelynn didn’t cry.
Was something wrong with his baby girl?
Doctors gave her mother, Kristy Smith, Pitocin to induce labor at 7 that October morning in 2002. Contractions started about 4 that afternoon.
Jaelynn was born at 1:50 the next morning, and although she turned out fine, she needed a bit of encouragement and resuscitation.
Their second child, Ben Jr., born on a recent Sunday, required neither inducement nor resuscitation.
Pennell and Smith got to Saint Elizabeth at 3:30 a.m. Ben Jr. came out screaming at 4:27 a.m.
“This one, phfttt!” Pennell said.
A third of all deliveries nationwide involve Pitocin, a synthetic form of the hormone oxytocin. It’s also used to augment weak natural contractions.
Sue Gullo, managing director of the Institute for Healthcare Improvement in Cambridge, Mass., said use of the drug has grown dramatically since 1990, apparently for reasons of convenience.
Until recently, Lincoln hospitals didn’t distinguish between using the drug to induce or to augment, so it was tough to tell if it was used to trigger labor or enhance it.
Still, there are indications of scheduling.
Nationwide in 2005, an average of 13,169 babies were born on Tuesdays and an average of 7,374 on Sundays. Among the nation’s 500 most populous counties, Lancaster County fell into the top fifth of most scheduled, using that comparison.
That’s changed, said Saint Elizabeth’s Chambers.
“I’m already changing my staffing patterns,” she said.
The trend toward scheduling fit into the larger culture of elective surgery. What happened, Chambers said, was kind of like speed limit creep: The sign says 75 mph, so most drive 80.
People started to think it was OK to induce at 36 weeks.
The Institute for Healthcare Improvement defines a full-term pregnancy as 39 weeks, and the American College of Obstetricians and Gynecologists defines it as 37 to 41 weeks.
But everyone agrees the last weeks are critical.
Final maturation occurs not only in the lungs, said Chambers, but also in the brain and gut.
A study published in the Journal of the American Medical Association examined millions of births in the United States and Canada and found babies born at 34 to 36 weeks’ gestation were nearly three times more likely to die in their first year than full-term infants.
One problem with inducing at 38 weeks is that a pregnancy could actually be at 36 weeks because a due date easily could be two weeks off.
Lincoln Dr. George Hansen said elective early deliveries were resulting in unnecessary premature babies.
“We’ve clearly seen a decrease in inappropriate pre-39-week inductions,” he said. “In the long run, convenience is not the safest.”
Reach Mark Andersen at 473-7238 or mandersen@journalstar.com.
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Easy for the staff to imply that some mothers "can't see the forest for the trees". If the mother hasn't slept in three days because of early and frequent contractions, she's in no condition to give birth and the risk of c-section rises. What would two weeks of sleeping pills do to the fetus? I would hope the mother's sleep patterns would be considered a medical reason and not just a 'forest for the trees' metaphor. "
A Sad Day In Lincoln wrote on May 11, 2008 9:04 am:
Whats next, I am at a competing hospital, and I have a need for something from the other medical center and it will not be provided because of rivalry?
A sad day indeed. "
Jana wrote on May 11, 2008 9:47 am:
peb wrote on May 11, 2008 11:20 am:
too bad wrote on May 11, 2008 3:27 pm:
M wrote on May 11, 2008 7:04 pm:
W wrote on May 11, 2008 7:43 pm:
AJ wrote on May 11, 2008 8:51 pm:
No one can predict when a baby is ready to come out except nature. There are lots of reasons to induce labor, but convenience is not one of them. Thank you for being willing to make hard decisions and rules that help provide a standard care in accordance with the evidence based medical knowledge and not the social pressures of obstetrics. "
JB wrote on May 11, 2008 8:53 pm:
Another thing wrote on May 11, 2008 9:44 pm:
DM wrote on May 12, 2008 12:12 am:
Its not just the mothers wrote on May 12, 2008 12:20 pm:
Its about time wrote on May 13, 2008 1:39 pm: