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Tuesday
Nov172009

The March of Dimes Fights Iatrogenic Prematurity

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The March of Dimes released its 2009 Premature Birth Report Card today. For the second consecutive year, the United States only earned a “D”, which the organization claims indicates that “more than half a million of our nation’s newborns didn’t get the healthy start they deserved.”

March of Dimes president Jennifer L. Howse, PhD, introduces Prematurity Awareness Day in this video:

 

The rate of premature birth increased by 36 percent between the early 1980s and 2006 and the March of Dimes’ Prematurity Awareness Campaign delves into the dynamics behind this trend. One page on the March of Dimes site, About Prematurity: Why Do Women Deliver Early? , lists the main reasons for spontaneous premature labor, noting that in nearly 40 percent of premature births, the cause is unknown. However, studies suggest that there may be four main routes that lead to spontaneous premature labor, which are:

  • Infections/Inflammation
  • Maternal or fetal stress
  • Bleeding
  • Stretching (of the uterus)

In addition to the fighting the causes of spontaneous premature labor, the March of Dimes challenges the increase in iatrogenic prematurity.

The Institute of Medicine’s Committee to Study the Prevention of Low Birthweight  defined iatrogenic prematurity in its 1985 report, “Preventing Low Birthweight”:

Iatrogenic prematurity refers to the birth of a physiologically immature and/or low-weight infant who is delivered prematurely as a result of medical intervention. Justifiable iatrogenic prematurity may result from cesarean sections performed before term to avoid even more serious consequences for the mother or the infant. Some cases of iatrogenic prematurity are accidental, however, resulting from either mistiming of induced labor pr nonemergency cesarean section, or from unintentional induction of labor during an oxytocin challenge test or some other procedure. Accidental iatrogenic prematurity is probably most frequently associated with an overestimation of gestational age by physicians responsible for scheduling repeat cesarean sections.

This is confirmed by Dr. Lucky Jain, MD, MBA of the Emory University School of Medicine, who states that United States obstetrics has literally shaved one week off of gestation between 1992 and 2002, shifting the peak from 40 weeks to 39 weeks. Said Jain, “In the good old days when mothers went into spontaneous labor, there was really no need to keep an accurate log of timing because natural labor told us what the biologic clock was. You went into labor, you were term gestation and you often delivered at the right time.” [Warning: Video contains graphic surgery footage.]

 

Because many doctors are willing, if not eager, to support women in scheduling their births, the March of Dimes has a long article on its site for women thinking about scheduling their baby’s birth for non-medical reasons. One section focuses on why scheduling an early birth can be a problem:


Experts are learning that scheduling an early birth for non-medical reasons can cause problems for mom and baby. For example:

  • Your due date may not be exactly right. Sometime it’s hard to know just when you got pregnant. If you schedule to induce labor and have a cesarean birth (also called a c-section) and your date is off by a week or two, your baby may be born too early.
  • Inducing labor may not work. If your labor is induced, the medicine your doctor or CNM gives you may not start your labor. When this happens, you may need to have a c-section.
  • A c-section can cause problems for your baby. Babies born by c-section may have more breathing and other medical problems than babies born by vaginal birth. (Most babies are born by vaginal birth. The mother’s uterus contracts to help push the baby out through the vagina, also called the birth canal.)
  • C-sections can cause problems in future pregnancies. Once you have a c-section, you may be more likely in future pregnancies to have a c-section. The more c-sections you have, the more problems you and your baby may have, including problems with the placenta
  • A c-section is major surgery for mom. It takes longer for you to recover from a c-section than from a vaginal birth. You can expect to spend 2 to 4 days in the hospital after a c-section. Then you’ll need 4 to 6 weeks after you go home to fully recover. You also could have complications from the surgery, like infections and bleeding. So it’s important to stay in touch with your health care provider even after you go home.

The March of Dimes and obstetric provider groups advise that you wait until at least 39 weeks to induce labor or have a c-section if it is needed. Wait this long unless there are medical problems that make it necessary to have your baby earlier.

 

Another section is dedicated to induction by request:

Some women may prefer to have an induction, even without medical need. Inducing labor may appeal to both the woman and the health care provider because it helps them plan their schedules. The March of Dimes recommends that labor be induced only when the health of the woman or baby is at risk.

In 2003, labor was induced in 1 out of 5 deliveries in the United States. The rate has more than doubled since 1990. Some health care providers believe that many inductions are medically unnecessary.

 

The Risk of Late Preterm Birth

Inductions may contribute to the growing number of babies who are born “late preterm,” between 34 and 36 weeks gestation. While babies born at this time are usually considered healthy, they are more likely to have medical problems than babies born a few weeks later at full term (37-42 weeks).

A baby’s lungs and brain mature late in pregnancy. Compared to a full-term baby, an infant born between 34 and 36 weeks gestation is more likely to have problems with:

•Breathing

•Feeding

•Maintaining his or her temperature

•Jaundice

It can be hard to pinpoint the date your baby was conceived. Being off by just a week or two can result in premature birth. This may make a difference in your baby’s health. Keep this in mind when scheduling an induction.

 

Some doctors inform their patients upfront that they prefer daylight obstetrics with web sites that credit their “successful” continuous care and presence at their patients’ birth to their patients’ willingness to opt for unnecessary induction, such as this Evansville, Indiana obstetrician:

One of my biggest concerns is being there for your delivery. I may not be available for delivery when I am not on call or when the office is closed. I perform around 200 deliveries a year and am available for 90-95% of them. The reason I am so successful at attending most of my deliveries is that many patients will elect to have an induction of labor after 39 weeks of pregnancy.

In addition, she offers her personal opinion about the safety of purely elective induction of labor for convenience, recommending Cytotec for first time mothers and Pitocin for others:

Will induction increase my risk for C-Section?

Because I make sure you have cervical dilation that is favorable for a vaginal delivery, most studies show this will not increase your risk for C-Section. Since I feel that induction affords a delivery that will occur with a baby that hasn’t had time to overgrow, we have a greater chance to achieve a vaginal delivery. My C-section rate has traditionally been below the national C-section rate of 25%. I do not feel that induction of labor in a properly selected patient will increase the risk for C-section.

Does induction of labor cause me more pain than natural labor?

Induction of labor does not cause any more or less pain than natural labor. Induction of labor will produce contractions that are no different from the contractions produced during spontaneous labor. Both contractions are a result of Pitocin either produced by the body or given by IV. Most women in spontaneous labor will usually need additional IV pitocin to achieve adequate contractions to deliver vaginally. If you are planning on an epidural during labor, contraction pain is eliminated. No matter whether you are induced or have spontaneous labor, contractions must be of a sufficient force to achieve a vaginal delivery. Therefore, contraction pain is the same in either situation.

Will my baby be safe?

I do try to wait until 39 weeks of pregnancy to deliver your baby. The American College of Obstetrics and Gynecology feels that waiting until this gestational age will not increase risk for babies to have breathing problems with delivery. However, some women will need delivery prior to 39 weeks of pregnancy due to health conditions of the baby or mother. If this is the case, I will discuss these issues with you at your prenatal visits.

 

But why not wait until labor begins spontaneously to ensure that one’s baby is truly ready? Every week counts.

 

 

 

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Reader Comments (17)

I didn't realize my body made Pitocin.

November 17, 2009 | Unregistered CommenterSelena

Obviously the younger the gestational age of the preemie, the higher the morbidity and mortality of the infant. Babies born before 32 weeks gestation do the most poorly. I was quite shocked however to learn, that by sheer numbers, the highest amount of deaths in preemies is in the late preterm age (35-37 weeks gestation). How sad if any of these deaths are due to iatrogenic reasons.

November 17, 2009 | Unregistered CommenterReality Rounds

I know this is more an induction comment than a prematurity comment (you'll see why I have it on the brain in a second: Ugh ugh ugh re: that doctor's induction justifications. ("I wait till 39 weeks to induce, and I'm at all the deliveries!" My goodness, I would just love to have that OB at my delivery - you know, if it was convenient for her.) I had a bit of a facebook kerfuffle this weekend (hazards of posting birth stuff in my status updates) when I hated on inductions (I believe said "Induction? More like labor in-SUCK-tion". Hey, I was at it all weekend, and believe me it sucked for all concerned.) Somebody whose wife had an induction then posted back somewhat defensively. (It's funny how people who feel like you're judging their births when you weren't there, feel fine judging your accumulated experience attending many births at which they were not present, or the birth at which you just attended at which they were also not present.) I posted back basically explaining, inductions have their place but do carry risk. and done without a good reason, suck a lot more than people necessarily understand going in, especially starting from zero. It sounds like this doctor at least does base the decision to induce on SOME readiness for labor, but I bet most of her patients end up believing you HAVE to spend 24-48 tedious, exhausting hours in the hospital before you get to have a baby. Ugh.

November 17, 2009 | Unregistered CommenterRebecca

That Evanston OB's website demands a post all to itself so you can dissect its blatant misinformation line by line. And possibly host a photoshop contest about it.

"Most women in spontaneous labor will usually need additional IV pitocin to achieve adequate contractions to deliver vaginally."

How were babies EVER BORN prior to the invention of synthetic oxytocin? WTF?!

November 17, 2009 | Unregistered CommenterMegan

Oh, I just went to that OB's website itself. Are you kidding me? Take a look at her schedule for birth. How nice to know that you will have a baby by 5 pm on your "day of delivery." And how magically convenient for the doctor's dinnertime! Does anyone really believe that a doctor who induces "most" of her patients this way so she can be there for 95% of her births, all of which take place between the hours of 2 and 5pm, has a c/s rate "traditionally" below 25%? Is that physically possible? I used to think people were inventing these conspiracy theories about OBs, but now I realize - there's no need to make anything up.

November 17, 2009 | Unregistered CommenterMegan

Uh...yeah, I would definitely agree that particular OB's website requires an entire post of it's own. Gotta love how she says that:

All first time Moms receive Cytotec or Misoprostol the night before delivery day. This medication is taken by mouth and serves to ready your cervix for pitocin the following day.

Megan - You are right...why invent the conspiracy theory, there are plenty of real life examples. They aren't hidden either, they're so very out in the open!! Also a good reminder that this kind of attitude does not necessarily depend on care provider gender.

November 17, 2009 | Unregistered CommenterPampered Mom

I'm with Megan on this Dr. Basinski. What a heaping country crock of ARGH. On top of what Megan already pointed out, the concept of trading womens' concerns about the realistic unlikelihood of having one's own doctor attend their birth for their cooperation in consenting to elective induction? CHAGRIN.

And I love this: "I make sure you have cervical dilation that is favorable for a vaginal delivery". I wonder what her c-section rate is like these days? She mentions that the national average is 25%, and as we all know, it hasn't been there in a while, so either her information is outdated or just plain wrong. Given the other misinformation and half-truths she's spewing, I'd wager it's both.

Aside from this being HIGHLY DEBATABLE (brain-blood barrier, anyone?): "Induction of labor will produce contractions that are no different from the contractions produced during spontaneous labor," the following sentence is quite revealing: "Both contractions are a result of Pitocin either produced by the body or given by IV." Anyone see it?

Yes, apparently our bodies now produce PITOCIN!

Megan already covered the idea that "most women" in spontaneous labor require "additional IV Pitocin" (you know, on top of the synthetic oxytocin our bodies are already creating) to achieve adequacy.

More fun to be found on her schedule: Both the Cytotec and the Pitocin inductees will have their membranes ruptured between 7:30 and 8:30 AM. Can't you just picture her arriving at the hospital for her daily morning routine, amniohook in one hand, grande latte, perhaps, in the other, efficiently strolling in and out of women's rooms? Chop chop, spit-spot, pop pop pop! I'm sure her patients really appreciate that she also offers chemical peels in her office. (Doesn't Dr. Lisa's office offer cosmetic procedures too? What' is up with this?)

OH, I could go on and on.

November 17, 2009 | Unregistered CommenterDou-la-la

I sent the OB web link to my sis the RN who had this to say:
"Most women in spontaneous labor will usually need additional IV pitocin to achieve adequate contractions to deliver vaginally"
should actually say...
most women in spontaneous labor who have early epidurals, cont EFM, and lay in bed all day will need additional IV pitocin to delivery vaginally.
or
most women in spontaneous labor will need additional IV pitocin to deliver by dinner time.

November 17, 2009 | Unregistered CommenterMegan

If I was hoping for a normal birth, I would run as far and fast as I could from a care provider whose bio reads "During medical school, I found that I loved to be in the operating room...After careful consideration, I felt Obstetrics and Gynecology gave me the opportunity to combine my joy of operating and caring for women."

I do wonder, though, if this OB is even providing OB services any more? I can't find the page you linked to if I just navigate their site. I can only find references to GYN services, not OB.

November 17, 2009 | Unregistered CommenterLiz Chalmers

I'm glad that someone as credible as the March of Dimes is talking about the problem of inductions and scheduled c-sections. I guess doctors may not consider them credible, but most moms would be concerned if they heard this message.

It saddens me when I hear that less than half of all American babies are born on their intended birth days because of scheduled c-sections and inductions, particularly since I've gone into labor spontaneously at 34 wk 6 days. While it's true that my baby didn't spend any time in the NICU, nursing was tough, and he had a hard time regulating his temperature. It's not something that you'd go through willingly if you knew you had safe options. Of course, when I bring this up with my friends who believe everything their OBs tell them, many of them point out how sick their induced babies were and how being born early probably saved their lives. I can't get them to realize that their babies might not have had any problems at all if they'd just been born when they were ready.

November 17, 2009 | Unregistered CommenterAmy
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