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Monday
Jul052010

Should We Rethink Inductions and Cesareans Prior to 39 Weeks?

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Guest post by Allie Sakowicz

 

Soon after a woman finds out she is pregnant and her due date is calculated, she promptly proceeds to mark that special date on the calendar with circles, hearts, lines, ribbons, bows, you name it.  Even though there is only about a 5% chance that the baby will be born on his or her due date, it still provides an adequate estimation as to when the stork may be arriving with a special package.  Once a woman reaches 37 weeks of gestation, she is considered to be term, meaning that the birth could safely take place at any point from then on.  However, a recent study conducted by a group of physicians associated with the March of Dimes organization points out that considering babies term at 37 weeks may not be such a good idea after all. 


The article says that “term birth (37– 41 weeks of gestation) has previously been considered a homogeneous group to which risks associated with preterm (less than 37 weeks of gestation) and post-term births (42 weeks of gestation and beyond) are compared.”  But there seems to be new evidence that suggests that the outcome for a baby born after less than 37 completed weeks of pregnancy is significantly different for one born after 38 completed weeks.  The study proposes that the phrase “late preterm” be used when describing neonates born between 37 0/7 weeks and 38 6/7 weeks because of the new research which states that babies born during this period suffer from increased mortality and neonatal morbidity when compared to children born later in the pregnancy. 


This finding is particularly interesting considering that most scheduled cesarean sections are performed at 39 weeks, which is only one day after the late preterm risk would pass.  The most common reason for scheduling c-sections at this time is so that the mother does not go into labor on her own, since there are some rare cases where a vaginal delivery could be dangerous to mom and baby.  Also, there are some conditions that might cause a physician to schedule an induction at this time.  While an ultrasound-calculated due date can be a good estimation of a baby’s birthday, it is certainly not a perfect science and there is a very real possibility that it could be misleading.  Therefore, it’s not unlikely that some of the babies that are being delivered at 39 weeks actually fall into the category of late preterm and are at risk for some complications.


While the article makes very few conclusions, it does offer an interesting perspective into something that we had been making assumptions on for decades.  There’s only so much that medical professionals and parents can do to dictate when a baby’s birthday will be, but perhaps this new analysis will cause doctors to rethink performing cesareans and inductions at 39 weeks.  Because, at the end of the day, it’s that 7 pound bundle of joy that’s calling all of the shots.


What are your thoughts on this new article?  Was your baby born in the late preterm category?  Do you think that scheduled c-sections and inductions should be done at 40 weeks instead of 39 weeks?  I welcome all of your questions or comments.

 

Allie reviewed the article Rethinking the Definition of “Term Pregnancy” by Alan R. Fleischman, MD, Motoko Oinuma, BA, and Steven L. Clark, MD which appeared in July 2010’s Green Journal.

 

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Reader Comments (13)

That's a really interesting article! My son was born at 38w2d when my water broke spontaneously. He was on the smaller side (7 pounds even) compared to my first baby but thankfully we had no complications with his health. He was mildly jaundiced but we just used the sunlight method. While I think he was ready to be born, I agree wholeheartedly that most babies need to "cook" longer. A due date isn't an expiration date, and I really hope that OBs (and in some cases, impatient mamas) can start holding off longer on inductions and C-sections, especially in light of this new research.

Great work, Allie!

July 5, 2010 | Unregistered CommenterMegan

Megan, here's an excerpt from the article you'll find interesting:

Moreover, early induction has a greater chance of resulting in a cesarean delivery, particularly with an unfavorable cervix.(24) A survey of women who recently gave birth found that over half believed that full term was reached at 37–38 weeks of gestation and that most believed it is safe to deliver before 39 weeks of gestation when there are no other medical complications requiring early delivery.(25) Thus, in addition to quality improvement programs and physician education to address this issue from the perspective of the provider, it is also important to communicate to pregnant women and their families the possible negative consequences of early elective delivery.

I tend to think this attitude stems from years of seeing elective inductions performed and assuming that it must be safe-- after all, doctors perform early inductions and they wouldn't do anything that's not safe for mother and baby, right?

July 5, 2010 | Registered CommenterJill

Did the study look at parity & racial differences?

July 5, 2010 | Unregistered Commenterabundant b'earth

My son was born at a freestanding birth center at 36 weeks 5 days. He was absolutely fine--had no trouble nursing and no health problems. I was charting my cycles when I conceived him and am certain of dates.
This being said, I think the key here is that I went into labor on my own. My baby was already 7 lb 9 oz, and he was just ready to be born. (My husband and his brothers were all about 9 lb when they were born, so my son would have followed suite if he had made it to 40 weeks.) Bottom line is that my baby was ready to come out. If I ever have to be induced or plan a c/s for whatever reason in a future pregnancy, I would want to wait as long as was safe. My first baby was born at 41 weeks (8 lb even), so there is just no magic formula as to when a baby should be forced out of the mom.

July 5, 2010 | Unregistered CommenterErinK

Abundant: sort of. It's a short article but race was mentioned.

An analysis of U.S. singleton live births at term between 1995 and 2001 found that the mortality rate decreased with increasing gestational age from 0.66 per 1,000 live births at 37 weeks to 0.33 per 1,000 live births at 39 weeks and remained stable from 39 to 40 weeks.(12) Despite a low absolute risk of infant death at term, the risks were more than 50% higher at 37 weeks than at 40 weeks, and although the main analysis was restricted to non-Hispanic whites, there were similar patterns among non-Hispanic African Americans.

July 5, 2010 | Registered CommenterJill

Well, by the standards set out in that study, my first baby was "late preterm" at 38+1, and I went into labor spontaneously. He was 7 lbs. 9 oz., so a good size baby, and certainly appeared full term. He did have latching problems, which I have always attributed to him being a boy and "on the early side of normal." Interesting stuff. Great post Allie!

July 5, 2010 | Unregistered CommenterLori

my daughter was born around 38 weeks. She was definatly early as one of her ears was still uncurling and her prints weren't full yet but she was also 8 full pounds, latched on like hoover, a little jaundice but sunlight made it alright and general good health from then on. While I agree that we shouldn't be pressing children to come out early I think we also have to trust when they come out naturaly on their own. Ultrasounds as well as last period due dates can be inacurate up to two weeks from what I've been taught so generaly pressing a child to come out before their ready based on when you mark on the calander can be unsafe. There is a reason a child chooses to be born when they're born and one way or another unless there is some very legitimate cause to immediately get a baby out, we need to learn to trust our children.

July 5, 2010 | Unregistered Commenteratara

I'm with Erin and atara--only both of mine came even earlier (35.2 and 36.3)--but, again, in both cases my labor was spontaneous. (Well, with my first, my water broke at 5am, and they said they'd give me till mid-afternoon before they induced, but I went into labor on my own and he was born about 1pm.) One technically premature, one only 3 days on the "safe" side of premature, but they both topped over 7 lbs and were absolutely healthy with no complications. We joke in the family that I have a convection oven rather than a standard model.

While I agree wholeheartedly that we need to pay more attention to the idea that Babies Come When They Come and not expect them to arrive on schedule, I think there's a little danger in statistics like this which imply that a 37 week baby, for example, should have stayed in till 40 weeks and was lucky to be okay--for THAT baby, 37 weeks might have been just right, while inducing the baby that should've come at 42 weeks 3 weeks early is taking a chance. But I do agree that the whole 39-week-induction (hell, ANY induction without real medical cause!) thing is a big scary mess.

(By the way, while I count myself as really fortunate to have had a couple of really fast births--which saved me from a lot of interventions, I'm sure--I had fairly sucky pregnancies, which may be why my body was so eager to get them out the moment it could...)

July 6, 2010 | Unregistered CommenterJenn

Late preterm is a term that is already in use to describe 34-36 weekers. 34 weeks is currently the cutoff as to when a dr/midwife would not stop labor from occurring naturally on its own.So thet term would have to be changed- or a different one would have to be employed to describe 37 weekers & beyond. Furthermore, I think this classification is only applicable to inductions. Babies who are born naturally between 37-39 weeks are usually perfectly fine. All 3 of mine were not considered 'term' according to your classifications (one of them was not even considered term my current medical 'wisdom') & all of them were normal spontaneous vaginal births. I am 31 3/7 weeks with number 4 now & I am not expecting to go past my due date. I would not appreciate the late preterm label, because that would just put my baby at risk for more interventions. They are already at risk for being toward the small end of the scale & the number of blood draws & other meaningless tests are just abhorrent. So while this new classification might potentially prevent inductions before 'term' (whenever that is), you will not be doing the moms of babies spontaneously born before their due dates any favors. (My second daughter was 36 weeks and 5 days. The fuss the medical staff made because of those 2 days & my GBS+ status were not to be believed. Babies are NOT pincushions.)

July 6, 2010 | Unregistered CommenterRachael

Interesting, for sure. I face the opposite problem, I get past 41 weeks and out come the induction monsters :P My first was 40 5/7 wks when they did an u/s she was breech and cord around her neck x2 so they opted for a C-section in 3 days. I never had any labour. I am thankful they didn't find out before 40 weeks, I would have fought to put off the section. As it was I asked for a few days to get her to turn, but no such luck. She was 8lbs 10 oz, so I believe she as term.

My 2nd went 40 4/7 and on that day I went to see the doctor who was panicing about induction the prior week and basically told me I had 3 days to go into labour before they'd induce (I begged it out of him, I did NOT want induction). My husband and I walked, ate Mexican, and a few other labour inducing things after that appointment and my water broke that night. He was 8lbs 9 oz.

I'm 16 wks with my third, and I look forward to another VBAC whenever my baby is ready. But if for some reason they scheduled a C, I would not want to have it before 40 weeks.

July 6, 2010 | Unregistered CommenterTapanga
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