Monday, September 16, 2013

So are Early (Elective) Inductions Still the Norm in Your Community?

If early (elective) inductions are still the norm in your community, they shouldn't be.  Three of the most influential groups in maternity care: the March of Dimes, AWHONN, and ACOG/AAFP have launched campaigns to not only educated expectant mothers/families but also care providers.

While an analysis of 230,000 medical records of US women giving birth from 2002 to 2008 in a consortium of 19 hospitals reported an induction rate of 44% among women planning vaginal birth (Optimal Care in Childbirth: The Case for a Physiologic Approach by Goer and Romano citing Zhang, et al. Contemporary cesarean delivery practice in the US.  American Journal of Obstetrics and Gynecology 2010; 203 (4): 326 e1-e10.)

This prompted ACOG (the American College of Obstetricians and Gynecologists) to join with 49 other
organizations through the ABIM Foundation to come up with a talking paper on why scheduling early delivery is not a good idea. Their Choose Wisely campaign hopes to reach those who still use non-medical reasons to induce early: family is in town for a short time, desire to pick a birthday, suspected large baby/macrosomia, etc.  This campaign dovetails with ACOG's Committee Opinion Number 561 April 2013 which states: Morbidity and mortality rates are greater among neonates and infants delivered during the early-term period compared with those delivered between 39 weeks and 40 weeks of gestation. Nevertheless, the rate of nonmedically indicated early-term deliveries continues to increase in the United States. Implementation of a policy to decrease the rate of nonmedically indicated deliveries before 39 weeks of gestation has been found to both decrease the number of these deliveries and improve neonatal outcomes; however, more research is necessary to further characterize pregnancies at risk for in utero morbidity or mortality. Also of concern is that at least one state Medicaid agency has stopped reimbursement for nonindicated deliveries before 39 weeks of gestation. Avoidance of nonindicated delivery before 39 weeks of gestation should not be accompanied by an increase in expectant management of patients with indications for delivery before 39 weeks of gestation. Management decisions, therefore, should balance the risks of pregnancy prolongation with the neonatal and infant risks associated with early-term delivery. However, ACOG Guidelines for Elective Labor Induction state that commonly used indications for labor induction that make the induction elective: include impending macrosomia, history of fast labors, family in town, and maternal exhaustion or discomforts.  These guidelines "while not intended to reflect or establish a standard of care", definitely includes Criteria for Initiating an Elective Induction, Implementation Suggestions as well as auditing suggestions.

AWHONN, the Association of Womens Health, Obstetrics and
Neonatal Nurses, have posted 40 reasons to go the full 40 weeks and divided the reasons into 3 categories: Finish healthy and well, Manage your risks, and Enjoy this time.  With a separate website devoted to the campaign, Health Mom & Baby, plus an iPhone/iPad app AWHONN is working hard to educate moms-to-be and reduce elective induction.  AWHONN has an Assessment and Care of the Late Preterm Infant Implementation Toolkit available for $499.  They also have Assessment & Care of the Late Preterm Infant Guideline 2010 for $53.95, and Hyperbilirubinemia in the Term and Near-Term Infant, 2nd Edition for $34.95.

March of Dimes in conjunction with the WHO have the Born Too Soon Campaign and have identified the fact that 49 countries do maternity care better than the US for infant mortality. Free to all is the Born Too Soon Global Action Report.  This 125 page report, written in conjunction with the WHO, is
designed to focus on prevention and care.  The report defined preterm birth as classified into two broad subtypes: (1) spontaneous preterm birth (spontaneous onsiet of labor or following prelabor premature rupture of membranes (pPROM) and (2) provider-initiated preterm birth (defined as induction of labor or elective cesarean before 37 completed weeks of gestation for maternal or fetal indications (both "urgent" or "discretionary"), or other non medical reasons. 

A wonderful free Toolkit, "Elimination of Non-medically Indicated (elective) Deliveries Before 39 weeks Gestational Age", developed with Federal Title V block grant funding from the California Department of Public Health; California Maternal Quality Care Collaborative and the March of Dimes.  The information in this Toolkit includes complications of non-medically indicated deliveries between 37-39 weeks as an increase in NICU admissions, transient tachypnea of the newborn, respiratory distress syndrome, ventilator support, suspected or proven sepsis, and newborn feeding problems and other transition issues.  In one very telling slide titled "What Motivates Some Obstetricians to Perform Elective Inductions", these reasons are listed: the physician convenience, physician guaranteed attendance at the birth, avoid potential scheduling conflicts, reduce being woken during the night, and "the NICU can handle it".

Other free information is available at  Registration is required but is also free and opens up to journal articles, and power points with many free downloads!

The bottom line: iatrogenic early preterm babies = NICU stays and complications = $$$ for hospitals, convenience for physicians.  Education for ALL is vital to stopping this unnecessary epidemic.

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