Tuesday, March 29, 2016

Why I Will Not Be Referencing The University of Pennsylvania Study on Combination Induction Methods that Speed Delivery

Dr. Lisa Levine reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine that the combination of misoprostol and a cervical Foley was the most effective, with a mean time to vaginal delivery of 11 hours, compared with 16 hours for the drug and the catheter alone. 

In Dr. Levine’s study, the mean Bishop score at induction was 3.

“More than 20% of pregnant women undergo an induction each year – that’s almost 1 million women,” she said. “If combination methods were used for all these women, there would be more than 3.5 million fewer hours of labor. This would have a large impact on healthcare utilization. If we could find a way to shorten the length of labor without increasing the cesarean
delivery rate or neonatal complications, this would have an obvious clinical impact.”

If I am reading this correctly, and I’d like to think that I am, the bottom line is that with more inductions and “no significant difference in any of neonatal outcomes”, it is, in fact, all about the money.  With 3.5 million fewer hour of labor, this is a cost savings for health care.

While I was not in attendance during Dr. Levine’s presentation, I still do have the following questions (in no particular order):

  1. With the focus on physical significant differences, why were these mothers induced?
  2. With a Bishop score of 3/dilation less than 2, doesn’t that indicate that the mother is not a candidate for induction?
  3. In the study, it was mentioned that “oxytocin” was administered.  Do you mean “Pitocin”? If so, they are not chemically the same, so please do not use them interchangeably.
  4. Was there complete informed consent prior to induction and using the 491 women in the study?
  5.  The statement was made that there is no significant difference (physically) for mother or baby.  What are the positives? Benefits?
  6. What are the clinical implications of needing to increase the rate of induction by nearly 80%?
  7. Were the mothers in significant pain during the use of Cytotec (misoprostol)? What pain management did they use?
  8. What was the patient satisfaction rate?
  9. What do you mean by statements such as “large impact on healthcare utilization” and “practice-changing”? Does this indicate a higher concern for financials and staffing time over maternal-infant welfare?

Why is maternal/neonatal length of stay an issue?  Why is there so much rushing here?

With statistical data still demonstrating that the U.S. is significantly behind the rest of the industrialized nations in the world in maternal/infant morbidity/mortality, I truly fail to see the significance of this study in reference to maternal/infant well-being.  Pittsburgh childbirth educator Deena Blumenfeld E-RYT, RPYT, LCCE of Shining Light Prenatal Education says, “It’s not about mothers and babies.  It’s about staffing and hospital costs.”

Here are a few last questions:

  1. If a mother was truly given the opportunity for informed consent (with complete knowledge of physiologic birth), would she have given consent to this?
  2. The findings of the study do no significant harm, but what is defined as a good outcome  for these mothers and babies?
  3. Is forcing labor in this manner interfering with the hormonal harmony of birth?
  4. The outcomes are for the very short term.  Are there any long term side effects from rushing labor in this way?
  5. Are there no other ways a hospital can create financial savings and solve staffing issues except to promote “drive-thru” deliveries?  And at what expense to mothers and their babies?

With only 40 year’s experience in the maternity health care industry, I would like to suggest that a combination of evidence-based, comprehensive childbirth education with a focus on non-pharmacologic pain relief, doula support and midwifery care might be good alternatives to this issue.

To read more about this study, click this link:

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