Medicine
A recent article published in the Journal of the American Board of Family Medicine reported that fewer than 1 in 5 board-certified family physicians provide routine prenatal care, and just over 13 percent perform deliveries. Therefore, more family physicians are referring patients for maternity care and have less influence over troubling national trends, such as declining rates of vaginal births after previous Cesarean delivery (VBAC) and increasing rates of "late" premature delivery (between 34 and 38 6/7ths weeks gestation) due for the most part to elective inductions.
In an editorial in the December 15th issue of American Family Physician, Drs. Michael Cacciatore and D. Ashley Hill argue that the preponderance of evidence demonstrates that infants delivered before 39 weeks gestation without a medical indication have worse outcomes than those delivered closer to term:
The baseline neonatal intensive care unit (NICU) admission rate at 39 weeks was 2.6 percent, but this rate nearly doubled for each week before 38 weeks. Another group analyzed 13,258 elective cesarean deliveries, of which 35.8 percent were performed before 39 weeks, and found that infants born before 39 weeks had a significantly increased risk of adverse outcomes. Notably, this was also true for the neonates born at 38 weeks. A retrospective review of almost 180,000 births showed that the risk of severe respiratory distress syndrome was 22.5-fold higher for neonates born at 37 weeks and 7.5-fold higher for infants born at 38 weeks compared with those born at or after 39 weeks. The risk of an early term neonate being admitted to the NICU is approximately one in 20 deliveries, compared with about one in 50 for neonates born between 39 and 40 weeks.
If elective inductions before 39 weeks gestation are apparently harmful, why are so many patients consenting to them? The authors point to a variety of reasons, including lack of knowledge, maternal discomfort, convenience, and patient and physician preference. To improve pregnancy outcomes, they recommend the universal adoption of several health system interventions shown to prevent early elective inductions. In addition, family physicians and other primary care clinicians who do not provide maternity care themselves can educate their patients and colleagues about the unnecessary harms that may result from this practice.
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The above post was first published on the AFP Community Blog.
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Medicine
First, do no harm: preventing elective inductions before 39 weeks
A recent article published in the Journal of the American Board of Family Medicine reported that fewer than 1 in 5 board-certified family physicians provide routine prenatal care, and just over 13 percent perform deliveries. Therefore, more family physicians are referring patients for maternity care and have less influence over troubling national trends, such as declining rates of vaginal births after previous Cesarean delivery (VBAC) and increasing rates of "late" premature delivery (between 34 and 38 6/7ths weeks gestation) due for the most part to elective inductions.
In an editorial in the December 15th issue of American Family Physician, Drs. Michael Cacciatore and D. Ashley Hill argue that the preponderance of evidence demonstrates that infants delivered before 39 weeks gestation without a medical indication have worse outcomes than those delivered closer to term:
The baseline neonatal intensive care unit (NICU) admission rate at 39 weeks was 2.6 percent, but this rate nearly doubled for each week before 38 weeks. Another group analyzed 13,258 elective cesarean deliveries, of which 35.8 percent were performed before 39 weeks, and found that infants born before 39 weeks had a significantly increased risk of adverse outcomes. Notably, this was also true for the neonates born at 38 weeks. A retrospective review of almost 180,000 births showed that the risk of severe respiratory distress syndrome was 22.5-fold higher for neonates born at 37 weeks and 7.5-fold higher for infants born at 38 weeks compared with those born at or after 39 weeks. The risk of an early term neonate being admitted to the NICU is approximately one in 20 deliveries, compared with about one in 50 for neonates born between 39 and 40 weeks.
If elective inductions before 39 weeks gestation are apparently harmful, why are so many patients consenting to them? The authors point to a variety of reasons, including lack of knowledge, maternal discomfort, convenience, and patient and physician preference. To improve pregnancy outcomes, they recommend the universal adoption of several health system interventions shown to prevent early elective inductions. In addition, family physicians and other primary care clinicians who do not provide maternity care themselves can educate their patients and colleagues about the unnecessary harms that may result from this practice.
**
The above post was first published on the AFP Community Blog.
- Once A Cesarean ... Now, A Vaginal Delivery
A recent essay in the "Narrative Matters" section of Health Affairs by physician and health policy researcher Carla Keirns highlighted the challenges that even a highly educated, well-informed patient faces in achieving the desired outcome of a vaginal...
- Why Are Doctors Still Prescribing Bed Rest In Pregnancy?
Maternity care providers have traditionally prescribed "bed rest," or activity restriction, for a host of pregnancy complications (including preterm contractions, short cervix, multiple gestation, and preeclampsia) despite evidence that it does not improve...
- How Long Does A Cough Last? (longer Than You'd Think)
At December's annual meeting of the North American Primary Care Research Group (NAPCRG), fellow American Family Physician editor Mark Ebell, MD, MS presented the findings from a study that provided an original take a seemingly simple question: how...
- Vbac Redux
Several months ago, I wrote in this blog about the precipitous decline of vaginal births after Cesarean (VBAC) in the U.S., which I attributed in part to the the internalization by obstetric specialists of the medical maxim "hearing hoofbeats, thinking...
- Vbac And Home Birth: Evaluating The Evidence
Thanks to a recent pronouncement from the American College of Obstetricians and Gynecologists, my two-year old daughter, who arrived via a vaginal birth after Cesarean section (VBAC), may not be a medical rarity for much longer. In a previous post, I...