The art of delivery

Those final weeks of a pregnancy sometimes seem to drag for some soon-to-be Mums.

“I’m over it, can’t you do something?” is not an uncommon request. Back & hip pain, reflux, swollen legs, waddling gait, can’t sleep…..and that’s just me

Now without opening an argument about expectant management versus induction of labour (today), would I be doing anything bad by relieving my patient of these problems and delivery their babe as soon as they get to term. Are these real medical indication. Will the mother be at risk by continuing the pregnancy? Or do these request fall under the heading of social inductions? Along with requests for inductions because my husband will be flying off to work, war or a week surfing with his mates, there’s  a lamb sale on next week or it has to be tonight there’s a full moon you know!

Or, I just want to plan a big fishing trip and don’t want to be stuck in hospital and miss the tuna!

By way of definition, a pregnancy is considered “at term” after 37  weeks , but is less than 42 weeks of gestational age.

A 2010 commentary by Fleischman et al (http://www.leapfroggroup.org/media/file/ACOGRethinkingDefinitionofTermPregnancy.pdf) argued for a redefinition of a term pregnancy based upon outcomes. Early term babies those born between 37 and 38+6 weeks had a higher rates of mortality and morbidity than those born after 39 weeks. The numbers showed that mortality was half at the later gestation. In the US this was 0.66 per 1,000 live births at 37 weeks compared to 0.33 per 1,000 live births. Small numbers, I know. Studies of babies born by caesarean section at 37 and 29 weeks shows increased rates of respiratory problems, albiet short lived and the need for NUCU admission.

A 2009 study by Toita et al (http://www.nejm.org/doi/full/10.1056/NEJMoa0803267) also found higher rates of neonatal sepsis and hypoglyacemia associated with delivery at 37 to 38 weeks.

As a member of RANZCOG, I get a copy of the Australian New Zealand Journal of Obstetrics and Gynecological or the Red Journal. Occasionally there are is a paper in it which is interesting to a Rural GP Obstetrician.

April’s had a paper by pyschologist Dr Monique Robinson,  (the et al includes Fiona Stanely from http://www.childhealthresearch.org.au/).  They looked at behaviour of children born at 37 week  compared with those born later weeks. Using data from 2900 pregnancies in Western Australia, they compared scores on the Child Behaviour Checklist. They found that children born at 37 weeks had a increased risk of for behavioural problems with an odd ratio of 1.4. They suggested that 37 weeks’ gestation may not be the optimal cutoff for defining perinatal risk as it applies to behavioural development.  http://onlinelibrary.wiley.com/doi/10.1111/ajo.12012/abstract

RANZCOG, BCOG and ACOG all recommend that unless there is a compelling medical indication, that a caesarean section be deferred until 39 weeks.  To me it seems sensible to apply the same rules to an induction of labour given that the end are the same.

In the US, the March of Dimes organisation is leading a campaign to reduce early term deliveries. “We know the best incubator is the uterus, and if there is no reason for a baby to be delivered early then it should never occur before 39 weeks.”

So, 39 weeks it will be from now on…patience may be indeed a virtue.

And then to throw a spanner into my logic, I find a paper that found that at least in one US hospital a policy limiting elective delivery before 39 weeks was associated with a small reduction in NICU admissions; however, macrosomia (>4000 grams) and stillbirth (2.5 to 9.1 per 10,000 term pregnancies) increased. Actual numbers of still births were 7 versus 15, and all were in the under 37 to 38 week group. Damned statistics. http://journals.lww.com/greenjournal/Abstract/2011/11000/Neonatal_Outcomes_After_Implementation_of.12.aspx

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One thought on “The art of delivery

  1. Yes it’s a tricky issue! My personal preference is to delay “elective” or “social” induction until after 39 weeks and one of my very first patient encounters as a GP obstetrics registrar was making a patient cry when I told her I wouldn’t induce her earlier. She did very well though and we became friends after the initial bumpy road. Having said that, I have induced patients early when their quality of life has been significantly impaired eg by severe itching from PUPPPs rash, unmanageable musculoskeletal pain etc but it does require careful counselling of risks and benefits. Elective caesareans are a bit trickier, particularly if your hospital only lets you book 2 patients per week and you have to somehow juggle the ever increasing demand for elective caesarean spots… And of course booking all of them after 39 weeks will inevitably lead to more NELUSCS for patients booked for C/S presenting in labour or with prelabour ROM. Obviously there may be consequences from tired staff doing after hours sections which is also hard to measure.

    Great work on the post – look forward to reading more in the future!

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