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Exclusive Q&A with Rebecca Dekker – What Does the Evidence Say about Induction for Going Past your Due Date?

April 15th, 2015 by avatar

What does the evidence say about dueToday on Evidence Based Birth, occasional contributor Rebecca Dekker, Phd, RN, APRN, provides a comprehensive research review –  Induction for Going Past your Due Date: What does the Evidence Say?  I had an opportunity to preview the article and ask Rebecca some questions about her most recent project on due dates. I would like to share our conversation here on Science & Sensibility with all of you. Rebecca’s website has become a very useful tool for both professionals and consumers to read about current best practice.Consumers can gather information on the common issues that they maybe dealing with during their pregnancies. Professionals can find resources and information to share with students and clients.  How do you cover the topic of inductions at term for due date?  After reading today’s S&S post and Rebecca’s research post, do you think you might share additional information or change what you discuss?  Let us know in the comments section.- Sharon Muza, Community Manager, Science & Sensibility.

Note: if the Evidence Based Birth post is not up yet, try again in a bit, it should be momentarily.

Sharon Muza: Why did you decide to tackle the topic of due dates as your next research project and blog post?

Rebecca Dekker: Last year, I polled my audience as to what they would like me to write about next. They overwhelmingly said that they wanted an Evidence Based Birth article about Advanced Maternal Age (AMA), or pregnancy over the age of 35. As I started reviewing the research on AMA, it became abundantly clear to me that I had to first publish an article all about the evidence on due dates. This article on induction for due dates creates a solid foundation on which my readers can learn about induction versus waiting for spontaneous labor in pregnant women who are over the age of 35.

SM: When you started to dig into the research, were there any findings that surprised you, or that you didn’t expect?

RD: There were two topics that I really had to dig into in order to thoroughly understand.

The first is the topic on stillbirth rates. I began to understand that it’s really important to know which mathematical formula researchers used to calculate stillbirth rates by gestational age. It was interesting to read through the old research studies and letters to the editors where researchers argued about which math formulas were best. In the end, I had to draw up diagrams of the different formulas (you can see those diagrams in the article) for the formulas to make sense in my head, and once I did, the issue made perfect sense!

Before 1987 (and even after 1987, in some cases) researchers really DID use the wrong formulas, and it’s kind of funny to think that for so many years, they used the wrong math! In general, I thought the research studies on stillbirth rates by gestational age were really interesting…it raised questions for me that I couldn’t answer, like why are the stillbirth rates so different at different times and in different countries? Also, it was really clear from the research that stillbirth rates are drastically different depending on whether you are looking at samples that include or don’t include babies who are growth-restricted.

The other big breakthrough or “ah ha” moment I had was when I finally realized the true meaning of the Hannah (1992) Post-Term study. There was such a huge paradox in their findings… why did they find that the expectant management group had HIGHER Cesarean rates, when clinicians instinctively know that inductions have higher Cesarean rates compared to spontaneous labor? Since all of the meta-analyses rely heavily on the Hannah study, I knew I needed to figure this problem out.

There are a couple different theories in the literature as to why there were higher C-section rates in the expectant management group in Hannah’s study. One theory is that the induction group had Prostaglandins to ripen the cervix, while the expectant management group did not. However, in a secondary data analysis published by Hannah et al. in 1996, they found that this probably played just a minor role.

Another theory is that as women go further along in their pregnancy, physicians get more nervous about the risk of stillbirth, and so they may be quicker to recommend a Cesarean in a woman who is past 42 or 43 weeks, compared to one who is just at 41 weeks. This theory has been proposed by several different researchers in the literature, and there is probably some merit to it.

But in the end, I found out exactly why the C-section rates are higher in the expectant management group in the Hannah Post Term study (and thus in every meta-analysis that has ever been done on this topic). Don’t you want to know why? I finally found the evidence in Hannah’s 1996 article called “Putting the merits of a policy of induction of labor into perspective.” The data that I was looking for were not in the original Hannah study… they were in this commentary that was published several years later.

dekker headshotThe reason that Cesarean rates were higher in the expectant management group in the Hannah study is because the women who were randomly assigned to wait for spontaneous labor, but actually ended up with inductions, had Cesarean rates that were nearly double of those among women who had spontaneous labor. Some of these inductions were medically indicated, and some of them were requested by the mother. In any case, this explains the paradox. It’s not spontaneous labor that leads to higher Cesarean rates with expectant management… the higher Cesarean rates come from women who wait for spontaneous labor but end up having inductions instead. 

So the good news is that if you choose “expectant management” at 41-42 weeks (which is a term that I really dislike, because it implies that you’re “managing” women, but I digress), your chances of a Cesarean are pretty low if you go into spontaneous labor. But if you end up being one of the women who waits and then later on chooses to have an induction, or ends up with a medically indicated induction, then your chances of a Cesarean are much higher than if you had just had an elective induction at 41 weeks.

SM: What information do you recommend that childbirth educators share to help families make informed decisions about inductions and actions to take as a due date comes and then even goes, and they are still pregnant.

RD: First of all, I think it’s important for all of us to dispel the myth of the 40 week due date. There really is no such thing as a due date. There is a range of time in which most women will go into labor on their own. About half of women will go into labor by 40 weeks and 5 days if you’re a first-time mom (or 40 weeks and 3 days if you’ve given birth before), and the other half will go into labor after that.

The other thing that it is important for childbirth educators to do is to encourage families—early in pregnancy—to talk with their health care provider about when they recommend induction, and why.

There are some health care providers who believe strongly that induction at 39, 40, 41, or 42 weeks reduces the risk of stillbirth and other poor outcomes. There are parents who have the same preference. Then there are other health care providers who believe strongly that induction for going past your due date is a bad thing, and shouldn’t be attempted unless there are clear medical reasons for the induction. And there are parents who will tend to share that same preference. Either way, parents need accurate information about the benefits and risks of waiting versus elective induction at 41-42 weeks—because both are valid options.

But it’s probably best to avoid a mismatch between parents and providers. If parents believes strongly that they want to wait for spontaneous labor, and they understand the risks, but they have a care provider who believes strongly in elective induction at 41 weeks, then they will run into problems when they reach 41 or 42 weeks and their care provider disagrees with their decision.

Clearly, there are benefits to experiencing spontaneous labor and avoiding unnecessary interventions. But at the same time there is a rise in the relative risk of stillbirth starting at about 39 weeks, depending on which study you are looking at. However, the overall risk is still low up until 42 weeks. At 42 weeks, the risk of stillbirth rises to about 1 in 1,000 in babies who are not growth-restricted. The risk may be higher in some women who have additional risk factors for stillbirth. Women who experience post-term pregnancy (past 42 weeks) are more likely to experience infections and Cesareans, and their infants are more likely to experience meconium aspiration syndrome, NICU admissions, and low Apgar scores.

SM: Would you recommend that families have conversations about how their due date is being calculated, at the first prenatal with their health care providers. What should that conversation include?

RD: I would recommend asking these questions:

  • What is the estimated date range that I might expect to give birth—not based on Naegele’s rule, but based on more current research about the average length of a pregnancy?
  • Did you use my Last Menstrual Period or an early ultrasound to determine my baby’s gestational age?
  • Has my due date been changed in my chart at any point in my pregnancy? If so, why?

SM: The concept of being “overdue” if still pregnant at the due date is firmly ingrained in our culture. What do you think needs to happen both socially and practically to change the way we think about the “due date?”

RD: We need to start telling everyone, “There is no such thing as a due date.” To help women deal with the social pressure they may experience at the end of pregnancy, I’ve created several Facebook profile photos that they can use as their Facebook profile when they get close to their traditional “due date.” To download those photos, visit www.evidendebasedbirth.com/duedates

SM: How available and widely used are first trimester ultrasounds? If first trimester ultrasounds were done as the standard of care in all pregnancies, would it result in more accurate due dates and better outcomes? Do you think there should be a shift to that method of EDD estimation?

RD: I think the option of having a first trimester ultrasound definitely needs to be part of the conversation between a woman and her care provider, especially because it has implications for the number of women who will be induced for “post-term.” I could not find any data on the percentage of women who have an ultrasound before 20 weeks, but in my geographic area it seems to be nearly 100%, anecdotally.

If your estimated due date is based on your LMP, you have a 10% chance of reaching the post-term period, but if it’s based on an early ultrasound, you only have a 3% chance of reaching 42 weeks.

One strange thing that I noted is that ACOG still prefers the LMP date over an early ultrasound date. They have specific guidelines in their practice bulletin about when you need to switch from the LMP date to an ultrasound date, but the default date is still the LMP. I found that rather odd, since research is very clear that ultrasound data is more accurate than the LMP, for a host of reasons!

Before I published the due dates article, I reached out to Tara Elrod, a Certified Direct Entry Midwife in Alaska, to get her expert feedback as a home birth midwife. She raised an excellent point:

“It is of significant interest to me as a licensed midwife practicing solely in the Out-of-Hospital setting that ultrasounds done in early pregnancy are more accurate than using LMP. If early ultrasound dating was achieved, it’s thought that this would ultimately equate to less women being induced for post-term pregnancy. This is significant to midwives such as myself due to the scope-of-care regulation of not providing care beyond 42 weeks. While an initial- and perhaps arguably by some ‘elective’ ultrasound-  may not be a popular choice in the midwife clientele population, a thoughtful risk versus benefit consideration should occur, as to assess the circumstance of “risking out” of care for suspected post-dates. [In my licensing state, my scope of care is limited to 37+0 weeks to 42+0 weeks, with the occasional patient reaching 42 weeks and therefore subsequently “risking out,” necessitating a transfer of care.]” ~Tara Elrod, CDM

SM: What do you think the economic cost of inductions for due dates is? The social costs? What benefits might we see if we relied on a better system for determining due dates and when to take action based on being postdates?

RD: There are economic costs to both elective inductions and waiting for labor to start on its own. The Hannah Post-Term trial investigators actually published a paper that looked at the cost effectiveness of their intervention, and they found that induction was cheaper than expectant management. This was primarily because with expectant management, there were extra costs related to fetal monitoring (non stress tests, amniotic fluid measurements, etc.) and the increased number of Cesareans in the expectant management group.

But there are many unanswered questions about the cost-effectiveness of elective induction of labor versus waiting for labor to begin (with fetal monitoring), so I’m afraid I can’t make any definitive statements or projections about the economic and social costs of elective inductions. Here is a study that may be of interest to some with further information on this topic.

I do know that in a healthy, low-risk population, birth centers in the National Birth Center Study II provided excellent care at a very low cost with women who had spontaneous births all the way up to 42 weeks. I would love to see researchers analyze maternal and neonatal outcomes in women stratified by gestational age in the Perinatal Data Registry with the American Association of Birth Centers.

 SM: I very much look forward to all your research posts and appreciate the work  and effort you put into doing them. What is on your radar for your next piece?

RD: The next piece will be Advanced Maternal Age!! After that, I will probably be polling my audience to see what they want, but I’m interested in tackling some topics related to pain control (epidurals and nitrous oxide) or maybe episiotomies.

SM: Is there anything else that you want to share about this post or other topics?

RD: No, I would just like to give a big thank you to everyone who helped in some way or another on this article!! There was a great interdisciplinary team who helped ensure that the due dates article passed scrutiny—we had an obstetrician, family physician, nurse midwife, several PhD-prepared researchers, and a certified direct entry midwife all provide expert review before the article was published. I am so thankful to all of them.

References

Hannah, M. E., C. Huh, et al. (1996). “Postterm pregnancy: putting the merits of a policy of induction of labor into perspective.” Birth 23(1): 13-19.

Hannah, M. E., W. J. Hannah, et al. (1992). “Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group.” N Engl J Med 326(24): 1587-1592.

 

 

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, informed Consent, Maternal Quality Improvement, Maternity Care, New Research, Research , , , , ,

The Straight Scoop On Inductions – Lamaze International Releases New Infographic

November 21st, 2013 by avatar

Click image to see full size

The health concerns that affect preterm babies are well documented and much is known about the impact of an early birth on the long term health of children.  Some of these issues were discussed in a recent post on Science & Sensibility highlighting World Prematurity Day.  The issue of babies being born too soon was highlighted by the American College of Obstetricians and Gynecologists (ACOG) in a new committee opinion recently published in the November issue of Obstetrics and Gynecology.

In a joint committee opinion, “The Definition of Term Pregnancy” released by ACOG and the Society for Maternal Fetal Medicine, these organizations acknowledge that previously it was believed that “the period from 3 weeks before until 2 weeks after the estimated date of delivery was considered ‘term’ with the expectation that neonatal outcomes from deliveries in this interval were uniform and good.”  More recent research has demonstrated that this is not the case.  The likelihood of neonatal problems, in particular issues related to respiratory morbidity, has a wide variability based on when during this five week “term” window baby is born.

ACOG has released four new definitions that clinicians and others can use when referring to gestational age; early term, full term, late term and postterm.

  1. Early term shall be used to describe all deliveries between 37 0/7 and 38 6/7 weeks of gestation.
  2. Term shall indicate deliveries from 39 0/7 and 40 6/7 weeks of gestation.
  3. Late term refers to all delivers rom 41 0/7 to 41 6/7 weeks of gestation.
  4. Postterm indicates all births from 42 0/7 weeks of gestation and beyond.

These new definitions should be put into practice by all those who work with birthing women, including researchers, clinicians, public health officials and organizations AND childbirth educators. We can and should be teaching and using these terms with our students.

As we move forward, we can expect to see these terms applied and research defined by the new categories, which will yield rich and useful information for those working in the field of maternal-infant health.

Lamaze International has long been focused on evidence based care during the childbearing year and continues to support childbirth educators, consumers and others by providing useful and fact based information that women and their families can use to make informed choices about their maternity care.  As part of this continued effort, Lamaze is pleased to share a new induction infographic created by the Lamaze Institute for Safe & Healthy Birth committee. This easy to read infographic is designed to highlight the facts about induction and encourage women to carefully consider all the information before choosing a non-medically indicated induction.  More than one in four women undergo an induction using medical means, and 19% of those inductions had no medical basis.

Since many women are pressured by providers or well-meaning but misguided friends and family to be induced, Lamaze encourages women to learn what are the important questions to ask during conversations with their providers and to get the facts about their own personal situation.  It is also recognized that a quality Lamaze childbirth education class can provide a good foundation for understanding safe and healthy birth practices.

Lamaze International is proud of their Six Healthy Birth Practices for safe and healthy birth, and this infographic supports the first birth practice; let labor begin on its own.  Women need to be able to gather information to discern between a medically indicated induction, which protects the baby, the mother or both from those induction that are done for a social or nonmedical reason which increases the risk of further interventions, including cesarean surgery for mothers and NICU stays for babies who were not ready to be born. This infographic can be shared with students, clients and patients.  It can be hung in classrooms and offices.  Educators can use it in creative ways during teaching sessions, when discussing the topics of inductions, informed consent and birth planning.

As the benefits of a term baby are more clearly understood, and research is revealing how critical those last days are for a baby’s final growth and development, it is perfect timing for Lamaze to share this infographic.  This tool will reduce unneeded inductions and help women learn how important it is to allow their babies to receive the full benefit of coming when the baby is ready.  There has been a huge push to stop inductions before at least 39 weeks.  March of Dimes has their “Healthy Babies are Worth the Wait” campaign. The new induction infographic provides an accessible and easy to use information sheet to help families reduce non-medical inductions. Many organizations, including Lamaze are joining together to make sure that babies are born as healthy as possible and women go into labor naturally when baby is ready.

You can find and download the full version of the Induction infographic on the Let’s Talk Induction page of Lamaze’s Push for Your Baby campaign website.  Alternately, if you are a Lamaze member, you can also download the infographic and many other useful handouts from the Teaching Handouts Professional Resource Page from Lamaze International.

Please take a moment to read over this great, new infographic and share in the comments below, both your thoughts on the finished product and how you might use this to help mothers to push for the best care. Lamaze International and its members are doing their part to help reduce the number of early term babies who arrive before they are ready.  I look forward to hearing your thoughts and your ideas for classroom use.

References

The American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. Committee Opinion No 579: Definition of Term Pregnancy. Obstet Gynecol 2013; 122:1139.

Declercq, E. R., & Sakala, C. (2013). Listening to mothers III: Pregnancy and childbirth.”. 

 

ACOG, Babies, Childbirth Education, Evidence Based Medicine, Healthy Birth Practices, informed Consent, Maternal Quality Improvement, Medical Interventions, New Research, Newborns, NICU, Practice Guidelines, Pre-term Birth, Push for Your Baby, Research , , , , , , , , , , ,

A Look Beyond the Headlines: Induction, Augmentation and Autism

August 29th, 2013 by avatar

Today on Science & Sensibility, regular contributor Deena Blumenfeld takes a look at the recent study that examined a link between induction and augmentation of labor with an autism diagnosis in those same children during their school years.  Did you have a chance to read the study?  Take a look at what Deena found. – Sharon Muza, Community Manager, Science & Sensibility

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source: momaroo.com

As the parent of an autistic child, my ears perked up when I saw my Facebook feed (and Twitter and G+ feeds…) light up with links about the latest study on Autism. This time, it wasn’t vaccines or mercury they were talking about. It was labor induction and augmentation.

On August 12, 2013, JAMA sent out a press release regarding the study entitled:  Association of Autism With Induced or Augmented Childbirth in North Carolina Birth Record (1990-1998) and Education Research (1997-2007) Databases. The media took note, and ran with it as evidenced by the following links:

As is often the case, the “big news” headlines and associated media stories attract a lot of attention, but one must look at the study to really assess what the real information has to say.  When someone only reads the short media blasts, the reader does not get the full information and bases an opinion on only the headline or sound bite. This is a type of cognitive distortion which is commonly known as jumping to conclusions. When doing so, the most common conclusion will be a negative one. 

The topic of Autism is a hot button issue. These headlines are specifically designed to garner a quick reaction from the reader. I was interested in taking a more thorough look at the study discussed, and want to share it with Science & Sensibility readers.

Gregory, et. al. acknowledge that there are both genetic predispositions and environmental factors linked to autism. They choose to look at one environmental factor, labor induction and augmentation. The team looked at 625,000 births in North Carolina. After controlling for other factors, such as congenital abnormalities, multiples, maternal education, marital status, maternal smoking, parity and mode of delivery, the group of infants was narrowed down to those who were comparable using the North Carolina Detailed Birth Record (NCDBR). These infants were followed through their school years using the North Carolina Education Research Data Center (NCERDC) containing the indicator for exceptionalities, designation autism.

After comparing the data, there does appear to be a correlation between autism and induction/augmentation. 

Approximately 1.3% and 0.4% of male and female children were diagnosed as having autism, respectively. Amon g both sexes, the percentage of induced or augmented mothers was higher among children with autism compared with non cases.

Moreover, children with autism were more likely to have a birth characterized by fetal distress or meconium.

But what correlates to what? Is the fetal distress the cause of autism, the meconium? Is it the induction? Is the fetal distress due to the induction, or for some other reason? Is the fetal distress due to pre-existing autism? Correlation is not causation.

Compared with children whose mothers were neither induced nor augmented during labor, children born to mothers who were either induced and augmented, induced only, or augmented only experienced increased odds of autism. Autism diagnosis differentially associated with induction/augmentation by sex, whereby a stronger association was observed among male children.

To our knowledge, this is the first large scale study to address the relationships among birth induction/augmentation and autism. This study also confirmed previously documented risk factors for autism such as advanced maternal age and maternal education, parity, and singleton birth (as reviewed by Gardener et al3 and Guinchat et al13).

The more risk factors mother and baby have, the higher the rates of autism in the baby. However, “We controlled for each of these variables and found that labor inductions and augmentation continued to be independently associated with ASD in offspring.”

 The authors speculate about exogenous oxytocin and its effect on the fetal brain. “Exposure to exogenous oxytocin during induction/augmentation may have a functional effect through, as yet, unidentified genetic or epigenetic factors.”

Gregory, et al. is not the first study to look at the relationship between oxytocin and autism. There are a number of studies which examine the relationships between oxytocin and vasopressin and autism in both boys and girls. The hypothesis that artificial oxytocin, administered during labor, has a negative affect on the fetus’ brain has been around for some time – this is Hollander’s theory. A 2004 review of the literature by Wahl, suggests at a molecular level (in animals) that Hollander may be on the right track, but systematic research is needed. Gregory, et al. is the beginning of that systematic research.

Is perinatal brain injury, whether through induction, augmentation, hypoxia or other issues, a cause of autism? Maybe?

We do know that there are side effects to everything we do during labor, from induction to augmentation, assisted delivery and cesarean sections. It’s not time to throw the baby out with the bathwater and give up on labor interventions. It may be a question of risk mitigation, or choosing one set of risks over another. There is no easy or straightforward answer as to whether or not we do more harm with a medical intervention than do we help. Each mother, each baby and each labor must be addressed on an individual case by case basis to determine the cost/benefit of each potential intervention. A physiologic approach to birth generally has better outcomes and avoids iatrogenic complications.

So, from Gregory, et al. we so know that there is an increased risk of autism, especially in boys with the use of labor induction and augmentation. Many pieces of the puzzle are still missing, however. It is still too early to determine if this is correlation or causation. 

“Our results are not sufficient to suggest altering the standard of care regarding induction or augmentation; our results do suggest that additional research is warranted.”

In other words, it’s far too soon to change how we treat women when it comes to induction and augmentation. We need to go deeper, and study further the effects of artificial oxytocin on the fetal brain.

As an educator, and as a mother to a child on the spectrum, I will address this in my classes in the same manner I always have. I give parents the best evidence-based information, tell them to use their BRAINS questions and let them go with what their hearts, and their heads, tell them is best for mother and baby. As of now, the evidence isn’t strong enough to point the finger at induction and augmentation. It is, in my opinion, strong enough to encourage our parents to ask more questions with regards to the effects of induction and augmentation on their babies.

Have you discussed this research with your students?  Have any questions been raised?  Do you discuss these research findings when you discuss benefits and risks to labor induction and augmentation? Please share your thoughts in the comments section of our blog. – SM

References:

Carter CS. Sex differences in oxytocin and vasopressin: implications for autism spectrum disorders? Behav Brain Res. 2007;176(1):

Gregory SG, et al “Association of autism with induced or augmented childbirth in North Carolina birth record (1990-1998) and education research (1997-2007) databases JAMA Pediatr 2013; DOI: 10.1001/jamapediatrics.2013.2904.

Wahl RU, “Could oxytocin administration during labor contribute to autism and related behavioral disorders?–A look at the literature.” Med Hypothesis, Initiative for Molecular Studies in Autism (IMSA) 2004.

Gardener H, Spiegelman D, Buka SL. Prenatal risk factors for autism: comprehensive meta-analysis. Br J Psychiatry. 2009;195(1):7-14.

Gardener H, Spiegelman D, Buka SL. Perinataland neonatal risk factors for autism: a comprehensive meta-analysis. Pediatrics. 2011;128(2):344-355.

Gregory SG, Connelly JJ, Towers AJ, et al. Genomic and epigenetic evidence for oxytocin receptor deficiency in autism. BMC Med. 2009;7:62.

 

Babies, Childbirth Education, Guest Posts, Medical Interventions, New Research, Research, Uncategorized , , , , ,

A Game of Telephone and Misinterpreting Information

March 19th, 2013 by avatar

© http://flic.kr/p/bS581K

Regular contributor Deena Blumenfeld shares her recent experience with a “research” article that washed over social media outlets and was shared and discussed by many birth professionals.  Deena explains how she fell in step with others and ended up being lead down the wrong path.  Have you every made this mistake too?  Please share your thoughts in our comment section.- Sharon Muza, Science & Sensibility Community Manager.

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Gathering information from social media can be like playing a giant game of “telephone” with a million of your closest friends.

This is often how it goes:

  • Someone reads an article. They post to Facebook (or other venue) a link and a comment.
  • We read this person’s comment and add our own comment.
  • Then we go back and skim the article, and comment again.
  • Next we post a link to the article, with our own comments and opinions regarding the article.
  • The next reader takes our opinion as gospel, only reads the headline of the article and then shares our opinion on their page, neglecting to link the article with their comment.
  • So now we have a rumor about an opinion and after 345 more postings, no one knows where the original source was of what anyone is talking about anymore.  But, whatever it is, it sounds AWFUL and we are indignant about it.

Does this sound familiar to you? Have you ever taken a rumor, opinion or comment about an article or study to be gospel truth, without fully reading and researching the information on your own… and then go on to repeat that rumor or opinion? 

I’ll sheepishly raise my hand here…

Not too long ago, there was an article on medpagetoday.com entitled New Form of Misoprostol Speeds Up Labor.” Now, without reading the article, doesn’t it seem that we now have a form of misoprostol being used for augmentation? 

This is the misinterpretation that was flying around Facebook, Twitter and other social media sites for days after the article was published on February 18, 2013. The outrage, fear and condemnation of anyone who thought it might possibly be a good idea to use misoprostol for augmentation was overwhelming. I read, and participated in, many discussions regarding the dangers of this drug; uterine rupture, mothers who have died, babies who have died, the Safe Motherhood Quilt Project, and so on. 

But yet we all missed it, me included.  That misleading headline leads us to believe that this was misoprostol for augmentation of labor; when in reality, it is an article about a new form of misoprostol, designed in the appropriate dosage, to induce labor.  This ‘little oops’ caused a big stir for not much. 

So, let’s look at what the article really talks about and what we should know.

  • This is an article about an abstract which was presented at a conference. It is not a peer-reviewed, published study.
  • We do not have access to the full study, since it isn’t published. So, we cannot evaluate it effectively.
  • The study compared the efficacy of this new form of misoprostol suppository to the existing dinoprostone (cervadil) suppository for induction of labor.
  • This study of 1,358 women found that the misoprostol suppository worked more quickly than the dinoprostone to get women to active labor as well as to birth.

“Along with the primary efficacy benefit of shorter time to vaginal delivery, the novel agent was also associated with faster delivery of any type, vaginal or cesarean (median 18.3 hours versus 27.3 hours with dinoprostone, P<0.001).”

“Other secondary outcome benefits were shorter time to active labor at 12.1 hours versus 18.6 hours, respectively (P<0.001), with substantially fewer women needing oxytocin prior to delivery (48% versus 74%, P<0.001).” 

Hang on a minute: “faster delivery of any type, vaginal or cesarean.” If the results of the induction end up as a cesarean, can we call it a successful induction? I’m not sure we can. I think this is a failed induction. Sure the medication worked to get labor started, but for whatever reason she ended up with a cesarean section. Faster to a cesarean section – wouldn’t it have been even faster to just schedule the cesarean section? 

“T’he primary safety outcome of cesarean delivery came out similar between groups at 26% with misoprostol and 27% with dinoprostone (P=0.65). Nor was there a difference in indication for cesarean section.”

When asked at the session why a faster vaginal delivery didn’t translate into fewer cesarean deliveries, Wing pointed to the myriad other factors that play into delivery mode. “We can flip the switch on but that doesn’t always get us the desired result,” she told the audience.” 

The article is leaning towards “faster is better” in terms of labor. We are left with more questions than answers. The answers may be found within the study itself, however, we don’t have access to the study. My questions:

But why? Why is a faster induction (or faster labor) better than a slower one?

Aren’t faster labors more painful? Aren’t contractions more challenging to cope with when they are more intense?

Do we have high rates of fetal distress with a faster labor vs. a slower one?

Who benefits from a faster birth?

The articles states that fewer women needed to be augmented with pitocin with a misoprostol induction vs. a dinoprostone induction. Is that a good thing? Bad? Neutral?

We also don’t know the researcher’s intentions. Without being able to read the study, we can only make assumptions. Do we assume the intention is a faster labor? Do we assume the intention is to make misoprostol safer for induction? Something else? Or maybe, just maybe, we don’t assume anything at all. Assumptions can be very dangerous and in most cases, they are wrong. 

How to avoid misinterpreting the data and spreading rumors:

  • Always go to the study! An article about the study is someone else’s opinion. The abstract is the Cliff’s Notes version of the study.
  • Admit when you don’t understand something and talk to someone who does.
  • Look to the citations and in the study to check for further information.
  • Use the Cochrane Library and other sources for more information.
  • Don’t make assumptions based on other people’s opinions.
  • If you don’t know for sure, don’t spread the information!
  • If you made a mistake and misinterpreted a study or article, say so. It’s better to admit you are wrong than to continue to spread inaccurate information.

My Take Away

The take away from all of this is that an article about an abstract presented at a conference leaves us with more questions than answers. We cannot accurately evaluate that which we cannot read in its entirety. Social media is a good tool, but we should be cautious about that which sounds too good (or bad!) to be true. We should take others opinions as just that – opinions, until we’ve done our own solid research. We should also be cautious about the ‘click and share’ phenomenon. Double check, do your homework and make sure the information we share is accurate. I’ll do better next time too.

For more on misoprostol for labor induction please read:

  1. Science & Sensibility: Update on Spin Doctoring Misoprostol (Cytotec): Unsafe at Any Dose
  2. Science & Sensibility: ACOG’s 2009 Induction Guidelines: Spin Doctoring Misoprostol (Cytotec)
  3. Journal of Perinatal Education: The Freedom to Birth—The Use of Cytotec to Induce Labor: A Non-Evidence-Based Intervention by Madeline Oden
  4. WHO: Misoprostol for cervical ripening and induction of labour
  5. WHO: WHO Recommendations for Induction of Labor, 2011
  6. Induced and Seduced: The Dangers of Cytotec by Ina May Gaskin
  7. Adverse Events Following Misoprostol Induction of Labor by Marsden Wagner, MD, MS

 

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternity Care, Medical Interventions, New Research, Research, Uncategorized , , , , , , , , ,

“Choosing Wisely” in maternity care: ACOG and AAFP urge women to question elective deliveries.

February 21st, 2013 by avatar

 

http://flic.kr/p/4v3Zeh

Last April, the ABIM Foundation, with Consumer Reports and other partners, drew national attention to overuse of ineffective and harmful practices across the health care system with their Choosing Wisely campaign. As part of the campaign, professional medical societies identified practices within their own specialties that patients should avoid or question carefully. Today, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) have joined the campaigndrawing national attention to the overuse and misuse of induction of labor. ACOG and AAFP are telling women and their maternity care providers:

Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.

Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable. 

(“Favorable” means the cervix is already thinned out and beginning to dilate, and the baby is settling into the pelvis. Another word for this is “ripe,” and doctors and midwives use a tool called the Bishop Score to give an objective measurement of ripeness. Although ACOG and AAFP do not define “favorable,” studies show cesarean risk is elevated with a Bishop Score of 8 or lower in a woman having her first birth and 6 or lower in women who have already given birth vaginally.)  

Much work has already been done to spread the first message. Although ACOG has long advised against early elective deliveries, a confluence of quality improvement programs and public awareness campaigns have made it increasingly difficult for providers to perform non-medically indicated inductions or c-sections before 39 weeks.

But as the public and the health care community have accepted the “39 weeks” directive, concern about unintended consequences has grown. Christine Morton, a researcher at the California Maternal Quality Care Collaborative and regular contributor to Science & Sensibilitysums up concerns shared by many, including Childbirth Connection:

It is possible that this measure may sensitize stakeholders to the wrong issue: timing of birth rather than the fact that it is generally best when labor begins on its own.  Additionally, is it possible that 39 weeks could become the new “ideal” gestational age, because it will be assumed that 39 completed weeks is the best time to be born?

The second Choosing Wisely statement aims to mitigate these unintended consequences. Inducing with an unripe cervix significantly increases the chance of a c-section and its many associated harms. Women considering induction for a non-medical reason deserve to know about these excess risks, and should question whether it is worth any non-medical benefits of elective delivery they perceive or expect. Lamaze International has spoken to the importance of letting labor begin on its own, as it is the first topic in the Six Healthy Birth Practices.

But will the new message lead women and care providers to think that delivery is indicated once a woman’s cervix is ripe? Through the Choosing Wisely campaign ACOG and AAFP have made powerful statements acknowledging that scheduled delivery is unwise if the baby or the woman might not be ready for birth. Although gestational age and the Bishop score are tools to estimate readiness for birth, the best indicator of readiness is still the spontaneous onset of labor at term, the culmination of an intricate interplay of hormonal signals between the fetus and the woman. Anytime we intervene with the timing of birth we have to weigh the potential benefits and harms of overriding that process in the context of the fully informed preferences and values of women.

This summer, our collaboration with the Informed Medical Decisions Foundation will culminate in the release of our first three Smart Decision Guides. These evidence-based, interactive decision support tools will help women learn the possible benefits and harms of scheduled delivery versus waiting for labor to start on its own and to weigh these based on what is most important to them. These tools help women choose wisely – to identify when an option is not appropriate or safe for them, and to thoughtfully weigh options when there are both pros and cons to consider.

Interested in learning more about shared decision making in maternity care? Sign up for a free webinar on March 13 sponsored by the Informed Medical Decisions Foundation to hear more about what clinicians, consumers, employers, and others thinking about the importance of maternity care shared decision making.

 

ACOG, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthcare Reform, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Quality Improvement, Medical Interventions, Practice Guidelines, Pre-term Birth, Webinars , , , , , , , , , ,

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