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Published November 02, 2009, 12:00 AM

Hospitals tighten early labor rules to prevent preemies

WASHINGTON – Labor is becoming less of a late-night surprise, but some hospitals are starting to tighten the rules for elective deliveries – because some babies are being delivered too early.

By: Lauran Neergaard / Associated Press, INFORUM

WASHINGTON – Labor is becoming less of a late-night surprise, but some hospitals are starting to tighten the rules for elective deliveries – because some babies are being delivered too early.

More hospitals are expected to crack down as regulators begin new quality measurements next spring that aim to reduce too-early elective inductions and first-time cesareans.

Induced labor is on the rise for lots of reasons, some medical and some not. But recent research shows a troubling link between elective inductions and these so-called late preemies.

These aren’t the dire too-small babies that the word premature conjures, but near-term babies who nonetheless are at higher risk of breathing disorders and other problems than babies who finish their very last weeks in the womb.

“It was an ‘aha’ moment for me,” recalls Dr. Bryan Oshiro of his visit to a Utah intensive-care nursery several years ago, where neonatologists pointed to babies there simply because they’d been induced too soon.

National guidelines from the American College of Obstetricians and Gynecologists have long discouraged elective deliveries before the 39th week of pregnancy. But some hospitals that took a close look were surprised.

At Utah’s Intermountain Healthcare, for example, 28 percent of elective deliveries were breaking ACOG’s rules in 2001, Oshiro told a March of Dimes meeting on preventable prematurity last month.

Both hospitals in Fargo, MeritCare and Innovis Health, said they adhere to the 39-week guideline for elective induced births, saying it is in the best interest of both the baby’s and mother’s health.

Still, Dr. Jon Dangerfield, a MeritCare obstetrician-gynecologist, said he regularly gets requests from patients to induce labor for reasons of convenience. He said that’s understandable, given the demands of pregnancy and the increasing demands on peoples’ time.

Requests for induced births arise “every day, multiple times a day,” he said. “It’s usually the patients. It’s not so much the doctors anymore.”

It’s important to add, Dangerfield said, that medical reasons can warrant an induced birth at any stage after 32 weeks of pregnancy. Sometimes the statistics for medical and elective induced births are mixed, he added.

Terry Burrell, who heads the ob-gyn department at Innovis Health, said births can be medically induced for mothers with high blood pressure and swelling, or for babies that have growth problems or other abnormalities.

Most were being induced in week 37, such a small difference that local obstetricians argued it wasn’t a problem.

Only about 3 percent of elective deliveries today occur before 39 weeks, and infant hospitalizations have dropped, saving money, too, says Oshiro. Inductions are allowed only after meeting a checklist of requirements.

A maternal-fetal medicine specialist at Loma Linda University in California, Oshiro is about to pilot a similar program at hospitals in that area.

“If there’s no need to intervene, please don’t intervene,” is Oshiro’s message.

Labor is induced in more than 1 in 5 births, double the rate in 1990, according to the Centers for Disease Control and Prevention. Many cases are for clear health reasons, such as a problem with the fetus or a sick mom or a pregnancy that has dragged well beyond the woman’s due date.

There’s little data on how many are elective. But a Hospital Corporation of America study of nearly 18,000 births at 27 of its hospitals around the country suggests 10 percent of all births are performed electively before 39 weeks. That date is considered the point at which doctors can be sure a pregnancy has reached full-term, typically defined as 40 weeks give or take about a week.

There are many reasons to perform an elective induction, such as if the mother lives two hours from a hospital, notes Dr. John Fisch of the University of Pittsburgh Medical Center’s Magee-Women’s Hospital.

Patient and doctor preference helped drive the rise in inductions, such as women timing grandma’s arrival to take care of the siblings, or minimizing 3 a.m. deliveries. Then there’s defensive medicine, where doctors worried about litigation induced for minor reasons like a slight uptick of the mother’s blood pressure.

So Pittsburgh also had “a little bit of a hard sell” after discovering nearly 12 percent of elective deliveries broke the 39-week rule in 2004, Fisch says. “It was perceived to be a safe and effective way in delivering a baby – and it is, as long as it meets certain criteria.”

After Magee began strict enforcement – requiring that a mother’s cervix be nearly ready for natural labor and limiting the beds available for elective inductions – too-early inductions dropped to 4 percent by 2007 and are “effectively zero” today, Fisch says. Overall, elective inductions dropped 30 percent.

More hospitals are expected to start enforcing those criteria this spring, when the joint commission that regulates health quality will require hospitals to report all elective deliveries and the gestational age to its public database, providing peer pressure for improvement.

Hospitals also will have to report cesareans for first-time mothers, too often a result of a failed induction.

“That’s not a good outcome for the baby or the mom,” says joint commission president Dr. Mark Chassin. “We believe this will be a very important driver of improvement in perinatal care.”

Forum reporter Patrick Springer contributed to this article