Friday, June 6, 2008

New Strategy/Protocol for Inductions

A recent article about inducing labor between 37-41 weeks as a method to "prevent c-sections and improve outcomes" is making the rounds. You can read the whole article at Medical News Today. (The study was done at the University of Pennsylvania School of Medicine and published in this month's issue of the American Journal of Obstetrics and Gynecology.)

Some quotes:

"The alternative method is known as Active Management of Risk in Pregnancy at Term, or AMOR-IPAT, for short. AMOR-IPAT uses "risk-based preventative labor induction to ensure that each pregnant woman enters labor at a gestational age that maximizes her chance for vaginal delivery," says lead researcher, James M. Nicholson, MD, Assistant Professor of Family Medicine and Community Health at Penn....

"Over the past decade, the rates of cesarean delivery have climbed above 30%," says Dr. Nicholson. "Cesarean delivery, when compared with vaginal delivery, is associated with higher rates of postpartum hemorrhage, major postpartum infection and hospital readmission," he adds....

"The findings of this study suggest that the AMOR-IPAT approach to obstetric risk lead to healthier babies and better birth outcomes for mothers. In addition, the results challenge the current belief that a greater use of labor induction necessarily leads to higher rates of cesarean delivery. In order to further explore the potential benefits of the AMOR-IPAT method of care, further research involving larger randomized clinical trials in more diverse populations is needed."
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Taking such an intensively managed approach to normal birth is of cause for alarm. Particularly quotes such as this "...labor induction to ensure that each pregnant woman enters labor at a gestational age that maximizes her chance for vaginal delivery." Hmmm. Doesn't a woman's body generally enter labor at the right gestational age for both of them, no induction necessary (or calculation of the "proper" time to induce)?!

There is an editorial called "Association Not Causation" that rebuts the claims of an earlier study on the protocol above. This rebuttal was written by a family practice physician and published in the Annals of Family Medicine.

One of the best portions of the rebuttal is as follows:

"We can learn something about complex care for a complex problem/phenomenon from midwifery. In midwifery care in the hospital or at home, cesarean section rates and other outcomes are as good as or better than those reported in the current study. What is the intervention in midwifery care? It is the totality of the care. It includes a coherent philosophy and an articulated, highly noninterventive approach. Induction rates are low, and women whose pregnancy is post-term are usually allowed to progress to labor on their own much later than in conventional physician practice."

The physician also draws a parallel between this "new best thing" and previous prophylactic intervention techniques that were advocated in previous decades: "An historical example of enthusiasts taking up the challenge of their leader before the intervention was fully examined is what happened when Joseph B. DeLee exhorted his followers to implement the "prophylactic forceps operation," with associated episiotomy. He believed this delivery style could improve outcomes for both mother and fetus at a time when, as today, there was a real problem, when childbirth was indeed quite dangerous. It seemed like a good idea at the time, and it has taken us more than 80 years to recover." (emphasis mine)

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Thanks to Kathy of Woman-to-Woman CBE for pointing me in the direction of the editorial referenced above!

And thanks to Jim for noting that the editorial was actually written in regard to an earlier study. The research quoted at the beginning of the post is from a newer study (May 2008).

2 comments:

Mychelle said...

I am not a midwife or an OB, but it is my anecdotal understanding that inductions odten lead to c-sections...no?

Jim Nicholson said...

The difference between this new study (May 2008) and the study covered by the referenced editorial (July 2007) is that the new study was a randomized controlled trial. Randomized controlled trials are supposed to provide the best evidence to guide us when there are disagreements about what is the best treatment option. In comparison, the work of DeLee was not based on randomized controlled trials. With the US cesarean delivery rate probably above 33%, and with maternal mortality rates and NICU admission rates increasing, it would seem imprudent to ignore the implications of this study. The current attitude about "preventive labor induction" is similar to early (and ongoing)reactions concerning childhood immunizations. However, immunizations are a main stay of modern preventive medicine.