Stepping up to do the right thing
Oregon, my home state, is being heralded as the latest state to take a hard line on out of control c-sections and inductions. Here's what the headlines say:
Hospitals take 'hard stop' on early elective C-sections and inductions - Oregon is the latest state where some hospitals are refusing to do the procedures before 39 weeks of pregnancy.
The way this reads, it sounds like everybody got together in a conference room and agreed they'd make a radical change in the way they practice obstetrics and, by God, everything's going to be different.
Well, not so fast. What these headlines mean is, come September, our hospitals are enforcing guidelines that have been on the books for years. They're mandating that doctors do what they should have been doing all along – using discretion about when they induce and c-section. Hospitals are now providing punitive and financial incentives to push doctors towards following the same old guidelines that dictate when c-sections and inductions are and are not appropriate.
The only thing that's really different here is that now, all the major healthcare systems, hospitals and insurance providers are going to put their money where their mouth is. They're going to make doctors follow the rules. This will also provide support for doctors against the rare patient who insists on inductions or elective, early c-sections. It's not usually the patient's idea though.
The American Congress of Obstetricians and Gynecologists has always said 39 weeks is the earliest date that's appropriate to deliver by c-section or induce, unless there's a clear medical indication why the baby should be delivered earlier. A clear medical indication would be something like severe maternal hypertension or fetal distress. Being tired, cranky and "so done" with pregnancy is not a clear medical indication.
So, why do doctors allow and encourage healthy women to deliver before 39 weeks? Besides being convenient, there's been a gradual erosion of what's considered too early. For example, if a patient is officially 39 weeks on Sunday (which is still a week before her due date), why not schedule her induction for Friday? That's 38 weeks and 5 days - really close to 39 weeks. That gives her the weekend to recover and of course, gives the doctor the weekend off. Seriously, what's a couple days? Pretty soon, it was 38 weeks and 3 days; then it was 37 weeks. Little by little, the prevailing attitude became, "What the heck, it's close enough, right?
Then hospitals noticed some worrisome trends. Their C-section and induction schedules were crowded with non-medically indicated, early patients, which left no room to schedule medically urgent ones. That put mothers and babies who seriously needed to be delivered at risk. There was no room at the inn.
In addition, a lot of those "close enough" babies landed in the NICU with breathing and blood sugar problems. Close enough wasn't good enough. Babies need the whole 40 weeks to finish developing. Some are fine with being delivered even as early as 36 or 37 weeks, but a whole lot of them aren't fine with it. They're not fine at all and they need intensive medical care to survive.
One of my doctor buddies, Desiree Bley, MD, OB-Gyn in Portland, OR says, "This isn't really about creating bold new policies. In every hospital, there are doctors who follow the rules and doctors who don't. Some doctors will do unnecessary inductions and c-sections a little too early, no matter what the rules are. Since it works out for them and their patients most of the time, they don't feel any need to do anything different. That's why hospitals are now going to penalize them if they don't comply with appropriate guidelines. The thing that makes this headline-worthy is that all the local hospitals agreed, everybody has to get with the program. If one hospital continues allowing early deliveries that will just drive patients to the one hospital that's not complying."
We've had a lot of comments on Fit Pregnancy's Facebook page on this subject and some women are ticked off that hospitals are dictating what women can do with their own bodies. They don't think hospitals and doctors should be able to tell women she can't have a c-section if she wants one or be induced early if that's what's best for her schedule. This is a variation on the "women's right to choose," discussion.
Let's get real here. Most women don't have a right to choose how they're going to deliver, especially if they've already had one c-section. Hospitals all over the country tell women that can't have a vaginal birth after cesarean, by refusing to offer that option. It's kind of ironic, that now they're saying, women can't choose a vaginal delivery, an early induction or elective c-section either.
How a woman delivers isn't a choice that impacts only Mom. While most "slightly early" babies are fine, far too many go to the NICU. Not only does that put baby in a dangerous health situation, it also fills the NICU up with babies who shouldn't be there. That takes staff and incubators away from babies with legitimate health problems. It drives up medical costs and insurance premiums for everybody and that's just not cool for any one.
I'm proud of Oregon and other states for taking a stand, but really, they're just finally doing the right thing after years of bending the rules.
Jeanne Faulkner, R.N., lives in Portland, Oregon with her husband and five children. Got a question for Jeanne? E-mail it to firstname.lastname@example.org and it may be answered in a future blog post.
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