Femalepatient.com

[ Editorials | Departments and Series | Index ]

Editorial JULY 2010

Pretty Safe or Safe Enough and Late Preterm Birth

Ronald T. Burkman, MD

The recently concluded Annual Clinical Meeting of ACOG in San Francisco addressed a number of important issues during the plenary sessions and the smaller venues during the program. One of the obstetric issues discussed was late preterm births, defined as births between 34 and 36 weeks’ gestation, although many would suggest that births before 38 completed weeks should also fit into this category.

It is well documented that such births are associated with increased neonatal morbidity. For example, a retrospective analysis performed in 1999 on nearly 180,000 deliveries demonstrated that compared to infants born at 39 to 41 weeks of gestation, those born at 37 and 38 weeks had a 22.5-fold and 7.5-fold higher rate of severe respiratory distress syndrome, respectively.

Another study demonstrated that the rates of NICU admission for infants delivered electively at 37 to 38 weeks and 38 to 39 weeks were 17.8% and 8%, respectively, compared to a rate of 4.6% in pregnancies of 39 weeks and beyond. There have been a number of efforts across the country to eliminate the practice of performing elective inductions or elective repeat cesarean deliveries before 39 weeks of gestation. In one such study, implementing a policy of not doing elective inductions before 39 weeks reduced the frequency of earlier-than-39-week elective inductions from 11.8%—at the time the policy was introduced—to 4.3% more than 3 years later. An obvious question is: Why has this issue been so difficult to resolve?

Rene Amalberti, MD, PhD, Professor in the Department of Cognitive Sciences at IMASSA, an aerospace/air force medical research laboratory in France, has studied the problem posed by trying to achieve ultrasafe health care for a number of years. He and coworkers in the field note that health care places a premium on autonomy, productivity, and economics, which can affect safety practices. For example, achieving high performance, particularly in a system where care providers can be relatively autonomous, may lead to sacrificing a degree of safety to achieve performance goals. At some point, there has to be a limit to maximum performance.

This is similar to what determines how fast we go on an expressway with a speed limit of 65 mph. Our beliefs, vulnerabilities, and life pressures, coupled with a need to achieve a performance goal, eg, reach a destination on time when already running late, will affect whether we speed. Many would speed at 70 mph by identifying this as illegal but normal; ie, much of the traffic is going at this rate, and it still is “a pretty safe speed.” However, going 80 mph, even if it may help to achieve our performance goal, will be viewed by most as too risky.

Similarly, over the years, many elective inductions have been done at 37 to 39 weeks’ gestation to achieve performance goals—eg, I’m on-call that day, the patient’s mother will be in town, it’s the last week of December and the family wants a deduction. The perception was that it was “pretty safe,” particularly if performed during the 38th week of gestation. Using data cited above, a practitioner doing 30 elective inductions a year may only do 3 before 39 weeks. If particularly vigilant, he or she might note that a baby is admitted to the NICU due to an early induction every couple of years. However, most of us may not even notice this. Further, when departmental statistics are presented, the reaction may be that it’s the other clinicians who are causing the problem, not me.

So how do we stop this practice? We need to reduce some of the autonomy in our health care decision making. This requires significant standardization as well as following stricter regulations or policies. For example, relative to the latter, to eliminate elective inductions or repeat cesarean deliveries earlier than 39 weeks, hospitals can use booking forms that use “hard stops.” That is, duration of pregnancy of at least 39 weeks and/or fetal lung maturity must be documented by an acceptable ultrasound standard or amniocentesis, respectively, before the patient is even scheduled for admission.

Note that the emphasis is on regulation and policy, not guidelines. However, achieving ultimate safety in health care will be difficult. As Amalberti and coauthors point out, the risks in medicine are not homogenous. In addition, the degree of medical error that is acceptable and the impact on medical outcomes are also highly variable across specialties. Finally, the health care system is complex; it must try to accommodate what the public wants or needs, deal with how best to educate students and staff, and often manage with a lack of adequate resources, especially trained staff. However, we must accept these challenges if we want to make the health care environment safer than it already is.

Ronald T. Burkman, MD, Editor-in-Chief