What to Reject When You’re Expecting

Article from March/April Newsletter 2014

Although the U.S. health care system outspends the rest of the world, infants and mothers fare worse in this country than in many other industrialized nations. For example, infant mortality rates in Japan are more than 60 percent lower than the U.S., and we rank behind 41 other countries in preventing maternal mortality during childbirth.

A key reason for this is that our health system prioritizes convenience over ensuring the best outcomes for patients. Childbirth is the leading reason for hospital admission, and the health care system has developed into a highly profitable labor-and-delivery machine, operating according to its own timetable rather than the less predictable schedule of mothers and babies. The system keeps things chugging along using technological interventions that can interfere with healthy, natural processes — and increase risks.

In 2013, as part of the Choosing Wisely campaign, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP), warned against overusing planned early deliveries and inducing labor without good reason.That year, Consumer Reports (CR) Health wrote an article on over-use of medically unnecessary procedures, recommended actions to take during pregnancy, and a wealth of other useful information. CR has kindly agreed to let NWHN excerpt its excellent report. Here is CR’s list of 10 over-used procedures, and 10 things to do when you’re expecting; the full report is longer and has additional information.

10 Overused Procedures

When not medically necessary, these interventions are associated with poorer outcomes for mothers and/or babies.

1. Elective early delivery

A full-term pregnancy lasts at least 39 weeks, but in the last 2 decades it’s become common to artificially induce labor earlier than that. Between 1990 and 2007, births at 37 and 38 weeks increased 45 percent, according to the March of Dimes, and full-term births dropped by 26 percent.2 But, carrying an infant to term has big health benefits.

Full-term babies have lower rates of breathing problems and are less likely to need neonatal intensive care. They are less likely to have cerebral palsy, jaundice, and feeding problems and have higher first-year survival rates. They may even benefit from cognitive and learning advantages through adolescence. Moms of late preterm infants are more likely to suffer from postpartum depression, and the procedures for intentionally delivering babies early (induced labor or cesarean-section) carry higher complication risks than full-term vaginal delivery. Several professional medical organizations now urge moms and doctors to avoid planned early deliveries when possible.3

2. Inducing labor without a medical reason

The percentage of U.S. births that result from artificially induced labor more than doubled from 1990 to 2008. Yet, artificially inducing labor frequently leads to further interventions (i.e., epidurals for pain relief, deliveries with forceps or vacuums, and C-sections) with their own risks. And, a woman who goes into labor naturally usually spends the early portion at home, moving around comfortably. Induced labor occurs in a hospital, where the woman is hooked up to at least one intravenous line and an electronic fetal monitor. A 2011 study found babies born from induced labor without a recognized indication were 64 percent more likely to wind up in a neonatal intensive care unit.

3. C-section with a low-risk first birth

Cesarean section rates have risen steadily over the past two decades such that nearly one in three American babies now enters this world through a surgical incision. A C-section is major surgery; rare but potentially life-threatening complications include severe bleeding, blood clots, and bowel obstruction. C-sections can also complicate future pregnancies. Babies born by C-section can be accidentally injured or cut during it, are more likely to have breathing problems, and less likely to breastfeed. As C-section rates decline, so do rates of several complications, especially infection or pain at the incision site. Women can help avoid an unnecessary C-section by using providers and birthing environments that support vaginal birth: the hospital or birthing center’s C-section rate should be below 24 percent, and preferably lower.

4. Automatic second C-section

Just because your first baby was delivered by C-section doesn’t mean your second has to be, too. But, rates of Vaginal Birth After Cesarean (VBAC) have declined sharply since the 1990s. Most women who have had a C-section with a “low-transverse incision” on the uterus are good VBAC candidates, says ACOG, and about three-quarters of women who attempt VBAC do deliver vaginally. Some OBs don’t do VBACs because they lack hospital support, training, or malpractice insurance coverage. Women seeking VBAC may have trouble finding a supportive practitioner and hospital. If you’ve had a C-section, find out if your OB and hospital are willing to try VBAC.

5. Ultrasounds after 24 weeks

Some practitioners use ultrasounds after 24 weeks to estimate fetal size or due date. The margin of error increases significantly as the pregnancy progresses. Unless your provider is tracking a specific condition, an ultrasound isn’t needed after 24 weeks. It doesn’t provide any additional information leading to better outcomes for either mothers or babies, according to a 2009 review of 8 trials involving 27,024 women.4 In fact, the practice was linked to a slightly higher C-section rate.

6. Continuous electronic fetal monitoring

Continuous monitoring involves hooking the mom up to a monitor to record the baby’s heartbeat throughout labor. This restricts the woman’s movement, increases the chance of a C-section and delivery with forceps, and doesn’t reduce the baby’s risk of cerebral palsy or death. Continuous electronic monitoring is recommended if you’re given oxytocin to strengthen labor, had an epidural, or are attempting VBAC. Otherwise, the baby should be monitored by a periodic electronic fetal monitor, handheld ultrasound device, or special stethoscope.

7. Early epidurals

An epidural puts anesthesia directly into the spinal canal so the woman doesn’t feel any pain below the administration point. But, epidurals can slow labor. And, the longer an epidural is in place, the more medication accumulates, and the less likely the mother will be able to feel to push. If you do have an epidural, ask your anesthesiologist about a lighter block, which allows women to move their legs and buttocks.

8. Routinely rupturing amniotic membranes

Doctors sometimes rupture the amniotic membranes (i.e., breaking the water), erroneously believing it strengthens contractions and shortens labor. This can cause rare but serious complications, including problems with the umbilical cord or the baby’s heart rate. It can also increase the risk of having a C-sections, according to a 2009 review of 15 trials involving 5,583 women.5

9. Routine episiotomies

Practitioners sometimes make a surgical cut just before delivery to enlarge the vaginal opening. Routine episiotomies often don’t help and can be associated with several big problems, including damage to the perineal area and longer healing times, according to a 2009 review involving more than 5,000 women.6

10. Sending your newborn to the nursery

When there is a problem that needs special monitoring, sending the baby to a nursery or intensive care unit is essential. Otherwise, letting healthy infants and moms stay together promotes bonding and breast-feeding. Moms get just as much sleep, and learn to respond to their babies’ feeding cues.

Conclusion

As of 2014, the Joint Commission, an independent, nonprofit group that accredits hospitals, will require hospitals with 1,100 or more annual births to report maternal and infant quality measures — such as the number of elective deliveries and C-sections for first-time births — to a public database. This will empower women by giving them the information they need to navigate the system and work together with their providers to make the best choices for themselves and their babies.

10 Things You Should Do When You’re Pregnant

Until the system changes, you can take positive steps during your pregnancy and seek out practitioners who are already following patient-centered models of care, such as the following 10 items.

1. Set your due date

If you’re not positive about your date of conception or last period, get an ultrasound early in pregnancy to establish your due date. The first ultrasound provides the most accurate due date.

2. Make a birth plan and a backup plan

A birth plan helps women talk about concerns and desires with their providers and hospital staff. For example, if you’ve had a C-section and want to consider VBAC, discuss it up-front with your provider. And, have a backup plan in case things change.

3. Consider a midwife

Women with low-risk pregnancies may consider using a certified midwife (CM), certified nurse midwife (CNM), or certified professional midwife (CPM). These professionals have specific graduate degrees, accreditation, and special training, and provide many of the same services as physicians — including prescribing medication and ordering tests. They practice in diverse settings including homes, hospitals, and birthing clinics. Most health insurance plans cover midwife care; check the American College of Nurse-Midwives’ list of CNMs and CMs who are licensed to practice in your state.

According to a 2009 review of 11 studies involving more than 12,000 women, there are several benefits to using a midwife. Women who used midwives were more likely to be cared for in delivery by their primary provider (rather than whoever’s on call) and to have a spontaneous vaginal birth without epidurals, forceps, or vacuum extractions. They were more likely to report feeling in control during their birth experience and to initiate breast-feeding.

4. Reduce the risk of early delivery

Women with a history of spontaneous premature delivery can reduce the risk of preterm birth by about one-third by taking a special form of progesterone weekly starting at 16 – 20 weeks. Women with a significant risk of delivering their baby early and who are between 23 — 34 weeks pregnant can reduce the risks by taking corticosteroids.

5. Ask if a breech baby can be turned

Because a baby delivered buttocks- or feet-first can be in danger, many practitioners recommend a C-section when the baby isn’t coming out head first. However, a technique called “external version” may enable a skilled practitioner to turn a breech baby in the pregnancy’s last weeks. If your provider isn’t experienced with the procedure, get a referral to someone who is. The procedure carries some risk and should be performed in a hospital.

6. Stay at home during early labor

Discuss with your provider at what point in labor you should go to the hospital or maternity center. Don’t be disappointed if the staff checks you and sends you home because the cervix isn’t dilated to 3 or 4 centimeters yet.

7. Be patient

Mothers today tend to be in labor longer than their grandmothers, for a variety of reasons. But, most doctors learned about labor courses from timetables set back in the 1950s. Talk to your practitioner (and anyone else who’s supporting you) in advance about allowing your labor to progress on its own timetable.

8. Get labor support

Women who receive continuous support have shorter labor and are less likely to need intervention. The most effective support comes from someone who’s neither a member of the hospital staff nor in your social network—a doula, or trained birth assistant, for example, according to a review of 21 studies involving more than 15,000 women. See if your insurance company will cover doula care, and ask your provider for a referral.

9. Listen to yourself

Walking, rocking, or moving during contractions, and changing positions between contractions, can make women more comfortable and speed labor. Being upright or on one’s side when it’s time to push (vs. on one’s back) allows the pelvis to open and works with gravity.

10. Touch your newborn

Placing healthy newborns naked on their mother’s bare chest immediately after birth has numerous benefits. Babies that get skin-to-skin contact interact more with their mothers, stay warmer, cry less, and are more likely to be breast-fed (and breast-feed longer) than those who are taken away to be cleaned up, measured, and dressed.

For the original article, including resources, references, success stories, and tips for things to do before you become pregnant, see (consumerhealthchoices.org/wp-content/uploads/2013/04/ExpectRejectGeneral.pdf).

 

By Consumer Reports Health

The “What to Reject When You’re Expecting” report is published by Consumer Reports, the nation’s expert, independent, and nonprofit consumer organization. It is part of a health communication program created by Consumer Reports, based on articles that originally appeared in Consumer Reports magazine or other Consumer Reports publications

 


REFERENCES

1. Choosing Wisely, The American College of Obstetricians and Gynecologists (ACOG) and American Academy of Family Physicians (AAFP), Five Things Physicians and Patients Should Question, Available at:http://www.choosingwisely.org/doctor-patient-lists/american-college-of-obstetricians-and-gynecologistsand http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-family-physicians.

2. March of Dimes, Toward Improving the Outcome of Pregnancy: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives (TOIP III), White Plains, NY: March of Dimes, 2010.

3. Choosing Wisely, The American College of Obstetricians and Gynecologists (ACOG) and American Academy of Family Physicians (AAFP), Five Things Physicians and Patients Should Question, Available at:http://www.choosingwisely.org/doctor-patient-lists/american-college-of-obstetricians-and-gynecologistsand http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-family-physicians.

4. Bricker, L., et al, “Routine ultrasound in late pregnancy (after 24 weeks’ gestation),” The Cochrane Library, Jul. 8, 2009, pp. 1-20.

5. Smyth, R., et al, “Amniotomy for shortening spontaneous labour,” Cochrane Library, Apr. 15, 2009 (assessed as up to date on May 28, 2011), pp. 1-31.

6. Carroli, G. et al, “Episiotomy for vaginal birth,” Cochrane Library, Jan. 21, 2009, pp. 1-17.