By TODD ACKERMAN
July 21, 2009, 12:18AM
Doctors are being advised not to induce labor for non-medical reasons prior to 39 weeks into a pregnancy under revised guidelines released today by the nation's association of obstetricians and gynecologists.
The guidelines, the first since 1999, arrive amid concern about the increase in the number of such procedures in the last two decades. The rate of induced labor has increased from 90 per 1,000 births in 1990 to 225 per 1,000 births in 2006.
“It's really become an epidemic,” said Dr. Mildred Ramirez, an author of the American College of Obstetricians and Gynecologists guidelines and professor of ob-gyn at the University of Texas Medical School at Houston. “The doctor and patient need to weigh the risks and benefits — there will be exceptions — but I hope the consequence of the guidelines is a reduction in the rate.”
But another Houston ob-gyn called the guidelines “pretty lax” and said she doubted they would have a significant effect.
Ramirez characterized the rate as “alarmingly high” in many hospitals and said there are ones in Houston where labor is induced 50 percent of the time.
While induction is relatively safe, it's been associated with increased risk of Caesarean sections. Studies have found it also leads to longer hospital stays and higher costs.
There are many occasions when there are clear-cut medical reasons for inducing, such as when health problems complicate a pregnancy and when pregnancies are more than two weeks past the due date. The health problems include diabetes or high blood pressure in the pregnant woman, premature rupture of membranes that encase the unborn baby and fetal issues such as an irregular heartbeat.
The new guidelines focus mostly on setting forth when and how to induce labor in such situations. Ramirez said there is significant new data since 1999 comparing the different regimens and their side effects.
Guidelines not set in stone
The guidelines are non-binding, but could be interpreted to make a doctor more liable if he or she doesn't follow them and something goes wrong.
Over the past 20 years, the decision to induce has increasingly involved not health concerns but convenience — for the mother, family or doctor. Patients often request induction because they're tired of the pregnancy, want to make sure their doctor is there instead of a different doctor who might have to deliver if labor occurs at night or prefer to time the delivery to most efficiently manage their allotted time off from work.
The guidelines take no position on such so-called “soft” reasons for inducing labor.
But for the first time, they stress that mature fetal lung test results before 39 weeks of gestation by themselves aren't enough to justify inducing. Such results — fetal lungs are mature at 37 weeks 90 percent of the time — sometimes have been used as a criterion to induce early.
They also call for a physician capable of performing a Caesarean to be available if induction doesn't produce a successful vaginal delivery.
The increased rate has led some hospitals around the nation in recent years to implement their own stricter guidelines on elective use of the procedure. But Dr. Damla Dryden, an ob-gyn with the Women's Specialists of Houston at Texas Children's Hospital, said the demand is so great it will take a stronger statement than the new guidelines to get more hospitals on board.
“People keep pushing to induce earlier and earlier,” said Dryden. “The new guidelines stress the issue a little more clearly than previously, but journal articles and studies have pointed out the trend for a while now and doctors still feel a lot of pressure from patients for it.”
Dryden called the trend the same one that's caused Caesarean sections to increase recently, “the idea that some patients want to get the baby out before something goes wrong.”
Ramirez said the authors didn't delve more into the overuse of labor induction because they saw the guidelines' purpose as educating physicians about the current state of knowledge given the procedure's frequency, but acknowledged it's “a valid point” that they could have used the occasion to come out more forcefully against the trend.
Ramirez said the authors didn't delve more into the overuse of labor induction because they saw the guidelines' purpose as educating physicians about the current state of knowledge given the procedure's frequency, but acknowledged it's “a valid point” that they could have used the occasion to come out more forcefully against the trend.
There is no one accepted number for the rate of inductions done for nonmedical reasons, but studies have put it from 15 percent to 55 percent of the total number.
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