This relates to my older post about Preterm babies and my inquiry as to why they weren’t talking about sections.  ”There are increases across the board,” she (CDC epidemiologist Joyce A. Martin) said — in all age groups, for most race and ethnic groups and in all states. Overall, the rate of preterm births increased from 6.8 to 8.1 percent, according to the report. The percentage of induced late preterm births more than doubled between 1990 and 2006, from 7.5 to 17.3 percent, according to the report. The percentage of late preterm births delivered by cesarean rose by 46 percent, from 23.5 to 34.3 percent.

The report goes on to highlight the problems with preterm births, including the higher instance of respiratory problems and long-term neurological problems.  They mention how advances in monitoring and subsequent identification of ‘problems’ with babies (distress) are leading to these higher rates, but also the fact that technological advances have made health care providers more ‘comfortable’ with delivering preterm babies.

I guess doctors feel it’s better to avoid the lawsuit involved with knowingly letting a premature ‘distressed’ baby keep going through labor than to potentially deal with the consequences of the long term effects of premature birth. (Most likely they won’t be held accountable there, after all, they can prove that they did everything to get that baby out.) No studies that I know of are addressing the issue of premature induction-which is causing most of these c-sections.

If a baby is not full term, and the mother is induced, could it be possible that the baby will experienced undo stress simply because they are not ready to come out?  Even if a mother is supposedly full term, and an induction of labor results in fetal stress, should we not attempt to stop the labor and wait another week or so (providing that the baby is not showing signs of distress in absence of contractions).  Could it be possible that the dates are wrong?  In other words, could babies experience stress during labor simply because they are not full term?

In many other aspects of our lives, we all know that ‘staying the course’ is not the best practice when evidence shows that there is a better way to achieve the goal.  Why is it that doctors feel the need to keep going-seeing their only option as c-section?  Why not stop the induction and wait?  We have the technology to do that.

Dr. James is aiming to take a bit of the ‘intuition’ out of medicine and replace it with evidence-based practice and his successes have been impressive. However, with evidenced-based practice comes protocols- and many doctors enjoy the autonomy of acting without specific rules which is why many people think that his approach will never catch on. Too bad, because he really is on to something.

One part of the article talks about how Intermountain Hospital (where his projects are taking place) has reduced the number of perterm deliveries and the number of babies who spend time in their neonatal-intensive-care unit. They did this by creating a committee back in 1998 whose prime success has been to reduce the number of elective inductions (births that are induced without medical reason). They felt that the risks to neonates outweighed the convenience that elective induction afforded doctors and patients, plus induced labors were generally longer and resulted in more C-sections. Since 1999 ACOG has recommended that no elective inductions be performed before 39 weeks, yet around the country roughly 30% of inductions are done before 39 weeks. Back in 1998, Intermountain shared that figure of around 30% early inductions. When the committee adopted the protocol, the rate began to fall and now hovers around less than 2%. YAY! The number of newborns with respiratory problems has also dropped as did the C-section rate of those doctors that complied to the protocol.

This was my favorite part: “One hospital in southwest Utah has gone so far as to allow nurses to refuse a doctor’s early induction orders unless the medical director gives permission” (!)

As I was reading this article, it really made me pause and think about autonomy and protocols. I basically quit nursing because I felt I didn’t have any autonomy. Nursing school teaches you to think critically and independently, yet on the job we are expected to follow a doctor’s order with no questions asked. We are expected to adhere to a very clear set of standards and protocols for each duty we perform. The doctor on the other hand is trained to ‘follow intuition’ and is given license to treat in any way he or she sees fit, almost balking at rules or protocol irregardless of the evidence. It makes me think that if we could move to a model of evidence-based practice, doctors and nurses would be able to work more as a team, nurses would be able to hold doctors accountable for crappy practices and it might result in happier nurses. I would even argue that a move to evidence-based medicine could even help solve the nursing shortage. Most smart women these days don’t want to be nurses- mainly because it’s hard work in a thankless environment. But if a nurse could be an important part of a medical TEAM whose goal was to provide good outcomes for patients, then maybe more people would be attracted to the profession.