Earlier today, a patient that I saw for an ultrasound asked me a peculiar question.  

“When am I going to have my baby?”  A review of her medical records revealed that she was 30 years old and pregnant for the first time.  Her estimated due date was in the second week of January.  She has had no medical problems and has had an uncomplicated prenatal course.

On one level, my answer to her question should have been pretty clear.  ”I don’t know when you are going to have your baby.  Your baby will arrive whenever it is ready to come…”  

If pressed, I could have responded with a little more definition, as in “Well, I doubt that you are going to have the baby within the next hour.  And I am very confident that you will not be pregnant on Valentines day…”

But of course that type of glib irony is not appreciated by most pregnant women.  Trust me.  I know.

After further questioning the patient I discovered her OB-GYN had told her that she was going to have her baby “about 2 weeks early”.  

Amazing.  I wonder if that OB-GYN could help me out with some lottery numbers…

One of the things that I have noticed during my years of practice has been the way in which increasing numbers of patients and doctors are unwilling to allow the natural birth process play itself out prior to the birth of a baby.  It is very common for patients and their doctors to plan an elective induction at a pre-arranged date not for medical reasons but because it fits their schedules.  

As a father of three boys, I can relate to the angst and anxiety that comes at the end of a pregnancy and the desire to “get the baby out” at a time is convenient.  There is also the nagging concern that something might happen to the baby “in there”; but that the baby will be safe when it is “outside”.  I understand the reasoning behind delivering early.

This would be fine if the process of labor induction was the same as the process of spontaneous labor.  But it is not.  When a mother undergoes induction of labor, there is always the chance that the induction process will fail and that a cesarean delivery will be necessary.  Indeed, a large part of the increased cesarean rate in the US is due to failed inductions of labor.  This is important because, although a cesarean is very common and very safe; it is not (and never will be) as safe as a vaginal delivery (statistically speaking).  

Furthermore, once a patient has had one cesarean delivery the prospects for a vaginal birth after cesarean (VBAC) are becoming vanishingly smaller since many physician (unfortunately in my opinion) do not offer a trial of labor for VBAC.  The risks of a previous cesarean are not limited to repeat cesarean deliveries either.  Patients who have had one cesarean are at risk for abnormal placement of the placenta (placenta previa), bleeding problems and surgical complications with future children.

The birth process is amazingly efficient.  I often tell patients that for 90% of pregnancies a high risk pregnancy specialist like myself is not necessary.  (Oops.  Should I be admitting that?).  But it’s true.  We provide high risk perinatal services to a large group of the uncomplicated pregnancies to catch that 10% because we have made the decision that it would be unacceptable to discount those babies.  However, it does not change the fact that for the most part, women with uncomplicated pregnancies tend to do better with less rather than more intervention.

So, my point for consideration today is this.  Certainly, there will be cases where there is a medical reason for an expedited early delivery.  But such cases are in the distinct minority.  Perhaps one of the best “low tech” ways we could improve health care outcomes for women in this country would be to allow babies to do what they have done for centuries.  Come when they are ready! 

This is a case where we as doctors and our patients should sit back and allow things to occur.  In the end, I suspect the outcome will be better for everyone involved.  

Posted via web from onyeije’s posterous