The 39 week rule has led to an increase in stillbirths

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The road to hell is paved with good intentions … such as the intention to prevent complications by banning inductions prior to 39 weeks of pregnancy, also known as the 39 week rule.

I’ve been writing about the 39 week rule for years. I’ve argued that:

Have we created a major disaster in an effort to fix a minor problem?

1. Given that we know that the stillbirth rate is higher at 39 weeks than at 37-38 weeks, implementation of the 39 week rule would increase term stillbirths.

2. The attempt to reduce perinatal morbidity from early term delivery is fatally misguided. Sometimes the only way that you can prevent perinatal death is to deliver a baby early, which will result in increased morbidity like transient breathing problems and brief admissions to the NICU. An effort to reduce morbidity from early term delivery will NECESSARILY result in an increase in stillbirths.

It appears that this is precisely what has happened.

Changes in the patterns and rates of term stillbirth in the USA following the adoption of the 39-week rule: a cause for concern? was presented at the recent annual meeting of the Society for Maternal-Fetal Medicine.

Between 2007 and 2013 in the USA, the implementation of the 39-week rule achieved its primary goal of reducing the proportion of term births occurring before the 39th week of gestation. During the same period the rate of USA term stillbirth increased significantly. Assuming 3.5 million term USA births per year, more than 300 more term stillbirths occurred in the USA in 2013 as compared to 2007. This study raises the possibility that the 39-week rule may be causing serious unintended harm. Additional studies measuring the possible impact of the implementation of the 39-week rule on major childbirth outcomes are urgently needed. Pressures to enforce the 39-week rule should be reconsidered pending the findings of such studies.

As lead author James Nicholson, MD commented to Medscape:

This study raises the possibility that the 39-week rule may be causing serious unintended harm.

Term stillbirth is clearly one of worst obstetrical outcomes, and it occurs with relatively high frequency — in one per 1000 deliveries that reach 37 weeks …

Unless or until high-quality research is published that proves that the 39-week rule does not increase term stillbirth rates, the forced imposition of the 39-week rule should be immediately reconsidered.

The authors presented an very impressive graph of stillbirth rates:

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This increase in stillbirths neatly matches the change in gestational age at delivery that occurred during the same time period; the proportion of births at 38 weeks steadily declined while the proportion of births at 39 weeks steadily increased.

The data presented by Dr. Nicholson and colleagues seems pretty damning. In an effort to reduce mild, transient complications in newborns, we’ve let nearly 300 babies die stillborn each year, exactly as critics of the 39 weeks rule such as myself predicted.

BUT there’s an extremely important caveat. Two critical pieces of data are missing and without them, it’s difficult to draw any conclusions at all.

What’s missing?

While the increase in the stillbirth rate between 2007-2013 is impressive, it doesn’t mean much unless we know that the trend in stillbirth rates was before 2007. If stillbirth rates were steady or dropping in the years prior to 2007, there would be a very strong case that the 39 week rule is the cause of the observed increase in stillbirths. But if the stillbirth rate were rising in the years prior to 2007, we would have to postulate a different reason for the increase in stillbirth.

The other critical information that’s missing is the perinatal mortality rate. If the 39 week rule is responsible for the increased stillbirth rate, the perinatal mortality rate should have risen, too. If it didn’t rise, we’d have to consider the possibility that the babies who were stillborn would have died anyway after they were born and that the 39 week rule has merely changed the timing of death, not the eventual outcome.

It’s difficult to find these missing pieces of data because the authors used a custom database to determine the term stillbirth rate and it may not be comparable to the rates published by the CDC for the same years. I left a question on the Medscape article asking if some of that data could be provided. Without it, it’s nearly impossible to determine whether the authors’ contentions are true.

If 300 babies a year are stillborn who would have lived in the absence of the 39 week rule, we have created a major disaster in an effort to fix a minor problem. But until we learn the overall trend of stillbirths prior to 2007 and the perinatal mortality rates from 2007-2013, there’s no way to know for sure.

  • Lee McCain MD

    One point me and my partners have argued to no avail is that if one looks at the actually numbers there is no statistical difference between 38-39 weeks in in the various benchmarks discussed. What Leapfrog and MOD have done is include 37-38 weeks in their numbers to change the overall outcome of their data. When I was a resident OB GYN twenty years ago our rule was “nothing good happens after 37 weeks”. I still wholeheartedly believe this today!

  • CanDoc

    The natural conclusion of this discussion is that all women should be offered elective delivery at 37-38 weeks to mitigate the small risk of stillbirth associated with ongoing pregnancy. Is this what you’re suggesting?

    • MaineJen

      No, I think it’s more like women with obvious risk factors should be delivered earlier than 39 weeks if they and their doctor deem it necessary. Also, women who present in labor at 37-38 weeks should not be turned away (or their labor stopped). You know…common sense things.

      • StephanieA

        Does anyone stop labor at 37-38 weeks? I have never seen that happen. (I’m genuinely curious).

        • Ceridwen

          I have a friend who went into labor with her second child at 37+3. She labored for 2 days, got an epidural, got to more than 6cm. Then labor stalled at 37+5 and her doctor would not do anything to augment. They would not give her any pit, would not break her water. She’d been having blood pressure issues for two weeks prior to that and had been sent for monitoring for potential pre-e multiple times. They pulled the epidural out and sent her home with narcotics to help her sleep through contractions happening every 10-15 minutes. She went another 10 days before the doctor agreed to induce at 39 weeks. Baby was born with a true knot and nuchal cord.

          Not quite as far as actively stopping labor, but still a pretty extreme example of how far this sort of thing is taken.

        • CanDoc

          I’ve never even heard of this, and I’ve been practicing for 15 years. The rule of thumb is no tocolytics (medications to stop labour) for sure after 36 weeks, but probably not after 34 weeks. Our center doesn’t use tocolytics after 34 weeks because there is no evidence of better perinatal outcomes.

        • nomofear

          There are many anecdotal cases in the comments on this site, including at least one death.

      • CanDoc

        I absolutely agree… but this post doesn’t clarify that. It simply points to increasing stillbirth with increasing gestation and seems to point to elective early delivery as a solution. Which I think is a slippery slope.
        (Although for the record, by the end of my career I expect that women will be routinely offered 39 week induction of labour.)

        • Ceridwen

          I hope that induction of labor does start to be routinely offered at 39 weeks, with appropriate informed consent. Sadly, I suspect it will be used by NCB fanatics to scream about how terrible doctors are for “pushing” induction on everyone.

          I don’t think I’d have selected induction at 39 weeks for my first, due to my unripe cervix, though I’m doubtful that it would have changed the outcome of my labor/birth given that I went into labor on my own with an unripe cervix and spent more than 40 hours in labor. I was definitely happy that my doctor was willing to induce me at 39+3 for my second though. My cervix was borderline but everything was textbook. Five and a half hours start to finish and a very healthy baby who was over a pound bigger than his sister despite being a week earlier. I was glad we didn’t wait longer.

    • fiftyfifty1

      I don’t see that as being a natural conclusion. We do know that 1 out of 1,000 who reach 37 weeks die of stillbirth. But would delivering all women at 37 weeks decrease the perinatal death rate, or would the deaths that are prevented be offset by other deaths (e.g. due to breathing problems)? This is the obvious question that needs to be answered.

      All we know is that right now, the current plan of tying doctors hands is resulting in more stillbirths.

      • Daleth

        The number for mono-di twins is 1 in 50 (that’s how many babies die if the mother’s pregnancy exceeds 38 weeks). So for women carrying mono-di twins, yes, they should all be offered elective delivery at 37 weeks, because the risk is not “small” at all.

        • CanDoc

          But that’s not who we’re talking about. We deliver all of our Monochorionic twins at 36 weeks, Di/Di twins at 37. Of course they’re high risk. But this data doesn’t clarify who is having the stillbirths. Are they high risk women who aren’t being delivered appropriately at 37-39 weeks,depending on the clinical situation? Or is it all women?

    • Anonymous

      What’s wrong with that? It’s her body. 37 weeks is pretty much full-term anyway, isn’t it? So, if she feels that that’s the right time to give birth, then why not?

      • Roadstergal

        Silly Nonymous. Women don’t need to be given Choices with all of those messy lists of Risks and Benefits. They just need to be told what to do in order to check off the next step on the Good Mom list.

      • CanDoc

        By your argument, “it’s her body”, then we should also be willing to electively deliver women and put their babies in the NICU to grow at 32 or 34 weeks because it’s “her body” if she feels that it’s “the right time” to give birth. Or 28 or 30 weeks. I’m asking the question about the point at which we go from practicing good medicine (i.e. recognizing that overall complications are lowest when low risk pregnancies are delivered at term, and high risk patients are delivered earlier), to the extreme (deliver every woman before she has a stillbirth.)
        I don’t know the answer, but I think the question is important.
        (To clarify, 37 weeks isn’t exactly just “pretty much full term”. The risk of severe life-threatening respiratory distress from a cold section (i.e. CS with no labour) is about 1:100 to 1:150 at 38-38+6 weeks gestation, so delivery should only happen then for good reasons (cholestasis, pre-eclampsia, IUGR, poorly controlled diabetes, etc).)

        • Grace Adieu

          What is the risk of severe life-threatening respiratory distress at 39 weeks?

        • Ceridwen

          I think this comes down to the question Amy asks near the end of the post. Under which situation is perinatal mortality higher? Ideally we would add a measure of morbidity in there too to try to assess which one results in more long term problems, not just assessing the difference in deaths. That research takes a lot longer and is more difficult to do though.

          Ultimately there does exist some tipping point, where mortality is going to be lower with delivery before X date (we used to think this was more like 41 weeks but increasingly research suggests it’s 39 weeks or earlier). And there will also be a range in which you are trading a small risk of death for a small (but somewhat higher) risk of some sort of morbidity. And then the challenge is to determine where within that range we consider it reasonable to just allow a woman and her doctor to make a choice which they prefer, and in what parts of it there needs to be more justification than just “this is what we prefer to do” due to the substantial differences between the risk profiles.

          Right now (via the 39 week rule) we are assuming that no reasonable mother or doctor would choose delivery before 39 weeks in the absence of an obvious medical reason. This type of research suggests there are potentially valid reasons some might choose elective delivery (or at the very least, delivery for soft indications) between 37 and 39 weeks.

        • rh1985

          Well, I would argue there are limited reasons besides physical conditions that might justify delivery at 32 or 34 weeks such as a serious maternal mental health condition that can no longer be managed while she remains pregnant. I also feel a 37-38 week delivery is ethically justified for extreme maternal discomfort (such as hyperemsis), especially since at 38 weeks the risk of death to the baby from delivery vs continuing the pregnancy is basically equal.

          Mostly, I don’t care for the 39 week rule because it interferes with the decision of the doctor and patient how best to mitigate the risks of that particular pregnancy. If a woman is 37-38 weeks and has symptoms that indicate a serious problem may be developing, but hasn’t yet, without the 39 week rule the doctor could offer the woman an earlier elective delivery to try and prevent the complications from ever happening in the first place. Now, his or her hands are tied and the doctor has to wait for something bad to happen before he or she can offer to just go ahead and deliver the baby.

          At around 37 1/2 weeks I had symptoms severe enough that my OB ran a whole lot of tests but nothing was abnormal enough on the tests. Seeing my misery – I was throwing up almost everything I ate for no apparent reason after having not thrown up at all past the first trimester, I had awful headaches, I just felt really unwell beyond the discomfort of being huge and pregnant, and I had already stopped a medication I really needed to prevent withdrawal symptoms at birth since I had no way to know when my baby would come – I was offered an elective CS at 39 weeks. There was zero chance my baby was younger than the due date because the due date was calculated based on IVF (LMP was swapped for 14 days before egg retrieval). I honestly feel I should have had the option to deliver at 38 weeks. Instead I ended up so sick my doctor decided my baby needed to be born in less than an hour because my blood pressure suddenly shot through the roof. I think it could have been avoided, my body was obviously done and so much vomiting when I didn’t have a virus or food poisoning or anything like that just wasn’t normal….

    • rh1985

      I would have loved to have had the option to deliver at 37-38 weeks. I think my body was obviously just done, which is probably why my OB offered an elective CS at 39w as an option. The due date was certain because I did IVF. In hindsight, I was so sick because I was developing pre-eclampsia. I didn’t have a bad outcome, but since pre-eclampsia may have certain health risks later in life, I would rather have avoided it altogether.

  • not so sunny

    It feels like this whole thing started after a rumor that some models and actresses were being induced at 37 weeks so they could avoid two weeks of weight gain. The rule has that flavor of preventing women from being “selfish” (i.e. being anything other than perpetually cheerful grateful walking incubators).

    • AA

      There also tends to be a thing about “I heard that X celebrity got a c-section and tummy tuck at the same time, and also had the c-section early to prevent stretch marks!”

      • Madtowngirl

        Because early c-sections totally prevent stretch marks.

        • guest

          Ha. I had no stretch marks before my induction was started at 36 weeks. All pushing and stretching of the c-section gave me stretch marks.

          • Megan

            Me too. No stretch marks until after my CS!

          • Dr Kitty

            Whether or not you get stretch marks is largely genetic.
            Sometimes stretch marks only become visually obvious on a flaccid postpartum belly, rather than a gravid one, even though they were created during the pregnancy.

          • Megan

            Great. Well, I can’t wait to see what my belly looks like in a few weeks. *rollseyes*

    • Busbus

      That is just another example for the national obsession with women’s/mother’s “selfishness” – it’s an argument that gets thrown around when it comes to c-sections, formula feeding, and, in the NCB crowd, even about epidurals. Ditto all the pregnancy food restrictions, where instead of looking at actual data, it’s all about “you wouldn’t want to risk your baby’s health just for cold cuts/coffee/an occasional sip of wine… (or are you that selfish!?)” Cultural misogyny at it’s finest…

      • Roadstergal

        Exactly. Lord forbid a woman should just want to stop being pregnant.

    • Elizabeth A

      I have heard that rumor and it actually makes sense to me – if your income stream depends on being thin, and on making a schedule set possibly years in advance, you take steps like scheduling an induction the moment you hit term.

      Everyone loves to shit all over models and actresses for every possible sign of shallowness or obsession with looks. Which is unpleasantly ironic, given that they get paid to be pretty.

      • Roadstergal

        Yes – it’s worthwhile to note that _they_ aren’t the ones who monetized their looks.

  • Jen

    With my third baby I had an elective induction at 38+3 – babies one and two born happy and healthy after spontaneous labours at 38+3 and 38 weeks. The difference with number three was that I had gestational diabetes and didn’t want to go past 39 weeks, and at 39 weeks it would have been my son’s birthday so an induction four days earlier ensured that she had her own birthday.

    I just wanted her safely in my arms and my Ob was more than happy to induce after 38 weeks.

    • demodocus

      I hear you about the birthday thing. We have 5 birthdays within 7 days of my current passenger’s due date. Not her brother, though, so it’s not as bad.

      • Mishimoo

        We managed to space ours out pretty well by accident – there’s about 3 months between most of the birthdays in our family (but two weeks between my husband and our son). The only problem is that our middle kiddo’s birthday is pretty close to Christmas.

    • Dr Kitty

      My sister was born two days before my birthday and died the day before it.
      Making sure your kids have their own birthdays is a very good idea.

  • The Computer Ate My Nym

    I think the 39 week rule is part of a general trend of misapplication of results of clinical trials in the name of “evidence based medicine”. Another example is the recommendation to give potassium sparing diuretics to people who have had heart attacks. It reduced further events and mortality–in clinical trials where people were carefully screened for renal failure and closely monitored for changes in potassium levels. Applying it to every patient with an MI, including those with renal insufficiency, especially without careful monitoring of potassium, led to an increase in fatal arrythmias. I like the idea of evidence based medicine, it certainly seems like a better idea than relying entirely on intuition, but it’s got to be based on good evidence in the right context. Which the blanket 39 week rule is not.

    • CrownedMedwife

      Upvote.
      ACOGs Committee Opinion on Medically Indicated Induction of Labor serves well to provide a framework to guide timing of delivery in many indications. However, it is a general recommendation and does not address every risk factor for adverse outcomes, thus intuition and evaluation of each woman and her individual risk factors needs to remain a key factor in the autonomy of providers. I don’t advocate for a flippant disregard of the 39 week rule, but if multiple soft indicators are present I’m unwilling to ignore my intuition to proceed with delivery in select circumstances. Being required to defend my actions in a peer review is relatively painless as compared to having a poor outcome as a result of blatant adherence to a 39 week rule. Both situations leave a mark on my statistics and arise at annual credentialing, but overlooking the opportunity to prevent an adverse outcome would be the only one to keep me awake at night.

      • Daleth

        You rule.

      • CanDoc

        Agree!
        When your spidey sense tingles, it would be foolish not to pay attention.

    • demodocus

      Context is always important. PBS just did a segment on their NewsHour that discussed some of the problems the poor in Baltimore have getting good health care. One element was just the difficulty in getting a hold of the meds you need, (and then there’s the understandable lack of trust)

    • the wingless one

      I feel like this HAS to be a part of it, mainly because I’ve seen my beloved (retired now) MFM mentioned as one of the doctors who led this initiative and he was always so insistent that there was no way they’d “let” me go past 39w – this was even during my preconception visits. When my son had to be delivered at 34w he was the one who made the call with zero hesitation and I know he routinely made the decision to deliver women before 39w (after all he was seeing only high risk pregnancies). He induced the friend of a friend who I referred to him before 39w too. I just can’t imagine him being like “39w no matter what” given my personal experience with him.

  • Shauna Ewing Libsack

    Dr. Amy – Dr. Nicholson is on the Medical Advisory Board of the Star Legacy Foundation and was just at our Annual Gala this past weekend. We had some very good discussions that I think you might like to hear straight from Dr. Nicholson himself. If you want to send me a note at info@starlegacyfoundation.org I will give you his contact information if you wish.

    In the meantime – here is another good blod that really tells the story on the history of this ‘rule’ https://stillbirthmatters.wordpress.com/?s=do+we+really++need+obs

    • BeatriceC

      From your link:

      “Most troubling is when the labor is stopped, the family is sent home, and they return in the following days or weeks to deliver a stillborn child. It appears that these pregnancies had reached the end of their ability to sustain the baby, yet we intervened for a rule that was created without adequate research or reasoning.”

      I can’t believe I’m saying this again. I really hate the tort culture in the US, but I’m gonna say it again. These are the families that need to sue the hospitals and insurance companies for everything they have. Maybe a class-action suit if there’s enough of them can go against the national organizations mentioned in the post. I don’t know, but one thing is clear: until it hits them in the wallet, they’re not going to change, and babies will die needlessly.

      • The Computer Ate My Nym

        Much as I agree about the lawsuit culture in the US (I’ve been threatened with a frivolous suit before), I find the argument “and if something goes wrong (when we implement this stupid cost cutting measure) how are we going to defend the decision in court?” a useful one in making administrators back off of really dumb decisions. By “dumb decisions” I mean things like ordering the kitchen worker with typhoid to come to work anyway. KITCHEN WORKER. TYPHOID AS IN “MARY”. Yeah, I don’t know either. I only know about that one because that particular workers union shop steward was my housemate and he asked me about the advisability of having someone with typhoid working in a hospital cafeteria. (He knew it was a bad idea, it was just so outrageous a suggestion that he felt the need to check and make sure he didn’t misunderstand.)

        Sorry. That was nearly 20 years ago but I still get ranty when I think about it.

        • BeatriceC

          It just burns me up that there are so many frivolous lawsuits choking up the courts and actually winning at times (and even if they lose wasting the time, energy and money of a lot of people), when there are real, legitimate issues of conscious decisions that cause actual harm that aren’t being litigated.

          I’m not a sue happy person. I threatened to sue once and only once. I’ve mentioned before that two of my boys have a genetic bone disease. One day he was helping unload 2.5 gallon jugs of pool chlorine off a truck and his arm went completely paralyzed. He dropped it and of course it shattered. Moving on instinct alone at that point, I picked up the garden hose that was a couple feet away, turned it on and aimed it at his face and eyes (he was complaining that the chlorine hit his eyes). I was thinking back to my university days in chemistry labs and trying to recreate a shower and eyewash at the same time as quickly as possible. In the meantime, rescue was called. They continued to flush his eyes on the scene and transported him to the children’s hospital. Neurology admitted him and proceeded to run a battery of tests to determine the cause of the sudden onset, temporary paralysis (motion and partial feeling had come back after a few minutes). There was a giant bone tumor that had partially severed a nerve. They called in Ortho. It was the opinion of Neuro that the nerve damage was caused by the tumor and could not be repaired until the tumor was removed. Ortho decided it was too dangerous as it was far to close to an artery and he could lose his arm and even his life. Neurology dug in and refused to discharge him until they could repair the nerve, which they couldn’t do with the tumor still there. After a 10 day stand off I’d had enough. Both the child and I were fully aware of the risks, and we’d decided that the best course of action was to remove the tumor. Did I mention this was his dominant arm? And that the tumor was growing rapidly (x-rays from only year prior showed that area had an extremely tiny tumor and this sucker was almost 10cm long at this point)? I called several other children’s hospitals and two of them reviewed his records and agreed to take him if I could get him there. So I made arrangements to meet a friend who’s a well-respected lawyer. We set up a meeting with the administration, ortho and neuro. The gist of the meeting was that they had three choices. They could do the surgery the next morning. They could arrange for transport to one of the other hospitals (both many states away) and pay for it, or this nicely prepared lawsuit would be filed when the courts opened the next day. They chose to operate. The procedure went well. This was several years ago. He recovered almost all nerve function (10% loss at this point) and still has occasional temporary paralysis issues. As it turns out, there’s also a spinal deformity that’s a contributing factor that hadn’t been diagnosed at the time. But still, on the day of the surgery, Ortho went first and removed the tumor. It had actually gotten so large it had cracked in half completely through the tumor itself and into the bone. Neuro then took over and repaired the nerve as best they could. It was partially severed. So even though that wasn’t the only reason, it was a factor.

          Sorry, I still get irritated about the whole situation. When it came time for me to move away from that area, I made my decision on where to go to based on children’s hospitals and their orthopedics departments. That situation and the doctors at those other two hospitals played a pivotal role in where I chose to go.

          • The Bofa on the Sofa

            It just burns me up that there are so many frivolous lawsuits choking up the courts and actually winning at times

            A lawsuit that is won is not frivolous. It is pretty much, by definition, a legitimate lawsuit.

        • demodocus

          Good lord! I’d get ranty too

  • StephanieA

    My friend just went through a stressful pregnancy; baby had IUGR, suspected mosaic placenta, and false positives on genetic testing. Baby was measuring in the 3rd percentile for ultrasounds, and she was having twice weekly NSTs. Doctors kept going back and forth in regards to when she should deliver, they ended up letting her go to 39 weeks and being induced. Baby is doing well, but I was anxious for her at the end. With an almost certain faulty placenta, I would’ve pushed for an earlier term delivery. I’m happy they are doing well considering.

    • Kelly

      That is ridiculous. They are starting to sound like the midwives where they wont do anything until it all hits the fan.

    • CanDoc

      Hmm. ACOG guidelines are pretty clear on this one about delivery at 38 weeks with suspected IUGR, sooner if there are other concerns (e.g. low fluid). Either doctors concerned about prolonging pregnancy or more to the story.

      • StephanieA

        She kept me very updated during the pregnancy, so I’m not sure if there’s something I’m missing. Initially doctors were thinking 36 weeks, then baby kept doing well on NSTs so delivery kept getting pushed back. She was seeing a MFM at the Cleveland clinic and her OB in a smaller town. There was definitely suspected IUGR, so I really don’t know why she was allowed to go to 39 weeks.

  • BeatriceC

    This is the sort of thing that happens when the bureaucrats take over. While the stakes in medicine are definitely higher, these are the exact same types of issues that teachers have been screaming about for years. While there were, and still are, critical problems in education, making unbendable rules and taking away the power of the teachers to cater their lessons to their individual students simply creates new problems. Many schools, particularly in the inner city have moved to scripted curriculums, where the teacher literally sits and reads, word for word from a script, with no room for student questions or alternate explanations. Failure to adhere to the script, even if it’s to help the student understand, is grounds for disciplinary action. This is one of the reasons I’m no longer a teacher. When they took away my ability to actually teach, I had no desire to go back.

    Now doctors are on the receiving end of the same kind of treatment and the consequences are no longer a bad education and higher chance of drugs, gangs, drop outs, etc. The consequences are life and death. It may be fatalistic of me, but I can’t help but think of the phrase that goes something like “first they came for the X, but I was not X, so I did nothing. Then they came for the Y, but I was not Y, so I did nothing. Next they came for me, but there was nobody left to help me.” The various powers that be have gone after teachers, not only at the k-12 level, but at the university level as well, choking our scientists. We’ve allowed these people to be painted as “public enemy” and not pushed back.

    Now they’re going after the doctors, not allowing their years of experience to dictate the best patient care. The bean counters have been doing it for years, but we’ve let it slide, little by little. When do we get angry and push back, not just with medicine, but education, scientific research, and any other area where the “powers that be” get to dictate what’s best for the patient/student/etc instead of the people who are in the trenches, taking care of those people.

    • Who?

      It’s the rise of the professional manager, and the accompanying catchcry ‘You can’t manage what you can’t measure’.

      I’m all for systems, love ’em, at their best they help manage risk, share knowledge and manage cost. At their best they are protective. However good, though, they are always a tool, not an end in themselves.

      Medicine is also struggling with everyone wanting individualised care, which is expensive. What is sold as available, and what is actually available at hospital or in a doctor’s rooms, won’t always be the same thing. Accountants have their part to play, and the tension between wanting people to know the great stuff that’s out there (or in private systems, selling ‘care’) and providing it at the lowest possible cost is felt all the time.

      • BeatriceC

        This might be the appropriate time to drop the blueberry story. Patients, like students, are individuals, not cogs in a factory. I think with a few tweaks, the analogy can be applied to medicine as well.

        http://www.jamievollmer.com/blueberries.html

        • ONE.SIZE.DOES.NOT.FIT.ALL, or, when will someone use their common sense?

          • Who?

            An accountant’s idea of what is common sense is different from other people’s. It is actually the antithesis of a caregiver’s concept of common sense.

            For now, accountants rule. And they leave frontline people to pick up the pieces,, citing productivity improvements and rationalisation as the how to. How often do you see an accountant risking professional sanctions after a decision of their’s has done harm to the core business of the organisation they work for?

          • BeatriceC

            Unfortunately, even by their own measure, they’re not using common sense. I see over and over (and in areas other than medicine as well) where short term savings lead to much higher long term expenditures. They look at one quarter or one year, but fail to address the domino effect many of the policies have, which actually increase their costs in the long run.

          • Who?

            They’ll be long gone by the time it comes home to roost. There is almost zero interest in longevity in many organisations, and many remuneration packages reward short term savings, with the result (unintended but inevitable) that the long term is off the table.

            I don’t find ‘common sense’ a helpful measure for anything-the people doing what you and I deplore are engaging in what is common sense from their perspective. Given that it is the ultimate subjective test (with a hint of judginess/patronisation thrown in) 10 people asked for a common sense solution will come up with several-maybe even more than 10-common sense outcomes.

          • Elizabeth A

            As an accountant, I object. It is my job, every day, basically all the time, to tell people what things cost. I don’t make management decisions, and I don’t even work in medicine. However, I and many other accounting professionals are really damn clear about what advice we can and cannot give. I can advise that a decision or an action will cost X, and I also often advise that not everything we do is about money. I am not above raising concerns about legal liability or utterly non-financial issues to get people to do the right thing.

            If I screw up badly and baldly enough, I can lose my license to practice. That’s pretty rare, though. Usually what happens to accountants who fuck up is that they get fired, and then they have a really hard time finding other jobs. Entire corporations have been taken down for financial malfeasance.

  • Laura

    I’ve heard of women with ICP who are victims of the 39-week rule. It’s disgusting.

    • Laura

      I never had a problem getting induced at 37 weeks with my cholestasis, for the record.

      • Kelly

        I just got induced at 37 weeks for it as well. My hospital had the 39 week rule too.

        • Laura

          My hospital had the 39-week rule too, but it appears it is only for non-medical inductions. Most women I know who have even been the slightest bit high risk had no problem getting delivered early.

          • Kelly

            It sound like that is the same for my hospital as well. It just worries me for some of my friends whose hospitals won’t induce or do a c-section until everything goes wrong.

          • Laura

            Ditto.

    • OttawaAlison

      I’m “fortunate” since I lost my girl at 37 weeks (something is itself that was opposite of fortunate), that they will consider an early C-section for me if I have another pregnancy.

  • Dr Kitty

    My first was born by elective CS at 39w exactly by LMP, but 38w2d based on my dates. My OB was happier to go with the earlier date rather than the later one.

    My second was born by elective CS at 39w exactly, after my OB basically had a fight on the phone with the person in charge of the theatre lists, who tried to insist that 39w4d was the earliest they could schedule an ERCS.

    I think his “She doesn’t want every opportunity to go into labour and have a VBAC! If she goes into labour it’ll be an emergency CS and that’ll mess with the theatre lists even more, so just schedule it for when I say!” was telling.

    Trading TTN for late stillbirth is not a winner.
    I wonder if babies with poor placental function are less able to tolerate later inductions, leading to more intrapartum distress and higher rates of associated morbidity than would have been the case if they had been subjected to labour a week or two earlier, but that would be much harder to prove.

    Anyway, I think the UK is beginning to realise that “less intervention and more births at home and in MLU” and “halving the rate of stillbirth” might be mutually exclusive goals.

    • fiftyfifty1

      “Anyway, I think the UK is beginning to realise that “less intervention and more births at home and in MLU” and “halving the rate of stillbirth” might be mutually exclusive goals.”

      Have there been explicit conversations to that effect?

      • yugaya

        Yes – RCOG has special surveillance program called “Each Baby Counts” on top of the national MBRRACE ones:

        “Key findings for the provision of antenatal care

        At least one element of the antenatal care for half of all term, singleton, normally formed, antepartum stillbirths included in the enquiry was identified as requiring improvement.

        There was evidence of a failure to identify risk factors for gestational diabetes and to refer women for testing as per the NICE Guideline on Diabetes in Pregnancy.

        There was evidence of a failure to monitor fetal growth in line with NICE guidance, either by not taking symphysis fundal height measurements, not plotting the measurements on a chart or not responding when growth was abnormal

        There was evidence of a failure to respond appropriately to attendance and repeat attendance by women with reduced fetal movements; either a lack of investigation, misinterpretation of the fetal heart trace or a failure to respond appropriately to additional risk factors.” https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202015.pdf

        • AA

          Wow, that is sad. The NICE guidelines for GD are quite clear. What % of these antepartum stillbirths were because of inadequate referral for testing? That is preventable!

          • yugaya

            Blame for those preventable deaths is on RMC – midwife is the antenatal care provider who is supposed to accurately identify and record risk factors and recommend GD testing as well as monitor the pregnancy.

          • Dr Kitty

            Yup.
            Every SINGLE time MBRRACE identifies that stillbirths could be prevented if the existing guidelines for identifying risks during pregnancy and labour were followed AND if transfers to obstetrician led care is made at the first sign of such risk. With CLUs having 24:7 on site consultant cover as an ideal.

            There is only so long RMC can keep using “midwives are too stretched to provide basic antenatal care like urinalysis and SFH, so these deaths aren’t really our fault ” while simultaneously insisting that they are perfectly placed to be lead professionals for normal pregnancy and best placed to deliver any and all public health initiatives from promoting Breast feeding, PPD diagnosis, SIDS prevention and home safety.
            Multi-tasking appears not to be their strong suit.

            It is no accident that Scotland has reduced their still birth rate much more quickly than England. For logistical reasons, home births in Scotland are rarer and when women do deliver in hospitals they are more likely to be large units with 24hr consultant cover.

  • Jules B

    I was induced at 38 weeks because my blood pressure was slowly but surely going up, and my daughter had a heart rate decel during a NST in response to a Braxton hicks contraction. I had been having trouble doing kick counts, as well, because of an anterior placenta, so it was really hard for me to tell wtf was going on with baby in there (and thus I had a lot of anxiety as well). All that together led to my OB wanting to induce, but she got some push back from the hospital (this was in 2012 in Canada). She won the argument, though, and I think it was a good thing too because they found a knot in the cord post-delivery that they said was pretty tight and was likely causing the decel issues (during the NST and labour). She ended up being fine but I do occasionally wonder what might have happened if I had not been induced/gone past 38 weeks? (Impossible to know, I know, but I am glad I was induced earlier rather than later).

  • AirPlant

    I am not generally the type to play doctor as god, but these hospital policies can be just so bewildering at times. I don’t think there are very many doctors who go to work seeking bad outcomes, and doctors are (for the most part) highly trained, intelligent individuals who have a vested interest in their patients not dying and having the hospital handicap their decisions seems like a special kind of lunacy. Its right up there with my insurance company deciding which asthma inhaler that I get to use.

    • BeatriceC

      You’d think they’d figure out that hog-tying doctors actually increases their costs. Using me as Exhibit A:

      I have an extremely severe allergy to tomatoes. My insurance will only pay for three epi-pens per year. Not three prescriptions, three pens. Of course they come in two packs, effectively limiting me to two pens per year. It takes two doses of epi to keep me breathing long enough after an ingestion reaction to even get rescue crews to me. Basically they’re saying that I can somehow control things so that I only have one reaction a year. Try that with an allergy bad enough that skin contact causes anaphylaxis.

      In the previous 12 months I’ve had 4 reactions, 3 of which requiring hospitalization because I didn’t have quick enough access to rescue drugs. I do everything in my power to avoid it, but it’s so severe that if my kid is eating doritos and doesn’t wash his hands, then touches me, I’m going to have problems (No doritos in the house, but they eat them at school sometimes). In an attempt to save my life long term, I use one pen and wait for rescue, even though it means I’m probably not going to be breathing anymore by the time they get there. It would have been far cheaper to buy me 100 epi pens than have to pay for even one of those hospitalizations, let alone three.

      • toni

        How much are epi-pens out of pocket?

        • BeatriceC

          Depending on where you live, between $350-$420 for a two pack.

      • The Computer Ate My Nym

        That is wrong on so many levels. I can’t imagine who thought restricting the number of epipens someone could get was a good idea. Do epipens have a high street value? Are people likely to use them frivolously? Are they fun at parties? What possible advantage is there to limiting epipen use (to 3 per year–good god, even without the 2 pack problem that’s a ridiculously small number)? I just don’t get this even as a cost saving measure. Even if you assume, as seems likely, that the insurance company has no interest in your health, aren’t they interested in protecting their bottom line by limiting the number of times you end up in the hospital?

        • BeatriceC

          Most of the time, if you need to use the epi, you’re at least going to have an ER visit, but the cost of an ER visit is still lower than a hospital stay with or without ICU.

          I don’t think epi-pens are used as street drugs. I could be wrong, but I’ve never hears of that. I suppose I could see people abusing them in sports situations, but the benefits would be extremely limited in duration and the cost very high.

      • Charybdis

        The evil insurance people limited my migraine drugs to something like 9 every 3 months. Thankfully, my doctor would load me up with samples, so I didn’t have to rely on just the prescription meds. When reps started limiting their samples they would provide, he stopped giving me samples. Mainly because he has a lot of older patients, some of who have migraines, and with their limited incomes, they needed the samples more. Which I totally get and have no problems with, other than someone who is NOT an MD is making medication choices for me, not my actual MD.

        After we got my migraines under some semblance of control (they used to be 4-day ordeals every time I had one and for awhile I would have one, maybe two days migraine free before I got another one), I asked if I could stop with the triptans, as they had really stopped working for me and I started having side effects to them.

        So now I’m on a preventative regimen and staying away from triggers as much as I can (flashing, flickering lights, aspartame, sucralose and major weather fronts) and taking my rescue meds as needed. Thankfully, my migraines are now shorter (2 days) and the length of time between them has lengthened. But I think the limit on triptans is still in effect, which is INSANE. As is a lot of the hoops I have to jump through to get my rescue meds.

      • AirPlant

        I am still trying to figure out how a daily or rescue inhaler is not considered preventative care. It is preventing me from having an asthma attack. How is this complicated?

        • Angharad

          The burreaucracy is astonishing. Before the ACA my insurance company once tried to refuse to cover birth control because it was for a pre existing condition (I guess technically I was already not pregnant and was trying to stay that way…) Fortunately I got a decent customer service rep when I called them and they were able to fix it for me, but still.

          • BeatriceC

            *blinkblinkblink* Just when I’d thought I’d heard it all…

          • AirPlant

            what in the hell? Fertility is a preexisting condition?

          • Charybdis

            I also hate the fact that my insurance insists that ALL maintenance meds must be supplied by mail order, in 90 day supplies. I refuse to do that and have a decent workaround, but it is just one more example of how non-medical people can dictate every facet of healthcare.

      • AA

        BeatriceC–would you be willing to email me or message me somehow? Can’t do it directly through Disqus. I’d be willing to provide a throwaway Reddit account or email address.

        • BeatriceC

          Beatrice is not my real name. It’s an alter-ego named after a 16th century Italian woman named Beatrice Cenci. If you smoosh her first and last names together, I have my own burner account at outlook. 🙂

          • AA

            OK, I gave it a go, hopefully I figured out your clue!

  • Inmara

    I happened to have my last prenatal check-up in the day before delivery (I suspected that contractions may have started but was not sure of it, and I’ve heard enough about false labors when contractions start but then stop again). Knowing that my due date is quite reliable (cycle is regular, conception date plausible, ultrasound datings were only 2-3 days off EDD) I asked what to do if I don’t deliver in following days and what are my options for induction. My gynecologist brushed it off and said that it’s better to not interfere and that induction will be discussed only if I go over 41 weeks (apparently, these are guidelines for low risk pregnancies, or it was an opinion of my doctor – haven’t been able to find any official guidelines but skimming through google search results regarding labor induction was a painful encounter with woo). Labor started in the same evening and I delivered next day (so I’m one of not-that-common examples of actually delivering in EDD). The thing is, baby was completely “ready” and with some signs of postmaturity (peeling skin, lack of vernix). So what would happen if labor didn’t start itself and I would have to wait until 41+ weeks? Somehow I doubt that I would had an induction based on my belief in scientific studies (which were discussed here and showed that inductions before 40 weeks show better outcomes than late inductions) because, you know, every intervention has risks (but going overdue doesn’t?)

    • Megan

      That’s another good point. My daughter was born at 37+4 and was already 7lbs 6oz with great head/neck control and peeling skin/no vernix. I knew her EDD from charting and knew my date of conception. Every baby is different. Isn’t it the NCB advocates themselves always going on and on about how babies aren’t library books? If some babies come late, there will inevitably be some who come early (it in your case, right “on time”).

      • StephanieA

        Interesting. My first came at 38+4, was 7lbs9oz and was holding his head up. Second baby came at 39+6 and was 8lbs5oz. I always wonder why some babies come earlier than others, it’s something that’s always interested me. I read a study done on mice about the possibility that the baby’s lungs ‘signal’ that they are mature and may be a trigger for labor (surfactant protein I think?)

        • Kelly

          Mine came at 37, 38, and 39+0. I guess I just make my babies quicker. They have all been pretty small except for the 37 weeker. She was a pound heavier than her sisters.

      • rh1985

        My daughter was born at 39w exactly – emergency c-section for preeclampsia. I was not in labor and had been scheduled (before I got sick) to have an elective CS the following day. My daughter basically seemed perfectly “cooked” – not much vernix left, but she didn’t have peeling skin and she was an average size. No breathing or feeding issues. Honestly she probably could have been born a few days earlier, been fine, and I would have avoided pre-e. But I had to schedule the CS at 39w because of the rule. She’s an IVF baby so dates were exact, but that didn’t matter.

    • StephanieA

      My doctor said she would be happy to induce me at 40 weeks if I wanted. I didn’t need it (baby came at 39+6) but I was happy to have the option. I don’t like how 41+ weekers often look on the monitors.

    • Suzi Screendoor

      I’m pretty happy with the practice in my area, which is to schedule the induction for 41 weeks if the mom reaches her due date without popping. This allows a bit of a window for getting bumped and/or failed attempts at induction before the (average) mother reaches 42 weeks and the risks start going up. My doctor scheduled mine for 39+6, but I got bumped the first day and was induced at 41 weeks, had the baby at 41+1. She was certainly a bit overcooked… no vernix, peely skin, pretty big, etc.

  • Sandhya Subramanian

    Sorry, I know I’m being dense. Can someone please explain this paragraph?

    The other critical information that’s missing is the perinatal mortality
    rate. If the 39 week rule is responsible for the increased stillbirth
    rate, the perinatal mortality rate should have risen, too. If it didn’t
    rise, we’d have to consider the possibility that the babies who were
    stillborn would have died anyway after they were born and that the 39
    week rule has merely changed the timing of death, not the eventual
    outcome.

    • attitude devant

      Some perinatal deaths are due to anomalies incompatible with life.

    • If 300 babies died after having their birth delayed until after 39 weeks because of the delay, then prior years’ numbers would show approximately 300 fewer deaths nationwide at the time of birth.

      If the deaths were all preventable, the numbers would show it.

    • Anne

      Perinatal mortality rate = stillbirth rate plus early neonatal mortality rate.
      Maybe the increase represents moving the death from neonatal to intrauterine by delaying the birth.

  • CSN0116

    (I would argue) Nowhere is the detriment of the 39-week rule more obvious than the timing of delivery of uncomplicated mo/di twins. This is a population to which I have dedicated the majority of my research, including my dissertation.

    We have seen provider reluctance for a 36+6/37+0 delivery – which study after study, outside of the 39 week rule, proves is the safest timing – and a subsequent dramatic rise in stillbirths at the 38 to 39 week range. It is homicidal, quite frankly.

    But for may of the patients, they are told by their OBs that the hospitals will not allow an earlier delivery, despite evidence to the contrary. I find this appalling. I have personally seen about five late term still births in the last few months, where ultrasound and NST just days prior were A-OK, but gestation just ran too late. Given that only about 0.3% pregnancies are mo/di, and I only come into contact with a mere fraction of the population, this is an astounding number.

    I despise the 39 week rule >:-o

    • Amy M

      I have mo/di twins, and my OB had to “schedule” a Csection at 39 weeks. At the point she did that, I’d already had several episodes of pre-term labor, and I asked if she thought the babies would even wait that long. She said “No way” and she was basically counting on labor spontaneously beginning early. (After 34wks they wouldn’t even try to stop labor). As it happened, they came at 36wks, but I don’t know what the OB would have done if they went to term. Maybe looked for some reason to section? She was pretty conservative.

      • CSN0116

        Oh, my. My mo/di twins were born at 36+0 via scheduled cesarean. I had zero labor and no signs of it anytime soon. My OB is a fucking rock star though. He told me I could pick 36+0 to 36+6 and nothing beyond. He also insisted cesarean, which I didn’t like but trusted (and still trust). This was 2009 also.

        I have seen so many 39 week stillborn mo/di’s in the five or so years I’ve been conducting researching 🙁

      • Old Lady

        I had a scheduled c-section at 38 weeks for fraternal, the longest my OB wanted to wait and I agreed with her on that after reading about it. Twin A never turned head down though so it’s better that I didn’t go into labor…I can’t imagine she would have had me wait that long if I was was threatening labor. I wasn’t even aware of the 39 week rule and I gave birth in that time frame.

    • StephanieA

      Not to mention that carrying twins to 38/39 weeks just seems awful for the mother.

      • guest

        That depends on the mother. I had a twin pregnancy that really wasn’t uncomfortable for me. I did have complications requiring intervention and was grateful for them, but I was just big enough and the babies small enough that the day-to-day wasn’t anything special to complain about.

        • StephanieA

          You’re right, I shouldn’t generalize. I guess I’m just thinking how awful I felt at the end of my singleton pregnancies.

          • guest

            I wonder how much of this 39 week policy is motivated by the idea that uncomfortable moms will be requesting inductions earlier for relief. It’s incredibly patronizing if that’s a factor. And yet, maternal discomfort shouldn’t be ignored, either.

          • Happymom

            My mo/di twins were born at 36&6 and were 6lbs8oz and 7lbs13oz. It was miserable from about 31 weeks on. I have had singletons too. But it was completely miserable. I was taking Tylenol and Advil around the clock, was waking several times per night, it hurt to live.

    • Daleth

      Wait, wait, there are hospitals in the USA that apply the 39-week rule to mo/di twins!??!!?! WTF?! ACOG specifically says that mo/di twins should be delivered between 34w0 and 37w7! And even earlier (32w0) if there is “isolated fetal growth restriction.”

      http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Medically-Indicated-Late-Preterm-and-Early-Term-Deliveries

      The 39-week rule is for SINGLETONS. It’s not for any kind of twins, and especially not mo/di or mo/mo. The parents of those five stillbirths should sue your hospital NOW.

      I had mo/di twins and in the absence of any complications my hospital wouldn’t schedule a c-section until 37w0. Even waiting THAT long terrified me. I ended up getting preeclampsia right before that and having an emergency cs.

      • The Bofa on the Sofa

        Yeah, I was going to say something similar. The 39 week rule certainly does not apply to twins.

        • Charybdis

          But the bean counters and policy makers apparently are not interested in nuance or shades of gray. Or any variation in people.

      • CSN0116

        Yeah, well that’s not well understood in practice. I have sent women with 15+ print outs of the latest studies, coupled with the ACOG guidelines (which, frankly, 37 6/7 is far too long – the placentas look like shit), and their OBs tell them time and time again that the hospital will not permit it, but “don’t worry, you probably won’t make it that far anyway.” Well, some do. I see “frequent” increased spontaneous demise from 38 weeks on. There needs to be soooo much more research done on twin anemia-polycythemia sequence (TAPS) and ACOG needs to modify it’s 37 7/6 like yesterday.

        A dear friend was just forced to carry her di/di twins to 40+2. Her OB thought it was grand that she made it that far and shot down her every plea to start labor sooner. Her natural labor ended in a CS anyway. They were a measly 4.5 lbs a piece and probably stopped growing weeks prior. Don’t even get me started :/

        • CrownedMedwife

          In what universe does that meet a perceived standard of care? Reckless. Grateful her babies are ok, despite the gamble her provider took with their well-being all for the sake of achieving a gestational age.

        • Daleth

          If my OBs had said that (or rather my MFMs–that’s who oversees mono-di pregnancies at my hospital), I would have hotfooted it to the patient advocate and, if necessary, hired a lawyer. Where do they get off ignoring ACOG guidelines?!

    • rh1985

      The parents need to sue. Hospitals will change the policy quick if it hurts their wallets.

      • Who?

        Insurers will require them to change their policy, is the disturbing reality.

    • CanDoc

      The “39-week-rule” isn’t the problem here…. some kind of a brutal misapplication of the rule is the problem. I’ve never even heard of mono-dis being allowed to go past 37 weeks, in our centre we do them at 36.

  • Erin

    This issue resonates with me. I’m 32.1 weeks pregnant right now and my previous pregnancy ended in a stillbirth at 34 weeks due to severe preeclampsia and HELLP syndrome. The presentation of these complications was atypical, asymptomatic, and acute, so I am very anxious to get this baby out of me, alive, ASAP. I certainly don’t trust my body and birth at this point. Barring any developing issues, I cannot be induced sooner than 39 weeks. As someone who experienced a lightning strike out of nowhere, without warning, I would prefer to have my son born sooner rather than later.

    • DiomedesV

      What a terrible experience, I am so sorry. Please voice your fears to your caregivers. Perhaps you can come up with a way, together, to get you an early induction. At the least, you should be monitored aggressively for similar presentation during this pregnancy.

      Best wishes for the safe arrival of your little one.

      • Erin

        Thank you.

        Unfortunately, I have voiced, and voiced, and stressed my concerns, anxieties, and desire for earlier term induction to my OB. Her response is still along the lines of, “Yes, you had this very severe complication, but the way it presented itself is extremely rare and not likely to happen again. So, we feel, rigorous monitoring for earlier detection of developing problems is appropriate at this time. Should you develop any problems, we are referring you out to the level 3 NICU hospital in the area for immediate delivery. Until then, the plan is to keep going along with additional antenatal testing until 39 weeks, and then we will induce you.”

        This was the plan laid out by the MFM specialist.

        So basically, what happened to me will probably not happen again, so until then, nothing is wrong until it’s actually wrong…

        That is what I’m getting.

        • Who?

          I’m so sorry, that all sounds terrible. While it sounds logical, it doesn’t take into account your understandable anxiety and concerns.

          All crossed everything goes well.

        • Gatita

          FYI, I switched OBs at 28 weeks because I was so unhappy with my care and I’m very glad I did. The rest of my pregnancy went much more smoothly. I don’t know what the situation is like in your city for MFM specialists but if you can find someone else I’d consider switching.

          • BeatriceC

            Erin said she had Tricare, which gives her pretty limited options.

          • Gatita

            Ugh. That’s so depressing.

        • Gatita

          Can you write a letter to the hospital CEO and the head of risk management outlining your concerns? I’m sure folks here would help you compose something. If you are able to make your case dispassionately but being clear your fears that waiting could result in your baby’s death, you may be able to get the hospital to accommodate you or transfer your care now.

        • meglo91

          Also consider contacting the hospital’s patient advocate. All military hospitals have one. They can sometimes help.

        • DiomedesV

          Is this in the US?

          This is so different from my experience. Honestly, at this point, in your shoes, I might seek the opinion of a psychiatrist, and make the argument that an early induction or MRCS is a matter of mental health.

          I too have heard the “this is an extremely rare complication and not likely to happen again” line. It’s meant to be comforting, but as a scientist, it rings hollow. Priors matter.

    • demodocus

      Good luck for you, your partner, and your boy.

    • Guest OB

      Your h/o stillbirth in third trimester is enough to warrant an earlier delivery. That is one exception to the 39wk rule. Your OB can deliver at 37-38 wks.

      • Erin

        According to the hospital policy, she feels her hands are tied until I exhibit complications (which was already too late last time), in which case, she’s referring me out to Sacred Heart with the level 3 NICU in my area for early delivery, because I would be beyond their facility’s capacity. The hospital feels, in the absence of any signs and symptoms, that closely monitoring me is sufficient enough care because they believe so firmly in this 39 week rule without some documented indication–ie, growth retardation, oligo, nonreactive NSTs, etc.. I should probably disclose I am a military spouse with Tricare Prime and as such, as little intervention as possible is their business model (it’s cheaper that way). If I wanted to go civilian care without a referral (which they denied me), I have to pay out of pocket, unless it’s deemed a medical emergency, and financially, my husband and I can’t manage 100% of the cost. So, the military hospital philosophy is “We’re just gonna watch you closely, but act like nothing is wrong until it actually is wrong.”

        • Inmara

          Do they offer you to stay in hospital for last weeks for continuous monitoring? Because with your history nothing less would do for “watching closely”.
          I’m so sorry you have to deal with this. It’s frustrating to no end that such policies and lack of feasible alternatives endanger lives.

        • Megan

          That is absolutely shitty.

        • somethingobscure

          If I were you I would switch hospitals. Sounds downright irresponsible of them to force you to wait till 39 weeks given your medical history!

        • militaryspouse

          You should have gone on Standard. The military facilities here suck, so I went on Standard to get seen by civilians. My idiot military doctor refused to refer me out and my condition almost killed me. My co-pays can’t exceed $1000 in a calendar year, after that everything is paid 100%. And prenatal is free even under Standard.

          But I know women on Prime who have gotten them in gear with things. You need to contact TriCare, have your doctor contact TriCare, and be very very pushy. Daily calls will get them in gear, I promise you.

        • meglo91

          Ah. I understand now. I was active duty for 5 years and am still a reservist, though I am happily ensconced in the civilian system. I had my last 2 kids in a military hospital, and with the first one they let me go to 40+5, no BP meds, no induction, even though I had blood pressure readings in the 170s/110s. The night I went into labor I took my blood pressure at home and got a reading of 190/120 or thereabouts. I called L&D and they said I must be doing it wrong. With the second they induced early. No clue why the difference in care.
          Can you switch to Standard? And if not, can you maybe try to game the system? Tell your OB you’re experiencing limb swelling. Tell her you’re getting visual disturbances and bad headaches. Those symptoms, combined with your history, may be enough to put you over the top.
          I feel slightly bad, but not very bad, about advising you to lie. In my former job in the military, I saw some things that made me feel less than confident in the military healthcare system, quite apart from my own experience as a patient. Do what you must to get the care you need.

    • Megan

      I’m so sorry for your loss. I hope your doc is able to get you the early term delivery you want and deserve this time around.

    • Bugsy

      Hugs and best wishes, Erin.

    • Montserrat Blanco

      Erin, I hope you have a smooth end of the pregnancy, a safe delivery/CS and get a healthy baby. Receive my very best wishes and hopes for that.

      I know it is terrifying. I decided to never ever under no circumstance get pregnant again after HELLP.

    • Ob in OZ

      I will start by saying I am an unapologetic patient advocate first and foremost. Without knowing more, watchful waiting is appropriate at this stage. How intense you should be watched is debatable, I try to get to 39 weeks if all truly went perfectly, but that would include a patient who was doing well physically and emotionally. Anything slightly concerning would change that plan. Keep informing the doctors of your concerns, ask for more and more surveillance as you get to 34-35 weeks and I expect you’ll be informing us of a happy compromise prior to 39 weeks. I’ll say a little prayer as well. Good luck.

    • meglo91

      Jesus. I’m 31 weeks with my third. With my previous two pregnancies I had severe PIH, and with the last I was induced at 38 weeks due to preeclampsia. My OB has already consulted with an MFM who recommends delivery NO LATER than 39 weeks, and possibly at 37-38 weeks if BP issues arise, and I’m sure they will as my readings have already edged into the “above normal for me” territory. If I said I wanted to be induced at 37 or 38 weeks, I know she’d be OK with it. Can you maybe find a new OB? I’d think that, just in terms of managing your anxiety, you could find someone who’d induce you at 37 weeks.

  • Megan

    The other glaring problem with this is that dating is not an exact science. Someone could easily be off on their dates by a few weeks by LMP and even an early dating US can be off by up to 3-5 days. These policies assume that we know exactly when a mom is due down to the day. 38w6d is not OK but 39 weeks is??

    • Bugsy

      That’s a great point. I was scheduled to be induced with #2 on my due date by my request. I was petrified of having a late term stillbirth, which was part of the reason my OB was willing to induce. That being said, I firmly believe she agreed to a due date induction because, being an IVF pregnancy, we knew the date of conception down to the minute. With a wonky menstrual cycle myself, I never would have had the faintest idea of the conception date if my boys were conceived without assistance.

    • Kelly

      Yes! I just wanted to be induced a few days before 39 weeks so that I would not have a precipitous home birth with two young children with me. My doctor was willing to induce me earlier than 39 weeks if I could basically find a medical complaint to give her. Thankfully, I ended up with a condition that got me induced at 37 weeks. I really think they need to give their doctors the benefit of making the best decision based on the many factors of a patient’s history.

  • PrimaryCareDoc

    Very interesting. I appreciate your nuanced look at this! Here’s hoping that we get more data.

  • Megan

    This is exactly what I was posting about the other day. Our hospital was just bought by a larger health system that employs the 39 week rule and has now implemented it for our hospital. As a mom with a history of gestational hypertension and oligohydramnios, I am terrified my numbers will be bad enough to increase risk to my baby but not “bad enough” to meet criteria for early term RCS should I need it. Plus, my last delivery was a CS and there’s this study that shows moms with previous CS actually do better with early term deliveries:
    http://www.medscape.com/viewarticle/820391

  • CodeWench

    I’m a layperson, so I’m little unclear on how this rule is being implemented. Is it that the doctors are picking up on something questionable during weeks 37 and 38 that in the past would have caused them to induce immediately but because of this rule, they are ignoring it and waiting until 39 weeks?

    • Megan

      It’s supposed to mean that elective (planned) deliveries (CS or inductions) aren’t scheduled until after 39 weeks and there are supposed to be exceptions for medical indications. Problem is, often hospitals have criteria for what is an “acceptable” reason and doctors face losing hospital privileges if they don’t follow them. There is required paperwork to be done in order to get these scheduled deliveries approved. The real issue becomes when you have a mom with multiple “soft” indications for delivery or a mom or a problem that in the doctor’s judgment may lead to issues but doesn’t neatly fit those criteria. There have also been instances in which moms have been sent home in labor before 39 weeks or have received tocolytics when in labor before 39 weeks because the rule has been incorrectly applied.

      • Megan

        Sorry, that should say:
        “or a mom with a problem that in the doctor’s judgment may lead to issues”

      • CodeWench

        OK, gotcha. So that would also include deliveries where a doctor scheduled a repeat c-section at 38 weeks just to make sure mom didn’t go into labor and risk an abruption or something and it just so happens that some percentage of those labors would have resulted in a stillborn baby if the pregnancy had continued.

        • Megan

          Right. Or a hypothetical example using myself, if I were to continue with labile blood pressures that are bad at work but not as bad at home, and fine at my doctor’s visits that results in low fluid levels that are abnormal but don’t meet the threshold for early term delivery (I’ve seen some places require AFI<6 in order to schedule early term induction). I am still at higher risk for abruption and stillbirth but may not technically meet their criteria for scheduling a delivery at 37 or 38 weeks.

          • attitude devant

            Requiring a particular AFI to schedule early delivery is crazy. AFI is just a symptom, placental insufficiency is the disease—the baby isn’t peeing because the kidneys aren’t being perfused well. Treat the disease, not the symptom.

      • MaineJen

        LOL…the trick is to go in with your water broken, like I did both times. My son was born at 38+3 and required induction, my daughter at 37+1 and labor was already going. Hospitals don’t let you sit with water broken, they will induce you at that point if you are at “term.”

        But I guess babies only “know when to be born” after 39 weeks, huh? Ludicrous that there is a hard and fast rule that doesn’t allow for common sense exceptions.

    • attitude devant

      Your name is surprisingly apt, vis a vis your question. At most hospitals there is a list of diagnosis codes that are used to determine whether an early delivery is acceptable. The codes are surprisingly strict in definition, in that I may see fetal growth slowing and amniotic fluid indices falling and ascertain (correctly) that the placenta is failing but the codes can’t be applied before the fluid is a certain level or the growth lag reaches a certain low percentage point. Problem is, the kid can be in trouble earlier than those codes allow. Another problem is that the codes chosen make no allowance for maternal non-obstetric diseases. They assume all pregnant women are healthy. Recently we had a mom with bad gall bladder disease, in the hospital on morphine. We delivered at 37 weeks after an amnio showed lung maturity, for maternal benefit…..and got dinged because cholecystitis is not an acceptable code for early delivery.

      • Who?

        This is the problem with rigid rules-they end up actually applying to almost no one while limiting capacity to do what is needed.

        What does getting dinged entail? I hope it’s less (bureaucratic) misery and paperwork than a dead/sick mum/baby.

        • attitude devant

          We got a sanctimonious letter from the Chief Medical Officer for the hospital corporation and a ‘non-compliant with hospital policy’ comment on our stats. (insert Bronx cheer here)

          • Who?

            Well that sounds just terrible 😉

            I love a good system, but yours lost me at ‘They assume all pregnant women are healthy’. Quite an assumption when everyone is getting older and fatter.

          • Chi

            It is a really bad assumption too when pregnancy itself can cause a NUMBER of health issues in the mother.

            I was lucky, I got off lightly with hemorrhoids the had to be surgically removed they were that bad, and major heartburn in the 2nd trimester.

            But what about those mothers who develop blood pressure issues? Or other potentially fatal complications?

            Assuming the mother is in good health is NOT a smart assumption. What’s the adage? Hope for the best but prepare for the worst?

          • Dr Kitty

            That is insane.
            Utterly bonkers.
            Antithetical in every way to patient-centred holistic care.

      • Mel

        That makes my head hurt.

      • CanDoc

        Holy moley. I had no idea that was how this worked in some hospitals. Brutal. 🙁

  • Madtowngirl

    Very interesting. I have seen the March of Dimes commercial urging women not to schedule induction/c-section before 39 week. Imagine my panic when my water broke at 36+4! She was small at birth, and had a bit of trouble maintaining her temperature, but was otherwise healthy.

    It will be interesting to see if you can get the data for previous years.

    • Kelly

      I feel like these commercials are scaring people. I know this is anecdotal but all of the babies that I know that have been born 35-38 weeks and after have had minimal to no interventions necessary after birth. These commercials make it seem like these kids are going to have the same problems as those born at 24 weeks.

      • guest

        35 weeks is pretty young. I’m all for doctors deciding on a patient-by-patient basis, but most 35 weekers are going to require a NICU stay, which is massively expensive, and prematurity does carry health risks further down the line. Maybe your definition of “minimal” interventions is different from mine, but most of the 35-26 weekers I know (and I have spoken with 5-6) required NICU stays, and often Early Intervention treatment later one for various delays. Sometimes it’s best to get babies out that early, but I wouldn’t be cavalier about it.

        • guest

          *35-36 weekers, I mean, not 26.

        • Kelly

          I am not trying to be cavalier about it. That is why I said that it was anecdotal. I recognize that there is higher likelihood of having complications if born before 39 weeks but generally they will be much healthier than a 24 week preemie. I would also not advocate for doctors to start inducing at 35 weeks because a woman is tired of being pregnant. I just feel that these commercials try to scare women of ever having a child earlier than 39 weeks.

          • guest

            I haven’t seen the commercials, but March of Dimes’ whole existence is anti-prematurity, so it wouldn’t surprise me. The general recommendation is sound, though – maternal request inductions before 38-39 weeks in the absence of any complications or prior history of complications isn’t a good idea. While each doctor should have the ability to recommend earlier delivery, I don’t see a problem with telling women to avoid scheduling them earlier without cause.

      • Madtowngirl

        I agree with you. My daughter is, so far, showing normal development and health. Many babies are born before 39 weeks and turn out healthy. I suspect it started from a viewpoint of “don’t schedule a c-section out of convenience!” I’m pretty certain that “convenient c-sections” are as much of an urban legend as “too posh to push.”

        • Kelly

          I guess my wanted induction was for “convenience” but I thought it was the best logical answer. I didn’t want to give birth at home in front of my preschooler and toddler while my husband was at work. Other people thought that I was going to be putting my child in the NICU because what I really wanted was to be induced two days before 39 weeks because my first two were born around that time. I don’t see how two days at that stage of pregnancy was going to hurt my child. I am just glad that my OB was on board and that was all that mattered. If I was being ridiculous I know she would have not supported it. People annoy me so much. I know bad things happen. I have seen it happen a lot but lets not be so overzealous that women are questioning or feeling bad about having to be induced or have an early c-section when they have a valid medical reason.

      • demodocus

        I certainly didn’t need any interventions despite 7 months gestation (probably late 7 months). My parents told me i had a bit of a hole in my heart but that it sealed by itself when i was small.