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Re: Switching patients**41 plus From: Braun, R. Daniel (rbraun@iupui.edu) Fri Aug 27 06:44:03 2004 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: RModugno@aol.com: "Re: LSH was UAE Option" Previous message: Braun, R. Daniel: "Re: Twins" CMAJ. 1999 Apr 20;160(8):1145-9. Related Articles, Links Effect of labour induction on rates of stillbirth and cesarean section in post-term pregnancies. Sue-A-Quan AK, Hannah ME, Cohen MM, Foster GA, Liston RM. Department of Obstetrics and Gynaecology, Sunnybrook & Women's College Health Sciences Centre, Toronto, Ont. BACKGROUND: Meta-analyses of randomized controlled trials suggest that elective induction of labour at 41 weeks' gestation, compared with expectant management with selective labour induction, is associated with fewer perinatal deaths and no increase in the cesarean section rate. The authors studied the changes over time in the rates of labour induction in post-term pregnancies in Canada and examined the effects on the rates of stillbirth and cesarean section. METHODS: Changes in the proportion of total births at 41 weeks' and at 42 or more weeks' gestation, and in the rate of stillbirths at 41 or more weeks' (versus 40 weeks') gestation in Canada between 1980 and 1995 were determined using data from Statistics Canada. Changes in the rates of labour induction and cesarean section were determined using data from hospital and provincial sources. RESULTS: There was a marked increase in the proportion of births at 41 weeks' gestation (from 11.9% in 1980 to 16.3% in 1995) and a marked decrease in the proportion at 42 or more weeks (from 7.1% in 1980 to 2.9% in 1995). The rate of stillbirths among deliveries at 41 or more weeks' gestation decreased significantly, from 2.8 per 1000 total births in 1980 to 0.9 per 1000 total births in 1995 (p < 0.001). The stillbirth rate also decreased significantly among births at 40 weeks' gestation, from 1.8 per 1000 total births in 1980 to 1.1 per 1000 total births in 1995 (p < 0.001). The magnitude of the decrease in the stillbirth rate at 41 or more weeks' gestation was greater than that at 40 weeks' gestation (p < 0.001). All hospital and provincial sources of data indicated that the rate of labour induction increased significantly between 1980 and 1995 among women delivering at 41 or more weeks' gestation. The associated changes in rates of cesarean section were variable. INTERPRETATION: Between 1980 and 1995 clinical practice for the management of post-term pregnancy changed in Canada. The increased rate of labour induction at 41 or more weeks' gestation may have contributed to the decreased stillbirth rate but it had no convincing influence either way on the cesarean section rate R. Daniel Braun, MD "If everyone likes you, you're doing something wrong." Kinky Friedman I believe a self-righteous liberal or conservative with a cause is more dangerous than a Hell's Angel with an attitude. Andy Rooney -----Original Message----- From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of art fougner, md Sent: Thursday, August 26, 2004 5:13 PM To: Multiple recipients of list OB-GYN-L Subject: Re: Switching patients**41 plus Obstet Gynecol. 2003 Jun;101(6):1312-8. Labor induction versus expectant management for postterm pregnancies: a systematic review with meta-analysis. Sanchez-Ramos L, Olivier F, Delke I, Kaunitz AM. Department of Obstetrics and Gynecology, University of Florida, Jacksonville, Florida, USA. luis.sanchez@jax.ufl.ede OBJECTIVE: To compare routine labor induction with expectant management for patients who reach or exceed 41 weeks' gestation. DATA SOURCES: Computerized databases, references in published studies, and textbook chapters in all languages were used to identify randomized controlled trials (RCTs) evaluating induction and expectant management of labor for postterm pregnancies. METHODS OF STUDY SELECTION: We identified RCTs that compared induction and expectant management for uncomplicated, singleton, live pregnancies of at least 41 weeks' gestation and evaluated at least one of the following: perinatal mortality, mode of delivery, meconium-stained fluid, meconium aspiration syndrome, meconium below the cords, fetal heart rate (FHR) abnormalities during labor, cesarean deliveries for FHR abnormalities, abnormal Apgar scores, and neonatal intensive care unit (NICU) admissions. The primary outcomes assessed were cesarean delivery rate and perinatal mortality. TABULATION, INTEGRATION, AND RESULTS: Sixteen studies met inclusion criteria for this review. For each study with binary outcomes, an odds ratio (OR) with 95% confidence intervals (CIs) was calculated for selected outcomes. Estimates of ORs for dichotomous outcomes were calculated using fixed and random-effects models. Homogeneity was tested across the studies. Compared with women allocated to expectant management, those who underwent labor induction had lower cesarean delivery rates (20.1% versus 22.0%) (OR 0.88; 95% CI 0.78, 0.99). Although subjects whose labor was induced experienced a lower perinatal mortality rate (0.09% versus 0.33%) (OR 0.41; 95% CI 0.14, 1.18), this difference was not statistically significant. Similarly, no significant differences were noted for NICU admission rates, meconium aspiration, meconium below the cords, or abnormal Apgar scores. CONCLUSION: A policy of labor induction at 41 weeks' gestation for otherwise uncomplicated singleton pregnancies reduces cesarean delivery rates without compromising perinatal outcomes. art At Thu, 26 Aug 2004, Garry E. Siegel, M.D. wrote: > >Ignoring the social conundrum here, Lenora, I would be a bit reluctant >to send home someone who is 41+, favorable, and doesn't want to go >home. While it is very unlikely, any poor outcome would lead to the >question--why didn't you keep her. > >I disagree with your commment about no medical indication, as she is >41+, and that is an indication. Sanchez, I believe, did a >41+meta-analysis >in the Green Journal in 11/03 and the conclusion was that delivery at >41 weeks irrespective of cervical exam and parity led to the best >outcomes. > >Garry >> >>---A former patient comes in to L&D in false/prodromal labor. She is >>41+ weeks with a favorable cervix (3/70/-1) and does not want to go home--the FHTs >>are reassuring. She knows me and asks to be induced. She can't understand >>why I tell her to go home and see her own obstetrician on Monday >>(this is >>Sat.) when he comes back from vacation. If she were our patient I would grant >>her wish, but don't feel it appropriate to induce Dr. M.'s patient with no >>medical indication. >> >-- >Garry E. Siegel, M.D. >Private Practice >Roswell, GA > -- art fougner, md ich bin ein New Yorker Next message: RModugno@aol.com: "Re: LSH was UAE Option" Previous message: Braun, R. Daniel: "Re: Twins"

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