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Re: A caseFrom: Robert J. Woolley (wooll005@gold.tc.umn.edu)Thu Dec 5 16:59:49 1996
In message <199612032021.MAA16945@unixg.ubc.ca> writes: > > NEJM June 11 1992 pp1587 - 1592 > > In the abstract: > Conclusions: In post-term pregnancy, the induction of labour results in a > lower rate of cesarean section than serial antenatal monitoring ... > > in the discussion: > If anything therefore, a policy of inducing labor in post-term pregnancy > may decrease the perinatal mortality rate. > > In a SOGC Committee Opinion (simmilar to ACOG committee opinions) > (Principle author Mary Hannah, same as the NEJM article) > > Summary: > Women who reach 41 weeks gestation should be appropriately counselled > regarding the higher risk to themselves and to their babies if they should > pursue a policy of expectant management. These results suggest that a > policy of induction is, in general, to be preferred. > > So, does the skeptic counsel his patients that they are at higher risk if > they are managed expectantly over 41 weeks? No, because that has not been demonstrated. Your quotations from the study are a bit too selective for my taste. "Because our trial did not use blinding, the differences in the rates of cesarean section may have been due to differences in the interpretation of fetal heart-rate tracings. A physician may be more likely to perform a cesarean section at 32 weeks of gestation than at 41 weeks, or when labor has been induced." The accompanying editorial shared this perspective: "Hannah et al note with caution that the urge to perform a cesarean section may hve influenced the clinicians in the expectant-management group, since they may have anticipated placental insufficiency in these women. In addition, the study was ocnducted at many centers, and fetal distress was not defined in a way that ensured it was the same at each center. Thus, since perinatal morbidity and mortality were similar in the two groups, this study does not resolve the issue of which approach is preferable in terms of these outcomes.... Thus, despite many attempts to examine out practices, no single method of treatment has emerged as the standard of care for women with post-term pregnancies."
Your quotation of "> If anything therefore, a policy of inducing labor in
post-term pregnancy
> may decrease the perinatal mortality rate" is not discussing the Hannah study I notice that you completely omitted mentioning the primary outcome of the study: that there was no significant difference in perinatal morbidity and mortality between the management group. Perhaps you overlooked this point in your reading. In short, there is, IMHO, no substantial justification for your assertion that patients "are at higher risk if they are managed expectantly over 41 weeks," and if you are so informing your patients, you are giving them questionable, if not outright erroneous, information. You are also setting them up for unjustified worrying should induction fail and the pregnancy continue. But I am not hard-nosed about remaining non-interventionist in this situation (assuming a high degree of confidence in establishing the EDC). I explain that watchful waiting and induction have equivalent outcomes, and leave the decision with the patient. And yes, they usually choose induction. Committee opinions can never be better than the hard data on which they are based. When, as in this case, they go beyond what the evidence actually demonstrates, they are worth far less than the primary data.
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