Ugggh!!!

[caryn]

I want to add a quick note about correlation and causation.

While there is data showing a correlation between early delivery and changes in neonatal brains, that does not prove causation. It's in fact quite likely that the early delivery *and* the changes in neonatal brains are both driven by some other underlying factors, and that the changes are not caused by early delivery.

[mom29]

I hope this OB/GYN publication with the study results will be considered an acceptable source of information.

http://journals.lww.com/greenjournal/Ab ... of.12.aspx

OBJECTIVE: To evaluate the association of a new institutional policy limiting elective delivery before 39 weeks of gestation with neonatal outcomes at a large community-based academic center.

METHODS: A retrospective cohort study was conducted to estimate the effect of the policy on neonatal outcomes using a before and after design. All term singleton deliveries 2 years before and 2 years after policy enforcement were included. Clinical data from the electronic hospital obstetric records were used to identify outcomes and relevant covariates. Multivariable logistic regression was used to account for independent effects of changes in characteristics and comorbidities of the women in the cohorts before and after implementation.

RESULTS: We identified 12,015 singleton live births before and 12,013 after policy implementation. The overall percentage of deliveries occurring before 39 weeks of gestation fell from 33.1% to 26.4% (P<.001); the greatest difference was for women undergoing repeat cesarean delivery or induction of labor. Admission to the neonatal intensive care unit (NICU) also decreased significantly; before the intervention, there were 1,116 admissions (9.29% of term live births), whereas after, there were 1,027 (8.55% of term live births) and this difference was significant (P=.044). However, an 11% increased odds of birth weight greater than 4,000 g (adjusted odds ratio 1.11; 95% confidence interval [CI] 1.01–1.22) and an increase in stillbirths at 37 and 38 weeks, from 2.5 to 9.1 per 10,000 term pregnancies (relative risk 3.67, 95% CI 1.02–13.15, P=.032), were detected.

CONCLUSION: A policy limiting elective delivery before 39 weeks of gestation was followed by changes in the timing of term deliveries. This was associated with a small reduction in NICU admissions; however, macrosomia and stillbirth increased.

[lemons]

mom29- Thanks for posting the actual study.

[mom29]

My 33 weeker did not have severe complications, but it was very hard leaving her every night. Some of her nurses were great and some were not. That is amazing your SIL says they had a good nicu experience. Did they have option to stay 24/7? I would have been so thankful to be able to stay with my daughter 24/7. As it was, I was just overjoyed the day we were able to bring her home. Running back & forth to nicu was exhausting. I developed blood clots the day she came home and wound up in the ER. I am so glad that experience is over!

24/7 access makes a huge difference, I think. If I weren't able to be with my daughter whenever I wanted to it would have been much more difficult than it already was. Our NICU had private rooms for the babies (although it took a few days for our daughter to be stabilized enough to be transferred from the pod to her room) with sofas that folded into single beds for a parent to sleep on. They also had hospital grade breast pumps right there in the room we could use, and a kitchenette area for sterilizing our equipment and having meals/snacks. We were allowed to come whenever we wanted, and were only asked to step out when they were performing sterile procedures (for example, inserting and removing chest tubes) or when she had chest x-rays taken. The rest of the time we were encouraged to help with her regular care (diaper changes, taking her temperature, etc.).

I'm so sorry you had a rougher time, including the blood clots. That sounds horrible!

JB, That is WONDERFUL the nicu your daughter was in enabled 24/7 rooming in for you. I didn't anticipate having an early baby so I didn't even consider going to another hospital in our area that has a brand-new nicu with this option. How long was your daughter in nicu?

The blood clots scared me a bit more than having pre-e. Five weeks of lovenox shots took care of it though and I am so very very thankful for modern medicine!

[mom29]

mom29- Thanks for posting the actual study.

You are welcome. Thanks for catching the math error.
You are so right there are actual families behind the statistics, we lost a son at 14 months so we have first hand experience.

[JB]

JB, That is WONDERFUL the nicu your daughter was in enabled 24/7 rooming in for you. I didn't anticipate having an early baby so I didn't even consider going to another hospital in our area that has a brand-new nicu with this option. How long was your daughter in nicu?

The blood clots scared me a bit more than having pre-e. Five weeks of lovenox shots took care of it though and I am so very very thankful for modern medicine!

My daughter was in the NICU just over 7 weeks. I have since learned that our NICU is pretty state-of-the-art when it comes to patient amenities. They are one of the few places that has a window between the receiving pods and the birth center surgery room (they call it their "drive-thru window"), which allows babies to be handed immediately into the NICU without a trip down the hallway. While we were there I saw them giving tours to other hospital administrators who were interested in setting up their NICUs the same way. The only things they didn't do there were open major surgeries. The micro preemie in the room next to ours had to be transferred downtown to have eye surgery.

At the beginning of this pregnancy my OB said that if I had to transfer my primary care to the MFMs I would have to go to the hospital downtown where they have privileges (they have a satellite office down here south of the city for consults, but only do their primary care out of their main hospital and offices). I was pretty worried about that, because we loved our NICU so much (the doctors and nurses were all really great) and it and was so convenient for us (we live literally up the road from the hospital, so it was easy to come whenever we wanted). Since I have made it to 36 weeks so far without preeclampsia my OB now says that if things go south I can go ahead and just deliver here with her.

Blood clots are very, very scary. You are lucky that they were detected and you got treatment for them!

[lemons]

mom29- I'm so sorry that you lost your son. I can't imagine how difficult that is. And then to have PE and a 33 weeker... My heart goes out to you.

[mom29]

mom29- I'm so sorry that you lost your son. I can't imagine how difficult that is. And then to have PE and a 33 weeker... My heart goes out to you.

Thank you. I think we make a choice between dwelling on the difficult things in our lives or being thankful for the good things. It was hard having my daughter in nicu for 10 days, but that was such a short stay compared to how long other babies stay. 33 weeks is good in terms of preemie births, so many life threatening problems were avoided by that gestational age. I'm truly thankful both of us came out of that pregnancy okay. It took a bit of time to process the experience, but now we just marvel at the photos that show how tiny she was. She is 7 months old and feels like a moose at 15 pounds now We are loving having this little person in our lives and all her siblings dote on her. My little boys are happy I actually let them pat her head without making them wash their hands first.

[mom29]

Diana,

I like your tag line acknowledging the loss of your first child AND rejoicing in your daughter's good health. It makes life sweeter to overcome the difficult things. That is amazing she started out so incredibly tiny and is doing well today!

"Miscarriage at 10 weeks (June 2009).
DD at 30+0 weeks weighing 2lbs 9oz (October 2010) due to PE and IUGR. Today, a happy and healthy toddler."

[blythe]

Strongmom, feel free to look through the archives at my early posts. Almost nine years ago I felt very similar - induction for what I thought was doctor convenience and a tiny baby in the NICU, when everyone assured me that 37weekers do fine. After about 4000 hours of reading I came to the reluctant conclusion - in my case, your case may very well be different - that my doctor did exactly the right thing and I am grateful to her.

I can't comment on your actual diagnosis, if you didn't meet criteria when they induced you and it was against your wishes I am very sorry. What I can tell you is that the diagnosis of preeclampsia does not require bad labs, only two readings, taken at least 6 hours apart, of 140/90 or higher with 300mg protein in a 24-hour urine collection. (And at 37 weeks many doctors I know of won't bother with a 24-hour collection, they'll induce on bp alone.) Bad labs would not diagnose PE, you only need bp and protein for that, bad labs indicate HELLP, an especially severe form of PE.

One of the problems in timing delivery with preeclampsia - or as HYPITAT found, just hypertension - is that the average time from diagnosis to delivery is two weeks, but that encompasses women who limp along stable for months -- and women who get very sick or die or have abruptions or stillbirths within hours. And no one can predict who will be the slow moving case and who will have the sudden nuclear meltdown. It is not a case of risking your health instead of risking an early delivery, as Angie b said, it is risking your health *and* your baby's health by staying pregnant in a compromised pregnancy. Again, if your pregnancy truly was normal my heart goes out to you, no one should have to worry over a NICU baby, but once we preeclamptics get sick enough to diagnose - and sometimes even before we reach the official diagnostic criteria - we are ticking time bombs. Time bombs that don't explode often, true, but doctors are balancing rare *death* over a transient NICU stay. And Caryn's point is very well taken - she links to articles and studies that show that the factors in our blood that are especially elevated in preeclampsia are elevated up to 6 weeks before diagnosis (and I've heard of some predictive tests that might actually detect issues much earlier). The "soft" neurological issues are shown to be correlated, they aren't shown to be causal with early delivery. It may be that the early delivery caused the issues, or it may be that our pregnancies were compromised from the beginning and that the same thing that made us deliver early was the cause of the "soft" issues.

I'm surprised that your hospital had many 37 weekers in the NICU, on these boards, in nine years, I can think of maybe two other 37 week babies (other than my firstborn and yours) who needed NICU time. It seems like most of "our" babies, induced or sectioned, do fine - it's common around here for 35+ weekers to room in with no NICU time. I'm so sorry your baby, like mine, got the short straw.

Mom29, thank you so much for that study (and thank you for your poise in not debating a blog here.). Does anyone have full-text access for the study? I'm wondering if women with hypertensive issues were included in that study - I've always been told that hypertensive issues were medical reasons for inductions and would therefore be left out of the studies that count "elective" deliveries - making the number of stillbirths that much more alarming, especially because those should have been "normal" pregnancies. Lemons, thank you for your math and for reminding us about the families behind those stillbirths. **edited to add - huge thanks to lemons in a subsequent post later in this thread for a full text summary and analysis, my guesses and assumptions here were incorrect!**

Strongmom, I am so sorry your birth and your son's NICU time gave you PTSD, I hope our comments can be helpful and I am very sorry if they are not. I wish you peace after your difficult experience.