Choosing Wisely Round 2, From the AAFP

Interview With Dr. Glen Stream

Carol Peckham; Glen Stream, MD, MBI


June 25, 2013

In This Article

Editor's Note: Choosing Wisely® , an initiative of the American Board of Internal Medicine (ABIM) Foundation, comprises evidence-based recommendations from specialty organizations on commonly used tests and procedures. The goal of the campaign is to use these recommendations as the starting point for discussions between clinicians and patients about avoiding unnecessary care. Choosing Wisely launched in 2012 with 5 recommendations each from 9 specialties; as of the date of this interview, 49 specialty societies have joined the campaign, and 17 of them provided new lists on February 21, 2013.

Last year, Medscape interviewed Glen Stream, MD, MBI, Board Chair of the American Academy of Family Physicians (AAFP), on their first 5 recommendations. The second set was announced this year, and Dr. Stream discussed these latest recommendations with Medscape.

Recommendations 1 and 2: Elective Induction of Labor

Medscape: The first 2 Choosing Wisely recommendations in this new set involve elective, non-medically indicated induction of labor. The first advises physicians not to schedule elective, non-medically indicated induction of labor or cesarean deliveries before 39 weeks. The second says to avoid elective, non-medically indicated induction of labor between 39 and 41 weeks unless the cervix is deemed favorable. What was the basis for these recommendations?

Dr. Stream: These recommendations on delivery were developed by the AAFP in collaboration with the American College of Obstetrics and Gynecology (ACOG). Ob/gyn and family physicians are the 2 specialties that deliver babies, and so it made sense to collaborate in the development of these.

As a reminder, these recommendations are in the absence of a medical indication. Obviously, if there is evidence of problems with the baby or health issues for the mother, then these guidelines don't apply and other medical decision-making is involved.

Medscape: Could you discuss the first recommendation a bit, which was not to schedule elective, non-medically indicated induction of labor or cesarean deliveries before 39 weeks?

Dr. Stream: My understanding is that it is based on solid medical evidence that primarily has to do with complications in infants, rather than the mothers.[1,2,3] We used to focus mostly on lung maturity and whether babies were ready to be born, but there are some neurologic and developmental issues if they're delivered prematurely

Medscape: Has there been a decrease in elective induction before 39 weeks, even before this Choosing Wisely recommendation was issued?

Dr. Stream: There is a national initiative independent of Choosing Wisely targeting this recommendation. It has been a focus of quality improvement in hospitals settings for the past couple of years and was already a target for reducing the numbers below whatever is current. Until recently, for instance, I was on the board of trustees for one of the local hospitals, and this was one of the quality initiatives being followed there.

Medscape: Under what circumstances would someone choose to deliver electively before 39 weeks?

Dr. Stream: With an uncomplicated pregnancy, there are a few reasons why a woman might choose elective induction. For example, it's August and the pregnancy is now at 38 or 39 weeks. The poor woman is just tired of being pregnant, which is understandable, and she may say, "Gee, I'm close enough; can't you induce me?"

It also may be done for the convenience of the physician. For example, you're getting ready to go on vacation and a patient you've taken care of for their whole pregnancy -- and maybe more than 1 pregnancy -- would really like you to be at her delivery. Shouldn't you try to deliver them before you leave town? Well, if it's earlier than 39 weeks, even given a reasonable desire for the woman to deliver or for the physician to be present at the delivery, the evidence shows an unnecessary risk to the baby.

Medscape: Could you also describe the second recommendation, which is to avoid elective, non-medically indicated inductions of labor between 39 and 41 weeks unless the cervix is deemed favorable.

Dr. Stream: The first recommendation, avoiding elective delivery before 39 weeks, has to do with the potential impact on the health of the baby. The basis for the second is an increased risk for failed induction and a higher cesarean section rate if the cervix hasn't ripened sufficiently, so there are higher risks for the mother, the baby, or both.

Again, this recommendation against induction is for women with an uncomplicated pregnancy. If the mother has diabetes, preeclampsia, or other relevant health issues, you do whatever you can to have a successful induction, recognizing the risks for higher failure and for C-section. I have also practiced in fairly rural areas, so if a woman lives 50 miles from the hospital, you may be worried that she will go into labor and deliver somewhere between home and the hospital, particularly if she's had more than 2 babies. That's sometimes a reason to think about elective induction. But even under that circumstance, if the cervix is unfavorable, you're taking the risk for a failed induction and higher C-section risk.

Medscape: What are the indications for induction of labor before 39 weeks?

Dr. Stream: Among the most common ones would be intrauterine growth retardation, where the baby stops growing and the placenta is not adequately providing nourishment. Elective induction might also be related to the mother's health, often because of preeclampsia. If the mother is diabetic, often babies tend to grow larger, and one might induce delivery before the baby gets so large that vaginal delivery would not be possible. Those are some of the most common indications, but it's a long list.

Medscape: A couple of sources, including a 2010 AAFP survey, indicate that only about 10% of family physicians delivery babies.[4,5] Which physicians are doing this?

Dr. Stream: It depends on where the physician practices. It's more frequent in underserved rural and particularly in rural areas, where the population may not be high enough to support an ob/gyn specialist.


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