Let ob/gyns practice smart medicine: Change the 39-week rule

Thank you for publishing in the July 2011 issue both Dr Charles Lockwood's discussion on the "Industrialization of medicine"¹ and Dr Allan Jacobs' "Is 'progress' good for your practice?"² Both beautifully articulate how physicians have lost their ability and autonomy to individualize care when they believe that they are acting in their patients' best interest.

A striking example is the spreading governmental oversight and hospital regulations preventing scheduled repeat cesarean delivery prior to the completed 39th week. Dr Lockwood discusses this in his editorial in the March 2009 Contemporary OB/GYN.³

In the classic Tita article, "Timing of elective repeat cesarean delivery at term and neonatal outcomes,"⁴ the study's exclusion of more than 8.5% of patients from the analysis was inappropriate. The statistical conclusions of the study could have been altered by the addition of the neonatal outcomes of patients with a previous myomectomy and by including those babies without assumed abnormal uteroplacental function.

As pointed out in Dr [Michael] Greene's editorial in that same publication,⁵ by Dr Lockwood,³ and by others,^6-10 a certain percentage of babies will die in utero during the 39th week. Which is worse, transient tachypnea of the newborn or permanent fetal neurologic injury?

A major problem of the conclusions of the Tita study was that the dating of the patients was not ±3 days. Should we not treat patients with assisted reproductive technology or ultrasounds done prior to the 9th week-who truly have excellent dates-differently? Yet with the industrialization rules and the bureaucratization oversight, governmental bodies, the March of Dimes, and even our very own American College of Obstetricians and Gynecologists have created an environment in which no exceptions can be made to the 39-week rule.

At our institution patients scheduled for cesarean delivery regularly go into labor, causing logistical nightmares and putting those patients at increased risk for morbidity. As Salim¹¹ has argued and large studies¹² have shown, more than 10% of patients awaiting the magic 39th week go into labor the week before.

To quote Hartley Shawcross: "There comes a point where a man must refuse to answer to his leader if he is also to answer to his conscience." Is it not time for our profession to fight against industrialization and the bureaucratization of obstetrics and gynecology when we believe that we can be supported by reasonable data individualized for our specific patient populations?

HOWARD C. MANDEL, MD, FACOG
LOS ANGELES, CALIFORNIA