On August 22nd, 2017, Sandy Parker from On the Path Yoga and I drove to the New Holland Brewery in Grand Rapids to hear Dr. June Murphy, DO, Maternal Fetal Medicine Fellowship Director at St. Joseph Mercy Oakland Hospital, talk about “Advances in Management of Preterm Labor: Achieving Optimal Practice.” The lecture was at an event that combined the journal clubs of obstetric residents at Mercy Health Hackley in Muskegon and Metro Health (University of Michigan) in Grand Rapids. The event was sponsored by Hologic, the makers of the fetal fibronectin test.
Understanding the ever-changing standard of care involving preterm labor is important for maternal and infant health advocates, like doulas and childbirth educators. People who experience preterm labor are often confused about why treatment varies so much between patients. Not understanding the standard of care can lead to anger when it appears that patients have not been treated equally. While unequal care can occur, protocols can prevent bias and reassure patients that everything possible is being done to protect them and their infant.
While preterm labor is the leading cause of infant mortality in the US, it is very common and often harmless. In fact, I learned that as many as 1 in 4 women will experience four contractions per hour prior to 32 weeks! However, 30% of preterm labor resolves spontaneously, without treatment. Only 1 in 10 women who are diagnosed with preterm labor will give birth within 7 days. In other words, uterine contractions poorly predict whose baby will be born too soon!
To complicate matters, steroids given to mothers with preterm labor improve newborn outcomes when given as late as 34 – 36 weeks, but can be harmful when given unnecessarily.
So, what are providers supposed to do? Fortunately, the March of Dimes created the Preterm Labor Assessment Tool (PLAT), an algorithm, or decision tree, based on the Rose et al study (2010), to assist healthcare providers in deciding whether to admit someone in preterm labor. Dr. Murphy explained how the cut-offs for cervical length combined with the fetal fibronectin results best predicted who would deliver early. Unfortunately, the protocol does not prevent preterm birth, but does save money, time and stress from unnecessary hospitalizations.
In addition to the lecture, residents reviewed two articles, one comparing the efficacy of vaginal progesterone to an injection. Studies in the last decade have shown that progesterone treatment to prevent preterm birth is effective. Barriers to this treatment include problems with insurance reimbursement and compliance with office visits to receive injections. Vaginal progesterone has the advantage of being cheaper and easier to administer. Although the study was small, it showed promise for an alternative, but effective, treatment to prevent preterm delivery and save lives.
Dr. Murphy said that if a woman presents to a hospital in preterm labor and there was a thought bubble above her fetus, if would say, “Follow the protocol!” The causes of prematurity are complex and interrelated. Clinical providers have a limited role in addressing the underlying causes of prematurity and the infant mortality that results. Standardized care based on the latest research can reduce treatment influenced by bias and help achieve equity.