Overtreatment at the Beginning of Life

Molly Beinfeld, MPH, Solution Strategist

Editor’s Note: Join us as we explore important pregnancy topics that consumers and organizations are facing. Check back for additional posts, we’ll have a new one each week.

Becky is a nurse from Charlottesville, VA. At 38 weeks of pregnancy, she went in for her routine prenatal visit with her obstetrician (OB), and the OB measured her belly. She was “measuring large for gestational age,” her OB said. Becky did feel large, but she thought all women so late in pregnancy felt this way. “Let’s get an ultrasound to check the size of the baby,” her OB said. The ultrasound showed that her baby could be as big as 10 pounds. With 2 weeks to her due date, she wondered how much bigger the baby could get!

Concerned about a rare but serious outcome of shoulder dystocia, in which the baby’s shoulder gets stuck behind the pelvic bone during labor, the OB arranged to induce labor a few days later. When Becky went in for her induction, her cervix was not ready, so various methods were used to soften and dilate it. After 2 days of “poking and prodding” (in Becky’s words), her cervix was swollen shut and her baby’s heart rate was dropping with every contraction. An emergency cesarean was done. When they put her baby on the scale, Becky’s heart sank. Her daughter weighed 8 pounds, 5 ounces, well within normal. All of those procedures had been unnecessary after all.

Becky and her baby were fine, although the baby had to spend a few days in the NICU for breathing problems. And Becky’s hospital bill was 2 to 3 times the average for a birth. This is not a tragic story. But it is a story of overtreatment, of doing more and achieving less, and of what can happen when shared decision making isn’t the norm. If shared decision making had happened, Becky would have learned that sizing ultrasounds are wrong about half the time. And she would have known that inducing labor for suspected big baby doesn’t reduce the risk of shoulder dystocia and that it can introduce other problems, like C-section. And Becky’s OB would have learned that Becky preferred a natural labor and wanted to avoid a C-section as much as possible.

By getting decision support in a timely fashion, well before these issues become emergencies, women can consider these decisions carefully and prepare themselves for a shared-decision-making conversation with their health care provider. A woman’s interaction with the decision aids, including what treatment choice she’s leaning toward, any strong preferences she has about her birth, and her top questions, are viewable by the health care provider so the provider can focus the conversation on key issues.