Past-Term Pregnancies
Education about potential medical interventions should start at the first patient encounter and should be part of the birth plan. It is important to determine, at the earliest possible time, if the patient has unreasonable fears or expectations. The patient must understand that whereas induction of labor is medically necessary in many situations, it should not be done as a matter of physician or patient convenience. Patients should be discouraged from seeing induction of labor as a benign process, but they also must appreciate its usefulness in appropriate circumstances.
A patient’s birth plan should detail the indications and risks of induced labor. These should include the medical reasons for what might otherwise appear to be an induction done merely for convenience. If the mother lives in a secluded area where emergency services are nonexistent, then induction at near term may be safer than risking an unattended home delivery in a snowbound mountain cabin. If a mother is likely to need special care for herself or the infant and the entire area is under a hurricane warning, it may be better to deliver her than to leave her to compete for attention in a hospital on disaster status. These are valid indications for inducing labor and should be documented in the chart. This documentation will be important if the snow does not fall or the hurricane hits elsewhere and the delivery has an unfortunate outcome.
The patient should understand that babies that are well past dates may need to be delivered by induction or section. Physicians should enlist the aid of the woman in ensuring that the progress of the pregnancy is appreciated. If the physician is suspicious about the patient’s reported dates, this should be investigated before the patient is grossly past term. The problem of past-dates babies has been exacerbated by the fragmentation of the medical care delivery system. It is easy for a woman to get lost in a group practice where all the prenatal care is delivered by nonphysician personnel. If no one physician is responsible for her care, there may be no one to notice if she misses an appointment or is several weeks overdue.
As changing health insurance plans force patients to move to new physicians, it is difficult for a physician to know if the patient has left the practice or is just not coming in for her appointments. Physicians must have tracking systems for pregnant patients. If the patient has been lost to follow- up as her due date approaches, the physician should attempt to contact her. If she is under the care of another physician, refuses to come in for an appointment, or cannot be located, this information should be documented in the chart.