1. Note: location of logos to be determined
Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestation
Note: location of logos to be determined

2. Objectives
Describe the increase in non-medically indicated (elective) deliveries before 39 weeks and identify the contributing factors.
Discuss the risks of early term deliveries and the benefits of delaying delivery beyond 39 weeks gestation.
Outline successful initiatives to reduce elective deliveries before 39 weeks at hospital, health- system and state-wide levels.
Describe a sample implementation plan for the prevention of elective deliveries before 39 weeks.

3. Terminology Late Preterm Early Term Preterm Term Post term 20 0/7
First day of LMP
Week #
20 0/7
340/7
37 0/7
39 0/7
416/7
Preterm
Term
Post term
With apologies to my neonatal colleagues:
Let us look at the definition of late preterm:
Term gestation is between 260—294 days
Preterm is before that
A duration of 17 weeks
The last 3 weeks of this period we have been calling late preterm, this I must happened after a workshop at NICHD.
Drawing courtesy: William Engle, MD, Indiana University
Raju TNK. Pediatrics , 2006; Oshiro BT Obstet Gynecol 2009;113:804 * 3

4. Inductions of Labor
Since 1979, ACOG cautions against inductions before 39 wks in the absence of a medical indication.
Confirmation of gestational age:
Ultrasound before 20 weeks gestation to establish accurate gestational age of the fetus
Documentation of fetal heart tones by 30 weeks using Doppler ultrasonography
Confirmation that it has been 36 weeks since a positive pregnancy test was obtained

5. Change in Distribution of Births by Gestational Age: United States, 1990-2006
Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics

6. U.S. Cesarean Section and Labor Induction Rates Singleton Live Births by Week of Gestation,1992 and 2002.
2002 C-S
Early Term
1992 C-S
2002 Induction
1992 Induction
Source: NCHS, final natality data
Prepared by March of Dimes Perinatal Data Center, April 2006.

7. Increasing C/S and Labor Induction Rates in the United States
Induction of labor in the United States has more than doubled as a proportion of all births, from 9%
if 1989 to 21% in 2002,

8. Cesarean Delivery Rate: United States
32%
23%
21%
Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for National vital statistics reports, Web release; vol 57 no 12. Hyattsville, MD: National Center for Health Statistics. Released March 18, 2009.

9. Rates of Induction of Labor by Race and Hispanic Origin
Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics

10. Why are elective/planned deliveries increasing in frequency?

11. Sounds like a good idea…
Advanced planning
Convenience
Delivered by her doctor
Maternal intolerance to late pregnancy
Excess edema, backache, indigestion, insomnia
Prior bad pregnancy
And, it’s okay right?
Why has elective deliveries or increased? Most people, both patients and obstetricians are unaware of any harm. And there are definitely perceived benefits for timing the delivery.
Clin Obstet Gynecol 2006;49:

12. Obstet Gynecol 2009;114:1254

13. The Gestational Age Respondents Considered a Baby Full Term
Obstet Gynecol 2009;114:1254

14. The Gestational Age Respondents Considered it Safe to Deliver
Obstet Gynecol 2009;114:1254

15. “Non-Medical” Reasons for Induction?
Maternal intolerance to late pregnancy
Excess edema, backache, indigestion, insomnia
Prior labor complication
Prior shoulder dystocia
Suspected fetal macrosomia
History of Rapid labor/ lives far away
Possible lower risk for mom or baby
Lower stillbirth rate, less macrosomia, less preeclampsia

16. What’s in it for me? The Obstetricians
Physician convenience
Guarantee attendance at birth
Avoid potential scheduling conflicts
Reduce being woken at night
… what’s the harm?
Amnesia due to rare occurrence.
The NICU can handle it.
And…
Clin Obstet Gynecol 2006;49:

17. Suspected Fetal Macrosomia (Non-Diabetic Population)
Does not reduce risk of shoulder dystocia
Doubles risk of cesarean delivery
262 pregnancies EFW >90%
Elective Group:
57% cesarean delivery rate
5.3% shoulder dystocia
Spontaneous labor group:
31% cesarean delivery rate
2.5% shoulder dystocia
However, some of these assumptions are wrong. Take for example inducing someone for suspected macrosomia. There were more cases of shoulder dystocia and cesarean sections in the induction of labor group.
Combs et al: Obstet Gynecol 1993; 81:

18. Risks of Elective Delivery Before 39 weeks.

19. Delivery indications at late-preterm gestations and infant morality rates in the U.S.
NCHS 2001 birth cohort linked birth/death files of 3,483,496 live singleton births at weeks.
Categorized by
Maternal medical conditions
OB complications
Major congenital anomalies
Isolated spontaneous labor; VD without induction and complications
No recorded indication
Infant deaths/ live births
Reddy et al. Pediatrics 2009;124:

20. Neonatal and Infant Deaths by Weeks Gestation
Reddy et al. Pediatrics 2009;124:

21. Neonatal and Infant Mortality by Indication
Reddy et al. Pediatrics 2009;124:234

22. Morbidity of Late Preterm Infants in Massachusetts
Late preterm infants : 22.2% vs Term infants: 3%
Sample: Term (377,638), Late Preterm (26,170)
Morbidity rates doubled for each gestational week earlier than 38 weeks
40 wks: %
39 wks: %
38 wks: 3.3%
37 wks: 5.9%
36 wks: 12.1%
35 wks: 25.6%
34 wks: 51.9%
Shapiro-Mendoza CK et al. Effect of late-preterm birth and maternal medical conditions on newborn morbidity risk. Pediatrics. 2008;121 :e223 –e232

23. NICU Admissions
A study by Oshiro et al, OG 2009;113;804 showed increasing risk for NICU admits for each week before 39 weeks.
Oshiro, B. et al. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstet Gynecol, : p

24. RDS
Increased risk for respiratory distress syndrome for each week before 39 weeks.
Oshiro, B. et al. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstet Gynecol, : p

25. Ventilator Use
And neonates on ventilators for each week before 39 weeks.
Oshiro, B. et al. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstet Gynecol, : p

26. 13,258 elective repeat cesarean births in 19 centers
Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes
13,258 elective repeat cesarean births in 19 centers
35.8% done <39 weeks gestation
Increased risk of neonatal morbidity
Respiratory, hypoglycemia, sepsis, NICU admissions, hospitalization > 5 days
Even among babies delivered week
Among a large cohort of women with viable singleton pregnancies who underwent elective repeat cesarean sections, more than a third of deliveries were performed before 39 weeks of gestation
As compared with deliveries at or after 39 weeks, deliveries before 39 weeks of gestation - even those during the last 3 days before week 39 - were associated with an increased risk of a composite primary outcome that included neonatal death, respiratory complications, need for mechanical ventilation, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit
Tita AT, et al, NEJM 2009;360:111

27. Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery
Table 3. Odds Ratios for Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery.
Tita AT, et al, NEJM 2009;360:111

28. 35 weeks 20 weeks 40 weeks Slide Courtesy, Dr. Hannah Kinney, 2006
Golgi drawings: Chan and Armstrong, 2002

29. Fetal Brain Development
Corticol volume increases by 50% between 34 and 40 weeks gestation. (Adams Chapman, 2008)
Brain volume increases at rate of 15 mL/week between 29 and 41 weeks gestation.
A 5-fold increase in myelinated white matter occurs between wks gestation.
Frontal lobes are the last to develop, therefore the most vulnerable.
(Huttenloher, 1984; Yakavlev, Lecours, 1967; Schade, 1961; Volpe, 2001).

30. Examples of Successful Programs to Reduce Elective Deliveries Before 39 week of Gestation
Magee Women’s Hospital (Pittsburg)
Intermountain Healthcare (Utah)
Ohio State Department of Health

31. Magee-Womens Hospital’s Experience
Magee-Womens Hospital is the largest maternity hospital in Western Pennsylvania, performing more than 9,300 deliveries in 2007.
A rise in the use of induction, reaching a high of 28% in 2003.
In 2006, a process improvement initiative changed the induction scheduling process and strictly enforced the guidelines.
Fisch et al Obstet Gynecol 2009;113:797

32. Magee Women’s Experience with Guidelines
3mos 2004
(baseline)
3mos (voluntary)
14mos (enforced)
Deliveries
2,139
2,260
10,895
Elective Inductions <39wks (N) / Total Elective Inductions (rate) % %
30 4.3% (p<0.001)
Elective Nullip Inductions (N) Elective Nullip Inductions =>C/S (N) Elective Nullip Inductions =>C/S (rate) % %
% (p<0.01)
Total Induction Rate
24.9%
20.1%
16.6%
Fisch et al Obstet Gynecol 2009;113:797

33. Magee Women’s Experience
The importance of strong physician and nursing leadership cannot be overstated. The change in the induction scheduling process that began to enforce the guidelines strictly in late 2006 was spearheaded by the Ob Process Improvement Committee, whose members included the hospital’s Vice President for Medical Affairs, the Medical Director of the Birth Center, and the nursing leadership for the Birth Center.
Fisch et al Obstet Gynecol 2009;113:797

34. Intermountain Healthcare’s Experience
Intermountain Healthcare is a vertically integrated healthcare system that operates 21 hospitals in Utah and Southeast Idaho and delivers approximately 30,000 babies annually.
Computerized L&D system.
MFMs hired by system, but OBs are independent.
January of 2001, nine urban facilities participated in a process improvement program for elective deliveries.
28% of elective deliveries were occurring before 39 completed weeks’ of gestation.
Oshiro, B. et al. Obstet Gynecol, : p

35. % Elective Deliveries <39 Weeks January 1999 – December 2005
Oshiro, B. et al. Obstet Gynecol, : p

36. Common themes
Education provided to obstetricians regarding ACOG guidelines, best practice.
Little change until guidelines were enforced.
Medical leadership important.

37. Ohio Perinatal Quality Collaborative
Reduce inappropriate scheduled deliveries at 36+1 to 38+6 weeks
20 Maternity hospitals
5,830 scheduled deliveries through July 2009 (47% of the population

38. Births at 360 -386 weeks without documented medical or obstetrical indications
Aggregate reportPercent of scheduled deliveries at 360/7-386/7 weeks without medical or obstetric indication documented.Ohio Perinatal Quality Collaborative Writing Committee. A statewide initiative to reduce inappropriate scheduled births. Am J Obstet Gynecol 2010.
American Journal of Obstetrics & Gynecology 2010; 202:243.e1-243.e8

39. Percent of births at 36-38 weeks induced without medical or obstetric indication
Percent of births at weeks induced without medical or obstetric indicationArrow indicates OPQC startup; dotted line indicates aggregate rate of participants; ______ line indicates the mean rate; line indicates control limits of the rate.Ohio Perinatal Quality Collaborative Writing Committee. A statewide initiative to reduce inappropriate scheduled births. Am J Obstet Gynecol 2010.
Source: American Journal of Obstetrics & Gynecology 2010; 202:243.e1-243.e8
Copyright © 2010 Mosby, Inc. Terms and Conditions

40. Alleviating fears
Obstetricians voiced concerns regarding a potential increase in perinatal mortality and maternal morbidity.

41. Stillbirths Before and After Implementation of Guidelines at Intermountain Healthcare
Oshiro, B. et al. Obstet Gynecol, : p

42. Wouldn’t keeping people pregnant longer increase their risk for adverse outcomes?
The experience in Ohio and Utah has shown that morbidity remained the same for macrosomia, preeclampsia, and maternal infections.
Decreases were seen in stillbirth, low apgars scores, cesarean section for fetal distress, meconium aspiration and postpartum anemia.

43. Reasons to Stop Elective Deliveries before 39 Weeks
To decrease harming the baby or mother.
There is no apparent harm in keeping a mother pregnant beyond 39 weeks if there is no medical or obstetrical indication.
National Quality Measures:
National Quality Forum (NQF)
LeapfrogGroup
The Joint Commission (TJC)

44. Fundamental Issues Identify the list of “approved” indications
Have Departmental criteria for making certain diagnoses (e.g. hypertensive complications of pregnancy)
Consider second oponions
Identify the criteria for establishing Gestational age >39 weeks

45. ACOG List of Example Indications
Abruptio placentae
Chorioamnionitis
Fetal demise
Gestational hypertension
Preeclampsia, eclampsia
Premature rupture of membranes
Postterm pregnancy
Maternal medical conditions (eg, diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension, antiphospholipid syndrome)
Fetal compromise (eg, severe fetal growth restriction, isoimmunization, oligohydramnios)
ACOG Practice Bulletin: Induction of Labor. Number 107, August 2009

46. To be redone…

47. Confirmation of Term Gestation
Ultrasound measurement at less than 20 weeks of gestation supports gestational age of 39 weeks or greater.
Fetal heart tones have been documented as present for 30 weeks by Doppler ultrasonography.
It has been 36 weeks since a positive serum or urine human chorionic gonadotropin pregnancy test result.
ACOG Practice Bulletin: Induction of Labor. Number 107, August 2009

48. Overview: Critical Elements for Successful Implementation

50. What do we need to get started?
Assess the situation
Organize a team
Plan an implementation strategy
Implement the strategy
Track progress

51. Assess the Situation What is your induction and cesarean section rate?
Elective vs indicated
Before 39 weeks
Assess your scheduling process
Who schedules
Do you know the EGA and indication at the time of scheduling?
Who are the champions and problem children?
What is the process for refereeing a case?

52. Organize a team L&D manager Perinatal QI RN
OB Chair, MFM, Neonatologist, pediatrician, nurse midwife
Lead scheduler
Data analyst/ decision support
Key obstetrician leaders

53. Plan an implementation strategy
Develop or revise the scheduling process
Establish an appeal process for scheduling conflicts
Develop physician, staff, and patient education materials
Amend hospital policies and procedures
Develop data tracking and reporting system and audit tool
Plan kickoff

54. Implement strategy
Convene department and staff meetings to educate physicians and staff
Provide educational materials for physicians, staff, and patients
Choose start date and begin data collection and reporting on a regular basis

55. Track progress
Use data and audit tools to track the number of elective deliveries <39 weeks
Report back to staff and providers on a regular basis
Address issues and concerns as soon as possible

56. Scheduling Process
All scheduled deliveries (inductions or cesarean sections) must have the following documented at the time of scheduling:
Gestational age.
The indication for induction or cesarean section.

57. Scheduling Process:continued
Patients can be scheduled either calling the scheduler or faxing in the request.
Elective deliveries including repeat scheduled cesarean sections must be at least 39 weeks gestation based upon ACOG criteria.
Any scheduling conflicts will be directed to the OB Chair or Director of L&D for resolution.
On going problems that are identified will either be taken care of as soon as possible or discussed at future department meetings.
Data will be reported back on a regular basis to inform everyone how the project is going.

59. What providers can do.
Educate your patients and staff about the risks and benefits of delivery before or after 39 weeks.
Perform an ultrasound before 20 weeks to confirm gestational age on all your patients.
Educate your staff on the new scheduling process.
Take a lead on promoting best practice.

60. Fetal lung maturity testing before 39 weeks and neonatal outcomes
Gestational age and Fetal Lung Maturity (FLM) tests are related but independent predictors of fetal maturity.
Bates E, Rouse D, Chapman V, Mann ML, Carlo W, Tita A. Am J Obstet Gynecol 201:(6) S17, 2009