Elective Delivery <39wks Resources

More than 22% of all gravid women undergo induction of labor in the United States, and the overall rate of induction of labor in the US has more than doubled since 1990 to 225 per 1,000 live births in 2006 (1). The goal of induction of labor is to achieve vaginal delivery by stimulating uterine contractions before the spontaneous onset of labor. Generally, induction of labor has merit as a therapeutic option when the benefits of expeditious delivery outweigh the risks of continuing the pregnancy. The benefits of labor induction must be weighed against the potential maternal and fetal risks associated with this procedure (2). The purpose of this document is to review current methods for cervical ripening and induction of labor and to summarize the effectiveness of these approaches based on appropriately conducted outcomes-based research. These practice guidelines classify the indications for and contraindications to induction of labor, describe the various agents used for cervical ripening, cite methods used to induce labor and outline the requirements for the safe clinical use of the various methods of inducing labor.

The goal of induction of labor is to achieve vaginal delivery by stimulating uterine contractions before the spontaneous onset of labor. According to the National Center for Health Statistics, the overall rate of induction of labor in the United States has increased from 90 per 1,000 births in 1989 to 184 per 1,000 live births in 1997. Generally, induction of labor has merit as a therapeutic option when the benefits of expeditious delivery outweigh the risks of continuing the pregnancy. The benefits of labor induction must be weighed against the potential maternal or fetal risks associated with this procedure. The purpose of this bulletin is to review current methods for cervical ripening and induction of labor and to summarize the effectiveness of these approaches based on appropriately conducted outcomes-based research. These practice guidelines classify the indications for and contraindications to induction of labor, describe the various agents used for cervical ripening, cite methods used to induce labor and outline the requirements for the safe clinical use of the various methods of inducing labor.

OBJECTIVE: The risk of neonatal morbidity with delivery  39 weeks (wks) is reduced by prior confirmation of fetal lung maturity (FLM). We assessed whether the risk is reduced to levels obtained with delivery at 39-40 wks. STUDY DESIGN: Retrospective cohort study of women delivered at 36-38 wks after positive FLM or at 39-40 wks at our center from ’99-’08.FLMwas positive if phosphatidyl glycerol was present or if L/S ratio
2 (non-diabetics) or
3.5 (diabetics). Multiples and conditions suggesting fetal compromise (major congenital anomalies, cord prolapse, non-reassuring antepartum testing, abruption and oligohydramnios) were excluded. The primary outcome was a composite of perinatal death and neonatal morbidities including those in the table. We also compared neonatal ICU (NICU) admission and hospital stay. RESULTS: 442 delivered at 36-38 wks after positive FLM and 12,881 delivered at 39-40 wks. Mean gestational age and birth weight were 37.2 vs. 39.8 wks and 3115 vs. 3360 g, respectively; both p0.001. Compared to births at 39-40 wks, morbidities, NICU admission and prolonged hospital stay increased with earlier birth after positive FLM and remained so after adjusting for differences in mode of delivery, diabetes, hypertension, age, parity, ethnicity and quality of dating (Table). Risks of bronchopulmonary dysplasia, persistent pulmonary hypertension, surfactant use, hyperbilirubinemia and feeding difficulties were also significantly higher with FLM and delivery39 wks. Risks of perinatal death and seizures were similar. CONCLUSION: Delivery before 39 wks after confirmed FLM is associated with increased neonatal morbidity compared to 39-40 wks, suggesting that purely elective delivery before 39 wks even after positive FLM should be avoided.

The increasing trend of delivering at earlier gestational ages has raised concerns of the impact on maternal and infant health. The delicate balance of the risks and benefits associated with continuing a pregnancy versus delivering early remains challenging. Among singleton live births in the United States, the proportion of preterm births increased from 9.7% to 10.7% between 1996 and 2004. The increase in singleton preterm births occurred primarily among those delivered by cesarean section, with the largest percentage increase in late preterm births. For all maternal racial/ethnic groups, singleton cesarean section rates increased for each gestational age group. Singleton cesarean section rates for non-Hispanic black women increased at a faster pace among all preterm gestational age groups compared with non-Hispanic white and Hispanic women. Further research is needed to understand the underlying reasons for the increase in cesarean section deliveries resulting in preterm birth

OBJECTIVE: No studies exist that have examined the effectiveness of different approaches to a reduction in elective early term deliveries or the effect of such policies on newborn intensive care admissions and stillbirth rates. STUDY DESIGN: We conducted a retrospective cohort study of prospectively collected data and examined outcomes in 27 hospitals before and after implementation of 1 of 3 strategies for the reduction of elective early term deliveries. RESULTS: Elective early term delivery was reduced from 9.6-4.3% of deliveries, and the rate of term neonatal intensive care admissions fell by 16%. We observed no increase in still births. The greatest improvement was seen when elective deliveries at
39 weeks were not allowed by hospital personnel. CONCLUSION: Physician education and the adoption of policies backed only by peer review are less effective than “hard stop” hospital policies to prevent this practice. A 5% rate of elective early term delivery would be reasonable as a national quality benchmark.

OBJECTIVE: To quantify adverse neonatal and maternal outcomes associated with elective term delivery at less than 39 completed weeks of gestation.
STUDY DESIGN: Prospective observational study conducted in 27 hospitals over the course of 3 months in 2007.
RESULTS: Of 17,794 deliveries, 14,955 (84%) occurred at 37 weeks or greater. Of term deliveries, 6562 (44%) were planned, rather than spontaneous. Among the planned deliveries, 4645 (71%) were purely elective; 17.8% of infants delivered electively without medical indication at 37-38 weeks and 8% of those delivered electively at 38-39 weeks required admission to a newborn special care unit for an average of 4.5 days, compared with 4.6% of infants delivered at 39 weeks or beyond (P ! .001). Cesarean delivery rate in women undergoing induction of labor was not influenced by gestational age but was highly influenced by initial cervical dilatation and parity, ranging from 0% for parous women induced at 5 cm or greater to 50% for nulliparous women at 0 cm.
CONCLUSION: Elective delivery before 39 weeks’ gestation is associated with significant neonatal morbidity. Initial cervical dilatation is highly correlated with cesarean delivery among women undergoing induction of labor in both nulliparous and parous women. Elective delivery before 39 completed weeks’ gestation is inappropriate. Women contemplating elective induction at or beyond 39 weeks’ gestation with an unfavorable cervix should be counseled regarding an increased rate of cesarean delivery.

OBJECTIVE: The aim of this study was to determine gestational age specific, adjusted infant mortality rates for Ohio. STUDY DESIGN: Using a retrospective cohort design, all births and infant deaths from 2003–2005 were included in multivariable regression analyses. Variations in cause and timing of infant death were determined. RESULTS: Compared with births at 39 or 40 weeks, adjusted likelihood of infant death increased progressively between 38–32 weeks’ gestational age. At later gestational ages, death was more likely caused by sudden infant death syndrome or intentional injury compared with congenital malformations and asphyxia or cerebral palsy at earlier gestational ages. Less mature infants tended to die earlier. CONCLUSION: The current study confirms for Ohio and extends the findings of others that infant mortality risk is increased for births at late preterm and near-term gestational ages. Decisions to deliver before 39 weeks should consider increased likelihood of infant death that may be unrelated to fetal malformations or maternal illness.

OBJECTIVE: We sought to reduce scheduled births between 360/7-386/7 weeks that lack appropriate medical indication. STUDY DESIGN: Twenty Ohio maternity hospitals collected baseline data for 60 days and then selected locally appropriate Institute for Healthcare Improvement Breakthrough Series interventions to reduce the incidence of scheduled births. Deidentified birth data were analyzed centrally. Rates of scheduled births without a documented indication, birth certificate data, and implementation issues were shared regularly among sites. RESULTS: The rate of scheduled births between 360/7-386/7 weeks without a documented medical indication declined from 25% to
5% (P
.05) in participating hospitals. Birth certificate data showed inductions without an indication declined from a mean of 13% to 8% (P
.0027). Dating criteria were documented in 99% of charts. CONCLUSION: A statewide quality collaborative was associated with fewer scheduled births lacking a documented medical indication.

OBJECTIVE: To examine the effects that medical staff education and a new process for scheduling inductions had on decreasing inappropriate inductions.
METHODS: At our institution in 2004, guidelines were developed and shared with the medical staff and reinforced in 2005. The guidelines for elective induction required patients to have completed 39 weeks of gestation and to have a Bishop score of at least 8 for nulliparas and 6 for multiparas. In 2006, the induction scheduling process was changed and the guidelines were strictly enforced. All scheduled inductions during the same 3-month time period (June through August) in 2004 (n=533) and 2005 (n=454) and during a 13-month period from November 2006 to December 2007 (n=1,806) were compared. Outcomes included elective inductions less than 39 weeks, cesarean birth rate for elective inductions among nulliparas, and the overall induction rate.
RESULTS: From 2004-2007, the overall induction rate dropped from 24.9% to 16.6%, a 33% reduction(P<.001); the elective induction rate dropped from 9.1% to 6.4%, a 30% reduction (P<.001); the percentage of elective inductions before 39 weeks of gestation dropped from 11.8% to 4.3%, a decrease of 64% (P<.001); and the frequency of cesarean delivery among nulliparas undergoing elective induction dropped from 34.5% to 13.8%, a decrease of 60%. (P=.01).
CONCLUSION: Medical staff education and the development and enforcement of induction guidelines contributed to a decrease in inappropriate inductions, a lower cesarean birth rate for electively induced nulliparas, and a lower elective and overall induction rate.

Term birth (37-41 weeks of gestation) has previously been considered a homogeneous group to which risks associated with preterm (less than 37 weeks of gestation) and post-term births (42 weeks of gestation and beyond) are compared. An examination of the history behind the definition of term birth reveals that it was determined somewhat arbitrarily. There is a growing body of evidence suggesting that significant differences exist in the outcomes of infants delivered within this 5-week interval. We focus attention on a subcategory of term births called "early term," from 37 0/7 to 38 6/7 weeks of gestation, because there are increasing data that these births have increased mortality and neonatal morbidity as compared with neonates born later at term. The designation "term" carries with it significant clinical implications with respect to the management of pregnancy complications as well as the timing of both elective and indicated delivery. Management of pregnancies should clearly be guided by data derived from gestational age-specific studies. We suggest adoption of this new subcategory of term births (early term births), and call on epidemiologists, clinicians, and researchers to collect data specific to the varying intervals of term birth to provide new insights and strategies for improving birth outcomes.

BACKGROUND: Labor induction rates in the United States rose from 9.0 percent in 1989 to 20.5 percent in 2001, but reasons for the increase are poorly defined. A birth database from a region of upstate New York, including 31,352 deliveries from 1998 through 1999, was used to determine the degree of variation of labor induction rates among hospitals and practitioners.
METHODS: Total and elective labor induction rates were calculated for 16 hospitals and individual staff, and then evaluated using chi-square testing and regression.
RESULTS: Using all laboring women as the denominator, the regional labor induction rate was 20.8 percent; of these inductions, 25 percent had no apparent medical indication. Total induction rates and percent of elective inductions that were elective varied significantly among hospitals (10%-39% and 12%-55%, respectively, p<0.0001) and among practitioners within hospitals (7%-48% and 3%-76%, respectively, p<0.0001). Hospitals varied in size, risk status, and cesarean section rates, but these factors did not correlate with induction rates.
CONCLUSIONS: Labor induction rates are highly variable among and within hospitals. Delivery volume, population risk status, and differences in cesarean section rates did not explain this variation.

OBJECTIVE: To determine factors and outcomes associated with elective medical induction of labor as compared with spontaneous labor in low-risk women.
STUDY DESIGN: Using a birth certificate database including 11,849 low-risk, laboring women, univariate and multiple logistic regression was used to evaluate demographic and obstetric factors associated with elective labor induction. Low risk was defined as singleton, vertex, 37-41 weeks' gestation, no prior cesarean section, and no presenting medical/obstetric diagnoses considered indications for cesarean or induction. Adverse neonatal outcome was defined as 1- or 5-minute Apgar score < 7, neonatal intensive care unit admission or respiratory distress. Spontaneously laboring women (n = 10,608) were compared with women who underwent induced labor for no apparent medical/obstetric reason (n = 1,241). Interventions and outcomes during and after labor induction were adjusted for relevant associated variables.
RESULTS: Odds ratios for epidural anesthesia, cesarean delivery and diagnoses of nonreassuring fetal heart rate patterns were independently increased following elective induction; odds ratios for cephalopelvic disproportion, instrumental delivery and adverse neonatal outcome were not. Maternal length of stay was 0.34 days longer with induction than with spontaneous labor (p < 0.0001). Slightly more induced labors ended before midnight.
CONCLUSION: As compared with spontaneous labor, elective labor induction is independently associated with more intrapartum interventions, more cesarean deliveries and longer maternal length of stay. Neonatal outcome is unaffected.

OBJECTIVES: To estimate women’s understanding of the definition of full term and the gestational age at which it is safe to deliver an otherwise healthy pregnancy. METHODS: A national sample of 650 insured women who recently gave birth were surveyed about their beliefs related to the meaning of full term and the safety of delivery at various gestational ages. Descriptive statistics including means and 95% confidence intervals were calculated for the demographic variables and survey measures; multivariate logistic regression analyses were also performed. RESULTS: Twenty-four percent of women surveyed considered a baby of 34–36 weeks of gestation to be full term, and 50.8% believed full term to occur at 37–38 weeks of gestation, while only 25.2% considered full term to occur at 39–40 weeks of gestation. In response to,“What is the earliest point in pregnancy that it is safe to deliver the baby, should there be no other medical complications requiring early delivery?” 51.7% choose 34–36 weeks of gestation, and 40.7% choose 37–38 weeks of gestation, while only 7.6% choose 39–40 weeks of gestation. CONCLUSION: The American College of Obstetricians and Gynecologists recommends that elective deliveries not occur before 39 weeks of gestation. However, many women believe that full term is reached before 37 weeks of gestation, and most believe full term occurs before 39 weeks of gestation. Nearly half believe it is safe to deliver before 37 weeks of gestation, and almost all believe it is safe to deliver before 39 weeks of gestation. The data reported here suggest that many women believe that term is reached early and that a safe delivery does not require waiting to 39 weeks of gestation.

Abstract: The frequency of labor induction has increased significantly in recent years. Although medically indicated inductions comprise a portion of this increase, elective inductions have increased in frequency as well. Given that elective inductions, by definition, provide no benefit from a strictly medical standpoint, it is particularly important to evaluate whether women who undergo these inductions incur greater risks than those who labor spontaneously. This article will assess whether elective inductions are associated with changes in pregnancy outcomes, and evaluate how these associations are influenced by parity and cervical ripeness. Key words: elective labor induction, cesarean, pregnancy outcomes

OBJECTIVE: To investigate the association between elective caesarean sections and neonatal respiratory morbidity and the importance of timing of elective caesarean sections.
DESIGN: Cohort study with prospectively collected data from the Aarhus birth cohort, Denmark.
SETTING: Obstetric department and neonatal department of a university hospital in Denmark.
PARTICIPANTS: All liveborn babies without malformations, with gestational ages between 37 and 41 weeks, and delivered between 1 January 1998 and 31 December 2006 (34 458 babies).
MAIN OUTCOME MEASURES: Respiratory morbidity (transitory tachypnoea of the newborn, respiratory distress syndrome, persistent pulmonary hypertension of the newborn) and serious respiratory morbidity (oxygen therapy for more than two days, nasal continuous positive airway pressure, or need for mechanical ventilation).
RESULTS: 2687 infants were delivered by elective caesarean section. Compared with newborns intended for vaginal delivery, an increased risk of respiratory morbidity was found for infants delivered by elective caesarean section at 37 weeks' gestation (odds ratio 3.9, 95% confidence interval 2.4 to 6.5), 38 weeks' gestation (3.0, 2.1 to 4.3), and 39 weeks' gestation (1.9, 1.2 to 3.0). The increased risks of serious respiratory morbidity showed the same pattern but with higher odds ratios: a fivefold increase was found at 37 weeks (5.0, 1.6 to16.0). These results remained essentially unchanged after exclusion of pregnancies complicated by diabetes, pre-eclampsia, and intrauterine growth retardation, or by breech presentation.
CONCLUSION: Compared with newborns delivered vaginally or by emergency caesarean sections, those delivered by elective caesarean section around term have an increased risk of overall and serious respiratory morbidity. The relative risk increased with decreasing gestational age.

One of the biggest challenges a newborn faces after birth is the task of making a smooth transition to air breathing. This task is complicated by the fact that fetal lungs are full of fluid which must be cleared rapidly to allow for gas exchange. Respiratory morbidity as a result of failure to clear fetal lung fluid is not uncommon, and can be particularly problematic in some infants delivered by elective cesarean delivery (ECS). Given the high rates of cesarean deliveries in the USA and worldwide, the public health and economic impact of morbidity in this subgroup is considerable. Whereas the occurrence of birth asphyxia, trauma, and meconium aspiration is reduced by elective Cesarean delivery, the risk of respiratory distress secondary to transient tachypnea of the newborn,surfactant deficiency, and pulmonary hypertension is increased. It is clear that physiologic events in the last few weeks of pregnancy coupled with the onset of spontaneous labor are accompanied by changes in the hormonal milieu of the fetus and its mother, resulting in preparation of the fetus for neonatal transition. Rapid clearance of fetal lung fluid is a key part of these changes, and is mediated in large part by transepithelial Na reabsorption through amiloride-sensitive Na channels in the alveolar epithelial cells, with only a limited contribution from mechanical factors and Starling forces. This chapter discusses the physiologic mechanisms underlying fetal lung fluid absorption and explores potential strategies for facilitating neonatal transition when infants are delivered by ECS before the onset of spontaneous labor.

Background: Previous studies have demonstrated an association between preterm delivery and increased risk of special educational need (SEN). The aim of our study was to examine the risk of SEN across the full range of gestation. Methods and Findings: We conducted a population-based, retrospective study by linking school census data on the 407,503 eligible school-aged children resident in 19 Scottish Local Authority areas (total population 3.8 million) to their routine birth data. SEN was recorded in 17,784 (4.9%) children; 1,565 (8.4%) of those born preterm and 16,219 (4.7%) of those born at term. The risk of SEN increased across the whole range of gestation from 40 to 24 wk: 37–39 wk adjusted odds ratio (OR) 1.16, 95% confidence interval (CI) 1.12–1.20; 33–36 wk adjusted OR 1.53, 95% CI 1.43–1.63; 28–32 wk adjusted OR 2.66, 95% CI 2.38–2.97; 24–27 wk adjusted OR 6.92, 95% CI 5.58–8.58. There was no interaction between elective versus spontaneous delivery. Overall, gestation at delivery accounted for 10% of the adjusted population attributable fraction of SEN. Because of their high frequency, early term deliveries (37–39 wk) accounted for 5.5% of cases of SEN compared with preterm deliveries (,37 wk), which accounted for only 3.6% of cases. Conclusions: Gestation at delivery had a strong, dose-dependent relationship with SEN that was apparent across the whole range of gestation. Because early term delivery is more common than preterm delivery, the former accounts for a higher percentage of SEN cases. Our findings have important implications for clinical practice in relation to the timing of elective delivery.

Babies of 37–41 wk gestation are, by international convention, said to be born at ‘term’, but some still develop respiratory distress. It is not clear how mature a baby has to be to be free of risk of primary surfactant deficiency. An area-based retrospective study of all the 179 701 babies of 34 or more weeks’ gestation born alive in a defined area of the north of England in 1988–92 identified 149 babies with features of respiratory distress typical of surfactant deficiency severe enough to be managed with ventilatory support and with no evidence of aspiration or intrapartum infection. Gestation was carefully cross-validated against antenatal information, including at least one ultrasound assessment in the first half of pregnancy. Thirty-six of these babies were born at or after 37 wk gestation. Only 4 of the 35 delivered at 37–38 wk went into spontaneous labour. Seven became ill enough to be candidates for ECMO and two died. A review of all neonatal deaths in the study area between 1981 and 1995 identified four similar deaths in 1981–87 and two in 1993– 95. Babies who are not premature, using the internationally agreed definition, can show signs of potentially lethal pulmonary immaturity at birth, especially if subjected to pre-labour Caesarean delivery. Those born at 37–38 wk are 120 times more likely to receive ventilatory support for surfactant deficiency than those born at 39–41 wk. Elective delivery should only be undertaken before 39 wk gestation for good medical reasons. & Assisted ventilation, epidemiology, mortality, population study, surfactant deficiency, term infant

Martin JA. United States vital statistics and the measurement of gestational age. Paediatric and Perinatal Epidemiology 2007; 21(Suppl. 2): 13–21. Estimates of the gestational age of the newborn based on US Birth Certificate data are extensively used to monitor trends in infant and maternal health and to improve our understanding of adverse pregnancy outcome. Two measures of gestational age, the ‘date of the last normal menses’ (LMP) and the ‘clinical estimate of gestation’ (CE), have been available from birth certificate data since 1989. Reporting irregularities with the LMP-based measure are well-documented, and important questions remain regarding the derivation of the CE. Changes in perinatal medicine and in vital statistics reporting in recent years may have importantly altered gestational age data based on vital statistics. This study describes how gestational age measures are collected and edited in US national vital statistics, and examines changes in the reporting of these measures by race and Hispanic origin between 1990 and 2002. Data are drawn from the National Center for Health Statistics’ restricted use US birth files for 1990–2002. Bivariable statistics are used. The percentage of records with missing LMP dates declined markedly over the study period, overall, and for each racial/Hispanic origin group studied. A marked shift in the distribution of the CE of gestational age was also observed, suggesting changes both in the true distribution of age at birth, and in the derivation of this measure. Agreement between the LMP-based and CE estimates increased over the study period, especially among preterm births. However, a high proportion of LMP dates continue to be missing or invalid and the derivation of the CE is still uncertain. In sum, although the reporting of gestational age measures in vital statistics appears to have improved between 1990 and 2002, substantial concerns with both the LMP-based and the CE persist. Efforts to identify approaches to further improve upon the quality of these data are needed.

US births increased 3% between 2005 and 2006 to 4,265,996, the largest number since 1961. The crude birth rate rose 1%, to 1.42 per 1000 population, and the general fertility rate increased 3%, to 68.5 per 1000 women 15 to 44 years. Births and birth rates increased among all race and Hispanic-origin groups. Teen childbearing rose 3% in 2006, to 41.9 per 1000 females aged 15 to 19 years, the first increase after 14 years of steady decline. Birth rates rose 2% to 4% for women aged 20 to 44; rates for the youngest (10-14 years) and oldest (45-49) women were unchanged. Childbearing by unmarried women increased steeply in 2006 and set new historic highs. The cesarean-delivery rate rose by 3% in 2006 to 31.1% of all births; this figure has been up 50% over the last decade. Preterm and low birth weight rates also increased for 2006 to 12.8% and 8.3%, respectively. The 2005 infant mortality rate was 6.89 infant deaths per 1000 live births, not statistically higher than the 2004 level. Non-Hispanic black newborns continued to be more than twice as likely as no-Hispanic white and Hispanic infants to die in the first year of life in 2004. For all gender and race groups combined, expectation of life at birth reached a record high of 77.9 years in 2005. Age-adjusted death rates in the United States continue to decline. The crude death rate for children aged 1 to 19 years decreased significantly between 2000 and 2005. Of the 10 leading causes of death for children in 2005, only the death rate for cerebrovascular disease was up slightly from 2000, whereas accident and chronic lower respiratory disease death rates decreased. A large proportion of childhood deaths, however, continue to occur as a result of preventable injuries.

Objective: To determine the effects of elective induction on the risk of cesarean delivery in a cohort of women with low-risk term pregnancies and to evaluate the costs of elective induction services within our hospital system. Methods: Records of 1135 eligible women with low-risk, singleton, vertex pregnancies at 38 – 41 weeks’ gestation who were eligible for vaginal delivery were analyzed retrospectively after elective induction (n 􏰆􏰆􏰆 263) or spontaneous labor (n 􏰆􏰆􏰆 872). Outcome measures included cesarean delivery and direct costs. Variables evaluated were parity, maternal age, estimated gestational age, birth weight, prior cesarean delivery, epidural anesthetic use, and provider category. Analysis was by univariable and multivariable regression modeling. Results: Elective induction placed nulliparas at a twofold higher risk for cesarean delivery (odds ratio 2.4, 95% confidence interval 1.2, 4.9) after adjustment for birth weight, maternal age, and gestational age. We found a significantly increased risk of cesarean delivery with increased birth weight for nulliparas (2– 66.7%). Increasing maternal age increased the risk of cesarean delivery in all parity groups (P <<< .05), but particularly among nulliparas (3–26.3%) (P <<< .001). Electively induced labors that ended in vaginal delivery cost $273 more and required an average of 4 hours more in the hospital before delivery than did noninduced vaginal deliveries (P <<< .001). Conclusion: Elective induction significantly increased the risk of cesarean delivery for nulliparas, and increased in-hospital predelivery time and costs. (Obstet Gynecol 2000; 95:917–22. © 2000 by The American College of Obstetri- cians and Gynecologists.)

OBJECTIVE: To establish whether the timing of delivery between 37 and 42 weeks gestation influences neonatal respiratory outcome and thus provide information which can be used to aid planning of elective delivery at term.
DESIGN: All cases of respiratory distress syndrome or transient tachypnoea at term requiring admission to the neonatal intensive care unit were recorded prospectively for nine years.
SETTING: Rosie Maternity Hospital, Cambridge.
SUBJECTS: During this time 33,289 deliveries occurred at or after 37 weeks of gestation.
MEASURES: This information enabled calculation of the relative risk of respiratory morbidity for respiratory distress syndrome or transient tachypnoea in relation to mode of delivery and onset of parturition for each week of gestation at term.
RESULTS: The incidence of respiratory distress syndrome at term was 2.2/ 1000 deliveries (95 % CI; 1.7-2.7). The incidence of transient tachypnoea was 5.7/1000 deliveries (95 % CI; 4.9-65). The incidence of respiratory morbidity was significantly higher for the group delivered by caesarean section before the onset of labour (35.5/ 1000) compared with caesarean section during labour (12.2/1000) (odds ratio, 2.9; 95% CI 1.9-4.4; P <0.001), and compared with vaginal delivery (5.3/1000) (odds ratio, 6.8; 95 % CI 52-8.9; P < 0.001). The relative risk of neonatal respiratory morbidity for delivery by caesarean section before the onset of labour during the week 37+0 to 37+6 compared with the week 38+0 to 38+6 was 1.74 (95 % CI 1.1 -2.8 ; P < 0.02) and during the week 38+O to 38+6 compared with the week 39+0 to 39+6 was 2.4 (95% CI 1.2-4.8; P < 0.02).
CONCLUSIONS: A significant reduction in neonatal respiratory morbidity would be obtained if elective caesarean section was performed in the week 39+0 to 39+6 of pregnancy.

OBJECTIVE: The American College of Obstetricians and Gynecologists has recommended that elective deliveries not be performed before 39 weeks of gestation, to minimize prematurity-related neonatal complications. Because a worrisome number of elective deliveries were occurring before 39 weeks of gestation in our system, we developed and implemented a program to decrease the number of these early term elective deliveries. Secondary objectives were to monitor relevant clinical outcomes.
METHODS: The electronic medical records of an integrated health care system involving nine labor and delivery units in Utah were queried to establish the incidence of patients admitted for elective induction of labor or planned elective cesarean delivery. These facilities have open staff models with obstetricians, family practitioners, and certified nurse midwives. Guidelines were developed and implemented to discourage early term elective deliveries. The prevalence of early term elective deliveries was tracked and reported back regularly to the obstetric leadership and obstetric departments at each facility.
RESULTS: The baseline prevalence of early term elective deliveries was 28% of all elective deliveries before the initiation of the program. Within 6 months of initiating the program, the incidence of near-term elective deliveries decreased to less than 10% and after 6 years continues to be less than 3%. A reduced length of stay in labor and delivery occurred with the introduction of the program, and there were no adverse effects on secondary clinical outcomes.
CONCLUSION: With institutional commitment, it is possible to substantially reduce and sustain a decline in the incidence of elective deliveries before 39 weeks of gestation.

OBJECTIVE: The purpose of this investigation was to examine the economic impact of performing elective repeat cesarean during 37 or 38 weeks of gestation relative to the American College of Obstetricians and Gynecologists recommendation of a 39-week delivery. STUDY DESIGN: Decision analysis modeling was used to estimate economic outcomes for a hypothetical cohort of neonates using data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network study of “Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes.” Costs and charges were estimated using the Florida Healthcare Cost and Utilization Project. RESULTS: A total of 82,541 deliveries occurring between 37-39 completed weeks of gestation were analyzed for the incidence of adverse outcomes and their hospital costs and charges. The model demonstrated increased costs through increasing adverse outcomes among elective repeat cesarean deliveries performed
39 weeks of gestation. CONCLUSION: Our findings suggest that there are benefits to waiting until 39 weeks of gestation to perform an elective repeat cesarean delivery.

AIMS: 1. Ascertain antenatal and intrapartum risk factors for term neonates ventilated primarily for respiratory problems. 2. Describe the neonatal morbidity and mortality. Methods. Population-based case control cohort study. SETTING: Sydney and four large rural/urban Health Areas in New South Wales, 1996. SUBJECTS: Singleton term infants, no major congenital anomaly: subset of 99 infants ventilated primarily for respiratory problems from 182 cases admitted to a tertiary neonatal intensive care unit (NICU) for mechanical ventilation, and 550 randomly selected controls. OUTCOME: Risk factors for case status by maternal, antenatal, labor, delivery, and combined epochs, adjusted Odds Ratios (OR), 95 per cent Confidence Intervals (CI), p<0.05. RESULTS: Predictors of case status by multivariate epochs: mother’s age >35 years (1.9 (1.1, 3.2) p<0.03), primigravida (1.8 (1.1, 2.8) p<0.01), any antenatal complication (3.8 (2.4, 5.9) p<0.0001), birth weigh<3rd percentile (3.7 (1.5, 9.1) p<0.006), gestational diabetes (2.9 (1.3, 6.9) p<0.01), maternal pyrexia (6.5 (1.6, 27.2) p<0.01), birth weight >90th percentile (1.8 (1.01, 3.2) p<0.047), gestation 37–38 weeks (2.3 (1.5, 3.6) p<0.0004), forceps (4.4 (2.1, 9.1) p<0.0001), elective cesarean section (3.7 (2.0, 6.5) p<0.0001), emergency cesarean section (4.5 (2.4, 8.4) p<0.0001). Case mortality rate was 5 per cent. CONCLUSIONS: The pathways to neonatal respiratory morbidity in term infants are multifactorial. Several areas which warrant more in-depth study are: elective cesarean section at 37–38 weeks gestation, fetal growth restriction, macrosomia and the pattern of in-utero growth, maternal weight gain during pregnancy, gestational diabetes, pyrexia in labor and the role of chorioamnionitis.

Aims. 1. Ascertain antenatal and intrapartum risk factors for term neonates ventilated primarily for ‘perinatal asphyxia’. 2. Describe the neonatal morbidity and mortality. Methods. Population-based case control cohort study. Setting. Sydney and four large rural/urban health areas in New South Wales. Subjects. Singleton term infants, no major congenital anomaly: subset of 83 infants ventilated primarily for ‘asphyxia’ from 182 cases admitted to a tertiary neonatal intensive care unit (NICU) for mechanical ventilation, 550 randomly selected controls. Outcome. Risk factors for case status by maternal, antenatal, labor, delivery, and combined epochs, adjusted odds ratios (OR), 95 per cent confidence intervals (CI), p􏰁0.05. Results. Predictors of case status by multivariate epochs: Primigravida (1.8 [1.1, 2.8]), thyroid disease (7.8 [1.1, 57.0]), any antenatal complication (5.1 [3.0, 8.6]), growth restriction (4.2 [1.7, 10.4]), male gender (2.1 [1.3, 3.5]), gestational age 􏰂40 weeks (1.9 (1.1, 3.3)), prolonged rupture of membranes (9.7 [1.3, 72.5]), complicated labor (6.6 [3.7, 11.9]), induced labor (2.2 [1.3, 3.9]), prostaglandins 2.46 [1.23, 4.91]), maternal pyrexia (10.8 [2.8, 42.7]), placental hemorrhage in labor (OR 4.24 [1.45, 12.42]), forceps delivery (4.1 [1.9, 8.5]), emergency cesarean section (4.7 [2.6, 8.7]). Twenty case infants (24%) and no control infants died. Conclusions. This study has shown maternal and antepartum risk factors for severe neonatal morbidity in term infants. More centers need to become interested in the term baby, so that a larger multicenter study can further elucidate the heterogeneous causal pathways to term neonatal morbidity.

Background: Because of increased rates of respiratory complications, elective cesarean delivery is discouraged before 39 weeks of gestation unless there is evidence of fetal lung maturity. We assessed associations between elective cesarean delivery at term (37 weeks of gestation or longer) but before 39 weeks of gestation and neonatal outcomes. Methods: We studied a cohort of consecutive patients undergoing repeat cesarean sections performed at 19 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network from 1999 through 2002. Women with viable singleton pregnancies delivered electively (i.e., before the onset of labor and without any recognized indications for delivery before 39 weeks of gestation) were included. The primary outcome was the composite of neonatal death and any of several adverse events, including respiratory complications, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit (ICU). Results:Of 24,077 repeat cesarean deliveries at term, 13,258 were performed electively; of these, 35.8% were performed before 39 completed weeks of gestation (6.3% at 37 weeks and 29.5% at 38 weeks) and 49.1% at 39 weeks of gestation. One neonatal death occurred. As compared with births at 39 weeks, births at 37 weeks and at 38 weeks were associated with an increased risk of the primary outcome (adjusted odds ratio for births at 37 weeks, 2.1; 95% confidence interval [CI], 1.7 to 2.5; adjusted odds ratio for births at 38 weeks, 1.5; 95% CI, 1.3 to 1.7; P for trend <0.001). The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks. Conclusions: Elective repeat cesarean delivery before 39 weeks of gestation is common and is associated with respiratory and other adverse neonatal outcomes.

Reviews of perinatal care have consistently pointed to failures of communication among the care team and documentation of care as common factors in adverse events that occur in labor and delivery. They are also prime factors leading to malpractice claims. Idealized Design of Perinatal Care is an innovation project based on the principles of reliability science and the Institute for Healthcare Improvement’s (IHI’s) model for applying these principles to improve care. The Idealized Design model focuses on comprehensive redesign to enable a care system to perform substantially better in the future than the best it can do at present. The goal of Idealized Design of Perinatal Care is to achieve a new level of safer, more effective care and to minimize some of the risks identified in medical malpractice cases. The model described in this white paper, Idealized Design of Perinatal Care, represents the Institute for Healthcare Improvement’s best current assessment of the components of the safest and most reliable system of perinatal care. The four key components of the model are: The development of reliable clinical processes to manage labor and delivery The use of principles that improve safety (i.e., preventing, detecting, and mitigating errors) The establishment of prepared and activated care teams that communicate effectively with each other and with mothers and families A focus on mother and family as the locus of control during labor and delivery Two perinatal care "bundles" — a group of evidence-based interventions related to a disease or care process that, when executed together, result in better outcomes than when implemented individually — are being tested in this Idealized Design project: the Elective Induction Bundle and the Augmentation Bundle. The assumption of this innovation work is that reliably applying these evidence-based interventions in the delivery of perinatal care can dramatically improve outcomes. This white paper provides detail about the Idealized Design process and examines some of the initial work completed by teams in the innovation project.

DESCRIPTION: Patients with elective vaginal deliveries or elective cesarean sections at 37 to 39 weeks of gestation completed.
RATIONALE: For almost 3 decades, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have had in place a standard requiring 39 completed weeks gestation prior to ELECTIVE delivery, either vaginal or operative (ACOG, 1996). A survey conducted in 2007 of almost 20,000 births in HCA hospitals throughout the U.S. carried out in conjunction with the March of Dimes at the request of ACOG revealed that almost 1/3 of all babies delivered in the United States are electively delivered with 5% of all deliveries in the U.S. delivered in a manner violating ACOG/AAP guidelines. Most of these are for convenience, and result in significant short term neonatal morbidity (neonatal intensive care unit admission rates of 13- 21%) (Clark et al., 2009). According to Glantz (2005), compared to spontaneous labor, elective inductions result in more cesarean deliveries and longer maternal length of stay. The American Academy of Family Physicians (2000) also notes that elective induction doubles the cesarean delivery rate. Repeat elective cesarean sections before 39 weeks gestation also result in higher rates of adverse respiratory outcomes, mechanical ventilation, sepsis and hypoglycemia for the newborns (Tita et al., 2009).
TYPE: Process.
IMPROVEMENT: Decrease in the rate.
NUMERATOR: Patients with elective deliveries. Included Populations: ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for one or more of the following: * Medical induction of labor as defined in Appendix A, Table 11.05 * Cesarean section as defined in Appendix A, Table 11.06 Excluded Populations: None. Data Elements: * ICD-9-CM Other Procedure Dates * ICD-9-CM Principal Procedure Code.
DENOMINATOR: Patients delivering newborns with 37 to 39 weeks of gestation completed Included Populations: Not applicable. Excluded Populations: * ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for conditions justifying elective delivery as defined in Appendix A, Table 11.07 * Less than 8 years of age * Greather than or equal to 65 years of age * Length of stay > 120 days * Enrolled in clinical trials * Active Labor * Spontaneous Rupture of Membranes