Quality Improvement - Perinatal Case Studies 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.

BACKGROUND: Implementation of evidence-based obstetrical practices remains a significant challenge. Effective strategies to disseminate and implement such practices are needed.
METHODS: We randomly assigned 19 hospitals in Argentina and Uruguay to receive a multifaceted behavioral intervention (including selection of opinion leaders, interactive workshops, training of manual skills, one-on-one academic detailing visits with hospital birth attendants, reminders, and feedback) to develop and implement guidelines for the use of episiotomy and management of the third stage of labor or to receive no intervention. The primary outcomes were the rates of prophylactic use of oxytocin during the third stage of labor and of episiotomy. The main secondary outcomes were postpartum hemorrhage and birth attendants' readiness to change their behavior with regard to episiotomies and management of the third stage of labor. The outcomes were measured at baseline, at the end of the 18-month intervention, and 12 months after the end of the intervention.
RESULTS: The rate of use of prophylactic oxytocin increased from 2.1% at baseline to 83.6% after the end of the intervention at hospitals that received the intervention and from 2.6% to 12.3% at control hospitals (P=0.01 for the difference in changes). The rate of use of episiotomy decreased from 41.1% to 29.9% at hospitals receiving the intervention but remained stable at control hospitals, with preintervention and postintervention values of 43.5% and 44.5%, respectively (P<0.001 for the difference in changes). The intervention was also associated with reductions in the rate of postpartum hemorrhage of 500 ml or more (relative rate reduction, 45%; 95% confidence interval [CI], 9 to 71) and of 1000 ml or more (relative rate reduction, 70%; 95% CI, 16 to 78). Birth attendants' readiness to change also increased in the hospitals receiving the intervention. The effects on the use of episiotomy and prophylactic oxytocin were sustained 12 months after the end of the intervention. CONCLUSIONS: A multifaceted behavioral intervention increased the prophylactic use of oxytocin during the third stage of labor and reduced the use of episiotomy.

OBJECTIVE: The purpose of this study was to examine complications of labor induction compared to spontaneous labor in multiparas.
STUDY DESIGN: This was a retrospective cohort study of multiparous women with live, singleton pregnancies at term, who had no contraindications to labor or labor induction. Cesarean delivery was the primary outcome.
RESULTS: Of the study subjects, 7208 experienced spontaneous labor, 2190 underwent labor induction with oxytocin, and 239 underwent labor induction requiring cervical ripening agents. Oxytocin-induced multiparas were 37% more likely to require cesarean compared to those with spontaneous labor (OR, 1.37; 95% CI, 1.10-1.71) and nearly 3 times more likely to undergo cesarean when cervical ripening agents were used (OR, 2.82; 95% CI, 1.84-4.53). Women requiring cervical ripening were also 10 times more likely to spend more than 12 hours in labor than those with spontaneous labor.
CONCLUSION: Multiparas undergoing labor induction are at increased risk for obstetric complications compared to spontaneous labor.

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

Objectives: Two programs targeting urban African-American women are presented as promising models for preconception care, which includes interconception care. Methods: The Grady Memorial Hospital Interpregnancy Care (IPC) Program in Atlanta, Georgia, and the Magnolia Project in Jacksonville, Florida, are described. The IPC program aims to investigate whether IPC can improve the health status, pregnancy planning and child spacing of women at risk of very low birthweight (VLBW). The Magnolia Project aims to reduce key risks in women of childbearing age, such as lack of family planning and repeat sexually transmitted diseases (STDs), through its case management activities. Results: Seven out of 21 women in the IPC were identified as having a previously unrecognized or poorly managed chronic disease. 21/21 women developed a reproductive plan for themselves, and none of the 21 women became pregnant within nine months following the birth of their VLBW baby. The Magnolia Project had a success rate of greater than 70% in resolving the key risks (lack of family planning, repeat STDs) among case management participants. The black to white infant mortality (IM) ratio was better for babies born to women managed in the Magnolia Project compared to the same ratio for the United States. Conclusions: Preconception care targeted to African-American women at risk for poor birth outcomes appears to be effective when specific risk factors are identified and interventions are appropriate. Outreach to women at risk and case management can be effective in optimizing the woman's health and subsequent reproductive health outcomes.

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.

Induction of labor has become routine practice in perinatal units across the United States, with rates reaching a high of 21.2% of births in 2003-2004. This article describes the process our institution used to standardize the criteria for scheduling inductions. Specifically, we aimed to increase the consistency in practice for scheduling and performing elective inductions, including mandating gestational age of 39 completed weeks, ensuring cervical ripeness, and disallowing the use of cervical ripening agents. The nurses’ participation, from planning to implementation, was critical in the success of this evidence-based practice change.

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.

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.

BACKGROUND: Decreasing the use of continuous electronic fetal monitoring and increasing professional labor support for low-risk pregnancies are recommended by the Society of Obstetricians and Gynecologists of Canada. This study explored factors influencing the successful (and unsuccessful) introduction of an evidence-based fetal health surveillance guideline.
METHODS: This qualitative case study was conducted at two tertiary and one community hospital. Data were collected in 14 clinician focus groups (51 nurses), followed by 8 interviews with nurse administrators and educators. Analysis of verbatim transcripts and unit records included coding and categorizing data to form profiles that were compared across hospitals.
RESULTS: Implementation of the guideline recommendations in the hospital settings was affected by many different factors originating in the practice environment, with the potential adopters, and related to the characteristics of the guideline. The influences of these diverse factors interacted sometimes to magnify or counteract each other's effect. The physical setting, adopter concerns, and the medicolegal issues surrounding the guideline played critical roles in uptake. In addition, changes preceding the introduction of the recommendations, the institution's agenda, and nursing and medical leadership influenced the uptake of guideline recommendations. The number and experience of nurses in each setting and availability of equipment also affected guideline acceptance and use.
CONCLUSIONS: When implementing best practice, it is important to identify organizational barriers to the change that will need managing by the appropriate level of administration in the organization. Careful tailoring of implementation interventions to the barriers originating with the potential adopters is also necessary. Be prepared for unanticipated effects.

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.

Context: Formorethan30years,guidelinesforperinatalregionalizationhaverecommended that very low-birth-weight (VLBW) infants be born at highly specialized hospitals, most commonly designated as level III hospitals. Despite these recommendations, some regions continue to have large percentages of VLBW infants born in lower-level hospitals. Objective: To evaluate published data on associations between hospital level at birth and neonatal or predischarge mortality for VLBW and very preterm (VPT) infants. Data Sources: Systematic search of published literature (1976–May 2010) in MEDLINE, CINAHL, EMBASE, and PubMed databases and manual searches of reference lists. Study Selection and Data Extraction Forty-one publications met a priori inclusion criteria (randomized controlled trial, cohort, and case-control studies measuring neonatal or predischarge mortality among live-born infants 1500 g or 32 weeks’ gestation delivered at a level III vs lower-level facility). Paired reviewers independently assessed publications for inclusion and extracted data using standardized forms. Discrepancies were decided by a third reviewer. Publications were reviewed for quality by 3 authors based on 2 content areas: adjustment for confounding and description of hospital levels. We calculated weighted, combined odds ratios (ORs) using a random-effects model and comparative unadjusted pooled mortality rates. Data Synthesis: We observed increased odds of death for VLBW infants (38% vs 23%; adjusted OR, 1.62; 95% confidence interval [CI], 1.44-1.83) and VPT infants (15% vs 17%; adjusted OR, 1.55; 95% CI, 1.21-1.98) born outside of level III hospitals. Consistent results were obtained when restricted to higher-quality evidence (mortality in VLBW infants, 36% vs 21%; adjusted OR, 1.60; 95% CI, 1.33-1.92 and in VPT infants, 7% vs 12%; adjusted OR, 1.42; 95% CI, 1.06-1.88) and infants weighing less than 1000 g (59% vs 32%; adjusted OR, 1.80; 95% CI, 1.31-2.46). No significant differences were found through subgroup analysis of study characteristics. Metaregression by year of publication did not reveal a change over time (slope, 0.00; P=.87). Conclusion: For VLBW and VPT infants, birth outside of a level III hospital is significantly associated with increased likelihood of neonatal or predischarge death.

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.

Failure to rescue is an indicator that has been used to measure quality of care for surgical patients by evaluating the number of patients who die after developing postoperative complications. There are 2 key components of failure to rescue: (a) careful surveillance and timely identification of complications and (b) taking action by quickly initiating appropriate interventions and activating a team response. This concept has not been explored as a potential method to evaluate quality of intrapartum care. In obstetrics, complications leading to death are relatively rare because mothers and infants are generally healthy. Thus, there are not large numbers of maternal or infant deaths in individual hospitals or healthcare systems that allow the types of statistical analyses that have been previously used to measure failure to rescue rates. With modifications in the measurement process for failure to rescue in this population, there are direct implications for perinatal patient safety and lessons to be learned. A new use of the failure to rescue concept in a population not previously considered is proposed.

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.

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.

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.

A reasonable trigger tool for nursing charting on L&D. From: Appendix to Saving Mother's Lives (2007); also published in: International Journal of Obstetric Anesthesia (2006) 15, S1-S43 Abstracts of free papers presented at the annual meeting of the Obstetric Anaesthetists? Association, Glasgow 11-12 May, 2006. “Early-warning scoring in obstetrics”. P Harrison, C Hawe, F McIlveney. Department of Anaesthesia, Stirling Royal Infirmary, Stirling, UK.