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Medically Indicated Deliveries Before 39 weeks
The document discusses the risks associated with non-medically indicated early deliveries before 39 weeks gestation, emphasizing that such practices can lead to neonatal complications without benefits for mothers or infants. It outlines the evolution of obstetric guidelines, particularly the American College of Obstetricians and Gynecologists' (ACOG) recommendations against early elective deliveries and the redefined terminology around term pregnancies. The conclusion stresses the importance of eliminating unnecessary early deliveries to reduce neonatal risks, supported by various national quality measures.
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Medically Indicated Deliveries Before 39 weeks
- 1. Medically Indicated Deliveries Before39 Weeks Gestational Age “MIDB39 weeks” Chukwuma I. Onyeije, M.D. Atlanta Perinatal Associates 1
- 2. Research and ExperienceShow: Early ELECTIVE delivery without MEDICAL or OBSTETRICAL indication is linked to neonatal morbidities with NO benefit for the mother or infant. HOWEVER…. There are numerous maternal and fetal indications for deliveries BEFORE 39 weeks gestation ALSO… Elective deliveries AFTER 39 weeks are not necessarily without risks for mother and infant. 2
- 3. Is there reallya problem here? “What’s the big deal?” “It’s only a couple of days?” “No one is going to tell me how to practice medicine.” Actual quotes from OBGYN providers regarding 39 week policy. Circa 2002. 3
- 4. Inductions of Labor •ACOG has cautioned against inductions before 39 weeks in the absence of a medical indication since 1979. (Committee Opinion #22) • ACOG also suggests that “a mature fetal lung maturity test result before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is NOT an indication for delivery” (Committee Practice Bulletins #97 and #107) 4
- 6. How did we get here? 1992 To2002 “The Lost Decade” 6
- 7. Change in Distributionof Births by Gestational Age: United States, 1990-2006 Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for 2006. National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics. 2009.
- 8. 2002 C-S Early Term Percentof Singleton Live Births (%) U.S. Cesarean Section and Labor Induction Rates Among Singleton Live Births by Week of Gestation, 1992 and 2002 1992 C-S 2002 Induction 1992 Induction Gestational Age (week) Source: NCHS, Final Natality Data, Prepared by March of Dimes Perinatal Data Center, April 2006.
- 9. Rates of Inductionof Labor in Singleton Births by Race and Hispanic Origin in the U.S. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for 2006. National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics. 2009.
- 10. Percent Singleton LiveBirths Changing Distribution of US Live Births 1992 - 2002 11/06/13 Davidoff et al Sem Perinatology 2006
- 11. Why are Non-medically Indicated(Elective) Deliveries Increasing in Frequency?
- 12.
- 13. The Gestational Agethat Women Considered a Baby to be Full Term 29.1% 21.7% 20.8% 17.4% 3.3% Obstet Gynecol 2009;114:1254 3.3% 4.8%
- 14. The Gestational Agethat Women Considered it Safe to Deliver 35% 31% 30% 25% 22% 19% Women's Responses 20% 15% 14% 10% Obstet Gynecol 2009;114:1254 5% 0% 7% 3% 4% Weeks of Gestation
- 15. Pressure on Obstetricians Reasonsthat physicians may resist elimination of elective deliveries < 39 weeks: •Physician Convenience • Guarantee attendance at birth (“co-dependency”) • Avoid scheduling conflicts • Reduce being awakened at night •…what’s the harm? • Bad outcomes are unrecognized and rare • The NICU handles these issues just fine •Limit risk of a bad pregnancy outcome Clin Obstet Gynecol 2006;49:698-704
- 16. Risks of Non-medically Indicated(Elective) Delivery Before 39 Weeks
- 17. Complications of Non-medicallyIndicated (Elective) Deliveries Between 37 and 39 Weeks • • • • • • Increased NICU admissions Increased transient tachypnea of the newborn (TTN) Increased respiratory distress syndrome (RDS) Increased ventilator support Increased suspected or proven sepsis Increased newborn feeding problems and other transition issues Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997
- 18. QUESTION: WHO (EXACTLY)IS TERM? 18
- 19. OLD Terminology Late PretermEarly Term First day of LMP Week # 0 20 0/7 340/7 Preterm 37 0/7 39 0/7 Term 416/7 Post term Modified from Drawing courtesy of William Engle, MD, Indiana University Raju TNK. Pediatrics, 2006;118 1207. 19
- 20. NEW Terminology October 31,2013 20
- 21. Term Pregnancy Redefinedby ACOG and SMFM Published in the November 2013 Green Journal. Four new definitions of “term pregnancy” were issued by ACOG & SMFM in a joint Committee Opinion. Terminology designed to put the focus on preventing deliveries before 39 weeks’ gestation. 21
- 22. ACOG and SMFMnow discourage the use of the general label “term pregnancy” Early Term: Between 37 weeks 0 days and 38 weeks 6 days Full Term: Between 39 weeks 0 days and 40 weeks 6 days Late Term: Between 41 weeks 0 days and 41 weeks 6 days Postterm: Between 42 weeks 0 days and beyond 22
- 23. Okay. How do Iknow if my patient is “Full Term”? 23
- 24.
- 25. Confirmation of TermGestation • Early ultrasound (< 20 weeks gestation) is more accurate than an ultrasound after 20 weeks gestation at determining gestational age and benchmarking < 39 weeks gestation. • Ultrasound-established dates should take precedence over LMP-established dates when the discrepancy is greater than 7 days in the first trimester and 10 days in the second trimester… OR if the LMP-established dates are uncertain. 25
- 26. Actual Case: JT presentedfor prenatal care on 9/7/13 with an LMP of 2/19/13. She was assigned an EDD of 11/26/13 and an EGA of 28 weeks. Her first ultrasound on 9/25/13 showed an EFW which placed her fetus at < 10 %tile. Her second ultrasound on 10/28/13 showed an EFW which placed her fetus at < 10 %tile. 26
- 27. At the timeof her second ultrasound the physician performing the ultrasound asked if she had had any previous ultrasounds. She pulled this out of her pocket from an emergency room visit on 5/23/13 (almost 5 months earlier) for spotting…… 27
- 28. Emergency Room Ultrasound Dateperformed: 5/23/13 CRL: 49.5 mm EGA: 11w5d 28
- 29. NEW EDD: 12/7/13 NEW EFW%tile: 54% 29
- 30. Clinician and/or PatientDesire to Clinician and/or Patient Desire to Schedule a Non-medically Schedule a Non-medically Indicated (Elective) Induction or Indicated (Elective) Induction or Cesarean Section Cesarean Section Clinician, Staff & Clinician, Staff & Patient Education Patient Education Elective Delivery Elective Delivery Hospital Policy Hospital Policy Physician Leadership Physician Leadership A. Enforce policy A. Enforce policy B. Approve exceptions B. Approve exceptions Reduce Demand Public Public Awareness Awareness Campaign Campaign Induction //Cesarean Induction Cesarean Scheduling Process Scheduling Process Case NOT Case NOT Scheduled Scheduled if Criteria if Criteria Not Met Not Met QI Data QI Data Collection Collection & Trend & Trend Charts Charts 30
- 31. Okay. Let’s get real. Not alldeliveries before 39 weeks are for “convenience”. 31
- 32. Timing of IndicatedLate-Preterm and Early-Term Birth. Obstetrics & Gynecology. 118(2, Part 1):323-333, August 2011.
- 33. ACOG Committee Opinion:April 2013 Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10. 33
- 34. ACOG Committee Opinion:April 2013 The neonatal risks of late preterm and early-term births are well established. HOWEVER, there are a number of complications in which either a late-preterm or early-term delivery is warranted. The timing of delivery must balance the maternal and newborn risks of late-preterm and early-term delivery with the risks of further continuation of pregnancy. 34
- 35. ACOG Committee Opinion:April 2013 Decisions regarding timing of delivery must be individualized. Amniocentesis for the determination of fetal lung maturity in well-dated pregnancies generally should not be used to guide the timing of delivery. 35
- 36. Terminology Recall…. Early Term: Between 37weeks 0 days and 38 weeks 6 days Full Term: Between 39 weeks 0 days and 40 weeks 6 days Late Term: Between 41 weeks 0 days and 41 weeks 6 days Postterm: Between 42 weeks 0 days and beyond 36
- 37. Terminology for MedicallyIndicated Deliveries Late Preterm Between 34 weeks 0 days and 36 weeks 6 days. Early Term: Between 37 weeks 0 days and 38 weeks 6 days Full Term: Between 39 weeks 0 days and 40 weeks 6 days Late Term: Between 41 weeks 0 days and 41 weeks 6 days Postterm: Between 42 weeks 0 days and beyond 37
- 38. Categories for MedicallyIndicated Deliveries: 38
- 39.
- 40. Placental / UterineIssues Condition General Timing Suggested Specific Timing PLACENTA PREVIA LATE PRETERM/EARLY TERM 36 0/7 to 37 6/7 WEEKS OF GESTATION PLACENTA PREVIA WITH SUSPECTED ACCRETA, INCRETA, OR PERCRETA LATE PRETERM 34 0/7 to 35 6/7 WEEKS OF GESTATION PRIOR CLASSICAL CESAREAN LATE PRETERM/EARLY TERM 36 0/7 to 37 6/7 WEEKS OF GESTATION PRIOR MYOMECTOMY EARLY TERM/TERM (INDIVIDUALIZE) 37 0/7 to 38 6/7 WEEKS OF GESTATION Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10. 40
- 41.
- 42. GROWTH RESTRICTION (SINGLETON) Fetalissues Condition OTHERWISE UNCOMPLICATED, NO CONCURRENT FINDINGS General Timing Suggested Specific Timing EARLY TERM / TERM 38 0/7 to 39 6/7 WEEKS OF GESTATION LATE PRETERM / EARLY TERM 34 0/7 to 37 6/7 WEEKS OF GESTATION CONCURRENT CONDITIONS (OLIGOHYDRAMNIOS, ABNORMAL DOPPLER STUDIES, MATERNAL COMORBIDITY (IE, PREECLAMPSIA, CHRONIC HYPERTENSION) Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10. 42
- 43. GROWTH RESTRICTION (TWINS) FETALISSUES: Condition General Timing Suggested Specific Timing Di – Di TWINS WITH ISOLATED FETAL GROWTH RESTRICTION LATE PRETERM/EARLY TERM 36w 7d 37w 6d Di – Di TWINS WITH CONCURRENT CONDITIONS LATE PRETERM 32w 7d 34w 6d Mono – Di TWINS WITH ISOLATED FETAL GROWTH RESTRICTION LATE PRETERM 32w 7d 34w 6d GESTATION GESTATION GESTATION 43
- 44. MULTIPLE GESTATIONS FETAL ISSUES: Condition GeneralTiming Di – Di TWINS EARLY TERM Mono - Di TWINS LATE PRETERM/ EARLY TERM Suggested Specific Timing 38w 0d 38w 6d GESTATION 34w 7d 37w 6d WEEKS OF GESTATION Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10. 44
- 45. OLIGOHYDRAMNIOS FETAL ISSUES: Condition General Timing SuggestedSpecific Timing OLIGOHYDRAMNIOS LATE PRETERM EARLY TERM 36w 0d 37w 6d GESTATION Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10. 45
- 46.
- 47. HYPERTENSIVE DISORDERS MATERNAL INDICATIONS CONTROLLED& NO MEDICATIONS EARLY TERM/TERM 38w 0d 39w 6d GESTATION CONTROLLED ON MEDICATIONS EARLY TERM/TERM 37w 0d 39w 6d GESTATION LATE PRETERM/EARLY TERM 36w 0d 37w 6d GESTATION EARLY TERM 37w 0d 38w 6d GESTATION DIFFICULT TO CONTROL GESTATIONAL HYPERTENSION 47
- 48. HYPERTENSIVE DISORDERS (Preeclampsia) MATERNAL INDICATIONS SEVEREPREECLAMPSIA MILD PREECLAMPSIA LATE PRETERM AT DIAGNOSIS AFTER 34w 0d GESTATION*** EARLY TERM AT DIAGNOSIS AFTER 37w 0d GESTATION *** Clinical judgment important 48
- 49. DIABETES PREGESTATIONAL: WELL-CONTROLLED* MATERNAL INDICATIONS PREGESTATIONAL WITH VASCULAR COMPLICATIONS PREGESTATIONAL: POORLYCONTROLLED GESTATIONAL: WELL CONTROLLED ON DIET OR MEDICATIONS GESTATIONAL: POORLY CONTROLLED LATE PRETERM, EARLY TERM BIRTH NOT INDICATED EARLY TERM / TERM 37w 0d 39w 6d GESTATION LATE PRETERM OR EARLY TERM INDIVIDUALIZED LATE PRETERM, EARLY TERM BIRTH NOT INDICATED LATE PRETERM OR EARLY TERM INDIVIDUALIZED 49
- 51. PREMATURE RUPTURE OF MEMBRANES(PROM) OBSTETRICAL INDICATIONS PPROM LATE PRETERM 34w 0d GESTATION 51
- 52. Conclusion: Reasons to EliminateNon-Medically Indicated (Elective) Deliveries Before 39 Weeks Reduction of neonatal complications No harm to mother if no medical or obstetrical indication for delivery Strong support from ACOG Now a national quality measure for hospital performance: - National Quality Forum (NQF) - Leapfrog Group - The Joint Commission (TJC) 52
- 53. HOW AM IGOING TO REMEMBER ALL OF THIS? 11/06/13
- 54. • These areguidelines. Clinical judgement and common sense should come first. • This presentation is available online. • http://bit.ly/midb39 • There’s an app for this. http://bit.ly/midb39app OR • http://bit.ly/midb39play 11/06/13
- 55.
- 56. Mecically Indicated Deliveries Before39 weeks. There's an app for that... http://bit.ly/midb39app
Editor's Notes
- #2 Slide Set #1
- #31 This schematic gives an overview of the process for implementing a successful program to reduce or eliminate elective deliveries taking place before 39 weeks gestation. The patient and clinician are critical in reducing elective deliveries. This process must begin with educating not only the clinician, but also the patient as to why it is unsafe to deliver before 39 weeks unless there is a medical or obstetrical reason to do so. The hospital staff is also a key player in this process. In addition, a policy must be created and the medical leadership must be on board. The process will be a lot smoother and cause less angst amongst the hospital staff if they are not placed in a position of having to tell the physician they cannot schedule a delivery. In the event that there is a dispute, the staff must be empowered to refer the scheduling physician to medical leadership for resolution. Finally, in order to track progress, data must be collected and charts reviewed periodically to confirm progress.