“39 weeks is the rule, provided delivery is truly elective”
“If you give magnesium sulfate for fetal neuroprotection, adhere to a protocol”
(Update on Obstetrics; January 2011)
John T. Repke, MD, and Jaimey M. Pauli, MD
“More strategies to avoid malpractice hazards on labor and delivery”
(Second of two parts; Focus on Professional Liability; January 2011)
Martin L. Gimovsky, MD, and Alexis C. Gimovsky, MD
Obstetricians and other providers of intrapartum care can improve birth outcomes significantly by eliminating the practice of elective delivery before 39 full weeks of gestation. That’s a key recommendation in a report issued by the March of Dimes at the end of 2010.1
In tandem with the report and accompanying formal recommendations for clinical care, the March of Dimes is expanding a quality improvement program to reduce unnecessary inductions and cesarean deliveries, noted Scott D. Berns, MD, MPH, at a presentation by the organization in New York on December 15. Dr. Berns is senior vice president for Chapter Programs of the March of Dimes and editor of the report, Toward Improving the Outcome of Pregnancy III (TIOP III). He is also clinical professor of pediatrics at the Warren Alpert Medical School at Brown University.
“It’s about babies being born at the right time for the right reasons,” Dr. Berns said.
Medical inductions are too common
A key focus of TIOP III is the need to curtail the practice of elective “term” delivery at 37 and 38 weeks of gestation. As the report notes, although “there are many valid medical and obstetric indications for delivery before 39 weeks of gestation, medical justification for a significant proportion of early deliveries is questionable.”1
Of particular concern is the use of medical induction of labor at 37 to 39 weeks without a legitimate indication—a practice that has increased dramatically over the past decade and that raises the rate of cesarean delivery, said Mark R. Chassin, MD, MPP, MPH, who spoke at the New York release of the report. Dr. Chassin is President of the Joint Commission.
Morbidity rises with early delivery
Early term delivery is widespread. As many as 30% of all births in the United States are performed electively (“without identifiable medical or obstetric indication”) before 39 weeks’ gestation, said Dr. Berns. This statistic includes elective induction of labor and elective primary and repeat cesarean delivery, he added.
The morbidity associated with these early births is significant:
- The rate of admission to a newborn intensive care unit (NICU) doubles in infants born electively at 38 to 39 weeks of gestation, compared with those delivered at or beyond 39 weeks
- “Infants born before 39 completed weeks of gestation also have a higher incidence of respiratory distress syndrome and infant death than those delivered later”1
- There is evidence that neonatal morbidity increases even after fetal lung maturity is confirmed when elective delivery takes place before 39 weeks.1
ACOG has also warned against early elective delivery.2
The March of Dimes Foundation offers a toolkit on its Web site for clinicians to use to reduce the rate of elective delivery before 39 full weeks of gestation. It’s available at http://www.marchofdimes.com/professionals/less-than-39-weeks-toolkit.aspx.
Other intrapartum actions can boost outcomes
Other recommendations for improving intrapartum care and pregnancy outcomes included in TIOP III:
- Introduce facility-based protocols and develop effective leadership to eliminate elective deliveries before 39 weeks’ gestation
- Use standardized, low-dose oxytocin protocols for induction and augmentation of labor. (According to TIOP III: “Oxtyocin is the drug most commonly associated with preventable adverse events during childbirth and is also the drug most frequently implicated in professional liability claims.”1
- Uniformly implement unambiguous protocols for monitoring oxytocin infusion
- Avoid “inappropriate” cesarean delivery and de-emphasize the cesarean delivery rate as a primary quality indicator
- Adopt protocols for administration of magnesium sulfate for fetal neuroprotection in preterm infants
- Enhance and support a team approach to obstetric emergencies, and promote clinician understanding of intermediate and abnormal fetal heart rate patterns
- Use available checklists to document maneuvers—including those avoided—in the management of shoulder dystocia
- Develop a “robust quality improvement program” for intrapartum care processes.1