Successful Policy Changes In Elective DeliveryMain Category: Pregnancy / Obstetrics
Article Date: 13 Feb 2013
In a study to be presented on February 14 between 1:15 p.m., and 3:30 p.m. PST, at the Society for Maternal-Fetal Medicine's annual meeting, The Pregnancy Meeting ™, in San Francisco, California, researchers will present data showing changes in elective delivery policy have been successful in reducing elective deliveries prior to 39 weeks.
Due to the troubling trend of elective delivery and induction, significant attention has been paid to the neonatal benefits of reducing elective deliveries before 39 weeks, both on the national and institutional level. Elective delivery or induction before 39 weeks can lead to bad outcomes for infants including feeding problems, trouble maintaining temperature, having to spend time in the neonatal intensive care unit, and can even put the infant at risk of death.
Studying singleton births at tertiary care centers from 2006 - 2011, researchers at the Brigham and Woman's Hospital in Boston, Ma. found an overall decrease in the proportion of term deliveries that occurred between 37-38 weeks.
"We found a significant reduction in both early elective inductions and early elective cesareans," said Sarah Little, of Brigham and Women's Hospital. "We even found a decrease in inductions for indications considered non-elective."
However, researchers found no significant change in neonatal or maternal morbidity and also found a nonstatistically significant increase in the rate of stillbirths after 37 weeks. Further study on a much larger scale is needed to accurately assess any increased risk from prolonging high risk pregnancies to 39 weeks.
Abstract 27: Does elective delivery policy change affect maternal or fetal morbidity?
OBJECTIVE: Over the last 5 years, attention on both a national and institutional level has focused on the neonatal beneﬁts of reducing elective deliveries prior to 39 weeks. We investigated whether this has impacted maternal or fetal risks.
STUDY DESIGN: We reviewed all singleton term births at a tertiary care center between 2006 and 2011. We categorized inductions as elective if the stated indication was elective, history of fast labor, advanced cervical exam, maternal discomfort, unstable lie or macrosomia. We considered cesarean deliveries elective if they were scheduled repeat or breech deliveries.
RESULTS: There were 33,662 term deliveries. Between 2006 and 2011, there was no change in the mean gestational age (39.51 to 39.52 weeks; p = 0.38) but there was a reduction in the overall proportion of 37-38 week deliveries (29.9% to 25.4%; p < 0.01). The reduction in early term deliveries was seen amongst both elective inductions (23.0% to 5.3%; p < 0.01) and elective cesareans (49.5% to 18.3%; p < 0.01). Of note, this reduction in early term deliveries was also seen for delivery indications that were not considered elective (Figure). There were no signiﬁcant changes in the rate of macrosomia (1.4% to 1.0%), shoulder dystocia (0.4% to 0.4%), uterine rupture (0.4% to 0.5%), postpartum hemorrhage (3.2% to 2.8%), severe laceration (2.0% to 1.4%), pre-eclampsia (6.3% to 6.7%), or nighttime deliveries (52.3% to 53.0%). There was a non-signiﬁcant increase in the rate of stillbirths after 37 weeks from 8.6 per 10,000 (CI 4-20 per 10,000) to 12.1 (CI 6-24 per 10,000); in order to have 80% power to detect a two-fold increased risk in stillbirth we would have needed four times the sample size.
CONCLUSION: Policy efforts were successful as we found a reduction in elective deliveries prior to 39 weeks in our large cohort. There was also a trend toward later delivery for indications not considered purely elective. Further study is needed to characterize the degree of increased risk incurred by prolonging high risk pregnancies to 39 weeks.
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