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Medically Indicated
Deliveries Before 39
Weeks Gestational Age
“MIDB39 weeks”
Chukwuma I. Onyeije, M.D.
Atlanta Perinatal ...
Research and Experience Show:
Early ELECTIVE delivery without MEDICAL or
OBSTETRICAL indication is linked to neonatal
morb...
Is there really a problem here?
“What’s the big deal?”
“It’s only a couple of days?”
“No one is going to tell me how
to pr...
Inductions of Labor
• ACOG has cautioned against inductions before 39
weeks in the absence of a medical indication since 1...
How did
we get
here?
1992
To 2002
“The Lost
Decade”

6
Change in Distribution of Births by Gestational Age:
United States, 1990-2006

Martin JA, Hamilton BE, Sutton PD, Ventura ...
2002 C-S

Early Term

Percent of Singleton Live Births (%)

U.S. Cesarean Section and Labor Induction Rates Among
Singleto...
Rates of Induction of Labor in Singleton Births
by Race and Hispanic Origin in the U.S.

Martin JA, Hamilton BE, Sutton PD...
Percent Singleton Live Births

Changing Distribution of US Live Births 1992 - 2002

11/06/13

Davidoff et al Sem Perinatol...
Why are Non-medically
Indicated (Elective) Deliveries
Increasing in Frequency?
Obstet Gynecol 2009;114:1254
The Gestational Age that Women Considered
a Baby to be Full Term
29.1%
21.7%

20.8%

17.4%

3.3%

Obstet Gynecol 2009;114:...
The Gestational Age that Women Considered
it Safe to Deliver
35%

31%
30%
25%

22%
19%

Women's Responses

20%
15% 14%
10%...
Pressure on Obstetricians
Reasons that physicians may resist elimination of
elective deliveries < 39 weeks:
•Physician Con...
Risks of Non-medically
Indicated (Elective) Delivery
Before 39 Weeks
Complications of Non-medically Indicated (Elective)
Deliveries Between 37 and 39 Weeks
•
•
•
•
•
•

Increased NICU admissi...
QUESTION: WHO (EXACTLY) IS TERM?

18
OLD Terminology
Late Preterm Early Term
First day of
LMP

Week #

0

20 0/7

340/7

Preterm

37 0/7

39 0/7

Term

416/7

...
NEW Terminology

October 31, 2013

20
Term Pregnancy Redefined by
ACOG and SMFM
Published in the November 2013 Green Journal.

Four new definitions of “term pre...
ACOG and SMFM now discourage the use of
the general label “term pregnancy”

Early Term:

Between
37 weeks 0 days and
38 we...
Okay. How
do I know if
my patient is
“Full Term”?

23
24
Confirmation of Term Gestation
• Early ultrasound (< 20 weeks gestation) is more
accurate than an ultrasound after 20 week...
Actual Case:
JT presented for prenatal care on 9/7/13 with an
LMP of 2/19/13. She was assigned an EDD of
11/26/13 and an ...
At the time of her second ultrasound the
physician performing the ultrasound asked if she
had had any previous ultrasound...
Emergency Room Ultrasound
Date performed:
5/23/13
CRL: 49.5 mm
EGA: 11w5d

28
NEW EDD:
12/7/13

NEW EFW %tile:
54%

29
Clinician and/or Patient Desire to
Clinician and/or Patient Desire to
Schedule a Non-medically
Schedule a Non-medically
In...
Okay.
Let’s get
real.

Not all deliveries before 39 weeks
are for “convenience”.

31
Timing of Indicated Late-Preterm and Early-Term Birth.
Obstetrics & Gynecology. 118(2, Part 1):323-333, August 2011.
ACOG Committee Opinion: April 2013

Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560....
ACOG Committee Opinion: April 2013
 The neonatal risks of late preterm and early-term births
are well established.
 HOWE...
ACOG Committee Opinion: April
2013
Decisions regarding timing of delivery must be
individualized.
Amniocentesis for the ...
Terminology Recall….
Early Term:

Between
37 weeks 0 days and
38 weeks 6 days

Full Term:

Between
39 weeks 0 days and
40 ...
Terminology for Medically Indicated
Deliveries
Late Preterm

Between 34 weeks 0 days and
36 weeks 6 days.

Early Term:

Be...
Categories for Medically Indicated Deliveries:

38
39
Placental / Uterine Issues
Condition

General Timing

Suggested Specific Timing

PLACENTA PREVIA

LATE PRETERM/EARLY TERM
...
41
GROWTH RESTRICTION (SINGLETON)
Fetal issues
Condition

OTHERWISE

UNCOMPLICATED,

NO CONCURRENT FINDINGS

General Timing

...
GROWTH RESTRICTION (TWINS)
FETAL ISSUES:
Condition

General Timing

Suggested Specific Timing

Di – Di TWINS WITH
ISOLATED...
MULTIPLE GESTATIONS
FETAL ISSUES:
Condition

General Timing

Di – Di TWINS

EARLY TERM

Mono - Di TWINS

LATE PRETERM/
EAR...
OLIGOHYDRAMNIOS
FETAL ISSUES:
Condition

General Timing

Suggested Specific Timing

OLIGOHYDRAMNIOS

LATE PRETERM
EARLY TE...
46
HYPERTENSIVE DISORDERS
MATERNAL INDICATIONS
CONTROLLED & NO
MEDICATIONS

EARLY TERM/TERM

38w 0d  39w 6d
GESTATION

CONTR...
HYPERTENSIVE DISORDERS
(Preeclampsia)
MATERNAL INDICATIONS
SEVERE PREECLAMPSIA

MILD PREECLAMPSIA

LATE PRETERM

AT DIAGNO...
DIABETES
PREGESTATIONAL:
WELL-CONTROLLED*

MATERNAL INDICATIONS

PREGESTATIONAL
WITH VASCULAR
COMPLICATIONS
PREGESTATIONAL...
PREMATURE RUPTURE OF
MEMBRANES (PROM)
OBSTETRICAL INDICATIONS

PPROM

LATE PRETERM

34w 0d
GESTATION

51
Conclusion:
Reasons to Eliminate Non-Medically
Indicated (Elective) Deliveries Before 39
Weeks
 Reduction of neonatal com...
HOW AM I GOING TO REMEMBER ALL OF THIS?

11/06/13
• These are guidelines. Clinical judgement and
common sense should come first.
• This presentation is available online.
• ...
http://bit.ly/midb39play
Mecically Indicated Deliveries
Before 39 weeks.
There's an app for that...

http://bit.ly/midb39app
Medically Indicated Deliveries Before 39 weeks
Medically Indicated Deliveries Before 39 weeks
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Medically Indicated Deliveries Before 39 weeks

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A presentation on Medically Indicated Deliveries Before 39 weeks.
Includes updated information from ACOG.

Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10.

Published in: Health & Medicine

Medically Indicated Deliveries Before 39 weeks

  1. 1. Medically Indicated Deliveries Before 39 Weeks Gestational Age “MIDB39 weeks” Chukwuma I. Onyeije, M.D. Atlanta Perinatal Associates 1
  2. 2. Research and Experience Show: 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. 3. Is there really a 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. 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
  5. 5. How did we get here? 1992 To 2002 “The Lost Decade” 6
  6. 6. Change in Distribution of 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.
  7. 7. 2002 C-S Early Term Percent of 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.
  8. 8. Rates of Induction of 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.
  9. 9. Percent Singleton Live Births Changing Distribution of US Live Births 1992 - 2002 11/06/13 Davidoff et al Sem Perinatology 2006
  10. 10. Why are Non-medically Indicated (Elective) Deliveries Increasing in Frequency?
  11. 11. Obstet Gynecol 2009;114:1254
  12. 12. The Gestational Age that 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%
  13. 13. The Gestational Age that 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
  14. 14. Pressure on Obstetricians Reasons that 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
  15. 15. Risks of Non-medically Indicated (Elective) Delivery Before 39 Weeks
  16. 16. Complications of Non-medically Indicated (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
  17. 17. QUESTION: WHO (EXACTLY) IS TERM? 18
  18. 18. OLD Terminology Late Preterm Early 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
  19. 19. NEW Terminology October 31, 2013 20
  20. 20. Term Pregnancy Redefined by 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
  21. 21. ACOG and SMFM now 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
  22. 22. Okay. How do I know if my patient is “Full Term”? 23
  23. 23. 24
  24. 24. Confirmation of Term Gestation • 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
  25. 25. Actual Case: JT presented for 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
  26. 26. At the time of 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
  27. 27. Emergency Room Ultrasound Date performed: 5/23/13 CRL: 49.5 mm EGA: 11w5d 28
  28. 28. NEW EDD: 12/7/13 NEW EFW %tile: 54% 29
  29. 29. Clinician and/or Patient Desire 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
  30. 30. Okay. Let’s get real. Not all deliveries before 39 weeks are for “convenience”. 31
  31. 31. Timing of Indicated Late-Preterm and Early-Term Birth. Obstetrics & Gynecology. 118(2, Part 1):323-333, August 2011.
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. Terminology Recall…. 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 36
  36. 36. Terminology for Medically Indicated 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
  37. 37. Categories for Medically Indicated Deliveries: 38
  38. 38. 39
  39. 39. Placental / Uterine Issues 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
  40. 40. 41
  41. 41. GROWTH RESTRICTION (SINGLETON) Fetal issues 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
  42. 42. GROWTH RESTRICTION (TWINS) FETAL ISSUES: 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
  43. 43. MULTIPLE GESTATIONS FETAL ISSUES: Condition General Timing 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
  44. 44. OLIGOHYDRAMNIOS FETAL ISSUES: Condition General Timing Suggested Specific 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
  45. 45. 46
  46. 46. 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
  47. 47. HYPERTENSIVE DISORDERS (Preeclampsia) MATERNAL INDICATIONS SEVERE PREECLAMPSIA MILD PREECLAMPSIA LATE PRETERM AT DIAGNOSIS AFTER 34w 0d GESTATION*** EARLY TERM AT DIAGNOSIS AFTER 37w 0d GESTATION *** Clinical judgment important 48
  48. 48. DIABETES PREGESTATIONAL: WELL-CONTROLLED* MATERNAL INDICATIONS PREGESTATIONAL WITH VASCULAR COMPLICATIONS PREGESTATIONAL: POORLY CONTROLLED 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
  49. 49. PREMATURE RUPTURE OF MEMBRANES (PROM) OBSTETRICAL INDICATIONS PPROM LATE PRETERM 34w 0d GESTATION 51
  50. 50. Conclusion: Reasons to Eliminate Non-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
  51. 51. HOW AM I GOING TO REMEMBER ALL OF THIS? 11/06/13
  52. 52. • These are guidelines. 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
  53. 53. http://bit.ly/midb39play
  54. 54. Mecically Indicated Deliveries Before 39 weeks. There's an app for that... http://bit.ly/midb39app

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