Perinatal Safety

Initiative:

EliminatingElective Delivery

<39 wks gestation

Making the Case

Elective inductions of labor and elective

cesarean section deliveries less than 39 weeks

gestation are increasing despite the ACOG

guidelines.

Making the Case

Non-medically indicated (elective) deliveries before 39 weeks gestation carry significant risks for the baby with no known benefit to the mother.

The odds of a serious neonatal complications increase with decreasing gestational duration. Common serious morbidities include respiratory complications, sepsis and hypoglycemia.

These risks are not diminished despite amniocentesis documenting a mature lung profile. Clinicians are advised that a mature lung profile does not necessarily lessen the risk of morbidity.

Making the Case• Early term deliveries: The delivery of infants who are born between 37 0/7 through

38 6/7 weeks gestation.

• Elective induction of labor: Induction of labor without an accepted medical or obstetrical indication before the spontaneous onset of labor or rupture of membranes.

• Gestational age confirmation:

Below are the ACOG criteria for determining term gestational age:

• Ultrasound measurement at less than 20 weeks of gestation supports a gestation age of 39 weeks or greater.

• Fetal heart rate tones have been documented as present for 30 weeks by Doppler ultrasonography.

• It has been 36 weeks since a positive serum or urine human chorionic gonadotropin pregnancy test.

Accepted Indications for Delivery < 39 Weeks Gestation

Things that should be taken into account:

• Maternal and fetal conditions

• Gestational age

• Cervical status

• Other factors

Gestation should be ≥ 39 weeks or a mature fetal lung test should be established, but a mature fetal lung test before 39 weeks, is not an indication for delivery, nor does it mean that the baby will experience breathing difficulties after birth.

Joint Commission Statement

Performance Measure: Elective Delivery

Description: Patients with elective vaginal deliveries or elective cesarean sections at >=37 and <39 weeks of gestation completed.

Improvement noted as: Decrease in rate

Numerator Statement: Patients with elective deliveries

MHP FY 2012 Statistics

July2011

Aug2011

Sept2011

Oct2011

Nov2011

Dec2011

Jan2012

Feb2012

March 2012

April 2012

May2012

June2012

FY2012

Elective induction of labor at <39 weeks gestation

0 0 0 0 0 0 0 0 0 0

Elective Cesarean Section at <39 weeks gestation

0 0 0 0 0 0 0 1 2 1

July2011

Aug2011

Sept2011

Oct2011

Nov2011

Dec2011

Jan2012

Feb2012

March 2012

April 2012

May2012

June2012

FY2012

Elective induction of labor at <39 weeks gestation

0 0 0 0 0 0 0 0 0 0 0

Elective Cesarean Section at <39 weeks gestation

0 0 0 0 0 0 0 1 1 0 1

MHP FY 2012 Statistics

Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12

Elective induction of labor at <39 weeks gestation

0 0 0 0 0 0 0 0 0 0 0 NaN

Elective Cesarean Section at < 39 weeks gestation

0 0 0 0 0 0 0 1 1 0 1 NaN

0.5

1.5

2.5

3.5

FY 2012 - Mahaska Health Partnership

Ele

ctiv

e D

eliv

ery

MHP FY 2012 StatisticsFebruary2012

Patient Name

Provider Indication Induction Method

Delivery Method

Gravida/Para Gestational AgeBallard/EDC

APGAR Infant Need for Supplemental

Oxygen

Infant need for transfer

AW 362/929 RCS N/A RCS 3/2 38/38 9/9 Yes Yes

March2012

Patient Name

Provider Indication Induction Method

Delivery Method

Gravida/Para Gestational AgeBallard/EDC

APGAR Infant Need for Supplemental

Oxygen

Infant need for transfer

AH 362/929 RCS N/A RCS 6/6 39/38 9/10 No No

May2012

Patient Name

Provider Indication Induction Method

Delivery Method

Gravida/Para Gestational AgeBallard/EDC

APGAR Infant Need for Supplemental

Oxygen

Infant need for transfer

MH 362/929 RCS N/A RCS 5/2 39/38.5 9/9 No No

Policy Changes

Current policy does not address elective inductions.

Recommendations include:

New Policy: Cesarean Section/Induction of Labor Scheduling Policy

Revise Policies:

- All induction policies to be combined into one Induction of Labor policy

- Define gestations as Preterm (<37 weeks, late preterm 34-36 wks), Term (37-42 wks, early term 37-39 wks), Post term (>42 wks).

- Include reporting and re-education processes

Create scheduling form

Revise Pitocin and Cytotec/Cervidil consents

Scheduled Delivery

Form

Pitocin Checklist/Consent

Cytotec or Cervidil Checklist/Consent

Questions?

Assessment of Gestational Age by what factor? Gestation being the amount of time a baby has been in the womb.

Ultrasound <20 wks supports gestation 39 wks or greater

Elective Induction >39 wks

Monitoring for normal FHR

Completed Pelvic assessment

Monitoring and management of tachysystole

Tracking TechniquesIf an elective induction or c-section is performed at less than 39 wks

gestation, the following will be tracked and shared monthly with the Clinical Quality Committee and with clinicians at the bi-monthly Birthing Center Committee meeting.

Provider

Indication

Induction method

Delivery method

Gravida/Para

Gestational Age of Fetus (EDC)

APGAR

Infant need for supplemental oxygen

Infant need for transfer

Goals

Reduce morbidity to mother and baby, provide risk appropriate care, increase patient centered care delivery.

• Add elective induction to list of OB Committee Review Triggers

• Confirm method of determining Gestational Age (Ballard/EDC)

• Change policy and procedures to prohibit physicians from performing elective inductions or c-sections on women who are less than 39 weeks gestation, unless medically indicated.

Reasons and Implications

By following the safest elective induction process, a hospital care team can reduce the chance of harm for

both mother and baby and means that separating mother and infant from delivery is less likely. Oxytocin, used for labor augmentation and induction, has been

classified as a High-Alert Medication by the Institute for Safety Medication Practices (ISMP) and proper

informed consent should be received before administering this medication.