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An Unfinished Master Piece- The Curse of Early Elective DeliveriesRaja Nandyal, M.D; F.A.A.P;Associate Professor of PediatricsNeonatal Section-Department of PediatricsOUHSCJuly 22nd 2011Speaker Disclosure:I have no financial relationships or affiliations to disclose

I am a full time faculty member of Oklahoma University Health Sciences center (the department of Pediatrics) and Oklahoma University Childrens Physicians group

There is no reference to off-label or investigational use of drugs or products in my presentation

I am a member of the National Perinatal Associations Steering Committee working on the Guidelines for the Care of the Late Preterm Infants with 11 others.

I am also the chairman of the Oklahoma Infant Alliance organization which in September 2010 published its Guidelines

Dr. Tonse N.K. Raju of NICHD who worked on Late Preterm Infants project was one of my mentors.

2OBJECTIVES:The audience at the end of the presentation:

1. Will be able to define the terms- Late Preterm and Early Term Infant

2. Will be able to list 3 common complications of Early Term Births

3. Will be able to state 3 common reasons for Early Term Delivery

Human contributions: Mona Lisa (1503- 1519 AD)- Leonardo da Vinci

Taj Mahal (1632 to 1653 AD)- Moghul Emperor Shah Jahan 7

8

A Term Infant: Natures Master Piece

Early Term: Another Unfinished MP- needs several finishing touches

DEFINITION of the WORDS- Preterm, Late Preterm, Term and Early Term.

The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG)

Defined a preterm infant as one who is born before the end of the 37th week (259th day) of pregnancy, counting from the first day of the last menstrual period

A wide range of gestational-age combinations exist between 33 weeks and term

Descriptive terms such as marginally preterm, moderately preterm, minimally preterm, and mildly preterm have been used to describe this subset of preterm infants

Optimizing Care and Outcome for Late-Preterm (Near-Term) Infants. Tonse Raju et al. Pediatrics 2006; 118; 1207-1214

The NICHD Consensus Panel suggested designating the gestational ages of 34 weeks and 0/7 days through 36 weeks and 6/7 days (239th259th day) as late preterm and discontinue the use of the phrase near term

The panel felt that near term conveyed an impression that these infants are almost term, resulting in underestimation of risk and less diligent evaluation, monitoring, and follow-up

The panel confirmed that gestational age should be rounded off to the nearest completed week, not to the following week. Thus, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks

Optimizing Care and Outcome for Late-Preterm (Near-Term) Infants. Tonse Raju et al. Pediatrics 2006; 118; 1207-1214

What is term then?

WHO defined a term pregnancy at a GA ranging between 37 0/7 weeks and 41 6/7 weeks)

In USA, until the beginning of the last decade, a term pregnancy was considered- ranging between GA of 38 0/7 weeks to 41 6/7 weeks, because of evidence of increased morbidity in so called 37 weekers.

But, we changed (had to) our definition, to be in sync with WHO s definition. Lot of us are not happy as there was old data which showed 37 weekers (and even 38 weekers) had increased morbidity like transient tachypnea (wet lung), feeding problems, jaundice, increased readmissions etc.

Are there differences between 37-38 and 39-41 weeks?

Currently, GA starting with 37 0/7 weeks and ending with 38 6/7 weeks is called as the Early Term. New data is now accumulating rapidly covering these GAs.

AGAIN EMPHASIZING THE FACT THAT EVERY WEEK COUNTS

I am going to present some available data looking at morbidity and mortality of 37 and 38 weekers when compared to 39 to 41 weekers

ACOG Evidence-Based Guidelines:No elective induction or elective cesarean delivery before 39 weeks unless evidence of fetal lung maturity

To assess fetal lung maturity an amniocentesis is usually done to collect amniotic fluid for testing

There are potential risks as for any invasive procedure

ACOG Practice Bulletin no.10; November 1999.

ACOG Practice Bulletin No. 10, November, 1999.20Despite all of the complicated factors fueling the increases in late preterm birth, ACOG has remained steadfast in its evidence-based guidelines and position that there be no elective induction or elective section until 39 weeks of gestation without evidence of fetal lung maturity (ACOG Practice Bulletin, No. 10, November 1999, Induction of Labor). Although there are different ways to ascertain fetal maturity, today most clinicians will perform an amniocentesis to obtain a sample of amniotic fluid which will be tested. Since every invasive procedure has some risk, women need to apprised of potential consequences which should be weighed in situations of elective induction or delivery prior to 39 weeks for patient or provider convenience. There should be an obstetrical, medical or legitimate logistical reason if early delivery is planned, warranting confirmation of fetal maturity. Inductions of Labor:Since 1979, ACOG has cautioned against inductions before 39 weeks in the absence of a medical indication.

Confirmation of gestational age is CRITICAL:Ultrasound before 20 weeks gestation to establish accurate gestational age of the fetus Documentation of fetal heart tones for 30 weeks using Doppler ultrasonographyConfirmation that it has been 36 weeks since a positive pregnancy test was obtained Since 1979, the American Congress of Obstetricians & Gynecologists (ACOG) has cautioned against inducing women before 39 weeks unless there is a medical or obstetrical indication to do so. An obvious issue is to accurately determine gestational age. Fortunately, ACOG has given us some guidance on this issue in their publication on induction of labor. (Read the bullets on confirmation of gestational age).21Terminology:Modified from Drawing courtesy of William Engle, MD, Indiana UniversityRaju TNK. Pediatrics, 2006;118 1207. First day of LMP0Week #37 0/7416/7PretermTermPost term340/720 0/739 0/7Late PretermEarly Term2222It is understood that prematurity poses significant risks to the neonate. And it is understood that the risks of neonatal morbidity from prematurity are inversely related to advancing gestational age. Due to the tremendous advances in neonatal care, many of us have become complacent about the risks to babies of delivering beyond 34 weeks. It is becoming increasingly clear that there is not only a risk to babies born in the late preterm period (between 34-37 weeks) but there is an increased risk for babies born in the early term period, defined as deliveries taking place between 37 weeks and 0 days and 38 weeks and 6 days.Q1: The Preterm Birth Rate in US is-A: Increasing

B: Decreasing because of major advances in OB care

C: No changeQ1: The Preterm Birth Rate in US is-A: Increasing (most of the increase is because of increase of LPI)

B: Decreasing because of major advances in OB care

C: No change

Whats the BIG DEAL? (about these Early Term Infants?)

Change in Distribution of Births by G.A: United States, 1990-2006Martin 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.

Source: CDC/NCHS, National Vital Statistics Systems.This slide illustrates the changing distribution of births to a lower gestational age over a 16 year period. As you can see, there is a sharp decline in deliveries occurring after 39 weeks with a concomitant sharp increase in births occurring particularly between 36-38 weeks gestation.27U.S. Cesarean Section and Labor Induction Rates-Among Singleton Live Births by Week of Gestation, 1992 and 2002.

Source: NCHS, Final Natality Data, Prepared by March of Dimes Perinatal Data Center, April 2006.2002 Induction 2002 C-S1992 C-S1992 InductionEarly Term28This graph illustrates a significant increase in both induction of labor and cesarean deliveries in 2002 compared to 1992. The largest increase in induction of labor seems to occur in the early term and term period and although the cesarean section increase is fairly constant and begins to narrow at around 34-35 weeks, a significant difference only disappears after 39 weeks.Rates of Induction of Labor 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.

The increased rates of induction have been similar across all racial groups, with the highest increase in non-Hispanic whites.29US Cesarean Section Rates: Final 1995- 2006; Preliminary 2007 and 2008

www.CDC.GOV , Vital Statistics, April 10, 2010

http://www.cdc.gov/nchs/VitalStats.html

Elective Induction: Sounds like a good idea (to a lot of Hospitals, Physicians and Families)Advanced planningMother lives far away; history of quick laborsDelivered by her doctorMaternal intolerance to late pregnancyExcess edema, backache, indigestion, insomniaPrior bad pregnancyAnd, its okay right?

Clin Obstet Gynecol 2006;49:698-70432Why have elective deliveries increased? It is not totally clear. Although the physician is the one who controls the act of scheduling, it is not clear what drives that decision. It may very well be impacted by the fact that patients and obstetricians are unaware of any harm. And there are definitely perceived benefits for timing the delivery. So why not plan the delivery around a convenient date for both the obstetrician and the expectant mother and her family?

Why are Non-medically Indicated (Elective/Planned) Deliveries Increasing in Frequency?Lets take a look at some of the reasons that elective deliveries are increasing.34Womens Perceptions:

Obstetric Gynecol 2009;114:1254The Gestational Age that Women Considered a Baby to be Full Term

Obstet Gynecol 2009;114:1254When participants were asked At what gestational age do you believe the baby is considered full term?, nearly 25% chose 34-36 weeks. Another 50% chose 37-38 weeks and only 25% chose 39-40 weeks.37The Gestational Age that Women Considered it Safe to Deliver

Obstet Gynecol 2009;114:1254Weeks of GestationWhen women were asked What is the earliest point in the pregnancy that it is safe to deliver the baby, should there be no other medical complications requiring early delivery?, more than half of the mothers chose 34-36 weeks. Only 7.6% chose 39-40 weeks. 38Non-medical Indications Often Given for InductionsMaternal intolerance to late pregnancyExcess edema, backache, indigestion, insomnia

Prior labor complicationPrior shoulder dystociaSuspected fetal macrosomiaHistory of rapid labor/ lives far awayPossible lower risk for mom or babyLower stillbirth rate, less macrosomia, less preeclampsia

With an increasing role of patients in the decision-making process it is important for not only the physician, but also the patient to understand what constitutes a safe gestational age for the delivery of their babies.39What Motivates Some Obstetricians to Perform Elective Inductions?Physician convenienceGuarantee attendance at birthAvoid potential scheduling conflictsReduce being woken at night

whats the harm? Amnesia due to rare occurrenceThe NICU can handle itAnd

Clin Obstet Gynecol 2006;49:698-704It is of utmost importance that obstetrical providers time the delivery for a good reason and not simply for our convenience.40Suspected Fetal Macrosomia(Non-Diabetic Population)Does not reduce risk of shoulder dystociaDoubles risk of cesarean delivery

262 pregnancies EFW >90%Elective group:57% cesarean delivery rate5.3% shoulder dystocia Spontaneous labor group:31% cesarean delivery rate2.5% shoulder dystocia

Combs et al. Obstet Gynecol 1993; 81:492-49641Induction for macrosomia needs special attention. This has become perhaps one of the leading issues for a planned early induction of labor. However, numerous studies such as this study by Combs et al. show that induction of labor does not decrease the incidence of shoulder dystocia, nor does it decrease the incidence of cesarean deliveries.Obesity in Childbearing Years: Obesity epidemic is growing

C-section likelihood increases

Risk of late preterm infants increases

May enhance future problems in this population

Still, Whats the Big Deal?? (about Early Term Deliveries!!)Risks of Non-medically Indicated (Elective) Delivery Before 39 WeeksSo lets take a look at the risks of elective deliveries before 39 weeks.44Complications of Non-medically Indicated (Elective) Deliveries Between 37 and 39 Weeks:

Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997Increased NICU admissionsIncreased transient tachypnea of the newborn (TTN)Increased respiratory distress syndrome (RDS) Increased ventilator supportIncreased suspected or proven sepsisIncreased newborn feeding problems and other transition issuesThere is nearly a doubling of the risks for admissions to the neonatal intensive care unit, an increase in respiratory complications and other complications as shown here for every week below 39 weeks.45Morbidity of Late Preterm Infants in Massachusetts Late preterm infants: 22.2% vs Term infants: 3%Sample: Term (377,638), Late Preterm (26,170)Morbidity rates doubled for each gestational week earlier than 38 weeks40 wks: 2.5%39 wks: 2.6%38 wks: 3.3%37 wks: 5.9%36 wks: 12.1%35 wks: 25.6%34 wks: 51.9%Shapiro-Mendoza CK et al. Effect of late-preterm birth and maternal medical conditions on newborn morbidity risk. Pediatrics. 2008;121:e223e232This study looking at infants delivered in Massachusetts, also shows that morbidity increases significantly before 39 weeks and nearly doubles for each gestational week below 39 weeks.46Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery: Absolute RiskAdapted from Tita AT, et al. NEJM 2009;360:111

47The actual percent affected for adverse neonatal outcomes according to completed week of gestation at delivery is shown here. Again, it is clear that EARLY term cesarean births before 39 weeks increase neonatal morbidity.Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery: Odds RatiosAdapted from Tita AT, et al. NEJM 2009;360:111

48The odds ratios for adverse neonatal outcomes according to completed week of gestation at delivery is shown here. The odds ratios vary from 2 to 4-fold higher for births under 38 weeks and 1.5 to 2.5-fold higher for births in the 38th week.

NICU Admissions By Weeks Gestation Deliveries Without Complications, 2000-2003Oshiro et al. Obstet Gynecol 2009;113:804-811. NICU AdmissionsA study by Oshiro et al. looked at elective deliveries in a large integrated healthcare system in Utah and showed increasing risk for NICU admits for each week before 39 weeks.

RDS By Weeks GestationDeliveries Without Complications, 2000-2003Oshiro et al. Obstet Gynecol 2009;113:804-811.RDSThere was also an increased risk for respiratory distress syndrome for each week before 39 weeks.

Ventilator Usage By Weeks GestationDeliveries Without Complications, 2000-2003

Oshiro et al. Obstet Gynecol 2009;113:804-811.Ventilator UseAnd an increase in neonates on ventilators for each week before 39 weeks.

Proportion of Patients At Each EGA:(Data Based on 434,665 NICU infants where Respiratory Support Type Was Reported, 1997-2008)

Source, Pediatrix Clinical Data Warehouse

Q2: The Brain volume of a 34 weeker is-A: 1/3rd of the size of the term babys brain

B: 2/3rd of the size of the term babys brain

C: 4/5th of the size of the term babys brain

D: same as the size of the term babys brainQ2: The Brain volume of a 34 weeker is-A: 1/3rd of the size of the term babys brain

B: 2/3rd of the size of the term babys brain

C: 4/5th of the size of the term babys brain

D: same as the size of the term babys brain

Late Preterm Infants: Brain DevelopmentHuppi et al. Ann Neurol 1998; 43:224-35

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58This Late Preterm Brain Development card is available from the March of Dimes and is for use by health care providers (e.g. physicians, midwives, nurses, physician assistants). It is designed to present a graphic representation of fetal brain growth and maturation in the last month of pregnancy. Specific information is summarized in the 5 bulleted points describing some of the increased risks for late preterm compared to term infants. As clearly stated at the end of the card, it is strictly informational and not intended to be used as medical advice. The card also encourages the pregnant woman to discuss concerns with her health care provider.

It is important that the card be used in the context of a discussion with a provider. The card should not be simply passed out to pregnant women. A consumer brochure will soon be available to provide additional information about late preterm birth which can be given to pregnant women and interested consumers.

Growth Charts: Head Circumference

Morbidity for Infants by gestational AgeMorbidity = >5d in hospital, transfer for higher care level, or death. 1998-2003 - MassachusettsShapiro-Mendoza, et al., Pediatr., 121, 2008 Acquired GI Disease Proportion By EGA:

Source, Pediatrix Clinical Data Warehouse

Singleton NMR by GA (weeks) by Race and Ethnicity

Reddy et al- Obstet Gynecol 2011; 117:1279-87

Infant Mortality Rate by GA among singleton live births 1995- 2006Reddy et al- Obstet Gynecol 2011; 117:1279-87Infant Mortality among Late Preterm and Term Singletons, United States, 1995 - 2002

Rate per 1,000 live birthsLate preterm is between 34 and 36 weeks gestation Source: National Center for Health Statistics, period linked birth/infant death dataPrepared by March of Dimes Perinatal Data Center, 200765Recently researchers at NCHS and the Perinatal Data Center at March of Dimes demonstrated that for late preterm infants, the mortality rate was 6 times higher in the first week of life (early neonatal mortality) than that of full-term babies, and 3 times as high in the first year of life. This study on more than 27 million singleton live births was published in Pediatrics in November 2007. The increased risk on infant death is displayed in this graph. This provides yet another reason why it is so important to prevent every preventable preterm birth.

Q3: Early Term infants Morbidities include-A: Respiratory distress

B: Jaundice

C: Feeding difficulties

D: Hypoglycemia

E: Temperature instability

F: Sepsis

G: All of the above

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Q3: Early Term infants Morbidities include-A: Respiratory distress

B: Jaundice

C: Feeding difficulties

D: Hypoglycemia

E: Temperature instability

F: Sepsis

G: All of the above

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After Finishing Touches:::::::::::::::::::::::::::::::::::::::

Questions????????????????

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Chart10.0330.0330.1740.2170.2910.0480.208

Response (%)Weeks of GestationWomen's Responses

Sheet134353637383940Response (%)3.30%3.30%17.40%21.70%29.10%4.80%20.80%

Chart10.1370.0720.3080.2150.1920.0340.042

Response (%)Weeks of GestationWomen's Responses

Sheet134353637383940Response (%)13.7%7.2%30.8%21.5%19.2%3.4%4.2%

Chart10.01920.00300694010.00300694010.00680.00116893210.00116893210.00420.00069581830.00069581830.00410.0008945750.0008945750.00670.00238224430.00238224430.00780.01073477960.0107347796

RDSGestational WeeksPercent

Chart20.06661667290.00546393370.00546393370.03360016850.00256310040.00256310040.02470995930.00167027530.00167027530.02652925870.00224978470.00224978470.03440621530.00532260650.00532260650.04263565890.02465308830.0246530883

% NICUGestational WeeksPercent

Sheet1GestationRDS+/-37th Week (8,001)1.92%38th Week (18,988)0.68%39th Week (33,185)0.42%40th Week (19,601)0.41%41st Week (4,505)0.67%42nd Week (258)0.78%2002-2003GestationDeliveriesMom V CostNICU% NICUVent% VentBaby LOSBaby CostC-SectionsC-Section RateRDS% RDS374083$1,252.613247.94%531.30%53.56$659.5684820.8%882.16%389220$1,162.583553.85%440.48%47.58$512.59162717.6%710.77%3918449$1,159.915102.76%510.28%46.20$473.16295516.0%820.44%4011660$1,173.153172.72%360.31%45.58$475.87144012.3%460.39%412717$1,244.061033.79%150.55%47.31$507.1342315.6%230.85%42160$1,221.3842.50%10.63%44.61$469.153320.6%00.00%462892000-2001GestationDeliveriesMom V CostNICU% NICUVent% VentBaby LOSBaby CostC-SectionsC-Section RateRDS% RDS373918$1,165.322095.3%421.07%50.6$534.1267717.3%661.68%389768$1,118.912832.9%450.46%46.9$446.72153515.7%580.59%3914736$1,103.583102.1%310.21%45.1$401.92189612.9%570.39%407941$1,152.162032.6%220.28%45.0$417.2488611.2%340.43%411788$1,263.04522.9%60.34%46.6$437.4125914.5%70.39%4298$1,315.6577.14%00.00%47.3$493.221515.3%22.04%38249

Sheet2CombinedGestationDeliveriesMom V CostNICU% NICUVent% VentBaby LOSBaby CostC-SectionsC-Section RateRDS% RDS37th Week (8,001)8001$1,209.865336.66%951.19%52.11$598.13152519.06%1541.92%8599.133022205338th Week (18,988)18988$1,140.126383.36%890.47%47.22$478.70316216.65%1290.68%19466.703950193839th Week (33,185)33185$1,134.908202.47%820.25%45.70$441.52485114.62%1390.42%33626.523856459240th Week (19,601)19601$1,164.655202.65%580.30%45.33$452.12232611.87%800.41%20053.116509235141st Week (4,505)4505$1,251.591553.44%210.47%47.03$479.4668215.14%300.67%4984.459420058842nd Week (258)258$1,257.19114.26%10.39%45.61$478.294818.60%20.78%736.2883959451GestationRDS37th Week (8,001)1.92%0.30%38th Week (18,988)0.68%0.12%39th Week (33,185)0.42%0.07%40th Week (19,601)0.41%0.09%41st Week (4,505)0.67%0.24%42nd Week (258)0.78%1.07%Gestation% NICU+/-37th Week (8,001)6.66%0.55%38th Week (18,988)3.36%0.26%39th Week (33,185)2.47%0.17%40th Week (19,601)2.65%0.22%41st Week (4,505)3.44%0.53%42nd Week (258)4.26%2.47%

Sheet3

Chart10.01920.00300694010.00300694010.00680.00116893210.00116893210.00420.00069581830.00069581830.00410.0008945750.0008945750.00670.00238224430.00238224430.00780.01073477960.0107347796

RDSGestational WeeksPercent

Sheet1GestationRDS+/-37th Week (8,001)1.92%38th Week (18,988)0.68%39th Week (33,185)0.42%40th Week (19,601)0.41%41st Week (4,505)0.67%42nd Week (258)0.78%2002-2003GestationDeliveriesMom V CostNICU% NICUVent% VentBaby LOSBaby CostC-SectionsC-Section RateRDS% RDS374083$1,252.613247.94%531.30%53.56$659.5684820.8%882.16%389220$1,162.583553.85%440.48%47.58$512.59162717.6%710.77%3918449$1,159.915102.76%510.28%46.20$473.16295516.0%820.44%4011660$1,173.153172.72%360.31%45.58$475.87144012.3%460.39%412717$1,244.061033.79%150.55%47.31$507.1342315.6%230.85%42160$1,221.3842.50%10.63%44.61$469.153320.6%00.00%462892000-2001GestationDeliveriesMom V CostNICU% NICUVent% VentBaby LOSBaby CostC-SectionsC-Section RateRDS% RDS373918$1,165.322095.3%421.07%50.6$534.1267717.3%661.68%389768$1,118.912832.9%450.46%46.9$446.72153515.7%580.59%3914736$1,103.583102.1%310.21%45.1$401.92189612.9%570.39%407941$1,152.162032.6%220.28%45.0$417.2488611.2%340.43%411788$1,263.04522.9%60.34%46.6$437.4125914.5%70.39%4298$1,315.6577.14%00.00%47.3$493.221515.3%22.04%38249

Sheet2CombinedGestationDeliveriesMom V CostNICU% NICUVent% VentBaby LOSBaby CostC-SectionsC-Section RateRDS% RDS37th Week (8,001)80011209.8639195885330.0666166729950.011873515852.108269167598.133022205315250.19060117491540.01924759418599.133022205338th Week (18,988)189881140.116522836380.0336001685890.004687170847.2212089467478.703950193831620.16652622711290.006793764519466.703950193839th Week (33,185)331851134.89792631478200.0247099593820.002470995945.704381161441.523856459248510.14618050321390.004188639433626.523856459240th Week (19,601)196011164.64578005455200.0265292587580.002959032745.3299373368452.116509235123260.1186674149800.004081424420053.116509235141st Week (4,505)45051251.59026940451550.0344062153210.004661487247.0266625671479.45942005886820.1513873474300.00665926754984.459420058842nd Week (258)2581257.1860497083110.042635658910.00387596945.6114647083478.2883959451480.186046511620.007751938736.2883959451GestationRDS+/-37th Week (8,001)1.92%0.30%38th Week (18,988)0.68%0.12%39th Week (33,185)0.42%0.07%40th Week (19,601)0.41%0.09%41st Week (4,505)0.67%0.24%42nd Week (258)0.78%1.07%

Sheet3

Chart10.01920.00300694010.00300694010.00680.00116893210.00116893210.00420.00069581830.00069581830.00410.0008945750.0008945750.00670.00238224430.00238224430.00780.01073477960.0107347796

RDSGestational WeeksPercent

Chart20.06661667290.00546393370.00546393370.03360016850.00256310040.00256310040.02470995930.00167027530.00167027530.02652925870.00224978470.00224978470.03440621530.00532260650.00532260650.04263565890.02465308830.0246530883

% NICUGestational WeeksPercent

Chart30.01187351580.00237344880.00237344880.00468717080.00097151980.00097151980.00247099590.00053417550.00053417550.00295903270.00076041090.00076041090.00466148720.00198909870.00198909870.0038759690.00758216230.0075821623

% VentGestational WeeksPercent

Sheet1GestationRDS+/-37th Week (8,001)1.92%38th Week (18,988)0.68%39th Week (33,185)0.42%40th Week (19,601)0.41%41st Week (4,505)0.67%42nd Week (258)0.78%2002-2003GestationDeliveriesMom V CostNICU% NICUVent% VentBaby LOSBaby CostC-SectionsC-Section RateRDS% RDS374083$1,252.613247.94%531.30%53.56$659.5684820.8%882.16%389220$1,162.583553.85%440.48%47.58$512.59162717.6%710.77%3918449$1,159.915102.76%510.28%46.20$473.16295516.0%820.44%4011660$1,173.153172.72%360.31%45.58$475.87144012.3%460.39%412717$1,244.061033.79%150.55%47.31$507.1342315.6%230.85%42160$1,221.3842.50%10.63%44.61$469.153320.6%00.00%462892000-2001GestationDeliveriesMom V CostNICU% NICUVent% VentBaby LOSBaby CostC-SectionsC-Section RateRDS% RDS373918$1,165.322095.3%421.07%50.6$534.1267717.3%661.68%389768$1,118.912832.9%450.46%46.9$446.72153515.7%580.59%3914736$1,103.583102.1%310.21%45.1$401.92189612.9%570.39%407941$1,152.162032.6%220.28%45.0$417.2488611.2%340.43%411788$1,263.04522.9%60.34%46.6$437.4125914.5%70.39%4298$1,315.6577.14%00.00%47.3$493.221515.3%22.04%38249

Sheet2CombinedGestationDeliveriesMom V CostNICU% NICUVent% VentBaby LOSBaby CostC-SectionsC-Section RateRDS% RDS37th Week (8,001)8001$1,209.865336.66%951.19%52.11$598.13152519.06%1541.92%8599.133022205338th Week (18,988)18988$1,140.126383.36%890.47%47.22$478.70316216.65%1290.68%19466.703950193839th Week (33,185)33185$1,134.908202.47%820.25%45.70$441.52485114.62%1390.42%33626.523856459240th Week (19,601)19601$1,164.655202.65%580.30%45.33$452.12232611.87%800.41%20053.116509235141st Week (4,505)4505$1,251.591553.44%210.47%47.03$479.4668215.14%300.67%4984.459420058842nd Week (258)258$1,257.19114.26%10.39%45.61$478.294818.60%20.78%736.2883959451GestationRDS37th Week (8,001)1.92%0.30%38th Week (18,988)0.68%0.12%39th Week (33,185)0.42%0.07%40th Week (19,601)0.41%0.09%41st Week (4,505)0.67%0.24%42nd Week (258)0.78%1.07%Gestation% NICU+/-37th Week (8,001)6.66%0.55%38th Week (18,988)3.36%0.26%39th Week (33,185)2.47%0.17%40th Week (19,601)2.65%0.22%41st Week (4,505)3.44%0.53%42nd Week (258)4.26%2.47%Gestation% Vent+/-37th Week (8,001)1.19%0.24%38th Week (18,988)0.47%0.10%39th Week (33,185)0.25%0.05%40th Week (19,601)0.30%0.08%41st Week (4,505)0.47%0.20%42nd Week (258)0.39%0.76%

Sheet3