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Early Births: Elective Inductions and Elective C-sections

Early Births: Elective Inductions and Elective C-sections. Sandra L Gardner, RN MS CNS PNP© 2006 Director, Professional Outreach Consultation Co-editor: Handbook of Neonatal Intensive Care , ed6, 2006 Legal Aspects of Maternal-Child Nursing Practice , 1997

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Early Births: Elective Inductions and Elective C-sections

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  1. Early Births: Elective Inductions and Elective C-sections Sandra L Gardner, RN MS CNS PNP© 2006 Director, Professional Outreach Consultation Co-editor: Handbook of Neonatal Intensive Care, ed6, 2006 Legal Aspects of Maternal-Child Nursing Practice, 1997 www.professionaloutreachconsultation.com www.npdpa.com

  2. Healthy People 2010 DHHS, 1999 • Objective to reduce the preterm birth rate to 7.6% by 2010 from the 11.6% rate of 1998. • The 2004 prematurity rate was 12.5% IOM,2006 • 2/3 of the increase in prematurity rate is due to increasing rates of “near term” births---34-36 6/7 weeks (8.5% of all US births for 2002) IOM,2006 ©Gardner, 2006

  3. Preterm Births as a Percentage of Live Births in the US IOM, 2006

  4. Racial and Ethnic Disparities in Preterm Birth Rates IOM, 2006

  5. Institute of Medicine (IOM) 2005 • Committee on Understanding Premature Birth and Assuring Healthy Outcomes 2005 • 21 month study (6 Professional meetings and 3 Public workshops) • Findings: Growing public health problem Results in significant short and long term consequences for families Costs society at least $26 Billion/yr There has been an increase of 30% of preterm births since 1981©Gardner 2009

  6. Outcomes of PrematurityIOM, 2006 • “Babies born before 32 weeks have the greatest risk for death and poor health outcomes, [including IVH/PVL,CP, subnormal cognitive scores] however infants born between 32-36 weeks, who make up the greatest number of preterm births, are still at higher risk for health and developmental problems compared to those born full term.”IOM, 2006 • 10% of all health care costs for children in the US are for needs of infants born preterm/LBW Moos, 2004 © Gardner 2006

  7. Institute of Medicine: Four Key LessonsIOM, 2007 • 1) Preterm birth is a complex expression of many conditions • 2) Little is known about how preterm birth can be prevented • 3) Racial-ethnic, and socioeconomic disparities are striking and largely unexplained • 4)Infants born at Late-Preterm (32-36 wks ga) are at increased risk for adverse health and developmental outcomes that should not be ignored ©Gardner 2009

  8. NFMOD: Changes in GA Distribution among US Single Births, 1992-2002Davidoff,2006 • Length of PG in US changing: • In 2002 the most common length of PG was 39 weeks • > 40 weeks gestation markedly decreased while there was an increase of births from 34-39 weeks gestation • 34-36 weeks GA account for 75% of all singleton preterm births; 36 completed weeks of gestation were 40.1% ©Gardner 2006

  9. Leading Causes of Infant Mortality in the US from 1990-2000CDC,2007 • Birth Defects • Preterm/LBW • SIDS • RDS • All the above causes of death decreased during this period EXCEPT prematurity/LBW that actually increased • Mortality rates for moderately preterms (32-36 weeks) rose from 8.9 to 9.2/ 100,000 live births from 2001-02 while the rate for FAGAs was stable at 2.5/100,000 © Gardner 2006

  10. NIH Panel: CDMR, March 2005 • Barbara Hughes, CMN

  11. NIH/NICHD: “Optimizing care and long-term outcome of near-term pregnancy and near-term newborns” July 2005 • NIH/NICHD workshop of experts convened to discuss examine problem • Proceedings documented in: Seminars in Perinatology Fall, 2006 ©Gardner 2009

  12. NIH Panel: “Near Term” Infants “Near term” conveys that the infant is “almost term”Engle, 2006 • There is an increasing trend to place these infants in Normal Newborn Nurseries because they are “considered functionally full term and management decisions are made accordingly”Wang, 2004 ©Gardner 2006

  13. NIH Panel: “Near Term” Infants become “Late Preterms” Proposal that “near term” be replaced with “late preterm” because this better reflects the higher risk for complications of preterm birth experienced by this subgroup of preterms (due to their biological and developmental immaturity) Engle, 2006 • “Late Preterm” would be defined as from 34 0/7-36 6/7 weeks gestationEngle, 2006 © Gardner 2006

  14. Temperature Instability Hypoglycemia IV Infusions Respiratory Distress Jaundice Apnea/Bradys Sepsis Eval Poor feeding Wang 2004 10% 0% 15.6% 5.3% 26.7% 5.3% 28.9% 4.2% 54.4% 37.9% 4.4% 0% 36.7% 12.6% 76% 28.6% ©Gardner2006 Morbidities in the “Late Preterm” Infant(35-36 6/7 weeks)“Near Term” Full Term

  15. Late Preterm: LOS: average of 8.8 days Cost: average of $26,054 Rehospitalized:15.2% First year costs: $12,247. Term Infants: LOS: average of 2.2 days Cost: average of $2,061. Rehospitalized: 7.9% First year costs: $4069. ©Gardner 2009 Comparison of Costs and Length of Stay (LOS) at BirthMcLaurin2009

  16. Morbidities in the “Late Preterm” Infant: Research Basis • Increased Respiratory Morbidity with Decreasing Gestational Age: • 1) Prospective study of causes for mechanical Clark 2005 ventilation in 1011 near-term (>34 weeks EGA) neonates Mean EGA was 37 + 2weeks: RDS most common respiratory illness CLD/BPD in 11% Neurologic C/O: 9% Mortality: 5% Adjunctive therapies: 85% one therapy; 52% two therapies; 30% three therapies

  17. Respiratory Failure requiring assisted ventilation: RDS- MAS- Pneumonia/ sepsis- 35-36wks 37-42wks 62% 43% 1.3% 9.7% 8% 8.3% ©Gardner 2006 Morbidities in the “Late Preterm” Infant: Research Basis Clark, 2005

  18. Increased Morbidities in the “Near Term”: Research Basis Escobar 2006 • 2) Review of existing published data and re-analysis of existing databases or retrospective cohort analyses • Neonates of 35-36 weeks gestation, born from 1/1/98 through 6/30/04 • In US 7% of all live births and 58.3% of all preterms are 35-36 weeks gestation • Experience greater morbidity/mortality than full term infants © Gardner 2006

  19. Morbidities in the “Late Preterm” Infant: Research Basis Escobar 2006 Supplemental oxygen: 8% required for at least 1 hour; this is 3 times the rate in neonates > 37 weeks • Mortality rate 0.8% of those with respiratory failure • Increasing risk of ventilation with decreasing GA: 37 weeks: 2 x as likely 36 weeks: 5 x as likely 35 weeks: 9 x as likely ©Gardner 2006

  20. Re-hospitalization Rates in First Month of Life • Increasing risk of readmission with decreasing GA:Oddie2005 > 40 weeks: 2.4% 38-40 weeks: 3.4% 35-37 weeks: 6.3% • Increasing risk of readmission with decreasing GA:Escobar2006 >41 weeks: 3.6% 38-40 weeks: 4.4% 37 weeks: 5.6% 36 weeks: 7.3% 35 weeks: 6.8% 34 weeks: 9.1% 33 weeks: 9.3% ©Gardner 2009

  21. “Brain” Outcomes of Late Preterm • Late preterm infants admitted to NICU have the same risk as very preterm infants of requiring interventional therapies:Kalia, 2009 • 30% late preterms qualified for services at 12 months CA: 28%: Physical Therapy 16%: Occupational Therapy 10%: Speech Therapy 6%: Special Education ©Gardner 2009

  22. “Brain” Outcomes of Late Preterm • Early school-age outcomes of Late Preterm compared to Term Infants:Morse,2009 • 36% higher risk of Developmental Delay • 19% higher risk for suspension in kindergarten • 10-13% higher risk for: disability in pre-k at 3-4 years of age exceptional student education retention in kindergarten • “Not ready to start school”—borderline significant ©Gardner 2009

  23. Parent Teaching in Hospital and for DischargeAWHONN, 2005 • Feeding: problems with breast and bottle • Sleeping: may sleep through feeds and needs to be awakened to eat • Respirations: if having diff. and cannot/will not feed –call/ to ER ASAP • Temperature: may need hat/extra blankets and attention to preventing cold stress • Infections/Jaundice: teach/watch for S/S of infections, incl. developing jaundice; screened before d/c; seen by hc provider within 24-48 h after d/c © Gardner 2006

  24. AAP: “Late-preterm” infants: A population at risk”Engle,2007 • “Recommended minimum criteria for discharge:” • Accurate GA • Individualize timing of d/c • F/U care within 24-48hr • VS all wnl • Stooled at least once • Successfully fed for 24 hrs prior to d/c (evaluate for dehydration: >2-3% weight loss/day or max of 7% wt.loss since birth) • BF ability/success evaluated/documented at least twice daily • Feeding plan developed/taught to parents who will comply and understand why ©Gardner 2009

  25. AAP: “Late-preterm” infants: A population at risk”Engle,2007 • Assessed with nomogram for risk of elevated bili and F/U plans established • PE wnl • Circ-- no active bleeding for 2hr prior to d/c • All MOC/NB lab work complete/ evaluated • Hep B given or plans for outpatient adm. • NB screen drawn and repeat draw at F/U • Passes car seat test/challenge • Hearing screen done • Social, environmental, familial risk factors assessed/ d/c delayed prn • Parents able (with education/ demonstration) to provide care for NB after d/c ©Gardner 2009

  26. The End

  27. Other Speakers • Steve Holt MD: Timing of Elective Inductions and Elective C-sections • Judie Walker, RN: Institute for Healthcare Improvement (IHI Bundles)

  28. Timing of Elective C-Section: at Term and Neonatal outcomes Tita: NEJM, 2009 • Evaluated repeat, elective C-sec (37- before 39 wks) • n= 13,258 elective, singleton, before labor onset and without indication for delivery at 19 centers in the NICHD MFM Network from 19992002 • Demographics of MOC: Older, white, married, private insurance, GA based on clinical/ earliest US

  29. Studies of Elective C-Section: • Infants born at 37-38 weeks GA were 120 times more likely to receive ventilator support for surfactant deficiency (RDS) than infants born at 39-41 weeks Madar, 1999 • Timing of elective section is a risk factor for RDSZanardo, 2004 • The risks of iatrogenic RDS (e.g.0.4%) are greatly reduced if delivery occurs at 39 weeks GAMinkoff,2003; Morrison,1995;Zanardo, 2004 ©Gardner, 2006

  30. Studies of Elective C-Section: Rates of Elective C-sections: > 51-83% in European Studies Morrison 95; Zanardo 04;Graziosi 98; van den Berg 01; Hansen 08 > 21% of births early (before recs of 39 wks/ ACOG) without documentation of fetal lung maturity Laye: AJObGyn2006 > Outcomes: Consistently show increase respiratory morbidity with elective C-sec < 39 weeks GA ©Gardner 2009

  31. Studies of Elective C-Section: • Hanson 2007---systematic review

  32. Studies of Primary C-Section: • Outcomes: • Similar increase in respiratory C/O with delivery < 39 weeks GA van den Berg01; Hansen 08

  33. Timing of Elective C-Section: at Term and Neonatal Outcomes Tita: NEJM, 2009 • Evaluated repeat, elective C-sec (37- before 39 wks) • n= 13,258 elective (singleton, before labor onset and without indication for delivery) C-sections at 19 centers in the NICHD MFM Network from 19992002 • Demographics of MOC: Older, white, married, private insurance, GA based on clinical/ earliest US ©Gardner 2009

  34. Timing of Elective C-Section: at Term and Neonatal Outcomes Tita: NEJM, 2009 • Outcomes: (respiratory C/O; mechanical ventilation; sepsis; hypoglycemia; adm NICU; LOS > 5days; death): • 37 wks (6.3%)---Increase by 1.8 to 4.2 • 38 wks (29.5%)---Increase by 1.3 to 2.1 • Total of (35.8%)—delivered prior to 39 wks • 39 wks (49.1%) ©Gardner 2009

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