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Patricia R Chess MD Associate Professor of Pediatrics and Biomedical Engineering University of Rochester Golisano Childr

Improved Perinatal Outcomes through Reduction of Elective Deliveries Prior to 39 Weeks. Patricia R Chess MD Associate Professor of Pediatrics and Biomedical Engineering University of Rochester Golisano Children’s Hospital at Strong. Humankind has been delivering babies for millions of years….

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Patricia R Chess MD Associate Professor of Pediatrics and Biomedical Engineering University of Rochester Golisano Childr

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  1. Improved Perinatal Outcomes through Reduction of Elective Deliveries Prior to 39 Weeks Patricia R Chess MD Associate Professor of Pediatrics and Biomedical Engineering University of Rochester Golisano Children’s Hospital at Strong

  2. Humankind has been delivering babies for millions of years… • Homo Habilis- “Handy man” walked the earth 14 million- 1,750,000 years ago • Homo Sapiens- “Wise Man” 130,000 years ago • Biblical Adam- 6000 years ago • The “wise man” has managed to shorten the length of human gestation an average of 1 full week over just 10 years!

  3. Changing Distribution of US Live Births Percent Singleton Live Births Davidoff et al Sem Perinatology 2006

  4. Gestational age-specific total cesarean section and labor induction rates among all singleton live births, United States, 1992 and 2002 M.J. Davidoff et al. Semin Perinatol 2006

  5. Medically Indicated Factors to Deliver • Placental abruption/ previa with bleeding • Infection • Maternal medical conditions: hypertension, cancer, transplant, SLE etc • Preeclampsia • Idiopathic preterm labor • Premature rupture of membranes • Intrauterine growth restriction • Multiple gestations • Fetal congenital anomalies- eg: Gastroschisis with edema of intestines • Poor placental function/ severe oligo • Isoimmunization with anemia

  6. When to electively schedule delivery • Preterm: < 37 completed weeks • ie before the 259th day counting from the first day of the last menstrual period • Late preterm=34 0/7-36 6/7 weeks • Term: 37 0/7- 41 6/7 • Low risk of morbidity after 37 weeks • Ergo: 37 weeks is close enough when scheduling an elective delivery, or is it…

  7. Elective Delivery • Scheduled, nonurgent: • C/S • Induction • Indications: • Elective repeat C/S • Relative medical reasons-LGA, twins etc • Doctor/ patient schedule • work schedule/ OR or L&D availability/ vacations • Patient anxiety/ discomfort

  8. Elective Delivery • 30.2% of births C/S (1.2 million in 2005) • Trial of labor after C/S not without risk • Up to 50% of C/S are repeat C/S • 10% of infants in US delivered by elective repeat C/S • Inductions for non-medical reasons also on the rise • Timing of delivery is critical and can lead to iatrogenic potentially preventable morbidity and mortality ACOG Comm Op 2007

  9. The good… survival >90% after 27 weeks

  10. The bad…Neonates born at 36-39 weeks’ at increased risk of • Transient Tachypnia of the Newborn • Respiratory Distress Syndrome • Temperature instability • Hypoglycemia • Hyperbilirubinemia/ Kernicterus • Higher rates of rehospitalization • Feeding problems • Apnea/ SIDS • Seizures Riskin et al, Am J Perinat 2005

  11. Hypothermia increases with decreasing gestational age • Increased need for intervention in DR • Decreased subcutaneous tissue • Increased proportion of surface area to total body size • Increased risk of infection Raju et al, Pediatrics 2006

  12. Hypoglycemia • 18% at 35-36 weeks’ gestation • 4% at term • Decreased subcutaneous tissue • Cold stress • Poor po feeding • Infection Raju, Pediatrics 2006

  13. Hyperbilirubinemia • Decreased hepatic uptake of bilirubin from plasma, delayed bilirubin conjugation, increased enterohepatic circulation of bilirubin, dehydration • 54% receive Rx @ 35, 36 wks, 38% @ FT • Narrow margin of safety, especially with LGA late preterm infants Maisels, Pediatrics 1998

  14. Brain • At 35 weeks of gestation significantly fewer sulci and brain weight is only 60% of term infants • Over last 4 weeks of gestation there is a dramatic increase in gyri, sulci, synapses, dendrites, axons, oligodendrocytes, astrocytes, microglia • Higher rate of seizures at earlier gestation due to immaturity of neurons • May be at increased risk of bilirubin-induced brain injury Kinney et al, Sem Perinat 2006

  15. Recurrent Apnea • 4-5% of late-preterm infants, close to 0 at term • Neurodevelopmental immaturity- increased REM sleep • GER • Infection Hunt et al, Sem Perinatology 2006

  16. Apparent Life-Threatening Events • 8-10% incidence in preterm infants • 1% incidence in full-term infants • 30% of ALTE infants preterm and of these 87% were late preterm Hunt et al, Sem Perinatology 2006

  17. Sudden Infant Death Syndrome • Late-preterm infants at 2 fold higher risk • 1.4 cases/1000 at 33-36 weeks’ gestation • 0.7/1000 at term • Monitors not found to decrease morbidity or mortality from SIDS • Place infant, including late-preterm infants, on back to sleep Hunt et al, Sem Perinatology 2006

  18. Respiratory morbidity:4 fold increase at 38 weeks, 5 fold at 37 weeks Hansen et al BMJ 2008

  19. Risk of PneumothoraxDecreases as Gestational Age Increases Zanardo et al J Pediatrics 2007

  20. Need for Respiratory Resuscitation in DR 1284 ECS, 1284 matched vaginal deliveries Zanardo et al, Ped Crit Care Med, 2004

  21. Long- term Sequelae Lindstrom et al, Pediatrics 2007

  22. Total Number of Neonatal Respiratory ECMO Runs Decreasing data from ELSO registry

  23. Delivery Trends in ECMO Patients data from ELSO registry

  24. ECMO trends looked at another way… # pts Jain et al, Sem Perinat, 2006

  25. * * * And the ugly… Mortality on ECMO Neonates with respiratory conditions C= cesarean EC= elective cesarean V= vaginal * p<0.001, data from ELSO registry 1990-2007

  26. ECMO after elective C/SNeonates with respiratory conditions * * p<0.001, data from ELSO registry 1990-2007

  27. Mortality Related to Gestational Age Young et al, Pediatrics 2007

  28. We’re casualties of our own success • As medical care improves resulting in improved outcomes at lower gestational ages, and lives get more hectic, people trade a perceived negligible risk of elective delivery prior to 39 weeks for • Convenience • Decreased discomfort • Relief of anxiety • ….

  29. Choosing When to Deliver • ACOG recommends elective deliveries be avoided prior to 39 weeks, and if they are scheduled prior to 39 weeks an amniocentesis be done to assess lung maturity • Many elective deliveries occur prior to 39 weeks, most without amniocentesis for lung maturity- how does one change practice? ACOG Practice Bulletin #10 11/99

  30. Scheduled Cesarean: Gestational AgesLow risk, not in laborFinger Laker Region N=3661 (>40% below 39 weeks)

  31. NICU Admission after Scheduled Low-risk Cesarean SectionFinger Lakes Region

  32. How to address the issue • Education of risks directed to • Medical care providers • Families

  33. Aim: to decrease scheduled deliveries prior to 39 weeks, and increase amniocenteses to assess for lung maturity if scheduled before 39 weeks- as easy as teaching an old dog new tricks…

  34. Approach • Identify factors contributing to the choice to delivery electively prior to 39 weeks • Develop educational materials and outreach efforts related to risks of such deliveries directed to care providers and families aimed at decreasing this choice • Assess the effectiveness of the efforts using the PDS

  35. Objective 1. Determine the incidence of elective delivery prior to 39 weeks • Identify elective deliveries < 39 weeks at regional hospital • Validate PDS data on elective delivery by conducting a PDS data audit in which indications for elective delivery identified in the medical record are compared with PDS data.

  36. Objective 2. Identify key factors influencing decision for elective delivery • Using the RPC medical record and health care provider review, identify factors related to choice to deliver electively prior to 39 weeks (both physician and patient)

  37. Objective 3. Statewide definition of elective delivery using PDS data • Using PDS data develop a standard definition of elective delivery • To serve as baseline to track incidence

  38. Objective 4. QI Bundle • Develop educational brochures for mothers related to benefit of full 9 month pregnancy and risk of early inductions for nonmedical reasons and distribute throughout 9 county region • Develop educational program for providers consisting of grand rounds, outreach, pamphlets after obtaining provider feedback of optimal format/ mode of dissemination of material

  39. Objective 5. Implement QI bundle • Distribute educational material to 9 county area covered by RPC • to OB offices • to offices where prenatal labs are drawn • include with OB admission packets • Meet with OBs to discuss ACOG guidelines, risks of delivering electively before 39 weeks • Track elective deliveries < 39 weeks • Provide feedback to caregivers who continue to deliver electively prior to 39 weeks

  40. Objective 6. Measure effectiveness of educational program by using perinatal database to measure rate of elective deliveries prior to 39 weeks after educational initiative • Analyze Perinatal Database for number of elective deliveries prior to 39 weeks beginning 12 months after completion of project

  41. Project Design • Retrospective review • Population • Mothers presenting for delivery to Strong Memorial Hospital • Singleton deliveries occurring from January 2006 to December of 2007 (one year to develop definition of elective delivery from PDS, second year to test definition) • Gestational age 36 0/7 - 38 6/7 weeks gestation from QS system • Design • Review of maternal charts • Data collection of specific information • Reason for admission • Indication of Delivery • Outcome

  42. Delivery Classified in QS as Medical:any of following listed as reason for maternal admission in electronic medical record • Labor • Bleeding • Decreased fetal movement • NST performed • PIH • ROM • Version

  43. Delivery Classified in QS as Possible Elective: any of following listed as reason for maternal admission in electronic medical record- all paper charts in these categories reviewed • No reason listed • Induction • Observation • Repeat cesarean section • Primary cesarean section

  44. Medical record data collection form

  45. Results • 1707 patients were screened using QS • 130 omitted: duplicates, multiple gestations in the QS • 725 identified as possible elective deliveries and charts reviewed • 459 determined to be elective • 266 determined to be medically indicated • 1118 patients were deemed nonelective based on predetermined criteria listed • 852- evidence for medical indication from QS system • 266- based on chart review after initial identification as possible elective

  46. Reason for Maternal Admission at Gestations 36 0/7-38 6/7 weeks Probable Nonmedical Probable Medical

  47. n=1577 P< 0.001 *

  48. Comparing variables • of/to elective deliveries

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