1. Perinatal Safety Initiative: Eliminating Elective Delivery <39 wks gestation

2. Making the Case Elective inductions of labor and elective cesarean section deliveries less than 39 weeks gestation are increasing despite the ACOG guidelines.

3. 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.

4. 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.

5. 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.

6. 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

7. MHP FY 2012 Statistics July 2011 Aug 2011 Sept 2011 Oct 2011 Nov 2011 Dec 2011 Jan 2012 Feb 2012 March 2012 April 2012 May 2012 June 2012 FY 2012 Elective induction of labor at <39 weeks gestation 0000000000 Elective Cesarean Section at <39 weeks gestation 0000000121 July 2011 Aug 2011 Sept 2011 Oct 2011 Nov 2011 Dec 2011 Jan 2012 Feb 2012 March 2012 April 2012 May 2012 June 2012 FY 2012 Elective induction of labor at <39 weeks gestation 00000000000 Elective Cesarean Section at <39 weeks gestation 00000001101

8. MHP FY 2012 Statistics

9. February 2012 Patient NameProviderIndication Induction Method Delivery Method Gravida/Para Gestational Age Ballard/EDC APGAR Infant Need for Supplemental Oxygen Infant need for transfer AW362/929RCSN/ARCS3/238/389/9Yes March 2012 Patient NameProviderIndication Induction Method Delivery Method Gravida/Para Gestational Age Ballard/EDC APGAR Infant Need for Supplemental Oxygen Infant need for transfer AH362/929RCSN/ARCS6/639/389/10No May 2012 Patient NameProviderIndication Induction Method Delivery Method Gravida/Para Gestational Age Ballard/EDC APGAR Infant Need for Supplemental Oxygen Infant need for transfer MH362/929RCSN/ARCS5/239/38.59/9No

10. 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 ( 42 wks). - Include reporting and re-education processes Create scheduling form Revise Pitocin and Cytotec/Cervidil consents

11. Scheduled Delivery Form

12. Pitocin Checklist/Consent

13. Cytotec or Cervidil Checklist/Consent

14. 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

15. Tracking Techniques If 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

16. 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.

17. 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.