1. The 39 Weeks Project: Eliminating Elective Deliveries Under 39 Weeks’ Gestation
The first maternal health initiative of the Perinatal Quality Collaborative of North Carolina

2. PQCNC 39 Weeks Project
GOAL: Eliminate elective delivery <39 weeks without documented fetal lung maturity in participating hospitals
Project director – Nancy Chescheir, MD (Perinatologist)
Project coordinator – Kate Berrien, RN, MS
Expert panel of obstetricians, nurse manager and clinical nurse specialist from hospitals with existing 39 weeks guidelines
Partnership with NC March of Dimes
40 participating hospital teams
Nurse champion
Physician champion
Hospital administrator

3. 39 Weeks Project participating hospitals
Alamance Regional Medical Center
Albemarle Hospital
Blue Ridge Regional Hospital
Cape Fear Valley Medical Center
Carolinas Medical Center
Carolinas Medical Center - Lincoln
Carolinas Medical Center - NorthEast
Carolinas Medical Center - University
Carteret General Hospital
Catawba Valley Medical Center
Central Carolina Hospital
Columbus Regional Healthcare System
Duke University Hospital
Durham Regional Hospital
FirstHealth Richmond Memorial Hospital
FirstHealth Moore Regional Hospital
Forsyth Medical Center
Grace Hospital, Blue Ridge Healthcare
Halifax Regional Medical Center
Iredell Memorial Hospital
Lenoir Memorial Hospital
Mission Hospital
Morehead Memorial Hospital
Nash General Hospital
New Hanover Regional Medical Center
Onslow Memorial Hospital
Pitt County Memorial Hospital
Presbyterian Hospital Huntersville
Randolph Hospital
Rex Health
Rowan Regional Medical Center
Stanly Regional Medical Center
The Outer Banks Hospital
The Women's Hospital of Greensboro
Transylvania Regional Hospital
University of North Carolina Hospitals
WakeMed Cary Hospital
Watauga Medical Center
Wilkes Regional Medical Center
Wilson Medical Center

4. 39 Weeks Project – Timeline
August 2009: Webinar to orient teams to “lookback” data collection (50-chart review)
September 2009: Learning session for all teams (38) to review evidence, site-specific data and to develop goals/action plan
October 2009: Data collection began, sites beginning to test changes. Two additional teams joined.
December 2009: PQCNC annual meeting, half of teams attended and participated in “town meetings.”
January 2010: All-team webinar with national speakers
March 2010: Regional town meetings
August 2010: Final learning session
Late Fall 2010: Next maternal health collaborative begins

5. 39 Weeks Project – Data collection
Data collected on every induction and scheduled c-section between 36w0d and 38w6d
Criteria for establishing gestational age
Cervical exam at admission (for inductions)
Mode of delivery
Maternal complications
Newborn complications
Respiratory support (anything beyond blow-by O2 in the delivery room)
NICU admission
Sepsis
Meconium aspiration syndrome
Transfer out
Death
Indication(s) for delivery and presence of objective data to support each indication
The disclaimer: Please note that we do not endorse all of these as legitimate medical reasons for planned delivery. This list includes items that you may encounter as “indications for delivery.” You may ultimately decide in your hospital’s action plan not to allow some of these without a preceding amniocentesis to confirm gestational age if delivery is planned before 39 weeks. 5

6. 39 Weeks Project – Indications on data collection tool
Coagulation defects (thrombophilia, Factor V Ledien
anticardiolipin antibodies, antiphospholipid syndrome)
HIV/AIDS
Venous thromboembolism
Isoimmunization
Fetal hydrops
Fetal anomaly
History of prior stillbirth
Genital herpes infection – active or prodromal
Maternal drug use
Oligohydramnios
Multiple gestation
Prior CS with classical or unknown incision
Prior CS with low transverse incision
Long distance from hospital
Prior precipitous labor
Nonvertex presentation
Macrosomia
Polyhydramnios
Previous myomectomy
Advanced cervical dilation
Elective/social/psychosocial
No indication given by provider
Other indication (write in):__________________
Non-reactive NST (Check another indication to explain why test was done)
BPP ≤ 4 (Check another indication to explain why test was done)
Eclampsia
HELLP syndrome
PPROM
Placenta previa with active bleeding
Acute placental abruption
Fetal demise
Chorioamnionitis
Chronic hypertension
Pregnancy-induced hypertension/Gestational hypertension
Preeclampsia
Third trimester bleeding
IUGR (SGA + oligo and/or abnormal testing)
SGA only
Chronic placental abruption
Placenta previa without current bleeding
Diabetes—poor control
Diabetes—good control
Cholestasis of pregnancy
Proteinuric renal disease
Lupus
Decreased fetal movement 6

7. Why 39 Weeks?
Joint Commission Perinatal Care Core Measures, effective April 2010:
Elective delivery < 39 weeks
Cesarean section for first-time, low-risk women
Use of antenatal steroids
Health care-associated blood stream infections
Exclusive breastfeeding at hospital discharge
NQF-endorsed voluntary consensus standard for hospital care
The Leapfrog Group perinatal care measure

8. C-section rates
In 2007 U.S. cesarean rate was 31.8%, a 54% increase since 1996.
North Carolina c-section rate was 31.2% in 2007 and 31.3% in 2008.
Primary electives, failed inductions in primiparas
Role of decline in rate of attempted VBAC
40% of 1.3 million C/S annually in US are repeat

9. Induction of labor
In 1990, 9.5% of all US births started as inductions of labor
In 2006, 22.3% of all US births were inductions
Rate of increase of medically indicated inductions was lower than overall induction rate increase
Elective inductions are approximately 10% of all US deliveries

10. Fetal Lung Maturity ACOG Practice Bulletin #97, August Fetal Lung Maturity ACOG Practice Bulletin #107, August 2009 Induction of Labor
To prevent iatrogenic prematurity, fetal pulmonary maturity should be confirmed before scheduled delivery at less than 39 weeks of gestation unless fetal maturity can be inferred from any of the following historic criteria:
US at < 20 weeks confirms EGA of ≥39 weeks
FHT by Doppler >30 weeks or by fetoscope >20 weeks
36 weeks since + pregnancy test
This is an update of ACOG bulletin 230 from 1996 also stating scheduled delivery should not occur before 39 weeks without confirmation of fetal lung maturity.

11. Shift in gestational age at birth, 1990-2005
SOURCE: National Vital Statistics System. Births: preliminary data for Available at

12. Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes Tita ATN, Landon MB, Spong CY, et al. New England Journal of Medicine; 360: January 2009
Study of 24,077 repeat c-sections at term, at 19 hospitals
13,258 (55%) were elective repeat c-sections; of these, 35.8% were before 39 weeks gestation (6.3% at 37 weeks, 29.5% at 38 weeks)
Looked at neonatal outcomes
Primary outcome was a composite of neonatal death, respiratory distress syndrome, TTN, hypoglycemia, sepsis, NICU admission, NEC, hypoxic-ischemic encephalopathy, CPR, ventilator support, arterial pH below 7.0, 5-minute Apgar 3 or below, prolonged hospitalization (5 or more days).
The other 45% were either <37 weeks, or were done for medical or obstetric indication: multiple gestation, major malformation, labor/attempted induction (15.5%), hypertensive disorder, diabetes, cardiac disease, hx of myomectomy, renal disease, HIV, connective-tissue disorder, chorioamnionitis, SROM; indications for nonelective cesarean: classical/vertical/T/J/unknown incision, nonreassuring antepartum fetal testing, suspected macrosomia, genital herpes, previa, abruption, nonvertex presentation

13. Tita et al, NEJM 2009
There was a higher risk among neonates born at 38 and 4-6 days vs. 39 weeks. (51% of pre-39 week elective deliveries were at this age.) The relative risk was 1.21 with CI
Patients with fetal lung maturity testing were not able to be separated – another study showed that 22% of early elective c-sections were done without fetal lung maturity testing, so in this study either no one did have lung maturity testing or they did and still had the higher rates of neonatal outcomes at earlier gestational ages
Increased morbidity at 41+ weeks, but less than 5% of deliveries in this group.

14. Tita et al, NEJM 2009
There was a statistically significant higher risk among neonates born at 38w4-6d vs. 39 weeks (51% of pre-39 week elective deliveries were at this EGA). The relative risk was 1.21 with CI
Women who delivered before 39 weeks were more likely to be:
Older
Lower BMI
White
Privately insured
Had 1st or 2nd trimester U/S for dating

15. Neonatal and maternal outcomes associated with elective term delivery Clark SL, Miller DD, Belfort MA, et al. American Journal of Obstetrics & Gynecology; 200:156.e1-156.e4. February 2009
Prospective observational study in 27 hospitals over 3 months in 2007 (n=17794)
Of term (>37 weeks) deliveries, 44% were planned. Of planned term deliveries, 71% were purely elective
16% of all deliveries were elective induction at term; 9.6% of all deliveries were elective at weeks, with about equal numbers of inductions and repeat C/S, and 121 primary elective C/S <39 weeks.

16. 37 weeks 38 weeks 39+ weeks ELECTIVE INDUCTIONS 112 678 204
CLARK, FEB 09 AJOG (1)
37 weeks
38 weeks
39+ weeks
ELECTIVE INDUCTIONS
112
678
204
NICU ADMISSIONS 17 44 61 %
15.2 *
7.0*
6.0
ELECTIVE PRIMARY CS 24 97
153 5 16 12
20.8*
16.5*
7.8

17. TOTAL ELECTIVE DELIVERIES 241 1471 2983
CLARK FEB 2009 AJOG (2)
37 weeks
38 weeks
39+ weeks
ELECTIVE REPEAT CS
105
696
776
NICU ADMISSION 21 58 62 %
20.0*
8.3
8.0
TOTAL ELECTIVE DELIVERIES
241
1471
2983
NICU ADMISSIONS 43
118
135
17.8*
8.0*
4.6

18. CS rate by dilation at time of induction Clark et al
Among inductions, C-section rate not related to gestational age but highly correlated with cervical dilation for nulliparous and multiparous

19. Health Care Cost & Utilization Project data from AHRQ: 2003
Increased “throughput” – unclogs labor and delivery and postpartum units.
Better outcome for mom/baby dyad? – moms doing 2-3 induction plus c/section are tired and in pain
Health Care Cost & Utilization Project data from AHRQ: 2003

20. The patient’s voice
What is driving the increase in scheduled delivery before 39 weeks?
Maternal complications
Fetal complications
Patient request
Provider schedules
Employment issues
Deployment issues
Family availability
What else?

21. Women’s Perceptions Regarding the Safety of Births at Various Gestational Ages Goldenberg RL, McClure EM, Bhattacharya A, Groat T, Stahl. Obstetrics & Gynecology, 114: December 2009.
The gestational age respondents consider a baby full term (n=650).

22. Goldenberg et al, 2009
The gestational age respondents considered it safe to delivery a neonate.

23. What’s next? 39 Weeks Project ends this summer
Focus on “spread” to other NC hospitals and maintenance at those who have decreased rate of electives <39 weeks
New initiative for 2011: increasing the rate of vaginal delivery among low-risk, first-time mothers at term (reducing the primary c-section rate)!

24. Questions? Kate Berrien, RN, BSN, MS
UNC Center for Maternal & Infant Health
39 Weeks Project Coordinator, PQCNC