1. Click to edit Master title style Click to edit Master subtitle style 1 Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age A Quality Improvement Toolkit Funding for the development of this toolkit was provided by: Federal Title V block grant funding from the California Department of Public Health; Maternal, Child and Adolescent Health Division was used by the California Maternal Quality Care Collaborative to develop the toolkit; and March of Dimes.

2. Click to edit Master title style Click to edit Master subtitle style 2 Induction 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, with one or more of the following: Ultrasound before 20 weeks to establish accurate gestational age Consistent with LMP Documentation of fetal heart tones for 30 weeks using Doppler Confirmation of 36 weeks since a positive pregnancy test

3. Click to edit Master title style Click to edit Master subtitle style 3 Change in Distribution of Births by Gestational Age: United States, 1990-2006 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. Source: CDC/NCHS, National Vital Statistics Systems.

4. Click to edit Master title style Click to edit Master subtitle style 4 U.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-S 1992 C-S 1992 Induction Early Term

5. Click to edit Master title style Click to edit Master subtitle style 5 Why Are Non-medically Indicated (Elective/Planned) Deliveries Increasing In Frequency?

6. Click to edit Master title style Click to edit Master subtitle style 6 Elective Induction: Sounds like a good idea… Advanced planning Mother lives far away; history of quick labors Delivered by her doctor Maternal intolerance to late pregnancy Excess edema, backache, indigestion, insomnia Prior bad pregnancy outcome Large baby And, it’s okay right? Clin Obstet Gynecol 2006;49:698-704

7. Click to edit Master title style Click to edit Master subtitle style 7 The Gestational Age That Women Considered A Baby To Be Full Term Obstet Gynecol 2009;114:1254

8. Click to edit Master title style Click to edit Master subtitle style 8 The Gestational Age That Women Considered It Safe To Deliver Obstet Gynecol 2009;114:1254 Weeks of Gestation

9. Click to edit Master title style Click to edit Master subtitle style 9 What Motivates Some Obstetricians To Perform Elective Inductions? Physician convenience Guarantee attendance at birth Avoid potential scheduling conflicts Reduce being woken up at night … what’s the harm? Amnesia due to rare occurrence “The NICU can handle it” Clin Obstet Gynecol 2006;49:698-704

10. Click to edit Master title style Click to edit Master subtitle style 10 Complications of Non-medically Indicated (Elective) Deliveries Between 37 and 39 Weeks See Toolkit for more data and full list of citations Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997 Increased NICU admissions Increased transient tachypnea of the newborn (TTN) Increased respiratory distress syndrome (RDS) Increased ventilator support Increased suspected or proven sepsis Increased newborn feeding problems and other transition issues

11. Click to edit Master title style Click to edit Master subtitle style 11 Morbidity of Late Preterm Infants in Massachusetts Morbidity rates doubled for each gestational week earlier than 38 weeks 40 wks: 2.5% 39 wks: 2.6% 38 wks: 3.3% 37 wks: 5.9% 36 wks: 12.1% 35 wks: 25.6% Shapiro-Mendoza CK et al. Effect of late-preterm birth and maternal medical conditions on newborn morbidity risk. Pediatrics. 2008;121:e223–e232

12. Click to edit Master title style Click to edit Master subtitle style 12 NICU Admissions by Weeks Gestation Deliveries Without Complications, 2000-2003 Oshiro et al. Obstet Gynecol 2009;113:804-811. NICU Admissions

13. Click to edit Master title style Click to edit Master subtitle style 13 Ventilator Usage by Weeks Gestation Deliveries Without Complications, 2000-2003 Oshiro et al. Obstet Gynecol 2009;113:804-811. Ventilator Use

14. Click to edit Master title style Click to edit Master subtitle style 14 Adverse Neonatal Outcomes According To Completed Week of Gestation at Delivery Adapted from Tita AT, et al. NEJM 2009;360:111 13,258 Elective RCS from 19 Hospitals

15. Click to edit Master title style Click to edit Master subtitle style 15 Magee-Women’s Hospital, Pittsburgh Magee-Women’s Hospital: >9,300 2007 deliveries Induction peaked at 28% in 2003 In 2006, a process improvement initiative changed the induction scheduling process and strictly enforced the guidelines. Fisch et al. Obstet Gynecol 2009;113:797

16. Click to edit Master title style Click to edit Master subtitle style 16 Magee-Women’s Experience With Guidelines Baseline 3mos 2004 Voluntary 3mos 2005 Enforced 14mos 2006-7 Deliveries2,1392,26010,895 Elective Inductions <39wks (N) Elective Inductions <39wks (rate) 23 11.8% 21 10.0% 30 4.3% (p<0.001) Elective Nullip Inductions (N) Elective Nullip Inductions =>C/S (N) Elective Nullip Inductions =>C/S (rate) 29 10 35.7% 33 5 15.2% 87 12 13.8% (p<0.01) Total Induction Rate24.9%20.1%16.6% Fisch et al. Obstet Gynecol 2009;113:797

17. Click to edit Master title style Click to edit Master subtitle style 17 Intermountain Healthcare’s Experience Operates 21 hospitals in Utah and southeast Idaho with ≈30,000 deliveries/year Independent OBs January 2001: 9 facilities participated in a process improvement program for elective deliveries. 28% of elective deliveries were occurring before 39 completed weeks of gestation. Oshiro, B. et al. Obstet Gynecol 2009;113:804-811.

18. Click to edit Master title style Click to edit Master subtitle style 18 Percent Non-medically Indicated Deliveries <39 Weeks, 1999 – 2005 Oshiro, B. et al. Obstet Gynecol 2009;113:804-811.

19. Click to edit Master title style Click to edit Master subtitle style 19 Common Themes at Intermountain Healthcare Education provided to OBs regarding ACOG guidelines & best practices Little change until physicians were held accountable, nurses were empowered, and guidelines were enforced Medical leadership important

20. Click to edit Master title style Click to edit Master subtitle style 20 Stillbirths Before and After Implementation of Guidelines at Intermountain Healthcare Oshiro, B. et al. Obstet Gynecol 2009;113:804-811. 1999-2000July 2001 to June 2006 Weeks of Gestation StillbirthsDeliveries%StillbirthsDeliveries%Odds Ratio 95% CI 37174,1170.412213,0770.170.4060.22-0.77 38199,9540.192128,2090.070.3900.21-0.72 391013,7520.072851,7210.050.7440.36-1.53 40107,9250.131424,1400.060.4590.20-1.03 4121,9380.1035,5710.050.5220.09-3.12 All5837,6860.1588122,7180.070.4660.33-0.65

21. Click to edit Master title style Click to edit Master subtitle style 21 Summary: Reasons to Eliminate Non-medically Indicated (Elective) Deliveries Before 39 Weeks Reduction of neonatal complications No harm to mother if no medical or obstetrical indication for delivery Now a national quality measure: National Quality Forum (NQF) Leapfrog Group The Joint Commission March of Dimes NYS Department of Health Medicaid (?)

22. Click to edit Master title style Click to edit Master subtitle style 22 Eliminating Non-medically Indicated (Elective) Delivery Prior to 39 Weeks in Our Hospital What are the steps to make this happen?

23. Click to edit Master title style Click to edit Master subtitle style 23 First Step: Build Team and Gather Data Recruit committed members Nurse leaders: e.g., L&D Manager, Perinatal QI RN, Midwives Physician leaders: e.g., OB Chair, MFM, Neonatologist/Pediatrician Data Analyst and Risk Management Determine baseline induction and cesarean section rates Elective vs. indicated Before 39 weeks and ≥36 weeks Neonatal transfer/NICU admission rates and trends

24. Click to edit Master title style Click to edit Master subtitle style 24 Second Step: Indications and Dating Implement list of “approved” indications Have dept criteria for making certain diagnoses (e.g., hypertensive disorders of pregnancy) Identify medical leadership and empower nurses to handle “appeals” for exceptions Require ACOG criteria for ensuring ≥39 weeks gestational age

25. Click to edit Master title style Click to edit Master subtitle style 25 Overview of Changes To The Scheduling Process Patients scheduled either by calling scheduler or faxing request form. Elective deliveries (including RCS) must be ≥39 weeks based on ACOG criteria. Scheduling conflicts will be directed to the OB Chair or Director of L&D for resolution. Departmental meetings to discuss conflicts/issues. Data collected and reported back on a regular basis.

26. Click to edit Master title style Click to edit Master subtitle style 26 Sample Scheduling Form

27. Click to edit Master title style Click to edit Master subtitle style 27 Implementation Convene department and staff meetings to educate physicians and staff Baseline assessment Ongoing data collection plan Policy and procedure with Approved Indications New scheduling process and forms Provide educational materials for physicians, staff, and patients

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29. Click to edit Master title style Click to edit Master subtitle style 29 Revision Process Develop revised scheduling processes and guidelines Appeal process: Appoint physician leader(s) to enforce scheduling process and approve exceptions Describe the new guidelines Revise forms and scheduling policy and procedure Develop data collection plan and forms Determine what clinician and patient education materials are needed

30. Click to edit Master title style Click to edit Master subtitle style 30 What Providers Can Do Educate patients and staff about the risks and benefits of delivery before or after 39 weeks, and on the new scheduling process Perform ultrasound before 20 weeks to confirm gestational age on all your patients Take a lead on promoting best practice. “I’m sorry Ms. Jones, but it would not be consistent with ACOG guidelines to schedule you before 39 weeks…”

31. Click to edit Master title style Click to edit Master subtitle style 31 Tools to Educate Patients marchofdimes.com $10/10 $10/25

32. Click to edit Master title style Click to edit Master subtitle style 32 Track Progress Use data and audit tools to track the number of elective deliveries <39 weeks Develop trend charts and report back to staff and providers on a regular basis Address issues and concerns as soon as possible Anticipate fewer inductions and better outcomes

33. Click to edit Master title style Click to edit Master subtitle style 33 Bask in the glow of knowing you’re doing the right thing by upholding the standard of care!

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