Friday, September 28, 2012

The power of 40 weeks

Pat Bradley, RN,C, BS, thought something was amiss. The director of obstetrics at Edward Hospital & Health Services in Naperville, Ill., had noticed an increase in the number of nonmedically indicated elective deliveries before 39 weeks gestation — elective early-term deliveries, as the March of Dimes calls them.

Bradley, a veteran nurse with more than 40 years of obstetrics experience, suspected this trend was heightening the risk of complications for mothers and babies. But without data it was difficult to prove her theory. Then one week a perfect storm of events confirmed her suspicions.

First, the hospital’s clinical quality group informed her that 28% of the hospital’s births in 2010 were elective early-term deliveries. The national average, according to the Leapfrog Group, was 17%. Then she discovered neonatal outcome data that confirmed her fears. Studies have exposed the consequences of the practice of scheduling early delivery dates, which include increased risks for NICU admission, transient tachypnea of the newborn, respiratory distress syndrome, ventilator support and feeding problems.

"A single practitioner may not see increased complications caused by elective deliveries between 37 and 39 weeks, but when you look at large numbers of newborns, you start to see the trend," Bradley said.

RNs have begun raising public and provider awareness about the risks of elective early-term deliveries.
Risky business

Although the percentage of elective early-term deliveries at Edward Hospital sounds high, a study in the February 2009 issue of the American Journal of Obstetrics & Gynecology shows otherwise. Researchers collected data over a three-month period in 2007 and found that of the 15,000 births that occurred at 37 weeks or later, 6,500 were planned. Of the planned deliveries, 71% were nonmedically indicated. Additionally, data from the Centers for Disease Control and Prevention show the rate of births between 37 and 38 weeks increased by nearly 50% between 1990 and 2006.

Medically necessary reasons for early deliveries include premature rupture of the membranes, gestational hypertension, preeclampsia and gestational diabetes.

At Sutter Medical Center in Sacramento, Calif., studies about the potentially negative effects of elective early-term deliveries motivated hospital leaders to examine outcomes at their facility and use these cases to educate obstetrical care providers about the risks.

"It always helps to have data and cases from your own institution to demonstrate that our practices could also be improved," said Mary Campbell Bliss, RN, MS, CNS, a perinatal clinical nurse specialist at Sutter. Without larger studies, the effects of this trend initially were difficult to determine. But some hospitals began to explore cases that called into question the wisdom of elective early-term deliveries.
Taking action

Obstetric nurses such as Bradley and Bliss were concerned the rates of elective deliveries in their hospitals were too high, but they knew they needed help to change an established practice at their facilities.

In the summer of 2010, when the March of Dimes announced it needed hospitals to participate in a pilot program using a new toolkit aimed at reducing the number of elective early-term deliveries, Bradley and Bliss were eager to participate. The free toolkit, initially developed by the California Maternal Quality Care Collaborative, included data on the increased maternal-infant risks associated with nonmedically indicated elective deliveries and strategies to change hospital policies.

Bradley met with hospital administrators and physicians and presented data from the toolkit, and her audience was surprised by what they learned. For example, a study published in Obstetrics & Gynecology in 2009 found that in 21 hospitals in Idaho and Utah, rates of respiratory distress syndrome were 22.5 times higher for infants born at 37 weeks and 7.5 times higher for those born at 38 weeks compared with infants born at 39 weeks. The same study found the rates of NICU admissions were more than double for infants born at 37 weeks versus 39 weeks. The toolkit also explained brain growth in the last several weeks of gestation is important because an infant’s brain at 37 weeks weighs only 80% of what it would weigh at 40 weeks.

Although it may be tempting to blame healthcare providers for the trend of earlier scheduled deliveries, Bradley suggested patients also have contributed to the shift.

"A lot of moms are looking to deliver early because they are uncomfortable or because a caregiver for other children will be available at a certain time," she said. "There have also been a lot of advances in neonatal medicine, so people feel like their chances of [having] a healthy baby are high at 37 weeks."
Effecting change

During the pilot program, Edward Hospital started using a new scheduling form included in the March of Dimes toolkit. Physicians were required to fill out information about the infant’s gestational age and list why the early-term delivery was medically necessary. If a form did not meet the criteria for an early delivery, then the physician champion would call the fellow physician to see whether the delivery could be delayed.

The program was so successful that the elective early-term delivery rate dropped to less than 1% in one year. The hospital has been collecting outcome data for these deliveries.

At Sutter Medical Center, the toolkit pilot program also was successful. The rate of elective early-term deliveries dropped from 15% in 2010 to 5.5% in 2011.

"The biggest change has been waiting to schedule repeat C-sections until 39 weeks," Bliss said. "One of the concerns providers have is that if a woman who has previously had a C-section goes into labor, there is a risk of her uterus rupturing, but we have not seen this occur. The majority of these women do not go into labor prior to 39 weeks, and for the ones who do, we have performed successful C-sections."

Once the hospital implemented the new program, the number of spontaneous births also increased, translating to more deliveries on the night shift, Bliss said. As a result, the hospital has increased the number of nurses working that shift.
Go the full 40

In December 2011, the Association of Women’s Health, Obstetric and Neonatal Nurses launched a public education campaign to teach expectant mothers about the benefits of waiting until at least 40 weeks gestation to induce labor unless they have a medical reason to do so earlier.

The "Go the Full 40" campaign lists 40 reasons to wait until the expected due date. Catherine Ruhl, RN, MS, CNM, director of women’s health programs at the AWHONN, encourages nurses to read the list and educate their patients.

"For many women, it dawns on them what they have signed up for with an elective delivery once it is too late, but I hope we can change that," Ruhl said. "Ideally this education should start prenatally, but it can also happen when pregnant women come to the hospital when they mistakenly think they are in labor and are sent home. This is a perfect time for nurses to educate these women about the importance of waiting." •

Heather Stringer is a freelance writer.

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