A presentation on Medically Indicated Deliveries Before 39 weeks. Includes updated information from ACOG. Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10.

1. Medically Indicated
Deliveries Before 39
Weeks Gestational Age
“MIDB39 weeks”
Chukwuma I. Onyeije, M.D.
Atlanta Perinatal Associates
1

2. Research and Experience Show:
Early ELECTIVE delivery without MEDICAL or
OBSTETRICAL indication is linked to neonatal
morbidities with NO benefit for the mother or infant.
HOWEVER….
There are numerous maternal and fetal indications for
deliveries BEFORE 39 weeks gestation
ALSO…
Elective deliveries AFTER 39 weeks are not necessarily
without risks for mother and infant.
2

3. Is there really a problem here?
“What’s the big deal?”
“It’s only a couple of days?”
“No one is going to tell me how
to practice medicine.”
Actual quotes from OBGYN providers regarding 39 week policy. Circa 2002.
3

4. Inductions of Labor
• ACOG has cautioned against inductions before 39
weeks in the absence of a medical indication since 1979.
(Committee Opinion #22)
• ACOG also suggests that “a mature fetal lung maturity
test result before 39 weeks of gestation, in the absence
of appropriate clinical circumstances, is NOT an
indication for delivery”
(Committee Practice Bulletins #97 and #107)
4

6. How did
we get
here?
1992
To 2002
“The Lost
Decade”
6

7. 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.

8. 2002 C-S
Early Term
Percent of Singleton Live Births (%)
U.S. Cesarean Section and Labor Induction Rates Among
Singleton Live Births by Week of Gestation, 1992 and 2002
1992 C-S
2002 Induction
1992 Induction
Gestational Age (week)
Source: NCHS, Final Natality Data, Prepared by March of Dimes Perinatal Data Center, April 2006.

9. Rates of Induction of Labor in Singleton Births
by Race and Hispanic Origin in the U.S.
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.

10. Percent Singleton Live Births
Changing Distribution of US Live Births 1992 - 2002
11/06/13
Davidoff et al Sem Perinatology 2006

11. Why are Non-medically
Indicated (Elective) Deliveries
Increasing in Frequency?

12. Obstet Gynecol 2009;114:1254

13. The Gestational Age that Women Considered
a Baby to be Full Term
29.1%
21.7%
20.8%
17.4%
3.3%
Obstet Gynecol 2009;114:1254
3.3%
4.8%

14. The Gestational Age that Women Considered
it Safe to Deliver
35%
31%
30%
25%
22%
19%
Women's Responses
20%
15% 14%
10%
Obstet Gynecol 2009;114:1254
5%
0%
7%
3%
4%
Weeks of Gestation

15. Pressure on Obstetricians
Reasons that physicians may resist elimination of
elective deliveries < 39 weeks:
•Physician Convenience
• Guarantee attendance at birth
(“co-dependency”)
• Avoid scheduling conflicts
• Reduce being awakened at night
•…what’s the harm?
• Bad outcomes are unrecognized and rare
• The NICU handles these issues just fine
•Limit risk of a bad pregnancy outcome
Clin Obstet Gynecol 2006;49:698-704

16. Risks of Non-medically
Indicated (Elective) Delivery
Before 39 Weeks

17. Complications of Non-medically Indicated (Elective)
Deliveries Between 37 and 39 Weeks
•
•
•
•
•
•
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
Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997

18. QUESTION: WHO (EXACTLY) IS TERM?
18

19. OLD Terminology
Late Preterm Early Term
First day of
LMP
Week #
0
20 0/7
340/7
Preterm
37 0/7
39 0/7
Term
416/7
Post term
Modified from Drawing courtesy of William Engle, MD, Indiana University
Raju TNK. Pediatrics, 2006;118 1207.
19

20. NEW Terminology
October 31, 2013
20

21. Term Pregnancy Redefined by
ACOG and SMFM
Published in the November 2013 Green Journal.
Four new definitions of “term pregnancy” were issued by
ACOG & SMFM in a joint Committee Opinion.
Terminology designed to put the focus on preventing
deliveries before 39 weeks’ gestation.
21

22. ACOG and SMFM now discourage the use of
the general label “term pregnancy”
Early Term:
Between
37 weeks 0 days and
38 weeks 6 days
Full Term:
Between
39 weeks 0 days and
40 weeks 6 days
Late Term:
Between
41 weeks 0 days and
41 weeks 6 days
Postterm:
Between
42 weeks 0 days and beyond
22

23. Okay. How
do I know if
my patient is
“Full Term”?
23

24. 24

25. Confirmation of Term Gestation
• Early ultrasound (< 20 weeks gestation) is more
accurate than an ultrasound after 20 weeks
gestation at determining gestational age and
benchmarking < 39 weeks gestation.
• Ultrasound-established dates should take
precedence over LMP-established dates when
the discrepancy is greater than 7 days in the first
trimester and 10 days in the second trimester…
OR if the LMP-established dates are uncertain.
25

26. Actual Case:
JT presented for prenatal care on 9/7/13 with an
LMP of 2/19/13. She was assigned an EDD of
11/26/13 and an EGA of 28 weeks.
Her first ultrasound on 9/25/13 showed an EFW
which placed her fetus at < 10 %tile.
Her second ultrasound on 10/28/13 showed an
EFW which placed her fetus at < 10 %tile.
26

27. At the time of her second ultrasound the
physician performing the ultrasound asked if she
had had any previous ultrasounds.
She pulled this out of her pocket from an
emergency room visit on 5/23/13 (almost 5
months earlier) for spotting……
27

28. Emergency Room Ultrasound
Date performed:
5/23/13
CRL: 49.5 mm
EGA: 11w5d
28

29. NEW EDD:
12/7/13
NEW EFW %tile:
54%
29

30. Clinician and/or Patient Desire to
Clinician and/or Patient Desire to
Schedule a Non-medically
Schedule a Non-medically
Indicated (Elective) Induction or
Indicated (Elective) Induction or
Cesarean Section
Cesarean Section
Clinician, Staff &
Clinician, Staff &
Patient Education
Patient Education
Elective Delivery
Elective Delivery
Hospital Policy
Hospital Policy
Physician Leadership
Physician Leadership
A. Enforce policy
A. Enforce policy
B. Approve exceptions
B. Approve exceptions
Reduce Demand
Public
Public
Awareness
Awareness
Campaign
Campaign
Induction //Cesarean
Induction Cesarean
Scheduling Process
Scheduling Process
Case NOT
Case NOT
Scheduled
Scheduled
if Criteria
if Criteria
Not Met
Not Met
QI Data
QI Data
Collection
Collection
& Trend
& Trend
Charts
Charts
30

31. Okay.
Let’s get
real.
Not all deliveries before 39 weeks
are for “convenience”.
31

32. Timing of Indicated Late-Preterm and Early-Term Birth.
Obstetrics & Gynecology. 118(2, Part 1):323-333, August 2011.

33. ACOG Committee Opinion: April 2013
Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560.
American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10.
33

34. ACOG Committee Opinion: April 2013
 The neonatal risks of late preterm and early-term births
are well established.
 HOWEVER, there are a number of complications in
which either a late-preterm or early-term delivery is
warranted.
 The timing of delivery must balance the maternal and
newborn risks of late-preterm and early-term delivery
with the risks of further continuation of pregnancy.
34

35. ACOG Committee Opinion: April
2013
Decisions regarding timing of delivery must be
individualized.
Amniocentesis for the determination of fetal lung
maturity in well-dated pregnancies generally
should not be used to guide the timing of
delivery.
35

36. Terminology Recall….
Early Term:
Between
37 weeks 0 days and
38 weeks 6 days
Full Term:
Between
39 weeks 0 days and
40 weeks 6 days
Late Term:
Between
41 weeks 0 days and
41 weeks 6 days
Postterm:
Between
42 weeks 0 days and beyond
36

37. Terminology for Medically Indicated
Deliveries
Late Preterm
Between 34 weeks 0 days and
36 weeks 6 days.
Early Term:
Between
37 weeks 0 days and
38 weeks 6 days
Full Term:
Between
39 weeks 0 days and
40 weeks 6 days
Late Term:
Between
41 weeks 0 days and
41 weeks 6 days
Postterm:
Between
42 weeks 0 days and beyond
37

38. Categories for Medically Indicated Deliveries:
38

39. 39

40. Placental / Uterine Issues
Condition
General Timing
Suggested Specific Timing
PLACENTA PREVIA
LATE PRETERM/EARLY TERM
36 0/7 to 37 6/7
WEEKS OF GESTATION
PLACENTA PREVIA WITH
SUSPECTED ACCRETA, INCRETA, OR
PERCRETA
LATE PRETERM
34 0/7 to 35 6/7
WEEKS OF GESTATION
PRIOR CLASSICAL CESAREAN
LATE PRETERM/EARLY TERM
36 0/7 to 37 6/7
WEEKS OF GESTATION
PRIOR MYOMECTOMY
EARLY TERM/TERM
(INDIVIDUALIZE)
37 0/7 to 38 6/7
WEEKS OF GESTATION
Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560.
American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10.
40

41. 41

42. GROWTH RESTRICTION (SINGLETON)
Fetal issues
Condition
OTHERWISE
UNCOMPLICATED,
NO CONCURRENT FINDINGS
General Timing
Suggested Specific Timing
EARLY TERM / TERM
38 0/7 to 39 6/7
WEEKS OF GESTATION
LATE PRETERM / EARLY TERM
34 0/7 to 37 6/7
WEEKS OF GESTATION
CONCURRENT CONDITIONS
(OLIGOHYDRAMNIOS, ABNORMAL
DOPPLER STUDIES, MATERNAL COMORBIDITY (IE, PREECLAMPSIA,
CHRONIC HYPERTENSION)
Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560.
American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10.
42

43. GROWTH RESTRICTION (TWINS)
FETAL ISSUES:
Condition
General Timing
Suggested Specific Timing
Di – Di TWINS WITH
ISOLATED FETAL GROWTH
RESTRICTION
LATE PRETERM/EARLY TERM
36w 7d  37w 6d
Di – Di TWINS WITH
CONCURRENT CONDITIONS
LATE PRETERM
32w 7d  34w 6d
Mono – Di TWINS WITH
ISOLATED FETAL GROWTH
RESTRICTION
LATE PRETERM
32w 7d  34w 6d
GESTATION
GESTATION
GESTATION
43

44. MULTIPLE GESTATIONS
FETAL ISSUES:
Condition
General Timing
Di – Di TWINS
EARLY TERM
Mono - Di TWINS
LATE PRETERM/
EARLY TERM
Suggested Specific Timing
38w 0d 
38w 6d
GESTATION
34w 7d 
37w 6d
WEEKS OF
GESTATION
Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560.
American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10.
44

45. OLIGOHYDRAMNIOS
FETAL ISSUES:
Condition
General Timing
Suggested Specific Timing
OLIGOHYDRAMNIOS
LATE PRETERM
EARLY TERM
36w 0d 
37w 6d
GESTATION
Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560.
American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10.
45

46. 46

47. HYPERTENSIVE DISORDERS
MATERNAL INDICATIONS
CONTROLLED & NO
MEDICATIONS
EARLY TERM/TERM
38w 0d  39w 6d
GESTATION
CONTROLLED ON
MEDICATIONS
EARLY TERM/TERM
37w 0d  39w 6d
GESTATION
LATE PRETERM/EARLY
TERM
36w 0d  37w 6d
GESTATION
EARLY TERM
37w 0d  38w 6d
GESTATION
DIFFICULT TO CONTROL
GESTATIONAL HYPERTENSION
47

48. HYPERTENSIVE DISORDERS
(Preeclampsia)
MATERNAL INDICATIONS
SEVERE PREECLAMPSIA
MILD PREECLAMPSIA
LATE PRETERM
AT DIAGNOSIS
AFTER 34w 0d
GESTATION***
EARLY TERM
AT DIAGNOSIS
AFTER 37w 0d
GESTATION
*** Clinical judgment important
48

49. DIABETES
PREGESTATIONAL:
WELL-CONTROLLED*
MATERNAL INDICATIONS
PREGESTATIONAL
WITH VASCULAR
COMPLICATIONS
PREGESTATIONAL:
POORLY CONTROLLED
GESTATIONAL:
WELL CONTROLLED ON
DIET OR MEDICATIONS
GESTATIONAL:
POORLY CONTROLLED
LATE PRETERM, EARLY TERM BIRTH NOT INDICATED
EARLY TERM / TERM
37w 0d  39w 6d
GESTATION
LATE PRETERM OR EARLY
TERM
INDIVIDUALIZED
LATE PRETERM, EARLY TERM BIRTH NOT
INDICATED
LATE PRETERM OR EARLY
TERM
INDIVIDUALIZED
49

51. PREMATURE RUPTURE OF
MEMBRANES (PROM)
OBSTETRICAL INDICATIONS
PPROM
LATE PRETERM
34w 0d
GESTATION
51

52. Conclusion:
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
 Strong support from ACOG
 Now a national quality measure for hospital
performance:
- National Quality Forum (NQF)
- Leapfrog Group
- The Joint Commission (TJC)
52

53. HOW AM I GOING TO REMEMBER ALL OF THIS?
11/06/13

54. • These are guidelines. Clinical judgement and
common sense should come first.
• This presentation is available online.
• http://bit.ly/midb39
• There’s an app for this.
http://bit.ly/midb39app OR
• http://bit.ly/midb39play
11/06/13

55. http://bit.ly/midb39play

56. Mecically Indicated Deliveries
Before 39 weeks.
There's an app for that...
http://bit.ly/midb39app