Iowa Statewide Perinatal
Initiative
Stephanie Trusty RNC, BSN
Importance of Reducing elective
delivery prior to 39 weeks
Infants who have early term delivery (37 weeks
0 days to 38 weeks 6 days gestation) without a
medical indication may experience the
following:
◦ Increased morbidity
◦ Increased NICU admissions
◦ Increased neonatal deaths
Compared with those infants delivered at equal
to or greater than 39 weeks
Late–preterm Brain Development
March of Dimes

MOD public awareness campaign
◦ If your pregnancy is healthy, it’s best if you
baby is born at 40 weeks
◦ A baby’s brain at 35 weeks weighs only twothirds of what it will weight at 40 weeks
◦ In the last 6 weeks of pregnancy, the baby’s
brain adds connections needed for balance,
coordination, learning and social functioning.
During this time, the size of the brain almost
doubles
Brain development cont.
Babies born early have more learning and
behavior problems in childhood than
babies born at 40 weeks
 Feeding problems are more common
because they can’t coordinate sucking,
swallowing and breathing as well as full
term babies
 RDS and apnea are more common
 Increased risk of SIDS

NICU stay for both
babies
Vera - 6lbs 6 oz– RDS,
UAC, jaundice,
feeding problems
Everett - 5lbs 1 oz–
hypoglycemia, temp
instability, feeding
problems
Twins born at 35 4/7 weeks
Prevention of elective induction
prior to 39 weeks a national quality
metric

Considered sub standard by ACOG
◦

National Quality Forum


http://www.qualityforum.org/QPS/0469
Joint Commission


ACOG Practice Bulletin Practice bulletin no. 107. Induction of Labor
http://www.jointcommission.org/Perinatal_Care_Core_Measure_Set_Selection_Form/
March of Dimes, AAP, AWHONN
Toward Improving the Outcome of Pregnancy III (66-68)
http://www2.aap.org/sections/perinatal/pdf/TIOPIII.pdf

Center for Medicare and Medicaid Services (CMS)
Financial cost of early term
deliveries
Infants who were delivered electively between
37 and 39 weeks who are admitted to NICU
had an average length of stay of 4.5 days
 By avoiding these NICU stays for early term
elective deliveries the US health care system
could save $1 billion annually.

Clark SL, Frye DR, Meyers JA, et al. Reduction in elective delivery 39 weeks of gestation: comparative effectiveness of 3 approaches to
change and the impact on neonatal intensive care admission and stillbirth. Am J Obstet Gynecol 2010;203:449.e1-6.
Survey of Iowa Birthing Hospital Nurse
Managers about elective deliveries prior to
39 weeks
In 2011, IDPH, Iowa March of Dimes and
CDC collaborated to:
◦ Estimate the availability of guidelines or policies with
regard to elective inductions and elective cesarean
sections.
◦ Assess hospital level knowledge and practice
◦ Identify gaps between evidence and practice
◦ Determine availability and need for training
◦ Make recommendations to guide development of
educational interventions and providers tools.
General Information about the
survey
57.7% response rate
 20-25 minute telephone survey
 93% of those who completed the survey
were supervisor or nurse managers

◦ 73% Level I
◦ 22% Level II
◦ 4% Level III

60% participating hospitals had less than
200 deliveries in 2011.
Policy or guidelines
67% state they had a policy or guideline
regarding elective inductions
 40% had a policy or guideline regarding
elective cesarean deliveries
 Compliance with the elective induction
policy was reported most often as being
monitored by internal audits

Knowledge and Practice

64% incorrectly defined late preterm
birth, 22% did not know the definition

37% incorrectly defined early term birth,
53% did not know the definition
Need for training
Staff training was offered on elective
deliveries at 56% of the hospitals
 Training on elective deliveries was
mandatory at 21%
 71% of the respondents would like
assistance in identifying opportunities for
training on elective deliveries

Gaps between evidence and
practice

Results suggest a gap between respondent
knowledge and current evidence on the
risks associated with elective deliveries.
Survey Recommendations

Have IDPH update Guidelines for Peinatal
Services , 8th Edition with information on
elective deliveries including: definitions for
elective inductions and elective cesarean
deliveries, specific criteria for determining
gestational age, and examples of medical
indications for induction
Survey Recommendations

Policy Development
◦ 1/3 hospitals had no policy on elective
induction prior to 39 weeks
◦ 2/3 of the hospitals had no policy on timing of
routine repeat C-sections

Need for more education
◦ Statewide Perinatal Care Program
 http://www.idph.state.ia.us/hpcdp/statewide_perinatal_care.asp
◦ Healthy babies are worth the wait
39WeeksQI@marchofdimes.com
Resources

In 2010, The Joint Commission released a new set of
perinatal quality measures that includes the reduction of
non-medically indicated deliveries performed before 39
weeks gestational age. Available at:
http://www.jointcommission.org/NewsRoom/NewsReleases/r_112009.htm
Concurrently, the March of Dimes, in partnership with the
California Maternal Quality Care Collaborative (CMQCC)
and the California Maternal Child and Adolescent Division
within the state Department of Health, created a toolkit
entitled Elimination of Non-medically Indicated (Elective)
Deliveries Before 39 Weeks Gestational Age. This toolkit outlines
steps that hospitals can take to begin a quality improvement
initiative to eliminate elective deliveries prior to 39 weeks.
Download the toolkit from the Prematurity Prevention Resource
Center at prematurityprevention.org.
Resources

MOD catalog #37-2229-07 Late-preterm brain
development card 2/08
call 1-800-367-6630

http://www2.aap.org/sections/perinatal/pdf/TIOPIII.pdf
References
1.
Clark SL, Miller DD, Belfort MA, Dildy GA, Frye DK, Meyers JA. Neonatal
and maternal outcomes associated with elective term delivery. Am J
Obstet Gynecol 2009; 200:156.e 1-4.
2.
Clark SL, Frye DR, Meyers JA, et al. Reduction in elective delivery 39
weeks of gestation: comparative effectiveness of 3 approaches to change
and the impact on neonatal intensive care admission and stillbirth. Am J
Obstet Gynecol 2010;203:449.e1-6.
3.
Reddy UM, Ko CW, Willinger M. “Early” term births (37-38 weeks) are
associated with increased mortality. Am J Obstet Gynecol 206;195:S202.
4.
Iams J. for the Ohio Perinatal Quality Collaborative . A statewide initiative
to reduce scheduled births without appropriate indication. Am J Obstet
Gynecol 2009;201(suppl):s19