FINAL DRAFT
Colorado Perinatal Care Council:
Position Paper on Elective Delivery
The Colorado Perinatal Care Council (CPCC) supports perinatal care practices that promote the
best possible health outcomes for mothers and newborns. In recent years, the number of
scheduled deliveries for non-medical reasons for mother or baby, either through induction of
labor or scheduled cesarean section, has increased.
Numerous studies show increased morbidity and mortality for the newborn when elective
deliveries occur before 39 completed weeks of gestation. Late-preterm infants (born between 3436 6/7 weeks gestation)1 are at increased risk2 for adverse health and developmental outcomes
that include: 1) respiratory distress syndrome (RDS) due to surfactant deficiency,3-14 2) need for
mechanical ventilation primarily due to RDS,4,9,10,12,14 3) sepsis/sepsis evaluation,7,8,14 4)
hypoglycemia,7,8,14 5) hyperbilirubinemia/ jaundice,7,8,15 6) feeding problems,7,8,16 7) apnea7,8,16
8) temperature instability8,16, 9) admission to the neonatal ICU14, 10) hospitalization (for 5 days
or more at birth,14,17 11) re-hospitalizations in the first month and first year of life,10,17,18 and 12)
long-term neurologic and developmental delays and complications requiring physical,
occupational and speech therapy and special education.9,19,20 These risks increase progressively
as gestational age at birth declines.3,6,10-14,18
All causes of infant mortality (birth defects, sudden infant death syndrome, respiratory distress
syndrome) in the US have decreased, except for prematurity which has actually increased.
Mortality rates for late-preterm infants are higher (8.9 to 9.2/100,000 live births) than for full
term infants (2.5/100,000 live births).21 A recent study comparing death rates of term and latepreterm infants found that late-preterm infant mortality rates were threefold higher than term
infants (7.9 versus 2.4 deaths /1000 live births).22
The Institute for Healthcare Improvement (IHI) has recommended a process improvement
approach that will help to decrease neonatal morbidity and mortality.23 Through the IHI
initiative, a combination of experts and front-line practitioners have identified processes that they
believe will decrease the risk of birth trauma and other adverse events. Based on the best
available evidence and science, the process uses the theory that if the science is right and the
related processes are carried out consistently, the outcomes will improve. They have developed
a “bundle” approach that is driven by processes that, when executed together, result in better
outcomes than when implemented individually.23
Colorado Perinatal Care Council: Position Paper on Elective Delivery
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The Idealized Design of Perinatal Care includes an Elective Induction Bundle (www.ihi.org)
consisting of four components that support an evidence based approach to achieving improved
neonatal outcomes.23 The first component is gestational age 39 weeks or greater. Determination
of gestational age is defined in American College of Obstetricians and Gyneocologists’(ACOG)
Practice Bulletin #107 – “Induction of Labor”.24 While this bundle is aimed at elective
inductions, the same principle of delivery at 39 weeks or greater should be applied to elective
cesarean section as well.
The cesarean section rate in the United States in 2006 was 31.1% and continues to increase.25
Determining what proportion of this increase is attributable to elective cesarean section is
difficult. An international estimate of the elective cesarean section rate ranges between 4% and
18% .25 A portion of elective cesarean sections are performed because they are requested by the
patient. Some women request a cesarean section to avoid potential physical consequences after
vaginal delivery, such as possible urinary and anal incontinence and pelvic organ prolapse.
According to the National Institute of Health (NIH) (http://consensus.nih.gov), there is little
significant evidence to associate these concerns with any particular mode of delivery.26 The lack
of public awareness can be a contributing factor in maternal requests for cesarean section.
ACOG (www.acog.org) supports a patient’s request for elective cesarean section along with
appropriate discussions of benefits and risks. ACOG does not recommend Cesarean Delivery on
Maternal Request for women desiring several children due to increased risks of placenta previa,
placenta accreta and hysterectomy. It is important that care providers assure that patients have all
the information about the risks, benefits and alternatives of elective cesarean section, ensuring
that the final decision is a collaborative effort.27 It is also important to follow the IHI’s
recommendation that elective delivery not occur prior to 39 completed weeks of gestation. Care
providers need to be fully informed about these factors and need to assure that their patients are
well informed about the risks as well.
Colorado Perinatal Care Council Recommendations:
1. All care providers must be fully informed of both the maternal and neonatal risk
factors involved in scheduled delivery.
2. Electively scheduled delivery (whether induction or cesarean section) should only
occur when the patient has reached 39 completed weeks of gestation or greater. It is
important to emphasize that medical indications such as hypertension/ preeclampsia, previous uterine surgery including classical Cesarean section,
Colorado Perinatal Care Council: Position Paper on Elective Delivery
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intrauterine growth restriction, diabetes, advanced cervical dilation, history of rapid
labor, living far away from a hospital, and other pregnancy complications do justify
early delivery for the well-being of mother and/ or baby.
3. Assure that all patients are fully informed about elective delivery and the risks of
delivery occurring prior to 39 completed weeks of gestation. The March of Dimes
pamphlet, Why the Last Weeks of Pregnancy Count and the Late-Preterm Brain
Development Card, provide excellent patient information and can be utilized for
patient education.
4. Utilize the ACOG criteria (ACOG Practice Bulletin #107) to determine gestational
age.
5. The decision to have an electively scheduled delivery should be a collaborative
decision between a fully informed patient and her care provider.
6. Documentation of informed consent should be present in the medical record.
7. Apply the four criteria in the IHI bundle for Elective Induction if the patient is
induced.
8. Document that all criteria have been met when the procedure is scheduled.
References:
(1) Engle W: A recommendation for the definition of “late preterm” (near-term) and the birth weightgestational age classification system, Semin Perinatol 30:2, 2006.
(2) Engle W, Tomashek KM, Wallman C; and the Committee on Fetus and Newborn: “Late-preterm”
infants: a population at risk, Pediatrics 120:1390, 2007.
(3) Morrison J, Rennie J, Milton P: Neonatal respiratory morbidity and mode of delivery at term: influence
of timing of elective caesarean section, British J Obstet Gynaecol 102:101, 1995.
(4) Madar J, Richmond S, Hey E: Surfactant-deficient respiratory distress after elective delivery at ‘term’,
Acta Paediatr 88:1244, 1999.
(5) Minkoff H, Chervenak F: Elective primary cesarean delivery, N Engl J Med 348:946, 2003.
(6) Zanardo V, Simbi A, Franzoi M, et al: Neonatal respiratory morbidity risk and mode of delivery at
term: influence of timing of elective caesarean delivery, Acta Paediatr 93:643, 2004
(7) Barrington K, Vallerand D, Usher R: Frequency of morbidities in near-term infants, Pediatr Res
55:372A, 2004.
(8) Wang M, Dorer D, Fleming M, et al: Clinical outcomes of near-term infants, Pediatrics 114:372, 2004.
(9) Clark R: The epidemiology of respiratory failure in neonates born at an estimated GA of 34 weeks or
more, J Perinatol 25:251, 2005.
(10) Escobar G, Clark R, Greene J: Short-term outcomes of infants born at 35 and 36 weeks gestation: we
need to ask more questions, Semin Perinatol 30:28, 2006.
(11) Hansen AK, Wisborg K, Uldbjerg N, et al: Elective caesarean section and respiratory morbidity in the
term and near-term neonate, Acta Obstet Gynecol Scand 86:389, 2007.
(12) Hansen AK, Wisborg K, Uldbjerg N, Henricksen TB: Risk of respiratory morbidity in term infants
delivered by elective caesarean section: Cohort stidy, British Medical J 336:85, 2007
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(13) Engle W, Kominiarek M: Late preterm infants, early term infants, and timing of elective deliveries,
Clin Perinatol 35:325, 2008.
(14) Tita A, Landon M, Spong C, et al: Timing of elective cesarean delivery at term and neonatal outcomes,
N Engl J Med 360:111, 2009.
(15) Bhutani V, Johnson L: Kernicterus in late preterm infants cared for as healthy infants, Semin Perinatal
30:89, 2006
(16) Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN): Near-Term Infant
Initiative, Washington, DC, 2005> Available at: www.awhonn.org.
(17) McLaurin KK, Hall CB, Jackson EA, et al: Persistence of morbidity and cost differences between latepreterm and term infants during the first year of life, Pediatrics 123:653, 2009
(18) Oddie S, Hammal D, Richmond S, Parker L: Early discharge and readmission to the hospital in the
first month of life in the northern region of the UK during 1998: A case cohort study, Arch Dis Child
90:119,2005
(19) Kalia JL, Visintainer T, Brumberg HL: Comparison of enrollment in interventional therapies between
late-preterm and very preterm infants at 12 months’ corrected age, Pediatrics 123:804, 2009
(20) Morse SB, Zheng H, Tang Y, Roth J: Early school-age outcomes of late-preterm infants, Pediatrics
123:e622, 2009
(21) Institute of Medicine: Preterm birth: causes, consequences, and prevention, Washington, DC, 2006,
National Academies Press.
(22) Tomashek KM, Shapiro-Mendoza CK, Davidoff MJ, et al: Differences in mortality between latepreterm and term singleton infants in the United States, 1995-2002, J Pediatr 151:450, 2007
(23) Institute for Healthcare Improvement (2005) Idealized Design of Perinatal Care. Available at
www.ihi.org.
(24) ACOG: Practice Bulletin #107, Induction of Labor, 2009.
(25) Collard, T, Diallo, H, Habinsky, A, Hentschell, C, Vezeau, T: Elective Cesarean Section, Why Women
Choose it and What Nurses Need to Know, Nursing for Women’s Health 12(6):480, 2009.
(26) National Institutes of Health: NIH State-of-the-Science Conference Statement: Cesarean Delivery on
Maternal Request, Washington, DC, 2006. Available at http://consensus.nih.gov.
(27) ACOG (2003). New ACOG opinion addresses elective cesarean section controversy. Available at
www.acog.org.