Skip Navigation

Text Alternative: CME: Raising Awareness: Late Preterm Birth and Non-Medically Indicated Deliveries Prior to 39 Weeks

Skip sharing on social media links
Share this:

To view the original video, please go to http://www.nichd.nih.gov/ncmhep/isitworthit/Pages/medicalprof.aspx.

Video/Graphics Audio
This CME (Continuing Medical Education) Course is set up with a video inset on the left side of the screen and a rotating series of slides on the right hand side of the screen.

Video: Animated Medscape logo sits on left.

Introduction Slide: Title: “Raising Awareness: Late Preterm Birth and Non-Medically Indicated Deliveries Prior to 39 Weeks.

The slide also displays the National Child and Maternal Health Education Program logo and the Medscape logo in the lower right hand corner.
[MUSIC IN]








[MUSIC OUT]
Video: Dr. Alan Guttmacher on camera.

Text under the video: ”Dr. Alan Guttmacher, MD; Bethesda, MD”
Dr. Alan Guttmacher: Hello. I'm Alan Guttmacher, the director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. It is my pleasure to welcome you to this continuing education program on increasing awareness about the growing problems of late preterm birth and of non-medically indicated term inductions prior to 39 weeks gestation.

Two years ago, NICHD came together with 32 other federal agencies and professional organizations that focus on child and maternal health to create the National Child and Maternal Health Education Program. Our objective is to identify key challenges in child and maternal health, review the relevant research, identify research gaps, initiate activities, and propose solutions to advance the field. The National Child and Maternal Health Education Program Coordinating Committee identified the growing incidence of late preterm birth and of non-medically indicated term inductions prior to 39 weeks' gestation as a high priority and the first issue that this new national education program should address. The goal of this continuing education program is to raise awareness around this significant issue and communicate the message that even though 37 weeks is technically term, it is important for all pregnancies without complications that would increase maternal or fetal risk to reach 39 weeks. Further, the delivery prior to 39 weeks is appropriate only if medically indicated and with documented fetal lung maturity, as specified by American College of Obstetricians and Gynecologists guidelines.

This education program was designed to inform the practices of the wide spectrum of providers who take care of pregnant women in pursuit of our common goal of healthy mothers and babies. I hope you find this roundtable discussion useful.

I now would like to introduce Dr. Cathy Spong, Chief of the Pregnancy and Perinatology branch at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), who will moderate this discussion.
Video: Dr. Catherine Spong on camera.

Text under video: “Catherine Spong, MD; Bethesda, MD”

Slide 1: Title: “Faculty Experts.”

Text:
Moderator;
Catherine Spong, MD;
Chief, Pregnancy and Perinatology Branch;
Eunice Kennedy Shriver National Institute of Child Health & Human Development;
Bethesda, MD.

Panelists;
Jane Lamp, MS, RN-BC, CNS;
Clinical Nurse Specialist, Riverside Methodist Hospital;
Member, Association of Women’s Health, Obstetric and Neonatal Nurses Late Preterm Infant Science Team;
Columbus, Ohio.

Karna Murthy, MD;
Attending Physician, Neonatology;
Children’s Memorial Hospital;
Assistant Professor of Pediatrics;
Northwestern University Feinberg School of Medicine;
Chicago, Illinois.

Anne Moore, APN;
Professor of Nursing,
Vanderbilt University;
Fellow, American Academy of Nurse Practitioners; Nashville, Tennessee”
Dr. Catherine Spong: Thanks, Dr. Guttmacher. I am Dr. Catherine Spong and I would like to welcome you to this Medscape CME and CE spotlight panel discussion, entitled: Raising Awareness: Late Preterm Birth and Non-Medically Indicated Deliveries Prior to 39 Weeks.
Video: Four speakers, Spong, Lamp, Murthy and Moore, sit behind a table. The background includes a logo that reads “Spotlight.” Video transitions to Lamp on camera.

Text under video: “Jane Lamp, MS, RN-BC, CNS; Columbus, OH.” Spong speaks off screen.
Spong: I am joined today for this panel discussion by Ms. Jane Lamp, a Clinical Nurse Specialist at Riverside Methodist Hospital in Columbus, Ohio, and a member of the Association of Women's Health, Obstetric and Neonatal Nurses, Late Preterm Infant Science Team.
Video: Camera transitions to Murthy on camera. Text under video:  “Karna Murthy, MD; Chicago, IL.” Spong speaks off screen. Spong: Dr. Karna Murthy, an attending physician of neonatology and Assistant Professor of Pediatrics at Northwestern University, in Chicago, Illinois;
Video: Camera transitions to Moore on camera. Text under video: “Anne Moore, APN, WHNP-BC; Nashville, TN.” Spong speaks off screen. Spong: And Ms. Anne Moore, Professor of Nursing at Vanderbilt University, in Nashville, Tennessee, and a fellow of the American Academy of Nurse Practitioners.
Video: Camera transitions to the four speakers at the table. Video transitions to Spong on camera.

Slide 2: Title: “Learning Objectives.”

Text: “Identify the factors contributing to the rising rate of late preterm births and non-medically indicated inductions prior to 39 weeks; Identify the potential short- and long-term consequences of births occurring between 34 and 38 weeks’ gestation; Integrate best practice, evidence-based guidelines for delivery prior to 39 weeks.”
Spong: The objectives of today's program are to identify the factors contributing to the rising rate of late preterm births and non-medically indicated deliveries prior to 39 weeks, and to identify the short- and long-term potential consequences of births occurring between 34 and 38 weeks' gestation. This includes births in the late preterm period -- those at 34-36 weeks -- and infants born prior to 39 weeks, thus at 37 to 38 weeks' gestation, without an indication. Finally, to integrate the best-practice, evidence-based on guidelines for delivery prior to 39 weeks.
Video: The four speakers sit behind a table.

Video transitions to Spong on camera.

Slide 3: Title: “Prevalence of Births Between 34 and 36 Weeks’ Gestation.”

Text: “In 2007, 12.7% of all live births were preterm.[a]
  • Late pre-term births account for 70%[b]
  • There were nearly 400,000 late preterm births in the United States, representing around 9% of live births[c]”
Below the text is a graph which shows the change in distribution of birth by gestational age in the United States, 1997-2007. The graph shows a steady increase of preterm births as a proportion of total live births from 11.4% in 1994 to 12.7% in 2007.

Reference:
  • Martin JA et al. National Center for Health Statistics. 2010, Vol. 58, No.24.
  • Davidoff MJ et al. Semin Perinatol. 2006;30:8-15.
National Center for Health Statistics, final natality data. Available at: http://www.marchofdimes.com/peristats External Web Site Policy.
Spong: First, let's review the scope of the problem.  In 2007, 12.7% of births were preterm in the United States. Of these, late preterm births -- those births between 34 and 36 weeks' gestation -- account for 70% of preterm births. Thus, in 2007 there were nearly 400,000 late preterm births in the United States, representing about 9% of the live births in this country.
Video: The four speakers sit behind a table.

Video transitions to Spong on camera.
Spong: There are numerous contributing factors to preterm birth; however, despite much research over the last several decades, many causes of preterm birth are not clear. Of these factors, Anne, can you name some that contribute to these deliveries?
Video: Moore on camera. Video transitions to the four speakers behind a table, then transitions back to Moore.

Slide 4: Title: “Factors Contributing to Deliveries Prior to 39 Weeks’ Gestation.

Text reads:
  • “Maternal age[a]
  • Infertility treatments[a]
  • Multiple gestations[a]
  • Maternal obesity[a]
  • Maternal comorbid conditions[a]
    • Hypertension
    • Diabetes mellitus
    • Pregnancy-induced hypertension
  • Intrauterine growth restriction with reassuring fetal surveillance[a]
  • Incorrect dating (ultrasound)[b]  
  • Maternal request[c]
  • Prior stillbirth[d]
Reference:
  1. Loftin RW, et al. Rev Obstet Gynecol. 2010,3:10-19.
  2. Grobman WA, et a. Clin Obstet Gynecol. 2007;50:537-546.
  3. Simpson KR, et al. J Perinat Neonatal Nurs. 2005;19:134-144.
ACOG Committee on Practice Bulletins-Obstetrics. ACOG Pract Bull. 2009;102:1-14.
Anne Moore: Absolutely. Issues such as maternal age, infertility treatments, multiple gestations, maternal obesity, maternal comorbid conditions -- things like hypertension, diabetes, pregnancy-induced hypertension -- and intrauterine growth restriction, or as we used to call it, intrauterine growth retardation, but reassuring fetal surveillance. Prior stillbirth is another issue as well as incorrect dating, which we see with ultrasound quite a bit so the ultrasonographer perhaps gives a date that may not be consistent with dates based on the last menstrual period. But for whatever reason, the clinician goes with the ultrasound dating of the pregnancy and thereby delivers an infant that is at 37 weeks, 36 weeks, when the understanding was that the fetus, the infant was going to be larger, or bigger or, more mature I should say, than that. And then maternal request, we are seeing that quite a bit. I think the information to consumers has been inappropriate, and by that I mean that women will come in and say, "I want to have my baby on my husband's birthday," or "I want to have my baby when my other child was born," or "I want to have my baby on Valentine's Day," and I think they clearly don't understand the risks associated with making those requests. And unfortunately some clinicians are willing to buy into those requests, maybe because they are so pressured by the individual or the couple, and that is really unfortunate because all too often a baby is born too soon.
Video: The four speakers sit behind a table. Spong: Karna, do you have anything to add?
Video: Murthy on camera.

Slide 5: Title: “Prevalence of Births Between 37 and 38 Weeks’ Gestation.

Text: “The number of births at 37 0/7 to 39 6/7 weeks’ gestation has increased by 14% and 21%[a]
  • 17.5% of live births occurred at 37 and 38 weeks’ gestation[a]”
A bar graph shows a sharp rise in late preterm (34-36 weeks) and early term (37 and 38 weeks) births and a marked decline in births at 40 weeks or more. The increase is approximately 10 to 30% for preterm births and almost 50% for early term births. The decrease is approximately minus 45% for 41 weeks and minus 50% for 42 or more weeks.

Reference:
  1. Engle WA, et al. Clin Perinatol. 2008;35:325-341.
Dr. Karna Murthy: We've seen a decline in the stillbirth and postdate pregnancies over the last 1-2 decades. Perhaps an unintended consequence of that decline in postdate delivery has been an increase in these late preterm births and children born at just less than term as well. I think we have to be cognizant that we have achieved a benefit of reducing these later-date pregnancies and stillbirths, and this consequence is something that we have to deal with going forward.
Video: The four speakers sit behind a table. Video transitions to Spong on camera then back to the panel.

Slide 6: Title: “Common Morbidities for Late Preterm Infants Born at 34-36 Weeks’ Gestation.

Text:
  • “Respiratory distress syndrome[a]
  • Transient tachypnea of newborn[a]
  • Pneumonia[a]
  • Feeding problems[b]
  • Hypothermia[b]
  • Hypoglycemia[a]
  • Jaundice[c]
  • Culture-proven sepsis[b,d]
  • Intraventricular hemorrhage[e]
  • Dehydration[f]
  • Neurocognitive outcomes, including special education needs.[g]
Reference:
  1. Consortium on Safe Labor, et al. JAMA. 2010;304:419-425.
  2. Loftin RW et al. Rev Obstet Gynecol. 2010;3:10-19.
  3. Lease M, et al. Curr Opin Pediatr. 2010;22:352-365.
  4. Cohen-Wolkowiez M, et al. Pediatr Infect Dis J. 2009;28:1052-1056.
  5. Annibale DJ. Available at: http://emedicine.medscape.com
    /article/976654-overview
    External Web Site Policy.
  6. Engle WA, et al. Pediatrics. 2007;120:1390-1401.
  7. Engle WA, et al. Clin Perinatol. 2008;35:325:-341.
Spong: Now let's discuss the consequences of these births. What are the health risks for infants who are delivered at 34 to 36 and 6/7 weeks' gestation and the infants delivered at 37 and 38 weeks' gestation? Jane, would you identify some of the common morbidities for late preterm births?
Video: The four speakers sit behind a table. Video transitions to Lamp on camera. Jane Lamp: Certainly. Late preterm babies are at greater risk for respiratory distress syndrome, transient tachypnea of the newborn, and pneumonia. Feeding problems are common with these early babies, as well as hypothermia, hypoglycemia, jaundice, culture-proven sepsis, intraventricular hemorrhage, and neurocognitive outcomes, including special education needs are a common package of problems that a late preterm could encounter.
Video: The four speakers sit behind a table. Spong: Karna, can you give us some specific numbers about that risk of respiratory complications in these babies?
Video: Murthy on camera. Video then transitions to the four speakers sitting behind a table. Murthy: Sure, Cathy. The incidence of respiratory distress syndrome is well described to rise with decreasing gestational age, and for children in the late preterm period, approximately 10% of infants born at 34 weeks have respiratory distress syndrome that requires medical therapy, including mechanical ventilation and surfactant administration, compared with children at 38 and 39 weeks' gestation; those children have about a 0.3% risk for these needs and therapies after birth. Pneumonia is more common among children at 34 weeks -- approximately 1.5% pneumonia at this gestational age -- and also there seems to be a rise in the need for support for respiratory failure at 34-36 weeks' gestation. Those children require therapies approximately 1.6% of the time compared with children born at term (about 0.2% of those infants).
Video: The four speakers sit behind a table. Spong: Jane, can you describe some of the reasons for these feeding problems?
Video: Lamp on camera. Lamp: Certainly. Late preterm babies are not as developed, so they don't have a sense of being hungry, they are immature, and they don't send out feeding cues to their mothers. They tend to fatigue easily as they are trying to coordinate their feeding, sucking, swallowing, breathing, and all of that leads to a need for much more support at the bedside with babies that are feeding, especially breastfeeding babies.
Video: The four speakers sit behind a table.

Slide 7: Title: “Short-term Consequences of Late Preterm Infants Born at 34-36 Weeks’ Gestation.

Text: “Neonatal mortality and morbidity are higher for infants born between 34 and 36 weeks’ gestation. 6 times more likely than full-term infants to die in the first week of life (2.8 per 1000 vs 0.5 per 1000). 3 times more likely to die in the first year of life (7.9 per 1000 vs 2.4 per 1000). 2-fold increased risk for sudden infant death syndrome.”

Reference:
Your Premature Baby. March of Dimes. Available at: http://www.marchofdimes.com/professionals/
14332_1157.asp#head8
External Web Site Policy.
Spong: Karna, there was an idea that some of these problems are actually intertwined; can you speak to that?
Video: The four speakers sit behind a table. Video transitions to Murthy on camera.  Murthy: Of course. Children who have feeding difficulties are certainly more likely to have hypoglycemia. Some of the cause of those feeding difficulties can be perhaps immature temperature regulation among those infants, and addressing these problems becomes a multidisciplinary approach, often in a neonatal intensive care unit. Those children often need to be separated from their mothers in such an environment, which leads to both the medical interventions required in the NICU as well as the delayed psychosocial bonding with parents.
Video: Spong on camera. Spong: And Anne, how about hospital readmissions? Are they more common in these infants?
Video: Moore on camera. Moore: Definitely. And what we see from a standpoint of maternal-infant bonding and maternal sequelae is that there is a disconnect; there is certainly a higher risk of postpartum depression; there is the issue of if the infant is admitted to the hospital, will the parent be allowed to accompany the infant back to the hospital? Many times that is not the case, so the new mother is too often put in the situation where she is literally shuffling back and forth between a residence and a hospital setting that may not be as welcoming as we would like for it to be. So the entire perspective of the birth experience is really not realized, and that leads to multiple issues as a new mother tries to adjust just to the role of being a parent, so I think that that’s overlooked as well. The idea that you are going to go home with a healthy baby and stay there is the perception that all new mothers have, and it is really unfortunate that often times this can't happen in a late preterm delivery.
Video: The four speakers sit behind a table. Spong: And often these hospital readmissions are for things like jaundice and feeding difficulties, dehydration, and sepsis. Is that right?
Video: Moore on camera. Moore: Right, and building into what Jane was saying, the problem with feeding, particularly if the baby is jaundiced, is they are feeling not well. Being jaundiced, in and of itself, fatigues the newborn and makes the baby less likely to be interested in nursing, and so the whole problem builds on itself to create kind of a perfect storm. The dehydration occurs because the nutrition is lacking, because the infant isn't interested in nursing, because he or she has the jaundice issue going on; and, it just blows up into kind of a perfect storm. It is really unfortunate.
Video: The four speakers sit behind a table. Video then transitions to Spong on camera.

Slide 8: Title: “Brain Development: March of Dimes Brain Card.” Image shows two brains side by side. The left one is smaller and smoother and is captioned “35 weeks” while the right one is larger, has more folds, and is captioned “40 weeks.”

Reference:
#37-2229-07. Late-preterm Brain Development Card 2/08. Available at: www.marchofdimes.com External Web Site Policy.
Spong: It feeds on each other -- absolutely. There is a nice image of 2 brains: a baby's brain at 35 weeks of gestation, showing how well it is formed; and then a baby's brain at 40 weeks of gestation, with the formation of that brain itself. You can see the stark differences between those 2 brains at 35 weeks and 40 weeks. Jane, would you like to speak to that point?
Video: Lamp on camera. Lamp: Yes. Especially in the last 6 weeks of pregnancy, that is a vital time for the brain to develop in the neonate, and it is the size of the brain, as well as the white cortical and gray cortical matter, that has not developed well. This leads to the behavioral and neurobehavioral immaturity that we see in the late preterms.
Video: Spong on camera.

Slide 9: Title: “Brain Development: Risk for Brain Injury and Neurodevelopmental Abnormalities.

Text: “Cortex volume increases by 50% between 34 and 40 weeks’ gestation. In the last 6 weeks of pregnancy, a neonate’s brain adds connections needed for balance, coordination, learning, and social functioning. Brain volume increases at rate of 15 mL/wk between 29 and 41 weeks’ gestation. Between 36 and 40 weeks, gray matter volume increases at a rate of 1.4% per week. Rapid growth of the cerebellum with approximately 25% of its volume developing after the late preterm period. Frontal lobes are the last to develop. MRI evaluation in preterm infants has shown an impairment of cerebellar growth compared with term infants.

Reference:
Main E, et al. California Maternal Quality Care Collaborative Toolkit to transform Maternity Care. March of Dimes; 2010.
Spong: As I understand, during this time period, between 35 and 40 weeks, is really when the brain volume basically doubles. Is that correct?
Video: Spong on camera. Lamp speaks off camera. Lamp: Yes.
Video: The four speakers sit behind a table. Video then transitions to Murthy on camera. Murthy: That's right, and often this is the time when the babies are learning to acquire those neonatal reflexes and impulses that contribute to the successful transition to extrauterine life, such as feeding and temperature regulation, and that growth and maturation is occurring at a rapid rate during this key time period.
Video: The four speakers sit behind a table. Video then transitions to Lamp on camera. Lamp: I think we could add that the maternal-newborn interaction is different with a premature baby, so that there is a potential for altered attachment and bonding because the baby is not as interactive and responding with his mother.
Video: Lamp on camera. Murthy speaks off screen. Murthy: I agree.
Video: The four speakers sit behind a table.

Slide 10: Title: “Prevalence of Special Educational Need by Gestation at Delivery.” Graph shows prevalence of special needs decreases steadily as estimated gestational age rises until 42 weeks when prevalence of special needs increases.

Reference:
MacKay DF, et al. PLoS Med. 2010;7:e1000289.
Spong: How about the long-term consequences then? Here we have seen some of the short-term consequences, we have seen why this might happen, due to the development of the baby's brain. What about the long-term consequences? Karna, would you like to speak to that?
Video: The four speakers sit behind a table. Video then transitions to Murthy on camera. Murthy: There are studies that have shown both a higher mortality and morbidity among late preterm infants. For example, there have been developmental delays and school-related problems [described] in a study from Scotland. [The study demonstrated] that children born just prior to term at 37-38 weeks' gestation have approximately a 5% risk of special educational needs when they reach school age in their childhood. These needs could persist – they include reading and spelling disabilities-- many of them focus on receptive language throughout early childhood education. Even more to the point, at 8-10 years, really long-term development through childhood, their cognitive scoring on standardized testing has been lower compared with children born at term.
Video: Murthy on camera.

Slide 11: Title: “Long-term Consequences of Late Preterm Births.

Text: “Subsequent developmental delays and school-related problems.[a]
  • 5.5% of all cases of special education needs are attributed to early term births
  • Special educational needs, including reading and spelling disabilities, may persist throughout early childhood education
  • Lower IQ scores at 8 and 10 years of age
  • Cerebral palsy odds are 3-fold higher in late preterm births[a,b]
Reference:
  1. MacKay DF, et al. PLoS Med. 2010;7:e1000289.
  2. Petrini J, et al. J Pediatr. 2009;154:169-176.
Murthy: Another very interesting finding that has been shown here in the United States is that those children born at late preterm birth have been shown to have quite a significantly higher chance of having cerebral palsy: nearly a 3-fold higher chance compared with children born at term here in the United States.
Video: The four speakers sit behind a table. Video then transitions to Spong on camera. Spong: Now let's shift our discussion from these late preterm births, these births at 34 through the completed 36 weeks of gestation, to those deliveries at 37 and 38 weeks; they are term, but they are in the beginning part of the term period and they are before 39 weeks, which is when it is felt to be comfortable to deliver. In these babies who are electively delivered at 37-38 weeks, meaning there is neither a medical reason nor an obstetrical reason, is there any increase in morbidity? Anne, would you like to speak to that?
Video: The four speakers sit behind a table. Video then transitions to Moore on camera.

Slide 12: Title: “Common Morbidities in Infants Born at 37-38 Weeks’ Gestation.

Text: “In non-medically indicated inductions, the neonatal morbidity rates at 37-38 weeks result in:
  • Increased NICU admissions[a]
  • Risk for cerebral palsy[b]
  • Neonatal jaundice[c]
  • Feeding difficulties[d]
  • Respiratory complications[e-h]
  • including increased transient tachypnea of the newborn
  • increased ventilator support
  • increased respiratory distress syndrome”
Reference:
  1. De Luca R, et al. Pediatrics. 2009;123:e1064-e1071.
  2. Moster D. JAMA. 2010;304:976-982.
  3. Lease M, et al. Curr Opin Pediatr. 2010;22:352-365.
  4. Lease M, et al. J Perinatol. 2009;29:S12-17.
  5. Clark SL, et al. Am J Obstet Gynecol. 2009;200:e1-e4.
  6. Morrison J, et al. Br J Obstet Gynaecol. 1995;102:101-106.
  7. Madar J, et al. Acta Pediatr. 199;88:12244-1248.
  8. Oshiro BT, et al. Obstet Gynecol. 2009;113 804-811.
Moore: Sure, clearly I think this is where we have felt for quite some time that we are in the safety zone. Unfortunately, what we're seeing -- or fortunately, because I think we are becoming aware of it now -- we are seeing that neonates born around 37-38 weeks do have a higher incidence of admission to the NICU vs those babies born closer to the 40-week mark. There are higher rates of respiratory problems and transient tachypnea of the newborn. Babies requiring ventilator assistance also fall into this group of the 37- to 38-week gestational age timeframe. Difficulties in breastfeeding [are also observed]. I think the mantra of "stay pregnant as long as you can stay pregnant," so to speak -- taking into consideration that you don't want to go post-term -- [is appropriate considering that] we are seeing more and more compelling information that says this is the best strategy for a healthy newborn. Jaundice can occur in a 37 to 38-week baby, as can hypothermia, and there is an increased risk for cerebral palsy in neonates delivered prior to 40 weeks. So the closer they can get to the 39-40 weeks, the better the outcome all the way around.
Video: The four speakers sit behind a table. Spong: This, of course, speaks to the point that it is an elective delivery; it is not an indicated delivery.
Video: The four speakers sit behind a table. Moore: Yes, absolutely.
Video: Murthy on camera. Moore speaks off screen. Moore: Correct.
Video: Spong on camera. Spong: But for these elective deliveries, probably the best environment is going to be intrauterine until 39 weeks.
Video: Murthy on camera. Moore speaks off screen. Moore: Absolutely.
Video: The four speakers sit behind a table. Spong: Are there any maternal consequences to preterm birth?
Video: The four speakers sit behind a table. Video then transitions to Moore on camera.

Slide 13: Title: “Maternal Consequences of Late Preterm Births.

Text: “Postpartum depression[a,b]  Post-traumatic stress syndrome[a,b] Increased cesarean delivery with the complications
of[c-e]
  • Wound infection
  • Febrile morbidity
  • Anemia”
Reference:
  1. Voegtline KM et al. Infant Behav Dev. 2010. In press.
  2. Jukelevics N. Understanding the Dangers of Cesarean Birth. Praeger Publishers; 2008.
  3. Koroukian SM. Med Care Res Rev. 2004;61:203-224.
  4. Liu S, et al. CMAJ. 2007;176:455-460.
  5. Goer H. et al. Lamaze International; 2010. Available at: http://www.lamazeinternational.org/p/cm/ld/fid=126 External Web Site Policy.
Moore: I think we certainly see an increased incidence of postpartum depression, and the literature supports that this occurs in primiparous women probably more than multiparous women, who have an infant that is a 37-week gestation, 38-week gestation, but the baby doesn't come home with the mother, not the plan that she had. Posttraumatic stress syndrome, as Jane and I were discussing earlier, that tends to be an issue as well, that we don't really look at so much. [We tend to have a] "if you don't discuss it, it is not a problem" kind of approach. And then when you are looking at intentional delivery -- and I am going to say not for indications such as maternal or neonatal compromise -- but you certainly increase the risk for a cesarean delivery, and in that package comes the risk for wound infection, febrile morbidity, and anemia on the part of the mother. So she is compromised as well.
Video: The four speakers sit behind a table. Video then transitions to Spong on camera. Spong: Now let's discuss the consequences of these births, specifically what are the health risks for infants who are born between 34 weeks and 36 and 6/7 weeks of gestation, as well as those infants who are born in the 37th and 38th week of gestation. Focusing first on mortality, Karna, can you tell us about the mortality for these late preterm infants and those born at 34-36 weeks?
Video: Murthy on camera. Murthy: A few studies have defined that late preterm infants are more likely to endure mortality in the perinatal period as well as in the first year of life. Specifically, late preterm infants are 6 times more likely than full-term infants to die in the first week of life. Also, they are 3 times more likely to die during the first year of life after their birth. Some studies have even talked about a higher risk for SIDS, sudden infant death syndrome, during that first year of life where a cause of death is not able to be determined.
Video: Spong on camera.

Slide 14: Title: “Best Practices: Reducing Late Preterm  Births and Births at 37-38 Weeks’ Gestation.

Text: “The American College of Obstetricians and Gynecologists (The College) has identified the prevention of preterm births to be a public health priority, urging clinicians to reduce the number of voluntary inductions and elective cesarean deliveries prior to 39 weeks for which no medical indication exists.”

Reference:
ACOG Practice Bulletin. Obstet Gynecol. 2009;114:Part 1
Spong: Let's move on to a discussion of the best practices for reducing preterm birth. The American College of Obstetricians and Gynecologists has identified the prevention of preterm birth to be a public health priority, urging clinicians to reduce the number of voluntary inductions in elective cesarean deliveries prior to 39 weeks when no medical indication exists.
Video: Spong on camera while Lamp speaks off screen. Video then transitions to the four speakers behind a table.

Slide 15: Title: “Fetal and Maternal Conditions Indicating the Need for Delivery During the Late Preterm Period.

Text along the left side of the slide reads “Important to emphasize that indicated deliveries prior to 39 weeks due to a maternal or fetal complication necessitates early delivery.”

The text at right shows a list of medical indications for late preterm birth with a total sample size of 195.

Text:
  • Severe or unstable medical/obstetric condition. N equals 150.
    • Severe preeclampsia: 85 (56.7%).
    • HELLP syndrome: 3 (2%).
    • Eclampsia: 2 (1.3%).
    • Abnormal fetal testing: 46 (30.7%).
    • Placenta previa/accreta with vaginal bleeding: 5 (3.3%).
    • Maternal medical condition: 9 (6%).
  • High risk but mild and/or stable medical/obstetric. N equals 45.
    • Intrauterine growth restriction with reassuring fetal testing: 8 (17%).
    • Mild preeclampsia: 29 (64.4%).
    • Prior classic cesarean delivery: 2 (4.4%).
    • Prior myomectomy: 2 (4.4%).
    • Maternal medical condition 3 (6.6%).
    • Prior stillbirth: 1 (2.2%).
Reference:
  1. ACOG Practice Bulletin. Obstetrics & Gynecology. 2009;114.Part 1.
  2. Holland MG. AM J Obstet Gynecol. 2009;201:404.e1-e4.
Lamp: Cathy, it is important to emphasize that we are not discussing these indicated deliveries for a maternal or fetal cause. If a baby or a mother has a complication requiring delivery, these certainly should occur.
Video: Murthy on camera. Murthy: However, it seems like over the last decade or so, the threshold to induce women has been lowered and has contributed to the increased birth rates prior to 39 weeks. This is demonstrated by the rising rates of induction at all gestational ages, between 34 and 38 weeks' gestation. Some of this may have been driven by the improvements in neonatal medicine over the last 10-20 years and the technology that clinicians now have to take care of these babies. However, this is really balanced with a trade-off, because the infant mortality is probably higher for these children, and due to the larger burden of late preterm infants, there is a larger population at risk for mortality later in their infancy.
Video: The four speakers sit behind a table.

Slide 16: Title: “Best Practices: Reducing Late Preterm Births and Births at 37-38 Weeks’ Gestation.

Text: “Over the past decade, the threshold to induce labor has lowered and contributed to increased birth rates prior to 39 weeks. This has been demonstrated by the rising rate of induction, driven by improvements in neonatal medicine and technology.
  • Changes in the modality of gestational age ascertainment: from menstrual dating to ultrasound dating[a]
  • Prenatal methods for estimating gestational age have a margin of error of ± 2 weeks[b]
Reference:
  1. Kramer MS et al. JAMA. 1988;260:3306-3308.
  2. Engle WA, et al. Semin Perinatol. 2006;30:2-7.
Spong: Right, because remember: Late preterm births account for 70% of all preterm births. So that is a huge burden.
Video: The four speakers sit behind a table. Murthy: Absolutely -- a huge problem.
Video: The four speakers sit behind a table. Video then transitions to Lamp on camera.

Slide 17: Title: “Best Practices: Reducing Late Preterm Births and Births at 37-38 Weeks’ Gestation.

Text: “Practitioners should balance the risk: benefit of continued fetal health and expectant management vs early delivery[a] Inform women that better neonatal outcomes are associated with longer gestation (40 weeks) Induction of labor is associated with higher rates of cesarean delivery [b,c]”

Reference:
  1. March of Dimes. Late Preterm Birth: Every Week Matters. Medical Perspectives on Prematurity; 2006. Available at: http://health.utah.gov/wic/pdf/
    wic_wire/2010-09&20insert.pdf
    External Web Site Policy.
  2. Glantz, JC, et al. J Reprod Med. 2005;50:235-240.
  3. Goer H, et al. J Perinatal Ed. 2007;16:32S-64S.
Lamp: It is important to make the distinction then between pregnant women requesting to be delivered prior to 39 weeks and those who have medical indications for such. Practitioners who are balancing the risk: benefit of continued fetal health and expectant management vs delivery are vital in promoting healthy outcomes for babies and mothers.
Video: Spong on camera. Spong: So the practitioner has to weigh whether it is better for the pregnancy to continue or for the pregnancy to be delivered at these gestational ages, as at any time in pregnancy.
Video: Spong on camera. Jane Lamp speaks off screen. Lamp: Exactly.
Video: Moore on camera.

Slide 18: Title: “Increase Awareness of Risks to and Potential Consequences for Late Preterm Infants and Infants Born at 37-38 Weeks’ Gestation.

Text: “The best outcomes are for deliveries at/after 39 weeks unless there are fetal and maternal indications. Both clinicians and patients need to be aware of the complications of delivery before 39 weeks. Continued research is needed on best- and evidence-based practices.”
Moore: I think women have to be informed that it is not a safe option to determine that they want their child born at 37 weeks or 36 weeks. I have heard women say, "I want my baby born now because the baby will be smaller," and, "My sister's child was born at 34 weeks and he is doing just fine." So I think there is a misperception, and I think this builds into the technology that we have -- these babies survive. But one of the things that we are looking at pretty specifically is the quality of that survival and the long-term outcome. The longer the baby stays in the uterus, barring any medical problems and neonatal problems, the better -- providing, of course, that we don't go into a postdate situation. The other thing is that women don't appreciate the fact that a C-section delivery is often connected with an induction, a late preterm or early term -- if you want to put it in those terms -- induction. So they have to be alerted to the fact that this is not a benign process for either the mother or the neonate, or the infant, and operative deliveries are fairly common when an elective induction takes place.
Video: The four speakers sit behind a table. Spong: Especially when the cervix is unfavorable, which is common at this gestational age.
Video: The four speakers sit behind a table. Spong: Absolutely so. Yes.
Video: Spong on camera. Spong: Jane, can you describe the Ohio Perinatal Quality Collaborative Initiative?
Video: Lamp on camera.

Slide 19: Title: “Perinatal Collaboratives: Impact on Clinical Practice.

Text: “Goal: Improve Maternal-Fetal Outcomes. Commitment to quality of care by practitioners and nursing staff. Involvement of all relevant stakeholders in development and implementation of reform. Education on the excess risk associated with non-medically indicated delivery prior to 39 weeks helps overcome initial resistance and gain buy-in from clinicians, nursing staff, and patients.”
Lamp: Yes. Ohio is one of at least 7 states now that is doing a state-based perinatal quality collaborative, which is a formal process to take a look at ways to improve maternal-fetal outcomes and maternal and newborn outcomes. One of the criteria they are looking at is the percentage of scheduled deliveries less than 39 weeks, and there will be a figure to  demonstrate the improvement based on this formal process of those deliveries. They have had a lot of success with that.
Video: The four speakers sit behind a table. Spong: So as this initiative has gone into place, the rate of those deliveries, elective deliveries before 39 weeks, has declined.
Video: The four speakers sit behind a table. Lamp: Yes, it has.
Video: Spong on camera. Spong: What are some of the initiatives that have been put into place to try to reduce these deliveries less than 39 weeks?
Video: Lamp on camera.

Slide 20: Title: “Perinatal Collaboratives: Impact on Clinical Practice (cont).

Text: “Frequent detailed feedback on process measures and outcomes (peer review). Can achieve sustained decrease in overall induction rates, cesarean deliveries, nonmedical indications, and deliveries prior to 39 weeks in electively induced nulliparous women.”
Lamp: Cathy, the collaborative has implemented several formal processes to hold practitioners accountable, as well as providing and supporting the completion of an informed consent for parents to know the risk of having a baby before 39 weeks. That has been very helpful.
Video: The four speakers sit behind a table. Spong: Are there other key points for these initiatives? Because there are many initiatives, as I understand, across the country now trying to reduce deliveries less than 39 weeks. So let's share some of these key points that we have heard about from these initiatives. Anne, would you like to start?
Video: The four speakers sit behind a table. Video then transitions to Moore on camera.
Slide 21:

Title: “Ohio Perinatal Quality Collaborative Scheduled Deliveries.”

Text: “Percentage of Scheduled Deliveries 36 0/7th to 38 6/7th weeks without medical or obstetrical indication documented.” Graph shows decrease from over 25% in 07-08 (33/127) to below 5% in 05-10 (4/ 262).
Moore: Well, I think we have to revisit the idea of quality care. We have to revisit the idea that a pregnancy is 40 weeks, and I think maybe we are revisiting that initiative in this particular situation. So I applaud our efforts to not only educate the patients but also to educate the clinicians. I am involved in nurse practitioner education, and one of the things that I focus on is the benefit of having a term gestation, a true term gestation. That is one of the salient points that has to be looked at in medical schools and nursing schools and clearly communicated to the population, to the consumer. And we have to look at who the stakeholders are in achieving this reform and getting away from the idea that it is okay to induce at 37 or 38 weeks, to have that smaller baby, to undergo an operative procedure, and identify what those barriers might be so that we can kind of blow past them and get the real message out to everybody.
Video: Murthy on camera. Murthy: I think we also have to spend our efforts educating the clinicians, the hospitals, nurses, and fundamentally our patients on the higher risks of neonatal and maternal morbidities that we were discussing, associated with deliveries prior to 39 weeks. Initially that is going to be met predictably with some resistance to overcome that learning curve, but sustaining that buy-in over time is going to help this population of women achieve healthier peripartum outcomes.
Video: Lamp on camera. Lamp: Along those lines, how great would it be to have a culture of improvement developed and be sustained so that we can actually monitor, report, communicate our outcomes and our successes and share across the country so that we can improve the outcomes.
Video: The four speakers sit behind a table. Video then transitions to Spong on camera. Spong: I think we have seen that one of the key points that has come across from many of these initiatives is the peer-review process and reviewing these deliveries and reviewing the process measures associated with it. I think it is very, very important.
Video: Spong on camera. Jane Lamp speaks off screen. Lamp: Exactly.
Video: Spong on camera. Spong: By implementing these strategies, you can get significant decreases then in overall induction rates, elective induction rates, deliveries at less than 39 weeks, and cesarean deliveries, especially in elective deliveries of nulliparous patients or women in their first pregnancy. In many of these initiatives, such as the one that Jane spoke about, you can see a dramatic decline when these initiatives are put into place. Because, of course, our goal is to improve the outcome for both the mom and the baby.

Another important thing that we need to consider and discuss is how we can communicate the risks to both the patients and the clinicians. Karna, do you want to start talking about that?
Video: The four speakers sit behind a table. Video then transitions to Murthy on camera. The video then transitions back to the panel of four speakers.

Slide 22: Title: “Community and Outpatient Educational Resources.”

Text: “March of Dimes. American Academy of Pediatrics. Near-Term Infant Initiative Resource Center. American College of Obstetricians and Gynecologists. Association of Women’s Health, Obstetric, and Neonatal Nurses. National Healthy Mothers, Healthy Babies Coalition. Centers for Disease Control and Prevention: Developmental Milestones.”
Murthy: I think it is clear from this discussion and from what is known in our fields: that the best outcomes for the babies are for those deliveries that occur at or after 39 weeks, provided there is no medical obstetric indication for delivery, on behalf of either the mother or the fetus. In that setting, delivery is certainly warranted at the clinician's discretion. Both the clinicians and the patients need to be very aware of the complications of these deliveries prior to 39 weeks and all of the ramifications that we have been discussing so far. However, we still need to spend our time working on the outcomes, the research, and the improvement of these outcomes over time, using evidence that we can gain from clinical research studies, from laboratory science, as well as from monitoring our practices in large populations over time.
Video: The four speakers sit behind a table. Spong: And the community resources.
Video: Moore on camera. Moore: I think it is interesting that as we gain more knowledge, we seem to be moving back to some of the basics. I have seen what I would call aggressive management of labor, to a situation now, where we don't monitor as much as we used to. We have a little more control on the part of the mother and a little more of a natural process. So I am encouraged to see that we are looking now at pregnancy as something that should take place over a 40-week timeframe, that aggressive management or interventional management is now not being seen as perhaps the standard of care. I think everyone is benefitting from that.
Video: The four speakers sit behind a table.

Slide 23: Title: “Summary.”

Text: “Late preterm babies commonly remain in the room with their mothers after birth in the hospital; however, they are at an increased risk for health complications that require an increased level of care and surveillance. Advances in neonatal care may have shifted the risk from the perinatal period to chronic morbidities for late preterm infants. Ensuring healthy outcomes for mother and baby requires education of both patients and providers. There are risks to delivering prior to 39 weeks; in some cases, however, these risks are appropriate when mother or baby requires delivery for a medical or obstetrical indication.”
Spong: To wrap up, let's share some key points that we have garnered over this discussion, and we will start with Jane.
Video: The four speakers sit behind a table. Video then transitions to Lamp on camera. Lamp: Well, Cathy, late preterm babies commonly remain with their mothers in the hospital and yet they are at increased risk and require increased and prolonged surveillance. So that is a concern, as these babies often can be mainstreamed and appear to be mature; practitioners and parents need to recognize that they do have special needs.
Video: The four speakers sit behind a table. Video then transitions to Murthy on camera. Murthy: An argument that I have heard in my practice of neonatology is that there have been significant advances in neonatal care over the past 2 decades that may have shifted the risk to the infant from this immediate perinatal period or just prior to delivery, to more chronic morbidities of infant mortality, cerebral palsy, and hospital stays. And these risks are ones that need to be communicated in a balanced manner to parents prior to the initiation of deliveries, especially among women who either have no medical indication, or whose indications may not be clearly balanced towards a movement tof
Video: The four speakers sit behind a table. Video then transitions to Moore on camera. Moore: I think we have to educate patients about what is the healthier approach to pregnancy and delivering a term baby looking at the emotional burden, the physical burden, and the financial burden that goes along with mistiming or requesting an interventional delivery for nonmedical reasons. So I hope that this kind of information gets out and is embraced by clinicians and we translate that to patients so that they will get a better understanding of what a normal healthy pregnancy should look like.
Video: The four speakers sit behind a table. Spong: Keeping on that theme, clearly there are risks to delivering before 39 weeks. In some cases, these risks are absolutely appropriate when the mom or the baby requires delivery for a medical or obstetrical indication.
Video: The four speakers sit behind a table. Video then transitions to Spong on camera.

Slide 24: Text: “Thank you for participating in this activity.”
Spong: I'd like especially to thank Jane, Karna, and Anne for joining us today in this panel discussion, and to thank you, the audience, for joining us.
Fade to black screen.  
Last Updated Date: 10/25/2013
Last Reviewed Date: 10/25/2013