The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine are urging obstetricians to avoid delivering women with uncomplicated pregnancies before 39 weeks’ gestation, but also not to hesitate to perform early inductions when medically necessary.
In a set of policy statements published in Obstetrics & Gynecology in April, the two organizations laid out the best evidence for when early delivery is medically necessary and when it is not (Obstet. Gynecol. 2013;121:908-10;Obstet. Gynecol. 2013;121:911-5).
"For women who aren’t having any complications with their pregnancy, delivery at or after 39 weeks is the best thing to do," said Dr. George A. Macones, chair of the ACOG Committee on Obstetric Practice and chair of obstetrics and gynecology at Washington University in St. Louis. "But the flip side is we don’t want doctors not to deliver patients early who would benefit from that."
Dr. George A. Macones
Over the last several years, the number of nonmedically indicated deliveries performed before 39 weeks was on the rise, prompting some patient advocates and quality experts to push for the elimination of early elective deliveries. The March of Dimes, the Joint Commission, and the Leapfrog Group have all called on physicians to do more to curb early elective deliveries to avoid adverse outcomes for neonates.
The ACOG and SMFM statement #561 echoes those concerns, noting the greater rates of morbidity and mortality for neonates and infants delivered at 37 and 38 weeks, compared with those delivered at 39 and 40 weeks’ gestation.
For instance, a retrospective cohort study that included more than 200,000 births found higher rates of respiratory failure and ventilator use for infants delivered at 37 weeks, compared with those delivered at 39 weeks, regardless of the indication for delivery. Those infants delivered at 37 weeks’ gestation also had higher rates of respiratory distress syndrome, transient tachypnea of the newborn, pneumonia, and surfactant and oscillator use, compared with infants delivered at 39 weeks (JAMA 2010;304:419-25).
Mortality rates are also significantly higher for infants delivered at 37 and 38 weeks’ gestation, compared with infants who are delivered at 39 weeks, according to the statement.
The ACOG and SMFM also cautioned obstetricians not use fetal pulmonary maturity testing to justify an early elective delivery because even though the testing may help identify a fetus at risk for respiratory distress syndrome, it may not be able to predict other adverse outcomes.
But the ACOG and SMFM also have concerns that some efforts to eliminate early deliveries may be going too far. For instance, at least one state Medicaid agency has stopped paying physicians for non-indicated deliveries before 39 weeks’ gestation, they wrote in the policy statement.
Dr. Jeffrey L. Ecker
"That’s a problem," Dr. Macones said in an interview. "When insurance companies start to try to regulate medical care, that’s where we can get into some trouble."
These types of blanket payment policies, which typically rely on chart abstractions and billing codes, can overlook real medical indications for an early delivery, said Dr. Jeffrey L. Ecker, vice chair of the ACOG Committee on Obstetric Practice and a maternal-fetal medicine specialist at Massachusetts General Hospital in Boston. "There’s particular concern that good medicine sometimes doesn’t appear in documentation or in billing codes," he said in an interview.
It’s critical, Dr. Ecker said, that these policies don’t give physicians the message that they should never perform deliveries before 39 weeks.
The ACOG and the SMFM also issued a policy statement (#560) that offers general and specific recommendations on the timing of deliveries for several conditions that may require early delivery in either late-preterm (34 through 36 weeks) or early-term (37 through 38 weeks) periods. The conditions include placenta previa, prior classical cesarean, prior myomectomy, fetal growth restriction, chronic hypertension, diabetes, and preterm premature rupture of membranes (PPROM). The list is not meant to be all-inclusive, but gives physicians a sense of the most common indications for early delivery.
"We hope the list will make it easier for physicians to justify their actions to hospital leaders and insurers who may have strict policies about early deliveries," Dr. Macones said.
In a related policy statement (#559), ACOG also addressed the issue of cesarean delivery on maternal request (Obstet. Gynecol. 2013;121:904-7). The Committee on Obstetric Practice stated that physicians should recommend a vaginal delivery unless there are maternal or fetal indications for a cesarean. The committee specifically recommended against cesarean delivery on maternal request for women who plan to have several children because the risks of placenta previa, placenta accreta, and gravid hysterectomy increase with each cesarean delivery.