Transcript Preventing Elective Deliveries Before 39 Weeks

Preventing Elective
Deliveries Before 39 Weeks
John R. Allbert
Charlotte, NC
Elective Delivery
Adverse outcomes are increased if delivery
occurs before 39 weeks
 There is a nearly 5 fold and 4 fold increased risk
of respiratory morbidity in 37 and 38 week
deliveries respectively compared to 39 week
elective deliveries (NEMJ Jan 8 2009;360:111)
 For every 100 deliveries the cost savings for
delaying delivery until 39 weeks is $160,000
and $50,000 compared to delivering at 37 and
38 weeks respectively
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Induction of Labor
Confirming Gestational Age
Ultrasound measurement at less than 20
weeks of gestation supports GA of 39 wks
or greater
 Fetal heart tones with doppler
ultrasonography documented for 30 wks
 It has been 36 wks since a positive serum
or urine hCG pregnancy test
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ACOG Practice Bulletin 107, August 2009
Indications for Induction of Labor
Abruptio placentae
 Chorioamnionitis
 Gestational HTN
 Preeclampsia
 Maternal medical condition, (DM,cHTN)
 Fetal compromise, (isoimmunization,
IUGR, oligohydramnios)
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ACOG Practice Bulletin 107, August 2009
IUGR
SGA is EFW <10%
 IUGR is failure of the fetus to achieve its
growth potential
 Induction of labor for of IUGR prior to 39
weeks should some how confirm placental
dysfunction
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IUGR
Placental Dysfunction
Oligohydramnios
 Abnormal doppler of the umbilical artery
(>95%)
 Documented poor fetal growth over a 3
week interval, particularly the abdominal
circumference
 Nonreassuring NST, CST, BPP

Hypertension
Less Morbidity With Induction
Induction of labor vs expectant
management for gestational hypertention
 Inducing labor at term if DBP >95 mmHg
in hypertension and >90 mmHg in
preeclampsia vs observation
 Lower need for IV antihypertensives and
anticonvulsants in the induction group
 Lower C/S rate in primagravidas with
induction

Koopmans CM, Lancet 2009;374:979
Oligohydramnios
Estimated with ultrasonography
 AFI < 5 cm
 Deepest vertical pocket < 2 cm
 Ideal measurement for intervention has
not been established
 Delivery should be considered if
gestational age is at least 37 weeks but
may be individualized

ACOG Practice Bulletin Number 9,
Antepartum Fetal Surveillance
Induction
What is the commitment
If the cervix is unfavorable, reevaluate the
clinical criteria
 If you start the induction, you are not
always obligated to have that patient
delivered
 If the induction is not succeeding,
consider discharging the patient and
restart the induction in 2-4 days
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Category A
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Eclampsia
HELLP
syndrome
PPROM
Placenta previa
with active
bleeding
Acute placental
abruption
Fetal demise
Chorioamnioniti
s
Category B
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IUGR
Oligohydramnios
HIV (at 38 weeks)
Isoimmunization
Fetal hydrops
Multiple gestation
Cholestasis of
pregnancy
Third trimester
bleeding
Placenta previa
without current
bleeding
Decreased fetal
movement
Chronic placental
abruption
(symptom-free >7
days)
Venous
thromboembolism
Fetal anomaly
Nonreactive NST
BPP<4
Category C
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Preeclampsia
Pregnancyinduced
hypertension
Chronic
hypertension
Category D
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Poorly
controlled
diabetes
Maternal drug
use
Prior classical
c-section
Long distance
from hospital
Previous
myomectomy
Prior
precipitous
labor
History of prior
stillbirth
Nonvertex
presentation
Category F
Category E
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Well-controlled
diabetes
Genital herpes
infection (active
or prodromal)
Lupus
SGA with no
evidence of
placental
insufficiency
Coagulation
defects
Proteinuric renal
disease
(isolated)
Advanced
cervical dilation
Polyhydramnios
Unstable lie s/p
version
Macrosomia
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Elective
Repeat
LTCS
No
indication
given
Category G
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Other
(written in
on the
data
collection
form)
Other Indications
Cholestasis
 Lupus
 Diabetes
 Previous Classical C/S
 Prior C/S
 Previa
 Maternal drug use
 HIV
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