Checklist helps hospital curtail early c-sections

Elective deliveries before 39 weeks, often performed as a convenience to the patient or the physician, have long been known to threaten patient safety and risk hospital liability. One hospital is reporting great success with a checklist and firm refusal to permit early deliveries without a good reason.

The policy is tough but accepted practice at Vanderbilt University Medical Center in Nashville, says Bennett Spetalnick, MD, director of labor and delivery.

The hospital’s current policy is the culmination of about five years’ effort to discourage elective deliveries before 39 weeks, Spetalnick says. Clinical leaders at Vanderbilt decided five years ago that they wanted to adhere strictly to guidelines from The American Congress of Obstetricians and Gynecologists (ACOG) that say such procedures should not be performed without solid clinical indications.1

“We got the rate down very low so that we only got down to an appeal here and there for the case where the father is going to Afghanistan or Iraq, and the fetal lung maturity is good,” he says. “But over the last five years, even those outlier situations have almost entirely gone away. We don’t get requests because the mother-in-law will be in town or dad’s going on a business trip. Those situations have totally disappeared.”

Trying to avoid elective deliveries before 39 weeks is nothing new, but it is still a challenge to many hospitals. ACOG has long discouraged elective deliveries prior to 39 weeks. The group notes that evidence suggests that non-medically indicated obstetrical procedures such as elective inductions performed prior to 39 weeks have risen sharply in the United States over the past 20 years, with associated increases in cesarean and late preterm births.

The reported rate of labor induction in the United States more than doubled between 1990 and 2006, rising from 9.5% to 22.5%, according to ACOG. The group also states that a fetal lung test before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is alone not an indication for elective delivery prior to 39 weeks.

Furthermore, The Joint Commission Set Measure PC-01 focuses on patients with elective vaginal deliveries or elective cesarean sections at 37 to 39 weeks of gestation completed. (See “Resources on p. 117.) The rationale for the measure states, “For almost three decades, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have had in place a standard requiring 39 completed weeks gestation prior to ELECTIVE delivery, either vaginal or operative.” The Joint Commission (TJC) rationale goes on to say that a survey conducted in 2007 of almost 20,000 births in hospitals throughout the United States revealed that almost one-third of all babies delivered in the country are electively delivered, with 5% of all deliveries violating ACOG guidelines. “Most of these are for convenience, and result in significant short-term neonatal morbidity (neonatal intensive care unit admission rates of 13- 21%),” the TJC explains.

The clinical literature is clear that, compared to spontaneous labor, elective inductions result in more cesarean deliveries and longer maternal length of stay, Spetalnick says. The American Academy of Family Physicians notes that elective induction doubles the cesarean delivery rate.2 Repeat elective cesarean sections before 39 weeks gestation also result in higher rates of adverse respiratory outcomes, mechanical ventilation, sepsis, and hypoglycemia for the newborns, Spetalnick says.

“We use a hard stop. When people try to schedule anything less than 39 weeks, it automatically goes to me or the director maternal and fetal medicine,” Spetalnick says. “They can’t get it on the books unless it’s appealed, and those appeals are conversations about medical indications, not social indications.”

Vanderbilt puts the top OB leaders in the position of saying no, rather than leaving it to a scheduling nurse. That situation avoids giving the nurse the ability to make an exception, and it makes it pointless for physicians to pressure the nurse to do so. “If they ask because of some convenience issue like the patient living far from the hospital, usually when they’re told it’s going to be referred on to us they just say, ‘Oh, never mind,’” Spetalnick says. “But if it gets to me or the vice chairman, then we’re the bad guys, not the nurse.”

In 2007, Vanderbilt used the ACOG guidelines to write its own in-house policy for scheduling deliveries before 39 weeks, and it spelled out the specific criteria that must be met for the procedure to be scheduled. (See the story on p. 117 for a portion of the Vanderbilt policy.)

“The policy was explained thoroughly to the caregivers when the policy was first implemented, and then there was new evidence in the clinical literature in 2009 that really showed the value of what we had already implemented here. That got a lot more people on board,” Spetalnick says. “The education of our patients has come through our providers, who understand and can explain the reasons behind the policy.”

References

1. ACOG Practice Bulletin Number 10 – Induction of Labor. Ob Gyn 1999; 94(5).

2. American Academy of Family Physicians position on elective deliveries: Cacciatore M, Hill DA. Rationale for a 39-week elective delivery policy. Am Fam Physician 2011: 15;84(12):1,335-1,356.

Source/Resources

• Bennett Spetalnick, MD, Director of Labor and Delivery, Vanderbilt University Medical Center, Nashville, TN. Telephone: (615) 322-3894.

• Summary of The Joint Commission’s measure concerning elective deliveries is titled “Perinatal care: percentage of patients with elective vaginal deliveries or elective cesarean sections at greater than or equal to 37 and less than 39 weeks of gestation completed.” Web: http://tinyurl.com/JCAHOinduction.

The Joint Commission’s Set Measure PC-01 concerning elective deliveries. Web: http://tinyurl.com/JCAHOmeasure.

The March of Dimes toolkit to aid in discouraging elective deliveries before 39 weeks. Web: http://www.cmqcc.org/_39_week_toolkit.

“The Medical Center’s Labor and Delivery Policy.” Web: http://tinyurl.com/VUMCl-dpolicy.

Vanderbilt University Medical Center’s policy on induction of labor and Cesarean section scheduling. Web: http://tinyurl.com/VUMCinductionpolicy.