Elective policy aims to cut pre-39 week deliveries

This is a portion of the Elective Delivery Policy use at Vanderbilt University Medical Center in Nashville to minimize unnecessary deliveries before 39 weeks gestation:

Planned deliveries will be in one of the following categories:

1. Indications not requiring EGA [estimated gestational age] of >= 39 weeks gestation. Indicated deliveries based on provider decisions do not require confirmation of fetal lung maturity. Fetal lung maturity testing may be helpful in decision making for borderline indications. The provider should consider maternal and fetal conditions, gestational age, cervical status and other factors. The following list of indications for delivery is not to be considered either exhaustive or absolute. Indications for delivery may include:

a. Abruptio placentae
b. Chorioamnionitis
c. Fetal demise
d. Pregnancy Induced Hypertension (PIH), preeclampsia and eclampsia
e. Premature Rupture of Membranes (PROM)
f. Post term pregnancy
g Prior cesarean sections with vertical incision
h. Prior classical cesarean section
i. Maternal medical conditions, including but not limited to:

• Diabetes mellitus

• Maternal HIV disease

• Renal disease

• Chronic pulmonary disease

• Chronic hypertension

• Maternal heart disease

• Fetal compromise including but not limited to:

• Intrauterine growth restriction

• Oligohydramnios

• Fetal anomalies requiring early delivery

• Non-reassuring fetal surveillance

2. Indications for delivery that require an EGA of >=39 weeks gestation or confirmation of fetal lung maturation includes the following:

a. Logistical reasons
b. Risk of rapid labor
c. Distance from the hospital
d. Psychosocial indications

Fetal lung maturation MUST be confirmed before elective delivery at <39 weeks gestation (38 6/7 weeks or less) unless fetal lung maturation can be inferred from any of the following criteria listed below:

• Fetal heart tones have been documented for 20 weeks by nonelectric fetoscope or for 30 weeks by Doppler stethoscope.

• It has been 36 weeks since a serum or urine human chorionic.

• Gonadotropin was found to be positive by a reliable laboratory.

• Ultrasound measurement of the crown-rump length at 6-11 weeks of gestation supports a gestational age equal to or greater than 39 weeks.

• Ultrasound measurement at 12-20 weeks supports a clinically determined gestational age of 39 weeks or greater.

If any of these criteria confirms an EGA of >= 39 weeks in a patient with normal menstrual cycles (no oral contraceptive pill use immediately prior to conception), it is appropriate to schedule delivery at >= 39 weeks of gestation in accordance with menstrual dates. Ultrasonography may be considered confirmatory of menstrual dates if there is a gestational age agreement within one week by crown-rump measurements obtained at 6-11 weeks of gestation or within 10 days by an average of multiple measurements obtained between 12-20 weeks of gestation.

EGA based only on a third trimester ultrasound is not acceptable under ANY circumstance.

V. Procedure(s):

When an elective delivery is planned the following steps will be followed:

A. The provider will notify the charge nurse in Labor and Delivery (L&D). Scheduling of the case will be dependent upon unit census and staffing.
B. The charge nurse will document the following in the schedule case book:

1. Patient’s name, medical record number and phone number

2. Date and time of procedure and time patient is to come in to L&D

3. Name of the patient’s provider or provider group

4. EDC and gestational age

5. Indication for the procedure

6. The date the procedure was scheduled

7. Name of the attending provider who approved the scheduling

8. The signature of the person scheduling the procedure

9. FLM or documentation of fetal lung maturity when indicated.