It’s been almost 20 months since I sat in as a guest at the meeting of the Steering Committee on National Voluntary Consensus Standards for Perinatal Care for the National Quality Forum. (That is a lot of words for the name of that meeting.) The discussions and sometimes heated debates that day led finally to the adoption last summer of a new voluntary perinatal measure set for hospitals which will go into effect in April 2010. MSNBC got it wrong – the new measures are not required, BUT hospital administrators will want to impress the Joint Commission by implementing this newest measure set. Here is an excerpt from the new Joint Commission measure set on elective delivery:
“Rationale: For almost 3 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 (ACOG, 1996). A survey conducted in 2007 of almost 20,000 births in HCA hospitals throughout the U.S. carried out in conjunction with the March of Dimes at the request of ACOG revealed that almost 1/3 of all babies delivered in the United States are electively delivered with 5% of all deliveries in the U.S. delivered in a manner violating ACOG/AAP guidelines. Most of these are for convenience, and result in significant short term neonatal morbidity (neonatal intensive care unit admission rates of 13- 21%) (Clark et al., 2009).
According to Glantz (2005), compared to spontaneous labor, elective inductions result in more cesarean deliveries and longer maternal length of stay. The American Academy of Family Physicians (2000) also notes that elective induction doubles the cesarean delivery rate. 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 (Tita et al., 2009).
Type of Measure: Process
Improvement Noted As: Decrease in the rate”
Decrease in the rate! It will take a while, but eventually we will see a decrease in the number of elective inductions. As childbirth educators, we will play an important role in decreasing the number of elective inductions. In some communities, almost all women are scheduled for induction. Some physicians and pregnant women may resist giving up the convenience of scheduling the birth, but the evidence is strong to support the wisdom of letting labor begin on its own. If you are not already doing so, work with others at your hospital to create a plan for reducing the number of elective deliveries. Present evidence-based information in your childbirth classes about the risks to the baby and to the mother with elective induction and planned early cesarean section. Include information from the March of Dimes on why the last weeks of pregnancy matter and especially on the growth of the brain between 35 and 40 weeks. Provide time for small group discussions so that students can explore their own rationales for wanting to schedule their births, and hopefully measure those rationales against best evidence.
As a childbirth educator with more than 25 years experience (don’t ask!), it has been encouraging to have witnessed the process of development and eventual adoption of the new perinatal measures. Just as I have seen the acknowledgement that routine episiotomy is harmful and the slow decline of episiotomy, I hope to see a rapid decline in the number of elective inductions.
Note: If you’d like to read the other new perinatal measures, go to the link, Joint Commission measure set on elective delivery, and click on “Perinatal Care” in the first line.