Perinatal Care

Elective Delivery Before 39 Weeks

• The Case for Change
• Considerations for Success
• California Maternal Quality Care Collaborative 39 Week Toolkit
• Intermountain Healthcare
• Ohio Perinatal Quality Collaborative
• Diagnoses Excluded from the Joint Commission Early Delivery Measure

Even though pregnancies at 37 and 38 weeks gestational age are often described as “term,” elective delivery of those infants is associated with increased maternal and neonatal morbidity and mortality, even when fetal lung maturity criteria are met. The Joint Commission has an NQF-endorsed measure for elective deliveries: PC-01 measuring the portion of deliveries at 37 and 38 weeks that are elective. All cases with an ICD-9 code showing a possible indication for early delivery are excluded — see table below for details. Patients in active labor or with spontaneous rupture of membranes are considered non-elective deliveries.

The Regional Hospital Association collaboratives are addressing elective delivery before 39 weeks. For information on collaboratives in your area, please contact:

• Hospital Association of San Diego and Imperial Counties: Lindsey Wade lwade@hasdic.org
• Hospital Association of Southern California: Catherine Carson ccarson@hasc.org
• Hospital Council of Northern and Central California: Mary Lopez mlopez@hospitalcouncil.net

For information on CHPSO membership, contact Rory Jaffe rjaffe@calhospital.org.

The Case for Change

CHPSO has prepared a slide set describing the case for eliminating elective early term deliveries. CHPSO members can request a PowerPoint version that the hospital can then customize.

• ACOG Practice Bulletin No. 107: Induction of Labor. Obstetrics & Gynecology. 2009;114(2, Part 1):386–397.
• Bailit JL, Gregory KD, Reddy UM, et al. Maternal and neonatal outcomes by labor onset type and gestational age. American journal of obstetrics and gynecology. 2010;202(3):245.e1–245.e12. (free full access).
• Bates E, Rouse D, Chapman V, et al. 28: Fetal lung maturity testing before 39 weeks and neonatal outcomes. American journal of obstetrics and gynecology. 2009;201(6):S17–S17. (free full access).
• Clark SL, Miller DD, Belfort Ma, et al. Neonatal and maternal outcomes associated with elective term delivery. American journal of obstetrics and gynecology. 2009;200(2):156.e1–4.
• Donovan EF, Besl J, Paulson J, Rose B, Iams J. Infant death among Ohio resident infants born at 32 to 41 weeks of gestation. American journal of obstetrics and gynecology. 2010;203(1):58.e1-5.
• Farchi S, Di Lallo D, Polo a, et al. Timing of repeat elective caesarean delivery and neonatal respiratory outcomes. Archives of disease in childhood. Fetal and neonatal edition. 2010;95(1):F786.
• Fleischman AR, Oinuma M, Clark SL. Rethinking the definition of “term pregnancy.” Obstetrics and gynecology. 2010;116(1):136–9.
• Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ (Clinical research ed.). 2008;336(7635):85-7. (free full access).
• MacKay DF, Smith GC, Dobbie R, Pell JP. Gestational age at delivery and special educational need: retrospective cohort study of 407,503 schoolchildren. PLoS medicine. 2010;7(6):e1000289. (free full access).
• Macones GA. Elective delivery before 39 weeks: reason for caution. American journal of obstetrics and gynecology. 2010;202(3):208. (free full access).
• Robinson CJ, Villers MS, Johnson DD, Simpson KN. Timing of elective repeat cesarean delivery at term and neonatal outcomes: a cost analysis. American journal of obstetrics and gynecology. 2010;202(6):632.e1-6.
• Tita AT, Landon MB, Spong CY, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. The New England journal of medicine. 2009;360(2):111–20. (free full access).
• Wilmink Fa, Hukkelhoven CW, Lunshof S, et al. Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry. American journal of obstetrics and gynecology. 2010;202(3):250.e1–8. (free full access).

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Considerations for Success

CHPSO has prepared a slide set showing how several initiatives have addressed this challenge. CHPSO members can request a PowerPoint version that the hospital can then customize.

• Clark SL, Frye DR, Meyers JA, et al. Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth. American journal of obstetrics and gynecology. 2010;(1):1–6.
• Donovan EF, Lannon C, Bailit J, et al. A statewide initiative to reduce inappropriate scheduled births at 36(0/7)–38(6/7) weeks’ gestation. American journal of obstetrics and gynecology. 2010;202(3):243.e1–8. (free full access).
• Goldenberg RL, McClure EM, Bhattacharya A, Groat TD, Stahl PJ. Women’s perceptions regarding the safety of births at various gestational ages. Obstetrics and gynecology. 2009;114(6):1254–8.
• Oshiro BT, Henry E, Wilson J, Branch DW, Varner MW. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstetrics and gynecology. 2009;113(4):804–11. (free full access).

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California Maternal Quality Care Collaborative 39 Week Toolkit

CMQCC is devoted to eliminating preventable maternal death and injury and promoting equitable maternity care in California by bringing resources, tools, measures, and quality improvement techniques to providers, administrators, and public health leaders. The charge of the <39 Week Toolkit Development Task Force is to decrease deliveries before 39 weeks in California by developing a set of tools for dissemination to help determine best practices for prevention of early deliveries and to determine the most effective strategies for supporting California health care providers in implementing those practices.

• Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age: A California Toolkit to Transform Maternity Care.
• Information resources.

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Intermountain Healthcare

Intermountain Healthcare posted on its web site patient education materials and provider tools, and its elective induction and delivery guidline.

Their program and its success is documented in: Oshiro BT, Henry E, Wilson J, Branch DW, Varner MW. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstetrics and gynecology. 2009;113(4):804–11. (free full access).

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Ohio Perinatal Quality Collaborative

Their mission is to, through collaborative use of improvement science methods, reduce preterm births and improve outcomes of preterm newborns in Ohio as quickly as possible.

• Main web site
• Graphs showing results of initiative over time
• Scheduled Delivery at 36.0 – 38.6 Weeks data collection form
• Scheduled Delivery Brochure
• Scheduled Delivery Brochure (Spanish)
• Obstetric Measures Definitions

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Diagnoses Excluded from the Joint Commission Early Delivery Measure

ICD-9 Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation (from the Joint Commission)

ICD 9 Code	Description
042	Human immunodeficiency virus (HIV) disease
641.01	Placenta previa without hemorrhage, delivered, with or without mention of antepartum condition
641.11	Hemorrhage from placenta previa, delivered, with or without mention of antepartum condition
641.21	Premature separation of placenta, delivered, with or without mention of antepartum condition
641.31	Antepartum hemorrhage associated with coagulation defects, delivered, with or without mention of antepartum condition
641.81	Other antepartum hemorrhage, delivered, with or without mention of antepartum condition
641.91	Unspecified antepartum hemorrhage, delivered, with or without mention of antepartum condition
642.01	Benign essential hypertension complicating pregnancy, childbirth, & puerperium, delivered, with or without mention of antepartum condition
642.02	Benign essential hypertension complicating pregnancy, childbirth, & puerperium, delivered, with mention of postpartum complication
642.11	Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the puerperium, delivered, with or without mention of antepartum condition
642.12	Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the puerperium, delivered, with mention of postpartum complication
642.21	Other pre-existing hypertension complicating pregnancy, childbirth & puerperium, delivered, with or without mention of antepartum condition
642.22	Other pre-existing hypertension complicating pregnancy, childbirth & puerperium, delivered, with mention of postpartum complication
642.31	Transient hypertension of pregnancy, delivered, with or without mention of antepartum condition
642.32	Transient hypertension of pregnancy, delivered, with mention of postpartum complication
642.41	Mild or unspecified pre-eclampsia, delivered, with or without mention of antepartum condition
642.42	Mild or unspecified pre-eclampsia, delivered, with mention of postpartum complication
642.51	Severe pre-eclampsia, delivered, with or without mention of antepartum condition
642.52	Severe pre-eclampsia, delivered, with mention of postpartum complication
642.61	Eclampsia, delivered, with or without mention of antepartum condition
642.62	Eclampsia, delivered, with mention of postpartum complication
642.71	Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, delivered, with or without mention of antepartum condition
642.72	Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, delivered, with mention of postpartum complication
642.91	Unspecified hypertension complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition
642.92	Unspecified hypertension complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication
645.11	Post term pregnancy, delivered, with or without mention of antepartum condition
646.21	Unspecified renal disease in pregnancy, without mention of hypertension, delivered, with or without mention of antepartum condition
646.22	Unspecified renal disease in pregnancy, without mention of hypertension, delivered, with mention of postpartum complication
646.71	Liver disorders in pregnancy, delivered, with or without mention of antepartum condition
648.01	Diabetes mellitus, delivered, with or without mention of antepartum condition
648.51	Congenital cardiovascular disorders, delivered, with or without mention of antepartum condition
648.52	Congenital cardiovascular disorders, delivered, with mention of postpartum complication
648.61	Other cardiovascular diseases, delivered, with or without mention of antepartum condition
648.62	Other cardiovascular diseases, delivered, with mention of postpartum complication
648.81	Abnormal glucose tolerance, delivered, with or without mention of antepartum condition
648.82	Abnormal glucose tolerance, delivered, with mention of postpartum complication
649.31	Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition
649.32	Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication
651.01	Multiple gestation, twin pregnancy, delivered, with or without mention of antepartum condition
651.11	Multiple gestation, triplet pregnancy, delivered, with or without mention of antepartum condition
651.21	Multiple gestation, quadruplet pregnancy, delivered, with or without mention of antepartum condition
651.31	Multiple gestation, twin pregnancy with fetal loss and retention of 1 fetus, delivered, with or without mention of antepartum condition
651.41	Multiple gestation, triplet pregnancy, with fetal loss and retention of one or more fetus(es), delivered, with or without mention of antepartum condition
651.51	Multiple gestation, quadruplet pregnancy, with fetal loss and retention of 1 or more fetus(es), delivered, with or without mention of antepartum condition
651.61	Multiple gestation, other multiple pregnancy, with fetal loss and retention of 1 or more fetus(es), delivered, with or without mention of antepartum condition
651.71	Multiple gestation following (elective) fetal reduction, delivered, without mention of antepartum condition
651.81	Multiple gestation, other specified multiple gestation, delivered, with or without mention of antepartum condition
651.91	Multiple gestation, unspecified multiple gestation, delivered, with or without mention of antepartum condition
652.01	Unstable lie, delivered, with or without mention of antepartum condition
652.61	Multiple gestation with malpresentation of 1 fetus or more, delivered, with or without mention of antepartum condition
655.01	Central nervous system malformation in fetus, delivered, with or without mention of antepartum condition
655.11	Chromosomal abnormality in fetus, delivered, with or without mention of antepartum condition
655.31	Suspected damage to fetus from viral disease in the mother, delivered, with or without mention of antepartum condition
655.41	Suspected damage to fetus from other disease in the mother, delivered, with or without mention of antepartum condition
655.51	Suspected damage to fetus from drugs, delivered, with or without mention of antepartum condition
655.61	Suspected damage to fetus from radiation, delivered, with or without mention of antepartum condition
655.80	Other known or suspected fetal abnormality, not elsewhere specified
656.01	Fetal-maternal hemorrhage, delivered, with or without mention of antepartum condition
656.11	Rhesus isoimmunization, delivered, with or without mention of antepartum condition
656.21	Isoimmunization from other and unspecified blood-group incompatibility, delivered, with or without mention of antepartum condition
656.31	Fetal distress, delivered, with or without mention of antepartum condition
656.41	Intrauterine death, delivered, with or without mention of antepartum condition
656.51	Poor fetal growth, delivered, with or without mention of antepartum condition
657.01	Polyhydramnios, delivered, with or without mention of antepartum condition
658.01	Oligohydramnios, delivered, with or without mention of antepartum condition
658.11	Premature rupture of membranes, delivered, with or without mention of antepartum condition
658.21	Delayed delivery after spontaneous or unspecified rupture of membranes, delivered, with or without mention of antepartum condition
658.21	Delayed delivery after spontaneous or unspecified rupture of membranes, delivered, with or without mention of antepartum condition
659.71	Abnormality in fetal heart rate or rhythm, delivered, with or without mention of antepartum condition
663.5	Vasa previa
V08	Asymptomatic human immunodeficiency virus (HIV) infection
V23.5	Pregnancy with other poor reproductive history; Pregnancy with history of stillbirth or neonatal death
V27.1	Single stillborn

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