DOI: 10.1097/NMC.0b013e3182450e25

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PMID: 22357079

Issn Print: 0361-929X

Publication Date: 2012/03/01


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New Guidance on the Timing of Medically Indicated Births Before 39 Weeks Gestation

Kathleen Rice Simpson

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Author Information: is a Perinatal Clinical Nurse Specialist, St. John's Mercy Medical Center, St. Louis, MO, and an Editorial Board Member of MCN.

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Excerpt

Despite the national focus on eliminating elective births before 39 completed weeks of gestation, a list of maternal and fetal conditions recommended by the American College of Obstetricians and Gynecologists (ACOG, 2009) that may warrant early birth, and an algorithm for decision making from The Joint Commission (TJC, 2009) as part of the Perinatal Care Core Measures, controversies remain regarding what constitutes a medically indicated late preterm or early term birth. This issue often is a source of clinical disagreements when nurses are asked to take part in medically indicated labor inductions and cesarean births for which they do not support the indication as consistent with published guidelines and current evidence. At times the indication is contrary to ACOG recommendations such as macrosomia or request by the physician or patient. Other indications may seem “soft” such as “impending” preeclampsia with normal laboratory data. Nurses who are responsible for evaluating the medical indication listed before carrying out orders for labor induction or cesarean birth before 39 completed weeks of gestation will welcome new guidelines on this topic (Spong et al., 2011).
In February 2011, the National Institute of Child Health and Human Development and the Society for Maternal-Fetal Medicine sponsored a workshop of perinatal experts entitled Timing of Indicated Late Preterm and Early Term Births. The goals of this workshop were to review and synthesize current evidence related to various maternal and fetal conditions that may necessitate medically indicated births before 39 weeks of gestation, potential risks and benefits to the mother and baby of early birth versus continuing the pregnancy, and in cases where early birth may be beneficial, offer suggestions regarding timing of the birth (Spong et al., 2011). Although the evidence used to develop recommendations for each of the maternal and fetal conditions was based primarily on consensus and expert opinion rather than multiple randomized trials, this publication is an important first step in providing much needed guidance to clinicians who are trying to make sound decisions about timing of medically indicated births before 39 weeks. The expert panel acknowledged the limitations of the current state of the science. They also noted the multiple complex issues that should be considered in each individual situation in the clinical judgment leading to the decision as to whether to proceed with early birth.
Particularly helpful were the evaluation of potential risks and benefits to the mother and baby for each condition listed (Spong et al., 2011). For early term births, these include immaturity-related neonatal morbidity and mortality based on each week of gestation and maternal complications such as failed induction and cesarean birth. Potential consequences of continuing the pregnancy for the fetus include uteroplacental insufficiency or stillbirth and for the mother, maternal hemorrhage, hypertensive crisis, or uterine rupture.
Review these new guidelines and work with members of the perinatal team to incorporate the suggestions into unit policies related to elective and medically indicated births before 39 weeks of gestation. Doing so may avoid some of the ambiguity, tension, and clinical disagreements that are often common when considering late preterm and early term labor induction and cesarean birth.
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