The American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine

Early Deliveries Without Medical Indications: Just Say No

March 21, 2013

Washington, DC -- Suspecting a large baby is not a medical reason to deliver before 39 weeks, according to new recommendations issued today jointly by The American College of Obstetricians and Gynecologists (The College) and the Society for Maternal-Fetal Medicine (SMFM). In response to the rise in early-term births in the US, The College reemphasizes its position against deliveries before 39 weeks, unless there is a valid medical indication, because of the health risks to infants and mothers.

The College and SMFM have long recommended that doctors not induce labor or perform cesareans before 39 weeks of pregnancy without a clear medical reason. A full-term pregnancy lasts 40 weeks. “Early-term” deliveries are those that occur between 37 and 39 weeks of gestation.

There are certain medical indications that require early delivery, including preeclampsia/eclampsia, fetal growth restriction, placental abruption, multiple fetuses, and poorly controlled diabetes. However, suspecting that a baby is macrosomic (large) is not an indication to induce or deliver by cesarean before 39 weeks.

Early-term infants have higher rates of respiratory distress, respiratory failure, pneumonia, and admission to neonatal intensive care units compared with infants born at 39 to 40 weeks gestation. Infants born at 37 to 38 weeks also have a higher mortality rate than those born later.

Reducing the number of nonmedically indicated early-term births and improving newborn outcomes is possible, according to The College and SMFM. Hospitals around the country have successfully lowered their rates of nonmedically indicated early-term births by implementing policies to prevent them.

Committee Opinion #561, “Nonmedically Indicated Early-Term Deliveries,” is published in the April issue of Obstetrics & Gynecology.

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Other recommendations issued in this month’s Obstetrics & Gynecology:

Committee Opinion #556 "Postmenopausal Estrogen Therapy: Route of Administration and Risk of Venous Thromboembolism" (NEW!)
ABSTRACT:
The development of menopausal symptoms and related disorders, which lead women to seek prescriptions for postmenopausal estrogen therapy and hormone therapy, is a common reason for a patient to visit her gynecologist, but these therapies are associated with an increased risk of venous thromboembolism. The relative risk seems to be even greater if the treated population has preexisting risk factors for venous thromboembolism, such as obesity, immobilization, and fracture. Recent studies suggest that orally administered estrogen may exert a prothrombotic effect, whereas transdermally administered estrogen has little or no effect in elevating prothrombotic substances and may have beneficial effects on proinflammatory markers. When prescribing estrogen therapy, the gynecologist should take into consideration the possible thrombosis-sparing properties of transdermal forms of estrogen therapy. As part of the shared decision-making process, the gynecologist should weigh the risks against the benefits when prescribing combination estrogen plus progestin hormone therapy or estrogen therapy and counsel the patient accordingly.

Committee Opinion #557 "Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women" (NEW!)
ABSTRACT:
Initial evaluation of the patient with acute abnormal uterine bleeding should include a prompt assessment for signs of hypovolemia and potential hemodynamic instability. After initial assessment and stabilization, the etiologies of acute abnormal uterine bleeding should be classified using the PALM–COEIN system. Medical management should be the initial treatment for most patients, if clinically appropriate. Options include intravenous conjugated equine estrogen, multi-dose regimens of combined oral contraceptives or oral progestins, and tranexamic acid. Decisions should be based on the patient’s medical history and contraindications to therapies. Surgical management should be considered for patients who are not clinically stable, are not suitable for medical management, or have failed to respond appropriately to medical management. The choice of surgical management should be based on the patient’s underlying medical conditions, underlying pathology, and desire for future fertility. Once the acute bleeding episode has been controlled, transitioning the patient to long-term maintenance therapy is recommended.

Committee Opinion #558 "Integrating Immunizations Into Practice" (NEW!)
ABSTRACT: Given demonstrated vaccine efficacy, safety, and the large potential for prevention of many infectious diseases among adults, newborns, and pregnant women, obstetrician–gynecologists should embrace immunizations as an integral part of their women’s health care practice. To provide direct examples, evidence-based recommendations for three commonly administered immunizations by practicing obstetrician–gynecologists are discussed: 1) human papillomavirus vaccine, 2) influenza vaccine, and 3) tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine.

"Committee Opinion #559 Cesarean Delivery on Maternal Request" (NEW!)
ABSTRACT: Cesarean delivery on maternal request is defined as a primary prelabor cesarean delivery on maternal request in the absence of any maternal or fetal indications. Potential risks of cesarean delivery on maternal request include a longer maternal hospital stay, an increased risk of respiratory problems for the infant, and greater complications in subsequent pregnancies, including uterine rupture, placental implantation problems, and the need for hysterectomy. Potential short-term benefits of planned cesarean delivery compared with a planned vaginal delivery (including women who give birth vaginally and those who require cesarean delivery in labor) include a decreased risk of hemorrhage and transfusion, fewer surgical complications, and a decrease in urinary incontinence during the first year after delivery. Given the balance of risks and benefits, the Committee on Obstetric Practice believes that in the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended to patients. In cases in which cesarean delivery on maternal request is planned, delivery should not be performed before a gestational age of 39 weeks. Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management. Cesarean delivery on maternal request particularly is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and gravid hysterectomy increase with each cesarean delivery.

"Committee Opinion #560 Medically Indicated Late-Preterm and Early-Term Deliveries" (NEW!)
ABSTRACT: The neonatal risks of late preterm (34 0/7–36 6/7 weeks of gestation) and early-term (37 0/7–38 6/7 weeks of gestation) births are well established. However, there are a number of maternal, fetal, and placental complications in which either a late-preterm or early-term delivery is warranted. The timing of delivery in such cases must balance the maternal and newborn risks of late-preterm and early-term delivery with the risks of further continuation of pregnancy. Decisions regarding timing of delivery must be individualized. Amniocentesis for the determination of fetal lung maturity in well-dated pregnancies generally should not be used to guide the timing of delivery.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 56,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org

 

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