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    Fewer elective early term deliveries, more stillbirths?

    Studies have been looking at the effects of early term deliveries, and the news is mostly good.

     

    The primary outcomes were neonatal respiratory morbidity, sepsis, feeding difficulties, neonatal intensive care unit (NICU) admission, and infant mortality.

    The authors found no statistically significant increase in neonatal mortality in the early term induction group; however, even with the large numbers of pregnancies studied, given the rarity of such deaths, such a linkage cannot be entirely excluded. They also found no differences in respiratory morbidity, sepsis, or NICU admission in the early elective versus 39 to 40 week control group, although the former did have more feeding difficulties (OR 1.18; 99%CI: 1.02–1.36). However, when examining differences between nulliparous women and multiparous women without prior cesarean deliveries undergoing early elective induction, the latter group’s infants displayed higher NICU admission rates (OR 1.23; 99%CI: 1.06–1.42), and feeding difficulties (OR 1.28; 99%CI: 1.06–1.55). By contrast, infants delivered by early elective cesarean experienced a 66% increase in respiratory morbidity, 51% more NICU admissions, and 36% higher rate of feeding abnormalities as well as an increased risk of sepsis (OR of 1.13; 99%CI: 1.01–1.29) compared to those delivered at 39 to 40 weeks. Here again the infants of multiparous women without prior cesarean deliveries fared worse than infants of nulliparous women.

    Next: The cesarean epidemic; Are we too quick to cut?

    These findings suggest that the extent of neonatal morbidity accruing early elective induction of nulliparous women may be less than previously suspected. However, such inductions increase neonatal morbidity among multiparas. Clearly, early cesarean deliveries are associated with excess morbidity in both maternal groups. The authors state that “issues that surround the timing and reasons for delivery initiation are complicated and each pregnancy unique. This study cautions against a general avoidance of all elective early-term deliveries.”

    Take-home message

    We can be reasonably reassured that national quality assurance efforts aimed at reducing elective early term deliveries have not resulted in a dramatic increase in term stillbirth rates. However, the magnitude of the neonatal risks of elective early term delivery in nulliparous women, who are at greatest risk for subsequent stillbirth and obstetrical complications, may have been exaggerated by earlier studies. Moreover, there are real concerns that in our zeal to reduce truly “elective” early term deliveries, patients with bona fide medical or obstetrical indications for such early deliveries may be experiencing inappropriate and potentially harmful pregnancy prolongation.

    On balance, I believe that non-medically indicated early term deliveries should be discouraged but it falls to the obstetrician’s art to constantly assess whether a patient with a complicated pregnancy is better of delivered.

    References

    1. Martin JA, Hamilton BE, Osterman MJ, Curtin SC, Matthews TJ. Births: final data for 2013. Natl Vital Stat Rep. 2015;64(1)1–65. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_01.pdf. Accessed April 11, 2016.

    2. Reddy UM, Ko CW, Raju TN, Willinger M. Delivery indications at late-preterm gestations and infant mortality rates in the United States. Pediatrics. 2009;124(1):234–240.

    3. Tita AT, Landon MB, Spong CY, et al; Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med. 2009;360(2):111–120.

    4. Clark SL, Meyers JA, Milton CG, et al. Validation of the joint commission exclusion criteria for elective early-term delivery. Obstet Gynecol. 2014;123(1):29–33.

    5. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 561: Nonmedically indicated early-term deliveries. Obstet Gynecol. 2013;121(4):911–915.

    6. Oshiro BT, Kowalewski L, Sappenfield W, et al. A multistate quality improvement program to decrease elective deliveries before 39 weeks of gestation. Obstet Gynecol. 2013;121(5):1025–1031. Erratum in: Obstet Gynecol. 2013;122(1):160.

    7. Donovan EF, Lannon C, Bailit J, Rose B, Iams JD, Byczkowski T; Ohio Perinatal Quality Collaborative Writing Committee. A statewide initiative to reduce inappropriate scheduled births at 36(0/7)-38(6/7) weeks’ gestation. Am J Obstet Gynecol. 2010;202(3):243. e1–8. Erratum in: Am J Obstet Gynecol. 2010;202(6):603.

    8. Little SE, Zera CA, Clapp MA, Wilkins-Haug L, Robinson JN. A multi-state analysis of early-term delivery trends and the association with term stillbirth. Obstet Gynecol. 2015;126(6):1138–1145.

    9. MacDorman MF, Reddy UM, Silver RM. Trends in stillbirth by gestational age in the United States, 2006–2012. Obstet Gynecol. 2015;126(6):1146–1150.

    10. Salemi JL, Pathak EB, Salihu HM. Infant outcomes after elective early-term delivery compared with expectant management. Obstet Gynecol. 2016;127(4):657–666.

     

    Charles J Lockwood, MD, MHCM
    Dr Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...

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