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Fetal Outcomes of
Elective Delivery
MATTHEW K. HOFFMAN, MD, MPH, AUDREY A.
MERRIAM, MD and DEBORAH B. EHRENTHAL, MD, MPH
Christiana Care Health System, Department of Obstetrics &
Gynecology, Newark, Delaware
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402 Hoffman et al
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Fetal Outcomes of Elective Delivery 403
FIGURE 1. Respiratory morbidities by gestational week. Adjusted odds ratio by week of delivery
(39 to 40 wk). Adapted from Consortium on Safe Labor et al.3 Adaptations are themselves works
protected by copyright. So in order to publish this adaptation, authorization must be obtained
both from the owner of the copyright in the original work and from the owner of copyright in the
translation or adaptation.
outcome. Similarly, the individual outcomes with women who underwent spontaneous
showed a significant decrease in incidence labor, had an indicated delivery, or under-
with increasing gestational age. TTN went planned cesarean delivery. Nonethe-
showed a decreased incidence up to 40 less, the impact of elective induction had
weeks’ gestation and RDS until 41 weeks’ the lowest rate of ventilator use at 39
gestation.1 This would reinforce the ACOG weeks’ gestation. Gestational age had a
policy recommending performing elective more important impact on the rate of
cesarean deliveries at 39 weeks or later. ventilator use than type of labor onset.
The Consortium of Safe Labor likewise Not surprisingly, these respiratory meas-
examined respiratory outcomes among ures correlated strongly with need for
233,844 women who were delivered both neonatal intensive care unit (NICU) ad-
vaginally and by cesarean.3 This study mission; which was lowest among moth-
looked at morbidities including use of ers who were electively induced at 39
surfactant, pneumonia, and mechanical ven- weeks.8 This would suggest that a policy
tilation by gestational age. The results of of elective induction would provide some
these outcomes are displayed in Figure 1. As neonatal benefit assuming it is done at
one can clearly see, the incidence of respira- 39 weeks or beyond.
tory morbidities was lowest among neonates The aforementioned studies are all ret-
born at 39 to 40 weeks, whereas those born rospective examinations of neonatal out-
at 37 weeks had the highest rates of respira- comes and come with inherent flaws and
tory morbidity. biases in study design despite their large
Interestingly, using the same data set, sample size. Other authors have examined
Bailit and colleagues undertook a more the neonatal effects following the imple-
complex analysis comparing neonatal mentation of guidelines limiting elective
outcomes between women who under- induction of labor before 39 weeks’ gesta-
went elective labor delivery. After strat- tion. Oshiro and colleagues examined the
ifying for gestational weeks, women who effects of such a policy in an integrated
had an induction of labor had lower rates health care system in Utah and Idaho
of need for assisted ventilation compared which included a total of 28,150 women.
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404 Hoffman et al
Data were collected before the implemen- increased at 40 weeks and beyond but
tation of this policy (N = 11,813) through was similar between 37 and 39 weeks.
6 years after implementation (N = Two studies have examined the role of
16,337). Although successful in decreasing elective delivery in preventing meconium
the rates of early-term births (37 to 38 wk), aspiration. In a study of 2886 women who
neonatal RDS and ventilator usage did were electively induced compared with
not change after implementation of their 9648 women who spontaneously labored,
no elective induction of labor policy.2 Dublin et al19 noted no difference in the
It is interesting to note that several rate of meconium aspiration. In contrast,
other large studies have detailed success- Oshiro et al2 in his larger assessment of the
ful implementation of guidelines, none impact of a policy limiting elective deliv-
have commented on the change in need ery documented a significant decrease in
for respiratory support that resulted from meconium aspiration after the implemen-
these policy changes.9–14 tation of their policy. Although counter to
traditional thinking, this evidence would
RACIAL DIFFERENCES IN suggest that women who are not electively
PULMONARY IMMATURITY delivered are less likely to have meconium
Racial differences in obstetrical outcome aspiration.
have long been documented.15 Several
investigations have suggested that certain
ethnic groups have accelerated pulmo- Summary
nary maturity.16 As such the applicability The data on fetal lung immaturity after
of guidelines forbidding ‘‘early-term’’ de- elective induction of labor at term is var-
livery may not be relevant to all ethnic ied. Nonetheless it can be summated by
groups. Recently Vilchez and colleagues saying that gestational age is the most
examined the impact of being Hispanic on important predictor of respiratory mor-
the rate of several respiratory outcomes bidity with general consensus that the
following elective repeat cesarean deliv- lowest risk of pulmonary immaturity oc-
ery. In a large cohort of women identified curs at or beyond 39 completed weeks.
through an administrative data set Nonetheless, a single study with large
(N = 930,421), this group was unable to numbers (N = 28,150) has failed to dem-
identify any difference in the rate of as- onstrate improvement in either the rate of
sisted ventilation or surfactant use at 38 RDS or ventilator use.2 To truly under-
or 39 weeks compared with women who stand the impact of this change in policy,
were delivered at 40 weeks.17 further documentation of the impact this
policy change on this important outcome
should be a major focus of ongoing re-
Meconium Aspiration search and must account for the potential
Meconium aspiration remains a serious of racial differences.
but uncommon complication with a prev-
alence of 0.067%.18 Meconium aspiration
is generally believed to be increased by NICU Admission
prolongation of pregnancy. On the basis Admission to a NICU is predominantly
this assumption, one would presuppose related to respiratory outcomes but can
that elective induction would decrease the also be the result of a number of other
rate of meconium aspiration. In a large indications including: low birth weight,
population-based study by Fischer et al,18 hypoglycemia, sepsis, thermoregulation
they found the incidence of meconium among other indications. From a public
aspiration syndrome dramatically policy standpoint, NICU admission
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Fetal Outcomes of Elective Delivery 405
remains a significant source of cost and would require NICU admission per 131
therefore policies that result in lower rates women who were electively induced.22
of NICU admission can have a profound Once again studies documenting the
impact of hospital costs. NICU admis- impact of policy changes of limiting elec-
sions are known to be higher with prema- tive deliveries on NICU admission are
ture deliveries but have also been shown limited. Clark and colleagues examined
to be increased with early-term deliveries 3 different strategies to alter physician
(37 to 38 wk gestation). behavior in 27 different hospitals relative
Various retrospective cohort studies to elective induction and investigated the
have examined NICU admissions for impact of these policy changes on the rate
elective deliveries at term. Hoffmire and of NICU admission. The 3 strategies ex-
colleagues examined 1577 deliveries in amined were physician education, peer
Upstate New York. Their data included review, and a hard-stop policy; which
births between 36 0/7 and 38 6/7 weeks’ was the most effective in reducing the rate
gestation. They found that electively de- of elective preterm delivery. This group
livered infants were 46% more likely to also found that the rate of term NICU
require NICU admission. When stratified admission declined from 8.9% to 7.5%
by week the adjusted relative risk (RR) (P<0.01).11 Ehrenthal and colleagues
was highest for 36-week deliveries (RR, likewise examined the change in NICU
2.24; 95% CI, 1.72-2.91) but remained admission rate following their implemen-
elevated at 37 weeks (RR, 1.39; 95% CI, tation of a hard-stop policy. This group
1.07-1.79). In addition, the increased NI- likewise identified a significant decrease
CU admission rates were noted in both in the rate of term NICU admission
elective cesarean and vaginal deliveries, (9.29% prepolicy vs. 8.55% postpolicy,
with the former carrying a great risk of P = 0.044).9 They also chose to examine
NICU admission.20 A like retrospective if there were influences of race on this
study from Brussels looked at 7683 elec- important outcome. Following the imple-
tive inductions matched to 7683 patients mentation of a no elective delivery policy
in spontaneous labor between 38 0/7 and before 39 weeks, there was a statistically
41 0/7 weeks’ gestation. This investigation significant reduction of NICU admission
found an increased risk of NICU admis- among white women (OR, 0.89; 95% CI,
sion in the electively induced group during 0.79-1.00) but there were no differences
the first 48 hours of life (RR, 1.14; CI among African Americans (OR, 0.97;
1.03-1.25). Reasons for admission to NI- 95% CI, 0.82-1.16) or Hispanics (OR,
CU were cited as respiratory problems, 0.90; 95% CI, 0.70-1.16).9 Whether the
suspicion of perinatal infection, and hy- failure to find differences in these 2 groups
perbilirubinemia. Cesarean delivery was of women represents racial/ethnic varia-
also cited as a reason for NICU admission tions, insufficient numbers of patients in
and occurred more frequently in the elec- these categories or different groups of
tively induced cohort.21 care providers for these groups remains
Using a large data set of obstetrical unclear.
units in Scotland from 1981 to 2007, Stock
and colleagues examined the impact of COMPOSITE MORBIDITY AND
elective induction among 1,271,549 wom- MORTALITY
en. This group found that elective induc- Recognizing that different morbidities
tion resulted in a higher rate of neonatal may be competing (eg, respiratory imma-
admission to a NICU or special care turity vs. macrosomia), 2 recent studies
nursery for all gestational weeks before chose to look at a composite outcome.
41 weeks. They calculated that 1 neonate Chiossi and colleagues in a secondary
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406 Hoffman et al
analysis of a prospective registry collected the mean birth weight during the 2 time
by the Maternal-Fetal Medicine Units periods. Although neonates weighing
examined a neonatal composite of RDS, >4000 g or >4500 g were more common,
TTN, NEC (necrotizing enterocoloitis), following the implementation of such a
sepsis, ventilation, seizures, hypoxic is- policy this was not statistically significant
chemic encephalopathy, NICU admis- (P = 0.22 and P = 0.65, respectively).9
sion, 5-minute Apgar <4, or death. Oshiro and colleagues likewise examined
They found that neonatal outcomes were this outcome in their cohort. Similarly they
optimized by a strategy of elective deliv- found no difference in the rate of macro-
ery at 39 to 40 weeks.23 Another research somia (10.9% preimplementation vs. 10.6%
group chose to examine a composite out- postimplementation, P = NS).2
come using antepartum stillbirth/neona- Few studies have been powered to or
tal death, neonatal morbidity, NICU have adequate data to examine the issue of
admission, meconium aspiration, NEC, shoulder dystocia given its rare occur-
RDS, or IVH in a national cohort from rence.26 In one of largest studies to examine
the Netherlands (N = 985,321). This this question, Stock and colleagues exam-
group chose an at-risk approach and ex- ined the rate of shoulder dystocia among
amined 3 separate ethnic groups (whites, women who spontaneously labored com-
Mediterranean, and Africans). As anti- pared with those who were electively deliv-
cipated, this group found that Africans ered in a cohort of 1,271,549 women.
had poorer outcomes across the gesta- Contrary to what would be anticipated, they
tional continuums examined. Nonethe- found the rate of shoulder dystocia was
less, when they examined the gestational actually increased by elective induction of
age at which their outcomes were opti- labor (OR, 1.28; P<0.001); however, due to
mized as a function of their composite the rarity of this clinical event they were
morbidity, they found that for both unable to further segment this by gestational
whites and Mediterraneans it was at 39 age.22 Although a sole study, this investiga-
weeks, whereas for Africans it was at 38 tion strongly argues against the notion that
weeks.24 This would once again reinforce shoulder dystocia can be prevented through
the concept that racial/ethnic differences elective induction.
may play an important role in defining
the optimal gestational age at which to STILLBIRTH
be born. At term the rate of stillbirth is low, but it
rises continuously as pregnancy proceeds
MACROSOMIA AND SHOULDER and most rapidly after 41 weeks of com-
DYSTOCIA pleted gestation (Fig. 2).27,28 Understand-
Birth weight has long been felt to be a ing the stillbirth risk associated with
function of gestational age and a common continued pregnancy, balanced with the
reason why care providers have chosen to neonatal risks of an earlier delivery, is a
electively shorten the course of pregnancy, challenge. Nearly all evidence available is
despite the fact that convincing data to retrospective and observational. Expect-
support this practice is absent.25 Although ant management of pregnancy is recom-
numerous consequences of excessive fetal mended when observational data suggest
growth (macrosomia) exist, shoulder dysto- that the risks to the neonate outweigh
cia is one of the more consequential out- the very small risk of stillbirth. More
comes. Ehrenthal and colleagues examined recently, changes in obstetrical practice
the rate of macrosomia following imple- have enabled the evaluation of the
mentation of a policy limiting elective in- outcomes of an elective delivery on a
ductions. This group found no difference in population level. In this section, we will
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Fetal Outcomes of Elective Delivery 407
FIGURE 2. Prospective fetal mortality rate by single weeks of gestation: United States, 2005
Source: National vital statistics system, NCHS/CDC. The prospective fetal mortality rate is the
number of fetal deaths at a given gestational age per 1000 live births at that gestational age or
greater. Source: National vital statistics system, NCHS/CDC.
FIGURE 3. Rate of infant death, stillbirth, and total perinatal death at each completed gestational
week at term. From Rosenstein et al.28 Adaptations are themselves works protected by copyright. So
in order to publish this adaptation, authorization must be obtained both from the owner of the
copyright in the original work and from the owner of copyright in the translation or adaptation.
www.clinicalobgyn.com
408 Hoffman et al
stillbirths as the numerator and live births induction of labor are based on evidence-
at that gestational age as the denomina- based recommendations or expert opinion
tor, exaggerating the risk stillbirth risk at when evidence is lacking.5 It is noted that
the earliest gestational ages and under- there is variance in the guidelines regarding
estimating the risk during late-term and labor induction from the ACOG, Society of
post-term periods. His approach used the Obstetricians and Gynecologists of Canada,
currently accepted practice of considering and the Royal College of Obstetricians and
stillbirths per ongoing pregnancy and Gynaecologists, and the Royal Australian
showed the conditional and cumulative and New Zealand College of Obstetricians
risks of stillbirth associated with increas- and Gynecologists.30 Such differences reflect
ing gestational age for a population. that overwhelming evidence on best appro-
These estimated probabilities suggested aches to manage such instances does not exist.
a nadir in total perinatal mortality be- Recently, more detailed guidance about
tween 39 and 42 weeks.29 Similar results specific timing of delivery was provided by
were obtained when an analysis of more an expert panel convened by the Eunice K.
recent data from California were con- Shriver National Institute for Child Health
ducted (Fig. 3) by Rosenstein et al.28 and Human Development for placental,
uterine, fetal, and maternal issues based on
Stillbirth Risk Related to Characteristics a synthesis of the available evidence.31 The
of the Mother and Neonate panel considered the risks and benefits of
Certain characteristics of the mother and early delivery by indication, attempting to
fetus are associated with a significantly optimize the combined outcomes for the
greater likelihood of stillbirth at term. For mothers and offspring, but did not intend
some, pregnancy outcomes may be im- to define standard of care. For some indi-
proved by ensuring a delivery before the cations, there was broad leeway in the rec-
onset of spontaneous labor. Current ACOG ommended gestational age at delivery, as
recommendations for medically indicated can be observed in Table 1. This is consistent
TABLE 1. Recommendations for Timing of Delivery for Women With Hypertension and
Diabetes
Issue Gestational Age for Delivery (wk) Grade of Recommendation*
Hypertensive disorders
Chronic hypertension (no medications) 38-39 B
On no medications 38-39 B
Controlled on medications 37-39 B
Poorly controlled on medications 36-37 B
Gestational hypertension 37-38 B
Preeclampsia, severe At diagnosis C
Preeclampsia, mild 37 B
Diabetes
Antenatal DM, well controlled No early delivery B
Antenatal DM, with vascular disease 37-39 B
Antenatal DM, poorly controlled 34-39 B
GDM well controlled in diet or meds No early delivery B
GDM, poorly controlled 34-39 B
*Level A recommendation is based on good and consistent scientific evidence; level B on limited or inconsistent scientific
evidence; and level C on consensus or expert opinion.
Adapted from Spong et al.31 Adaptations are themselves works protected by copyright. So in order to publish this adaptation,
authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the
translation or adaptation.
DM indicates diabetes mellitus; GDM; gestational diabetes mellitus.
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Fetal Outcomes of Elective Delivery 409
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410 Hoffman et al
the timing of elective delivery after imple- policy. Although there was a small decline
mentation of practice guidelines eliminat- in admissions to the NICU, a small in-
ing elective delivery before 39 completed crease in stillbirth rate, primarily before
weeks.2,9,11–14 Only a few of these in- 39 weeks, was observed.9
cluded stillbirth as an outcome. All were
conducted in the United States.
SIDS AND POSTNATAL DEATH
Oshiro et al2 examined stillbirth before
and after implementation of a policy restrict- Although concerns about stillbirth have
ing elective delivery before 39 weeks across a been made to argue in support of elective
large integrated health care system. There delivery, it is important that these be
was a significant decline in elective deliveries weighted with the risk of postnatal death.
earlier than 39 weeks of completed gestation, Studies of postnatal death have histori-
and a decrease in overall stillbirth rate at cally been confounded by birth defects.
term from 0.09 to 0.03 per 10,000. This Recently Altman et al36 examined the
decrease was evident only in the 37 and 38 impact of gestational age between 37
weeks’ groups. However, stillbirth rate was and 41 weeks on postnatal death in a large
calculated as events per deliveries at that Swedish population of 2,152,738 non-
gestational age, rather than using events anomalous newborns. The authors in fact
per ongoing pregnancy. found that postnatal death was lowest
Clark and colleagues studied the result among children who were born at 40
of implementation of the ‘‘39-week rule’’ weeks after adjusting for a number of
across 27 birth hospitals in the United confounders. It is important to note that
States. There was heterogeneity in the the rate of postnatal death increased with
impact of the initiative on elective induc- every week of <40 weeks (Fig. 4). The
tions attributed to the stringency of the majority of this increase was due to SIDS
policy approach at each institution. Over- deaths which represented 39% of the
all, there was a decrease in elective deliv- postnatal deaths.
eries before 39 weeks. They found an Reddy and colleagues in an examination
absolute increase in the rate of stillbirth of the 2001 US Birth Cohort Linked birth/
[1522 stillbirths/222,084 (0.69%) before death file likewise examined the effect of
and 1497/211,467 (0.71%) after] which gestational age on infant and neonatal mor-
was not statistically significant.11 tality. Compared with 39 weeks this group
The study of outcomes at a single in- found that both neonatal and infant mortal-
stitution by Ehrenthal and colleagues also ity were statistically increased from 34 weeks
demonstrated a significant change in the through 38.37 Not surprisingly, gestational
gestational age and birth weight distribu- age was negatively correlated with mortality
tions after the implementation of the consistently.
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Fetal Outcomes of Elective Delivery 411
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412 Hoffman et al
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Fetal Outcomes of Elective Delivery 413
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