Just as The Leapfrog Group has released its most recent report showing dramatic reductions in medically unnecessary C-sections and inductions before 39 weeks, another study raises questions about the ideal time for repeat C-sections in patients having multiple C-sections.
For several years now there has been a campaign to reduce non-medically indicated labor inductions prior to 39 weeks of gestation (see our February 8, 2011 Patient Safety Tip of the Week “Inducing Too Early”). That campaign, originally sponsored by the March of Dimes, Leapfrog Group, California Maternal Quality Care Collaborative and the California Department of Public Health; Maternal, Child and Adolescent Health Divisions, and later adopted by the American College of Obstetricians and Gynecologists (ACOG) highlighted the risks to newborns delivered prior to 39 weeks of gestation and provided tools to help avoid “elective” inductions prior to 39 weeks. We’ve been on board for that campaign.
The Leapfrog Group has been publicly reporting hospital rates since 2010, though hospital reporting has been voluntary. This month The Leapfrog Group published the rates for 2013 and they demonstrate a continued striking improvement trend. The national average of 4.6 percent in 2013 stands in sharp contrast to the national average of 17 percent in 2010. Moreover, in 2013, 71 percent of the reporting hospitals met Leapfrog’s early elective deliveries target rate of less than 5 percent, compared to 46 percent of hospitals in the 2012 survey.
While the public reporting likely got more hospitals involved, the real reason for the improvement has been that hospitals have done a good job educating both pregnant women and providers about the benefits of avoiding early induction. Most hospitals we’ve worked with have simply not allowed scheduling of elective inductions in cases lacking a medical indication (though simply requiring the provider to give a medical reason and then doing audit and feedback also successfully reduced rates of inappropriate early inductions).
But a new study, presented as an abstract at the 2014 Society for Maternal-Fetal Medicine Annual Meeting, seems to challenge delaying repeat C-sections in some women who have had prior C-sections (Hart 2014). The researchers studied over 6000 women with prior cesarean section deliveries who lacked medical or obstetrical indications for early delivery during their current pregnancy. They found that for women with 2 prior cesarean section deliveries the risk of adverse maternal outcomes increased three-fold with a concomitant increase in the risk of adverse perinatal outcomes between 38 to 39 weeks. In women with ≥ 3 previous cesarean section deliveries, the risk of maternal complications increased four-fold between 37 to 38 weeks. They conclude that their findings suggest the optimal time for scheduled delivery of women with 2 previous cesarean section deliveries is between 38 wks 0 and 38wk 6 days and between 37 wks 0 and 37 wks 6 days for women with ≥ 3 previous cesarean section deliveries.
It’s not the first time there has been a challenge to the campaign. In our October 2013 What’s New in the Patient Safety World column “Challenging the 39-Week Campaign” we noted a study by researchers at the Oregon Health & Science University (Darney 2013) that found no difference in the risk for severe lacerations, operative vaginal delivery, perinatal death, NICU admission, respiratory distress, or macrosomia between the groups at any week studied. There was an increased risk of hyperbilirubinemia in infants with inductions lacking medical indication at 37 and 38 weeks of gestation and an increased risk of shoulder dystocia at week 39.
Note also that another study (Stock 2012) had found that elective induction of labor between weeks 37 and 40 was associated with decreased odds of perinatal mortality compared to expectant management and did not increase the risk of cesarean sections. Admissions to a neonatal unit were, however, increased in those cases having elective induction prior to 41 weeks.
The studies highlight the importance of ensuring that recommendations are evidence-based. The Hart study would seem to indicate that adherence to the 39-week “rule” might actually have some unintended consequences in some cases.
The Leapfrog Group. Hospital Rates of Early Scheduled Deliveries. March 2014
Hart L, Refuerzo J, Sibai B, Blackwell S. Abstract 40: Should the “39 week rule” apply to women with multiple prior cesarean deliveries? American Journal of Obstetrics & Gynecology 2014; 210(1 Supplement): S27, January 2014
Darney BG, Snowden JM, Cheng YW, et al. Elective Induction of Labor at Term Compared With Expectant Management: Maternal and Neonatal Outcomes. Obstetrics & Gynecology 2013; published ahead of print 6 September 2013
Stock SJ, Ferguson E, Duffy A, et al. Outcomes of elective induction of labour compared with expectant management: population based study. BMJ 2012; 344: e2838 Published 10 May 2012
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