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The Effect of the 39 Weeks Elective Delivery Guideline on the Rate of Unscheduled Cesarean Delivery
Abstract Number: F-62
Abstract Type: Original Research
The Hospital Corporation of America’s (HCA) “hard stop” policy (1) and American Congress of Obstetrics and Gynecology’s “39 week induction rule” (2) discourage the scheduling of elective deliveries before 39 weeks’ gestation because of associated worsened neonatal outcomes demonstrated in research studies (3). There are few investigations evaluating how the recommendations may affect the mother. As delayed scheduling may result in unplanned labor and delivery in the early term period, and as unscheduled cesarean deliveries (CD) may be riskier than scheduled CD, we chose to examine changes in the rate and numbers of early term unscheduled CD in the periods before (Pre-Rule) and after (Post-Rule) implementation of the “hard stop” policy on May 15, 2009.
This retrospective chart review was conducted at Wesley Medical Center, a regional HCA women and infants’ center with >6000 deliveries annually. We compared the rate and numbers of unscheduled early term (between ≥ 37 and <39 weeks’ gestation) CD in the two-year Pre-Rule period to the rate and numbers in the two-year Post-Rule. Independent samples t-tests were performed for statistical analyses.
The overall CD rate was 29.6% in the Pre-Rule period [3,730 CD] and 31.7% in the Post-Rule period [4,075 CD] (P= 0.0003). Despite the increase in overall cesarean sections in the Post-Rule time frame, the Pre-Rule period had more early term CD [1,022 vs. 729], and a higher early term CD rate [8.1% of all deliveries vs. 5.7%, (P <0.0002)]. As expected, the rate of unscheduled deliveries was greater in the Post-Rule period (Pre-Rule = 595 unscheduled out of 1022 total = 58.2%; Post-Rule = 487 unscheduled out of 729 total = 66.8% (P= 0.0001). Although there was also a higher rate of night-time unscheduled CD in the Post-Rule period (13.7% vs. 11.6% Pre-Rule), this difference was not statistically significant.
Unscheduled CDs are known to have higher morbidity and mortality (4). Our study demonstrated that implementation of the “hard stop” policy resulted in a decrease in overall early term and unscheduled early term CD numbers even though the actual rate of early term unscheduled CD was increased in the Post-Rule period. The study findings allow us to further evaluate the effectiveness of postponement of CD until ≥ 39 weeks’ gestation and suggest the rule also promotes maternal safety by decreasing the total number of early term unscheduled CD.
(1) Am J Obstet Gynecol 2010; 203: 449.e1–6. (2) American College of Obstetricians and Gynecologists Practice Bulletin Number 107. August, 2009. (3) Am J Obstet Gynecol 2009; 200: 156.e1–4. (4) Acta Obstet Gynecol Scand 2008; 87: 662–668.