ACOG Committee Opinion No. 765: Avoidance of Nonmedically Indicated Early-Term Deliveries and Associated Neonatal Morbidities

Association of early-term birth and breastfeeding practices with nutritional outcomes in singleton term infants: a multicenter cross-sectional study

BACKGROUND

Limited research has explored the associations of gestational age (GA) and breastfeeding practices with growth and nutrition in term infants.

METHODS

This multicenter cross-sectional study recruited 7299 singleton term infants from well-child visits in Shandong, China, between March 2021 and November 2022. Data on GA, gender, ethnicity, birth weight, parental heights, gestational diabetes and hypertension, age at visit, breastfeeding practices (point-in-time data at visit for infants < 6 months and retrospective data at 6 months for infants ≥ 6 months), complementary foods introduction, infant length and weight, were collected. 7270 infants were included in the analysis after excluding outliers with Z-scores of length (LAZ), weight or weight for length (WLZ) <-4 or > 4. Linear regression models adjused for covariates explored the impact of GA and breastfeeding practices on LAZ and WLZ, while logistic regression models evaluated their effect on the likelihood of moderate and severe stunting (MSS, LAZ<-2), moderate and severe acute malnutrition (MSAM, WLZ<-2) and overweight/obesity (WLZ > 2). Sensitivity analysis was conducted on normal birth weight infants (2.5-4.0 kg).

RESULTS

Infants born early-term and exclusively breastfed accounted for 31.1% and 66.4% of the sample, respectively. Early-term birth related to higher WLZ (< 6 months: β = 0.23, 95% confidence interval (CI): 0.16, 0.29; ≥6 months: β = 0.12, 95% CI: 0.04, 0.20) and an increased risk of overweight/obesity throughout infancy (< 6 months: OR: 1.41, 95% CI 1.08, 1.84; ≥6 months: OR: 1.35, 95% CI 1.03, 1.79). Before 6 months, early-term birth correlated with lower LAZ (β=-0.16, 95% CI: -0.21, -0.11) and an increased risk of MSS (OR: 1.01, 95%CI 1.00, 1.02); Compared to exclusive breastfeeding, exclusive formula-feeding and mixed feeding linked to lower WLZ (β=-0.15, 95%CI -0.30, 0.00 and β=-0.12, 95%CI -0.19, -0.05, respectively) and increased risks of MSAM (OR: 5.57, 95%CI 1.95, 15.88 and OR: 3.19, 95%CI 1.64, 6.19, respectively). Sensitivity analyses confirmed these findings.

CONCLUSIONS

The findings emphasize the health risks of early-term birth and the protective effect of exclusive breastfeeding in singleton term infants, underscoring the avoidance of nonmedically indicated delivery before 39 weeks and promoting exclusive breastfeeding before 6 months.

Impact of prenatal maternal depression on gestational length: post hoc analysis of a randomized clinical trial

Background

Shortened gestation is a leading cause of childhood morbidity and mortality with lifelong consequences for health. There is a need for public health initiatives on increasing gestational age at birth. Prenatal maternal depression is a pervasive health problem robustly linked via correlational and epidemiological studies to shortened gestational length. This proof-of-concept study tests the impact of reducing prenatal maternal depression on gestational length with analysis of a randomized clinical trial (RCT).

Methods

Participants included 226 pregnant individuals enrolled into an RCT and assigned to receive either interpersonal psychotherapy (IPT) or enhanced usual care (EUC). Recruitment began in July 2017 and participants were enrolled August 10, 2017 to September, 8 2021. Depression diagnosis (Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; DSM 5) and symptoms (Edinburgh Postnatal Depression Scale and Symptom Checklist) were evaluated at baseline and longitudinally throughout gestation to characterize depression trajectories. Gestational dating was collected based on current guidelines via medical records. The primary outcome was gestational age at birth measured dichotomously (≥39 gestational weeks) and the secondary outcome was gestational age at birth measured continuously. Posthoc analyses were performed to test the effect of reducing prenatal maternal depression on gestational length. This trial is registered with ClinicalTrials.gov (NCT03011801).

Findings

Steeper decreases in depression trajectories across gestation predicted later gestational age at birth, specifically an increase in the number of full-term babies born ≥39 gestational weeks (EPDS linear slopes: OR = 1.54, 95% CI 1.10-2.16; and SCL-20 linear slopes: OR = 1.67, 95% CI 1.16-2.42). Causal mediation analyses supported the hypothesis that participants assigned to IPT experienced greater reductions in depression symptom trajectories, which in turn, contributed to longer gestation. Supporting mediation, the natural indirect effect (NIE) showed that reduced depression trajectories resulting from intervention were associated with birth ≥39 gestational weeks (EPDS, OR = 1.65, 95% CI 1.02-2.66; SCL-20, OR = 1.85, 95% CI 1.16-2.97).

Interpretation

We used a RCT design and found that reducing maternal depression across pregnancy was associated with lengthened gestation.

Funding

This research was supported by the NIH (R01 HL155744, R01 MH109662, R21 MH124026, P50 MH096889).

Neonatal and maternal outcomes at early vs. full term following induction of labor; A secondary analysis of the OBLIGE randomized trial

INTRODUCTION

Birth at early term (37+0-38+6 completed gestational weeks [GW] and additional days) is associated with adverse neonatal outcomes compared with waiting to ≥39 GW. Most studies report outcomes after elective cesarean section or a mix of all modes of births; it is unclear whether these adverse outcomes apply to early-term babies born after induction of labor (IOL). We aimed to determine, in women with a non-urgent induction indication (elective/planned >48 h in advance), if IOL at early and late term was associated with adverse neonatal and maternal outcomes compared with IOL at full term.

MATERIAL AND METHODS

An observational cohort study as a secondary analysis of a multicenter randomized controlled trial of 1087 New Zealand women with a planned IOL ≥37+0 GW. Multivariable logistic regression was used to analyze neonatal and maternal outcomes in relation to gestational age; 37+0-38+6 (early term), 39+0-40+6 (full term) and ≥41+0 (late term) GW. Neonatal outcome analyses were adjusted for sex, birthweight, mode of birth and induction indication, and maternal outcome analyses for parity, age, body mass index and induction method. The primary neonatal outcome was admission to neonatal intensive care unit (NICU) for >4 hours; the primary maternal outcome was cesarean section.

RESULTS

Among the 1087 participants, 266 had IOL at early term, 480 at full term, and 341 at late term. Babies born following IOL at early term had increased odds for NICU admission for >4 hours (adjusted odds ratio [aOR] 2.16, 95% confidence intervals (CI) 1.16-4.05), compared with full term. Women having IOL at early term had no difference in emergency cesarean rates but had an increased need for a second induction method (aOR 1.70, 95% CI 1.15-2.51) and spent 4 h longer from start of IOL to birth (Hodges-Lehmann estimator 4.10, 95% CI 1.33-6.95) compared with those with IOL at full term.

CONCLUSIONS

IOL for a non-urgent indication at early term was associated with adverse neonatal and maternal outcomes and no benefits compared with IOL at full term. These findings support international guidelines to avoid IOL before 39 GW unless there is an evidence-based indication for earlier planned birth and will help inform women and clinicians in their decision-making about timing of IOL.

Contemporary Management of Cardiomyopathy and Heart Failure in Pregnancy

Cardiovascular disease is the primary cause of pregnancy-related mortality and morbidity in the United States, and maternal mortality has increased over the last decade. Pregnancy and the postpartum period are associated with significant vascular, metabolic, and physiologic adaptations that can unmask new heart failure or exacerbate heart failure symptoms in women with known underlying cardiomyopathy. There are unique management considerations for heart failure in women throughout pregnancy, and it is imperative that clinicians caring for pregnant women understand these important principles. Early involvement of multidisciplinary cardio-obstetrics teams is key to optimizing maternal and fetal outcomes. In this review, we discuss the unique challenges and opportunities in the diagnosis of heart failure in pregnancy, management principles along the continuum of pregnancy, and the safety of heart failure therapies during and after pregnancy.

Dinoprostone tablet versus continuous vaginal insert (Propess®) for elective induction in low-risk nulliparous women at term

OBJECTIVE

To evaluate the efficacy and safety of dinoprostone tablet and continuous vaginal insert (Propess®) in low-risk nulliparous women at term with insufficient cervical ripening receiving elective induction.

MATERIALS AND METHODS

A retrospective study was conducted between March 2020 and February 2022 and included 230 women who underwent elective induction with dinoprostone tablet or vaginal insert. The primary endpoint was failure of induction. Secondary endpoints included time to vaginal delivery, vaginal delivery rate, as well as maternal and neonatal complications and adverse outcomes.

RESULTS

No statistically significant differences were found between the two groups regarding the main outcome measures; however, the high responders had a significant higher proportion of hyperstimulation and non-reassuring fetal status. The high responder in the Propess group was statistically significant younger (31.68 ± 4.73 vs. 33.82 ± 4.39, p = 0.027), while they had a significantly lower BMI at delivery time of the tablet group (24.49 ± 2.24 vs. 27.42 ± 4.32, p = 0.024). Factors associated with success of vaginal delivery within 24 h (p = 0.015, OR = 0.9, 95%CI = 0.82-0.98) and the Cesarean section (p < 0.001, OR = 1.17, 95%CI = 1.08-1.27) was BMI at delivery time.

CONCLUSION

Slow-release vaginal insert and dinoprostone tablet had similar efficacy and safety for elective induction in low risk nulliparous women at term. Women with younger maternal age or lower BMI at delivery time may have a better response to dinoprostone and had a significantly higher proportion of hyperstimulation and non-reassuring fetal status.

Association Between Gestational Age and Academic Achievement of Children Born at Term

Importance

Differences in academic achievement by gestational age of children born at term, especially at 39 to 41 weeks, are not well understood.

Objective

To examine differences in academic achievement among children born between 37 and 41 weeks' gestational age.

Design, Setting, and Participants

This retrospective cohort study linked birth certificates of children born in Iowa from 1989 to 2009 with school test scores for grades 2 to 11 from 2017 to 2018. Statistical analysis was performed from January to March 2023.

Exposures

Gestational age at 37, 38, 39, and 41 weeks vs 40 weeks from clinical or obstetric and calendar measures.

Main Outcomes and Measures

Outcomes were scores in national percentile rankings (NPRs) on standardized school tests in math and reading. Covariates included demographic and prenatal risk factors.

Results

The sample included 536 996 children (50.7% male children and 49.3% female children) with math scores (3 576 045 child-grade observations; 6.6%, 15.7%, 28.6%, 35.5%, and 13.7% born at 37, 38, 39, 40, and 41 weeks, respectively) and 537 078 children with reading scores (3 590 408 child-grade observations). Score differences for those born at 39 vs 40 weeks were -0.028 NPRs (95% CI, -0.18 to 0.12 NPRs) for math and 0.085 NPRs (95% CI, -0.067 to 0.24 NPRs) for reading using the clinical or obstetric measure and 0.03 NPRs (95% CI, -0.14 to 0.20 NPRs) for math and 0.13 NPRs (95% CI, -0.042 to 0.31 NPRs) for reading using the calendar measure. With the clinical or obstetric measure, score differences between those born at 41 and 40 weeks were 0.19 NPRs (95% CI, -0.0052 to 0.38 NPRs) for math and 0.098 NPRs (95% CI, -0.096 to 0.29 NPRs) for reading. With the calendar measure, score differences for those born at 41 weeks were -0.22 NPRs (95% CI, -0.43 to -0.013 NPRs) for math and -0.28 NPRs (95% CI, -0.49 to -0.074 NPRs) for reading. With the clinical or obstetric measure, score differences between those born at 37 and 38 weeks vs 40 weeks were -0.59 NPRs (95% CI, -0.84 to -0.33 NPRs) and -0.44 NPRs (95% CI, -0.62 to -0.26 NPRs), respectively, for math, and -0.066 NPRs (95% CI, -0.32 to 0.19 NPRs) and -0.19 NPRs (95% CI, -0.37 to 0.0038 NPRs), respectively, for reading.

Conclusions and Relevance

This study suggests that there is no evidence of a difference in math and reading scores over grades 2 to 11 among children born between 39 and 40 weeks' gestation, and overall no evidence of better scores among those born at 41 weeks' gestation compared with 40 weeks' gestation. The results can further inform decisions on delivery timing at term birth by offering insights into long-term associations of delivery timing with cognitive development and school achievement.

The Impact of Malpractice Damage Caps on C-section Rates and Alternative Approaches

About half of the states in the United States have had noneconomic damage caps in place for at least 8 years. National aggregate data shows that women are just as likely to give birth by cesarean section (C-section) in states with damage caps as in ones without. For the most recent year studied, the national C-section rate for births in states with damage caps was 33.04% compared with a 32.10% ratefor births in states without caps. Other initiatives (malpractice insurance reform, accessible public disclosure of hospital C-section rates, and improved compensation for vaginal delivery) should be considered to reduce C-section rates.

Increases in Obstetric Interventions and Changes in Gestational Age Distributions of U.S. Births

Objective: To examine how changes in induction of labor (IOL) and cesarean deliveries between 1990 and 2017 affected gestational age distributions of births in the United States. Materials and Methods: Singleton first births were drawn from the National Vital Statistics System Birth Data for years 1990-2017. Separate analytic samples were created (1) by maternal race/ethnicity (Hispanic, non-Hispanic Black, non-Hispanic Asian, and non-Hispanic white), (2) by maternal age (15-19, 20-24, 25-29, 30-34, 35-39, 40-49), (3) by U.S. states, and (4) for women at low risk for obstetric interventions (e.g., age 20-34, no hypertension, no diabetes, no tobacco use). Gestational age was measured in weeks, and obstetric intervention status was measured as: (1) no IOL, vaginal delivery; (2) no IOL, cesarean delivery; and (3) IOL, all deliveries. The joint probabilities of birth at each gestational week by obstetric intervention status for years 1990-1991, 1998-1999, 2007-2008, and 2016-2017 were estimated. Results: Between 1990 and 2017, the percent of singleton first births occurring between 37 and 39 weeks of gestation increased from 38.5% to 49.5%. The changes were driven by increases in IOL and a shift in the use of cesarean deliveries toward earlier gestations. The changes were observed among all racial/ethnic groups and all maternal ages, and across all U.S. states. The same changes were also observed among U.S. women at low risk for interventions. Conclusion: Changes in gestational age distributions of U.S. births and their underlying causes are likely national-level phenomena and do not appear to be responding to increases in maternal risk for interventions.

Gestational Age at Term and Teacher-Reported Attention-Deficit Hyperactivity Disorder Symptom Patterns

OBJECTIVE

The objective of this study was to estimate associations between gestational age and teacher-reported attention-deficit hyperactivity disorder (ADHD)-related symptom patterns at age 9 years among children born at term (37-41 weeks).

STUDY DESIGN

A secondary data analysis of approximately 1400 children in the Fragile Families and Child Wellbeing study, a US birth cohort study that oversampled nonmarital births, was conducted. At age 9 years, students were evaluated by their teachers using the Conners Teacher Rating Scale-Revised Short Form that included subscales for symptoms of hyperactivity, ADHD, oppositional behavior, and cognitive problems/inattention. Unadjusted and adjusted negative binomial and logistic regression models of associations between gestational age and teacher-reported scores were estimated.

RESULTS

Each week of gestational age at term was associated with hyperactivity scores that were 6% lower (adjusted incidence rate ratio [IRR]: 0.94; 95% CI: 0.89-0.99) and ADHD and cognitive problems/inattention scores that were 5% lower (adjusted IRR: 0.95; 95% CI: 0.91-0.98 in both cases). Early-term birth (37-38 weeks) was associated with 23% higher hyperactivity scores (adjusted IRR: 1.23; 95% CI:1.07-1.41), 17% higher ADHD scores (adjusted IRR: 1.17; 95% CI: 1.05-1.30), and ∼50% higher odds of scoring 1.5+ SDs above the sample mean for hyperactivity (aOR: 1.51; 95% CI: 1.05-2.18) when compared with birth at 39-41 weeks. There were no significant associations between gestational age and oppositional behavior scores.

CONCLUSION

The findings add to growing evidence supporting current recommendations for delaying elective deliveries to at least 39 weeks and suggest that regular screenings for ADHD symptoms are important for children born at 37- to 38-weeks gestation.

Care of the Fetus With Congenital Cardiovascular Disease: From Diagnosis to Delivery

BACKGROUND

The majority of congenital cardiovascular disease including structural cardiac defects, abnormalities in cardiac function, and rhythm disturbances can be identified prenatally using screening obstetrical ultrasound with referral for fetal echocardiogram when indicated.

METHODS

Diagnosis of congenital heart disease in the fetus should prompt assessment for extracardiac abnormalities and associated genetic abnormalities once maternal consent is obtained. Pediatric cardiologists, in conjunction with maternal-fetal medicine, neonatology, and cardiothoracic surgery subspecialists, should counsel families about the details of the congenital heart defect as well as prenatal and postnatal management.

RESULTS

Prenatal diagnosis often leads to increased maternal depression and anxiety; however, it decreases morbidity and mortality for many congenital heart defects by allowing clinicians the opportunity to optimize prenatal care and plan delivery based on the specific lesion. Changes in prenatal care can include more frequent assessments through the remainder of the pregnancy, maternal medication administration, or, in selected cases, in utero cardiac catheter intervention or surgical procedures to optimize postnatal outcomes. Delivery planning may include changing the location, timing or mode of delivery to ensure that the neonate is delivered in the most appropriate hospital setting with the required level of hospital staff for immediate postnatal stabilization.

CONCLUSIONS

Based on the specific congenital heart defect, prenatal echocardiogram assessment in late gestation can often aid in predicting the severity of postnatal instability and guide the medical or interventional level of care needed for immediate postnatal intervention to optimize the transition to postnatal circulation.

Use of Scheduled Nonopioid Analgesia to Decrease Inpatient Opioid Consumption After Scheduled Cesarean Birth

OBJECTIVE

To compare opioid use and pain scores in women who had scheduled cesarean birth before and after implementing a scheduled nonopioid analgesia practice guideline.

DESIGN

Quality improvement project with a comparison of pre-/postintervention.

SETTING/LOCAL PROBLEM

A 170-bed community hospital where the administration of postcesarean pain medications was unstandardized.

PARTICIPANTS

Convenience sample of 175 individuals who were scheduled for cesarean birth (106 in preintervention group and 69 in postimplementation group).

INTERVENTION/MEASUREMENTS

All participants had received a dose of 150 mcg of intrathecal morphine intraoperatively. Care of participants in the postimplementation group included a new practice guideline using preoperative oral acetaminophen 1 g and postoperative intravenous ketorolac 30 mg that transitioned to ibuprofen 600 mg orally every 6 hours until discharge. Acetaminophen 1 g every 6 hours also continued until discharge. For breakthrough pain, oxycodone 5 mg to 10 mg was available.

RESULTS

Results were analyzed using the chi-square and t test. There was a statistical difference in the mean milligram morphine equivalent consumed after scheduled cesarean birth (preintervention = 21.15 vs. postintervention = 3.91, p < .001). Postimplementation, 84.1% of participants did not consume any opioids beyond the intrathecal dose compared to 47.2% of participants preintervention. Mean pain scores decreased from 2.49 to 1.62 (p < .001), and there was an observed decrease of the highest reported pain score from 5.39 to 4.03 (p < .001).

CONCLUSION

The results of this project support the current literature indicating that the administration of a scheduled nonopioid multimodal analgesia regimen to individuals with scheduled cesarean birth is an effective postoperative pain management strategy. This approach to managing surgical birth pain can decrease subjective reports of pain and overall opioid consumption during the hospital stay.

Delivery Timing and Associated Outcomes in Pregnancies With Maternal Congenital Heart Disease at Term

Background Current recommendations for delivery timing of pregnant persons with congenital heart disease (CHD) are based on expert opinion. Justification for early-term birth is based on the theoretical concern of increased cardiovascular stress. The objective was to evaluate whether early-term birth with maternal CHD is associated with lower adverse maternal or neonatal outcomes. Methods and Results This is a retrospective cohort study of pregnant persons with CHD who delivered a singleton after 37 0/7 weeks gestation at a quaternary care center with a multidisciplinary cardio-obstetrics care team between 2013 and 2021. Patients were categorized as early-term (37 0/7 to 38 6/7 weeks) or full-term (≥39 0/7) births and compared. Multivariable logistic regression was conducted to calculate the adjusted odds ratio for the primary outcomes. The primary outcomes were composite adverse cardiovascular, maternal obstetric, and adverse neonatal outcome. Of 110 pregnancies delivering at term, 55 delivered early-term and 55 delivered full-term. Development of adverse cardiovascular and maternal obstetric outcome was not significantly different by delivery timing. The rate of composite adverse neonatal outcomes was significantly higher in early-term births (36% versus 5%, P<0.01). After adjusting for confounding variables, early-term birth remained associated with a significantly increased risk of adverse neonatal outcomes (adjusted odds ratio 11.55 [95% CI, 2.59-51.58]). Conclusions Early-term birth for pregnancies with maternal CHD was associated with an increased risk of adverse neonatal outcomes, without an accompanying decreased rate in adverse cardiovascular or obstetric outcomes. In the absence of maternal or fetal indications for early birth, induction of labor before 39 weeks for pregnancies with maternal CHD should be reserved for routine obstetrical indications.

Head in the sand: Contemporary Australian attitudes towards induction of labour

Ambivalence in Australian thought on induction of labour, despite recent evidence, stands out in contrast to ever-increasing rates of this intervention. As consent obligations on information provision have crystallised in maternity care, this article examines whether consumer-led expectations and legal obligations may precipitate change to end the cultural stigma around induction of labour.

Alberta Infant Motor Scale (AIMS) Performance of Early-Term Greek Infants: The Impact of Shorter Gestation on Gross Motor Development among “Term-Born” Infants

Early-term birth (37⁺⁰ to 38⁺⁶ gestational weeks) may have a negative impact on infants’ neurodevelopment compared to delivery at 39 weeks or beyond. The purpose of this study was to evaluate the gross motor development of early-term infants using the Alberta Infant Motor Scale (AIMS). A total of 1087 healthy infants (559 early-term and 528 full-term infants born at 39⁺⁰ to 41⁺⁶ weeks of gestation) were studied. Mean AIMS scores were compared between the two groups at monthly intervals. The impact of gestational age on total AIMS scores was assessed by linear regression, after adjustment for chronological age, sex and SGA. Mean total AIMS scores, albeit within normal range, were significantly lower in early-term than full-term infants at the 2nd, 6th, 7th, 8th and 12th month of age; differences between groups were within three points. In multivariate regression analysis, a longer gestation by one week had a positive impact on total AIMS score during the first year of life (β = 0.90; 95% CI 0.45, 1.35). In conclusion, early-term infants exhibit worse gross motor performance during the first year of life in comparison with their full-term peers; however, the differences between the two groups are small.

Perinatal Carbon Monoxide Poisoning: Treatment of a 2-Hour-Old Neonate with Hyperbaric Oxygen

A 41-year-old gravida 4 para 3 (G4P3) and 38 ^5/7 weeks pregnant woman presented to labor and delivery with dizziness, headache, and decreased fetal movement after 12 hours of exposure to carbon monoxide (CO) from a grill that was used inside for heat. The mother was hemodynamically stable, and her neurologic examination was intact. Her carboxyhemoglobin level, which was obtained 12 hours after removal from the CO exposure, was 7.4%. The fetus's heart rate was 173 beats per minute with moderate variability and one late appearing deceleration, not associated with contractions. The biophysical profile score was 2 of 8. The obstetrics team performed a routine cesarean section. The 1- and 5-minute Apgar's scores were 7 and 8, respectively. The arterial cord gas result was as follows: pH = 7.05, PCO ₂  = 71 mm Hg, pO ₂  = 19 mm Hg, bicarbonate = 14 mmol/L, and carboxyhemoglobin = 11.9%. The mother and infant were treated with hyperbaric oxygen therapy consisting of 100% oxygen at 2.4 atmosphere absolutes (ATA) for 90 minutes at 2.5 hours after delivery. Following one hyperbaric oxygen treatment, the infant was transitioned to room air and routine postpartum treatment and was discharged 3 days later in good condition. Hyperbaric oxygen treatment was well tolerated in this neonate.

Clinical Characteristics and Pregnancy-Related Outcomes of Pregnant Women Hospitalized with COVID-19 During the Delta Wave: A Single-Center Observational Study

Background

Coronavirus disease 2019 (COVID-19) during pregnancy is associated with increased disease severity and an increased risk of perinatal complications. However, few studies of pregnant women with COVID-19 have been conducted in Korea. The purpose of this study was to describe the clinical course and pregnancy outcomes of pregnant women admitted to our hospital with COVID-19 according to the severity.

Materials and Methods

This retrospective cohort study included women aged 18 years of age or older who were hospitalized in the Gachon University Gil Medical Center with COVID-19 during pregnancy between July 1, 2021 and January 31, 2022. COVID-19 severity was classified according to the “Criteria for severity classification by symptoms of COVID-19” presented by the Korea Disease Control and Prevention Agency. Severe cases were defined as those who required oxygen treatment administered via a high-flow nasal cannula or invasive mechanical ventilation or should be applied extracorporeal membrane oxygenation (ECMO) or continuous renal replacement therapy.

Results

A total of 103 pregnant women were hospitalized with COVID-19 during the study period. Their mean age was 33 (± 4.14) years, and 4 (3.9%) had been vaccinated against COVID-19. At the time of diagnosis of COVID-19, 3 (2.9%), 33 (32.0%), and 67 (65.1%) patients were in the first, second, and third trimester, respectively. The most common symptoms were cough (99 patients, 96.1%) and fever (85 patients, 82.5%). There was 1 (1.0%) asymptomatic patient. Forty patients (38.8%) required supplemental oxygen and 19 patients (18.4%) had severe disease. Of the 19 severe cases, 7 were in the 2nd trimester and 12 were in the 3rd trimester. Forty-one (39.8%) patients delivered, including two twin deliveries. Of the 41 cases of delivery, 14 were premature, 4 out of 21 (19.0%) in mild, 4 out of 12 (25.0%) in moderate, and 6 out of 8 (75.0%) in severe. Severe disease was associated with an increased rate of preterm birth (P = 0.012). Four of the 43 neonates (9.1%) received oxygen treatment.

Conclusion

Pregnant women with COVID-19 had a high rate of severe disease and a high preterm delivery rate, especially among those with severe disease.

Elective cesarean delivery at term and its effects on respiratory distress at birth in Japan: The Japan Environment and Children's Study

BACKGROUND AND AIMS

Early-term birth between 37 and 38 weeks of gestation increases the risk of mortality and morbidity. This study investigated the status and impact of early-term birth among neonates born by cesarean section in Japan.

METHODS

All singleton live births that had data of gestational age at birth available in the Japan Environment and Children's Study (JECS), a nationwide birth cohort study launched in 2011, were eligible for this study. Neonates born by cesarean delivery at term without indications for early delivery were included to examine the association between early-term birth and respiratory distress at birth. The gestational age at birth was categorized as 37 weeks 0 day to 38 weeks 6 days (early-term), 39 weeks 0 day to 40 weeks 6 day (full-term), and 41 weeks 0 day to 41 weeks 6 days (late-term). Respiratory distress at birth included respiratory distress syndrome, transient tachypnea, and difficulty in breathing after birth. Univariable and multivariable analyses were performed using logistic regression models with a two-tailed significance level of 5%. All statistical analyses were performed using SAS, version 9.4, for Windows (SAS Institute, Cary, NC).

RESULTS

In total, 32 078 of 100 011 (32.1%) neonates had early-term birth. At 37 gestational weeks, 49.7% of the deliveries were via cesarean section, and half of the cesarean deliveries were due to a previous cesarean section. Among the 10 051 neonates born by elective cesarean delivery at term, neonates with early-term births were more likely to have respiratory distress at birth (adjusted odds ratio: 4.19; 95% confidence interval, 1.70, 10.34) than those born at full term.

CONCLUSIONS

Early-term birth is associated with a high risk of respiratory distress in births involving cesarean delivery without indication for early delivery. There is a need for guidelines for early delivery considering adverse effects of early-term births.

Association of Gestational Age at Birth With Subsequent Suspected Developmental Coordination Disorder in Early Childhood in China

IMPORTANCE

It remains unknown whether children born at different degrees of prematurity, early term, and post term might have a higher risk of developmental coordination disorder (DCD) compared with completely full-term children (39-40 gestational weeks).

OBJECTIVE

To differentiate between suspected DCD in children with different gestational ages based on a national representative sample in China.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted in China from April 1, 2018, to December 31, 2019. A total of 152 433 children aged 3 to 5 years from 2403 public kindergartens in 551 cities of China were included in the final analysis. A multilevel regression model was developed to determine the strength of association for different gestational ages associated with suspected DCD when considering kindergartens as clusters.

MAIN OUTCOMES AND MEASURES

Children's motor performance was assessed using the Little Developmental Coordination Disorder Questionnaire, completed by their parents. Gestational age was determined according to the mother's medical records and divided into 7 categories: completely full term (39 to 40 weeks' gestation), very preterm (<32 weeks), moderately preterm (32-33 weeks), late preterm (34-36 weeks), early term (37-38 weeks), late term (41 weeks), and post term (>41 weeks).

RESULTS

A total of 152 433 children aged 3 to 5 years (mean [SD] age, 4.5 [0.8] years), including 80 370 boys (52.7%) and 72 063 girls (47.3%), were included in the study. There were 45 052 children (29.6%) aged 3 years, 59 796 (39.2%) aged 4 years, and 47 585 (31.2%) aged 5 years. Children who were born very preterm (odds ratio [OR], 1.35; 95% CI, 1.23-1.48), moderately preterm (OR, 1.18; 95% CI, 1.02-1.36), late preterm (OR, 1.24; 95% CI, 1.16-1.32), early term (OR, 1.11; 95% CI, 1.06-1.16), and post term (OR, 1.17; 95% CI, 1.07-1.27) were more likely to be classified in the suspected DCD category on the Little Developmental Coordination Disorder Questionnaire than completely full-term children after adjusting for the same characteristics. Additionally, there was no association with suspected DCD in younger (aged 3 years) early-term and postterm children by stratified analyses.

CONCLUSIONS AND RELEVANCE

In this cohort study, every degree of prematurity at birth, early-term birth, and postterm birth were associated with suspected DCD when compared with full-term birth. These findings have important implications for understanding motor development in children born at different gestational ages. Long-term follow-up and rehabilitation interventions should be considered for children born early and post term.

The effect of mode of delivery and duration of labour on subsequent pregnancy outcomes: a retrospective cohort study

OBJECTIVE

To assess whether delivery mode and duration of labour in a first labour of spontaneous onset is associated with gestational length, delivery mode and neonatal outcome in the subsequent pregnancy.

STUDY DESIGN

Retrospective analysis of prospectively collected data.

SETTING

15 Maternity units in North West London (1988-2000).

POPULATION

30 840 women with spontaneous onset of labour in pregnancy 1 and a subsequent birth reported in the same database.

METHODS

Assessment of outcomes by mode of delivery in pregnancy 1, restricting the analysis to the difference in the gestational length between pregnancy 1 and 2.

MAIN OUTCOME MEASURES

Gestational length, mode of delivery and neonatal unit admission in pregnancy 2.

RESULTS

Caesarean section (CS) in the first or second stage of labour in pregnancy 1 was associated with pregnancy 2 being a median of 5 and 8 days shorter and a preterm birth rate of 6.0% and 10.1%, respectively, whereas following a normal or instrumental vaginal birth in pregnancy 1, the median duration was similar, with preterm delivery rates of 4.5% and 3.9%. In all, 56.2% of women with a CS in pregnancy 1 had a repeat CS and 12.5% of their babies were admitted to a neonatal unit, compared with 5.3% of women with vaginal birth. Longer labours were associated with shorter gestations in pregnancy 2.

CONCLUSIONS

Compared with vaginal birth, an emergency CS in the first-term pregnancy is associated with a shorter gestational length, increased rate of repeat CS and increased risk of NNU admission in the next pregnancy.

TWEETABLE ABSTRACT

An emergency caesarean section in the first-term pregnancy affects the duration and outcome of the next pregnancy.

Australia's persistently high rate of early-term prelabour Caesarean delivery

Objective To compare the incidence of prelabour Caesarean delivery (PCD) at early term (37 weeks and 0 days (370) to 38 weeks and 6 days (386) of gestation) between Australian states and hospital sectors over time and to compare these rates with those of England and the United States of America (USA). Method A population-based descriptive study of 556040 singleton PCDs at term (370-406 weeks) in all public and private hospitals in Australian states, 2005-16, was performed. The primary outcome was the early-term PCD rate, defined as early-term PCDs as a percentage of all term PCDs. Results Across Australian states, the early-term PCD rate fell from 56.4% in 2005 to 52.0% in 2016. Over a similar period, England's rate fell from 48.2% in 2006-07 to 35.2% in 2016-17, while the USA's rate fell from 47.4% in 2006 to 34.2% in 2016. Australian public hospitals reduced their rate from 54.2% in 2005 to 44.7% in 2016, but the rate increased in private hospitals from 59.1% in 2005 to 62.5% in 2016. There was considerable variation between states and hospital sectors. Conclusions The early-term PCD rate increased in Australian private hospitals from 2005 to 2016. The public hospital rate fell by nearly 10% over the period but remained ~10% above the English and USA national rates. What is known about the topic? Babies born at early term (370-386 weeks) are at greater risk of morbidity than babies born at full term (390-406 weeks). Australia has a persistently high rate of early-term prelabour Caesarean delivery (PCD). What does this paper add? This paper reveals concerning differences in the early-term PCD rate between Australian states and hospital sectors. Further, the paper highlights that both Australian hospital sectors (public and private) have not reduced their rates to levels achieved in England and the USA. What are the implications for practitioners? These results should inform efforts to reduce Australia's early-term PCD rate to prevent harm to babies.

Gestational Age at Term and Educational Outcomes at Age Nine

OBJECTIVES

To estimate associations between gestational age (GA) and teacher-reported academic outcomes at age 9 years among children born at term (37-41 weeks).

METHODS

A secondary data analysis of 1405 children participating in a national US birth cohort study was conducted. At age 9 years, students were evaluated by their teachers in the areas of mathematics, science and social studies, and language and literacy. Unadjusted and adjusted logistic regression models of associations between GA and teacher-reported academic outcomes were estimated and neonatal morbidities were explored as potential pathways.

RESULTS

A continuous measure of GA in weeks was significantly associated with above-average rankings in all areas. The associations were similar across outcomes (eg, mathematics [odds ratio (OR): 1.13; confidence interval (CI): 1.02-1.25], science and social studies [OR: 1.13; CI: 1.01-1.26], and language and literacy [OR: 1.16; CI: 1.05-1.28]) in a model that adjusted for child sex, maternal characteristics, and obstetric risk factors and delivery complications. Other specifications indicate a positive association between late term (41 weeks) and mathematics and a negative association between early term (37-38 weeks) and language and literacy, compared with term (39-40). The associations did not appear to operate through neonatal morbidity.

CONCLUSIONS

The findings highlight the importance of GA, even at term. Whereas current guidelines suggest waiting until at least 39 weeks to deliver when possible, our findings add to a small group of studies suggesting that GA through 41 weeks is associated with improvements in some educational outcomes.

Elective labor induction vs expectant management of pregnant women at term and children's educational outcomes at 8 years of age

OBJECTIVE

To estimate the effect of elective induction of labor at 39 weeks' gestation on children's educational outcomes as measured using the Australian National Assessment Program-Literacy and Numeracy (NAPLAN) tests in school year 3 (∼8 years of age), compared with expectant management.

METHODS

We merged perinatal data on all infants born in South Australia from 1999 to 2008 with children's school assessment data from NAPLAN. The study population included all singleton infants born without a malformation at 39-42 weeks in vertex presentation. Children who had undertaken the NAPLAN test in school year 3 were included. We excluded births to women who had a contraindication to vaginal delivery and those with a condition possibly justifying elective delivery before 39 weeks. The outcome of interest was children's educational outcome as measured using NAPLAN, which includes five learning domains (reading, writing, spelling, grammar and numeracy). Each domain was categorized according to performance at or below vs above the national minimum standard (NMS). Average treatment effects (ATEs) of elective induction of labor at 39 weeks compared with expectant management on the proportion of children performing at/below the NMS for each domain were estimated using the augmented inverse-propensity-weighted estimator, accounting for potential confounders.

RESULTS

Of 53 843 children born at 39-42 weeks in vertex presentation from 1999 to 2008 and who were expected to participate in the year-3 NAPLAN from 2008 to 2015, a total of 31 120 had at least one year-3 NAPLAN domain. Of these, 1353 children were delivered after elective induction of labor at 39 weeks while 29 767 children were born following expectant management. The ATEs (mean differences) of elective induction of labor at 39 weeks compared with expectant management on the proportion of children scoring at/below the NMS on each domain were 0.01 (95% CI, -0.02 to 0.03) for reading, 0.02 (95% CI, 0.00-0.04) for writing, 0.01 (95% CI, -0.01 to 0.04) for spelling, 0.02 (95% CI, -0.01 to 0.04) for grammar and 0.03 (95% CI, 0.00-0.05) for numeracy.

CONCLUSION

Elective induction of labor at 39 weeks did not affect children's standardized literacy and numeracy testing outcomes at 8 years of age when compared with expectant management. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Medically Indicated Late-Preterm and Early-Term Deliveries: ACOG Committee Opinion, Number 831

ABSTRACT

The neonatal risks of late-preterm and early-term births are well established, and the potential neonatal complications associated with elective delivery at less than 39 0/7 weeks of gestation are well described. 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 associated with further continuation of pregnancy. Deferring delivery to the 39th week is not recommended if there is a medical or obstetric indication for earlier delivery. If there is a clear indication for a late-preterm or early-term delivery for either maternal or newborn benefit, then delivery should occur regardless of the results of lung maturity testing. Conversely, if delivery could be delayed safely in the context of an immature lung profile result, then no clear indication for a late-preterm or early-term delivery exists. Also, there remain several conditions for which data to guide delivery timing are not available. Some examples of these conditions include uterine dehiscence or chronic placental abruption. Delivery timing in these circumstances should be individualized and based on the current clinical situation.

Morbidity associated with planned cesarean deliveries performed before the scheduled date: A cohort study

OBJECTIVE

Women with planned cesareans can require delivery before the scheduled date. However, data describing the morbidity associated with planned cesarean deliveries performed before the originally scheduled date is lacking. The objective of this study was to compare the morbidity associated with planned cesarean delivery performed before compared with on the scheduled date.

STUDY DESIGN

This retrospective single-center cohort study included all 3595 women with singleton pregnancies and cesarean deliveries after 36⁺⁶ weeks. All cases were reviewed individually to identify the initial intended mode of delivery, determined before 37 weeks. We excluded the 2145 (59.7%) unplanned cesareans initially planned as vaginal deliveries. Finally, the analysis included 1450 women with planned cesareans: 1232 (85.0%) performed as scheduled, and 218 (15.0%) before that date. The composite outcomes of maternal morbidity was one or more of the morbidity measures, including surgical complications, postpartum hemorrhage, infection and thrombo-embolism. Neonatal morbidity measures included 5 min Apgar score < 7, arterial cord blood pH < 7.00, and admission to the neonatal intensive care unit (NICU).

RESULTS

Reasons for performing planned cesarean delivery before the scheduled date were as follows: onset of labor (n = 109; 50.0%), rupture of membranes (n = 85; 39.0%), preeclampsia (n = 9; 4.1%), scar pain in women with a previous cesarean (n = 6; 2.8%), unexplained vaginal bleeding (n = 5; 2.3%), and nonreassuring fetal heart rate (n = 4; 1.8%). Mean gestational age for planned cesarean deliveries before the scheduled date was 38.7 weeks ± 0.8 versus 39.2 weeks ± 0.7 for those performed when scheduled (P < 0.0001). The maternal morbidity composite outcome rate was significantly higher among planned cesareans performed early compared with those on the scheduled date: 18.3% vs 9.7%, respectively, P = 0.0002. It was still higher in the multivariable analysis: aOR 2.17, 95% CI 1.46-3.21, P = 0.0001. The neonatal composite outcome did not differ significantly between the two groups.

CONCLUSION

In planned cesarean deliveries, maternal morbidity is higher for cesareans performed before rather than on the scheduled date. Studies without accurate intent-to-treat analyses underestimate the morbidity associated with planned cesareans. Accordingly, medical records must make it possible to distinguish planned cesarean deliveries performed before the scheduled date from those performed as planned.

A systematic review on the effectiveness of implementation strategies to postpone elective caesarean sections to ≥ 39 + (0-6) weeks of gestation

BACKGROUND

Caesarean sections often have no urgent indication and are electively planned. Research showed that elective caesarean section should not be performed until 39 + (0-6) weeks of gestation to ensure best neonatal and maternal health if there are no contraindications. This was recommended by various guidelines published in the last two decades. With this systematic review, we are looking for implementation strategies trying to implement these recommendations to reduce elective caesarean section before 39 + (0-6) weeks of gestation.

METHODS

We performed a systematic literature search in MEDLINE, EMBASE, CENTRAL, and CINAHL on 3rd of March 2021. We included studies that assessed implementation strategies aiming to postpone elective caesarean section to ≥ 39 + (0-6) weeks of gestation. There were no restrictions regarding the type of implementation strategy or reasons for elective caesarean section. Our primary outcome was the rate of elective caesarean sections before 39 + (0-6) weeks of gestation. We used the ROBINS-I Tool for the assessment of risk of bias. We did a narrative analysis of the results.

RESULTS

We included 10 studies, of which were 2 interrupted time series and 8 before-after studies, covering 205,954 elective caesarean births. All studies included various types of implementation strategies. All implementation strategies showed success in decreasing the rate of elective caesarean sections performed < 39 + (0-6) weeks of gestation. Risk difference differed from - 7 (95% CI - 8; - 7) to - 45 (95% CI - 51; - 31). Three studies reported the rate of neonatal intensive care unit admission and showed little reduction.

CONCLUSION

This systematic review shows that all presented implementation strategies to reduce elective caesarean section before 39 + (0-6) weeks of gestation are effective. Reduction rates differ widely and it remains unclear which strategy is most successful. Strategies used locally in one hospital seem a little more effective. Included studies are either before-after studies (8) or interrupted time series (2) and the overall quality of the evidence is rather low. However, most of the studies identified specific barriers in the implementation process. For planning an implementation strategy to reduce elective caesarean section before 39 + (0-6) weeks of gestation, it is necessary to consider specific barriers and facilitators and take all obstetric personal into account.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017078231.

Early term birth is associated with the risk of preterm and recurrent early term birth in women with 3 consecutive deliveries

BACKGROUND

We assessed the association of early term at first birth (ETB) with the risk of preterm birth (PTB) and ETB in women with 3 consecutive deliveries.

METHODS

We conducted a retrospective cohort study of all women with 3 consecutive singleton births at a single institute from 1994 to 2013. The risk of PTB (<37 weeks), spontaneous PTB and ETB (37-38 weeks) in the 3^rd delivery was explored.

RESULTS

Of 49,259 women delivered in our center during the study period, 4038 met inclusion criteria. The rate for subsequent PTB, spontaneous PTB and recurrent ETB in the 3^rd delivery significantly increased as the number of prior ETBs increased. The order of a single prior ETB in one of the first two deliveries was differently associated with the risk of complications in the 3^rd delivery, which was higher when the prior ETB was more recent to the third delivery.

CONCLUSION

A history of ETB is associated with the risk of future PTB and recurrent ETB. The risk is related to the number and order of prior ETBs.

Medically Indicated Late-Preterm and Early-Term Deliveries: ACOG Committee Opinion, Number 818

ABSTRACT

The neonatal risks of late-preterm and early-term births are well established, and the potential neonatal complications associated with elective delivery at less than 39 0/7 weeks of gestation are well described. 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 associated with further continuation of pregnancy. Deferring delivery to the 39th week is not recommended if there is a medical or obstetric indication for earlier delivery. If there is a clear indication for a late-preterm or early-term delivery for either maternal or newborn benefit, then delivery should occur regardless of the results of lung maturity testing. Conversely, if delivery could be delayed safely in the context of an immature lung profile result, then no clear indication for a late-preterm or early-term delivery exists. Also, there remain several conditions for which data to guide delivery timing are not available. Some examples of these conditions include uterine dehiscence or chronic placental abruption. Delivery timing in these circumstances should be individualized and based on the current clinical situation. This Committee Opinion is being revised to include frequent obstetric conditions that would necessitate delivery before 39 weeks of gestation and to apply the most up-to-date evidence supporting delivery recommendations.

Transcutaneous Bilirubin Levels and Risk of Significant Hyperbilirubinemia in Early-Term and Term Newborns

OBJECTIVE

To compare the course of the transcutaneous bilirubin (TcB) values of early-term newborns with those of term newborns in the first month of life and to investigate whether early-term newborns have an increased risk of significant hyperbilirubinemia requiring treatment.

DESIGN

A prospective, controlled cohort analysis.

SETTING

A tertiary level mother-child birth and health care center.

PARTICIPANTS

Four hundred early-term (37 0/7 to 38 6/7 weeks) and 320 term (39 0/7 to 41 6/7 weeks) newborns born during a 27-month period.

METHODS

A total of six TcB measurements in a longitudinal manner were made in early-term and term newborns: the first two at 6 and 48 hours after birth and the next four on routine examination days (Days 4, 7, 15, and 30). Demographic characteristics, values of daily TcB measurements, number of newborns with significant hyperbilirubinemia, and risk of jaundice requiring treatment were compared between the two groups.

RESULTS

All six TcB values were significantly greater in the early-term group than in the term group (p < .001 for each). Early-term newborns had a statistically significant increased risk of jaundice requiring treatment compared to term newborns (risk ratio = 1.91; 95% confidence interval [1.23-2.96]; p = .0046). Results of the repeated-measures analysis of variance and post hoc adjusted multiple comparison analysis showed that TcB levels increased to and peaked at 96 hours after birth and then gradually decreased to baseline (first measurement) levels at 30 days after birth in each group.

CONCLUSIONS

Early-term newborns should not be treated as full-term newborns because they have significantly higher TcB levels. These newborns should be closely monitored for pathologic jaundice because they have increased risk for significant hyperbilirubinemia requiring phototherapy.

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.

Advances in Maternal Fetal Medicine: Perinatal Quality Collaboratives Working Together to Improve Maternal Outcomes

State-based perinatal quality collaboratives (PQCs) address preventable causes of maternal and infant morbidity and mortality by implementing statewide quality improvement (QI) initiatives. They work with hospital clinical teams, obstetric provider and nursing leaders, patients and families, public health officials, and other stakeholders to provide opportunities for collaborative learning, rapid-response data, and QI science support to achieve clinical culture change. PQCs show that the application of collaborative improvement science methods to advance evidence-informed clinical practices using QI strategies contributes to improved perinatal outcomes. With appropriate staffing, infrastructure, and partnerships, PQCs can achieve sustainable improvements in perinatal care.

Maternal perceptions of the experience of attempted labor induction and medically elective inductions: analysis of survey results from listening to mothers in California

BACKGROUND

The rate of induction of labor in the U.S. has risen from 9.6% in 1990 to 25.7% in 2018, including 31.7% of first-time births. Recent studies that have examined inductions have been small qualitative studies or relied on either medical records or administrative data. This study examines induction from the perspective of those women who experienced it, with a particular focus on the prevalence and predictors of inductions for nonmedical indications, women's experience of pressure to induce labor and the relationship between the attempt to medically initiate labor and cesarean section.

METHODS

Study data are drawn from the 2119 respondents to the Listening to Mothers in California survey who were planning to have a vaginal birth in 2016. Mothers were asked if there had been an attempt to medically initiate labor, if it actually started labor, if they felt pressured to have the induction, if they had a cesarean and the reason for the induction. Reasons for induction were classified as either medically indicated or elective.

RESULTS

Almost half (47%) of our respondents indicated an attempt was made to medically induce their labor, and 71% of those attempts initiated labor. More than a third of the attempts (37%) were elective. Attempted induction overall was most strongly associated with giving birth at 41+ weeks (aOR 3.28; 95% C.I. 2.21-4.87). Elective inductions were more likely among multiparous mothers and in pregnancies at 39 or 40 weeks. The perception of being pressured to have labor induced was related to higher levels of education, maternal preference for less medical intervention in birth, having an obstetrician compared to a midwife and gestational ages of 41+ weeks. Cesarean birth was more likely in the case of overall induction (aOR 1.51; 95% C.I. 1.11-2.07) and especially following a failed attempt at labor induction (aOR 4.50; 95% C.I. 2.93-6.90).

CONCLUSION

Clinicians counselling mothers concerning the need for labor induction should be aware of mothers' perceptions about birth and engage in true shared decision making in order to avoid the maternal perception of being pressured into labor induction.

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.

A systematic review and time-response meta-analysis of the optimal timing of elective caesarean sections for best maternal and neonatal health outcomes

BACKGROUND

The rate of caesarean sections (CS) has increased in the last decades to about 30% of births in high income countries. Many CSs are electively planned without an urgent medical reason for mother or child. An early CS though may harm the newborn. Our aim was to evaluate the gestational time point after the 37 + 0 week of gestation (WG) (after prematurity = term) of performing an elective CS with the lowest morbidity for mother and child by assessing the time course from 37 + 0 to 42+ 6 WG.

METHODS

We performed a systematic literature search in MEDLINE, EMBASE, CENTRAL and CINAHL in November 2018. We included studies that compared different time points of elective CS at term no matter the reason for elective CS. Our primary outcomes were the rate of admissions to the neonatal intensive care unit (NICU), neonatal death and maternal death in early versus late term elective CS. Various binary and dose response random effects meta-analyses were performed.

RESULTS

We identified 35 studies including 982,749 women. Except one randomised controlled trial, all studies were cohort studies. We performed a linear time-response meta-analysis on the primary outcome NICU admission on 14 studies resulting in a decrease of the relative risk (RR) to 0.63 (95% CI 0.56, 0.71) from 37 + 0 to 39 + 6 WG. RR for neonatal death showed a decrease to 39 + (0-6) WG (RR 0.59 95% CI 0.43 to 0.83) and increase from then on (RR 2.09 95% CI 1.18 to 3.70) assuming a U-shape course and using a cubic spline model for meta-analysis of four studies. We only identified one study analyzing maternal death resulting in RR of 0.38 (95% CI 0.04 to 3.40) for 37 + 0 + 38 + 6 WG versus ≥39 + 0 WG.

CONCLUSION

Our systematic review showed that elective CS (primary and repeated) before the 39 + 0 WG lead to more NICU admissions and neonatal deaths, although death is rare and increases again after 39 + 6 WG. We did not find enough evidence on maternal outcomes. There is a need for more research, considering maternal outcomes to provide a balanced decision between neonatal and maternal health.

SYSTEMATIC REVIEW REGISTRATION

Registered in PROSPERO (CRD42017078231).

Trends in Neonatal Intensive Care Unit Utilization in a Large Integrated Health Care System

IMPORTANCE

There are few population-based studies addressing trends in neonatal intensive care unit (NICU) admission and NICU patient-days, especially in the subpopulation that, by gestational age (GA) and birth weight (BW), might otherwise be able to stay in the room with their mothers.

OBJECTIVE

To describe population-based trends in NICU admissions, NICU patient-days, readmissions, and mortality in the birth population of a large integrated health care system.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using data extracted from electronic medical records at Kaiser Permanente Southern California (KPSC) health care system. Participants included all women who gave birth at KPSC hospitals and their newborns from January 1, 2010, through December 31, 2018. Data extraction was limited to data entry fields whose contents were either numbers or fixed categorical choices. Rates of NICU admission, NICU patient-days, readmission rates, and mortality rates were measured in the total population, in newborns with GA 35 weeks or greater and BW 2000 g or more (high GA and BW group), and in the remaining newborns (low GA and BW group). Admissions to the NICU and NICU patient-days were risk adjusted with a machine learning model based on demographic and clinical characteristics before NICU admission. Changes in the trends were assessed with 2-sided correlated seasonal Mann-Kendall test. Data analysis was performed in August 2019.

EXPOSURES

Admission to the NICU and NICU patient-days among the birth cohort.

MAIN OUTCOMES AND MEASURES

The primary outcomes were NICU admission and NICU patient-days in the total neonatal population and GA and BW subgroups. The secondary outcomes were readmission and mortality rates.

RESULTS

Over the study period there were 320 340 births (mean [SD] age of mothers, 30.1 [5.7] years; mean [SD] gestational age, 38.6 [1.97] weeks; mean [SD] birth weight, 3302 [573] g). The risk-adjusted NICU admission rate decreased from a mean of 14.5% (95% CI, 14.2%-14.7%) to 10.9% (95% CI, 10.7%-11.7%) (P for trend = .002); 92% of the change was associated with changes in the care of newborns in the high GA and BW group. The number of risk-adjusted NICU patient-days per birth decreased from a mean of 1.50 patient-days (95% CI, 1.43-1.54 patient-days) to 1.40 patient-days (95% CI, 1.36-1.48 patient-days) (P for trend = .03); 70% of the change was associated with newborns in the high GA and BW group. The unadjusted 30-day readmission rates and mortality rates did not change.

CONCLUSIONS AND RELEVANCE

Admission rates to the NICU and numbers of NICU patient-days decreased over the study period without an increase in readmissions or mortality. The observed decrease was associated with the high GA and BW newborn population. How much of this decrease is attributable to intercurrent health care systemwide quality improvement initiatives would require further investigation. The remaining unexplained variation suggests that further changes are also possible.

Perinatal outcomes from preterm and early term births in a multicenter cohort of low risk nulliparous women

Preterm birth is the major contributor for neonatal and under-five years mortality rates and also accounts for a short- and long-term adverse consequences up to adulthood. Perinatal outcomes may vary according to lots of factors as preterm subtype, late prematurity, which account for the vast majority of cases, country and population characteristics. An under-recognition of the perinatal outcomes and its associated factors might have underpowered strategies to provide adequate care and prevent its occurrence. We aim to estimate the frequency of maternal and perinatal outcomes in women with different categories of preterm and term births, factors associated with poorer perinatal outcomes and related management interventions. A multicentre prospective cohort in five maternities in Brazil between 2015 and 2018. Nulliparous low-risk women with singletons were included. Comprehensive data were collected during three antenatal visits (at 19-21weeks, 27-29 weeks and 37-39 weeks). Maternal and perinatal outcomes were also collected according to maternal and neonatal medical records. Women who had spontaneous (sPTB) and provider-initiated (pi-PTB) preterm birth were compared to those who had term birth. Also, late preterm birth (after 34 weeks), and early term (37-38 weeks) were compared to full term birth (39-40 weeks). Bivariate analysis estimated risk ratios for maternal and adverse outcomes. Finally, a multivariate analysis was conducted to address factors independently associated with any adverse perinatal outcome (APO). In total, 1,165 women had outcome data available, from which 6.7% had sPTB, 4.0% had pi-PTB and 89.3% had a term birth. sPTB and pi-PTb were associated with poorer perinatal outcomes, as well as late sPTB, late pi-PTB and early term neonates. pi-PTB (RRadj 8.12, 95% CI [2.54-25.93], p-value 0.007), maternal weight gain between 20 and 27 weeks Collapse

Key Words

• medical research
• epidemiology

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MESH Headings

• Adult
• Brazil/epidemiology
• Female
• Humans
• Infant, Low Birth Weight/growth & development
• Infant, Newborn
• Longitudinal Studies
• Parity
• Pregnancy
• Premature Birth/epidemiology
• Prognosis
• Prospective Studies
• Risk Factors
• Term Birth/physiology
• Young Adult

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Affiliation(s)

Renato T Souza Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
Maria L Costa Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
Jussara Mayrink Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
Francisco E Feitosa MEAC - School Maternity of the Federal University of Ceará, in Fortaleza, CE, Brazil
Edilberto A Rocha Filho Department of Maternal and Child Health, Maternity of Clinic Hospital, Federal University of Pernambuco, in Recife, PE, Brazil
Débora F Leite Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil Department of Maternal and Child Health, Maternity of Clinic Hospital, Federal University of Pernambuco, in Recife, PE, Brazil
Janete Vettorazzi Department of Obstetrics and Gynaecology, Maternity of the Clinic Hospital, Federal University of RS, Porto Alegre, RS, Brazil
Iracema M Calderon Department of Obstetrics and Gynaecology, Botucatu Medical School, Unesp, Botucatu, SP, Brazil
Maria H Sousa Statistics Unit, Jundiai School of Medicine, Jundiaí, SP, Brazil
Renato Passini Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
Philip N Baker College of Life Sciences, University of Leicester, Leicester, United Kingdom
Louise Kenny Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
Jose G Cecatti Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil.

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Fetal CHD and perinatal outcomes

OBJECTIVE

To evaluate delivery management and outcomes in fetuses prenatally diagnosed with CHD.

STUDY DESIGN

A retrospective cohort study was conducted on 6194 fetuses (born between 2013 and 2016), comparing prenatally diagnosed with CHD (170) to those with non-cardiac (234) and no anomalies (5790). Primary outcomes included the incidence of preterm delivery and mode of delivery.

RESULTS

Gestational age at delivery was significantly lower between the CHD and non-anomalous cohorts (38.6 and 39.1 weeks, respectively). Neonates with CHD had a significantly lower birth weights (p < 0.001). There was an approximately 1.5-fold increase in the rate of primary cesarean sections associated with prenatally diagnosed CHD with an odds ratio of 1.49 (95% CI 1.06-2.10).

CONCLUSIONS

Our study provides additional evidence that the prenatal diagnosis of CHD is associated with a lower birth weight, preterm delivery, and with an increased risk of delivery by primary cesarean section.

The Rates of Any Breastfeeding at the Time of Postpartum Hospital Discharge for Early Term (370-386 Weeks) Versus Full Term (390-416 Weeks) Infants

OBJECTIVE

This study sought to compare the rates of any breastfeeding between early term (37⁰-38⁶ weeks) and full term (39⁰-41⁶ weeks) infants at the time of postpartum hospital discharge.

METHODS

A retrospective cohort study of women with live, singleton pregnancies who were delivered in St. John's, Newfoundland and Labrador, between April 2001 and March 2018 was completed. The primary outcome was any breastfeeding at the time of postpartum hospital discharge. Secondary analyses included a comparison of breastfeeding by week of gestational age at term and by maternal and neonatal demographics and outcomes of pregnancy. Univariate and multiple logistic regression analyses were performed.

RESULTS

A total of 34 511 women were included. Early term infants were less likely to be breastfed than were full-term infants (67.9 vs. 70.4%) (adjusted odds ratio [aOR] 0.91; 95% confidence interval [CI] 0.86-0.97). Multiple logistic regression analysis also showed a significant effect of maternal age (aOR 1.07; 95% CI 1.05-1.09), partner status (aOR 1.56; 95% CI 1.20-2.03), smoking (aOR 0.32; 95% CI 0.26-0.41), prenatal education (aOR 2.43; 95% CI 1.99-2.97), pre-pregnancy body mass index (kg/m²) (aOR 0.97; 95% CI 0.96-0.98), and cesarean section (aOR 0.72; 95% CI 0.60-0.88). When compared by week of gestational age at term, the likelihood of breastfeeding significantly increased with each successive week (aOR 1.08; 95% CI 1.007-1.16).

CONCLUSION

Early term delivery is an independent risk factor for not breastfeeding at the time of postpartum hospital discharge. It is important to target and support these women to increase breastfeeding rates. Additionally, these findings further validate recommendations to avoid non-medically indicated early term deliveries because of the increased risks of adverse outcomes.

ACOG Committee Opinion No. 764: Medically Indicated Late-Preterm and Early-Term Deliveries

The neonatal risks of late-preterm and early-term births are well established, and the potential neonatal complications associated with elective delivery at less than 39 0/7 weeks of gestation are well described. 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 associated with further continuation of pregnancy. Deferring delivery to the 39th week is not recommended if there is a medical or obstetric indication for earlier delivery. If there is a clear indication for a late-preterm or early-term delivery for either maternal or newborn benefit, then delivery should occur regardless of the results of lung maturity testing. Conversely, if delivery could be delayed safely in the context of an immature lung profile result, then no clear indication for a late-preterm or early-term delivery exists. Also, there remain several conditions for which data to guide delivery timing are not available. Some examples of these conditions include uterine dehiscence or chronic placental abruption. Delivery timing in these circumstances should be individualized and based on the current clinical situation. This Committee Opinion is being revised to include frequent obstetric conditions that would necessitate delivery before 39 weeks of gestation and to apply the most up-to-date evidence supporting delivery recommendations.

Updates on an At-Risk Population: Late-Preterm and Early-Term Infants

The American Academy of Pediatrics published a clinical report on late-preterm (LPT) infants in 2007 that was largely based on a summary of a 2005 workshop convened by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, at which a change in terminology from "near term" to "late preterm" was proposed. This paradigm-shifting recommendation had a remarkable impact: federal agencies (the Centers for Disease Control and Prevention), professional societies (the American Academy of Pediatrics and American College of Obstetricians and Gynecologists), and organizations (March of Dimes) initiated nationwide monitoring and educational plans that had a significant effect on decreasing the rates of iatrogenic LPT deliveries. However, there is now an evolving concern. After nearly a decade of steady decreases in the LPT birth rate that largely contributed to the decline in total US preterm birth rates, the birth rate in LPT infants has been inching upward since 2015. In addition, evidence revealed by strong population health research demonstrates that being born as an early-term infant poses a significant risk to an infant's survival, growth, and development. In this report, we summarize the initial progress and discuss the potential reasons for the current trends in LPT and early-term birth rates and propose research recommendations.

End of the line for fetal lung maturity testing

OBJECTIVE

During the last decade, guidelines published by the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal Fetal Medicine (SMFM) have emphasized an increasingly limited role for fetal lung maturity (FLM) testing. As a reference laboratory for FLM testing, we were therefore interested in determining the impact of changing guidelines on our test volumes.

METHODS

We retrospectively reviewed FLM test volume data from 2006 to 2016 for the following FLM assays: lecithin/sphingomyelin ratio, phosphatidylglycerol, disaturated lecithin, and lamellar body count.

RESULTS

We found that there was a precipitous decline in test volumes from 2006 to 2016; our analysis led us to discontinue providing reference laboratory FLM testing in 2016 given the very low volumes.

CONCLUSIONS

The 2019 ACOG guidelines now state that FLM testing no longer has clinical utility. Therefore, clinical laboratory directors should meet with obstetrics providers to discuss discontinuation of FLM testing at their institutions.