No Elective Deliveries Prior to 39 Weeks Gestation: Implications for Change In Clinical Practice
- Review national trends of frequency of elective deliveries less than thirty-nine weeks gestation.
- Examine maternal and newborn outcomes of elective inductions and cesarean sections prior to thirty-nine weeks gestation as determined in two multi-center trials in 2007.
- Compare the impact of three strategies of clinician engagement to promote clinical practice change regarding elective deliveries prior to thirty-nine weeks gestation.
In 2007, a large multi-hospital system with 220,000 annual births completed a retrospective review of biths in twenty-seven hospitals. The purposes of the study were to determine frequency of elective deliveries prior to 39 weeks gestation and measure associated adverse maternal and neonatal outcomes. Clinician leaders within the hospitals implemented strategies to change clinical practice. In 2009, the study was replicated to determine if there had been a decrease in the number of elective deliveries less than 39 weeks gestation. Another purpose of the study was to evaluate effectiveness of three approaches to effect change in providers responsible for elective deliveries pre 39 weeks gestation.
Proposed change:
The change proposed by clinician leaders of the system was to eliminate elective deliveries less than 39 weeks gestation. The system has one hundred ten facilities with perinatal services. Individual hospital leadership has the autonomy to govern practices of the facility. While system clinicians share evidence, resources, and approaches, there would be no dictum for practice change to accomplish the goal.
Implementation, outcomes and evaluation:
The system's Perinatal Clinical Work Group reviewed the 2007 study findings. Evidence was shared with physician and nurse representatives from each perinatal service in the system at an annual conference. The Perinatal Services Medical Director held conference calls to discuss study findings and work group recomendations with obstetrical providers throughout the system. Monitoring of individual hospital's adoption of a no elective delivery policy less than 39 weeks gestation began along with quarterly reporting of compliance.
In 2009, the original study was repeated to determine if there had been a decrease in elective deliveries less than 39 weeks gestation. Furthermore, investigators correlated hospital compliance to the major strategy employed by the facility. Those perinatal services with a "hard stop approach" experienced greater compliance than those who adopted a position statement with peer review or education only.
Implications for nursing practice:
To prevent elective deliveries pre 39 weeks gestation, nurses provide patient and family education and serve as a patient advocate. Hospital nurses reinforce efforts by partnering with care providers from physician offices, health departments, and community agencies. As demonstrated, nurses will have the greatest impact in preventing elective deliveries prior to 39 weeks gestation by collaboriating with obstetrical providers and hospital leaders to establish and enforce "hard stop" policies.
Keywords:
elective delivery; patient safety; practice change
