Keep Calm and "Carry On": The Journey To Decrease Elective Early Term Deliveries

Purpose for the program: Delivery prior to 39 weeks gestation is associated with increased neonatal morbidity and mortality.  Significant risks associated with early term delivery (defined as 37-38 6/7 weeks gestation) include respiratory distress, transient tachypnea of newborn, admission to the neonatal intensive care unit (NICU), temperature instability, hypoglycemia, feeding difficulties, and higher rates of hospital readmission.  Elective delivery is frequently utilized to accommodate patient and physician convenience, with an increased risk that it may be performed earlier than is appropriate.  In an effort to decrease neonatal complications, the March of Dimes and the American Congress of Obstetricians and Gynecologists recommend that elective delivery not occur prior to 39 weeks.  A multidisciplinary team of professionals at Baptist Hospital of Miami collaborated to adopt the 39 week elective early term delivery initiative, with voluntary data collection reported to Leapfrog Group.

Proposed change: BHM proposed to evaluate their elective early term delivery scheduling processes and implement changes aimed to decrease elective early term delivery rate to a benchmark proposed by the Leapfrog Group. 

Implementation, outcomes and evaluation: The first step of the evaluation involved retrospective data collection by Performance Improvement, who determined the elective early term delivery rate as 30%.  Educational programs were then presented to physicians and obstetrical personnel emphasizing the importance of the Initiative with the ultimate goal to decrease the incidence of elective early term deliveries to the nationally proposed benchmark rate.  Through implementation of educational programs for medical personnel and for patient population, surveillance of elective delivery schedules, and enforcement of practice policies including elimination of psychosocial indications for early delivery scheduling, the rate of elective early term delivery steadily declined from a rate of 30% to 5.1% over a period of four years.  This decline in early delivery rate occurred simultaneously with a decline in associated NICU admissions from fourteen cases in 2009 to two cases in 2013.   These results demonstrate a necessity for multidisciplinary vigilance against needless early term deliveries and shared responsibility for policy compliance to ensure optimal patient outcomes. 

Implications for nursing practice: Improved adherence to TJC recommendations with reduction of early term elective deliveries can be accomplished through initiatives involving education, surveillance of elective delivery schedules, enforcement of practice policies, and ongoing outcome data collection and evaluation. Through the application of evidence based practice, nurses are empowered to monitor elective deliveries with direct result to patient outcomes.

Keywords: early term delivery, elective delivery, patient safety