CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 57, Number 2, 401–414
Fetal Outcomes of
Elective Delivery
MATTHEW K. HOFFMAN, MD, MPH, AUDREY A.
MERRIAM, MD and DEBORAH B. EHRENTHAL, MD, MPH
Christiana Care Health System, Department of Obstetrics &
Gynecology, Newark, Delaware
Abstract: Retrospective observational studies have
suggested that delivery at or beyond 39 weeks has
numerous neonatal benefits including less need for
respiratory support, fewer neurodevelopmental delays
and lower health care costs. This has lead governmen-
tal agencies, and professional organizations to en-
dorse a policy of limiting elective delivery prior to 39
weeks. Nonetheless, studies which have examined the
implications of instituting such policies, have demon-
strated mixed benefits and signaled some concerns
about unintended outcomes, such as stillbirth. This
chapter will detail the evidence that these policies have
on certain neonatal outcomes and examine why the
promise of such policies may remain unfilled.
Key words: 39 weeks, stillbirth, respiratory, NICU,
shoulder dystocia, SIDS
Overview
With the advent of requirements for pub-
lic reporting of elective deliveries before
39 weeks, it is clear that policy makers
have come to shape a national standard of
care. This standard of care is largely the
outgrowth of several large retrospective
studies suggesting fetal respiratory benefit
to limiting elective early-term deliveries
(37 to 38 wk).1–4 Although these data are
Correspondence: Matthew K. Hoffman, MD, MPH
4755 Ogletown-Stanton Road, Newark, DE 19718.
E-mail: mhoffman@christianacare.org
The authors declare that they have nothing to disclose.
CLINICAL OBSTETRICS AND GYNECOLOGY
r 2014, Lippincott Williams & Wilkins
compelling, it must be remembered that
this standard of care is not based on
randomized studies nor does such an ap-
proach adequately explore all of the im-
plications for neonatal outcomes of such
a policy. Other outcomes including still-
birth, learning issues, and even sudden
infant death syndrome (SIDS) are influ-
enced by gestational age and must be
factored in the total assessment of ‘‘elec-
tive delivery.’’ Fortunately, untoward ob-
stetrical and neonatal outcomes are rare
and therefore even large cohort studies
may not be powered to detect differences
in rare outcomes.
From a methodological standpoint it is
crucial to define the term elective delivery
and understand the potential method-
ological flaws that exist broadly in the
research that has been done in this area.
For the purposes of this chapter we have
chosen to define elective delivery consis-
tent with the definition provided by the
American College of Obstetricians and
Gynecologists (ACOG). They define an
‘‘elective delivery’’ as being an iatrogenic
delivery before 41 weeks that does not
have a medically acceptable indication.5
Although a number of medical conditions
are accepted as ‘‘medically indicated,’’ it is
critical to understand why they have come
/ VOLUME 57 / NUMBER 2 / JUNE 2014
www.clinicalobgyn.com | 401
402 Hoffman et al
to be so designated. For this reason we
will take a deeper dive into the evidence
of how some of the commonly accepted
‘‘medical indicated’’ reasons have been
designated as it relates to stillbirth.
It is likewise important to remember
that retrospective studies which compare
delivery outcomes from one gestation
period to another do not provide direct
evidence that implementing a policy limit-
ing early elective deliveries will result in
those women having the same outcomes
as the women who delivered later. Women
who remain pregnant are at risk for spon-
taneous labor, preeclampsia, and other con-
ditions which would cause them to become
indicated deliveries. For this reason, we will
explore the fetal implications of elective
delivery by presenting data (from weakest
to strongest) beginning with retrospective
cohort studies, then moving to studies of
pre-post implementation of guidelines. In
addition, many fetal outcomes often reflect
the gestational age of delivery rather than
their indication for being delivered. For
this reason many of the concepts explored
will be discussed in the context
of the gestational age at delivery. Finally,
it has long been known that outcomes
vary by race and where possible we will
explore the implications on race and elec-
tive delivery.
Respiratory Outcomes
Respiratory outcomes are multifactorial
and are often a reflection of gestational
age. We have chosen to divide them into
acute needs for resuscitation, pulmonary
immaturity, and meconium aspiration.
ACUTE RESUSCITATION
Few studies have been chosen to look at
the acute need for resuscitation related to
elective delivery. Zanardo and colleagues
chose to look at 1284 women in the setting
of elective cesarean delivery compared
with women who delivered vaginally.
They found that neonates delivered to
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women who underwent elective cesarean
were more likely to require positive
pressure ventilation during acute resusci-
tation, assuming that they were <39
weeks. After 39 weeks, no differences
between the 2 groups were noted.6 Like-
wise, oxygen requirement at delivery was
examined in a small, retrospective study
from Rochester, NY including 831
patients. Vardo et al7 discovered in-
creased oxygen use at delivery when
patients underwent an elective induction
of labor at term [odds ratio (OR), 1.95;
95% confidence interval (CI), 1.3-2.93].
Although these studies suggest that acute
resuscitation is worsened by elective de-
livery regardless of whether it is vaginal
or cesarean, the meaningfulness of this
outcome is subject to question.
Immaturity/Need for
Respiratory Support
One of the serious morbidities associated
with premature birth is related to respira-
tory problems due to fetal lung immatur-
ity. Fetal lung development occurs during
the third trimester and complications
from fetal lung immaturity decrease dur-
ing this period. Although full term has
been defined as between 37 0/7 and 41/6/7
weeks, there appear to be differences in
respiratory complications at birth during
these gestational ages.
Tita and colleagues examined outcomes
of 24,077 term elective cesarean deliveries in
the Maternal-Fetal Medicine Units Net-
work from 1999 to 2002. Adverse respira-
tory outcomes were studied as a composite
and individually and included respiratory
distress syndrome (RDS) and transient ta-
chypnea of the newborn (TTN). There was a
significant decrease in the composite out-
come with increasing gestational age up to
40 weeks for patients with an elective cesar-
ean delivery at term. After 40 weeks there
was an increase in the percentage of infants
experiencing the composite respiratory
 Fetal Outcomes of Elective Delivery 403

FIGURE 1. Respiratory morbidities by gestational week. Adjusted odds ratio by week of delivery
(39 to 40 wk). Adapted from Consortium on Safe Labor et al.3 Adaptations are themselves works
protected by copyright. So in order to publish this adaptation, authorization must be obtained
both from the owner of the copyright in the original work and from the owner of copyright in the
translation or adaptation.

outcome. Similarly, the individual outcomes
showed a significant decrease in incidence
with increasing gestational age. TTN
showed a decreased incidence up to 40
weeks’ gestation and RDS until 41 weeks’
gestation.1 This would reinforce the ACOG
policy recommending performing elective
cesarean deliveries at 39 weeks or later.
The Consortium of Safe Labor likewise
examined respiratory outcomes among
233,844 women who were delivered both
vaginally and by cesarean.3 This study
looked at morbidities including use of
surfactant, pneumonia, and mechanical ven-
tilation by gestational age. The results of
these outcomes are displayed in Figure 1. As
one can clearly see, the incidence of respira-
tory morbidities was lowest among neonates
born at 39 to 40 weeks, whereas those born
at 37 weeks had the highest rates of respira-
tory morbidity.
Interestingly, using the same data set,
Bailit and colleagues undertook a more
complex analysis comparing neonatal
outcomes between women who under-
went elective labor delivery. After strat-
ifying for gestational weeks, women who
had an induction of labor had lower rates
of need for assisted ventilation compared
with women who underwent spontaneous
labor, had an indicated delivery, or under-
went planned cesarean delivery. Nonethe-
less, the impact of elective induction had
the lowest rate of ventilator use at 39
weeks’ gestation. Gestational age had a
more important impact on the rate of
ventilator use than type of labor onset.
Not surprisingly, these respiratory meas-
ures correlated strongly with need for
neonatal intensive care unit (NICU) ad-
mission; which was lowest among moth-
ers who were electively induced at 39
weeks.8 This would suggest that a policy
of elective induction would provide some
neonatal benefit assuming it is done at
39 weeks or beyond.
The aforementioned studies are all ret-
rospective examinations of neonatal out-
comes and come with inherent flaws and
biases in study design despite their large
sample size. Other authors have examined
the neonatal effects following the imple-
mentation of guidelines limiting elective
induction of labor before 39 weeks’ gesta-
tion. Oshiro and colleagues examined the
effects of such a policy in an integrated
health care system in Utah and Idaho
which included a total of 28,150 women.

www.clinicalobgyn.com
404 Hoffman et al
Data were collected before the implemen-
tation of this policy (N = 11,813) through
6 years after implementation (N =
16,337). Although successful in decreasing
the rates of early-term births (37 to 38 wk),
neonatal RDS and ventilator usage did
not change after implementation of their
no elective induction of labor policy.2
It is interesting to note that several
other large studies have detailed success-
ful implementation of guidelines, none
have commented on the change in need
for respiratory support that resulted from
these policy changes.9–14
RACIAL DIFFERENCES IN
PULMONARY IMMATURITY
Racial differences in obstetrical outcome
have long been documented.15 Several
investigations have suggested that certain
ethnic groups have accelerated pulmo-
nary maturity.16 As such the applicability
of guidelines forbidding ‘‘early-term’’ de-
livery may not be relevant to all ethnic
groups. Recently Vilchez and colleagues
examined the impact of being Hispanic on
the rate of several respiratory outcomes
following elective repeat cesarean deliv-
ery. In a large cohort of women identified
through an administrative data set
(N = 930,421), this group was unable to
identify any difference in the rate of as-
sisted ventilation or surfactant use at 38
or 39 weeks compared with women who
were delivered at 40 weeks.17
Meconium Aspiration
Meconium aspiration remains a serious
but uncommon complication with a prev-
alence of 0.067%.18 Meconium aspiration
is generally believed to be increased by
prolongation of pregnancy. On the basis
this assumption, one would presuppose
that elective induction would decrease the
rate of meconium aspiration. In a large
population-based study by Fischer et al,18
they found the incidence of meconium
aspiration syndrome dramatically
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increased at 40 weeks and beyond but
was similar between 37 and 39 weeks.
Two studies have examined the role of
elective delivery in preventing meconium
aspiration. In a study of 2886 women who
were electively induced compared with
9648 women who spontaneously labored,
Dublin et al19 noted no difference in the
rate of meconium aspiration. In contrast,
Oshiro et al2 in his larger assessment of the
impact of a policy limiting elective deliv-
ery documented a significant decrease in
meconium aspiration after the implemen-
tation of their policy. Although counter to
traditional thinking, this evidence would
suggest that women who are not electively
delivered are less likely to have meconium
aspiration.
Summary
The data on fetal lung immaturity after
elective induction of labor at term is var-
ied. Nonetheless it can be summated by
saying that gestational age is the most
important predictor of respiratory mor-
bidity with general consensus that the
lowest risk of pulmonary immaturity oc-
curs at or beyond 39 completed weeks.
Nonetheless, a single study with large
numbers (N = 28,150) has failed to dem-
onstrate improvement in either the rate of
RDS or ventilator use.2 To truly under-
stand the impact of this change in policy,
further documentation of the impact this
policy change on this important outcome
should be a major focus of ongoing re-
search and must account for the potential
of racial differences.
NICU Admission
Admission to a NICU is predominantly
related to respiratory outcomes but can
also be the result of a number of other
indications including: low birth weight,
hypoglycemia, sepsis, thermoregulation
among other indications. From a public
policy standpoint, NICU admission

remains a significant source of cost and
therefore policies that result in lower rates
of NICU admission can have a profound
impact of hospital costs. NICU admis-
sions are known to be higher with prema-
ture deliveries but have also been shown
to be increased with early-term deliveries
(37 to 38 wk gestation).
Various retrospective cohort studies
have examined NICU admissions for
elective deliveries at term. Hoffmire and
colleagues examined 1577 deliveries in
Upstate New York. Their data included
births between 36 0/7 and 38 6/7 weeks’
gestation. They found that electively de-
livered infants were 46% more likely to
require NICU admission. When stratified
by week the adjusted relative risk (RR)
was highest for 36-week deliveries (RR,
2.24; 95% CI, 1.72-2.91) but remained
elevated at 37 weeks (RR, 1.39; 95% CI,
1.07-1.79). In addition, the increased NI-
CU admission rates were noted in both
elective cesarean and vaginal deliveries,
with the former carrying a great risk of
NICU admission.20 A like retrospective
study from Brussels looked at 7683 elec-
tive inductions matched to 7683 patients
in spontaneous labor between 38 0/7 and
41 0/7 weeks’ gestation. This investigation
found an increased risk of NICU admis-
sion in the electively induced group during
the first 48 hours of life (RR, 1.14; CI
1.03-1.25). Reasons for admission to NI-
CU were cited as respiratory problems,
suspicion of perinatal infection, and hy-
perbilirubinemia. Cesarean delivery was
also cited as a reason for NICU admission
and occurred more frequently in the elec-
tively induced cohort.21
Using a large data set of obstetrical
units in Scotland from 1981 to 2007, Stock
and colleagues examined the impact of
elective induction among 1,271,549 wom-
en. This group found that elective induc-
tion resulted in a higher rate of neonatal
admission to a NICU or special care
nursery for all gestational weeks before
41 weeks. They calculated that 1 neonate
Fetal Outcomes of Elective Delivery 405
would require NICU admission per 131
women who were electively induced.22
Once again studies documenting the
impact of policy changes of limiting elec-
tive deliveries on NICU admission are
limited. Clark and colleagues examined
3 different strategies to alter physician
behavior in 27 different hospitals relative
to elective induction and investigated the
impact of these policy changes on the rate
of NICU admission. The 3 strategies ex-
amined were physician education, peer
review, and a hard-stop policy; which
was the most effective in reducing the rate
of elective preterm delivery. This group
also found that the rate of term NICU
admission declined from 8.9% to 7.5%
(P<0.01).11 Ehrenthal and colleagues
likewise examined the change in NICU
admission rate following their implemen-
tation of a hard-stop policy. This group
likewise identified a significant decrease
in the rate of term NICU admission
(9.29% prepolicy vs. 8.55% postpolicy,
P = 0.044).9 They also chose to examine
if there were influences of race on this
important outcome. Following the imple-
mentation of a no elective delivery policy
before 39 weeks, there was a statistically
significant reduction of NICU admission
among white women (OR, 0.89; 95% CI,
0.79-1.00) but there were no differences
among African Americans (OR, 0.97;
95% CI, 0.82-1.16) or Hispanics (OR,
0.90; 95% CI, 0.70-1.16).9 Whether the
failure to find differences in these 2 groups
of women represents racial/ethnic varia-
tions, insufficient numbers of patients in
these categories or different groups of
care providers for these groups remains
unclear.
COMPOSITE MORBIDITY AND
MORTALITY
Recognizing that different morbidities
may be competing (eg, respiratory imma-
turity vs. macrosomia), 2 recent studies
chose to look at a composite outcome.
Chiossi and colleagues in a secondary
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406 Hoffman et al
analysis of a prospective registry collected
by the Maternal-Fetal Medicine Units
examined a neonatal composite of RDS,
TTN, NEC (necrotizing enterocoloitis),
sepsis, ventilation, seizures, hypoxic is-
chemic encephalopathy, NICU admis-
sion, 5-minute Apgar <4, or death.
They found that neonatal outcomes were
optimized by a strategy of elective deliv-
ery at 39 to 40 weeks.23 Another research
group chose to examine a composite out-
come using antepartum stillbirth/neona-
tal death, neonatal morbidity, NICU
admission, meconium aspiration, NEC,
RDS, or IVH in a national cohort from
the Netherlands (N = 985,321). This
group chose an at-risk approach and ex-
amined 3 separate ethnic groups (whites,
Mediterranean, and Africans). As anti-
cipated, this group found that Africans
had poorer outcomes across the gesta-
tional continuums examined. Nonethe-
less, when they examined the gestational
age at which their outcomes were opti-
mized as a function of their composite
morbidity, they found that for both
whites and Mediterraneans it was at 39
weeks, whereas for Africans it was at 38
weeks.24 This would once again reinforce
the concept that racial/ethnic differences
may play an important role in defining
the optimal gestational age at which to
be born.
MACROSOMIA AND SHOULDER
DYSTOCIA
Birth weight has long been felt to be a
function of gestational age and a common
reason why care providers have chosen to
electively shorten the course of pregnancy,
despite the fact that convincing data to
support this practice is absent.25 Although
numerous consequences of excessive fetal
growth (macrosomia) exist, shoulder dysto-
cia is one of the more consequential out-
comes. Ehrenthal and colleagues examined
the rate of macrosomia following imple-
mentation of a policy limiting elective in-
ductions. This group found no difference in
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the mean birth weight during the 2 time
periods. Although neonates weighing
>4000 g or >4500 g were more common,
following the implementation of such a
policy this was not statistically significant
(P = 0.22 and P = 0.65, respectively).9
Oshiro and colleagues likewise examined
this outcome in their cohort. Similarly they
found no difference in the rate of macro-
somia (10.9% preimplementation vs. 10.6%
postimplementation, P = NS).2
Few studies have been powered to or
have adequate data to examine the issue of
shoulder dystocia given its rare occur-
rence.26 In one of largest studies to examine
this question, Stock and colleagues exam-
ined the rate of shoulder dystocia among
women who spontaneously labored com-
pared with those who were electively deliv-
ered in a cohort of 1,271,549 women.
Contrary to what would be anticipated, they
found the rate of shoulder dystocia was
actually increased by elective induction of
labor (OR, 1.28; P<0.001); however, due to
the rarity of this clinical event they were
unable to further segment this by gestational
age.22 Although a sole study, this investiga-
tion strongly argues against the notion that
shoulder dystocia can be prevented through
elective induction.
STILLBIRTH
At term the rate of stillbirth is low, but it
rises continuously as pregnancy proceeds
and most rapidly after 41 weeks of com-
pleted gestation (Fig. 2).27,28 Understand-
ing the stillbirth risk associated with
continued pregnancy, balanced with the
neonatal risks of an earlier delivery, is a
challenge. Nearly all evidence available is
retrospective and observational. Expect-
ant management of pregnancy is recom-
mended when observational data suggest
that the risks to the neonate outweigh
the very small risk of stillbirth. More
recently, changes in obstetrical practice
have enabled the evaluation of the
outcomes of an elective delivery on a
population level. In this section, we will
 Fetal Outcomes of Elective Delivery 407

FIGURE 2. Prospective fetal mortality rate by single weeks of gestation: United States, 2005
Source: National vital statistics system, NCHS/CDC. The prospective fetal mortality rate is the
number of fetal deaths at a given gestational age per 1000 live births at that gestational age or
greater. Source: National vital statistics system, NCHS/CDC.

explore what is known about the balance Measuring Stillbirth Risk

of risk and benefit associated with induc-
tion of labor at term as it relates to under-
standing the risk of stillbirth, the primary
driver of what has been deemed to be
‘‘indicated’’ deliveries.
More than a decade ago, Smith conducted
a life-table analysis estimating the cumu-
lative risk of perinatal death associated
with delivery by gestational age after 37
weeks. Prior analyses had considered

FIGURE 3. Rate of infant death, stillbirth, and total perinatal death at each completed gestational
week at term. From Rosenstein et al.28 Adaptations are themselves works protected by copyright. So
in order to publish this adaptation, authorization must be obtained both from the owner of the
copyright in the original work and from the owner of copyright in the translation or adaptation.

www.clinicalobgyn.com
408 Hoffman et al
stillbirths as the numerator and live births
at that gestational age as the denomina-
tor, exaggerating the risk stillbirth risk at
the earliest gestational ages and under-
estimating the risk during late-term and
post-term periods. His approach used the
currently accepted practice of considering
stillbirths per ongoing pregnancy and
showed the conditional and cumulative
risks of stillbirth associated with increas-
ing gestational age for a population.
These estimated probabilities suggested
a nadir in total perinatal mortality be-
tween 39 and 42 weeks.29 Similar results
were obtained when an analysis of more
recent data from California were con-
ducted (Fig. 3) by Rosenstein et al.28
Stillbirth Risk Related to Characteristics
of the Mother and Neonate
Certain characteristics of the mother and
fetus are associated with a significantly
greater likelihood of stillbirth at term. For
some, pregnancy outcomes may be im-
proved by ensuring a delivery before the
onset of spontaneous labor. Current ACOG
recommendations for medically indicated
TABLE 1. Recommendations for Timing of Delivery for Women With Hypertension and
Diabetes
Issue
Hypertensive disorders
Chronic hypertension (no medications)
On no medications
Controlled on medications
Poorly controlled on medications
Gestational hypertension
Preeclampsia, severe
Preeclampsia, mild
Diabetes
Antenatal DM, well controlled
Antenatal DM, with vascular disease
Antenatal DM, poorly controlled
GDM well controlled in diet or meds
GDM, poorly controlled
*Level A recommendation is based on good and consistent scientific evidence; level B on limited or inconsistent scientific
evidence; and level C on consensus or expert opinion.
Adapted from Spong et al.31 Adaptations are themselves works protected by copyright. So in order to publish this adaptation,
authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the
translation or adaptation.
DM indicates diabetes mellitus; GDM; gestational diabetes mellitus.
www.clinicalobgyn.com
induction of labor are based on evidence-
based recommendations or expert opinion
when evidence is lacking.5 It is noted that
there is variance in the guidelines regarding
labor induction from the ACOG, Society of
Obstetricians and Gynecologists of Canada,
and the Royal College of Obstetricians and
Gynaecologists, and the Royal Australian
and New Zealand College of Obstetricians
and Gynecologists.30 Such differences reflect
that overwhelming evidence on best appro-
aches to manage such instances does not exist.
Recently, more detailed guidance about
specific timing of delivery was provided by
an expert panel convened by the Eunice K.
Shriver National Institute for Child Health
and Human Development for placental,
uterine, fetal, and maternal issues based on
a synthesis of the available evidence.31 The
panel considered the risks and benefits of
early delivery by indication, attempting to
optimize the combined outcomes for the
mothers and offspring, but did not intend
to define standard of care. For some indi-
cations, there was broad leeway in the rec-
ommended gestational age at delivery, as
can be observed in Table 1. This is consistent
Gestational Age for Delivery (wk) Grade of Recommendation*
38-39 B
38-39 B
37-39 B
36-37 B
37-38 B
At diagnosis C
37 B
No early delivery B
37-39 B
34-39 B
No early delivery B
34-39 B

with their overriding recommendation to
consider individual patient factors including
comorbidities, patient preference, and insti-
tutional setting. Two common indications
for induction were not addressed by the
committee: post-dates pregnancy and man-
agement of women with advanced maternal
age. In the absence of a compelling indica-
tion to deliver, timing of these deliveries to
optimize outcome based on risk and benefit
is an area of active investigation.
Post-dates Pregnancy
One of the most common indications for
delivery to reduce stillbirth includes in-
duction when a pregnancy has completed
41 weeks of gestation. As discussed above,
observational data show consistently
that the risk of stillbirth rises with gestational
age.27–29 A recent analysis of administrative
data from California demonstrated once
again that rate of stillbirth per 10,000 on-
going pregnancies rises with each completed
week of gestation after 37 weeks, with the
greatest deflection occurring after 41 weeks
as can be seen in Figure 3.28
There have been a small number of
randomized controlled trials of induction
versus expectant management for women
who had completed 41 weeks, but none
were adequately powered to see small dif-
ferences in perinatal outcomes including
stillbirth. When systematically reviewed,
the evidence to support intervention with
induction or labor is mixed. In their 2009
systematic review, Wennerholm et al32
found no evidence to support induction
for post-dates. In contrast, the 2012 sys-
tematic review by Gülmezoglu et al33 of
trials of expectant management compared
with induction at 41 weeks for the
Cochrane Collaboration, found induction
for women who are post-term was associ-
ated with fewer perinatal deaths, but did
not observe any change in the rate of
stillbirth. Differences in the results of the
2 meta-analyses appeared to be due to
differences in the studies included. The
Wennerholm systematic review included
Fetal Outcomes of Elective Delivery 409
13 randomized controlled trials for a total
of 3119 in the labor induction group and
3097 in the expectant management group,
for a total of 6216 pregnancies. The RR of
perinatal death in the induced group was
0.33 (0.10, 1.09) when compared with ex-
pectant management. The Gülmezoglu
meta-analysis included an additional 4 tri-
als, bringing the total population studied to
7407. The RR was 0.31 (0.12, 0.81) reached
statistical significance for the larger meta-
analysis. Regardless, even if induction is
truly protective, 507 inductions would need
to be performed at 41 and 0 weeks to
prevent 1 stillbirth.34
Population-Level Outcomes
Outcomes after the implementation of
changes in obstetrical policy provide an
opportunity to learn more about the im-
pact of elective induction of labor on
stillbirth risk on a population level by
examining rates before and after. Sue-A-
Quan and colleagues investigated out-
comes related to the use of elective induc-
tion of labor of pregnancies 41 or more
completed weeks of gestation across
Canada. Over the nearly 20 years exam-
ined they documented a change in the
gestational age distribution of births
across the country reflecting a fall in the
percentage of total births delivered at 41
and 42 weeks’ gestation. This was associ-
ated with a change in induction practice.
Over that period, rates of stillbirth at 41 or
more weeks also decreased from 2.8 per
1000 total births in 1980 to 0.9 per 1000
total births in 1995.35 These findings sug-
gest that a policy of increasing induction
at 41 weeks and beyond decreased the rate
of still birth on a population level.
Implications of Preventing
Elective Induction in Regards
to Still Birth
Several institutions, care systems, and
states have reported success at shifting
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410 Hoffman et al
FIGURE 4. Postnatal mortality per 1000 births.
the timing of elective delivery after imple-
mentation of practice guidelines eliminat-
ing elective delivery before 39 completed
weeks.2,9,11–14 Only a few of these in-
cluded stillbirth as an outcome. All were
conducted in the United States.
Oshiro et al2 examined stillbirth before
and after implementation of a policy restrict-
ing elective delivery before 39 weeks across a
large integrated health care system. There
was a significant decline in elective deliveries
earlier than 39 weeks of completed gestation,
and a decrease in overall stillbirth rate at
term from 0.09 to 0.03 per 10,000. This
decrease was evident only in the 37 and 38
weeks’ groups. However, stillbirth rate was
calculated as events per deliveries at that
gestational age, rather than using events
per ongoing pregnancy.
Clark and colleagues studied the result
of implementation of the ‘‘39-week rule’’
across 27 birth hospitals in the United
States. There was heterogeneity in the
impact of the initiative on elective induc-
tions attributed to the stringency of the
policy approach at each institution. Over-
all, there was a decrease in elective deliv-
eries before 39 weeks. They found an
absolute increase in the rate of stillbirth
[1522 stillbirths/222,084 (0.69%) before
and 1497/211,467 (0.71%) after] which
was not statistically significant.11
The study of outcomes at a single in-
stitution by Ehrenthal and colleagues also
demonstrated a significant change in the
gestational age and birth weight distribu-
tions after the implementation of the
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policy. Although there was a small decline
in admissions to the NICU, a small in-
crease in stillbirth rate, primarily before
39 weeks, was observed.9
SIDS AND POSTNATAL DEATH
Although concerns about stillbirth have
been made to argue in support of elective
delivery, it is important that these be
weighted with the risk of postnatal death.
Studies of postnatal death have histori-
cally been confounded by birth defects.
Recently Altman et al36 examined the
impact of gestational age between 37
and 41 weeks on postnatal death in a large
Swedish population of 2,152,738 non-
anomalous newborns. The authors in fact
found that postnatal death was lowest
among children who were born at 40
weeks after adjusting for a number of
confounders. It is important to note that
the rate of postnatal death increased with
every week of <40 weeks (Fig. 4). The
majority of this increase was due to SIDS
deaths which represented 39% of the
postnatal deaths.
Reddy and colleagues in an examination
of the 2001 US Birth Cohort Linked birth/
death file likewise examined the effect of
gestational age on infant and neonatal mor-
tality. Compared with 39 weeks this group
found that both neonatal and infant mortal-
ity were statistically increased from 34 weeks
through 38.37 Not surprisingly, gestational
age was negatively correlated with mortality
consistently.
 Fetal Outcomes of Elective Delivery 411

TABLE 2. Incidence of Perinatal Morality unexplored. Recently, Boyle et al39 chose

Between Elective IOL Versus to examine the impact of gestational age at
Expectant Management delivery on health outcomes (defined as
Elective Expectant aOR being hospitalized >3 times by age 5) in a
IOL (%) P (95% CI) longitudinal cohort of 18,818 newborns.
Similar to other authors, Boyle and col-
37 0.06 0.18 NS 0.37 (0.5-2.70)
38 0.02 0.16 0.02 0.15 (0.02-1.05) leagues found high rates of hospitalization
39 0.05 0.16 0.02 0.36 (0.13-0.96) in children who were born prematurely
40 0.07 0.17 0.02 0.33 (0.13-0.82) compared with children who were born at
term. Interestingly, children who were born
aOR indicates adjusted odds ratio; CI, confidence interval;
IOL, induction of labor. in the early-term period (37 to 38 wk) were
also more likely to have >3 hospitalizations
PERINATAL MORTALITY compared with children who were born at
39 to 41 weeks (aOR, 1.9; 95% CI, 1.3-2.9).
Rather than focusing solely on stillbirth, This would once again suggest that limiting
several authors have chosen to focus on elective delivery before 39 weeks may pro-
perinatal mortality as an attempt to assess vide additional benefit.
the cumulative impact of neonatal deaths
and stillbirths. Stock and colleagues chose
to examine the impact of perinatal mor-
tality by examining a large Scottish cohort
(N = 1,271,549 births). This study used Learning Issues in the Newborn
an at-risk model. They found that women Child
who underwent elective induction were Neurodevelopment is a complex process
less likely to suffer a perinatal loss at all that occurs begins in pregnancy. When
gestational weeks (37 to 41 wk) compared examining the impact of early elective
with women who underwent expectant delivery on cognition, one can examine a
management.22 Nonetheless, it should be number of different approaches: anatom-
mentioned that they calculated that 1040 ic/embryologic considerations, IQ scores,
women would need to be induced to pre- motor issues, and behavioral/learning is-
vent 1 perinatal loss. This study did not sues. To date these studies have only been
address the risk of inductions to the observational correlating gestational ages
mother. with outcomes. Moreover, data showing
Darney and colleagues, in a like exer- that limiting elective delivery improves
cise, investigated the impact of elective outcomes in these domains postnatally
induction of labor on perinatal mortality are absent. Nonetheless, the available evi-
in a large cohort of women who delivered dence does paint a cohesive picture of the
in California in 2006. This group found impact of gestational age on cognition.
that perinatal mortality was reduced at all For example, anatomic studies have dem-
gestational ages between 38 and 40 weeks onstrated that significant neurological
(Table 2).38 changes including volume, gyrification,
and other histologic changes occur
CHRONIC MEDICAL CONDITIONS IN throughout the third trimester of preg-
THE NEWBORN nancy.40 These studies provide biological
Premature birth has long been noted to be plausibility that early delivery may affect
associated with the development of chronic neurological development. Nonetheless,
medical conditions, in particular respiratory direct evidence that these pathways are
complications. The role of delivery in the altered through the process of elective
early-term birth period has been largely birth is absent.

www.clinicalobgyn.com
412 Hoffman et al
Direct evidence linking gestational age
at delivery and cognition does exist. In a
study of 13,824 children, Yang et al41
examined the mean IQ score at an average
of 6.5 years and found that after adjusting
for a number of confounders, that the
highest IQ score peaked at 40 weeks’
gestation. Although statistically different,
it should be noted that the absolute differ-
ences were relatively small. For example,
the mean IQ at 37 weeks was 104 com-
pared with 106 at 40 weeks. A like result
was found by Rose and colleagues, who
prospectively examined a cohort of 1562
infants born between 37 and 41 weeks
using the Bayley Scales of Infant Develop-
ment. They found that for each week of
gestation children gained 0.8 points on the
Bayley Mental Development Index (an
early assessment of development with a
mean of 10 typically) and 1.4 points for
Psychomotor Development.42 The impact
of gestational age on executive function
has likewise been examined. Phua et al43
examined a cohort of 195 six-year-old
boys and found that gestational age pos-
itively correlated with better scores on
stop-signal tests (a marker correlated with
attention deficit hyperactivity disorder).
From a motor prospective, Moster et al44
examined the National Health Insurance
Registry examined outcomes of 1,682,441
children and linked gestational age at
delivery along with the prevalence of cer-
ebral palsy. Again, a U-shaped curve
emerged with the lowest incidence of cer-
ebral palsy occurring at 40 weeks’ gesta-
tion. Although the RR was 2.3 times
higher among babies delivered at 37
weeks and 1.5 times at 38 weeks, the
attributable risk was relatively small
(1.3/1000 at 37 wk and 0.5/1000 at
38 wk). Although these data tell a consis-
tent story they represent associations
rather than proof of causation; however,
in the absence of compelling data they do
suggest that neurodevelopment outcomes
may be impacted by early elective deliv-
ery, although the overall impact is small.
www.clinicalobgyn.com
Summary
When taken in aggregate, the available
evidence suggests that for most newborns
a policy of limiting elective delivery before
39 weeks appears to provide benefit in
most areas that we chose to examine.
Suggested benefits include lower risk of
pulmonary immaturity, NICU admis-
sion, postnatal death (including SIDS),
and learning benefits. Reasons commonly
cited for inducing women such as preven-
tion of macrosomia and shoulder dystocia
do not appear to be supported by the
limited available literature. Stillbirth re-
mains a controversial area with studies
suggesting that elective induction may
lower the risk of this occurring, although
these studies are inconsistent and the risk
appears to be small. Whether these risks
are outweighed by the risk of SIDS re-
mains unclear. Further studies clearly
documenting implementing guidelines
limiting elective delivery before 39 weeks
should be undertaken so clinicians, pa-
tients, and policy makers can truly under-
stand the risks and benefits that will
accrue from such policy changes.
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