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GoThe Full 40Weeks of Pregnancy

Go The Full 40 promotes AWHONNs Healthy Childbirth Initiative goals:

All women are informed and supported. All women receive care that facilitates the physiologic processes of labor and birth. All women receive medications and interventions only as medically indicated.

Introduction

Dont Rush MeThe Case for

Spontaneous Labor

Implementation Checklist

Graphics

CalendarSocial Media

40 Reasons to Go The Full 40

Handouts (English & Spanish)

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Introducing Go The Full 40

AWHONN Recommends Healthcare Providers &

Childbearing Women Wait for Labor When All Is Well

In 2012, AWHONN first launched its public health campaign Dont Rush Me Go the Full 40 in support of spontaneous labor and normal birth, by encouraging pregnant mothers to wait until labor begins spontaneously around 40 weeks. While birthing ones baby early may seem tempting, especially in the final weeks of pregnancy, its not without risks. AWHONNs consumer website Health4Mom.org and magazine Healthy Mom&Baby offer a number of resources that help women understand the importance of waiting for labor to start on its own when all else is healthy and well. In this toolkit of resources, youll find all you need to implement Go The Full 40, including handouts, ways to share the campaign, sample social media posts, and more.

AWHONN strongly recommends that women with healthy pregnancies wait for spontaneous labor to begin and progress on its own. This recommendation is based on research that shows that both moms and babies benefit from a full 40 weeks of gestation. Spontaneous labor triggers hormones that provide natural pain relief, increase mother-baby attachment after birth, enhance breastfeeding, and clear fetal lung fluid. Full-term babies are more alert and ready to breastfeed, cry less, sleep longer, and have bigger brains and improved weight gain.

As elective interventions that influence the timing of labor and birth are increasingly more common in the United States, the healthcare community needs to be educated about the risks and potential cascade of medical issues that can be caused by inducing labor or scheduling a cesarean birth without a medical need. Additionally, both healthcare providers and the women and infants for whom they provide care need to understand fully the many physiological benefits of spontaneous labor and normal birth for both mom and baby. Sharing that knowledge with women will empower them to make evidence-based decisions about their health and their pregnancies.

Please join AWHONNs efforts to encourage women to wait for labor. After all, nobody likes to be rushedespecially babies!

Lynn Erdman, MN, RN, FAAN

AWHONN CEO

Questions about how you can get involved? Carolyn Cockey | Director of Publications & Go The Full 40 Program Manager | AWHONN [email protected] | 877.377.5326

Summer Hunt | Editorial Coordinator | AWHONN [email protected] | 202.261.2428

http://www.awhonn.orghttp://www.health4mom.org/http://www.gothefull40.com/http://www.facebook.com/gothefull40mailto:[email protected]:[email protected]


Dont Rush Me . . . Go the Full 40 is a grassroots, public health campaign from the 25,000+ members of AWHONN that educates women about the physiologic benefits of full-term pregnancy for themselves and their babies. The campaign flows from a holistic nursing philosophy as 40 serious and fun reasons that relay actionable, evidence-based health advice for collaborative decision-making between women and their health care providers.

We had already worked through the 39-week hurdle and we were still trying to reduce our cesarean rate. This just wasnt possible if we were inducing before 40 weeks. This campaign was really where we needed to be and what our providers and patients needed.

Nurse

The new definition of 6 cm being active labor and the positive messages of Go The Full 40 are changing culture.

Nurse

My patients are seeing the posters and reading the 40 Reasons handout. This campaign is creating conversations about all that is happening in the last weeks of pregnancy, including when its appropriate or not to intervene.

Physician



For most women, spontaneous, natural labor and birth are the healthiest and safest ways for baby to emerge and for mom to end pregnancy and start breastfeeding.

Unless medically necessary, research shows inductions and cesarean surgery lead to more intensive care days, higher re-admission rates, and increase moms and babys risks for lifelong health consequences, including abdominal adhesions, hysterectomy, respiratory illnesses, and associated health risks from lower rates of breastfeeding.

Inducing labor is associated with iatrogenic prematurity (particularly late preterm infants), cesarean surgery, hemorrhage, longer lengths of stay for women and newborns, higher rates of NICU admissions, and infection.

Babies born before 37 completed weeks of gestation are at higher risk for serious complications including dying in the first year of life as compared with term infants. These risks include breathing & feeding problems, jaundice, low blood sugar and problems stabilizing their own body temperature.

Even babies born after 37 weeks and before 39 completed weeks early term babiesare at increased risks of dying in the first year of life, feeding and breathing problems and life-long learning disabilities. Experts agree the risks are greater for infants with elective induction of labor.

The normal length of human gestation is 40 weeks. The neonatal risks vary among all gestational ages. Evidence shows the best neonatal outcomes occur at 40 weeks. In 2000, the largest percent of singleton births in the U.S. occurred at 40 to 41 weeks. By 2009, the largest percent had shifted to occurring at 39 weeks.

Overuse of inductions increases both short- and long-term costs. For example, Intermountain Health Cares initiative to reduce elective inductions, regardless of gestational age, created savings of more than $50 million per year in short-term costs.

We do not fully understand what triggers a womans labor. Obstetric textbooks say the exact mechanisms that start labor are yet to be clearly defined but that baby's readiness for birthlet baby pick her own birthday (reason #16)and the biochemical and neurohormonal interactions between mom, baby and placenta are essential triggers.

Research shows when women receive education regarding

the risks of elective induction most women will not choose

an elective induction.



Implementation Checklist

Share Go The Full 40

Hang posters in exam rooms and triage area, on bathroom doors & in elevators Provide posters & handouts to hospitals, OB/GYN offices, public health clinics Discuss with perinatal quality improvement team Give 40 Reasons to Go The Full 40 article to patients Discuss reasons to wait for spontaneous labor with patients Share AWHONNs Healthy Mom&Baby magazine Broadcast on facilitys closed-loop TV Post on facilitys social media Dress a mannequin up like the pregnant woman in the Go The Full 40 ad for

use at health fairs and other events

Distribute 40 Reasons handouts at 6 key patient intersections

OB/GYN officesnew patient packs, 28-week visit Hospital tour/registration packs Hospital/clinic-based health fairs Childbirth education & breastfeeding classes OB Triage Labor & delivery units

Hang posters at these locations

OB triage areas Exam rooms Backs of bathroom doors In elevators Emergency department Labor & delivery units

Questions to Ask Moms

Why do you want to schedule aninduction or have a planned, electivecesarean?

Are you aware of the many benefits ofspontaneous labor and normal birthfor you and your baby?

Download posters and 40 Reasons handouts in English & Spanish at:

Health4Mom.org/nurses-resources

http://www.awhonn.orghttp://www.health4mom.org/http://www.gothefull40.com/http://www.facebook.com/gothefull40http://www.gothefull40.com/http:/www.health4mom.org/nurses-resources


G raphics to Share on Social MediaClick each image to download and share!

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Social Media Calendar Here are posts for every month of the year. Spread the word and share these posts, and this toolkit, with your hospitals marketing and communications teams. Then, be sure to like us on Facebook.com/GoTheFull40 !

Month Full 40 Posts Facebook Twitter January Folic acid awareness week

Birth defects prevention month

Thyroid awareness month

#1. End right by starting rightkeeping all of your prenatal appointments helps ensure a healthier ending.

#25. Relish in the fact that right now youre the perfect momyour healthy pregnancy habits are growing baby the best possible way.

Nurses share 40 reasons to go the full 40 weeks of pregnancy: GoTheFull40.com

Babys first 60 minutes after birth are so important; grab the Golden Hour. bit.ly/grabthegoldenhour

Waiting for labor has its definite advantagesgo the #full40! bit.ly/willyouwait4labor

February Heart health/wear red

Prenatal infection prevention month

Valentines Day

#3. Let nature take overthere are fewer complications and risks for both you and baby through normal birth.

#18. Reduce your babys risks of jaundice, low blood sugar and infection by waiting until hes ready to emerge.

Reduce your risk for unnecessary interventions by waiting till labor starts on its own. GoTheFull40.com

Nurses highlight 40 reasons for moms and babies to go the #full40 weeks: GoTheFull40.com

March National nutrition month

Poison prevention week

Trisomy awareness month

#5. Birth a brainier babyat 35 weeks your babys brain is only 2/3 the size it will be at term.

#39. Make the best-possible birth experience; dont rush it. GoTheFull40.com

Baby may face a lifetime of risks if born too early: bit.ly/whybabyneeds40weeks

During national nutrition month, learn from actress Mayim Bialik why breastmilk is the best food for your baby. bit.ly/HMBMayimBialik

Ignore people who say an induction is more convenient GoTheFull40.com #full40

At 35 weeks, your babys brain is only 2/3 the size it will be at termjust another reason to go the #full40!

April Infant immunization week

Infertility awareness week

Autism awareness month

STI awareness month

#6. Set her thermostatbaby will better regulate her temperature when born at term. GoTheFull40.com

#20. Maximize those little lungsbabies born just 2 or more weeks early can have twice the number of complications with breathing.

Avoid an induction and reap the benefits for both you and baby of a full term pregnancy when all is healthy and well. Full-term babies are less likely to have complications breathing than those born early. GoTheFull40.com

As nurses promote skin-to-skin contact, more born-too-early babies thrive GoTheFull40.com #full40

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May National Nurses Week

Preeclampsia Awareness Month

Mental health month

Mothers Day

#17. Skip an inductionwhich could lead to cesareanby waiting for labor to start on its own. #14. Eat healthfullybut its ok to indulge occasional cravings without remorse. GoTheFull40.com

Want the best care? Find a baby friendly birthplace. bit.ly/findbabyfriendly Happy Mothers Day! Wait for labor to start on its ownbabies are so much easier to care for in the womb when all is healthy and well. GoTheFull40.com

Preterm birth is any birth that occurs before the 37th week of pregnancy. bit.ly/whatisfullterm #full40

June Mens health week

Aphasia awareness month

Fathers Day

#21. Ignore people who say an induction is more convenient. Nothing is convenient about a longer labor and increasing your risk of cesarean. GoTheFull40.com #27. Relax! Babies are usually so much easier to care for in the womb when all is healthy and well.

Pregnant women avoid unnecessary induction when they understand the risks of induction, nursing research shows. bit.ly/termpregnancy

Unless theres a medical reason, its safer to avoid labor inductions. GoTheFull40.com #full40

July Cord blood awareness month

Group B strep awareness month

Juvenile arthritis month

#2. Savor the journeysoon you will meet your baby. GoTheFull40.com #19. Build your babys musclestheyll be strong and firm, and ready to help him feed and flex at term.

Nurses share 40 reasons to go the full 40 weeks of pregnancy: GoTheFull40.com @Health4Mom

40 Reasons to Go The #full40 weeks: GoTheFull40.com

Declare your babys independencelet her pick her own birthday! #full40

August World breastfeeding week

Breastfeeding month

Childrens eye health month

#7. Boost breastfeedingterm babies more effectively suck and swallow than babies born earlier. GoTheFull40.com #10. Nourish your bodya healthy diet and breastfeeding will help you lose the baby weight

Breastmilk: natures superfood. Give your baby the best chance with the breastterm babies are able to suck and swallow more effectively than those born earlier. bit.ly/babys1stfood

Plan to breastfeed your baby in the first hour after birth GoTheFull40.com #full40

September Womens/family health day

Infant mortality awareness

Ovarian cancer month

#22. Respond to requests to speed babys birth with the facts that inductions often create more painful labors and can lead to cesarean surgery. GoTheFull40.com #29. Postpone changing the eventual 5,000+ diapers baby will use. GoTheFull40.com

So youre in laborthe best way to keep baby moving down and out is to keep your own body active. bit.ly/bestwaytolabor Healthy mama = healthy baby: Pack your meals with nutritious eats for your 40 weeks of pregnancy. GoTheFull40.com

How can YOU help more babies to be born full term? GoTheFull40.com #full40

http://www.awhonn.orghttp://www.health4mom.org/http://www.gothefull40.com/http://www.facebook.com/gothefull40http://www.gothefull40.com/http://bit.ly/findbabyfriendlyhttp://www.gothefull40.com/http://bit.ly/whatisfulltermhttp://www.gothefull40.com/http://bit.ly/termpregnancyhttp://www.gothefull40.com/http://www.gothefull40.com/http://www.gothefull40.com/http://www.gothefull40.com/http://www.gothefull40.com/http://bit.ly/babys1stfoodhttp://www.gothefull40.com/http://www.gothefull40.com/http://www.gothefull40.com/http://bit.ly/bestwaytolaborhttp://www.gothefull40.com/http://www.gothefull40.com/


October Breast cancer awareness month

Domestic violence awareness

Down syndrome awareness

#4. Recover faster from normal birth than cesarean, which is major abdominal surgery that causes more pain, requires a longer hospital stay and a longer recovery. GoTheFull40.com #32. Relish parentingright now you know exactly where baby is and what hes doing.

Breastfeeding reduces moms overall cancer risks. Learn more at GoTheFull40.com Belly bumps make the perfect prop for reading material. Settle in with the latest issue of Healthy Mom&Baby at Health4mom.org.

Babies are so much easier to care for in the womb when all is healthy & well! GoTheFull40.com #full40

November World prematurity day/month

Diabetes awareness month

GERD awareness month

#15. Give babys development the benefit of time since you may not know exactly when you got pregnant. GoTheFull40.com #16. Let baby pick her birthdayif she decides to emerge after 37 weeks theres no need to try to stop your spontaneous labor.

Babys first 24 hours after birth are so importantheres whats happening: bit.ly/meetyourbaby GoTheFull40.com Give thanks that soon you will meet your baby! bit.ly/whybabyneeds40weeks

Help more babies make it to their first birthday. bit.ly/preemies1styear #full40 #worldprematurityday Finish pregnancy wellkeep all of your prenatal appointments to help prevent prematurity. #full40

December Hand washing awareness week

Safe toys & gifts month

World AIDS day

#26. Finish wellmore time in the womb usually means less time in the hospital. GoTheFull40.com #40. Write your own healthy reasonif it gets baby a full 40 weeks of pregnancy it deserves to be on this list. GoTheFull40.com

Did you know that due dates arent as accurate as you might think? bit.ly/estimatedduedate A healthy, full-term pregnancy is a gift of health you give yourself and your babyenjoy this special season. GoTheFull40.com

Give your baby the gift of healtha term pregnancy. #full40 GoTheFull40.com

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Nobody likes to be rushedespecially babies!Your baby needs a full 40 weeks of pregnancy to grow and develop. While being done with pregnancy may seem tempting,especially during those last few weeks, inducing labor is associated with increased risks including prematurity,

cesarean surgery, hemorrhage and infection. Labor should only be induced for medical reasonsnot for convenience

or scheduling concerns. Baby will let you know when shes ready to emerge. Until then, here are 40 reasons to go

at least the full 40 weeks of pregnancy:

Finish Healthy & Well1. End right by starting rightkeeping all of your prenatal appointments helps ensure a healthier ending2. Savor the journeysoon you will meet your baby3. Let nature take overthere are fewer complications and risks for both you and baby through natural birth4. Recover faster from a natural birth than cesarean, which is major abdominal surgery that causes more pain,

requires a longer hospital stay and a longer recovery5. Birth a brainier babyat 35 weeks your babys brain is only 2/3rds the size it will be at term 6. Set her thermostatbaby will better regulate her temperature when born at term7. Boost breastfeedingterm babies more effectively suck and swallow than babies born earlier8. Delight in those kicks and flipsmarvel at the miracle of the life inside 9. Enjoy your convenient excuse for every mood swing and crazy craving10. Nourish your bodya healthy diet and breastfeeding will help you lose the baby weight 11. Let others carry the groceries, mail, packages just a while longer12. Indulge in we time before youre a threesome or more13. Sport your bumpas your belly increases, so do your chances of getting a great seat almost anywhere

40 ReAsoNsTo Go the Full 40

Manage Your Risks14. Eat healthfullyindulge occasional cravings without remorse15. Give babys development the benefit of time since you may not know

exactly when you got pregnant16. Let baby pick her birthdayif she decides to emerge after 37 weeks

theres no need to try to stop your spontaneous labor17. Skip an inductionwhich could lead to cesareanby waiting for labor

to start on its own18. Reduce your babys risks of jaundice, low blood sugar and infection

by waiting until hes ready to emerge19. Build your babys musclestheyll be strong and firm, and ready to help

him feed and flex at term20. Maximize those little lungsbabies born just 2 or more weeks early can

have twice the number of complications with breathing21. Ignore people who say an induction is more convenient. Nothing is

convenient about a longer labor and increasing your risk of cesarean 22. Respond to requests to speed babys birth with the facts that inductions

often create more painful labors and can lead to cesarean surgery 23. Let others do the heavy liftingand the extra housecleaning24. Splurge on pedicuresor ask a friend to do them for you, especially

when you cant see or touch your feet25. Relish in the fact that right now youre the perfect momyour healthy

pregnancy habits are growing baby the best possible way26. Finish wellmore time in the womb usually means less time in the hospital

Enjoy This Time27. Relax! Babies are usually so much easier to care for in the womb28. Shamelessly wear comfy, stretchy clothes29. Postpone changing the eventual 5,000+ diapers baby will use30. Be out and about without having to buckle, unbuckle,

rebuckle baby into her car seat or stroller while running errands31. Carry your most stylish purses especially the ones too small

to hold diapers and wipes32. Relish parentingright now you know exactly where baby is

and what hes doing33. Snooze when you canwhat sleep youre currently getting is actually

quite a lot compared to the interruptions ahead34. Massage remains a mustask your partner to help ease the aches 35. Enjoy nights out without paying for a babysitter36. Indulge in shopping without the added responsibilities of baby in tow37. Redecorate your house around your nurserys theme38. Prop up your paperbackyour burgeoning belly peaks at just

the right reading height39. Make the best-possible birth experience; dont rush it40. Write your own healthy reasonif it gets baby a full 40 weeks

of pregnancy it deserves to be on this list

The nurses of AWHONN remind you not to rush your babygive her at least a full 40! www.GoTheFull40.com

carolyndcTypewritten Text(TM)

A nadie le gusta que lo apuren . . .especialmente a los bebs!

Su beb necesita 40 semanas completas de embarazo para crecer y desarrollarse. Aunque llegar al fin del embarazo quizs parezca tenta-dor durante esas ltimas semanas, inducir el parto est relacionado con un riesgo mayor de tener un parto prematuro, ciruga cesrea, hemo-rragia o infeccin. El parto slo se debe inducir por motivos mdicos, no por conveniencia o para cumplir con el programa que uno quiera. El beb le dir cundo est listo para nacer. Hasta llegar a ese punto, he aqu 40 razones para llegar a 40 semanas completas de embarazo:

Un final feliz y sano1. Termine bien al empezar bien: asistir a todas sus consultas prenatales ayudar a asegurar un parto saludable2. Disfrute la jornada: pronto conocer a su beb 3. Deje que la naturaleza se encargue del asunto: hay menos complicaciones y riesgos para usted y para su beb cuando

el parto es natural4. Recuprese ms rpido de un parto natural que de una cesrea, la cual es una ciruga mayor en el rea abdominal

que causa ms dolor y requiere una estada ms larga en el hospital y una recuperacin ms larga5. Cultive su cerebro: a 35 semanas de embarazo el cerebro de su beb slo tiene dos tercios del tamao que tendr a 40 semanas6. Ajuste su termostato: los bebs que nacen a trmino regulan mejor su temperatura7. Aumente el amamantamiento: los bebs nacidos a trmino maman y tragan de manera ms efectiva que los bebs

que nacen antes 8. Disfrute de las patadas y las maromas: maravllese con el milagro de la vida que lleva dentro9. Aproveche la excusa conveniente que tendr para explicar cada cambio de nimo o antojo absurdo10. Ntrase: tener una dieta saludable y dar pecho al beb le ayudarn a bajar el peso que gan durante el embarazo11. Deje que otros carguen con los comestibles y los paquetes durante un rato ms 12. Disfrute su tiempo de pareja antes de volverse un tro... o un cuarteto o quinteto!13. Lzcase con su panza: mientras ms grande sea, mejores son las probabilidades de obtener un asiento de primera fila

en prcticamente cualquier lugar

40 RAzonEsPara llegar a 40 completas

Mitiguesusriesgos14. Coma de manera sana pero consintase sin pena cuando tenga antojos 15. Dle ms tiempo de desarrollo al beb, ya que quiz no sepa exactamente

cundo qued embarazada16. Deje que el beb escoja su cumpleaos: si nace despus de las 37 semanas

no hay razn por la que debe detener el parto espontneo17. Evite la induccin la cual puede conducir a una cesrea al esperar hasta

que el parto empiece por s solo18. Reduzca el riesgo de que su beb sufra de ictericia, tenga un nivel bajo

de glucosa o desarrolle una infeccin al esperar hasta que est listo para nacer 19. Desarrolle los msculos de su beb: si llega a trmino, estos sern fuertes,

firmes y estarn listos para ayudarle a flexionar y a alimentarse 20. Maximice el poder de sus pulmones: los bebs que nacen 2 semanas o ms

antes de trmino pueden tener dos veces la cantidad de complicaciones con la respiracin21. No les haga caso a los que dicen que la induccin de parto resulta ms

conveniente. No hay nada de conveniencia en tener un trabajo de parto ms largo e incrementar el riesgo de tener una cesrea

22. Si le piden acelerar el nacimiento del beb, seale que a menudo las inducciones hacen que el trabajo de parto sea ms doloroso y que puede conducir a una cesrea

23. Deje que otros hagan el trabajo pesado... y los quehaceres caseros adicionales24. Dese un lujo y obtenga una pedicura... o bien pdale a una amiga que se lo haga,

especialmente si no puede ver ni tocar sus pies25. Disfrute el hecho de que en este momento usted es la madre perfecta: sus

hbitos sanos durante el embarazo estn haciendo que el beb crezca de la mejor manera posible

26. Termine bien: ms tiempo en el vientre de mam significa menos tiempo en el hospital

Las enfermeras de AWHONN se recuerdan que no debes apresurar a su beb www.GoTheFull40.com

Disfrute la poca27. Reljese! Es mucho ms fcil cuidar a los bebs cuando an estn en el vientre28. Pngase ropa cmoda y elstica sin ninguna pena 29. Posponga durante un rato ms los 5.000 cambios de paal que, en promedio,

tendr que hacerle al beb30. Salga sin tener que abrochar, desabrochar y volver a abrochar el beb en su

asiento de auto o coche cuando est haciendo mandados31. Ande con sus bolsos ms chic, especialmente los que son demasiado chicos

para guardar paales y toallitas de limpieza32. Disfrute ser mam: ahora mismo sabe exactamente donde est su beb

y lo que est haciendo33. Duerma cuando pueda: la cantidad de sueo que est obteniendo ahora

ser mucha comparada con la que obtendr despus de que nazca el beb 34. El masaje an es imprescindible: pdale a su pareja que le d uno35. Disfrute salir en pareja sin tener que pagar a una niera36. Consintase al ir de compras sin la responsabilidad adicional de ir con un beb 37. Redecore su casa usando el tema que us para el cuarto del beb 38. Lea con comodidad: su panza creciente sirve para apoyar libros y los pone

justo a la mejor altura para leerlos39. Haga que la experiencia del parto sea la mejor posible; no se apure40. Anote su propia razn saludable: si da por resultado que su beb reciba las

40 semanas completas de embarazo, merece estar en esta lista

carolyndcTypewritten Text(TM)

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ImprovingMaternalandInfantHealthbyReducingCesareanBirthRates

AWHONNsDontRushMe...GoTheFull40

APublicHealthInitiativetopromotespontaneous

laborandreducecesareanbirthrates

Version1;published12/16/2015 GoTheFull40.com

AboutAWHONNTheAssociationofWomen'sHealth,ObstetricandNeonatalNurses(AWHONN)istheforemostnursingauthoritypromotingthehealthofwomenandnewborns andstrengtheningthenursingprofessionthroughthedeliveryofsuperioradvocacy,research,education,andotherprofessionalandclinicalresources.AWHONNrepresentstheinterestsof350,000registerednursesworkinginwomen'shealth,obstetric,andneonatalnursingacrosstheUnitedStates.LearnmoreaboutAWHONNatAWHONN.org.

CopyrightAWHONN2015;AllRightsReserved.Contactpermissions@awhonn.orgregardingpermissionsquestionsorrequests

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WhyReduceCesareanRates?

CopyrightAWHONN2015;AllRightsReserved.Contactpermissions@awhonn.orgtoobtainpermissiontopresent&share.

CDC/NCHS,2012

Whydoesreducingtheoveruseofinductionandcesareanmatter?

Fewermother/babycomplications

Potentialforhigherpatientsatisfaction/scores

Shorterhospitalstays

Moreefficientuseofstaffandotherresources

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Electiveinterventionsareassociatedwithincreasedharmsformothersandbabies

.


Whileratesofelectiveinductionsandelectivecesareanhavestabilizedinrecentyears,largeincreasesinthefirstdecadeofthe21stcenturyhavecontributedto

increasesinmaternalandinfantmorbidityandmortality

GoTheFull40.com CopyrightAWHONN2015;AllRightsReserved.Contactpermissions@awhonn.orgtoobtainpermissiontopresent&share.

http://www.safehealthcareforeverywoman.org/downloads/CesareanBundle/SafeReductionofPrimaryCesareanBirthsBundleFinal10815.pdf

October2015

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PresentationRoadmap

EpidemiologicProfileandOutcomes

EvidenceBasedPracticeRecommendations

GoTheFull40PublicHealthCampaign


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Epidemiology


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PrimaryCesareanRatesByState,2012


38statesreporting,Osterman&Martin,2014

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GeographicVariationInCesareanRates

Higher cesarean rates do not correspond with better outcomes

Areas with higher cesarean rates perform the intervention in medically less appropriate populationsthat is, in relatively healthier womenand do not have lower maternal or neonatal morbidity and mortality.

Geographic variation is only partially explained by womens preferences and clinical status

Variation is largely influenced by nonmedical factors

provider practice patterns or differences in medical opinions

the capacity of the local health care system

malpractice pressureBaicker,BucklesandChandra,2006


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HospitalVariationinCesareanRates

Cesareanratesvaried10fold(7.1%to69.9%)acrosshospitalsforallwomen.

Cesareanratesvaried15fold(2.4%to36.5%)acrosshospitalsforwomenwithlowerriskpregnancies.

VastdifferencesinpracticepatternsarelikelydrivingthecostlyoveruseofcesareaninmanyU.S.hospitals.

Kozhamannil,Law&Virnig,2013


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VariationinInductionRates Induction"inonefacility(oroneprovider)isnotthesame

asaninductioninanotherfacility. Inductionsarenotmanagedthesame,theydon'thavethesameendpointsandmostimportantlytheydon'thavethesameoutcomes.

Datafromrandomizedcontroltrials(RCTs)inuniversityhospitalsdonotnecessarilyreflectwhatisseencommunityhospitals. RCTsatuniversityhospitalswithstrictprotocolsusuallyreporta

13%15%CSrateforwomenundergoinginduction. Yet,across250hospitalsinCAtheratesofCSfornulliparous

womenattermundergoinginductionvaryfrom10%60%(Mainetal.,2011).

CopyrightAWHONN2015;AllRightsReserved.Contactpermissions@awhonn.orgtoobtainpermissiontopresent&share. GoTheFull40.com

CesareanDeliveriesByGestationalAge:19962012


NCHS,Births(2013).FinalDatafor2012.NationalVitalStatisticsReports,62(9).

3

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InitialCervicalDilationandCesareanRates

13

14,955birthsat37weeks,44%plannedinductions


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Outcomes


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August,2014


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HarmstoWomen Cesareansurgery

Placentaprevia

Placentaaccreta

Infection

Postpartumhemorrhage

Cardiovascularevents

Hospitalreadmission


CentersforDiseaseControlandPreventionPregnancyMortalitySurveillanceSystem,2014

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MaternalMortalityRatiosInternationalComparisons


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CausesofMaternalDeath


CentersforDiseaseControlandPreventionPregnancyMortalitySurveillanceSystem,2014

Cardiovascularandnoncardiodisease

Infection,sepsis

Hemorrhage

Cardiomyopathy

Thromboticpulmonaryembolism

Hypertensivedisorderofpregnancy

Amnioticfluidembolism

Cerebrovascularaccident

Anesthesiacomplications

4

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MaternalMorbiditybyDeliveryMode&PreviousCesareanHistory


Curtin,Gregory,Korst andSayeedha ,2015

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SevereMaternalMorbidity

Largeincreasesinseverematernalmorbiditiesfrom19981999comparedto20082009:

75%increaseinseverematernalcomplicationsduringahospitalizationforbirth.

114%increaseinseverematernalmorbidityduringapostpartumhospitalization.


Callaghanetal.,2012

GoTheFull40.com21

Callaghan, Kuklina & Berg, 2010.

50%

26%

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RiseinBloodTransfusions


Callaghanetal.,2012

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Callaghan, Kuklina & Berg, 2010.

23 GoTheFull40.com

IncreasedNeonatalMorbidityElectiveDeliveryandCD

IncreasedratesofNICUadmissionsforimpairedrespiratoryfunctionforelectivedeliverybefore39weeks(Clarketal.,2009)

RiskoflacerationwithCD Risksofrespiratorymorbidity(CD,nolabor) Lowerratesofimmediateskintoskincontact Morebreastfeedingdifficulties


5

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NoIncreaseinTermStillbirths

ThereductioninearlytermdeliveriesacrosstheUnitedStatesbetween2005and2011wasnotassociatedwithanincreaseintherateoftermstillbirth.(Littleetal.,2015)

Thelackofchangeinprospectivestillbirthratesfrom2006to2012suggeststhatpreventingnonmedically indicateddeliveriesbefore39weeksofgestationdidnotincreasetheU.S.stillbirthrate.(McDorman,Reddy&Silver,2015)


CostsAssociatedwithCesareans


TruvenHealthAnalytics,2013

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CostsAssociatedwithInductions


Lowernursetopatientratio

Costassociatedwithmedicalinterventions

Longerhospitalstaysandreadmissions

HigherNICUadmissions

Averagehospitalcostsforselectconditionsamonglivehospitalbirthsbyinsurancecategoryfor2011

Kowlessar,Jiang,&Steiner, 2013

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UnderstandingHealthyChildbirth


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PerinatalHormonalPhysiology Evolvedoverthemillenniatoensurereproductivesuccess.

Hormonalphysiologyisinterrelated,coordinated,andmutuallyregulatedbetweenmomandbabytooptimizeoutcomesforboth. Example:skintoskincontactafterbirthmutuallyregulates

maternalandnewbornoxytocinsystems

Disruptionofperinatalhormonalphysiologymaythusadverselyimpactnotonlylaborandbirth,butalsobreastfeedingandmaternalinfantattachmentviabiologicalbonding.(Buckley,2015)


SpontaneousLaborisaPowerfulHormonalProcess

Increasesinoxytocinandprostaglandinreceptorsprimetheuterustopromoteeffectivecontractionsinlabor.

Increasesinbrainbased(central)receptorsforbetaendorphinsprepareendogenouspainrelievingpathwaystobenefitmominlabor


Buckley,2015 Image:Shu

tterstock

6

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SpontaneousLaborProvidesCriticalBenefitstoMomsandBabies

Elevationsinmammaryandcentraloxytocinandprolactinreceptorsprepareforbreastfeedingandmaternalinfantbiologicalbonding.

Risingcortisolsupportsmaturationofthefetallungsandotherorgans.

Prelaborpreparationsinoxytocinandcatecholaminesystemspromotefetalprotectiveprocessesinlaborandoptimalnewborntransition.


Buckley,2015

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PracticeRecommendations


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RecommendationsforPractice

Encourageandsupportwomenintheearlystageorlatentphaseofspontaneouslabor(usually

7

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Applystandardizedapproachestocareduringlaborthatpromotelaborprogressandpreventdysfunctionallabor. Movementandpositioning Physicalcomfortmeasures,includingpainmanagement

Physiologicsecondstagepractices Emotionalsupport Educationaboutwhattoexpectandadvocacyforwomenspreferences


RecommendationsforPracticePositioningwiththePeanutBall

Useapeanutballtoencouragelaborprogressforwomenwhoareinbed,especiallywithepidurals

Researchfindings: Decreasedfirstandsecondstagelabor

LowerCDincidence(significant)


Tussey etal.,2015,Rothetal.,2015

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UseevidencebasedmethodsofinterpretationanddocumentationintheassessmentofthefetalheartratestatusincludingadoptionofNICHDterminology.



ImplementACOG/SMFMcriteriafordystociainlabormanagementpractices:

Cervicaldilationof6cmshouldbeconsideredthethresholdfortheactivephaseofmostwomeninlabor.Thus,before6cmofdilationisachieved,standardsofactivephaseprogressshouldnotbeapplied.(Caughey etal,2014)


ACOG&SMFM,2014

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ACOG/SMFMCriteriaforDystocia1.DiagnosisofDystocia/ArrestDisorder(All3shouldbepresent)

2.DiagnosisofFailedInductionbefore6cmdilation(bothshouldbepresent)

3.DiagnosisofFailedInductionafter6cmdilation(seecriteria1)

Cervix6cmorgreater Membranesruptured,then NochangeX4hourswithadequateuterineactivity

BishopScore6cmbeforeelectiveinduction Oxytocinusedforaminimumof12hrs aftermembranerupture

Caughey etal,2014



Developandutilizeperformanceandoutcomemeasuresofsufficientdetailto comparetosimilarinstitutionpractices, utilizetoconductappropriatecasereviewtoallowcaresystemanalysisand

allowindividualproviderperformancerecommendations.


8

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OptionsforMeasuringCesareanBirths

TotalCesareanRate Includesrepeatandprimarycesareans

PrimaryCesareanRate Includesnullips andmultips (rateofnulliparityvariesgreatlyamongfacilitiesandstates)

NTSVCesareanRate Moredifficulttocollectthesedata Providespatientriskstratification Thebestmeasureforcomparinghospitals

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TheJointCommissionPerinatalCoreMeasures

PC01 ElectiveDelivery

PC02 CesareanBirth(NTSV)

PC03 AntenatalSteroids

PC04 HealthCareAssociatedBloodstreamInfectionsinNewborns

PC05 ExclusiveBreastMilkFeeding


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DefiningNTSV:Nulliparous,Term,Singleton,VertexPresentation

Nulliparouswomeninlaborwithaterm,singletonvertexfetusaccountforthemostvariableportionoftheCSepidemic.

ThispopulationhasthelowestriskforCSatthestartoflabor.

Managementoflaborinthispopulationismostaffectedbysubjectivity.


JointCommission,2015

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AWHONNQualityMeasures Theactionsofnurseshavesignificantimpactonpatientoutcomes.Forthatreason,measuringthequalityofcareprovidedbyregisterednursesisavitalcomponentofhealthcareimprovement.

SecondStageofLabor:MotherInitiated,SpontaneousPushing(Measure2)

LaborSupport(Measure10) Nonpharmacologiclaborsupportoptions

FreedomofMovementDuringLabor(Measure11)


AWHONN,2013

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PrimaryCesareanBundle:OutcomeMetrics

C/SratesderivedfromBirthCertificate(viastateagencySMMderivedfromfromHospitalDischargeDiagnosisfile

(viastateagency))

O1:SevereMaternalMorbidity

Denominator:Allmothersduringtheirbirthadmission,excludeectopics andmiscarriagesNumerator: Amongthedenominator,allcaseswithanySMMcode

O2:SevereMaternalMorbidity(excludingtransfusioncodes)

Denominator:Allmothersduringtheirbirthadmission,excludeectopics andmiscarriagesNumerator: Amongthedenominator,allcaseswithanynontransfusion(99.0x)SMMcode

O3:C/SDeliveryRateamongNulliparous,Term,Singleton,Vertex(NTSV)Population

Denominator:Womenwithlivebirthswhoarehavingtheirfirstbirth37weeksandhaveasingletoninvertex(Cephalic)position.Numerator:Amongthedenominator,allcaseswithacesareanbirth

O4:C/SDeliveryRateamongNulliparous,Term,Singleton,Vertex(NTSV)PopulationafterLaborInduction

Denominator:Womenwithlivebirthswhoarehavingtheirfirstbirth37weeksandhaveasingletoninvertex(Cephalic)positionANDwithalaborinductionNumerator:Amongthedenominator,allcaseswithacesareanbirth

http://www.safehealthcareforeverywoman.org/#

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PrimaryCesareanBundle:ProcessMetrics

P1:ProviderEducation

Reportestimatein10%increments(roundup)WhatcumulativepercentofOBphysiciansandmidwiveshavecompletedaneducationprogram(withinthelast2years)onnewACOG/SMFMlabormanagementguidelinesthatincludesteachingontheSafeReductionofPrimaryC/S(SupportforIntendedVaginalBirths)bundleandaunitstandardprotocol?

P2:NursingEducation

Reportestimatein10%increments(roundup)WhatcumulativepercentofOBnurseshavecompletededucationprogram(withinthelast2years)onnewACOG/SMFMlabormanagementguidelinesthatincludesteachingontheSafeReductionofPrimaryC/S(SupportforIntendedVaginalBirths)bundleandaunitstandardprotocol?

P3:CesareanBundleComplianceRateAlternateMeasureforS4:MultidisciplinaryCaseReviewsforC/SBundle

ReportActualComplianceRateWhatproportionofcasesreviewedmettheACOG/SMFMcriteria?seeS4nextslideforexamplesChooseoneormorebundlesbasedonlocalneed

AllreportedbyHospital(toAIMDataPortal)quarterly


9

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PrimaryCesareanBundle:ExamplesofMultidisciplinaryCaseReviews

(1) Dystocia/FailuretoProgressBundle

Denominator:NTSVwomeninlaborwithacesareanbirthforDystociaorFailuretoProgressNumerator: Amongthedenominator,thosewhodidnotmeetACOG/SMFMcriteria(ObGyn2014;123:693711)BOTHCRITERIASHOULDBEPRESENT:Cervix6cmorgreaterattimeofCesareanMembranesruptured,andNocervicalchangeX4hrs withAdequateUterineactivity(or6hrswithoxytocin)

(2)InductionBundle

Denominator: NTSVwomenwhoselaborwasinduced(includingcervicalripening)withacesareanbirthforDystociaorFailuretoProgressbefore6cmdilation(if6cm,thenuseDystociabundle)Numerator:Amongthedenominator,thosewhodidnotmeetACOG/SMFMcriteria(ObGyn2014;123:693711)BOTHCRITERIASHOULDBEPRESENT:BishopScore6beforeelectiveinductionOxytocinusedforaminimumof12hrs aftermembranerupture

(3)FetalConcernBundle

Denominator: NTSVwomenwhohadacesareanbirthduringlaborforFetalConcern(FetalDistressornonreassuringFetalHeartPattern)Numerator:Amongthedenominator,thosewhodidnotmeetaunitstandardcriteriamostcommonlyutilizedcriteriaare:Spong etal(ObGyn 2012;120:118193)orClarketal(AJOG2013;209:8997)

AllreportedbyHospital(toAIMDataPortal)quarterly


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ImprovingMaternalandInfantHealthbyReducingCesareanBirthRates

AWHONNsCampaign:

DontRushMe...GoTheFull40APublicHealthInitiative

topromotespontaneouslaborandreducecesarean

birthrates

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Barriers:ProviderAttitudes


o MDsmakethedecisionsandtheyhavebeenslowtochangetheirpractice.Manynurseshavegonealongwithelectiveinductionsforsolongthattheyareslowtochangetoo.

o Lotsofpressureisputonthephysicianstoinduceearly(inrelationtopatientsatisfactionscores.)

Hospitalbasednurses

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Barriers:WomensAttitudes


o Womenallseemtoknowsomeonewhohadababyearlyandtheyarefine.

o Momsaretiredatendofpregnancyandwanttodeliver.

Hospitalbasednurses

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WhatisDontRushMe...GoTheFull40?


GoTheFull40.com

GoalsofGoTheFull40Campaign

#1Increasethepercentageofwomenwhowaitforlabortostartonitsown,therebyreducingoverallelectiveinductionandprimarycesareanrates.#2Increaseawarenessamongprovidersandconsumersregardingthedocumentedphysiologicalbenefitsoftermpregnanciesthatculminateinspontaneouslabor.


10

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BenefitsofSpontaneousLabor


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HowGoTheFull40isShared


Printhandouts:40Reasonsarticle Discusswithwomen Hangpostersinexamrooms&triage

units;backofbathroomdoors,inelevators ShareAWHONNs HealthyMom&Baby

magazine Postonfacilitys socialmedia,including

textmessages Discussw/PerinatalQIteam Broadcastonfacilitys closedloopTV

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WhereGoTheFull40isShared


40Reasonshandoutsdistributedat6keyintersections:

o Maternitycareofficesnewpatientpacks,28weekvisit

o Hospital tour/registration packso Hospital/clinicbased health

fairso Breastfeeding&childbirth

educationclasseso Obstetrictriageandevaluation

unitso Birthunits


GoTheFull40CampaignComponentsAds&Posters 40Reasonsarticle ImplementationToolkit

http://bit.ly/Full40Toolkit


GoTheFull40Online GoTheFull40.comInteractiveEngagementZone FacebookChampionsGroup

GoTheFull40.com Facebook.com/GoTheFull40

GoTheFull40.com

HealthyMom&BabyHealth4Mom.org


11

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ImplementingGoTheFull40 Discussw/PerinatalQIteam Provideposters&handoutstoaffiliated

hospitals,maternitycareoffices,publichealthclinics,communityhealthcenters

Handout40Reasonsarticletowomenandfamilies

Discussgoingthefull40withwomen Hangpostersinexamrooms&triage;

backofbathroomdoors&inelevators Share HealthyMom&Babymagazine Broadcastonfacilitys closedloopTV Postonfacilitys socialmedia


Tellushowyoureusingtheseslidesandcontactustolearnmoreabout

orreceivecampaignmaterialsforGoTheFull40:

CatherineRuhl,CNM,MSAWHONNDirectorofWomensHealth

[email protected]

CarolynDavisCockey,MLSAWHONNDirectorofPublications

[email protected]

QuestionsaboutGoTheFull40

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ReferencesAmericanCollegeofObstetriciansandGynecologists.(2013).Nonmedically indicatedearlytermdeliveries.CommitteeOpinionNo.561.ObstetricsandGynecology, 121:9115

AssociationofWomensHealth,ObstetricandNeonatalNurses.(2010).GuidelinesforProfessionalRegisteredNurseStaffingforPerinatalUnits.Washington,DC:AssociationofWomensHealth,ObstetricandNeonatalNurses.

AssociationofWomensHealth,ObstetricandNeonatalNurses.(2013).Womenshealthandperinatalnursingcarequalitydraftmeasuresspecifications.Washington,DC:Author.

AssociationofWomensHealth,Obstetric&NeonatalNurses.(2014).Nonmedicallyindicatedinductionandaugmentationoflabor.JournalofObstetric,Gynecologic,&NeonatalNursing,43: 678681.doi: 10.1111/15526909.12499

Baicker,K.,Buckles,K.S.,&Chandra,A.(2006). Geographicvariationintheappropriateuseofcesareandelivery.HealthAffairs,25(5)35567.

Buckley,S.J.(2015).HormonalPhysiologyofChildbearing:EvidenceandImplicationsforWomen,Babies,andMaternityCare.NationalPartnershipforWomenandFamilies:Washington,DC.Accessedatwww.ChildbirthConnection.org/HormonalPhysiology

Callaghan,W.M.,Creanga,A.A.,&Kuklina,E.V.(2012).SeverematernalmorbidityamongdeliveryandpostpartumhospitalizationsintheUnitedStates.AmericanJournalofObstetrics&Gynecology,120(5),10291036.http://dx.doi.org/10.1097/AOG.0b013e31826d60c5

Callaghan,W.M.,Kuklina,E.V.,&Berg,C.J.(2010).Trendsinpostpartumhemorrhage:UnitedStates,19942006.Americanjournalofobstetricsandgynecology,202(4),353e1.

Caughey,A.B.,Cahill,A.G.,Guise,J.M.,andGrouse,D.J.(2014).Safepreventionoftheprimarycesareandelivery.ObstetricsGynecology. 123(3):693711


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ReferencesContinuedCentersforDiseaseControlandPrevention.(2014).PregnancyMortalitySurveillanceSystem.Retrievedfromhttp://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.htmlClark,S.L.,Miller,D.D.,Belfort,M.A.,Dildy,G.A.,Frye,D.K.,&Meyers,J.A.(2009).Neonatalandmaternaloutcomesassociatedwithelectivetermdelivery.AmericanJournalofObstetricsandGynecology,200,156.e1156.e4.Curtin,S.C.,Gregory,K.D.,Korst,L.M.,andSayeedha F.G.U.(2015).Maternalmorbidityforvaginalandcesareandeliveries,accordingtopreviouscesareanhistory:newdatafromthebirthcertificate,2013.NationalVitalStatisticsReports,64(4).Hogan,M.C.,Foreman,K.J.,Naghavi,M.,Ahn,S.Y.,Wang,M.,Makela,S.M.,etal.,(2010).Maternalmortalityfor181countries,19802008:asystematicanalysisofprogresstowardsMillenniumDevelopmentGoal5.Lancet, 375(9726):160923.doi:10.1016/S01406736(10)605181.James,BC,Savitz,LA.(2011).HowIntermountaintrimmedhealthcarecoststhroughrobustqualityimprovementefforts.HealthAffairs,30(6):11851191Kowlessar,N.M.,Jiang,H.J.,andSteiner,C.Hospitalstaysfornewborns,2011.HCUPStatisticalBrief#163.October2013.AgencyforHealthcareResearchandQuality,Rockville,MD.Kozhimannil,K.B.,Law,M.R.,Virnig,B.A.(2013).CesareanDeliveryRatesVary10FoldAmongUSHospitals;ReducingVariationMayAddressQuality,CostIssues.HealthAffairs,32(3)527535.doi:10.1377/hlthaff.2012.1030LittleSE,Zera CA,ClappMA,WilkinsHaug L,RobinsonJN.(2015).AMultiStateAnalysisofEarlyTermDeliveryTrendsandtheAssociationWithTermStillbirth,Obstetrics&Gynecology, Epub aheadofprint].Liu,S.,Liston,R.M.,Joseph,K.S.,Heaman,M.,Sauve,R.,&Kramer,M.S.(2007).Maternalmortalityandseveremorbidityassociatedwithlowriskplannedcesareandeliveryversusplannedvaginaldeliveryatterm.Canadianmedicalassociationjournal,176(4),455460.MacDormanMF1,ReddyUM,SilverRM.(2015).TrendsinStillbirthbyGestationalAgeintheUnitedStates,20062012.Obstetrics&Gynecology,[Epub aheadofprint].Main,E.,Morton,C.,Hopkins,D.,Giuliani,G.,Melsop,K.,&Gould,J.(2011).CesareanDeliveries,Outcomes,andOpportunitiesinCalifornia:TowardaPublicAgendaforMaternityCareSafetyandQuality:ACMQCCWhitePaper.Oakland:CaliforniaMaternalQualityCareCollaborative.Moore,J.E.(2014).Movingtowardpatientcenteredcare:women'sdecisions,perceptions,andexperiencesoftheinductionoflaborprocess.Birth, 41:2.DOI: 10.1111/birt.12080


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References(continued)NCHS,Births(2013).FinalDatafor2012.NationalVitalStatisticsReports,62(9).

Osterman,M.J.K.,andMartin,J.A.(2014).PrimaryCesareanDeliveryRates,byState:ResultsFromtheRevisedBirthCertificate,20062012.NationalVitalStatisticsReports,63(1).

TheJointCommission.(2015).MeasureInformationFormPC02.SpecificationsManualforJointCommissionNationalQualityMeasures(v2015B2),OakBrook,Illinois:TheJointCommission.Retrievedfromhttps://manual.jointcommission.org/releases/TJC2015B2/

TruvenHealthAnalytics.(2013)ThecostofhavingababyintheUnitedStates.AnnArbor,Michigan:TruvenHealthAnalytics.Retrievedfromhttp://transform.childbirthconnection.org/wpcontent/uploads/2013/01/CostofHavingaBabyExecutiveSummary.pdf .

Tussey,C.M.,Botsios,E.,Gerkin,R.D.,Kelly,L.A.,Gamez,J.,&Mensik,J.(2015).Reducinglengthoflaborandcesareansurgeryrateusingapeanutballforwomenlaboringwithanepidural.TheJournalofPerinatalEducation,24(1),1624.

ZhangJ,Troendle J,ReddyUM,Laughdon SK,BranchDW,Burkman R,vanVeldhuisen P(2010).ContemporarycesareandeliverypracticeintheUnitedStates.AmericanJournalofObstetricsandGynecology,203(4),326.e1326.e10.http://dx.doi.org/10/1016/j.ajog.2010.06.058


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