Choosing wisely and ACOG advises against non-medical indicated elective induction or C-section before 39 completed weeks.

choosing wisely, USA

Choosing Wisely campaign[1] was launched in April 2012 by the American Board of Internal Medicine Foundation, Consumer Reports, and nine medical specialty societies in guiding physician towards wise management of healthcare resources and to encourage patients to have conversation with physician about unnecessary tests, procedures and care.

Saving Healthcare Resources 

The campaign released a list of “Top Five” lists from nine founding specialty societies. Today More than 70 societies comprising over one million clinicians are now partners of the Choosing Wisely campaign.[2]

American College of Obstetricians and Gynecologists (ACOG)released a list of 10 ‘ Do’ and ‘Don’t’ for the physicians in February 21, 2013 and updated it again on August 24, 2016.

The first in the list is “Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks 0 days’ gestational age.”

ACOG and Choosing Wisely strongly advises against elective delivery before 39 weeks as it is associated with increase in cognitive disorders and morbidity in the newborn. It further adds that delivery before 39 weeks should be only carried out based on clear indication that favors positive outcome for mother and fetus. A fetal lung maturity in the absence of clear indication is not the reason for delivering the baby.

The '39 weeks rule'

The 39-week rule is now a strict clinical guideline that is enforced by professional organizations, governmental agencies and the medical insurance industry in US. 

In November 2013, ACOG and Society for Maternal and Fetal medicine(SMFM) made a recommendation of replacing the use of “term” pregnancy which accommodated gestations between 37 wks to 42 wks with the following designations:[3]

•  Early term: 37 weeks through 38 weeks and 6 days

 •  Full term: 39 weeks through 40 weeks and 6 days

 •  Late term: 41 weeks through 41 weeks and 6 days

 •  Postterm: 42 weeks and beyond

These changes were made by growing research evidence, a part of which has been led by Eunice Kennedy ShriverNational Institute of Child Health and Human Development, indicating that key developmental process for the fetus continue well beyond 37 weeks till 39 weeks. They also advocated that “Babies born at or after 39 weeks have the best chance at healthy outcomes compared to those born before 39 weeks.”

It was seen that the percentage of infants born preterm declined for the seventh straight year in 2013. The NIH also published a report that shows a decline in induction of labor for singleton birth in year 2011 (23.7%) and 2012 (23.3%), after 20 years of consecutive increases. There was also a decline in Early Elective Deliveries across the UnitedStates, from 17% of babies in the United States were delivered before 39 weeks in 2010 to a sharp decline to 4.6% in 2013. 

But many researchers and clinicians across US are not in favor of strict implementation of the ‘39 weeks rule.’

Dr. Baxi from New York University Langone Medical Center in New York City opined that timing of delivery is refined decision depending on many variable and it should be individualized per the circumstances and not governed by a rule.

Dr J.Nicholson is a strict opponent of  ’39 weeks rule’ and  says “the 39-week rule is not supported by high-quality evidence, its strict application unjustifiably obstructs patient autonomy, and it may actually cause harm in the form of early-term stillbirth. Because of these problems, the 39-week rule should be modified, made optional, or withdrawn. Patients should be able to request and receive early-term labor induction if they believe that such an intervention is in the best interest of themselves and/or their fetus.”[4]

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[1] http://www.choosingwisely.org/about-us/

[2] http://www.choosingwisely.org/about-us/history/

[3] http://www.acog.org/About-ACOG/ACOG-Departments/Deliveries-Before-39-Weeks

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4402696/