PROFESSIONAL CONNECTION
We All Speak the Same Language
ACNM Collaborates to reVITALize and Define “Term”
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by Tina Johnson, CNM, MS, ACNM Director of Professional Practice and Health Policy
n December 2012, ACNM participated in a multi-stakeholder meeting to review the definition of “term” pregnancy, discuss the assessment and definition of gestational age both in the United States and abroad, and evaluate the implications of redefining term pregnancy. Informed by a host of experts on the history of term, vital statistics and outcomes data, racial and ethnic considerations, and an examination of gestational age assessment, the group engaged in a robust discussion of the policy and practice implications of redefining term as well as a proposed approach for optimal determination of gestational age. The definition of term has been the same since pregnancy dating was based on recall of a woman’s last menstrual period (LMP), initial auscultation of the heart beat with a fetal stethoscope, and clinical assessment of uterine size. The advent of ultrasound, accurate early home pregnancy and ovulation tests, and artificial reproductive technologies, has improved dating of pregnancy in developed countries. The wide 37 to 42 week range of term was well suited to the wide range of error when dating was based on traditional methods; it may not be appropriate in light of current, more accurate dating procedures. On May 3, the recommendations of the workgroup were published in the Journal of the American Medical Association— see them at http://bit.ly/10rbxMf. The group decided the following by consensus: • Term pregnancy should be subcategorized according to the evidence, as infant morbidity and mortality is statistically lowest between 39 weeks 0 days and 40 weeks 6 days. • There should be no distinction in the definition of term based on race or ethnicity. • Precise language can inform the public and clinicians and influence care decisions, timing of delivery, and health outcomes for both mothers and newborns.
New definitions of term:
• Preterm: < 37 weeks • Late preterm: 34 0/7 to 36 6/7 weeks • Early term: 37 0/7 to 38 6/7 weeks • Full term: 39 0/7 to 40 6/7 weeks • Late term: 41 0/7 to 41 6/7 weeks • Post term: ? 42 weeks
This new definition of term coincides with the reVITALize project, an ongoing multi-stakeholder obstetric data definitions initiative that began in 2012. The project brought together over 80 leaders in women’s health, public health, and vital statistics and includes ACNM members Leslie Cragin, CNM, and Tonia MooreDavis, CNM. Prior to the conference, various national quality measures were identified, reviewed, and categorized into 5 data element categories: Delivery, Gestational Age and Term, Labor, Maternal Indicators Historical Diagnoses, and Maternal Indicators Current Co-Morbidities and Complications. Stakeholders were surveyed and data elements were ranked in order of importance within each of the above 5 categories. These results guided each of the workgroups corresponding to the 5 categories at the August 2012 reVITALize Conference. The goal of each workgroup was to produce definitions that were clinically accurate and operationally functional. Workgroups were assigned to revise or develop definitions for approximately 15 terms within their respective category. The newly refined definitions were presented to the large group for review, input, and applicable modifications as necessary. At the conclusion of the conference, at least 85% attendee support was reached on 44 refined data element definitions, while the rest were brought back to their respective workgroups for a period of additional review and revision. A total of 50 refined data element definitions were eventually brought forward for public comment. After comments were considered and modifications to the definitions were made as deemed appropriate, the refined data element definitions were sent for a legal review. In June, 42 data element definitions received final approval by reVITALize conference attendees. Next steps include submission to the Obstetrics & Gynecology for publication later this year, and further educational and dissemination efforts. Stay tuned!?
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In determining gestational age: • Estimated date of delivery (EDD) by unknown LMP should ide• Known LMP confirmed to within 5 days by crown rump length
ally be based on first trimester ultrasound. (CRL) obtained by ultrasound before 13 weeks 6 days is preferred. EDD should be based on ultrasound dates if discrepancy with LMP is 6 days or greater. • For ultrasounds ??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????15@?????????????????????????????????????????????????????????????????????????????????%??????????????????????????????????????????????????????????????????????????????????????????????????????()E?????????M????????$((??((