fetal-placenta unit in others. This analysis confirms that decelerationsare critical for evaluating the clinical significance of contractions.

286 Unexpected effects of reducing electiveinductions under 39 weeks gestationEmily Hamilton1, Ken Welch2, Yoni Barnhard3,Samuel Smith4, Eric Knox5, Daniel O’Keeffe6

1PeriGen, Obstetrics and Gynecology, McGill University, Montreal, QC,Canada, 2Banner Health, Banner Estrella Medical Center, Phoenix,AZ, 3Norwalk Hospital, Obstetrics and Gynecology, Norwalk, CT,4Franklin Square Hospital, Obstetrics and Gynecology, Baltimore,MD, 5PeriGen, Perinatal Research, Minneapolis, MN,6PeriGen, Perinatal Research, Princeton, NJOBJECTIVE: Reducing elective inductions below 39 wks is consistentwith best practice recommendations. Simply changing the recordedindication from elective to an acceptable term can result in fewerelective inductions. A clinically meaningful reduction should be mir-rored by a reduction in all inductions under 39 wks, as well as in alldeliveries under 39 wks and show no rise in complications. The studyobjective was to measure these related parameters in a group of hos-pitals participating in a quality improvement program with two com-mon aspects; 1. An intelligent EMR (PeriBirth, Princeton,NJ) thatrecognizes the intention to deliver or induce electively under 39 wksand requests written justification 2. Structured quarterly performancereviews with related measures. In addition, some institutions had for-mal objectives to reduce elective delivery under 39 wks, others did not.STUDY DESIGN: We examined an aggregate of 157,283 birth data be-tween 2007 and 2011 from settings ranging from small rural commu-nity to large urban teaching hospitals.RESULTS: Rates fell overall for; 1. Elective induction under 39 wks*0.98%-0.53%, 2. All elective births under 39 wks* 2.6%-1.4% (electiveinduction and elective CS) 3. Inductions under 39 wks for any reason*11.7%-9.5% and 4. All births under 39 wks* 43.9% -38.0%. The ratesof both primary CS and 5-min Apgar scores of 0-6 showed no changeduring the study period. Overall induction rates* rose from 32.6%-35.9%.(*P �0.0001).CONCLUSION: The intervention was highly successful in reducing elec-tive inductions under 39 wks without an increase in the rate of pri-mary CS or low 5-min Apgar scores. In addition, clinical behaviourchanged beyond the strict confines of elective induction, as we ob-served an unexpected decrease in induction rates under 39 wks for anyindication. This translated to a large reduction in the rate of all birthsunder 39 wks, which carries the greatest clinical significance. Further-more, these hospitals have greatly exceeded a recommended benchmark of �5% for elective delivery under 39 wks with their aggregaterate of 1.4% in 2011.

287 Breech deliveries in the Netherlands: effect of increasedcaesarean section rate on perinatal outcomeFloortje Vlemmix1, Jelle Schaaf2, Ageeth Rosman1,Anita Ravelli3, Arno Verhoeven4, Gerard Visser5,Ben Willem Mol1, Marjolein Kok1

1AMC, Obstetrics and Gynecology, Amsterdam, Netherlands, 2AMCAmsterdam, Medical Informatics, Amsterdam, Netherlands, 3AMC, MedicalInformatics, Amsterdam, Netherlands, 4not practicing, formerly RijnstateArnhem, Obstetrics and gynecology, Arnhem, Netherlands, 5UniversityMedical Center Utrecht, Obstetrics and Gynecology, Utrecht, NetherlandsOBJECTIVE: Publication of the results of the term breech trial (TBT)had a major impact on clinical practice in case of breech delivery allover the world. In the Netherlands, the planned CS rate increasedfrom 27 to 60% within three months. This resulted in a decreasedperinatal mortality rate from 0.35 to 0.18% (OR 0.53; 95%CI 0.33-0.83) and birth trauma from 0.29 to 0.08% (OR 0.26; 95%CI 0.14-0.50) between 1999 and 2003. In the present study, we analyzed themode of delivery for term breech birth and its effect on the neonataloutcome in the Netherlands up to 2007.STUDY DESIGN: We used data from the nationwide perinatal registryfrom 1999 to 2007. All singleton term breech deliveries from 37 weekswere selected, excluding pregnancies complicated by major congeni-tal malformations or antenatal death. We assessed the effect of modeof delivery on neonatal outcome (perinatal mortality, five minute Ap-gar score �7, and neonatal trauma), distinguishing the period beforeand after the publication of the TBT results.RESULTS: After the immediate shift in medical intervention behav-iour, the rate of planned CS, vaginal deliveries and emergency CS inwomen with a term breech delivery remained stable over a period ofseven years at 60%, 22% and 18%, respectively. The perinatal mortal-ity rate among planned CS and planned vaginal deliveries was 0.03%vs. 0.29% (OR 0.11, 95%CI 0.05 to 0.23), perinatal trauma rate was0.10% vs 0.41% (OR 0.24, 95%CI 0.15 -0.37), low apgar score rate was0.25% vs 2.15% (OR 0.11, 95% CI 0.09-0.15). The perinatal mortalitywithin the planned vaginal delivery group did not change after pub-lication the TBT (29% vs. 28%, OR 1.06, 95% CI 0.67 1.70).CONCLUSION: Ten years after publication of the TBT, still 40% of termbreech deliveries in the Netherlands are planned vaginal deliveries,with a tenfold mortality rate compared to the planned CS. Despite theclaim that selection for vaginal deliveries would improve neonataloutcome, there is no improvement since the TBT.

Poster Session II Diabetes, Labor, Medical-Surgical-Disease, Obstetric Quality & Safety, Prematurity, Ultrasound-Imaging www.AJOG.org

S138 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012