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Evidence-Based Practice to Improve

Outcomes for Late Preterm Infants
Brenda Baker

Correspondence
Brenda Baker, PhD, RN,
CNS
Nell Hodgson Woodruff
School of Nursing
Emory University
1520 Clifton Rd.
Atlanta, GA 30322.
brenda.baker@emory.edu

ABSTRACT
Infants born between 34 weeks 0 days to 36 weeks 6 days gestation have been identified as late preterm infants (LPIs)
and account for 70% of preterm births and 9% of all births. The rise in elective deliveries in the past decade is believed
to have contributed to the number of late preterm births. An interprofessional team including labor and delivery, neonatal
intensive care, and postpartum care providers collaborated to address this issue at an urban academic medical center.

JOGNN, 44, 127-134; 2015. DOI: 10.1111/1552-6909.12533

Accepted September 2014

Keywords
late preterm infants
LPI
evidence-based practice
elective delivery

Brenda Baker, PhD, RNC,

CNS, is an assistant
professor in the Nell
Hodgson Woodruff School
of Nursing, Emory
University, Atlanta, GA.

The author reports no conflict of interest or relevant

financial relationships.

http://jognn.awhonn.org

esearchers have clearly documented that

during the immediate newborn period, late
preterm infants (LPIs) are at increased risk of
developing hypothermia, respiratory complications, feeding difficulties, extended lengths of
stay, and higher infant mortality (Gouyon et al.,
2010; Kitsommart et al., 2009; Medoff-Cooper
et al., 2012; Melamed et al., 2009). Additionally,
long-term adverse outcomes for LPIs include
developmental delays in reading and academic
achievement (Chyi, Lee, Hintz, Gould, & Sutcliffe, 2008; Kalia, Visintainer, Brumber, Pici, &
Kase, 2009; Morse, Zheng, Tang, & Roth, 2009;
Nepomnyaschy, Hegyi, Ostfeld, & Reichman,
2012; Petrini, Young, Rogers, & Reily, 2009).

In the 1990s in the United States, a significant rise

in LPI births was noted that coincided with a peak
in the incidence of elective deliveries, whether
by induction or cesarean, that subsequently attracted the attention of professional organizations,
regulatory agencies, and payers (Association
of Womens Health, Obstetric and Neonatal
Nurses [AWHONN], 2014b; Bingham, Ruhl, &
Cockey, 2013; California Maternal Quality Care
Collaborative, 2011). To address this concern,
in 2009 our urban medical center convened an
interprofessional team of nurses and physicians
whose primary goal was to determine strategies
to decrease the rate of preterm birth. Building on
this effort in 2012 a second interprofessional team
addressed strategies to decrease the number

of elective deliveries at fewer than 39 weeks

gestation by the implementation of the March of
Dimes 39+ Weeks Quality Improvement project
(March of Dimes, 2014). Each of these initiatives has contributed to improved outcomes for
mothers and infants at our medical center.

How LPIs are Different

Although LPIs may only appear to be smaller than
their term infant counterparts, during the last 4 to
6 weeks of gestation, significant growth and development of critical body systems occur. In the
LPI hypothermia and hypoglycemia are frequent
complications due to limited brown fat stores,
greater body water content, immature metabolic
responses, and immature peripheral vasoconstriction mechanisms (Darcy, 2009; GyamfiBannerman, 2012). Hypothermia increases the
demands on energy stores and can develop in
response to hypoglycemia or infection. LPIs are
at higher risk of developing hypoglycemia than
term infants. Limited glycogen stores and rapid
depletion of glucose stores from the metabolic demands of the newborn transition period can result
in hypoglycemia. Cold stress, poor suck/swallow
ability and respiratory complications contribute to
the risk of developing hypoglycemia (Darcy, 2009;
Gyamfi-Bannerman, 2012). See Table 1.
An immature immune system increases the LPIs
risk of developing infections. The immune system


C 2014 AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses

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Table 1: Clinical Presentation, Pathophysiology, and Associated Interprofessional Care for

Late Preterm Infants
Clinical Presentation

Pathophysiology

Interprofessional Care

Respiratory Stability

Grunting, nasal flaring, tachypnea, retractions

Closely monitor respiratory rate and effort

due to immature terminal respiratory units

Monitor blood glucose
Apnea due to immature respiratory center in the Provide neutral thermal environment
brain
Provide supplemental respiratory support
Hypothermia

Immature epidermal barrier

Increase environmental room temperature at

time of delivery

Higher ratio of surface area to birth weight

Closely monitor axillary temperatures during

newborn transition care

Limited glycogen stores

Provide skin-to-skin contact as appropriate

Decreased brown fat stores

Provide external heat source as necessary

Greater body water content

Monitor blood glucose

Immature metabolic mechanisms

Delayed skin blood-flow control limiting
peripheral vasoconstriction
Hypoglycemia

Limited glycogen stores

Monitor blood glucose

Rapid depletion of glycogen stores

Provide oral intake

Provide neutral thermal environment

Sepsis

Immature immune system

Monitor closely for signs and symptoms of

sepsis including: hypothermia, hypoglycemia,
and respiratory instability

Limited transfer of maternal antibodies and

passive immunity
Increased incidence of preterm delivery related
to maternal infection
Hyperbilirubinemia

Increased bilirubin load

Monitor oral intake closely

Immature liver enzymes

Monitor output closely

Dehydration

Monitor bilirubin levels

Poor suck/swallow leading to poor oral intake

Feeding Difficulties

Uncoordinated suck/swallow/breathing

Monitor weight daily

Immature muscle tone

Feed frequently, 1012 feedings per day for

breastfed infants; 810 feedings per day for
formula fed infants

Immature feeding cues related to neurologic

Observe for feeding cues

immaturity
Rapidly fatigues during feeding

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of the LPI is further disadvantaged because

of decreased phagocytic cellular defenses. In
these infants, early-onset sepsis from birth through
72 hours of life is typically acquired in the perinatal
period from organisms found in the maternal
genital tract. Microorganisms commonly found in
the maternal genital tract that can lead to infection
include Streptococcus, Listeria monocytogenes,
Escherichia coli, group B Streptococcus, and
Candida. Preterm labor, premature rupture of
membranes, and chorioamnionitis are associated
with the development of early- onset sepsis
(Darcy, 2009). See Table 1.
Hyperbilirubinemia is the most common reason
for readmission in the LPI population, as the
peak serum bilirubin is often not seen until 5 to
7 days of life, often 3 to 5 days after discharge
from the hospital (Darcy, 2009; Premji, Young,
Rogers, & Reily, 2012). The mechanism of red
blood cell breakdown and elimination of bilirubin
of the LPI is the same as that of the term infant;
however, bilirubin levels increase in the LPI due
to less-than-optimal suck/swallow ability, dehydration, decreased elimination, and immature
liver enzymes. In particular, the ability to feed by
mouth is a complex process that requires skill and
coordination. The LPI often lacks the coordination,
muscle tone, and stamina to successfully feed
(Premji et al., 2009). See Table 1.
At 35 weeks gestation, significantly fewer sulci are
present in the neonatal brain, and only 60% of
the total brain weight has developed (Raju, Higgins, Start, & Leveno, 2012). Neurologic immaturity contributes to limited suck/swallow/breath
patterns and results in uncoordinated, exhausting feedings and inadequate intake of calories.
Neurologic prematurity also prevents the LPI from
giving feeding cues and maintaining awake periods for successful feedings (Darcy, 2009; Raju
et al., 2012). See Table 1.
The incidence of respiratory distress is significant
in infants born fewer than or equal to 35 weeks
gestation compared to infants born at greater than
or equal to 38 weeks gestation (Escobar, Clark, &
Greene, 2006). LPIs experience more respiratory
complications due to lack of pulmonary surfactant
and an immature respiratory center in the brain,
which increase the risk of respiratory distress syndrome and apnea (Darcy, 2009; Raju et al., 2006).
In the last 6 weeks of gestation, critical structural
changes in the lungs occur. The terminal respiratory units, alveolar saccules, mature into alveoli
lined with type I epithelial cells. Also during this

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The last 4 to 6 weeks of gestation are significant for infant

growth and development.

period, pulmonary capillaries necessary for gas

exchange begin to fill the alveoli and surfactant is
present (Darcy, 2009, Raju et al., 2006).

National Organizational Initiatives

Numerous national initiatives have focused attention on the need to avoid elective birth prior to
39 weeks gestation to promote the optimum outcomes for newborns by reducing the associated
risks of infants born during the late preterm period.
Organizations addressing the reduction in late
preterm birth and related adverse infant outcomes
include the March of Dimes (2014), AWHONN
(2014c, 2014d; Medoff-Cooper et al., 2012), American College of Obstetricians and Gynecologists
(ACOG; 2014), and the Joint Commission (2014).
These organizations have developed toolkits,
provider and consumer education, and quality
improvement programs aimed at the reduction
of nonmedically indicated (elective) deliveries
before 39 weeks gestation. In 2012 AWHONN
launched the Go the Full 40 consumer campaign
to educate women on the importance of delivering
at 40 weeks gestation and avoiding elective births
prior to term. This program was one of the first to
provide consumer education related to the risks
of elective delivery and possible preterm birth
(AWHONN, 2014a; Bingham et al., 2013).
In 2008 the Joint Commission addressed elective
deliveries, a practice believed to contribute
to the rise in late preterm birth, by publishing
Perinatal Care Core Measure PC-01 Elective
Deliveries Less than 39 Weeks Gestation. Organizations accredited by the Joint Commission
are now required to submit data on medically
and nonmedically indicated deliveries prior to
39 weeks gestation (Joint Commission, 2014).
The intent of requiring institutions to submit these
data was to increase institutional awareness and
accountability related to these practices. Additional, influential professional organizations joined
the cause to reduce elective delivery prior to
39 weeks gestation, including Leapfrog, a public
reporting agency (Leapfrog, 2012), the National
Quality Forum (2012), and the Centers for Medicare & Medicaid Services (2013). Cumulatively,
these efforts have increased the awareness of
physicians, nurses, and the consumer to the risks
associated with birth prior to 40 weeks gestation.

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Table 2: Comparison of Late Preterm Infant (LPI) Outcomes between 2008 and 2013.
2008
Total LPI Births

161

Average Gestational Age

2013

155

35.6

n/a

35.9

n/a

Temperature Instability

80

53%

12

Hypoglycemia

26

18%

12

Respiratory Instability

33

22%

16

10

Septic Workup

51

34%

18

12

Average Length of Stay (days)

5.6

n/a

4.2

n/a

Transfer/Admit to Neonatal Intensive Care Unit

58

36%

62

40

Numerous national initiatives have focused attention on the

need to avoid elective delivery prior to 39 weeks gestation.

These organizations recognize that at times

delivering an infant prior to 40 weeks gestation
may not be prevented due to maternal conditions
or complications experienced during pregnancy.
During these incidences, providing care specific
to the needs of the LPI becomes the priority.
The purpose of this article is to describe two
successful evidence-based projects completed
at an urban academic medical center with approximately 2200 deliveries per year. The center is
located in the southeastern United States serving
a wide range of women from numerous socioeconomic, cultural, and ethnic backgrounds. The
project goals included reducing the incidence of
elective deliveries prior to 39 weeks gestation,
establishing medical indications for delivery prior
to 39 weeks gestation, and providing evidencebased care to infants born between 34 and
0 days to 36 weeks 6 days gestation. The interprofessional team included members from labor
and delivery and neonatal intensive care and
postpartum nurses, obstetricians, perinatologist,
neonatologist, and pediatricians.

for the care of LPIs. The team identified opportunities for improvement in care and found
that transfer to the neonatal intensive care unit
(NICU) frequently occurred as compensatory
resources were exhausted and LPIs developed
hypoglycemia, respiratory complications, thermal
instability, and feeding difficulties. Transfer to the
NICU frequently resulted in additional interventions to rule out sepsis, resulting in prolonged
separation of mother and infant. See Table 2.
A review of the literature and published guidelines
on care of LPIs was completed using the key
words late preterm infant and near term infant.
From the review of literature, a LPI Clinical Practice
Guideline was developed and approved by the
Perinatal Practice Committee, an interprofessional
hospital committee with representatives from labor and delivery, mother/infant, and neonatal
intensive units. The clinical practice guideline
incorporates current evidence from AWHONN,
American Academy of Pediatrics, and the National
Institute of Child Health and Human Development
(AWHONN, 2014c, 2014d; Engle et al., 2007; Raju
et al., 2006). These guidelines recommend anticipatory care to conserve physiologic resources,
facilitate throughput to appropriate levels of care,
and avoid separation of mother and infant as
much as possible (see Figure 1).

In 2008, 161 LPIs were born in our facility; therefore, approximately 8% of all births were LPIs,
which closely matched the national rate of 9%
(Engle, Tomashek, & Wallman, 2007). Following
the retrospective review of LPI admissions, our interprofessional team began addressing strategies

In 2008, 161 LPIs were born and 36% were either

admitted or transferred to the NICU and had an
average length of stay of 5.6 days. In 2013, 155
LPIs were born and 40% were admitted or transferred to the NICU and had an average length of
stay of 4.2 days. The average gestational age of
all LPIs was 35.6 weeks in 2008 and 35.9 weeks
in 2013. In 2008, 53% of the LPIs experienced
hypothermia. In 2013 after the implementation of
staff education, the clinical practice guideline,

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Implementing Evidence-Based
Care for LPIs

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Management of Late Preterm Infants (LPIs)

Figure 1. Clinical Practice Guideline for Management of Late Preterm Infants (LPIs)

and skin-to-skin care, 7% of the LPIs experienced

hypothermia. The rate of hypoglycemia also
improved in the LPI population. In 2008 18% of
LPIs experienced hypoglycemia compared to 7%
in 2013 when anticipatory care was the standard
preventing depletion of resources. The rates
of respiratory instability and number of septic
workups between 2008 and 2013 also improved
(see Table 2). Although the number of LPIs
admitted or transferred to the NICU increased,
adoption of a clinical practice guideline that prevents depletion of critical resources in the infant
has improved outcomes for LPIs in this setting.

Eliminating Elective Deliveries

Prior to 39 Weeks Gestation
In 2009, awareness of LPI birth data and the
multiple national efforts to address elective deliveries lead to the development and adoption of a

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hospital policy, Elective Deliveries Prior to

39 Weeks Gestation. Adherence to the policy
varied by care provider leading to weekly reviews
of scheduled deliveries for medical indications by
medical staff leadership (see Figures 2 and 3). In
2012 the hospital was approached to participate in
the March of Dimes 39+ Weeks Quality Improvement program. Benefits of the March of Dimes
program include staff education, distribution of
patient education materials, a Grand Rounds
speaker on the topic of elective delivery at fewer
than 39 weeks, a procedure-scheduling tool, chart
review of all scheduled inductions and cesarean
births, and monthly reports from data collected
through the scheduling tool. A 12-months data collection and review process of all scheduled deliveries prior to 39 weeks gestation provided reports
specific to provider, deliveries by gestational age,
and medical indication for delivery. Timely reports
allowed leadership to identify specific patient

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Evidence-Based Practice to Improve Outcomes for Late Preterm Infants

Figure 2. Late Preterm Infant (LPI) Birth Rates 20092013

Maternal conditions may outweigh the risk of giving birth to an

infant before 37 weeks gestation.
circumstances for further review and staff
education on the topic of elective delivery.
Quarterly reports from the project were shared with
the medical and nursing staff. Another aspect of
the March of Dimes program was adoption of a
policy that included a hard stop for scheduling inductions or cesareans without documented
medical indications. The purpose of a hard stop
was to prevent elective delivery prior to 39 weeks.
The policy clearly outlined medical indications for

delivery prior to 39 weeks gestation and a requirement for medical leadership review to schedule or
admit women without a documented medical indication for delivery prior to 39 weeks (March of
Dimes 2014). Although the focus of this project
was elective delivery before 39 weeks, circumstances did arise that required modification to the
standard. These circumstances included (a) distance from home to the hospital, (b) history of rapid
or precipitous delivery, or (c) family schedules that
did not accommodate a due date such as military
fathers who were being deployed. Although these
circumstances were the minority of the indications
for scheduled delivery prior to 39 weeks gestation, the medical staff worked with families to meet

Figure 3. Late Preterm Infant Rates by Weeks Gestation 20092013

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their needs and ensure the well-being of mother

and newborn. During the 12-month data collection period, the rate of elective delivery either by
induction or cesarean section was less than 5%.

Association of Womens Health, Obstetric and Neonatal Nurses.

(2014c). Assessment and care of the late preterm infant:
Evidence-based clinical practice guideline. Washington, DC:
Author.
Association of Womens Health, Obstetric and Neonatal Nurses.
(2014d). Assessment and care of the late preterm infant

Implications for Practice

Implementation of the LPI Clinical Practice Guideline and weekly interprofessional review of births
prior to 39 weeks for medical indication improved
clinical care for LPIs changed the culture related
to elective births and raised the standard of care
for mothers and newborns. Next steps include
implementation of an electronic scheduling tool
that would incorporate medical indications for induction or cesarean. Currently, LPI outcomes and
elective birth prior to 39 weeks continue as data
points monitored by obstetric and neonatal leadership and staff as quality indicators.

implementation toolkit. Washington, DC: Author. Retrieved from

www.awhonn.org/awhonn/lpitoolkitresources/home.jsp
Bingham, D., Ruhl, C., Cockey, C. D. (2013) Dont rush me . . . Go the
full 40: AWHONNs public health campaign promotes spontaneous labor and normal birth to reduce oversue of inductions
and cesareans. Journal of Perinatal Education, 22(4), 189193.
California Maternal Quality Care Collaborative. (2011). Statistics. Retrieved from https://www.cmqcc.org/ob_stats
Center for Medicare and Medicaid Services. (2013). Strong
start toolkit. Retrieved from http://www.cms.gov/Outreach-andEducation/Outreach/Partnerships/StrongStartToolkit.
Chyi, L., Lee, H., Hintz, S., Gould, J., & Sutcliffe, T. (2008). School
outcomes of late preterm infants: Special needs and challenges
for infants born at 32 to 36 weeks gestation. Journal of Pediatrics,
153(1), 2531.
Darcy, A. (2009). Complications of the late preterm infant. Journal of
Perinatal Neonatal Nursing, 23(1), 7886.

Conclusions
Implementation of the LPI clinical practice guideline has established a standard of evidence-based
care that provides preventive care strategies to
conserve physiologic reserves and promote
transition of the LPI. This approach to care has
decreased the number of LPIs experiencing hypothermia, hypoglycemia, respiratory instability,
and the number of septic evaluations. For LPIs
admitted to the NICU, the length of stay has
decreased. Multiple initiatives focused on elective
delivery and care of LPIs have decreased the incidence of elective delivery prior to 39 weeks gestation, decreased the number of late preterm births,
decreased separation of mother and newborn due
to NICU admission, decreased length of stay following birth, and minimized invasive procedures
as transition is successfully managed. An interprofessional approach to evidence-based care
has significantly improved care for mothers and
newborns.

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Escobar, G., Clark, R., & Greene, J. (2006). Short-term outcomes of
near-term infants. Pediatrics, 30(1), 2833.
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