Elective induction IMPROVES maternal and neonatal outcomes

Better way road sign

Sometimes I almost feel sorry for natural childbirth advocates. Just about everything they think they know is factually false.

Elective induction is a case in point.

Judith Lothian explained in Saying “No” to Induction:

Saying “no” to induction and to other interventions that are becoming routine takes courage and confidence, as well as the knowledge that women have the right to informed refusal. What women learn from you about nature’s plan for labor and birth, including the beauty of waiting for labor to start on its own and the risks of interfering without clear medical indication, will insure that the women you teach will have the information they need to confidently say “no” to routine induction.

Except that study after study shows that saying “YES” to elective inductions IMPROVES both maternal and neonatal outcomes. A new study, Maternal and neonatal outcomes in electively induced low-risk term pregnancies, comprising 131,243 low-risk births is merely the latest example. As the authors explain:

Several studies have presented information refuting the association of induction with increased cesarean delivery. Two large prospective multicenter studies of late term (41 weeks’ gestational age) pregnancies found no difference or a decreased rate of cesarean delivery in elective inductions vs expectant management. A metaanalysis reported an absolute risk reduction in cesarean delivery rate with elective induction of 1.9% (95% confidence interval [CI], 0.2-3.7%) for late term and post term pregnancies. Similar findings have been reported across different obstetric cohorts, including those with hypertensive disease, fetal growth restriction, and diabetes.

Three recent retrospective analyses found no increase in operative delivery with induction of labor and a decrease in the cesarean delivery rate among nulliparous women delivering at 39-42 weeks’ gestational age and all women delivering in the term period (37-40 weeks). Cheng et al also reported improvement in other associated neonatal morbidities including meconium aspiration, 5-minute Apgar <7, infection, ventilator use, composite morbidity, and neonatal intensive care unit (ICU) admission with induction at 39 weeks’ gestation. Using discharge and birth certificate data, Darney et al also recently found a reduction in cesarean deliveries with induction of labor compared to expectant management at 37, 38, 39, and 40 weeks of gestation. Importantly, Darney et al also reported no increase in neonatal ICU admission or respiratory distress with elective induction of labor, including those performed at 37 and 38 weeks of pregnancy.

The new study confirms these previous studies:

Of 131,243 low-risk deliveries, 13,242 (10.1%) were electively induced. The risk of cesarean delivery was lower at each week of gestation with elective induction vs expectant management regardless of parity and modified Bishop score (for unfavorable nulliparous patients at: 37 weeks = 18.6% vs 34.2%, adjusted odds ratio, 0.40; [95% confidence interval, 0.18-0.88]; 38 weeks = 28.4% vs 35.4%, 0.65 [0.49-0.85]; 39 weeks = 23.6% vs 38.5%, 0.47 [0.38-0.57]; 40 weeks = 32.3% vs 42.3%, 0.70 [0.59-0.81]). Maternal infections were significantly lower with elective inductions. Major, minor, and respiratory neonatal morbidity composites were lower with elective inductions at ≥38 weeks (for nulliparous patients at: 38 weeks = adjusted odds ratio, 0.43; [95% confidence interval, 0.26-0.72]; 39 weeks = 0.75 [0.61-0.92]; 40 weeks = 0.65 [0.54-0.80]).

The authors note:

Using a cohort of low-risk pregnancies within the Consortium on Safe Labor database, we examined maternal and neonatal outcomes for women who were electively induced compared to those expectantly managed at each week of term gestation. For our primary outcome of mode of delivery, we observed a reduction in cesarean section with elective induction, regardless of week of gestation, parity, or cervical examination. For secondary outcomes including maternal and neonatal morbidity, no outcome was shown to be worse with elective induction. Conversely, several maternal outcomes including infectious morbidity, obstetrical lacerations, and shoulder dystocia were reduced with induction of labor. For those electively induced, we observed a reduction in composite neonatal morbidities with induction of labor at 38, 39, and 40 weeks’ gestation. (my emphasis)

How did natural childbirth advocates get it so wrong? They relied on studies that compared induced labor at specific gestational ages with spontaneous labor at the same gestational ages. The correct comparison is induced labor at specific gestational ages vs. waiting (expectant management).

The authors include an important caveat:

These data do not attempt to define what the best gestational age is for delivery at term. Rather, we submit that our results demonstrate that when maternal and newborn outcomes are analyzed through the prism of the true clinical alternatives of induction or waiting, the findings may be drastically different than what has been reported previously. Clearly, these data suggest that outcomes for mom and baby are complex with competing interests. Evaluations that only consider differences in observed neonatal morbidities by week of delivery paint an incomplete picture as they do not account for the risks of waiting… (emphasis in original)

Poor natural childbirth advocates. Yet again nature does not know best. Mothers who choose inductions for “convenience,” far from increasing their risk of C-section, maternal complications or neonatal complications, may actually be making the safer decision.

  • SL27

    I know this is an old article, but I love this because it helps me be excited for my induction on Friday at 39 weeks. I hear too many bad stories about inductions, so it is good to hear the actual numbers are good. I am so sick of being pregnant, and there are so many reasons why Friday is more convenient than waiting to see when I might go into labor: husband in grad school so now he won’t have to miss class, my mom can fly in the night before to watch my toddler instead of having to call a neighbor in the middle of the night to come stay with her, first baby was 8.5 lbs before her due date l, and our family has big babies and fast labors. Plus I’m gsb positive and now they can start me on antibiotics before anything else.

  • Ash

    How funny (sarcasm) that this NYTimes goes from this

    http://www.ipr.northwestern.edu/publications/docs/workingpapers/2013/IPR-WP-13-08.pdf

    http://www.nytimes.com/2014/10/12/upshot/heavier-babies-do-better-in-school.html

    without mention of stillbirth. Maternal death is mentioned, but stillbirth is not specifically mentioned, only as vague as “risks”.

    Play around with the handy graph, and the primary striking effect to the naked eye is that it’s extremely beneficial to be a white woman giving birth as opposed to a woman of color.

    Let’s be real here; alleviate poverty and racism and that is the key to healthier infant and maternal outcomes!

  • Sue

    But it’s not all about clinical outcomes!!! What about MIDWIFE SATISFACTION??

  • Momma Q

    I might have avoided my first C-section (and therefore, possibly my second) by doing an induction at 39.5 or 40 weeks (as recommended by the doctor) instead of the 41 weeks I had been tricked into believing was somehow more worthwhile. My daughter would have been smaller, easier to adjust from her malposition, my placenta would have been healthier, and she would have undergone less stress in labor. Most notably, she would almost certainly have NOT had to spend the first minute of her life with a tube stuck into her lungs sucking out the meconium she had expressed into the amniotic fluid. To this day I regret that I ever believed expectant management was better, and that it was the NCB advocates who put that ridiculous idea in my head in the first place, making me push back against my doctors. I was a fool and my daughter could have paid a terrible, irreversible price of her life or brain health.

  • rh1985

    If only they would do away with the 39 week rule, given the outcomes seen at 38 weeks were not worse, but somehow I doubt it after all the effort to implement it. I wanted to deliver at 38 weeks (I was having a CS, but same rule for both CS and induction) because I was pretty much throwing everything up but because the tests came back with levels within normal there was nothing that could be done due to hospital policies. I was scheduled for 39+1 but I kept getting sicker and sicker. A day before the scheduled CS I was diagnosed with severe pre-eclampsia and had an immediate CS an hour after the diagnosis. I think the pre-e could have been avoided if I had just delivered a few days earlier as I would have preferred. My daughter was born healthy and I just hope I have no long term damage as some studies have shown higher risk for hypertension later in life.

  • Carolina

    This post is fantastic and a good example of why I regularly read this blog. So helpful.

    OT, I found out today (12 weeks) that I have complete previa. I’m also on Lovanox, so I’m a little nervous about this. What are the odds that it will move soon?

    • araikwao

      I would have to look up the stats, but it is early on, and so IIRC, likely to improve

  • MaineJen

    I will never regret my induction with my son! A primip at 38+3 with ROM, no contractions, no dilation. We waited overnight to see if labor would start on its own (it didn’t!), I was induced in the morning, had a 12 hour labor and an uncomplicated vag delivery that night. A homebirth midwife would have let me sit at home for days with ROM, and who knows what complications may have developed. Knowing what I know now, I see that induction was a no brainer. It may have even saved me from a c section; the longer you wait with ROM, the higher the chance of complications, right? But according to NCB, I should be outraged. *shrug*

  • nomorequestionscatherine

    At my 40 week appointment for my second pregnancy (scheduled exactly at 40+0) the fetal heart tones were not in a normal audible rhythm. NST showed a normal strip but the unusual audible rhythm continued.

    My OB initially wanted me to go to the hospital for a BPP, but after back & forth with L&D department and discussion with her (considering it was mid-day on a Friday, I was 40 weeks, I already had a just in case induction scheduled at 40+5, I had family in town that weekend who could care for my older child, AND we had the audible arrhythmia of unknown significance that she thought there was no reason to wait out over the weekend and worry about it) she decided it would be best to send me direct to the hospital for induction that afternoon.

    I was actually very relieved though I suspected she gave me the induction partly for pity/elective reasons. I’m not sure she felt very strongly that the weird rhythm was indicative of anything, but I’m glad she recognized that we had really nothing to gain at that point by leaving him in so we might as well induce him out. Although the nurse doing my intake seemed rather confused by & dismissive of the reason for my induction, but oh well.

    It went quite smoothly (as did my first labor which was also an induction for entirely different reasons – both, incidentally, were vaginal deliveries), and on delivery we discovered a true knot in the umbilical cord. Whether that was contributory to the abnormal heart rhythm or not we’ll never really be able to know, but I am so grateful to my doctor for giving me an induction.

    Who knows what might have happened otherwise but because we did induce he’s a happy & healthy almost 4 month old now. I can live with that.

    • The Bofa, Being of the Sofa

      It’s a nice story, and it’s great that it all came out ok. Seriously, I have no idea how anyone could anything agin it. I’m sure there are those who would, though.

      There was something unusual, there was no reason to wait, so why not go ahead?

      • nomorequestionscatherine

        I agree. I’m certain that our outcome was better than expectant management in our situation. I am glad my doctor thought it was the best thing to do as well.

    • Sue

      In these days of supposed “patient-centered care”, it says a lot that anxiety and family circumstances should have to be characterised as “pity/elective” – why not just good, holistic patient care?

      Glad your OB had the courage to prioritise YOU and your family.

  • TwinMom

    Another piece of garbage film, that’s got a whole bunch of moms now up in arms about how devastating it was to have a c/s…smh.
    http://m.huffpost.com/us/entry/5618150?cps=gravity

  • Allie P

    I heart my induction. I was 40+5, with a highly unfavorable cervix. A bit of cervadil, eight hours, and I had a vaginal childbirth with a beautiful, perfectly healthy baby in arms. Nothing good happens after 40 weeks.

  • MelodyCason

    I suspected it was safer than I had heard. I was induced for both of my labors, and they were great experiences. With my first, it was definitely elective as I basically had to beg my Dr to induce me. We were moving across the country 2 weeks after my due date and I wanted to make sure I had SOME recovery time. With my second, they suspected my son was big and since I had a fast labor with my first and I was group b strep positive that time, they offered induction and I said yes. They said if I went into labor before the induction date, to not pass go or collect $200, but go straight to the hospital so I could get the full dose of antibiotics before baby came.

    Both of my deliveries went so well and I was very blessed. If we have another baby, if they offer induction again I think I will do it. I am so over the judgement surrounding this, though!

  • jb1021

    Interesting. Sounds like something I should think about bringing up with my CNM tomorrow at my appointment. I’m 36 weeks along now and the anticipation of ‘when will she arrive’ is stressing me out. Would that be annoying to bring a study to her attention? What’s the best way to ask her without undermining her expertise?

    And what a subtle but important distinction – comparing waiting for nature to inductions vs. inductions to same gestational age spontaneous births. That’s why they are the experts.

    • Sally RNC-NIC

      Darling, just ASK her! It’s your body, your baby, and you have every right to have your questions answered! You’re coming from a place of concern and safety for yourself and your sweet babe. And you are genuinely asking her opinion! That should be respected, and you have the right to advocate for yourself! It sounds to me this is coming from your gut….you must always trust your gut! It’s just so smart. : ) Good luck!

  • Jocelyn

    Related to induction – when my sister had her son last year, her water broke early in the morning. They went to the hospital a couple hours later, where she got both epidural and pitocin (I can’t remember which came first). She reached 10 cm sometime in the afternoon. The midwife then had her push for 4 1/2 hours, at which point a doctor came in, found the baby’s head to be in a bad position, and performed a forceps delivery. (He was blue and floppy and had an apgar of 3. Recovered just fine and is now healthy.)

    My sister mentioned to me today that she wonders if the pitocin pushed him down in the vaginal canal too quickly (or something like that), and wonders if she didn’t have the pitocin and she had reached 10 cm more slowly that he would have been in a better position when she started pushing.

    Is this legitimate, or bunk?

    • Jtmo

      Prolly bunk. There is a higher rate of pre-labor rupture of membranes with fetuses who are malpositioned, though. So that may have contributed to the whole scenario.

  • DoulaGuest

    First off: I want to say thanks Amy Tuteur and SOB community. I really enjoy reading and (sometimes) participating. I’ve learned a great deal, and a lot that has really helped me in nursing school and also as a doula. I know that there is so much here, between the tragic loss stories and wonderful breakdowns of studies and stats, that I will continue to use as I pursue midwifery.

    Secondly, to Dr. Tuteur, I have been wondering something for awhile. I understand why you a) haven’t gone into it and b) I also respect your decision if you wish not to answer my question. However, I thought it couldn’t hurt to ask. I noticed in the comments from others and from yourself (I think I remember that correctly), that you had two unmedicated births. I was wondering if that was a conscious choice, if there was a difference in your thinking/idea then about unmedicated birth, etc.

    I know you are not one to post your birth stories, so I’m of course not expecting something a la the posts we see from HB moms, just about your ideologies then and now….if at all different.

    I ask this with the utmost respect, and again understand if you wish not to answer.

    • attitude devant

      I think she said somewhere that for those two labors her pain wasn’t that bad and she (being an experienced mom) knew that her labors were usually short and that she was managing well, so she decided not to.

      • Sue

        I can’t answer for Dr Amy of course but I suspect that there has been no change at all in her outlook – she is arguing for ACCESS to appropriate medicine when it is required, not for compulsory medication.

      • Amazed

        She did say it. Actually, I remember her saying that the pain in those two births wasn’t that bad, she was progressing fast and it simply wasn’t worth the bother.

    • Amy Tuteur, MD

      I’ve answered this question many times in the past. My 3rd and 4th labors were relatively short and I felt I could manage without the epidural. The only difference between my first two labors with an epidural and my last two labors without one was the pain. I didn’t feel “empowered” by any of them. I got pregnant to have a baby, not a birth.

  • Sara

    DHH in my state has started the 39-week initiative and our local hospital is on board. I also just heard that the biggest insurer in the state & state Medicaid will not pay doctors for inductions scheduled before 39 weeks without a medical reason. That covers just about every birth in the state between those two payers.

    I find that extremely punitive and absolutely ridiculous. I know when I had a very clearly indicated medical induction it was delayed because of the paperwork that had to be done for the hospital. I can’t imagine having a less clear-cut, but still medical reason (like severe sciatica pain?) and being told I have to wait it out because the paperwork to prove it to some insurer or appeal would be too much of a hassle.

    • attitude devant

      We actually had a patient with terrible gallbladder pain. So bad she had to be admitted for pain management. Weeks and weeks of pain. So we checked an amnio for lung maturity and delivered at 37 weeks and promptly got dinged, because while (the reviewer said) our reasoning was defensible, her disease was not pregnancy-related and should not influence pregnancy management. I kid you not.

      • sdsures

        How is she doing now?

        • attitude devant

          She had her gallbladder out and is fine. But what the heck are we supposed to do? You can’t have your gallbladder out with a near-term pregnancy, and the poor thing was miserable! But no, the codes we could honestly apply were not approved codes, so we were bad girls for taking care of the human being in front of us. Absolute insanity.

          • Amy M

            Well, I guess the hospitals that are totally unreasonable about inductions will see an increase in adverse outcomes? How long until they notice and change policy?

          • attitude devant

            If THAT is what we have to wait for, then it might be a decade or more.

          • Sue

            I am preparing a talk for a conference that will be titled something like “Retaining your authenticity in an culture of micro-management”. A constant struggle.

          • The Computer Ate My Nym

            Thank you for giving this sort of talk! And good for whoever let you give it: most large organizations fight to make sure you do NOT retain your autonomy or authenticity.

          • attitude devant

            May I come to your talk?

          • Siri

            I also sadly recall a woman who died from pancreatic cancer soon after the birth of her baby. Her pain, too, was ignored or explained away or minimised until it was too late. OK, she might have died anyway, but her suffering could have been lessened considerably and she could have had a longer time with her baby.

          • Belle

            How sad..

          • toofargone

            I am curious, has switching to ICD-10 made a difference? I’m not sure if the switch is complete yet, I’ve been away from that environment. Id figure the chance to be more specific in coding might help justify the decision, but I guess if it’s not on the Joint Comissions’ or the insurer’s list then I suppose that doesn’t matter

          • attitude devant

            We are still in mid-switch. In fact, I see some of our entities wanting one, or the other, and some both

          • The Computer Ate My Nym

            This sort of thing is making me think seriously about getting out of clinical medicine. This and the harassment the hospital gives you for doing the right thing for the patient if they don’t get paid for it…Just not worth it any more.

          • attitude devant

            You and me both.

      • MamaBear

        I thought pregnancy can produce gallstones. With my second pregnancy I had gall stones forming. I would get these weird pains on one side of my stomach and thought it was normal pregnancy stuff so I never brought it up during prenatal appointments. Then at the 6 week post partum exam, the CNM touched that side of my stomach and I was like a cat on the ceiling. She never explained what could have caused the pain. Fast forward to 4 months later: I finally get my infant son to sleep and I’m about to go to bed myself, but I have this spasm ing pain in my side. I wake up later throwing up, the pain is worse, and I barely move. My mom takes me to the ER where the run some test including an ultrasound and they determine I have gallstones so severe my gallbladder needs to come out ASAP. I asked the ER what could have caused this and looking over my chart he said most likely it was pregnancy induced.

        • attitude devant

          You are correct MamaBear. The mnemonic to remember the risk factors for gallstones is the “Four F’s” and those are fertile (i.e., pregnant), female, forty, and fat. Any one of those increases your risk. It is so much a thing that ER docs know that a recently-delivered patient presents with belly pain, the gall bladder is the first place to look. Even so, the assumption of the people who run these programs is that pregnant women are only pregnant. All other organ systems are in abeyance for the duration.

      • Belle

        I believe it. I worked in hospital Case Management for a couple of years and insurance companies are the worst. If a patient doesn’t meet a certain set of criteria to a “t” the case has to be reviewed. Usually the medical director at the insurance company would review it and approve it especially in a situation like this.

      • Siri

        Oh god. I remember an antenatal patient who kept coming back with really bad pain, and was eventually admitted after she refused to leave. She was accused of being a drug seeker, addicted to pethidine, addicted to entonox etc. Her face was grey and she was miserable. Eventually, after much suffering, she was taken to gynae theatres for exploratory surgery (most unwillingly on the docs’ part as she was still pregnant). She had a twisted ovary that was gangrenous. Next time I saw her, her face was pink and she was smiling for the first time! Very useful lesson.

        • toni

          I hope she received an apology! I’ve never heard of gangrene in an ovary. Christ.. sounds absolutely grim.

  • attitude devant

    Sigh. In the midst of all this, the QA department at my hospital is making it more and more difficult to schedule inductions, AS A QUALITY ASSURANCE measure! They offer very limited openings for induction, and because they are chronically understaffed, often cancel scheduled inductions. And since I am my patient’s advocate, I push, and push, and push. I am so sick of this reflexive acquiescence to NCB claptrap. Most recently I had a patient with severe PIH, called the DR and was told they didn’t have a spot for four days. I asked if they would like me to enter into my patient’s chart that I tried to arrange her delivery and the hospital refused. That got me lots of dirty looks when I got to the labor floor later that day, but ask me if I care.

    • CrownedMedwife

      A clinician does a retrospective review of all IOL charts and deems whether each IOL meets diagnostic guidelines. This is in an attempt to comply with 39 week rule and to reduce overall IOL rates, which evidently are considered ‘too high’. Incidentally, CS rates are considered exceptionally low even with the inclusion of elective Cesareans. All the while and more importantly, maternal/neonatal outcomes are excellent. So where is the logic in QA prohibiting or discouraging IOLs?

      • attitude devant

        Exactly

      • Sue

        And why are we constantly chasing time-based or number-based targets instead of clinical outcomes?

    • DiomedesV

      Knowing there are doctors like you (and the other health professionals on this board, like CrownedMedwife) makes me feel a little bit better about the health care options available to women. But the situation overall is unacceptable.

    • Dr Kitty

      Oh I find it amazing how asking someone how they spell their name, for the notes, just in case you need to refer back in the event of an adverse outcome, can make people super helpful.

      Although, TBH, my preferred tactic is to talk to a Dr, rather than a secretary, nurse or midwife.

      Sometimes it is because I know the Dr and can ask them to do me a favour:

      “Remember when you were my houseman and I did the catheter for that homeless guy for you…well, I’d really like you to squeeze this patient into your clinic tomorrow, and we’ll call it even.”

      Sometimes it is just because they “get” my concerns quicker:

      “They are anxious first time parents and have come to see me every day for the last two weeks. Smiley GP reassurance is not working. They need grumpy paediatrician “don’t waste my time with your perfectly healthy baby” reassurance, after you make sure I haven’t missed something”.

      • Who?

        ‘Confirming the spelling’ never gets old. Mind you the need to resort to it does, really fast.

    • Medwife

      Ha. This is the hospital trying to run an l&d unit without adequate staffing, too. This happens to me WAY too much. The next time it happens I plan to move straight into the process of shipping a patient to another institution for IOL. Their failure to staff does not change my patients’ care plan.

      • attitude devant

        Amen!

      • Sue

        Yay for Medwife and Addie! THESE people are true patient and family advocates, not like narcissistic and bullying HBMWs!

    • Sue

      “I asked if they would like me to enter into my patient’s chart that I tried to arrange her delivery and the hospital refused. That got me lots of dirty looks when I got to the labor floor later that day, but ask me if I care.”

      Go you! But not every woman has a doctor who will constantly go in to bat for what is right, putting up with accusations of being always angry and endure the relentless fighting.

      You are spot on, though. They need to be held to account for the clinical outcomes that their administrative decisions might cause.

      • attitude devant

        To be fair, the nurses are super. Absolutely professional and really committed to good care. But the hospital undercuts them at every turn by keeping them so short-staffed they are reeling.

        • Belle

          Very true..

    • The Computer Ate My Nym

      Yep, that’s the one way to get through to a hospital: threaten to document that they demanded that you not give your patient the best possible management. Suddenly they see the light…

    • amazonmom

      I’m completely horrified that they didn’t hear “severe PIH” and just find a spot. I’m glad where I work will just MAKE a spot for people with medically indicated inductions. Apparently the QA demons have not arrived or have been defeated where I am.

  • braindoc

    Question for the OBs/CNMs/FPs and other professionals who deliver babies:
    I am 37 weeks pregnant and would like to have an elective induction at 39 weeks, mainly to prevent the small but avoidable risk of a term stillbirth between then and 40weeks or 41 weeks (my risk factors are age–35, IVF pregnancy, and primigravid status; otherwise I’m healthy). Reading this study and others suggesting no increased risk for c-section or other complications has further convinced me that I would like to be induced at 39 weeks. However, the OB group I see (an academic practice) is very reluctant to do inductions before 41 weeks. Besides discussing the above studies (which I assume they know about?), any suggestions for how I can persuade my OB to do an elective induction at 39 weeks?

    • braindoc

      I’m a MD myself, though in a field totally unrelated to OB, and if I had a patient who requested a particular course of treatment that fell within the standard of care, and persisted in preferring it after a discussion of risks and benefits, I would go along with their wishes even if it wasn’t my first choice–but it seems like the OB department where I go may be less flexible…

      • attitude devant

        So would I!

        • Laura Thomas

          With an unripe cervix, isn’t there a risk of a “failed induction” – leading to a c/s – for a primagravida at 39 weeks?

          • attitude devant

            Read the article again. Better outcomes REGARDLESS of parity or Bishop’s score.

          • Laura Thomas

            If this 39-week primagravida had an unripe cervix and wanted to be induced, how would you most likely advise her?

          • attitude devant

            So, my concern would not be a c/s, frankly. It’s the idea that I might not be able to get her into labor at all and would have to send her home undelivered. This does happen.

          • braindoc

            Good to know! If someone does have a failed induction and is sent home, what happens next? (Assuming she does not go into spontaneous labor in the near future). If she remains undelivered at 41 weeks, would you re-attempt induction or do a c-section? How far would you typically allow a patient to go past her due date if an induction failed (ie, if induction for post-dates failed?) Also, could the baby experience adverse consequences from a failed induction (meconium from stress of induced contractions), or if it failed does that mean that basically nothing happened in the uterus and therefore would not affect baby?

          • attitude devant

            I offer them another trial at a later date. Often they come in spontaneously laboring a few days later. And a failed induction attempt is no more stressful on the baby than labor (obviously less stressful, since the contractions weren’t strong enough to be effective!). (This is all presuming by the way that you do it right—-no huge doses of pitocin, careful use of prostaglandin, etct)

            As for being past 41 weeks, I get really sick at the stomach at that one. Luckily most people are inducible then.

          • Laura Thomas

            This was one of my concerns as well for her. It’s terribly discouraging to send a mom home who’s been in the hospital trying to get into labor and it just doesn’t happen.

    • attitude devant

      Just ask. If your cervix is not ripe, he/she will tell you.

    • CrownedMedwife

      You have already listed your known risk factors and your desire to proceed with a 39 week IOL. With the understanding each of your risk factors assumes an increased stillbirth risk, I don’t consider this an ‘elective’ induction of labor. I consider this an induction of labor with multiple soft indicators and you could approach it this way as well.

      As our understanding of maternal and neonatal outcomes with IOL increases, I wonder how long it will take providers or policies to incorporate this knowledge into practice. Why take the risk of multiple soft indicators to 41 weeks?

    • fiftyfifty1

      I don’t understand the variability among OBs in willingness to do inductions. Is it hospital climate? I ask because a friend of mine gave birth to her baby last year and had a number of risks that had me biting my nails: age 42, first baby, conceived after 3 IVF cycles *finally* produced a healthy egg. She and her fertility specialist went to great lengths to conceive this baby….and then her OB tells her there is no reason to recommend induction until 41 weeks because she is otherwise healthy. She delivered spontaneously at 40 +4 and everything turned out well. But why wait!??

      • antigone23

        I don’t know, but I suspect some OBs are responding to NCB criticism that OBs are too eager to induce for “convenience,” and that we have “too many inductions.” Many women I know believe this crap hook line and sinker and will shop around for an OB or CNM who will let them go longer without inducing.

    • Jessica

      I had chronic hypertension when pregnant (never spiked, no medication, just monitored), and early on in my pregnancy I told my doctor I did not want to go past my due date – not just due to the hypertension, but also because of my mother and aunt’s postdates stillbirths. I explained that I have an anxiety disorder and I wanted baby here safely. I don’t know if the anxiety alone would have been enough to order the induction (the hypertension was, obviously), but had he refused I would have started talking more aggressively about my mental health at the end of the pregnancy.

  • PrimaryCareDoc

    So much for the “cascade of interventions.”

  • lawyer jane

    So when you say “The correct comparison is induced labor at specific gestational ages vs. waiting (expectant management)” what does that mean exactly? Does that mean you compare the outcome of a pregnancy induced at say 40 weeks with pregnancies not induced at 40 weeks (no matter how the latter pregnancy ended)? How exactly do they do this comparison?

    • Dr Kitty

      The authors have a flow chart which explains a bit.

      Results from women who were still pregnant after 40 weeks weren’t included.

      The authors themselves have indicated the major issue with the study: “it may be that only women who were considered more likely to be successfully induced were electively induced, and women who were considered unlikely to be successful were not (healthy user bias).”

      BUT we are beginning to see this result replicated in other studies, which suggests that there is more going on than that.

    • fiftyfifty1

      The Materials and Methods section explains it pretty well. They compare the outcomes of mothers and babies electively induced at a given gestational age (say 38 weeks) with pregnancies that were NOT electively induced at that age but that were allowed to continue. These pregnancies that are allowed to continue are a mixed bag: some will go into spontaneous labor shortly after. Some will wait longer to go into spontaneous labor. Some mothers who wait will go on to develop a condition (e.g. pre-eclampsia) that needs medically-indicated induction or CS delivery. Some pregnancies will go post-dates and end up with a post-dates induction (which is not considered an elective induction because there is a reason). A tiny but predictable number will end up with a stillbirth.

    • Jtmo

      Additionally, some studies that appeared to show increased risks with inductions compared pregnancies induced with pregnancies that went into spontaneous labor at the SAME gestational age. So, 39 week inductions with 39 week spontaneous labors. Want you want to compare to are pregnancies not induced at 39 weeks, who go on to have any of the outcomes fiftyfifty1 describes (spontaneous labor, develop complications, induced later, etc).

  • guest

    My doc recommended induction by amniotomy at 39 weeks for me, since my last baby was born rather quickly. I was at 5-6 cm when I walked into the hospital without hard contractions. After she broke my water, baby popped out in less than 4 hours, with the easiest (and aside from the AROM, natural) labor ever. As in, I probably wouldn’t have thought to come to the hospital until baby’s arrival was imminent. So, my OB probably saved me from having my baby on the side of the road. Maybe the homebirthers would say she cheated me out of an unassisted birth experience? Whatever. My elective induction was awesome and we are both totally healthy.

    • Medwife

      If I AROM someone who is at least 4 cm dilated I call it augmentation instead of induction 🙂 helps me get around the 39 week rule to be honest.

      • Karen in SC

        Brilliant!

  • Young CC Prof

    I think one reason this evidence is only emerging now is that, even one generation ago, due dates weren’t dates, they were guesstimates. Iatrogenic prematurity is bad, so doctors weren’t about to induce unless they were really sure the mother really was overdue.

    Now, we finally have enough diagnostic technology, first trimester ultrasound, etc that a large percentage of pregnant women know their due date to within a few days, and almost all of those who get prenatal care are certain to within two weeks or less.

    So finally, this question has meaning: “In a low-risk pregnancy, in a woman with no prior history of c-section, at precisely what gestational age should we encourage induction to optimize outcomes for both mother and child?”

    And it appears it may be earlier than we thought.

    • Guesteleh

      Another reason dates are more accurate is because of ART. You know exactly when you were implanted. Even an ovulation kit is a form of ART and you generally know when you got pregnant if you are using one.

      • Amy M

        I agree with this, but was an outlier. I did IVF to conceive, and knew exactly when the embryo was transferred. However, the OB, during an ultrasound that was 7wks gestation, decided the date was 1 week earlier, and suddenly, I was 8wks gestation. I know there was no embryo on the date that would have correlated with 8wks gestation at that point, but the way the embryos grew, convinced the OB otherwise. So, my boys were born at 36wk instead of 35. I can’t explain it.

        • antigone23

          The way some providers cling to LMP even in cases of ART really amazes me. I conceived via IUI on CD21, so naturally, my due date SHOULD be a week later than LMP would indicate, because LMP due dates assume ovulation on CD14. Both me RE and my OB insisted on using the LMP due date because “it wasn’t more than a week off” despite the fact that 1) we KNEW when I conceived, and 2) ultrasound measurements were consistent with that (but I was measuring only 6 days behind LMP so “it wasn’t more than week, let’s keep LMP due date.” It was really frustrating to me.

          • Dr Kitty

            No, what is worse is someone who HAD a first trimester scan having their dates changed by the radiographer on the basis of the 20week anomaly scan.

            No.
            If the dates don’t match between scans either this baby is going to be bigger or smaller than average, or you’re measuring wrong.
            Don’t replace a more accurate dating measurement with a less accurate one.

            My OB and I had an understanding.
            I have short cycles and knew exactly when I conceived. MY EDD was 7 days later than LMP put it, but we agreed to use the LMP on the basis that neither of us wanted me to go post dates.

            My kiddo was delivered at “39+4” according to LMP, 38+4 based on my dates.

          • Young CC Prof

            Changing due dates on the basis of a later scan? That’s nuts. A big part of the reason they DO the dating scan is as a baseline for other scans, so they know what the baby is supposed to look like at any point.

    • Ash

      Anyone know about what % of pregnant women receiving prenatal care in the USA get a first trimester ultrasound?

      • rachel

        I don’t know any real numbers but everyone in my office and the other OB office in town. Not true of the family practice office in town–they don’t due the first trimester ultrasounds, so the first scan is the 18-20 week anatomy scan.

    • Ash

      If the outcomes were the same for both groups, I imagine that quite a few OBGYNs and families would be interested in elective induction in this population. At the very least it makes logistical planning easier.

      • Young CC Prof

        We’d also need to get past the idea that convenience inductions are inherently morally wrong. (No, no one should put convenience AHEAD of safety, but when Option A and Option B are equally safe, you don’t get points for choosing the harder one.)

        • Roadstergal

          And there’s a case to be made that convenience could improve safety. A scheduled, easy drive to the hospital at a time when you can make sure the other kids are being taken care of, when some friends or family can be around to help out, when your partner can take a few days off of work, vs a frantic rush to the hospital in the wee hours of the morning when everyone who said they could help is out of town…

          • Elizabeth A

            Absolutely. Convenience isn’t some kind of dirty word!

          • Amy M

            It is to the AP/NCBers, but who cares what they think?

          • Sue

            Of course convenience can improve safety. Most things go better when planned and staffed.

        • Ceridwen

          My next baby will almost certainly be an elective induction. I was cautious about inducing prior to my due date with my first. In part because I needed to finish my semester at school and in part because the research was still uncertain for the 39-41 week range. We were planning to schedule an induction for ~40+3 or so if I still hadn’t gone into labor at my 40+1 appointment. Didn’t end up needing to as labor started on my due date.

          Next time around we’ve got a toddler to worry about and we still live 2000+ miles from family with only a couple of friends who can potentially watch the toddler for us. We’ll most likely schedule the induction for right around 39 weeks so my family members can fly in to help us out. And increasingly science seems to indicate it’s a totally valid (and perhaps even preferable) choice.

          • Young CC Prof

            If I have another child, I almost certainly would do RCS, not because I’d necessarily be a bad candidate for trial of labor, but because I wouldn’t be emotionally comfortable with waiting for labor past 39 weeks OR with serious induction techniques on a scarred uterus.

        • CrownedMedwife

          The majority of L&D RN’s I work with are excellent, even still a few of the excellent have bought so far into AWHONN’s Full 40 Weeks initiative that I now have to deal with Nursing documentation that reflects inaccuracies or judgment. For instance, multigravida with favorable cervix 39.2 for IOL may have Nursing documentation “IOL because tired of being pregnant’ or “Because my CNM said I could”. Then patients being told by RN she should be going “The Full 40 Weeks” has reduced mothers to tears of guilt, fear and distrust of provider’s willingness to accomodate and support a 39+wk IOL. Morally, neither is wrong, but the fact that I have provided care to a particular mother for weeks or years & know her particular circumstances (ie cousin had 40 week IUFD, just, childcare availabe, spouse only has these days off and the fact she hasn’t slept more than 4 hours a night with intractable GERD or asthma symptoms) makes her IOL absolutely RIGHT for HER.

    • Who?

      One for the docs-I have a long cycle (about 45 days), so how would you work out the true dates? Ovulation is at day 30 or so, which makes LMP a bit of a weird measure when everyone else’s cycle is so much shorter.

      Both my kids were born at what we counted as 41 and 3 days, without being nudged. They both had mec but were okay pretty quickly after being prodded and poked by the neonatal team, who were there I think because of the meconium. They were biggish (3.8kg)-I was just over 50kg before getting pregnant-and longish, but didn’t look particularly overdone.

  • Michele

    I wish I’d known this with kid #1. I really thought I was doing what was best for him by waiting to schedule an induction for 41+3. He was born at 41 weeks but if we’d induced earlier maybe we could have saved him the NICU stay and I would have been less likely to need a c-section.

  • Ellen Mary

    A few questions here: where does this leave VBAC mothers?

    Could the success have changed because the induction agents have changed? In my last labor, Misoprostol was the only option for cervical ripening . . . Does the study specify what was used?

    I still have a lingering concern about Pitocin contractions vs. spontaneous contractions on the baby . . . The only time I have experienced contractions on Pit, they felt very different than spontaneous contractions to me . . . So I wonder if they are harder to deal with for the baby . . . In my last labor, I stopped the Pitocin because they were harder to deal with for the baby, but it was because they were strong contractions & he had a double knot and a nuchal that was later discovered. So I don’t think it was the Pit itself in that case . . . But the point is, this study didn’t assess long term outcomes, right?

    • moto_librarian

      Do you think that pitocin contractions feel different because they are consistently strong and don’t gradually increase in intensity as they typically do during spontaneous labor? I had some pitocin with my second because I had been stuck at 5 cm. for about 8 hours despite regular contractions. I could not “feel” the difference, but they had to stop the pit because our son was not tolerating it well. When the CNM broke my water, there was light mec in the fluid. When he was crowning, he went into severe distress, and I delivered him just as the nurse asked if she needed to page the obstetric emergency team. He rolled out of his cord (wrapped around his body 3 times), and he was a bit stunned. The NICU team was there because of the mec, and he got deep suction, O2 via CPAP, and vigorous stimulation. He was stable and in my arms within twenty minutes.

      Now, did the pitocin cause him to be distressed and pass mec, or were his issues directly related to his cord and would have presented if my labor had ever gotten going strongly on its own? I tend to think it’s the latter. I can’t say with certainty, but I suspect he would have shown stress during non-augmented, natural labor as well.

      • Ellen Mary

        Yes, I know my son would have shown stress during a natural labor as well, in that way the low dose of Pit I was on was almost like a ‘stress test’ (and it was a similar dose), that gave us a window on what labor would look like.

        I have always thought though that a Cesarean might be preferable from the baby’s POV than a long labor on Pit . . . It might be preferable to any long labor . . . But I wonder if there is something about Pit that is a risk to the baby specifically . . .

        • moto_librarian

          Pitocin has been used for a long time, so I do think that if there were specific risks for the baby, they would have been discovered by now. Dr. Amy probably can answer this better.

        • fiftyfifty1

          “But I wonder if there is something about Pit that is a risk to the baby specifically . . .”

          Well, most inductions use pit at some point, and this study says that induced babies did better than babies expectantly managed. So either there is no risk to baby of pit, or if there is some small risk to baby of pit, it is outweighed by the risks to baby of waiting.

          • auntbea

            But….maybe if I can narrow the question in some other way, I can get the answer I am absolutely positive is true?

        • attitude devant

          Here’s the differences (for the baby) between a pit contraction and a spontaneous contraction: if the mom is on pit and the contractions are coming too fast for the baby to tolerate, I can turn it down or off. I can’t do that with spontaneous contractions. With regard to the difference in feeling, pitocin contractions tend to onset a bit more abruptly, which if you’re doing Lamaze or Bradley, can be challenging. A spontaneous contraction starts more gradually, so you can get set for it more easily.

        • Amy M

          More anecdata: I had pit augmentation. My natural contractions were pretty useless, and the pit brought things up to speed. My babies tolerated it well and were born a few hours after the pit was brought on board. 5.5yrs later, they are fine, healthy boys. I suppose you might be interested in a seeing a study where one mom had pit for one of the children, and no pit for another? Of course it would be very difficult to account for confounders. Besides age of mom/SES/gestational age and why the pit was introduced in the first place.

    • fiftyfifty1

      Your questions are answered in the Methods section of the paper that Dr. Amy links to. VBAC mothers were excluded. Induction method was at the providers’ discretion and included all methods and all agents.

      • Ellen Mary

        Thx. I didn’t mean ‘were VBAC mothers included in the paper’, more like ‘where does this knowledge leave VBAC mothers now . . . ‘

    • auntbea

      What long-term outcomes are you imagining induction might cause that is not predicted by/correlate with outcomes at birth?

  • moto_librarian

    So if NCB advocates really want to lower c-section rates, they need to stop bitching about inductions as “unnecessary interventions.”

    • fiftyfifty1

      Not just stop bitching about them, but also start actively recommending them.

      • Young CC Prof

        Jen of VBAC (not necessarily) Facts does. ICAN and Lamaze International are still running around telling everyone that inductions cause c-sections.