Yet more evidence that elective induction of labor improves outcomes

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In February I wrote about new data presented at the Society for Maternal Fetal Medicine annual meeting that showed that elective induction at 39 weeks improves outcomes.

The accompanying press release noted:

Results include:

• Lower rates of cesarean birth among the elective induction group (19%) as compared to the expectant management group (22%)
• Lower rates of preeclampsia and gestational hypertension in the elective induction group (9%) as compared to the expectant management group (14%)
• Lower rates of respiratory support among newborns in the induction group (3%) as compared to the expectant management group (4%)

This was in keeping with previous studies that showed that elective induction decreases perinatal mortality:

Given the large body of evidence, women who want to be induced at 39 weeks gestation or thereafter should be accorded that option.

Stock, Sarah J., Evelyn Ferguson, Andrew Duffy, Ian Ford, James Chalmers, and Jane E. Norman. “Outcomes of elective induction of labour compared with expectant management: population based study.” BMJ 344 (2012): e2838.

And studies that showed that induction improves maternal and neonatal outcomes:

Gibson, Kelly S., Thaddeus P. Waters, and Jennifer L. Bailit. “Maternal and neonatal outcomes in electively induced low-risk term pregnancies.” American Journal of Obstetrics & Gynecology 211, no. 3 (2014): 249-e1.

Mishanina, Ekaterina, Ewelina Rogozinska, Tej Thatthi, Rehan Uddin-Khan, Khalid S. Khan, and Catherine Meads. “Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis.” Canadian Medical Association Journal 186, no. 9 (2014): 665-673.

In other words, contrary to the claims of natural childbirth advocates that babies are “not library books due on a certain date,” there is an optimal time to be born and poor outcomes rise on both sides of that optimal time.

But as I acknowledged at the time, we hadn’t yet seen the completed paper. Yesterday that paper was published in The New England Journal of Medicine titled Labor Induction versus Expectant Management in Low-Risk Nulliparous Women.

They found:

The primary perinatal outcome [a composite score of neonatal injury and death] occurred in 4.3% of the neonates in the induction group and in 5.4% in the expectant-management group (relative risk, 0.80; 95% CI, 0.64 to 1.00; P=0.049 [P

And:

The percentage of women who underwent cesarean delivery was significantly lower in the induc- tion group than in the expectant-management group (18.6% vs. 22.2%; relative risk, 0.84; 95% CI, 0.76 to 0.93; P<0.001). This finding did not change materially after adjustment for previous pregnancy loss. Women assigned to induction of labor were also significantly less likely than women assigned to expectant man- agement to have hypertensive disorders of pregnancy (9.1% vs. 14.1%; relative risk, 0.64; 95% CI, 0.56 to 0.74; P<0.001) and to have extensions of the uterine incision during cesarean delivery …

They concluded:

In summary, we found that elective labor induction at 39 weeks of gestation did not result in a greater frequency of perinatal adverse outcomes than expectant management and resulted in fewer instances of cesarean delivery. These results suggest that policies aimed at the avoidance of elective labor induction among low-risk nulliparous women at 39 weeks of gestation are unlikely to reduce the rate of cesarean delivery on a population level; the trial provides information that can be incorporated into discussions that rely on principles of shared decision making.

Two other recently published papers confirm advantages of induction.

Nonmedically Indicated Induction of Labor Compared with Expectant Management in Nulliparous Women Aged 35 Years or Older found:

In nulliparous women aged ≥ 35 years, NMII [nonmedically indicated induction] was associated with decreased odds of cesarean delivery at 37 to 39 weeks’ gestation and decreased odds of NICU admission at 40 weeks’ gestation compared with expectant management.

Elective induction of labor at 39 weeks among nulliparous women: The impact on maternal and neonatal risk showed:

Mathematical modeling revealed that eIOL at 39 weeks resulted in lower population risks as compared to EM [expectant management] with induction of labor at 41 weeks. Specifically, eIOL at 39 weeks resulted in a lower cesarean section rate, lower rates of maternal morbidity, fewer stillbirths and neonatal deaths, and lower rates of neonatal morbidity.

Not surprisingly, midwives who routinely demonize interventions are panicking.

Hannah Dahlen’s reaction is priceless — a whole lot of words that say nothing.

Dahlen, like many other midwives, believes in the faulty Panglossian paradigm that if something is natural, it must be best. In the context of evolution the Panglossian paradigm imagines that everything that exists in nature today is the product of intense natural selection and represents the perfect solution to a particular evolutionary problem.

But as evolutionary biologist Stephen J. Gould pointed out, an existing natural feature may not be the result of evolutionary pressure at all; it may be an incidental feature of a solution to an entirely different problem or it may represent the limits of genetic adaptation.

For example, it would undoubtedly be evolutionarily advantageous to have eyes in the back of our heads yet we never developed them. Instead technology gave us mirrors, which we can use to escape our biological limitations and see behind us. Two eyes don’t represent the best of all possible outcomes, merely the outcome that we have.

In the case of childbirth, each birth involves an evolutionary compromise between the neurological advantages of a larger neonatal brain and the potentially deadly consequences of a larger neonatal brain leading to obstructed labor.

The brain continues to grow throughout pregnancy. Babies born at later gestational ages have bigger heads and are more neurologically mature but also more likely to die in labor. Babies born at earlier gestational ages have small heads which gives them a tremendous advantage in childbirth. The optimal time to be born is when the baby’s head is as large as possible before it becomes too big to fit. That optimal time appears to be at 39 weeks.

The same thing applies to the size of babies relative to the function of the placenta. Some placentas last longer than others. The longer a baby remains inside the mother, the more neurologically mature and fitter it will be. However the longer a baby remains inside the mother, the greater the chance that its growth will outstrip the placenta’s ability to supply oxygen. If the baby stays inside longer than the placenta can function, the baby is stillborn. The optimal time to be born is immediately before the baby’s growth starts to outstrip the placenta’s ability to supply oxygen. That optimal time also appears to be at 39 weeks.

You could make a very good argument that all women should be induced at 39 weeks of pregnancy in order to optimize perinatal outcomes and decrease the C-section rate. No doubt ACOG and other professional organizations will resist that conclusion for the time being. However, given the large body of evidence, women who want to be induced at 39 weeks or thereafter should be accorded that option.

  • Kelly

    The hospital I will deliver just told the Obs that they can’t induce without a medical reason until 40 weeks. Now, I have gone before 40 for all three of my children but it still stresses me out with my fourth because I would rather my child come out a few days early than be stillborn. I asked my Ob why and she told me that they said it’s because it has a higher risk of a c-section. I was annoyed because I have already been induced and I didn’t even come close to a c-section. I hope that the hospital changes it’s mind after this study.

  • JDM

    There are two details about evolution that lay people should learn:

    1. evolution doesn’t always involve selection of any kind; many features come about via random drift of genes.
    2. selection doesn’t make for optimal, it makes for “good enough”.

    • High school biology tells us as much.

      • RudyTooty

        Fun fact.
        NARM, the organization that certifies Certified Professional Midwives (CPMs), began requiring a high school diploma for certification in 2012. This is the highest degree required by those holding that credential. Fully licensed and authorized to attend your birth in your state, or in a state near you!

        • Well, gee, I even minored in biology in college–I must be super-qualified to deliver babies! Or do I have too MUCH medical knowledge, and have lost the intuitive sense that all good CPMs have?

          • RudyTooty

            You may be overqualified. With that college biology minor. 😉

          • When it comes to delivering babies, I am qualified to call an ambulance, get towels, and, uh, hold the laboring woman’s hand and tell her to breathe.

          • Merrie

            Don’t sell yourself short. I’m sure you could also rub her back and bring her water.

    • Sarah

      I’d add a third, evolution doesn’t give a shit about whether an outcome is upsetting.

  • Lee McCain MD

    So when dear ACOG can we ditch the 39 week rule!?

  • RudyTooty

    http://annualmeeting.acog.org/support-for-elective-iol-at-39-weeks-growing/

    Ever since this ‘debate’ from the ACOG conference was publicized, I have been asking the question of my colleagues:

    “What is wrong with offering an intervention that reduces the cesarean rate, AND the rate of babies dying?”

    I really LOVE both of those outcomes.
    That is not hyperbole. I LOVE BOTH THESE OUTCOMES.

    Also, couldn’t this argument be reframed as: ’39 week inductions reduce unnecessary cesarean sections’?

  • Rebecca Doble

    I completely support a woman’s choice to be induced if she wishes. But the more accurate conclusion from this study is that induction at 39 weeks has a lower risk of caesarean section *for North American women who choose a doctor as their primary care provider*. The sample space does not include midwifery care, which has studies showing significantly lower caesarean rates, nor women from other countries with statistically lower caesarean rates. So stating that induction will *always* reduce caeserean rates is a terrible misuse of science. Don’t cherry pick science to suit your own view point!

    • A competent midwife will be on the same page as an MD, if she works within a system with the correct parameters. The goal should not be a “midwife delivery at all costs”. The MD isn’t an enemy; he is, or should be, the midwife’s colleague, to whom the patient is referred when appropriate.

      • LaMont

        For the life of me, I am still terrified at the idea of one day having children and being told some ideologue who thinks nature is our friend is going to be the gatekeeper between me and actual medical oversight, and ultimately I’ll be treated as though cure >> prevention. Hell no.

        • Rebecca Doble

          Heck no, I support all women to make the decisions that are best for themselves and their babies! It just annoys me that one study has the anti-midwife establishment saying how bad midwives and natural births are. The thing is, even if you choose OB care, you’ll still get a midwife for 80% of the time you’re in labour, cause the OB doesn’t have time to hold your hand the whole time. Improving relationships between the two groups is critical for best practice care. I’m just weary of them bashing each other all the time.
          It’s awesome that the study will help women get an induction at 39 weeks *if* that is what they choose.

          • Who?

            Perhaps there would be less bashing if the birth hobbyists who call themselves midwives would be quiet, if actual midwives stuck to their scope of practice, and doctors weren’t treated like pariahs for wanting to save lives, health and brains using medical knowledge and technology.

          • Rebecca Doble

            There have been excellent outcomes and improvements in maternity services from both obstetrics and midwifery. It’s not right to bash either profession. Please don’t.

          • Who?

            Who is bashing anyone?

            Birth hobbyists are not happy with these findings, as they mess with the business model.

            Some actual midwives also seem not to be, as they are distracted from outcomes for their patients by the need to maintain and extend their scope of care in hospitals and out of hospital.

            Those are just facts.

            If the folks in questions feel bashed, they should look to their motivations and consider whether they support optimum safe outcomes for mothers and babies, or their wallets and egos.

            Simple.

          • RudyTooty

            “Birth hobbyists” is an apt term.

          • Who?

            I think so. It’s very important to distinguish between highly trained professionals who work with their colleagues in other disciplines and within a scope of practice, and pregnancy-crazed wingnuts who think just because they catch a few babies and have a good line in patter, they have something of value to offer.

          • RudyTooty

            I’m not sure what the anti-midwife establishment is, but I am a nurse-midwife myself, and I’ve been very critical of the way some natural birth advocates and midwives have responded to this randomized controlled trial.

            I’m in the US. So midwifery and nurse-midwifery are practiced somewhat differently than where you are (Australia?) A woman in labor in the US will have a registered nurse specializing in obstetrical nursing attending her during labor (this is true regardless of whether the patient’s primary provider is an OB or nurse-midwife, or GP). Midwives in non US countries appear to take on the role of the obstetrical nurse as well as being the delivering provider. In the US, the delineation is between who monitors the patient during labor (customarily an OB nurse), and who ‘catches’ the baby (the physician or nurse-midwife.)

            It would be awesome if the evidence from this study would allow for women to elect to undergo induction of labor at 39 weeks gestation.

            I have no interest in forcing women to induce their labors if they don’t want to. If women are low-risk, I see no reason to coerce them into induction (that kind of makes it non-elective, if you’re forced, coerced or somehow convinced to do it, right?)

            What women in the care of U.S. OB providers are facing are institutional bans for elective induction of labor until 41+0 weeks in many facilities. And the rationale given for this restriction is that the risks of induction without medical indication are too high. Well, this recent RCT shows us that our previous assumptions about the risks of induction may have been incorrect.

            This isn’t bashing. This is looking at current evidence, sharing this evidence with the population we serve, and increasing choices for our patients.

          • Amy Tuteur, MD

            It’s not one study. This is just the latest example of a philosophy that privileges process above outcome, ignores scientific evidence that it doesn’t like and praises academic midwifery theorists who justify ignoring evidence in preference to intuition.

          • moto_librarian

            Um, midwives delivered both of my children. And other than when I was pushing, they were not there “holding my hand” throughout labor.

          • I think you mean “L&D nurse.” They don’t exactly hold your hands nonstop, but they do tend to be providing most of your care throughout labor, unless something goes pear-shaped. L&D nurses are great, and I’ve never had any that were anything but supportive of my husband’s and my wishes.

    • Merrie

      Midwives (are supposed to) see only low-risk patients who as such are less likely to end up needing a c/s anyway. So unless you’re comparing patients under doctor care who meet the criteria to see a midwife and are seeing a doctor anyway for whatever reasons, versus patients who see a midwife, it’s not a true comparison.

      • swbarnes2

        The whole study was supposed to be of “low risk” primips, so in theory they all could have been in midwife care. They didn’t see any differences based on the kind of provider (obstetrics–gynecology, maternal–fetal medicine, family practice, or midwifery), but with only 6% choosing midwifery, there might not have been enough power there.

        • Merrie

          Well, my guess is wherever Rebecca is getting her stats from does not feature equal comparator groups, and therefore is meaningless. Given that she hasn’t been back to respond, my suspicion of this is increasing.

    • MWguest

      What would a midwife do differently that would increase a woman’s risk of cesarean? Hypothetically speaking.

      Midwives tout a lower cesarean rate, and that they’re experts at ‘normal birth.’ So had all these patients been induced under the care of a midwife, wouldn’t the hypothesis be that the cesarean rate would be even lower?

    • momofone

      I absolutely agree. Don’t.

    • Jenny

      I was under the care of midwives and I was recruited to join this study. So not all midwifery care was excluded.

      • swbarnes2

        The papers mentions that 6% of the women were under midwife care. The midwife ideologues imagine that the women under expectant management care under midwives would magically not have as many c-sections as the women under OBs.

  • Anna

    Has Hannah Dahlens response been deleted or is it just because she blocked me on FB I cant read it?

    • RudyTooty

      I had posted her response on another comment, and Disqus marked it as spam. 😛 Can’t really disagree, but here it is again.

      —-
      Hannah Dahlen:
      Well everyone the ARRIVE trial has finally arrived. This was the elective induction of labour trial at 39 weeks. A total of 3062 women were assigned to labor induction, and 3044 were assigned to expectant management. The primary outcome of perinatal morbidity for the baby occurred in 4.3% of neonates in the induction group and in 5.4% in the expectant-management group (relative risk, 0.80; 95% confidence interval [CI], 0.64 to 1.00) (not significant). The frequency of cesarean delivery was significantly lower in the induction group than in the expectant-management group (18.6% vs. 22.2%; relative risk, 0.84; 95% CI, 0.76 to 0.93).
      But here are some interesting details:
      1. It took over three years to recruit the women for the study and over 50,000 women were screened for eligibility with 22,533 deemed eligible. Only 6106 (27%) agreed to be randomised (acceptability was therefore low). This means 16,427 women did not agree.
      2. In the study 94% had a doctor as care provider and only 6% a midwife. We know care provider a major issue when it comes to rates of normal birth. Providers could not be blinded to group allocation and 94% had doctor care who are more pro induction, so you do the math.
      3. Women in the elective induction group gave birth on average at 39.3 weeks and in the expectant management group at 40 weeks (5 days difference).
      4. 280 women in the expectant management group had an induction or elective caesarean section and 366 in the induction group did not follow protocol for induction at 39 weeks (not clear exactly how many decided to await spontaneous labour)
      5. These women were very low risk and still 1:5 had a caesarean section
      6. No one is looking at long term follow up regarding the effect of
      increased exposure to synthetic oxytocin and other possible epigenetic implications
      So in summary:
      • Most women said ‘no’ when asked to participate
      • Women were very low risk and still had a high caesarean section rate for this population
      • Women were not much different in their gestational ages in the two groups
      • Over 94% of women had medical care and only 6% midwifery (love to see a sub analysis on that group)
      • IOL at 39 weeks saved no more babies than waiting.
      • We have no idea about the long term effect
      We must not arrive at conclusions too early on this one. Caution is
      needed. Let’s see this study repeated in a midwifery led population and see if the normal birth rate is impacted on. The problem with this would be that even fewer women would agree to be randomised which tells us one thing: induction of labour is not readily embraced by women!
      /endquote

  • Sue

    Dahlen says “most women said no when asked to participate” – but probably not for the reason she assumes. More likely they didn’t want to be left when an induction might be indicated.

    • Jenny

      The expectant management group still would have gotten and induction if medically indicated (the control condition was standard of care), but a lot of women who said no, might have done so because they were worried about increased c-section risks, given this evidence to the contrary they might make a different decision. I think most people say no to participating in research studies generally, so I’m not sure that’s a great critique.

    • Anna

      Yeah I don’t think many women would be all that keen about participating in being randomly allocated to a study that could determine something so important. If you’re in Aus, NZ, Canada or the UK you’d have to be living under a rock not to have heard all the negativity about induction. In many circles induction itself is referred to as a negative outcome.

      • Sarah

        The problem also in the UK is that women undergoing induction are often left without pain relief for lengthy periods while it kicks in. And sometimes even once labour is established. Because of cuts and understaffing, it’s also not especially uncommon to be asked to come in at a particular time and end up waiting hours until someone is available to see you. Not an ideal start to proceedings, to start labour already tired from sitting around and waiting.

        I have had a CS, hence probably wouldn’t be a good candidate for anything more than a time limited attempt at induction, tops. So this is theoretical for me. But were I a good candidate for induction, I’d be worried enough to take this possibility into consideration when deciding. Particularly if there were no pressing medical need.

  • Jessica

    Makes me grateful for my doctor. I told her I was concerned about going past term given my age and the fact that I had to back sleep due to a medical condition. She was like, yep, you’re a good candidate for induction; we can do any time after 39 weeks, I am on call at 39+5 so let’s schedule you then. As it happened I went into natural labor at 39+1 so it wasn’t needed. But I appreciated the no-fuss pragmatic approach.

  • Allie

    This is, by far, my favourite comment on the link to Hannah Dahlen’s response:

    “Apparently some years ago, a study in New Zealand- Blind trial, showed sheep who were given the induction drugs, had problems bonding with their lambs. Sheep birthing naturally, had no problems bonding!” (sic)

    The level of stupid is astounding.

    • Anna

      It was a blind trial and someone sat around in the paddock watching the sheep bond??? Where do I sign up for this important work!? I guess they could have numbered each lamb to keep it blind. Oooh please PM or write in code the name of this commenter. If they are a midwife I want to laugh about it with my friends in the “anti-midwife establishment”.

  • Knittingbiddy

    Long time lurker, first time poster. I am a family doc who does deliveries in rural Canada. I just had my 3rd baby at my hospital and was hoping for a 39 week induction for AMA (2 months short of my 40th bday). Had to settle for 40 + 2 for logistical reasons and it was a bit of a tough sell to my very understanding physician/colleague. Inductions before 41 weeks are frowned upon here. It was my favourite labour/delivery of all my children (if that can be said for a labour that went so fast there was no time for an epidural!) Most of the research I read on reduction of stillbirth and c/s rate was for primips. Does anyone have any references on 39 week inductions for multips? (Especially multips of advanced age). Thanks in advance.

    • StephanieA

      I work at a busy community hospital, but your colleagues sound a lot like mine- induction before 41 weeks is frowned upon. I decided on an elective induction at 39 weeks for my third baby, and my co workers thought I was crazy. I felt like I constantly had to defend my decision, even though it should’ve just been between my doctor and me. I ended up having baby at 38 weeks, but if there is a 4th baby I will schedule an elective induction again.

    • guest

      I was 39 when I delivered my 2nd and had some odd test results that resulted in having weekly ultrasounds starting at 32 weeks just to make sure baby was doing okay. I was totally freaking about stillbirth. There was no discussion about induction from my OB, but maybe that’s because I didn’t make it far enough along to warrant it? At my 35 week ultrasound, my doctor told me that baby looked good and if I went into labor, they wouldn’t try to stop it. Also told me not to have the baby in the next week because she would be on vacation. I think she must have had suspicions because I delivered 5 days later, which I was grateful for and nervous about at the same time (just kept reminding myself the OB said the baby was fine to come early). I was so relieved when they gave baby the all clear. Even more relieved that because my daughter was early, I got a special nurse to care for her and she could go to the special care nursery when I wanted to sleep.

    • Gene

      I was AMA for all three of my kids. First arrived at 38wks on her own, but second two were inductions. #2 was at a hospital that refused to induce prior to 40w and my OB was griped at for trying at 39/5. For a 5kg kid. My last kid, I flat out asked the earliest I could be induced. Their practice was anytime after 39w. Last was born at 39w by maternal request induction when I was 40y. No idea of research separating multips vs primips. But there is data on AMAs.

  • RudyTooty

    ACNM is not doing much better with a response. And they should be.
    SMH.

    I can’t figure out what’s not to like about reduced cesarean rates, and better neonatal outcomes. I really, really like those outcomes. And I can’t figure out why I, as a midwife, wouldn’t offer elective induction to my patients at 39 weeks – FOR WHATEVER REASON THEY WANTED.

    There still seems to be plenty of room for patient choice and options – there are many patients who are ready to be done being pregnant at 39 weeks – I’m having a harder and harder time figuring out a valid reason to deny a maternal request for an induction at 39 weeks.

    This seems really simple to me.

    http://midwife.org/ACNM-Responds-to-Release-of-ARRIVE-Trial-Study-Results

    • RudyTooty

      More from ACNM leadership:

      “Some of the things that go along with an induction may not be part of
      what they had planned for their overall birth experience,” Kane Low
      tells Shots. “It does require an IV, it does require that you have
      continuous electronic fetal monitoring to be safe, and it requires the
      use of different medications in order to start the labor process. And
      all those things need to be factored into what someone was hoping for
      their overall birth experience.”

      https://www.npr.org/sections/health-shots/2018/08/08/636428119/pregnancy-debate-revisited-to-induce-labor-or-not

      • BeatriceC

        I hate shit like that. I had the worst birth “experiences” possible, including pregnancies that ended in second trimester miscarriages, and premature but viable babies. The least sick baby I had was the middle one, and he was 32 weeks. It was a relatively casual CS, almost a party atmosphere, if you ignored the NICU team in the corner. My oldest got stuck with a shoulder dystocia and wasn’t breathing and had a barely perceptible heart rate of 30bpm and dropping. My epidural had worn off by that point and the pain of my doctor using desperate measures to fee the baby because there wasn’t time to get into the OR and get an anesthesiologist on the premises (after business hours, so the on-call had gone home for dinner). And then I didn’t even get to see him for three days because he was life flighted to a hospital with a higher level NICU. I barely remember the youngest’s birth, as it was a “smash and grab” style CS at 24 weeks to save *my* life.

        And you know what? Not a fucking bit of it matters now. After 19 years I finally had surgery two weeks ago to repair the damage the birth of my oldest caused, and now I can sneeze without peeing myself, and I did need therapy to cope with having very sick newborns, but that’s the extent of the relevance of my experiences on the overall job of parenting. What’s important is that my kids have been given a chance to survive and grow up to be the amazing young men that they are.

        • RudyTooty

          We lose sight of what a truly bad birth experience is when we prattle on about “birth experiences.”
          The worst? Is having a dead baby.
          That’s the worst.
          (I suppose being dead yourself is the very worst, but not sure how you get to experience that. Death. It’s just bad for everyone.)

          Midwives carp on and on about the increased ***risk of death*** for the the mother if she has a c-section, now we’ve found an intervention (induction of labor) that demonstrates a decrease in the rate of c-section (and those associated risks) but that’s not good enough.

          Come. On.

        • Sarah

          Congratulations re the sneezing!

        • demodocus

          Yeah!! I hadn’t heard how your surgery went yet.

          • BeatriceC

            I thought I updated on FB. I don’t know. I’ve run across a couple posts I have no memory of making in the 12 hours or so after surgery.

          • demodocus

            I may’ve just overlooked it or something. *hugs*

      • The Bofa on the Sofa

        See those goalposts moved?

        First it was the unnecessarian. Now, we can reduce the number of c-sections, it’s…an IV? EFM? Oh dear!

        • RudyTooty

          Moving goalposts.
          We take a course on this in midwifery school. Per MERA standards, the ICM and Ina May’s Manifested Testimonial for Midwives.

          It’s a hallmark of midwifery.

        • Kelly

          It really annoys me because it makes it seem like women can’t decide for themselves what they want. My doctor can tell me what an induction entails and I am pretty dang sure I am smart enough to figure out what I do and do not want. I mean, I just made a huge medical decision about my daughter’s medical testing and no one batted an eye or made me feel like an idiot. Why can’t I do the same thing for myself and my unborn baby without being patronized?

          • Sarah

            Woman’s body, so rules are different.

      • swbarnes2

        The midwives are seriously arguing that women would rather a higher chance of C-section if it means they avoid IVs? As if the women who don’t like fetal monitoring are going to love a hurried C-section?

        • RudyTooty

          Gah. You know what. *Some* women are not going to want to be induced! And that’s okay! It really is. They’re not going to want to be induced for whatever reason: an IV, the phase of the moon, the preferred natural experience… whatever. That. Is. Okay.

          *Some* women want to not be pregnant any longer at 39 weeks, and we have data that show that inducing at that point is SAFE, doesn’t increase risk of harm, and **decreases the rate of cesareans** so why the EFF not just offer this?

          This issue is really getting under my skin here. But really. Why. The. Eff. Not?

          Rudy Tooty, BS, CNM

    • The Bofa on the Sofa

      I’ve been saying it for a while, the ACNM has a serious problem.

  • Amy Tuteur, MD
    • Who?

      Well their business model just got trashed.

      And what on earth is Henci Goer talking about?

      • Mel

        Goer is saying that induction and C-sections are equally bad outcomes that are being compared with induction coming out slightly ahead of a C-section.

        I thought that logic was stupid before I had my son. Now I find it deeply insulting as well as dumb.

        • Young CC Prof

          She defines induction itself as a bad outcome. Talk about moving the goal posts! And definitely not the way most mothers would see it.

          • Merrie

            I guess if you don’t want to be induced if you can help it, the idea of “Get induced to reduce your risk of a c-section” leaves you going “Yeah… but then I have to get induced and I wanted to avoid that too”. Though of course either is preferable to having the baby dead or damaged!

            I did not particularly like the idea of having to be hooked up to all those different things. Certainly if warranted I’d have been willing but it wouldn’t have been my first choice. I like even less the idea of having a baby in my kitchen, though, so given that my labor has gotten faster every time, if we had another I probably would get induced anyway.

    • RudyTooty
      • attitude devant

        I just love that “B.A” after he name. Makes me LOL every time.

        Signed,
        attitude devant, BA, MD, FACOG, CDTA, MMW, TYVM

        • RudyTooty

          Does my B.S. rank higher or lower than Goer’s B.A?

        • BeatriceC

          Where does my Ph.D. coursework, but unfinished degree, come in? And it’s not even an ABD Ph.D. I still had a couple of the competency exams before I could start on a dissertation.

        • RudyTooty

          You’ve all heard this one, right?

          “I can read,” is Goer’s self-appraisal of her qualifications for all her expertise.

          Her ability to read gives her the authority on any issue she wishes. According to her. Whew.

          https://uploads.disquscdn.com/images/c969484cf815c4bba7300a1374f6ac8ff74ec7011acdc64f9a257d48c6df8010.jpg

          • Amy Tuteur, MD
          • RudyTooty

            I should have known that you wouldn’t have let this lunacy get by you. 😀

            I will confirm that midwifery schools use her texts – and want to make sure everyone understands that it’s not just the fringey CPM midwifery schools, but Frontier Nursing University also uses a book Goer co-authored, Optimal Care in Childbirth, as a required text in their nurse-midwifery program.

            :-/ :-/ :-/

  • attitude devant

    I can’t access FB. If someone wants to copy-paste or screenshoot Hannah Dahlen’s comments I’d be thrilled. TIA

    • RudyTooty

      Hannah Dahlen:

      Well everyone the ARRIVE trial has finally arrived. This was the elective induction of labour trial at 39 weeks. A total of 3062 women were assigned to labor induction, and 3044 were assigned to expectant management. The primary outcome of perinatal morbidity for the baby occurred in 4.3% of neonates in the induction group and in 5.4% in the expectant-management group (relative risk, 0.80; 95% confidence interval [CI], 0.64 to 1.00) (not significant). The frequency of cesarean delivery was significantly lower in the induction group than in the expectant-management group (18.6% vs. 22.2%; relative risk, 0.84; 95% CI, 0.76 to 0.93).

      But here are some interesting details:

      1. It took over three years to recruit the women for the study and over 50,000 women were screened for eligibility with 22,533 deemed eligible. Only 6106 (27%) agreed to be randomised (acceptability was therefore low). This means 16,427 women did not agree.

      2. In the study 94% had a doctor as care provider and only 6% a midwife. We know care provider a major issue when it comes to rates of normal birth. Providers could not be blinded to group allocation and 94% had doctor care who are more pro induction, so you do the math.

      3. Women in the elective induction group gave birth on average at 39.3 weeks and in the expectant management group at 40 weeks (5 days difference).

      4. 280 women in the expectant management group had an induction or elective caesarean section and 366 in the induction group did not follow protocol for induction at 39 weeks (not clear exactly how many decided to await spontaneous labour)

      5. These women were very low risk and still 1:5 had a caesarean section

      6. No one is looking at long term follow up regarding the effect of
      increased exposure to synthetic oxytocin and other possible epigenetic implications

      So in summary:
      • Most women said ‘no’ when asked to participate
      • Women were very low risk and still had a high caesarean section rate for this population
      • Women were not much different in their gestational ages in the two groups
      • Over 94% of women had medical care and only 6% midwifery (love to see a sub analysis on that group)
      • IOL at 39 weeks saved no more babies than waiting.
      • We have no idea about the long term effect

      We must not arrive at conclusions too early on this one. Caution is
      needed. Let’s see this study repeated in a midwifery led population and see if the normal birth rate is impacted on. The problem with this would be that even fewer women would agree to be randomised which tells us one thing: induction of labour is not readily embraced by women!

      /endquote

  • attitude devant

    Heavens, this is terrific. Thank you. I am so DAMN TIRED of the moldy assumptions that keep us from inducing labor. For me, the ‘ah-hah!’ moment was realizing that you have to compare induction to expectant management. From there on it’s pretty straight forward.

    By the way, I’m not sure why you think ACOG won’t go for this. We’ve been working on the maternal safety bundles and those (in particular the hypertensive disorders of pregnancy guidelines) have led to many more inductions. This is only a small step further. I’m the oldest OB in my office (by far) but I’m the one always trying to push my partners away from the “let nature decide” mindset. Nature is not kind to mothers or babies. Why should She be in charge?

  • Ally

    Paradigm-changing studies like this one are what separates the scientists from the ideologues.

    When new data proves that a given assumption was wrong, a science-based healthcare provider will change their practice accordingly. My field (cardiology) has many such examples: we once believed beta-blockers were bad for heart-failure patients and we avoided them like the plague. Until new and convincing, reproducible data showed us they were in fact beneficial, and now they are recommended by every guideline worldwide. An entire field made a 180° turn in their practice, because they allowed the scientific evidence to change their minds.

    Ideologues, on the other hand neither need nor want research, because they already know all the answers and those answers are sacred and set in stone. Midwifery as it exists today, with its semi-religious adherence to ‘normal birth’ and ‘breast is best’ is an ideology rather than a science-driven healthcare field.
    Ideologues have no business steering healthcare policies (I’m looking at you, BFHI!) and inserting themselves between doctors and their patients.

    Midwives need to let go of the natural birth ideology, or they will find themselves progressively marginalized and eventually replaced.

    • RudyTooty

      I concur.

    • Anna

      Totally agree.

  • Montserrat Blanco

    So much for the “cascade of interventions” that leads to C-sections. It is more likely: if you wait that much that you finally get an induction in order to do not go after 42 weeks and increase fetal death you are highly likely to get a c section.

    • The Bofa on the Sofa

      Yep, that’s not it. It’s not the intervention that creates the c-section, it’s waiting so long that you have to intervene that is the issue.

      • Mari

        ALWAYS suspected this was the case.

    • maidmarian555

      Yeah I will always wonder if they’d let me have the bloody induction at 40wks like I asked whether my big-headed son would have got stuck like he did when they finally did it at 40+12. I mean, it’s quite possible that the same thing would have happened (and the OB that delivered him told me that it was always going to end in C-section for us- she may well have just said that to be kind afaik) but it strikes me that he would have had a better shot at getting out with a smaller head.

      • Since babies gain 30 gms a day, a baby at 40+12 is going to be substantially larger than at 40 wks. Unless, of course, the placenta packs up, and the baby is either starved of food and oxygen, or dies.

        • The Bofa on the Sofa

          “Nothing good happens after 40 weeks.” At best, all that happens is the baby gets bigger, which makes childbirth harder.

          So 30 gms a day… that makes it 420 gms a week. Almost a pound? Bah, close enough.

          I always figure, that a 40 wk baby will be basically 7.5 ± 0.5 lbs, Correct it by 1/2 lb for each week.

          From the more precise stats, it’s not a bad rule of thumb.

    • The Kids Aren’t AltRight

      The first time I heard of the Cascade of interventions, the causality was so obviously backwards. It was how I knew the friend that told me had a one-way ticket to wooville.

      • attitude devant

        Somewhere back in the archives of this blog is the day we came up with the idea of the Cascade of Non-intervention, where failing to act leads to c-section and adverse neonatal outcomes. An example would be: mom passes her due date but babies aren’t library books so nothing is done. Mom finally labors but at this point baby is very large and placenta has deteriorated and there’s meconium so baby doesn’t tolerate labor and a c-section is done, and neonatal meconium aspiration lands the baby in the nursery rather than with mom. Another: pre-eclampsia but let labor come naturally. Labor comes but mom refuses an IV or magnesium for seizure prevention. Seizure happens and appropriate intervention is stymied by lack of IV access and baby is so stressed by mom’s health deterioration that a c-section results and baby is hypoxic and acidotic at birth. Preventable bad outcomes, the natural consequence of non-intervention.

      • swbarnes2

        The first time I heard it, I was like …”well, maybe it makes sense that epidurals slow down labor, but the alternative is certainly worse!” And then I saw that the person was counting the antibiotic drip as the intervention that first changed things, and that was obvious nonsense.

        • Anna

          No, according to NCB stepping into hospital is the first step in the cascade! If youre a radical freebirther its peeing on the stick! Not even joking

  • The Bofa on the Sofa

    In nulliparous women aged ≥ 35 years, NMII [nonmedically indicated induction] was associated with decreased odds of cesarean delivery at 37 to 39 weeks’ gestation

    Are they suggesting induction at 37 weeks?

    • attitude devant

      There are good reasons to induce at 37 weeks in certain patients. I didn’t read they were suggesting it in all cases, but it is helpful to know that induction as early as 37 weeks is a reasonable option compared to expectant management.

      • Lilly de Lure

        Agree – sometimes babies just have to come out earlier than planned. Mine for example was an IUGR case with an increasingly wobbly looking heart trace and a dodgy looking umbilical cord so they tried an induction as soon as he hit 37 weeks because his in utero environment was looking less safe by the day, he simply could not have survived waiting until 39 weeks.

        • Merrie

          Similar happened to my friend. From that incident we also learned that you don’t have to be dilated to 10 cm to deliver a 3.5 lb baby. He’s now a small but healthy 3 1/2 year old.

        • The Bofa on the Sofa

          See above. Induction for IUGR is not “nonmedically indicated induction”

      • The Bofa on the Sofa

        Sure, medically indicated induction at 37 weeks makes sense. But this is talking about NMII at 37 weeks. If you have good (medical) reasons, it’s not NMII.

        I’m wondering when/where that is happening?

        • fiftyfifty1

          “If you have good (medical) reasons, it’s not NMII.”

          But attitude devant’s point, I believe, is that there is a grey area that is important. Right now, there are very specific criteria that must be met in order for an induction to be coded as medically indicated. Everything else gets called NMII. But AD knows that there are good reasons to induce at 37 weeks in certain patients even if they can’t meet strict criteria…everything from multiple borderline test results to rare medical conditions that are not on the list. In cases like these it is helpful to know that induction as early as 37 weeks is a reasonable option, and I bet that AD, as an advocate for her patients, will offer her patients this option even though the insurance companies have not (yet) seen the light…

  • Zornorph

    Lower rates of doctors missing their tee times on the golf course in the induction group (13%) as compared to the expectant management group (24%)
    Oddly enough, for all the woo people harp on this, very few of the doctors I know actually play golf.

    • LaMont

      Millennials are killing golf, so I hear 😉

      • Lilly de Lure

        Knew I liked them for a reason 😉

    • The Bofa on the Sofa

      When my SIL graduated med school, her husband bought her a set of golf clubs. Nowadays, he golfs a lot. I don’t know how often she does, though.

    • The Bofa on the Sofa

      Don’t forget that this induction approach led to more babies being born during the day and on weekdays, with far fewer being born in the middle of the night on weekends.

      It’s like they are scheduling the inductions at times that are more convenient to doctors and patients.

    • Ally

      It is a universal truth in medicine that whatever it is you are trying to do will be done better, faster and much safer if done during daylight hours by a well-rested and fully staffed team.
      If I ever have another baby, I’d rather have my shoulder dystocia or retained placenta at 10 AM on a Tuesday, when everyone I might need is physically present in the hospital and on their A-game, rather than at 3 in the morning when the terrified resident is trying to raise her exhausted fellow from his bed and the one anesthesiologist who isn’t at home in bed needs to quickly finish that appendix so they can rush to my bedside, and oh yes, the blood bank has only one staff member on night shift and she’s currently really busy with that GI bleed in the ER so it might be a while…
      Never let something that can be done electively become an after-hours emergency is a safety guideline in every other field of medicine. I don’t see why women and babies deserve anything less.

      • Zornorph

        But I thought babies ‘know’ the perfect time to be born! I actually did – I was born on election day (fitting for a politics junkie) but I waited until my mother was in the line to vote to start asking to come out. So she was able to vote then go right down the road to the hospital where I came out five hours later. I’m the only one of my mum’s five children to be born during the day, btw.

        • attitude devant

          By the way, you’re little guy is adorable. I hope you’re having fun.

          • Zornorph

            Thank you – though I realize that picture’s over a year old – he just turned 5! I’ve updated it.

          • attitude devant

            FIVE???? I remember when we were waiting for him. Five is THE BEST.

          • demodocus

            Happy birthday! I didn’t realize our boys were so close together. Guy Fawkes boy will be 5 later this year.

        • demodocus

          My boy was born on election day, too, but he was not so polite; I went into labor at 1030 the night before and had him at 620pm. No voting for Mommy that year. ‘Course it was also Guy Fawkes Day for our British cousins, so…

        • atheist mommy/Oma

          I missed my first presidential election because my daughter decided to come that day. I still tease her about it lol.

      • Merrie

        If I ever have another baby, I’d rather have my 2 hour labor start in the hospital rather than at home where I have to scramble around finding a babysitter and then dash to the hospital or alternately drag all 3 kids to the hospital. Each labor has been faster; this last one I woke up at 1:30 AM with contractions 2 minutes apart, and dashed to the hospital and he was born at 4:40 AM. I was so glad that my husband’s parents were already in town and asleep on our futon. What we would have done if that had happened a few days prior I don’t know.

        • Kelly

          This is my nightmare with the last two pregnancies. Thankfully, my last one was induced so I had time to plan. So far, I am not looking at induction and I can’t even get one until I am 40 weeks. I am hoping I start labor at night so my husband will be at home.

    • You used the wrong parameters — it’s tennis.

      • Gene

        It’s fishing for me. I hate both golf and tennis!