Induction of labor at term

Abstract

Souter et al1Souter V. Painter I. Sticov K. Caughey A.B. Maternal and newborn outcomes with elective induction of labor at term.Am J Obstet Gynecol. 2019; 220: 273.e1-273.e11Abstract Full Text Full Text PDF Scopus (27) Google Scholar have presented a careful and comprehensive evaluation of outcomes after elective induction of labor compared with expectant management. These authors have joined the ranks of others who offer labor induction at 39 weeks gestation as a favorable alternative to expectant management. An explanation for the findings of these groups is that expectant management is associated with a higher prevalence of preeclampsia and with larger babies, which are findings that were confirmed in the ARRIVE trial.2Grobman W.A. Rice M.M. Reddy U.M. et al.Labor induction versus expectant management in low-risk nulliparous women.N Engl J Med. 2018; 379: 513-523Crossref PubMed Scopus (375) Google Scholar The studies in this area are limited by the expectant management group being managed by modern obstetricians, whose inclination for intervention may be higher than is optimal. Larger babies mean longer labors, which may tax the patience of the modern obstetricians, and preeclampsia is alarming to some practitioners who may not be willing to stabilize the patient and wait for the uterus to respond to oxytocin. As gestation advances, there may be less amniotic fluid with consequent benign variable decelerations that are over-interpreted as fetal hypoxemia. The answer might come from a careful review of the cesarean deliveries in these studies to determine whether they represent a disadvantage of expectant management or a consequence of modern obstetrics training. Obstetricians of my vintage were trained when the cesarean delivery rate was considered high at 15% and when we didn’t have so many categories of fetal tracings. Even in the modern era, the midwives at my institution have a cesarean delivery rate of 3–5%, caring for exactly the kind of patient in the ARRIVE trial. The current high induction and cesarean rates in modern obstetrics have not given us better babies, and we would do well to be concerned about effects on maternal morbidity and mortality rates. Maternal and newborn outcomes with elective induction of labor at termAmerican Journal of Obstetrics & GynecologyVol. 220Issue 3PreviewA growing body of evidence supports improved or not worsened birth outcomes with nonmedically indicated induction of labor at 39 weeks gestation compared with expectant management. This evidence includes 2 recent randomized control trials. However, concern has been raised as to whether these studies are applicable to a broader US pregnant population. Full-Text PDF ReplyAmerican Journal of Obstetrics & GynecologyVol. 221Issue 1PreviewWe appreciate Dr Scialli’s thoughtful comments about our study on elective induction of labor (IOL) at term and his concerns about current obstetric practices that contribute to high rates of intervention in births beyond 39 gestational weeks.1 Full-Text PDF