Patients' perspectives regarding induction of labor in the absence of maternal and fetal indications: are our patients ready for the ARRIVE trial?

The ethics of induction of labor at 39 weeks in low-risk nulliparas in research and clinical practice

The "A Randomized Trial of Induction Versus Expectant Management" trial (ARRIVE trial) published in 2018 suggested that induction of labor can be considered a "reasonable option" for low-risk nulliparous women at ≥39 weeks of gestation. The study results led some professional societies to endorse the option for elective induction of labor at 39 weeks of gestation in low-risk nulliparas, and this has begun to change obstetrical practice. The ARRIVE trial provided valuable information supporting the benefits of induction of labor; however, the trial is insufficient to serve as the primary justification for widespread elective induction of labor at 39 weeks of gestation in low-risk nulliparas because of concerns about external validity. Thus, the French ARRIVE trial was designed to test the hypothesis in a different setting that elective induction of labor at 39 weeks of gestation in low-risk nulliparas leads to a lower cesarean delivery rate than expectant management. This ongoing trial has been criticized as "pseudoscientific" and telling "women where, when, and how to give birth." We reject these allegations and extensively examine the ethical framework that should govern clinical and research interventions, including elective induction of labor at 39 weeks of gestation in low-risk nulliparas. This study aimed to discuss the ethical issues that emerge from randomized trials of elective induction of labor at 39 weeks of gestation in low-risk nulliparas and the ethics of the clinical practice itself. The analysis of existing evidence shows the importance of further research on induction of labor at 39 weeks of gestation in low-risk women. Certain aspects of research ethics in this area, particularly the consent of pregnant women in a context where autonomy remains fragile, call for vigilance. In addition, we emphasize that childbirth is not only a medical object but also a social phenomenon that cannot be regarded only from the perspective of a health risk to be managed by clinical research. Further research on this issue is needed to allow pregnant women to make informed decisions, and the results should be integrated with social issues. The perspective of women is required in constructing, evaluating, and implementing medical interventions in childbirth, such as induction of labor at 39 weeks of gestation.

Effects of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) Trial on Elective Induction and Obstetric Outcomes in Term Nulliparous Patients

OBJECTIVE

To evaluate the effect of publication of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial on perinatal outcomes in singleton, term, nulliparous patients.

METHODS

An interrupted time series analysis was performed using clinical data for nulliparous singleton births at 39 weeks of gestation or later at 13 hospitals in the Northwest region of the United States (January 2016-December 2020). A modified Poisson regression was used to model time trends and changes after the ARRIVE trial (August 9, 2018). Outcomes of interest were elective induction, unplanned cesarean births, hypertensive disorders of pregnancy, a composite of perinatal adverse outcomes, and neonatal intensive care unit admissions.

RESULTS

The analysis included 28,256 births (15,208 pre-ARRIVE and 13,048 post-ARRIVE). The rate of elective labor induction was 3.6% during the pre-ARRIVE period (January 2016-July 2018) and 10.8% post-ARRIVE (August 2018-December 2020). In the interrupted time series analysis, elective induction increased by 42% (relative risk [RR] 1.42; 95% CI 1.18-1.71) immediately after the ARRIVE trial publication. Thereafter, the trend was unchanged compared with the pre-ARRIVE period. There was no statistically significant change in cesarean birth (RR 0.96; 95% CI 0.89-1.04) or hypertensive disorders of pregnancy (RR 0.91; 95% CI 0.79-1.06) immediately after the trial, and no change in trend. After the ARRIVE trial, there was no immediate change in adverse perinatal outcomes, but a statistically significant increase in trend of adverse perinatal events (1.03; 95% CI 1.01-1.05) when compared with a declining trend observed in the pre-ARRIVE period.

CONCLUSION

Publication of the ARRIVE trial was associated with an increase in elective induction, and no change in cesarean birth or hypertensive disorders of pregnancy in singleton nulliparous patients giving birth at 39 weeks or later. There was a flattening of the pre-ARRIVE decreasing trend in perinatal adverse events.

The (After)life of a Trial: Biocommunicability of an At-Risk Pregnancy

The publication of A Randomized Trial of Induction Versus Expectant Management (ARRIVE), conducted in the United States in 2018, heralded a paradigm shift within the obstetrical management of term pregnancy among people who have not previously given birth. ARRIVE finds its home among other canonical - and controversial - randomized controlled trials (RCTs) within obstetrics. We argue that RCTs have their own (after)life, both creating new subjects for biomedical intervention and recalibrating who reproductive health practitioners consider to be at risk of adverse health outcomes. These data have important consequences for medical social scientific engagement with RCTs to further interrogate the questions of risk and intervention within reproductive health.

Perinatal mortality and neonatal and maternal outcome per gestational week in term pregnancies: A registry-based study

INTRODUCTION

Human pregnancy is considered term from 37+0/7 to 41+6/7 weeks. Within this range, both maternal, fetal and neonatal risks may vary considerably. This study investigates how gestational age per week is related to the components of perinatal mortality and parameters of adverse neonatal and maternal outcome at term.

MATERIAL AND METHODS

A registry-based study was made of all singleton term pregnancies in the Netherlands from January 2014 to December 2017. Stillbirth and early neonatal mortality, as components of perinatal mortality, were defined as primary outcomes; adverse neonatal and maternal events as secondary outcomes. Neonatal adverse outcomes included birth trauma, 5-minute Apgar score ≤3, asphyxia, respiratory insufficiency, neonatal intensive care unit admission and composite neonatal outcome. Maternal adverse outcomes included instrumental vaginal birth, emergency cesarean section, obstetric anal sphincter injury, postpartum hemorrhage, hypertensive disorders of pregnancy and composite maternal outcome. The primary outcomes were evaluated by comparing weekly prospective risks of stillbirth and neonatal death using a fetuses-at-risk approach. Secondly, odds ratios (OR) for perinatal mortality, adverse neonatal and maternal outcome using a births-based approach were compared for each gestational week with all births occurring after that week.

RESULTS

Data of 581 443 births were analyzed. At 37, 38, 39, 40, 41 and 42 weeks, the respective weekly prospective risks of stillbirth were 0.015%, 0.022%, 0.031%, 0.036%, 0.069% and 0.081%; the respective weekly prospective risks of early neonatal death were 0.051%, 0.047%, 0.032%, 0.031%, 0.039% and 0.035%. The OR for adverse neonatal outcomes were the lowest at 39 and 40 weeks. The OR for adverse maternal outcomes, including operative birth, continuously increased with each gestational week.

CONCLUSIONS

The prospective risk of early neonatal death for babies born at 39 weeks is lower than the risk of stillbirth in pregnancies continuing beyond 39+6/7 weeks. Birth at 39 weeks was associated with the best combined neonatal and maternal outcome, fewer operative births and fewer maternal and neonatal adverse outcomes compared with pregnancies continuing beyond 39 weeks. This information with appropriate perspectives should be included when counseling term pregnant women.

Attitudes of pregnant women and healthcare professionals to labour induction and obtaining consent for labour induction

Induction of labour is experienced by up to one third of women and can be a negative experience, in relation to both the decision about whether to have an induction of labour (IoL) and the experience of the process of IoL. This paper reviews the limited evidence of women's views on and experiences of: information provision; shared decision-making; preferences for method and location of IoL; indications for IoL; pain management; and effective communication and support. Healthcare professionals' views are reviewed, but are underrepresented, and further research is needed to understand experiences of gaining consent for IoL. Systematic review evidence is drawn on where possible, but reviews often found small numbers of papers for inclusion, and provide insights rather than conclusive evidence. Future research would benefit from using validated measures to assess the experience of IoL.

Outpatient labour induction

The inexorable rise in induction rates over the past two decades, in parallel with increasing medical costs and pressure to reduce length of stay, has led to marked logistic difficulties for health care workers, managers and planners. Maternity services are being overwhelmed by the need to allocate staff and delivery suite space for the scheduling and undertaking of induction processes, rather than focussing care for women in spontaneous labour. Induction of labour according to the majority of current protocols and guidelines necessitates increased length of stay and relatively aggressive use of oxytocin (to reduce the time expended in the labour ward from artificial rupture of membranes (AROM) to establishment of labour). This increased oxytocin usage requires increased use of continuous electronic foetal monitoring, and may also increase epidural usage, further increasing the complexity of labour for the woman and her health care workers. Outpatient care after cervical priming and even outpatient care after AROM may help to ease these pressures and may reduce the medicalisation of the birth experience when induction is indicated, with a potential to reduce oxytocin use and associated interventions. If the period between cervical priming to AROM is managed as outpatient care, then the woman may be able to find better psychological and social support at home, as well as maintain autonomy and get better rest prior to the onset of labour. Inpatient AROM could also be followed by outpatient care until the pregnant person returns to the hospital, either in spontaneous labour, or for initiation of syntocinon after 12-18 h. High-quality research has already demonstrated that outpatient care for cervical ripening is acceptable to mothers and caregivers, has economic benefits and has an acceptable safety profile in appropriately selected low-risk inductions.

Evidence-based labor management: induction of labor (part 2)

Induction of labor is indicated for many obstetrical, maternal, and fetal indications. Induction can be offered for pregnancy at 39 weeks' gestation. No prediction method is considered sensitive or specific enough to determine the incidence of cesarean delivery after induction. A combination of 60- to 80-mL single-balloon Foley catheter for 12 hours and either 25-μg oral misoprostol initially, followed by 25 μg every 2-4 hours, or 50 μg every 4-6 hours (if no more than 3 contractions per 10 minutes or previous uterine surgery), or oxytocin infusion should be recommended for induction of labor. Adding membrane stripping at the beginning of induction should be considered. Once 5-6 cm of cervical dilation is achieved during the induction of labor, consideration can be given to discontinue oxytocin infusion if in use at that time and adequate contractions are present. Induction with oxytocin immediately (as soon as feasible) or up to 12 hours of term prelabor rupture of membranes if labor is not evident is recommended. Outpatient Foley ripening can be considered for low-risk women. Cesarean delivery should not be performed before 15 hours of oxytocin infusion and amniotomy if feasible and ideally after 18-24 hours of oxytocin infusion.