Cost of Elective Labor Induction Compared With Expectant Management in Nulliparous Women

Impact of the ARRIVE Trial in Nulliparous Individuals with Morbid Obesity: Interrupted Time Series Analysis

OBJECTIVE

 We aimed to examine rates of induction of labor at 39 weeks and cesarean delivery before and after the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial stratified by body mass index (BMI; kg/m2) category.

STUDY DESIGN

 This was a repeated cross-sectional analysis of publicly available U.S. birth certificate data from 2015 to 2021. We limited analyses to nulliparous individuals with a singleton pregnancy, cephalic presentation, without chronic hypertension, diabetes (gestational or pregestational), and fetal anomaly who delivered between 39 and 42 weeks' gestation. The pre-ARRIVE period spanned from August 2016 to July 2018 and the post-ARRIVE period spanned from January 2019 to December 2020. The dissemination period of the ARRIVE trial was from August 2018 to December 2018. Our co-primary outcomes were induction at 39 weeks and cesarean delivery. Our secondary outcomes were overall induction of labor and preeclampsia. We conducted an interrupted time series analysis after stratifying by prepregnancy BMI (<40 or ≥40). Negative binomial regression was used to calculate adjusted incident rate ratios with 95% confidence intervals.

RESULTS

 Of 2,122,267 individuals that were included, 2,051,050 had BMI <40 and 71,217 had BMI ≥40. In individuals with BMI <40, the post-ARRIVE period compared to the pre-ARRIVE period was associated with an increased rate of induction of labor at 39 weeks, a decreased rate of cesarean delivery, and an increased rate of overall induction of labor. In individuals with BMI ≥40, the post-ARRIVE period compared to the pre-ARRIVE period was associated with an increased rate of induction of labor at 39 weeks, an increased rate of overall induction of labor and a decreased rate of preeclampsia; however, the decrease in the rate of cesarean delivery was not significant.

CONCLUSION

 An increase in induction of labor at 39 weeks' gestation in individuals with BMI ≥40 was not associated with a decrease in the cesarean delivery rate.

KEY POINTS

· The ARRIVE trial increased 39-week labor inductions in BMI <40 and ≥40.. · BMI <40 had fewer cesareans; BMI ≥40 showed no significant decrease.. · Offering labor induction is reasonable as cesarean rates didn't increase..

The ARRIVE Trial

Timing of delivery such that maternal and perinatal outcomes are optimized is among the most important and commonplace decisions in obstetric care. Given the importance of this determination, it is somewhat surprising that there has been, until relatively recently, little in the way of high-quality evidence to guide obstetric clinicians in this decision. This chapter describes the evolution of studies examining the effects of labor induction and the importance of the ARRIVE trial in that context.

Implementation and Clinical Impact of a Guideline for Standardized, Evidence-Based Induction of Labor

OBJECTIVE

 This study aimed to assess the impact of implementation of an induction of labor (IOL) guideline on IOL length and utilization of evidence-based practices.

STUDY DESIGN

 We conducted a quality improvement project to increase utilization of three evidence-based IOL practices: combined agent ripening, vaginal misoprostol, and early amniotomy. Singletons with intact membranes and cervical dilation ≤2 cm admitted for IOL were included. Primary outcome was IOL length. Secondary outcomes included cesarean delivery and practice utilization. We compared preimplementation (PRE; November 1, 2021 through January 31, 2022) to postimplementation (POST; March 1, 2022 through April 30, 2022) with sensitivity analyses by self-reported race and ethnicity. Cox proportional hazards models and logistic regression were used to test the association between period and outcomes.

RESULTS

 Among 495 birthing people (PRE, n = 293; POST, n = 202), IOL length was shorter POST (22.0 vs. 18.3 h, p = 0.003), with faster time to delivery (adjusted hazard ratio [aHR] 1.38, 95% CI 1.15-1.66), more birthing people delivered within 24 hours (57 vs. 68.8%, adjusted odds ratio [aOR] 1.90 [95% CI 1.25-2.89]), and no difference in cesarean. Utilization of combined agent ripening (31.1 vs. 42.6%, p = 0.009), vaginal misoprostol (34.5 vs. 68.3%, p < 0.001), and early amniotomy (19.1 vs. 31.7%, p = 0.001) increased POST.

CONCLUSION

 Implementation of an evidence-based IOL guideline is associated with shorter induction time. Additional implementation efforts to increase adoption of practices are needed to optimize outcomes after IOL.

KEY POINTS

· Implementation of an IOL guideline is associated with faster time to delivery.. · Evidence-based induction practices were used more often after guideline implementation.. · Adoption of evidence-based induction practices is variable even with a guideline..

Randomized control trial comparing hygroscopic cervical dilators to cervical ripening balloon for outpatient cervical ripening

BACKGROUND

Outpatient term preinduction cervical ripening with mechanical agents has been associated with reduced length of stay, decreased cesarean delivery rates, low maternal and neonatal complications, and increased incidence of vaginal delivery within 24 hours.

OBJECTIVE

This study aimed to demonstrate equivalent efficacy between synthetic hygroscopic dilators and the single-balloon catheter for outpatient cervical ripening.

STUDY DESIGN

This randomized control equivalence trial compared synthetic hygroscopic dilators with the 30-mL silicone single-balloon catheter in primiparous and multiparous patients undergoing labor induction. The primary outcome was time from admission to delivery, with a prespecified 3-hour margin of equivalence. The secondary objectives were patient outcomes and perspectives.

RESULTS

Between March 1, 2019, and May 31, 2021, 1605 patients met the screening criteria, and 174 patients completed the study. The mean admission-to-delivery time was equivalent at 18.01 hours for the dilator group vs 17.55 hours for the balloon group (P=.04). The cesarean delivery rate of primiparous patients was similar at 28.1% with dilators vs 29.7% with the balloon. The groups had similar median cervical dilation and pain scores on insertion and admission. Overall patient satisfaction was high, 92.8% with dilators vs 96.2% with the balloon. The balloon group had significantly higher rates of early admission and device expulsion.

CONCLUSION

Although the enrollment goal was not met, our study suggests that synthetic hygroscopic dilators and the single-balloon catheter for outpatient cervical ripening are both efficacious with similar time from admission to delivery, pain scores, and patient satisfaction with the procedure.

The role of labor induction in modern obstetrics

A primary goal of obstetrical practice is the optimization of maternal and perinatal health. This goal translates into a seemingly simple assessment with regard to considerations of the timing of delivery: delivery should occur when the benefits are greater than those of continued pregnancy. In the absence of an indication for cesarean delivery, planned delivery is initiated with induction of labor. When medical or obstetrical complications exist, they may guide recommendations regarding the timing of delivery. In the absence of these complications, gestational age also has been used to guide delivery timing, given its association with both maternal and perinatal adverse outcomes. If there is no medical indication, delivery before 39 weeks has been discouraged, given its association with greater chances of adverse perinatal outcomes. Conversely, it has been recommended that delivery occur by 42 weeks of gestation, given the perinatal risks that accrue in the post-term period. Historically, a 39-week induction of labor, particularly for individuals with no previous birth, has not been routinely offered in the absence of medical or obstetrical indications. That approach was based on numerous observational studies that demonstrated an increased risk of cesarean delivery and other adverse outcomes among individuals who underwent labor induction compared to those in spontaneous labor. However, from a management and person-centered-choice perspective, the relevant comparison is between those undergoing planned labor induction at a given time vs those planning to continue pregnancy beyond that time. When individuals have been compared using that rubric-either in observational studies or randomized trials that have been performed in a wide variety of locations and populations- there has not been evidence that induction increases adverse perinatal or maternal outcomes. Conversely, even when the only indication for delivery is the achievement of a full-term gestational age, evidence suggests that multiple different outcomes, including cesarean delivery, hypertensive disorders of pregnancy, neonatal respiratory impairment, and perinatal mortality, are less likely when induction is performed. This information underscores the importance of making the preferences of pregnant individuals for different birth processes and outcomes central to the approach to delivery timing.

Labor induction at 41+0 gestational weeks or expectant management for the nulliparous woman: The Finnish randomized controlled multicenter trial

INTRODUCTION

Neonatal and maternal risks increase in term pregnancy as gestational age advances and become increasingly evident post-term. Management practices of late- and post-term pregnancies vary, and the optimal time point for intervention by labor induction is yet to be determined.

MATERIAL AND METHODS

This randomized controlled trial of 381 nulliparous women with unripe cervices compared labor induction at 41+0 gestational weeks (early induction) with expectant management and labor induction at 41+5 to 42+1 gestational weeks (expectant management). This multicenter study included all five university hospitals and the largest central hospital in Finland. The study period was 2018-2022. Participants were randomized to either early induction (48.8%, n = 186) or expectant management (51.2%, n = 195) with equal randomization ratios of 1:1. This was a superiority trial, and the primary outcomes were rates of cesarean section (CS) and composite of adverse neonatal outcomes. The trial was registered at the ISRCTN registry (ISRCTN83219789, https://doi.org/10.1186/ISRCTN83219789).

RESULTS

The rates of CS (16.7% [n = 31] vs. 24.1% [n = 47], RR 0.7 [95% CI: 0.5-1.0], p = 0.07) and a composite of adverse neonatal outcomes (9.7% [n = 18] vs. 14.4% [n = 28], RR 0.7 [95% CI: 0.4-1.2] p = 0.16) did not significantly differ between the groups, but the operative delivery rate was lower in the early induction group than in the expectant management group (30.6% [n = 57] vs. 45.6% [n = 89], p = 0.003). The rates of hemorrhage ≥1000 mL and neonatal weight ≥4000 g were also lower in the early induction group, as was the vacuum extraction rate in women with vaginal delivery. Of the women with expectant management, 45.6% (n = 89) had spontaneous onset of labor. No perinatal deaths occurred, but one case of eclampsia appeared in the expectant management group.

CONCLUSIONS

Offering labor induction to nulliparous women at 41+0 gestational weeks may decrease the probability of operative delivery, postpartum hemorrhage, and neonatal weight ≥4000 g. However, this study was underpowered to affirm the trends of rising rates of CS and adverse neonatal outcomes in the expectant management group. Thus, expectant management could remain an option for some, as one in two women with expectant management had a spontaneous onset of labor.

Gestational Age and Birth Outcomes in Term Singleton Pregnancies Conceived With Infertility Treatment

Importance

Despite the increased perinatal risks associated with pregnancies conceived with infertility treatment, there are no recommendations for timing of delivery among this at-risk population.

Objective

To identify the gestational age at which the ongoing risks of stillbirth are optimally balanced with the risks of neonatal comorbidities and infant deaths in term singleton pregnancies conceived with infertility treatment.

Design, Setting, and Participants

This cohort study used birth and death data from January 1, 2014, to December 31, 2018, in the US obtained from the National Center for Health Statistics. Singleton pregnancies conceived with infertility treatment delivered at term (37-42 weeks' gestation) were eligible for inclusion. The exclusion criteria were deliveries at less than 37 weeks' or at least 43 weeks' gestation and pregnancies with unknown history of infertility treatment, congenital anomalies, pregestational diabetes, pregestational hypertension, gestational hypertension, and preeclampsia. Data were analyzed from July 22, 2022, to June 24, 2023.

Exposure

Gestational age at delivery between 37 and 42 weeks.

Main Outcomes and Measures

The primary outcome was optimal timing of delivery. To ascertain this timing, the risk of delivery (rate of neonatal morbidity and infant death) at a given gestational week was compared with the risk of delivery in the subsequent week of gestation for an additional week (rate of stillbirth during the given week per 10 000 ongoing pregnancies plus rate of neonatal morbidity and infant death in the subsequent week of gestation per 10 000 deliveries). The rates of stillbirth, neonatal morbidity, and infant death (within 1 year of life) were compared at each week. Neonatal morbidity included an Apgar score of 3 or lower at 5 minutes, requirement of ventilation for 6 hours or more, neonatal intensive care unit admission, and seizures.

Results

Of the 178 448 singleton term pregnancies conceived with infertility treatment (maternal mean [SD] age, 34.2 [5.2] years; mean [SD] gestational age, 39.2 [1.2] weeks; 130 786 [73.5%] were non-Hispanic White patients). The risk of delivery in the subsequent week of gestation was lower than the risk of delivery at both 37 weeks (628 [95% CI, 601-656] vs 1005 [95% CI, 961-1050] per 10 000 live births) and 38 weeks (483 [95% CI, 467-500 vs 625 [95% CI, 598-652] per 10 000 live births). The risks of delivery in subsequent week of gestation significantly exceeded the risk of delivery at 39 weeks (599 [95% CI, 576-622] vs 479 [95% CI, 463-495] per 10 000 live births) and were not significant at 40 weeks (639 [95% CI, 605-675] vs 594 [95% CI, 572-617] per 10 000 live births) and 41 weeks (701 [95% CI, 628-781] vs 633 [95% CI, 599-669] per 10 000 live births).

Conclusions and Relevance

Results of this study suggest that, in pregnancies conceived with infertility treatment, delivery at 39 weeks provided the lowest perinatal risk when comparing risk of delivery at this week of gestation vs the subsequent week of gestation.

Analysis of Obstetric Outcomes by Hospital Location, Volume, and Teaching Status Associated With Non-Medically Indicated Induction of Labor at 39 Weeks

Importance

Non-medically indicated induction of labor has been demonstrated to potentially improve some obstetric outcomes, such as decreasing cesarean birth. It has been reported that rates of cesarean birth and other obstetric outcomes vary among hospitals with different characteristics.

Objective

To assess whether obstetric outcomes differ between nulliparous individuals with low-risk pregnancies managed with non-medically indicated induction of labor compared with expectant management in different types of hospitals.

Design, Setting, and Participants

This retrospective cohort study included non-medically indicated induction of labor at 39 weeks' gestation compared with expectant management of singleton, nonanomalous, births in nulliparous women with low-risk pregnancies in California between January 1, 2007, and December 31, 2011. The initial analysis of these data was performed in 2021. Outcomes were assessed by 3 hospital characteristics: location (urban vs rural), obstetric volume, and teaching (academic vs community) status. Volume was categorized based on the average number of births per year and grouped into low (<1200 births per year), medium (1200-2399 births per year), and high (≥2400 births per year). Births with previous or planned cesarean delivery were excluded, and non-medically indicated induction of labor was defined as induction of labor without a specific medical indication. Testing with χ2 and multivariable logistic regression analyses was used for statistical comparisons with a cutoff level of P = .01.

Exposure

Non-medically indicated induction of labor at 39 weeks' gestation.

Main Outcomes and Measures

The primary outcome was cesarean birth, and numerous secondary perinatal outcomes were also assessed.

Results

There were 455 044 births included in this study. When stratified by hospital variables, a number of sociodemographic characteristics were significantly different, such as race and ethnicity, age, body mass index, and insurance type. The adjusted odds ratios (aORs) of cesarean birth were significantly lower in all settings with induction of labor except for low-volume hospitals, in which there was no significant difference (aOR, 0.95; 95% CI, 0.82-1.09). Chorioamnionitis and postpartum hemorrhage were lower with induction of labor among nearly every hospital when stratified by hospital characteristics. Neonatal outcomes were improved in all settings with induction of labor compared with expectant management.

Conclusions and Relevance

These findings suggest that non-medically indicated induction of labor may be associated with a lower rate of cesarean births and some maternal and neonatal adverse outcomes in a range of hospital settings.

Outpatient vs inpatient induction of labor with oral misoprostol: A retrospective study

INTRODUCTION

Induction of labor is one of the most common obstetrical procedures today, with a successively rising rate. With a limited number of hospital beds, the option of starting induction at home has gained increasing attention. The primary aim of this study was to compare the proportion of women achieving vaginal delivery and the duration of hospital stay before delivery in induction of labor with oral misoprostol starting at home and induction with oral misoprostol at the hospital, in a low-risk population.

MATERIAL AND METHODS

Women with home induction (n = 282) were individually matched to controls induced at the hospital during the same time period regarding parity, age, body mass index, labor unit and indication for induction.

RESULTS

The rates of vaginal birth were similar in outpatients and inpatients (84.8% vs 86.2%; p = 0.5). Time from hospital admission to delivery in the outpatient group was significantly shorter than in the inpatient group (12.8 vs 20.6 h; p < 0.001), as was total hospital stay (2 vs 3 days; p < 0.001). There were no significant differences between the groups in neonatal or maternal outcomes. One patient undergoing outpatient induction had an unplanned home birth.

CONCLUSIONS

Starting induction at home reduced the time spent in hospital without affecting the vaginal delivery rate. Although underpowered to assess safety, this study did not show any differences in adverse maternal and perinatal outcomes between inpatients and outpatients. Further research is needed to evaluate the safety of outpatient induction of labor with misoprostol.

Cost-effectiveness analysis of induction of labour at 41 weeks and expectant management until 42 weeks in low risk women (INDEX trial)

Objective

To assess the cost-effectiveness of elective induction of labour (IOL) at 41 weeks and expectant management (EM) until 42 weeks.

Design

Cost-effectiveness analysis from a healthcare perspective alongside a randomised controlled trial (INDEX).

Setting

123 primary care midwifery practices and 45 obstetric departments of hospitals in the Netherlands.

Population

We studied 1801 low-risk women with late-term pregnancy, randomised to IOL at 41 weeks (N = 900) or EM until 42 weeks (N = 901).

Methods

The incremental cost-effectiveness ratio (ICER) was expressed as the ratio of the difference in costs and the difference in main perinatal outcomes. A Cost-Effectiveness Acceptability Curve (CEAC) was constructed to assess whether induction is cost-effective for a range of monetary values as thresholds. We performed subgroup analysis for parity.

Main outcome measures

Direct medical costs, composite adverse perinatal outcome (CAPO) (perinatal mortality, NICU admission, Apgar 5 min < 7, plexus brachialis injury and/or meconium aspiration syndrome) and composite severe adverse perinatal outcome (SAPO) (including Apgar 5 min < 4 instead of < 7).

Results

The average costs were €3858 in the induction group and €3723 in the expectant group (mean difference €135; 95 % CI -235 to 493). The ICERs of IOL compared to EM to prevent one additional CAPO and SAPO was €9436 and €14,994, respectively. The CEAC showed a 80 % chance of IOL being cost-effective with a willingness-to-pay of €22,000 for prevention of one CAPO and €50,000 for one SAPO. Subgroup analysis showed a willingness-to-pay to prevent one CAPO for nulliparous of €47,000 and for multiparous €190,000. To prevent one SAPO the willingness-to-pay is €62,000 for nulliparous and €970,000 for multiparous women.

Conclusions

Induction at 41 weeks has an 80 % chance of being cost-effective at a willingness-to-pay of €22,000 for prevention of one CAPO and €50,000 for prevention of one SAPO. Subgroup analysis suggests that induction could be cost-effective for nulliparous women while it is unlikely cost-effective for multiparous women.Cost-effectiveness in other settings will depend on baseline characteristics of the population and health system organisation and funding.

Cost-effectiveness of induction of labor at 39 weeks vs expectant management by cervical examination

BACKGROUND

Previous analyses have demonstrated the cost effectiveness of elective induction of labor at 39 weeks of gestation for healthy nulliparous people. However, elective induction of labor is resource intensive, and optimal resource allocation requires a thorough understanding of which subgroups of patients will benefit most.

OBJECTIVE

This study aimed to determine whether induction of labor at 39 weeks of gestation is more cost-effective in patients with favorable or unfavorable cervical examinations.

STUDY DESIGN

We constructed 2 decision analysis models using TreeAge software: one modeling induction of labor at 39 weeks of gestation vs expectant management for a group of nulliparous patients with unfavorable cervical examinations and the other modeling induction of labor at 39 weeks of gestation vs expectant management for a group with favorable cervical examinations. Estimates of cost, probability, and health state utility were derived from the literature. Based on previous literature, we assumed that people with favorable cervical examinations would have a lower baseline rate of cesarean delivery and higher rates of spontaneous labor.

RESULTS

In our base case analysis, induction of labor at 39 weeks of gestation was cost-effective for patients with unfavorable cervical examinations, but not for patients with favorable cervical examinations. The incremental cost per quality-adjusted life year was 50-fold lower for people with unfavorable cervical examinations ($2150 vs $115,100). Induction of labor resulted in 3885 fewer cesarean deliveries and 58 fewer stillbirths per 100,000 patients for those with unfavorable examinations, whereas induction of labor resulted in 2293 fewer cesarean deliveries and 48 fewer stillbirths with labor induction for those with favorable cervical examinations. The results were sensitive to multiple inputs, including the likelihood of cesarean delivery, the cost of induction, the cost of vaginal or cesarean delivery, and the probability of spontaneous labor. In Monte Carlo analysis, the base case findings held true for 64.1% of modeled scenarios for patients with unfavorable cervixes and 55.4% of modeled scenarios for patients with favorable cervixes.

CONCLUSION

With a willingness-to-pay threshold of $100,000 per quality-adjusted life year, induction of labor at 39 weeks of gestation may be cost-effective for patients with unfavorable cervical examinations, but not for patients with favorable cervical examinations. This result was driven by the likelihood of labor in patients with favorable cervical examinations, and the resultant avoidance of prolonged pregnancy and its complications, including hypertensive disorders of pregnancy and stillbirths. Health systems may wish to prioritize patients with unfavorable cervical examinations for elective induction of labor at 39 weeks of gestation, which may be opposite to common practice.

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.

Directly Measured Costs of Severe Maternal Morbidity Events during Delivery Admission Compared with Uncomplicated Deliveries

OBJECTIVE

To estimate the actual excess costs of care for delivery admissions complicated by severe maternal morbidity (SMM) compared with uncomplicated deliveries.

STUDY DESIGN

This is a retrospective cohort study of all deliveries between October 2015 and September 2018 at a single tertiary academic center. Pregnant individuals ≥ 20 weeks' gestation who delivered during a hospital admission (i.e., a "delivery admission") were included. The primary exposure was SMM, as defined by Centers for Disease Control and Prevention (CDC) criteria, CDC criteria excluding blood transfusion, or by validated hospital-defined criteria (intensive care unit admission or ≥ 4 units of blood products). Potential SMM events identified via administrative and blood bank data were reviewed to confirm SMM events had occurred. Primary outcome was total actual costs of delivery admission derived from time-based accounting and acquisition costs in the institutional Value Driven Outcomes database. Cost of delivery admissions with SMM events was compared with the cost of uncomplicated delivery using adjusted generalized linear models, with separate models for each of the SMM definitions. Relative cost differences are reported due to data restrictions.

RESULTS

Of 12,367 eligible individuals, 12,361 had complete cost data. Two hundred and eighty individuals (2.3%) had confirmed SMM events meeting CDC criteria. CDC criteria excluding transfusion alone occurred in 1.0% (n = 121) and hospital-defined SMM in 0.6% (n = 76). In adjusted models, SMM events by CDC criteria were associated with a relative cost increase of 2.45 times (95% confidence interval [CI]: 2.29-2.61) the cost of an uncomplicated delivery. SMM by CDC criteria excluding transfusion alone was associated with a relative increase of 3.26 (95% CI: 2.95-3.60) and hospital-defined SMM with a 4.19-fold (95% CI: 3.64-4.83) increase. Each additional CDC subcategory of SMM diagnoses conferred a relative cost increase of 1.60 (95% CI: 1.43-1.79).

CONCLUSION

SMM is associated with between 2.5- and 4-fold higher cost than uncomplicated deliveries.

KEY POINTS

· Severe maternal morbidity as defined by CDC criteria confers a 2.5-fold increase in delivery hospitalization costs.. · Intensive care unit admission or ≥ 4 units of blood products confer a fourfold increase in cost.. · Costs of maternal morbidity may motivate SMM review..

A double-blinded randomized controlled trial on the effects of increased intravenous hydration in nulliparas undergoing induction of labor

BACKGROUND

Rates of labor induction are increasing, raising concerns related to increased healthcare utilization costs. High-dose intravenous fluid (250 cc/h) has been previously demonstrated to shorten the time to delivery in nulliparous individuals in spontaneous labor. Whether or not this relationship exists among individuals undergoing induction of labor is unknown.

OBJECTIVE

Our study aimed to evaluate the effect of high-dose intravenous hydration on time to delivery among nulliparous individuals undergoing induction of labor.

STUDY DESIGN

Nulliparous individuals presenting for induction of labor with a Bishop score of ≤6 (with and without rupture of membranes) were randomized to receive either 125 cc/h or 250 cc/h of normal saline. The primary outcome was length of labor (defined as time from initiation of study fluids to delivery). Both time to overall delivery and vaginal delivery were evaluated. Secondary outcomes included the lengths of each stage of labor, the percentage of individuals delivering within 24 hours, and maternal and neonatal outcomes, including cesarean delivery rate.

RESULTS

A total of 180 individuals meeting inclusion criteria were enrolled and randomized. Baseline demographic characteristics were similar between groups; however, there was a higher incidence of diabetes mellitus in the group receiving 125 cc/h. Average length of labor was similar between groups (27.6 hours in 250 cc/h and 27.8 hours in 125 cc/h), as was the length of each stage of labor. Cox regression analysis did not demonstrate an effect of fluid rate on time to delivery. Neither the admission Bishop score, body mass index, nor other demographic characteristics affected time to delivery or vaginal delivery. There were no differences in maternal or neonatal outcomes, including overall cesarean delivery rate, clinically apparent iatrogenic intraamniotic infection, Apgar scores, need for neonatal phototherapy, or neonatal intensive care unit stay.

CONCLUSION

There were no observed differences in the length of labor or maternal or neonatal outcomes with the administration of an increased rate of intravenous fluids among nulliparous individuals undergoing induction of labor.

Moving preinduction cervical ripening to a lower acuity inpatient setting using the synthetic hygroscopic cervical dilator: a cost-consequence analysis for the United States

BACKGROUND

Leveraging the safety profile of the synthetic hygroscopic cervical dilator (SHCD), one potential way to reduce the burden-of-care provision in the labor-and-delivery unit without compromising safety is to introduce a low-acuity care room (ripening room) for patients undergoing cervical ripening as a part of labor induction at term.

METHODS

Implementing a ripening room using SHCDs was compared to scenarios using prostaglandins including a dinoprostone insert (PGE2 insert) or gel (PGE2 gel) and misoprostol given orally (oral PGE1) or vaginally (vaginal PGE1). A theoretical, cost-consequence model was developed to assess costs, staff time, and selected clinical outcomes related to cervical ripening. The model assessed a hypothetical cohort where patients remained in hospital from admission for induction of labor (IOL) to delivery, taking the US labor-and-delivery unit perspective. Model inputs were taken from structured searches of PubMed and ClinicalTrials.gov, published US guidance, and clinical practice. Results are presented as mean (95% credible interval [CrI]).

RESULTS

The ripening room using SHCDs cost US$3,210 and required 10.22 hours (h) of nurse time on average per patient. The cost difference to prostaglandins ranged from -$894 (-$2,269 to $398) for PGE2 gel to +$460 (-$1,467 to $1,539) for vaginal PGE1. Mean nurse time was shorter than all prostaglandins, with time savings ranging from -7.05 (-24.55 to 5.73) h for PGE2 insert to -0.97 (-14.69 to 9.59) h for vaginal PGE1. When outcomes of the probabilistic sensitivity analysis were ranked from 1 (best) to 5 (worst), the ripening room using SHCDs ranked 1.94 for costs and 1.97 for nurse time. In a nulliparous population, results improved for the ripening room using SHCDs relative to all prostaglandins.

CONCLUSION

In this theoretical study, implementing a ripening room using SHCDs resulted in the lowest time burden and the second lowest costs. The cheapest option for preinduction cervical ripening was vaginal misoprostol.

Impact of labor induction at 39 weeks gestation compared with expectant management on maternal and perinatal morbidity among a cohort of low-risk women

OBJECTIVE

To determine maternal and perinatal outcomes after induction of labor (IOL) at 39 weeks compared with expectant management.

METHODS

This is a retrospective national cohort study from the National Center for Health Statistics birth database. The study included singleton, low-risk pregnancies with a non-anomalous fetus delivered at 39-42 weeks gestation between 2015 and 2018. Maternal outcomes available included chorioamnionitis (Triple I), blood transfusion, intensive care unit (ICU) admission, uterine rupture, cesarean delivery (CD), and cesarean hysterectomy. Fetal and infant outcomes included stillbirth, 5-min Apgar ≤3, prolonged ventilation, seizures, ICU admission, and death within 28 days. We compared women undergoing IOL at 39 weeks to those managed expectantly. Non-adjusted and adjusted relative risks (aRRs) were estimated using multivariate log-binomial regression analysis.

RESULTS

There were 15,900,956 births available for review of which 5,017,524 met inclusion and exclusion criteria. For the maternal outcomes, the IOL group was less likely to require a CD (aRR 0.880; 95% CI [0.874-0.886]; p value < .01) or develop Triple I (aRR 0.714; 95% CI [0.698-0.730]; p value < .01) but demonstrated a small increase in the cesarean hysterectomy rate (aRR 1.231; 95% CI [1.029-1.472]; p value < .01). Among perinatal outcomes, the stillbirth rate (aRR 0.195; 95% CI [0.153-0.249]; p value < .01), 5-min Apgar ≤3 (aRR 0.684; 95% CI [0.647-0.723]; p value < .01), prolonged ventilation (aRR 0.840; 95% CI [0.800-0.883]; p value < .01), neonatal intensive care (NICU) admission (aRR 0.862; 95% CI [0.849-0.875]; p value < .01) were lower after 39 week IOL compared with expectant management. There were no differences in risk for neonatal seizures (aRR 0.848; 95% CI [0.718-1.003]; p value 0.011) or death (aRR 1.070; 95% CI [0.722-1.586]; p value 0.660).

CONCLUSIONS

IOL at 39 weeks of gestation in a low-risk cohort is associated with a lower risk of CD and maternal infection, stillbirth, and lower neonatal morbidity. There was no effect on the risk for neonatal seizures or death.

Transfusion Preparedness in the Labor and Delivery Unit: An Initiative to Improve Safety and Cost

OBJECTIVE

To evaluate patient safety, resource utilization, and transfusion-related cost after a policy change from universal type and screen to selective type and screen on admission to labor and delivery.

METHODS

Between October 2017 and September 2019, we performed a single-center implementation study focusing on risk-based type and screen instead of universal type and screen. Implementation of our policy was October 2018 and compared 1 year preimplementation with 1 year postimplementation. Patients were risk-stratified in alignment with California Maternal Quality Care Collaborative recommendations. Under the new policy, the blood bank holds a blood sample for processing (hold clot) on patients at low- and medium-risk of hemorrhage. Type and screen and crossmatch are obtained on high-risk patients or with a prior positive antibody screen. We collected patient outcomes, safety and cost data, and compliance and resource utilization metrics. Cost included direct costs of transfusion-related testing in the labor and delivery unit during the study period, from a health system perspective.

RESULTS

In 1 year postimplementation, there were no differences in emergency-release transfusion events (4 vs 3, P>.99). There were fewer emergency-release red blood cell (RBC) units transfused (9 vs 24, P=.002) and O-negative RBC units transfused (8 vs 18, P=.016) postimplementation compared with preimplementation. Hysterectomies (0.05% vs 0.1%, P=.44) and intensive care unit admissions (0.45% vs 0.51%, P=.43) were not different postimplementation compared with preimplementation. Postimplementation, mean monthly type and screen-related costs (ABO typing, antibody screen, and antibody workup costs) were lower, $9,753 compared with $20,676 in the preimplementation year, P<.001.

CONCLUSION

Implementation of selective type and screen policy in the labor and delivery unit was associated with projected annual savings of $181,000 in an institution with 4,000 deliveries per year, without evidence of increased maternal morbidity.

Induction of labour at 41 weeks of gestation versus expectant management and induction of labour at 42 weeks of gestation: a cost-effectiveness analysis

OBJECTIVE

To assess the cost-effectiveness of induction of labour (IOL) at 41 weeks of gestation compared with expectant management until 42 weeks of gestation.

DESIGN

A cost-effectiveness analysis alongside the Swedish Post-term Induction Study (SWEPIS), a multicentre, randomised controlled superiority trial.

SETTING

Fourteen Swedish hospitals during 2016-2018.

POPULATION

Women with an uncomplicated singleton pregnancy with a fetus in cephalic position were randomised at 41 weeks of gestation to IOL or to expectant management and induction at 42 weeks of gestation.

METHODS

Health benefits were measured in life years and quality-adjusted life years (QALYs) for mother and child. Total cost per birth was calculated, including healthcare costs from randomisation to discharge after delivery, for mother and child. Incremental cost-effectiveness ratios (ICERs) were calculated by dividing the difference in mean cost between the trial arms by the difference in life years and QALYs, respectively. Sampling uncertainty was evaluated using non-parametric bootstrapping.

MAIN OUTCOME MEASURES

The cost per gained life year and per gained QALY.

RESULTS

The differences in life years and QALYs gained were driven by the difference in perinatal mortality alone. The absolute risk reduction in mortality was 0.004 (from 6/1373 to 0/1373). Based on Swedish life tables, this gives a mean gain in discounted life years and QALYs of 0.14 and 0.12 per birth, respectively. The mean cost per birth was €4108 in the IOL group (n = 1373) and €4037 in the expectant management group (n = 1373), with a mean difference of €71 (95% CI -€232 to €379). The ICER for IOL compared with expectant management was €545 per life year gained and €623 per QALY gained. Confidence intervals were relatively wide and included the possibility that IOL had both lower costs and better health outcomes.

CONCLUSIONS

Induction of labour at 41 weeks of gestation results in a better health outcome and no significant difference in costs. IOL is cost-effective compared with expectant management until 42 weeks of gestation using standard threshold values for acceptable cost per life year/QALY.

TWEETABLE ABSTRACT

Induction of labour at 41 weeks of gestation is cost-effective compared with expectant management until 42 weeks of gestation.