Elective Induction: When? Ever?

Cesarean section rate: navigating the gap between WHO recommended range and current obstetrical challenges

The cesarean section (CS) rate is very heterogeneous all over the world, reflecting the differences in the access to healthcare services. In higher-income countries, changes observed in the obstetrical population brought to an increased rate of cesarean section for maternal request. Besides, clinicians are facing an increasing number of induction of labor, with the consequent risk of CS if the management is inappropriate. Analyzing the rate of primary CS, the interpretation of intrapartum CTG and a tailored management of labor are also red flags that must be considered. In this optic, the implementation of obstetrics training and simulation programs and the improvement of clinical protocols with the latest evidence can lead to the reduction of unnecessary CS.

Pregnancy outcomes of elective induction in low-risk term pregnancies: A propensity-score analysis

We investigated the mode of delivery and perinatal outcomes in low-risk pregnant women whose labor was electively induced or expectantly managed at term.Healthy women with viable, vertex singleton pregnancies at 37 to 40 weeks of gestation were included. Women electively induced (n = 416) in each week (37-37, 38-38, 39-39, 40-40 weeks) were compared with pregnant women with spontaneous labor (n = 487). The primary outcome was mode of delivery. A propensity score (PS) was derived using logistic regression to model the probability of elective induction group as a function of potential confounders. Altogether, 284 women with elective induction were matched with 284 women who underwent expectant management to create a PS-matched population. All analysis was performed using SAS software, version 9.4 (SAS Institute Inc., Cary, NC). All P values reported of the significance level was set at <.05.There are no significant differences of delivery mode, neonatal intensive care unit (NICU) admission, and neonatal complication between PS-matched groups. Incidence of antepartum complications showed higher in the elective induction group compared to the spontaneous labor group (P = .04). When comparing each gestational week, incidence of NICU admission at 38 weeks in the elective induction group [10/74 (13.5%)] was significantly higher than in and the spontaneous labor group [2/74 (2.7%)] (P = .04).Elective induction of labor at term is not associated with increased risk of cesarean delivery. However, overall incidence of NICU admission at 38 gestational weeks seems to be increased in elective induction.

Lack of controlled studies investigating the risk of postpartum haemorrhage in cesarean delivery after prior use of oxytocin: a scoping review

BACKGROUND

Postpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Experimental and clinical studies indicate that prolonged oxytocin exposure in the first or second stage of labour may be associated with impaired uterine contractility and an increased risk of atonic PPH. Therefore, particularly labouring women requiring cesarean delivery constitute a subset of patients that may exhibit an unpredictable response to oxytocin. We mapped the evidence for comparative studies investigating the hypothesis whether the risk for PPH is increased in women requiring cesarean section after induction or augmentation of labour.

METHODS

We performed a systematic literature search for clinical trials in Medline, Embase, Web of Science, and the Cochrane Library (May 2016). Additionally we searched for ongoing or unpublished trials in clinicaltrials.gov and the WHO registry platform. We identified a total of 36 controlled trials investigating the exogenous use of oxytocin in cesarean section. Data were extracted for study key characteristics and the current literature literature was described narratively.

RESULTS

Our evidence map shows that the majority of studies investigating the outcome PPH focused on prophylactic oxytocin use compared to other uterotonic agents in the third stage of labour. Only 2 dose-response studies investigated the required oxytocin dose to prevent uterine atony after cesarean delivery for labour arrest. These studies support the hypotheses that labouring women exposed to exogenous oxytocin require a higher oxytocin dose after delivery than non-labouring women to prevent uterine atony after cesarean section. However, the study findings are flawed by limitations of the study design as well as the outcome selection. No clinical trial was identified that directly compared exogenous oxytocin versus no oxytocin application before intrapartum cesarean delivery.

CONCLUSION

Despite some evidence from dose-response studies that the use of oxytocin may increase the risk for PPH in intrapartum cesarean delivery, current research has not investigated the prepartal application of oxytocin in well controlled clinical trials. It was striking that most studies on exogenous oxytocin are focused on PPH prophylaxis in the third stage of labour without differing between the indications of cesarean section and hence the prepartal oxytocin status.

Hypnosis for induction of labour

BACKGROUND

Induction of labour using pharmacological and mechanical methods can increase complications. Complementary and alternative medicine methods including hypnosis may have the potential to provide a safe alternative option for the induction of labour. However, the effectiveness of hypnosis for inducing labour has not yet been fully evaluated.

OBJECTIVES

To assess the effect of hypnosis for induction of labour compared with no intervention or any other interventions.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2014), handsearched relevant conference proceedings, contacted key personnel and organisations in the field for published and unpublished references.

SELECTION CRITERIA

All published and unpublished randomised controlled trials (RCTs) and cluster-RCTs of acceptable quality comparing hypnosis with no intervention or any other interventions, in which the primary outcome is to assess whether labour was induced.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the one trial report that was identified (but was subsequently excluded).

MAIN RESULTS

No RCTs or cluster-RCTs were identified from the search strategy.

AUTHORS' CONCLUSIONS

There was no evidence available from RCTs to assess the effect of hypnosis for induction of labour. Evidence from RCTs is required to evaluate the effectiveness and safety of this intervention for labour induction. As hypnosis may delay standard care (in case standard care is withheld during hypnosis), its use in induction of labour should be considered on a case-by-case basis.Future RCTs are required to examine the effectiveness and safety of hypnotic relaxation for induction of labour among pregnant women who have anxiety above a certain level. The length and timing of the intervention, as well as the staff training required, should be taken into consideration. Moreover, the views and experiences of women and staff should also be included in future RCTs.

Epidemiologic considerations: scope of problem and disparity concerns

Elective labor induction is an increasingly common practice not only in high-income countries but also in many low-income and middle-income countries. Many questions remain unanswered on the safety and cost-effectiveness of elective labor induction, particularly in resource-constrained settings wherein there may be a high unmet need for medically indicated inductions, as well as limited or no access to appropriate medications and equipment for induction and monitoring, comprehensive emergency obstetric care, safe, and timely cesarean section, and appropriate supervision from health professionals. This article considers the global perspective on the epidemiology, practices, safety, and costs associated with elective labor induction.

Maternal and neonatal complications of elective early-term deliveries

Approximately 10% to 15% of all deliveries in the United States are performed before 39 completed weeks of gestation without a true medical indication for early delivery, despite long-standing recommendations against this practice. Early-term deliveries are those that occur between 3707 and 3867 weeks. It is now recognized that maternal and neonatal complications have increased for deliveries that occur at early- vs late-term gestation. The reasons for the increase in the rate of elective early-term deliveries are unclear but likely involve both patient and physician factors. Various strategies have been used to increase awareness of the morbidities associated with the practice of elective early-term delivery and to reduce its frequency. Insurers and quality accrediting agencies are increasingly holding hospitals accountable for their rates of elective early-term deliveries, and this pressure will likely continue to lead to widespread change in the practice of obstetrics. The interventions to increase adherence to evidence-based medicine guidelines that are described within this review may also be applicable to other areas of medicine.

An Analysis of the NSW Midwives Data Collection over an 11-Year Period to Determine the Risks to the Mother and the Neonate of Induced Delivery for Non-Obstetric Indication at Term

Objective. To determine the risks of induced term delivery to the mother and neonate at different gestational ages in the absence of obstetric indications. Study Design. All deliveries in New South Wales (NSW) between 1998 and 2008 were reviewed from the MDC. Uncomplicated pregnancies which were induced for non-obstetric reasons after 37 completed weeks were reviewed. This was a retrospective, historical cohort study, and both maternal and neonatal outcomes were analysed and compared between different gestational age groups. Results. An analysis of the data shows that induction of labour after 37 completed weeks exposes the fetus and mother to different levels of risk at different gestations. Conclusion. In an uncomplicated pregnancy, induction of labour is associated with the highest rate of neonatal complication at 37 weeks as compared with rates at later gestations. With each ensuing week, the neonatal outcome improves. At 40 weeks the likelihood of neonatal intensive care admission, low Apgar scores, and perinatal death rate is at its lowest, and then there is a slight but not significant rise after 41 weeks. The likelihood of caesarean section is the lowest when inductions are carried out at 39 weeks and is the highest at 41 weeks and over.

Induction of labor in the United States: a critical appraisal of appropriateness and reducibility

Approximately 1 in 4 women in the United States are induced, with up to 1 in 10-12 being induced for elective reasons. National guidelines by the American College of Obstetricians and Gynecologists, the Society of Obstetricians Gynaecologists of Canada, and the Royal College of Obstetricians and Gynaecologists list 21 indications for inductions; however, all 3 concur in only 14% women (3 of 21). An induction should be considered appropriate if it meets the following 4 criteria: (1) concordant with women's autonomous informed decisions and desideratum; (2) optimizes maternal-fetal outcomes, including psychological maternal well-being; (3) congruous with evidence-based medicine; and (4) cost-effective. A meta-analysis of 22 randomized trials noted that membrane sweeping reduces the likelihood of induction. Implementing policies to prevent elective induction at 37-38 weeks provides conflicting results about the rate of macrosomia and stillbirth at early term. We argue that a well-designed randomized controlled trial, with adequate power to demonstrate whether prohibiting elective induction increases the rate of stillbirth or complications such as macrosomia, is warranted. Patient education during their prenatal course is a promising strategy to decrease the rate of induction.

Perinatal Pitocin as an early ADHD biomarker: neurodevelopmental risk?

OBJECTIVE

To investigate a potential relationship between coincidental increases in perinatal Pitocin usage and subsequent childhood ADHD onset in an attempt to isolate a specific risk factor as an early biomarker of this neurodevelopmental disorder.

METHOD

Maternal labor/delivery and corresponding childbirth records of 172 regionally diverse, heterogeneous children, ages 3 to 25, were examined with respect to 21 potential predictors of later ADHD onset, including 17 selected obstetric complications, familial ADHD incidence, and gender. ADHD diagnosis and history of perinatal Pitocin exposure distinguished groups for comparison.

RESULTS

Results revealed a strong predictive relationship between perinatal Pitocin exposure and subsequent childhood ADHD onset (occurring in 67.1% of perinatal Pitocin cases vs. 35.6% in nonexposure cases, χ(2)=16.99, p<.001). Fetal exposure time, gestation length, and labor length also demonstrated predictive power, albeit significantly lower.

CONCLUSION

The findings warrant further investigation into the potential link between perinatal Pitocin exposure and subsequent ADHD diagnosis.

Trends in induction of labor at early-term gestation

OBJECTIVE

To determine the trends and racial differences in early-term induction of labor in the United States.

STUDY DESIGN

Data from the National Center for Health Statistics were used to identify women eligible for induction between 37-42 weeks' gestation in the United States from 1991-2006. Annual early-term induction rates were calculated, and maternal race/ethnicity was classified into 4 groups. The change in frequency and odds of early-term induction stratified by race/ethnicity over time was assessed.

RESULTS

Among 39.2 million eligible women, early-term induction rates increased from 2.0% to 8.0% (P < .01) over 16 years. Cross-sectional and annual early-term induction rates were highest for non-Hispanic white women during the study period (P < .01). After adjusting for confounding factors, the odds of any early-term induction were highest (P < .01) and rose most rapidly (P < .01) among non-Hispanic white women compared with women from other racial/ethnic groups.

CONCLUSION

In the United States, early-term induction rates rose significantly and were highest among non-Hispanic white women.

Cost-effectiveness of elective induction of labor at 41 weeks in nulliparous women

OBJECTIVE

To investigate the cost-effectiveness of elective induction of labor at 41 weeks in nulliparous women.

STUDY DESIGN

A decision analytic model comparing induction of labor at 41 weeks vs expectant management with antenatal testing until 42 weeks in nulliparas was designed. Baseline assumptions were derived from the literature as well as from analysis of the National Birth Cohort dataset and included an intrauterine fetal demise rate of 0.12% in the 41st week and a cesarean rate of 27% in women induced at 41 weeks. One-way and multiway sensitivity analyses were conducted to examine the robustness of the findings.

RESULTS

Compared with expectant management, induction of labor is cost-effective with an incremental cost of $10,945 per quality-adjusted life year gained. Induction of labor at 41 weeks also resulted in a lower rate of adverse obstetric outcomes, including neonatal demise, shoulder dystocia, meconium aspiration syndrome, and severe perineal lacerations.

CONCLUSION

Elective induction of labor at 41 weeks is cost-effective and improves outcomes.

Women's experiences of induction of labour--findings from a Swedish regional study

BACKGROUND

 Induction of labour is common in modern obstetrics but its impact on women's birth experiences is inconclusive.

AIM

 The aim of the present study was to explore the prevalence of induction in a Swedish region and reasons for labour induction. A second aim was to compare the experience of spontaneous labour and birth for women to the experience of induction of labour. A third aim was to explore the difference in labour in relation to the length of pregnancy.

METHODS

 A one-year cohort of 936 women was included in a longitudinal Swedish survey in which data were collected by questionnaires, two months after birth. The main outcome was a set of data recording women's birth experiences.

RESULTS

Labour induction was performed in 17% of births and mostly performed for medical reasons. Women who were induced used more epidurals (OR 2.3; 95% CI 1.4-3.8) for pain relief and used bath/shower less frequently for pain relief (OR 0.3; 95% CI 0.2-0.5). Labour induction was associated with a less positive birth experience (OR 1.5; 95% CI 1.0-2.3), and women who were induced were more likely to totally agree that they were frightened that the baby would be damaged during birth (OR 2.1; 95% CI 1.2-3.9), but the assessment of feelings during birth differed with regard to length of pregnancy.

CONCLUSION

 Labour induction affects women's experiences of birth and is related to length of pregnancy.

Contemporary cesarean delivery practice in the United States

OBJECTIVE

To describe contemporary cesarean delivery practice in the United States.

STUDY DESIGN

Consortium on Safe Labor collected detailed labor and delivery information from 228,668 electronic medical records from 19 hospitals across the United States, 2002-2008.

RESULTS

The overall cesarean delivery rate was 30.5%. The 31.2% of nulliparous women were delivered by cesarean section. Prelabor repeat cesarean delivery due to a previous uterine scar contributed 30.9% of all cesarean sections. The 28.8% of women with a uterine scar had a trial of labor and the success rate was 57.1%. The 43.8% women attempting vaginal delivery had induction. Half of cesarean for dystocia in induced labor were performed before 6 cm of cervical dilation.

CONCLUSION

To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate is urgently needed. Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor.

Determinants of early ponderal and statural growth in full-term infants in the EDEN mother-child cohort study

BACKGROUND

Growth velocity in the first months of postnatal life has been associated with later overweight and obesity.

OBJECTIVE

We analyzed prenatal and postnatal factors in association with weight, length, and growth velocities in the first 3 mo of life.

DESIGN

We estimated weight, length, and instantaneous weight- and length-growth velocities (in g/d and mm/d) in 1418 term infants at 1 and 3 mo of age and evaluated the following potential determinants: maternal prepregnancy body mass index (BMI), 1-h plasma glucose concentrations during pregnancy, smoking, socioeconomic status, parity, paternal BMI, parental heights, and infant feeding, gestational age, and sex.

RESULTS

Maternal obesity and plasma glucose concentrations were associated with the weights and lengths of offspring at birth but not at 1 and 3 mo after birth. In contrast, there was no association between paternal BMI and anthropometric measures of offspring at birth, but by 3 mo of age infants of obese fathers had significantly higher weights and weight-growth velocities than did infants of fathers with a normal BMI. Maternal weight gain was a significant predictor of weight at birth and 3 mo of age. Exclusively breastfed infants had a slower weight-growth velocity as early as 1 mo of age compared with exclusively formula-fed infants.

CONCLUSIONS

In the first 3 mo of life, the positive associations between maternal obesity, plasma glucose concentrations, and infant anthropometric measures at birth seem to progressively fade away, whereas the emerging association with paternal BMI may indicate an early postnatal influence of paternal genetics. Among the determinants we evaluated, some are potentially modifiable, such as maternal gestational weight gain and infant feeding. The identification of optimal patterns of growth remains crucial before providing any clinical recommendations.

Decreased term and postterm birthweight in the United States: impact of labor induction

OBJECTIVE

We sought to assess recent trends in falling mean birthweight (BW) and gestational age (GA) among US non-Hispanic white singleton live births >or=37 weeks of gestation and the contribution of increased rates of induction to these trends.

STUDY DESIGN

This was an ecological study based on US vital statistics from 1992 through 2003.

RESULTS

From 1992 through 2003, mean BW fell by 37 g, mean GA by 3 days, and macrosomia rates by 25%. Rates of induction nearly doubled from 14% to 27%. Our ecological state-level analysis showed that the increased rate of induction was significantly associated with reduced mean BW (r = -0.54; 95% confidence interval [CI], -0.71 to -0.29), mean GA (r = -0.44; 95% CI, -0.65 to -0.17), and rate of macrosomia (r = -0.55; 95% CI, -0.74 to -0.32).

CONCLUSION

Increasing use of induction is a likely cause of the observed recent declines in BW and GA. The impact of these trends on infant and long-term health warrants attention and investigation.

Late preterm infants, early term infants, and timing of elective deliveries

Delivery of infants who are physiologically mature and capable of successful transition to the extrauterine environment is an important priority for obstetric practitioner. A corollary of this goal is to avoid iatrogenic complications of prematurity and maternal complications from delivery. The purpose of this review is to describe the consequences of birth before physiologic maturity in late preterm and term infants, to identify factors contributing to the decline in gestational age of deliveries in the United States, and to describe strategies to reduce premature delivery of late preterm and early term infants.