Is it really better for the baby's health to be born 2 weeks earlier?
After two easy, healthy, completely undrugged vaginal deliveries, my ob/gyn advised inducing the third a bit less than a week early because his head was not quite engaged and she didn't want me going into labor with the baby in that position. The pitocin contractions were so strong I requested my first ever epidural, as a result of which my blood pressure and the baby's heartbeat dropped so precipitously I had to be revived from being almost DEAD. After that the pitocin was removed and 12 hours later I had a c-section, which was horrible in every way, relative to a vaginal delivery. Recovery from the first two deliveries was about 24 hours, no tearing no scarring, no pain at all. The baby is now a perfectly healthy teenager, but it was a terrifying experience and I never returned to that ob/gyn. The worst part was the nurses and doctors; during the whole horrible day, they behaved as though it was I who was being inappropriately anxious and terrified. During my first two deliveries, I was neither anxious nor terrified; on the contrary - exhilarated, happy and very empowered.
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19% vs 22%: cesareans on head down, first births dont improve outcomes.they just get the baby out faster. All you have to do to decrease cesareans is not to do them.
6% needed fertility treatments to get pregnant. 53% were obese. 8% were smokers. The protocol states it excludes anyone with a major maternal medical illness such as any diabetes mellitus, lupus, any hypertensive disorder, cardiac disease, renal insufficiency . Yet 704 (5%) of women had hypertensive disorders and were included.
The study does not define what they mean by induction. It's like writing a publication titled, “antibiotic treatment versus placebo” without stating which antibiotic and at what dose.
5% of the women in the induction group were not induced and 5% of those in the non-induction group were induced, so the data doesnt reflect the actual protocol. No reason is given for why the data is analyzed by intention to treat instead of actual treatment.
The authors do not address the effect of epidural analgesia on these labors.
The increased newborn seizures and subdural hematomas in the induction group was not emphasized. 5% of the participants had a severe PPH > 1500 cc - losing half their blood volume.
Induction never has, never will improve outcomes in low risk women. (https://www.researchgate.net/publication/272835462_To_what_extent_do_Eng...
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I feel I have little standing to comment on a study that has such an enormous amount of information and confounding variables I can't understand, even as a medical researcher. I wish I could have learned more about the data analysis.
That said, the conclusion is indeed striking. I have no horse in this race - as a (healthy) elderly primigravida who gave birth at 38, I was more concerned about the potential for placental insufficiency than induction after 40 weeks of gestation with no sign of labor. I asked for induction at 40 weeks and was refused. I had a massive spike in blood pressure while approaching 41 weeks and had an (uneventful) emergency cesarian and healthy infant.
If this study is found to be reliable, I still have to ask why giving birth, an event that should occur without significant intervention, is needed? Is it our modern lifestyle and being sedentary? Standard American diet ? Demographics? What has changed that induction saves lives? Certainly this isn't an evolutionary adaption.
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Induction as a prophylactic is a bit extreme. However, where there are issues in a pregnancy induction as a first thing to try may be a good alternative to jumping straight to the major surgery of a c-section. I had two emergency deliveries (one for pre-eclampsia, the other due to being injured in an accident at 38 weeks), and both times induction successfully helped me avoid c-sections.
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Also, please be aware that there was plenty of preliminary evidence to support the ARRIVE Trial - it was definitely an ethical study. In contrast, and based on available evidence, one could argue that it would be unethical to NOT do this study.
Finally, consider that labor induction at 39 weeks is an example of preventive medicine (similar to pediatric immunizations). There is often no obvious need for intervention at the time that preventive care is provided, but when applied to a large group of patients the preventive intervention improves rates of important group outcomes. In the case of IOL at 39 weeks, there are lower rates of C/S and pregnancy-induced hypertension, and less frequent significant respiratory problems for babies at the time of birth. In addition, the use of IOL at 39 weeks within large groups will prevent some cases of term stillbirth. In my long experience, this type of induction is done specifically to improve outcomes. It is not done "for no reason at all."
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@Jim Nicholson "consider that labor induction at 39 weeks is an example of preventive medicine."
Really? Why then did I have to plead (and be refused) for an induction at 40 weeks and was told it was not standard of care? New York City, 2000. Has something changed?
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This is all very complicated and for many upsetting. However, the USA does have higher rates of C/S than many other countries. There are probably multiple reasons for that. However, we have the system that we have, and our outcomes will not improve unless better methods of care are employed. This study suggests that, within our current system, labor induction at 39 weeks lowers the risk of cesarean delivery in first time mothers. That is a good thing - especially for those women who thereby avoid C/S. Other changes in term pregnancy care might also be beneficial - but those who believe that other changes would be more beneficial should find a way to do a study like this one so as to prove that their recommended method of care lowers C/S rates within groups of USA pregnant women.
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Except that infant mortality rate is an irrelevant statistic because it measures pediatric care not obstetric care. Look at perinatal death rate and try again.
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OK. I will try again. Terminology is very important when considering changes in approaches to term pregnancy care. Infant mortality is not entirely irrelevant (serious neonatal morbidity can result from delivery-based complications), but I understand the need to be precise.
JAMA-PEDS recently reported that rates of US perinatal death (stillbirth + early infant mortality) have been decreasing over the past decade...BUT but this finding was based on all births at or beyond 28 weeks of gestation. If one does a re-analysis of data from that paper, one finds that the rate of TERM perinatal mortality (37 weeks and beyond) has actually gone up over the past decade.
Also, as I have reported in the medical literature, and as confirmed by other investigators, the rate of TERM stillbirth in the USA has been increasing over the past 10 years. Rates of TERM stillbirth have been increasing as rates of early term (37th and 38th week) labor induction have been decreasing because of the "39-week Rule."
There is growing scientific evidence that for many pregnancies the optimal time for delivery is prior to the "due date." This conflicts with opinions and traditional belief. Which should ideally be used to direct medical care - high quality scientific evidence or traditions and opinions? The ARRIVE Trial, being a randomized trial, is in the category of high quality medical evidence, and its findings are consistent with other recent high quality medical studies.
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@Someone I have to disagree. While the fetus is in the mother's body, obstetrics is highly relevant.
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Please consider first the lower rates of c-sections of several countries in western Europe (Scandinavia, France, Belgium, Netherlands - https://www.statista.com/statistics/283123/cesarean-sections-in-oecd-cou..., all of which have far better infant mortality rates than the US - and which do not induce labor unnaturally for no reason.
I have three children - all born naturally with no medical intervention - and never would have thought of inducing labor.
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@Sally, Those countries also have universally available prenatal care and health care in general. I'm not saying you are right or wrong, just that there is an obvious alternative explanation for better infant mortality rates.
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There’s good prenatal in the US. Mine was excellent, but many American women are older and/or overweight with conditions such as diabetes and hypertension when getting pregnant.... a recipe for maybe not disaster but trouble!
Prenatal care in the US is uneven, especially in rural areas where PCP and OB/GYN care may be scarce or non-existent. Add to this drives of up to 100 miles just to get to care, a lack of transportation due to low incomes, a lack of paid time off to get to prenatal care, and you can see that high numbers of women do without prenatal care. This is a recipe for maternal and infant death within the first year after birth, and one of the best arguments for expanded health care and paid leave access.
At 38 weeks I asked my doc to induce my first born at 39 weeks, as I had been extremely active and healthy throughout the pregnancy and had slowed to a painful crawl the last week and showed very little signs of progression. He agreed, had me wait the next week, and induced at 39 weeks. My baby was born 12 hours later, at 8 lbs 9 oz in perfect health. Her head was so big versus my pelvis I had to push for hours and she needed forceps. If I had waited, this probably would have been a c-section birth. With my second I knew she had dropped at 37 weeks, water broke 2 days later, and delivered her after a few hours of induced labor on the second push. At 37 weeks she was 7 lbs 15 oz. With both babies I was a heathy weight and gained 29 lbs with each. My point: stop shaming docs and moms. I was very in touch with what I wanted and needed, and probably avoided a c-section with my first by asking about induction. My doc encouraged his patients to be very active, and since I was, treated my very recent pain and inability to move much as a sign that maybe delivering my eldest was the best move. I certainly think so.
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This study seems highly unethical. How could an ethics board approve administering a treatment for no medical reason to a pregnant woman and her unborn child? The psychological damage experienced by the mother should anything happen to the baby would be terrifying.
Besides, due to the abnormally high number of c-sections performed in the United States, its whole premise is highly questionable.
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So the idea that Doctor knows best continues - construct a chaotic, stressful labor and delivery with medication that could slow labor and have an increase in C-sections. Then propose as an alternative to a forced C-section the inducement of labor ahead of time... No reason to think this is better. Fix the situation to begin with.
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@Margo Maybe the situation that needs fixing is our modern high insulin levels? This wasn't mentioned in the article, but I suspect that in the USA full-term babies are coming out bigger these days. One of my kids arrived two weeks early, I suspect because I had been snow shoveling off the porch. And after he arrived, I sure wouldn't have wanted him to have two more weeks to lie around fattening up!
@MTL If there is a medical NEED, sure. But in a what-if situation - count me out. Doctors want to doctor, I don't think waiting around is a big part of the training. Maybe use well trained midwives instead.
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What is wrong with the medical community? Why would you just intervene for no reason in a perfectly healthy pregnancy?
This is total madness. Why do women put up with this?
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@Cecelia It is not "for no reason" as the risk of stillbirth--a truly horrific outcome--goes up considerably after 39 weeks. Since that bad outcome is still pretty rare, this study wouldn't have been big enough to get statistical significance on whether induction at 39 weeks prevents stillbirth, but there is at least one good reason to start thinking about induction of perfectly healthy pregnancy at 39 weeks, and this study at least shows that doing so won't increase likelihood of c-section.
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@Sarah No, that is not a good reason. Artificially interfere with every pregnancy because some minuscule amount might have problems.
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@Sarah But remember, in many cases, the medical community is clueless as to why stillbirth occurs. Yes, a Rh+/Rh- situation can cause stillbirth, but, please identify some other causes. Sometimes, as terrible as that outcome is, a child who is conceived, dies in the womb at some point in time, prior to its expected date of birth. Such a stillborn baby can be delivered at 30 weeks and I wouldn't be surprised if that child at some point, prior to 3 months, pass away, perhaps due to SIDS.
Induction protocol sounds like a great income generating method for hospitals, birthing centers, and insurance companies. Nervous, first-time parents make excellent
prey.
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@Jeannie I was the one that requested induction at 39 weeks. I wasn't nervous, and it turned out my baby's head was very large and I might have needed a c-section had I waited.
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My babies were also very large, and I was induced 10 days early and was thankful for the option. One weighed 9’2 oz and one 8’6 oz.
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No one is taking away that "option." The question is, when does an option become a recommendation and become another unnecessary "standard" intervention?
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