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Elective induction of labor at 39 weeks associated with decreased cesarean rate
Question clinique
Is elective induction of labor at 39 weeks or expectant management associated with a lower cesarean delivery rate?
L’Essentiel
This meta-analysis of observational cohort studies found that among low-risk nulliparous women with singleton pregnancies in cephalic presentation, elective induction of labor was associated with a lower rate of cesarean delivery than expectant management (control), an approximately 10% relative difference. Secondary maternal and infant outcomes also favored elective induction. Most important among the secondary outcomes was a significantly lower rate of perinatal mortality. Cervical ripeness was not considered, and it could have been a systematic difference between the induced women and the control women. 2a
Référence
Plan de l'etude: Meta-analysis (other)
Financement: Unknown/not stated
Cadre: Various (meta-analysis)
Sommaire
For this meta-analysis, the authors selected 6 cohort studies in which elective induction of labor at 39 weeks' gestation was compared with expectant management. Women in the studies were all nulliparous (or the studies were stratified to select only nulliparous patients), without medical indication for induction, and had singleton pregnancies in cephalic presentation. The condition of the cervix at 39 weeks was not considered. The study included 66,019 women who underwent induction and 584,390 control patients. All included studies were conducted in the United States, and all were assessed to have a low risk of bias. The primary outcome was cesarean delivery rate, which was 26.4% with induction and 29.1% with expectant management (relative risk [RR] 0.83; 95% CI 0.74 - 0.93). Secondary outcomes that also favored induction included maternal peripartum infection (2.8% vs 5.2%; RR 0.53; 0.39 - 0.82), neonatal respiratory morbidity (0.7% vs 1.5%; RR 0.71; 0.59 - 0.85), meconium aspiration syndrome (0.7% vs 3.0%; RR 0.49; 0.26 - 0.92), neonatal intensive care admission (3.5% vs 5.5%; RR 0.80; 0.72 - 0.88), and perinatal mortality (0.04% vs 0.20%; RR 0.27; 0.09 - 0.76). There was no difference in the rates of neonatal hyperbilirubinemia (12.6% vs 12.2%; NS).
Reviewer
Linda Speer, MD
Professor and Chair, Department of Family Medicine
University of Toledo
Toledo, OH
Commentaires
Why the need to do elective…
Why the need to do elective induction at 39 weeks in the first place? What were the indications or rationale ? “ elective induction “ ??for convenience?
Why 39 weeks why not 40 weeks?
How were these patients counselled?
There is some unknown bias being played out here without understanding how this sample and this intervention came to be.
Were there gains to be had somewhere — other than convenience?
Was there ANY medical indication to earlier induction vs expectant management?
Is the point of this study to point to medical intervention as superior to “natural” induction in the completely health population?
The above statement is a bit extreme but having no context for the indications behind the elective inductions can create many spins ...
Without reading the full…
Without reading the full article it is hard to know the confounding factors.
The interesting result of the study was less the difference in C/S rate (26% vs 29%) but the neonatal outcomes which seems a relatively larger difference (meconium aspiration 0.7% vs 3.0%).
This article could be interpreted as saying that the definition for the length of normal human gestation should be reconsidered.
(If« Normal » is defined as the time before which, and after which, risk becomes higher.)
Whatever it really means, the sure result is that there will be a lot more inductions. Better invest in oxytocin production.