By Georgia Ragonetti-Zebell, MD
The American Congress of Obstetricians and Gynecologists (ACOG) had their Annual Clinical and Scientific Meeting last week, and one topic has stirred quite a bit of controversy. The debate centered on whether or not to induce all low risk women at 39 weeks in an effort to reduce neonatal and maternal morbidity and mortality. After the debate, Facebook lit up with discussions around this presentation (ok, so, maybe it was just my newsfeed and some of the posts were mine, but still). Let’s review.
Errol Norwitz, MD, PhD and Charles Lockwood, MD, took sides in the Edith Louise Potter Memorial Lecture Debate, entitled, “If No Elective Inductions Before 39 Weeks, Why Not Induce Everyone at 39 Weeks?” Dr. Norwitz took the “pro” side, concluding that everyone should be induced at 39 weeks. And Dr. Lockwood took…the same side.
So not exactly a debate, but that’s ok. Keep reading.
When I was in residency, we were not allowed to induce anyone electively, meaning without a medical indication, such as pre-eclampsia. I knew the private practice doctors in our hospital would sometimes electively induce a term pregnant woman, if she was 37 weeks or greater. But our attendings, the doctors that supervised the residents, thought this was too risky. More and more studies showed that babies born before 39 weeks were at higher risk of breathing problems, including pneumonia and respiratory failure. They are more likely to be admitted to the NICU and to require a ventilator. Neonatal mortality is also higher for babies born before 39 weeks.
Soon after, ACOG came out with official recommendations to avoid elective induction before 39 weeks. Further, it was recommended that elective inductions at 39 weeks or greater only be performed if the due date could be confirmed with an ultrasound at less than 20 weeks. Doctors changed their practices, hospitals and insurance companies altered policies and created payment restrictions, and today, elective induction at less than 39 weeks are almost unheard of. Some hospitals and doctors never induce without medical indication prior to 41 weeks.
With all of the research focused on gestational age and inductions, a new question arose. Is there an ideal timing of delivery?
Dr. Norwitz started the “debate.” He focused on three questions.
- Are there benefits to the baby past 39 weeks? According to Dr. Norwitz’s review of the literature, there is no benefit to the baby to stay inside after 39 weeks. The incidence of respiratory distress, serious infection, and hemorrhage in the brain are at the lowest at 39 weeks. The incidence does not decrease any more after that point. Thus, there does not appear to be a benefit.
- Are there harms to the baby to stay put past 39 weeks? Neonatal encephalopathy (neurologic dysfunction in the first few days of life leading to seizures, decreased muscle tone and difficulty breathing) increases significantly after 39-40 weeks. Stillbirth is also increased as the pregnancy progresses. A very interesting table presented showed the number of stillbirths was far higher than the number of deaths from congenital malformations or birth defects, prematurity, and SIDS combined. Neonatal mortality, or death after delivery, is also increased after 39 weeks.
- Is there harm to momma or baby with induction? A potential risk of an induction is that the gestational age of the infant is not correct and the baby could be born prematurely. However, with accurate dating, this is extremely rare. Both presenters agreed that 39 week inductions should only be performed in women with very accurate dates. And what about cesareans? Wouldn’t induction increase the cesarean rate? This is where the data is lacking. There aren’t many studies on 39 week elective induction. But, the data from 41 weeks shows a decrease in cesarean rate. Dr. Norowitz applies this data to 39 weeks, assuming a similar decrease in cesarean rate. However, he adds the caveat that the cesarean rate may be increased in women who have never had a baby before whose cervix is not favorable, meaning already dilated before labor.
Dr. Lockwood’s approach was slightly different. He reviewed the literature looking specifically at elective induction. He stated similar benefits to Dr. Norowitz, adding decreased incidence of macrosomia (very large babies) and shoulder dystocia (when the baby’s shoulders get stuck on the way out). He pointed out the risks of induction, including cord prolapse, hyperstimulation of the uterus and failed induction. He quickly reviewed several small studies that showed no increased risk of cesarean with induction, and in fact, a trend toward a decreased cesarean rate. He also mentioned that studies examining the mother’s experience and preferences showed no differences. His take was unique in that he acknowledged the lack of adequate randomized trial of elective induction versus expectant management to 41 weeks.
Here is where it got really interesting. Since the rates of complications in childbirth are quite low in uncomplicated pregnancies, a study to adequately address these issues would require millions women. So, that study does not exist and it is not likely that it would ever be performed (though a randomized trial is in the works). So, Dr. Lockwood created a statistical model that used the available rates of complications to compare elective induction and expectant management to 41 weeks. His model contained 30 variables, 60 evidence based estimates and 10 derived analyses. Using this model, he was able to show that elective inductions had significantly lower cesarean rates, lower stillbirth rates, and overall healthier babies. Elective induction was clearly the safer choice in the model. Dr. Lockwood expressed his disappointment in his findings, as he was intending to oppose Dr. Norwitz’s view.
Very interesting findings, indeed. As my Facebook “friends list” is full of mommas, doulas, midwives and physicians, the reactions to this were quite varied. Some OBs were very much in favor, as most of the information is not new. “Nothing good happens after 39 weeks.” We see that 39 week babies are most likely to do well. We also see the stillbirths and the overdue babies that are prone to complications. As we are pushing to lower our cesarean rates, the finding that induction does not increase surgical births was a welcome relief.
Others were hesitant. “Not what I would want as a patient.” “There is so much we don’t know about labor.” “We used to think 37 weeks was not too early, and we were wrong.” And, as many suspected, “this is not going to go over well with many women.”
Specifically, women in the natural childbirth community. A community of which I consider myself a part. Many saw it as an attack on women, to force women to give up control of their bodies. Others felt it was a way for doctors to make more money, though one presenter specifically commented on how the cost of such an idea was not considered. Some quotes from the presentation were off-putting- “nature is bad obstetrician” and that babies should be “rescued by birth” at 39 weeks.
And now I’m going to give my take on it.
First, it should be made clear that ACOG has not made any official recommendation about this at all. This was simply a discussion of current literature and potential benefits of 39 week induction. Many seemed to take this as a new guideline, which it was not. Just a couple of OBs telling us what they found. Before ACOG makes a recommendation, committees will convene and review the evidence again and again. Hopefully, a randomized trial of some size will be available by then. And like all ACOG guidelines, there will be wiggle room. ACOG always recommends that decisions are made after a complete discussion of risks and benefits, with full patient autonomy.
Evidence based medicine is constantly held as the standard of healthcare. One cannot practice evidence based medicine without examining the evidence, and that was what the doctors did in this instance. Research is a tricky thing. It is easy to find evidence to support almost anything. But confirmation bias (meaning picking out the literature that supports your belief) must be avoided. I think that Dr. Lockwood’s review of the available studies and subsequent modeling give a fairly unbiased view. I mean, he changed his own mind.
However, his model has not, to my knowledge, undergone the peer review required for publication yet. Peer review by several other experts in the field would be required for validation of his model. One piece that seemed to be missing is time to delivery. I have had three spontaneous labors and one induction. My induction lasted 14 hours, but my spontaneous labors were much shorter. Inductions can take days; how long were the women in the model in labor? In research conditions, strict criteria are used for failed induction or arrest of labor. In practice, we know that this varies significantly among doctors and hospitals.
We don’t practice in research studies. In research, there are strict inclusion and exclusion criteria. Must be 39 weeks by ultrasound performed before 20 weeks. Must be head down. Must not be hypertensive or diabetic or obese or growth restricted or asthmatic or hypothyroid. Must agree to participate in a research study. Good luck finding those millions of women. (In fact, I am interested to see how many women will agree to be randomized to induction in the study that is underway.) No, we don’t practice there. We practice in real life. We practice where women don’t find out they are pregnant until 30 weeks. We practice where women are hesitant to agree to pitocin and induction. We practice where women begin begging for induction at 34 weeks. We practice where women sign out against medical advice. We practice outside of computer models, with living, breathing mommas and their living, breathing babes.
The births of my children are the most important days of my life (and theirs for obvious reasons). This cannot be lost in the discussion. There were a few statements that were particularly inflammatory- that babies should be “rescued by birth” and that “nature is a bad obstetrician.” While I doubt this was the intent, these statements further the message that women receive on a daily basis–your body is not good enough. The baby must be rescued from the death trap that is the mother. Nature, which created women’s bodies, is not as good as the “rescuer.” As an obstetrician, I’ve seen firsthand the “dangers” of nature. Those tragedies are haunting, but are rare. If the good didn’t far outweigh the bad, I wouldn’t be able to continue this job. This journey of birth and motherhood cannot be approached with anything but respect. We must maximize safety and support for mommas and their babes. Again, I am sure this was not intended to come across as such, but was felt by many women as yet another way we are not meant to be in complete control of our bodies during this life changing time.
Still, control of our bodies comes only with complete information. We must take an unbiased look at the literature. It may not be what we were expecting or what we wanted to hear, but we have to look anyway. Today, it seems clear. Tomorrow will bring new information, and tomorrow we must look again.
(And hopefully tomorrow will add the cost analysis missing from the presentation. Three day inductions on woman after woman may not be cost effective or covered by insurance. Or, it may reduce cost by reducing the complications. While cost should not determine care, it is a fact of life, and certainly needs to be considered given our country’s high healthcare costs. The number of inductions needed to prevent a complication was not mentioned, but is likely to be quite high.)
In the end, this information is good to know. It helps us as physicians counsel our expecting mommas. For those requesting elective induction, 39 weeks seems to be perfectly reasonable, and even decreases many risks. For those concerned about all that we don’t know, here is what we do know. The overall risks to mom and baby are thankfully so small, that it impossible to make a research study large enough to show differences. But, when we extrapolate, when we use the knowledge that we do have, it seems that elective induction decreases stillbirth, neonatal complications, and may even help us decrease this high cesarean rate we’ve been talking so much about.
As always, it is my job to tell you what I know. This is what I know. Complication rates are low in elective inductions at 39 weeks and in spontaneous labor. We are getting better and better at inducing labor, and an induction will probably not increase your risk of cesarean, if guidelines are followed. However, there is no official recommendation to induce everyone at 39 weeks, so it is simply an option. And options are good to have.
And as always, it is your job, momma, to take that information and make the decision you feel is best for you and your baby.
Georgia Ragonetti-Zebell, MD is an OB/GYN practicing in Upstate South Carolina, and is mommy to four (yes, FOUR) boys. She is a graduate of the Women’s Health Pathway at Drexel University College of Medicine in Philadelphia, Pennsylvania and completed her residency in Obstetrics and Gynecology with the Greenville Health System in Greenville, South Carolina. She has a special interest in natural childbirth, breastfeeding, and alternative methods in labor and delivery. She enjoys yoga, crochet, and reading, but spends most of her free time cleaning up poop while trying not to step on Legos.