Induction at 39 weeks versus waiting for labor We considered the evidence discussed above in a broader context to develop the following list of potential Pros and Cons of week elective induction. No maternal deaths occurred in either group. The researchers did not report on uterine rupture. For babies: Babies in the elective induction group had a lower composite adverse outcome rate 1. One stillbirth occurred in the elective induction group at 40 weeks and 6 days before the mother was induced and two stillbirths occurred in the expectant management group while the mothers were waiting for labor.
One was to a first-time mother at 41 weeks and 3 days; her baby was small for gestational age. The other stillbirth was to an experienced mother at 41 weeks and 4 days; her placenta showed signs of infection. There were no newborn deaths in either group. There was no protocol for fetal monitoring it varied by local guidelines , but fetal monitoring and assessment of amniotic fluid levels was typically performed between weeks. For babies: The study was stopped early after five stillbirths and one early newborn death occurred in the expectant management group, out of 1, participants 4.
Zero deaths had occurred in the elective induction group, out of 1, participants. All five stillbirths in the expectant management group occurred between 41 weeks, 2 days and 41 weeks, 6 days. Three of the stillbirths had no known explanation, one was with a baby that was small for gestational age, and the other was with a baby who had a heart defect.
The one newborn death occurred four days after birth due to multiple organ failure in baby that was large for gestational age.
The author mentions that when complications are present at the end of pregnancy e. All of these perinatal deaths occurred with first-time mothers, which suggests that week induction may be especially beneficial for first-time mothers.
They found that it only took inductions at 41 weeks to prevent one perinatal death. This is a much lower number than previously thought. If you recall, the INDEX trial did not find a significant difference in perinatal death between the induction group and the expectant management group 1 versus 2 deaths, respectively.
It could also be that there was better fetal monitoring of participants between 41 and 42 weeks in the INDEX trial, leading to fewer perinatal deaths. There was no difference in the composite perinatal outcome 2. However, there was a significant difference in perinatal death alone. More mothers in the elective induction group had inflammation of the inner lining of the uterus usually due to infection, called endometritis 1. There were no cases of uterine rupture in either group.
In the induction group: Labor was induced within four days of entering the study usually about 4 days after 41 weeks. A maximum of 3 doses of gel were given every 6 hours. If this did not induce labor or if the gel was not used, participants were given IV oxytocin, had their waters broken, or both. They could not receive oxytocin until at least 12 hours after the last prostaglandin gel dose.
In the monitored expectant management group: Participants were taught how to do kick counts every day and had nonstress tests 3 times per week. The amniotic fluid level was checked by ultrasound times per week. What did researchers find in the Hannah Post-Term study? The findings on Cesarean rates differ depending on which set of numbers you compare. What happened in the original, randomly assigned groups?
But what happened to people who were actually induced or actually went into labor on their own? The same pattern holds true when you look at experienced mothers people who had given birth before : So what do these numbers mean?
Policy of routine induction before 42 weeks is still controversial The authors of a systematic review from raise concerns that routine induction prior to post-term puts a large number of pregnant people at risk of harmful side effects from induction Rydahl et al. Are there any benefits to going past your due date? Based on the available evidence, Dr. Is it safe for someone to wait for labor to begin on its own, if that is what they prefer? How long is it safe to wait? How should people and their care providers talk about the risk of stillbirth?
Access our Talking about Due Dates Handout. The Ontario Midwives Association has a really comprehensive, easy-to-understand set of guidelines. To download the free PDF, click here. To download the Society of Obstetricians and Gynaecologists of Canada guidelines Canada , click here.
In , ACOG reaffirmed their recommendations on post-term pregnancy. Although their guidelines are not freely available to the public, ACOG recommends that induction of labor should take place between 42 weeks 0 days and 42 weeks 6 days, and that induction at 41 weeks can also be considered. They concluded that it is reasonable to offer elective induction to low-risk, first-time mothers at 39 weeks of pregnancy.
They expressed concern that many women may not desire elective induction and proposed that costs might be better spent on less invasive but more effective approaches to reduce Cesarean rates, such as continuous labor support from a doula.
The bottom line Current research evidence has found that elective induction at 39 weeks does not make a difference in the rate of death or serious complications for babies. We have heard from people who are surprised at this finding, since for so long elective induction was thought to increase the Cesarean rate.
It would be interesting to see secondary analyses published on who actually was induced versus who actually had spontaneous labor for every study like we saw with the Hannah Post-Term trial. But from a decision-making perspective, it is most helpful to consider the results according to original group assignment active versus expectant management , since spontaneous labor is not a guarantee with expectant management.
Elective induction at 41 weeks and 0 to 2 days could help to reduce stillbirths and poor health outcomes for babies, especially among first-time mothers. Importantly, two large randomized, controlled trials published in both found benefits to elective induction at 41 weeks instead of continuing to wait for labor until 42 weeks.
One of the studies found fewer perinatal deaths with week induction and the other found fewer poor health outcomes for babies e. An earlier study called the Hannah Post-Term study found that waiting for labor after 41 weeks greatly increased the risk of Cesarean for people who ended up needing an induction for medical reasons, but not for people who went into labor on their own. The Bishop score that helps to determine if you are a good candidate for induction is based on five factors: How dilated or open is your cervix?
How effaced or thin is your cervix? How soft is your cervix? How far forward is your cervix? These non-medical factors are very real when it comes to individual decision-making. For example, the experience of being induced potentially more painful contractions, tethered to wires for monitoring and IV fluids, confined to bed may not make much of a difference to someone planning a birth with an epidural, but it can make a huge difference to someone planning to use movement and other comfort measures during an unmedicated birth.
On the other hand, someone who has experienced miscarriages or stillbirth in the past may have a strong preference for elective induction in order to lower the absolute risk of stillbirth by any means necessary.
All of these experiences and preferences are valid. References: Alfirevic, Z. American College of Nurse Midwives Accessed online December 1, Committee opinion no. Obstet Gynecol , American College of Obstetricians and Gynecologists , Reaffirmed Committee Opinion No.
Methods for Estimating the Due Date. A comparison of foetal and infant mortality in the United States and Canada. Int J Epidemiol 38 2 : Attanasio, L. J Midwifery Womens Health. Baskett, T. BJOG 11 : Bohren, M. Continuous support for women during childbirth.
Cochrane Database of Systematic Reviews, Issue 7. Boulvain, M. Prospective risk of stillbirth. Randomised trials of earlier induction of labour are needed. BMJ : Buckley, S. Washington, D. Carmichael, S. J Midwifery Womens Health, 64 5 Caughey A. Rockville, MD. March Caughey, A. Measuring perinatal complications: methodologic issues related to gestational age.
BMC Pregnancy Childbirth 7 : Complications of term pregnancies beyond 37 weeks of gestation. Obstet Gynecol 1 : What is the best measure of maternal complications of term pregnancy: ongoing pregnancies or pregnancies delivered? Am J Obstet Gynecol 4 : Cheyney, M. Cotzias, C. Prospective risk of unexplained stillbirth in singleton pregnancies at term: population based analysis.
Darney, B. Elective induction of labor at term compared with expectant management: maternal and neonatal outcomes. Obstet Gynecol, 4 , Declercq, E. New York: Childbirth Connection. Divon, M. Male gender predisposes to prolongation of pregnancy.
A functional definition of prolonged pregnancy based on daily fetal and neonatal mortality rates. Ultrasound Obstet Gynecol 23 5 : Fagerlin, A. Helping patients decide: Ten steps to better risk communication.
J Natl Cancer Inst 19 : Feldman, G. Obstet Gynecol 79 4 : Flenady, V. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis.
Lancet : Giscombe, C. Explaining disproportionately high rates of adverse birth outcomes among African Americans: the impact of stress, racism, and related factors in pregnancy. Psychol Bull 5 : Grobman, W. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med; Halloran, D.
Effect of maternal weight on postterm delivery. J Perinatol 32 2 : Click here. Hannah, M. Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. N Engl J Med 24 : Postterm pregnancy: putting the merits of a policy of induction of labor into perspective. Birth 23 1 : Hilder, L. Prolonged pregnancy: evaluating gestation-specific risks of fetal and infant mortality.
Br J Obstet Gynaecol 2 : BMJ : ; author reply Huang, D. Determinants of unexplained antepartum fetal deaths. Obstet Gynecol 95 2 : Johnsen, S. Fetal size in the second trimester is associated with the duration of pregnancy, small fetuses having longer pregnancies.
BMC Pregnancy Childbirth 8 : Jukic, A. Length of human pregnancy and contributors to its natural variation. Hum Reprod 28 10 : Keulen, J. Induction of labour at 41 weeks versus expectant management until 42 weeks INDEX : multicentre, randomised non-inferiority trial. BMJ, , l Khambalia, A. Predicting date of birth and examining the best time to date a pregnancy. Int J Gynaecol Obstet 2 : Kramer, M. Choosing to induce labor for non-medical reasons is a hot topic among experts and moms alike.
The American College of Obstetricians and Gynecologists doesn't recommend induction for non-medical reasons before 39 weeks. Any earlier, and you risk bringing your baby into the world before she's developmentally ready.
But she concedes there are nonmedical situations when induction is a viable option. Unless I want them to deliver on the highway, that's someone I want to have come in.
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If your pregnancy lasts longer than 42 weeks and you decide not to have your labour induced, you should be offered increased monitoring to check your baby's wellbeing. Induction will be offered if you do not go into labour naturally by 42 weeks, as there will be a higher risk of stillbirth or problems for the baby. If your waters break more than 24 hours before labour starts, there's an increased risk of infection to you and your baby.
If your waters break after 34 weeks, you'll have the choice of induction or expectant management. Expectant management is when your healthcare professionals monitor your condition and your baby's wellbeing, and your pregnancy can progress naturally as long as it's safe for both of you.
Your midwife or doctor should discuss your options with you before you make a decision. They should also let you know about the newborn neonatal special care hospital facilities in your area. If your baby is born earlier than 37 weeks, they may be vulnerable to problems related to being premature.
If your waters break before 34 weeks, you'll only be offered induction if there are other factors that suggest it's the best thing for you and your baby. You may be offered an induction if you have a condition that means it'll be safer to have your baby sooner, such as diabetes , high blood pressure or intrahepatic cholestasis of pregnancy. If this is the case, your doctor and midwife will explain your options to you so you can decide whether or not to have your labour induced.
Before inducing labour, you'll be offered a membrane sweep, also known as a cervical sweep, to bring on labour. To carry out a membrane sweep, your midwife or doctor sweeps their finger around your cervix during an internal examination.
This action should separate the membranes of the amniotic sac surrounding your baby from your cervix. This separation releases hormones prostaglandins , which may start your labour. Having a membrane sweep does not hurt, but expect some discomfort or slight bleeding afterwards. If labour does not start after a membrane sweep, you'll be offered induction of labour.
Induction is always carried out in a hospital maternity unit. You'll be looked after by midwives and doctors will be available if you need their help. If you're being induced, you'll go into the hospital maternity unit.
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