In May of 2016, attendees at the ACOG annual meeting participating in a stimulating debate on elective induction at 39 weeks. Points were made that fetal macrosomia increases after 39 weeks which can increase the incidence of should dystocia and increase the risk of cesarean section. Induction at 39 weeks could potentially reduce all of those risks, but admittedly, induction could be associated with a higher rate of cesarean. Errol Norwitz, chair of the Department of OB/GYN and professor at Tufts University of School of Medicine, made the now famous comment, “My position is 39 weeks and out!” He additionally said in the Washington Post, “Nature is a terrible obstetrician.”
On the other side of this issue is, among others, Rebecca Dekker, who has her doctorate in nursing and is founder and writes for the blog, Evidence Based Birth. Dekker is quick to shine light on the flaws in the research plus cautions about public complacency about inductions. Inductions are not benign, simple or non-invasive. Some of the medications used for induction, Pitocin or Cytotec, can create contractions that are too frequent, very painful, and can increase the risk of restricted blood flow and oxygen to the baby.
Still other questions need to be asked.
What part does a woman’s due dates play in the scenario? Are we absolutely certain that dates are accurate? And based on those dates, elective inductions are made. The answer here is there are no absolutes on the due date, which should actually be called Due Zones. Neonates are still maturing in the uterus, the optimum place for growth and maturity.
Studies show that cesarean section risk rises when the Bishop Score is 7 or less. Is the Bishop Score being taught by childbirth educators or doulas?
What happens with the American Board of Internal Medicine/Association of Women’s Health, Obstetric, and Neonatal Nurses “Choosing Wisely” Campaign? Being certain that patients have a clear understanding (for informed decision making) of the process of induction “don’t promote induction or augmentation of labor and don’t induce or augment labor without a medical indication; spontaneous labor is safest for woman and infant, with benefits that improve safety and promote short- and long-term maternal and infant health.
The question still remains, in the situation where there is no indication of clinical risk, should the pregnancy continue until labor begins on its own, or should care providers take prophylactic measures to end the pregnancy before there are complications? If the latter is the case, then full disclosure for clear and complete shared decision making must be completed. Women must know the risks and the benefits of maintaining the pregnancy and of elective induction. Scare tactics based on the discomfort that care providers may have about waiting for labor to begin on its own has no place in the shared decision making process.
This is not a simple question to answer and one that must be given careful consideration. In the Listening to Mothers Survey II, of the women in that sample (over 600) who experienced a medical (vs. self-initiated) induction, 25% gave the reason that their care provider was “concerned that they were overdue,” while only 19% had a medical indication. Then 17% reported that their induction was due to the care provider having concerns about the size of the baby.
We must be cautious about early elective induction and the complications for both mother and baby. Admitting preemies to the NICU due to “failure to wait” causes its own cavalcade of risks.
For further review:
ACOG Committee Opinion 561 Non-medically Indicated Early-Term Deliveries, Reaffirmed 2015.
AWHONN Position Paper on Non-Medically Indicated Induction and Augmentation of Labor
Evidence on Inducing Labor for Going Past the Due Date by Rebecca Dekker (Evidence Based Birth)
Major Survey Findings of Listening to Mothers III: Pregnancy and Birth.