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Serving the Greater Los Angeles area
Serving the Greater Los Angeles area

LABOR INDUCTION TREND

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labor-induction

Edited from June 2021 Interview of CNM Stephanie Tillman https://evidencebasedbirth.com/ Founder Rebecca Dekker, PhD, RN and Henci Goer, Researcher, Childbirth U.

Since the 2018 ARRIVE study, many care providers and the media are telling women that 39-40 week induction is better than waiting for labor to begin on its own, that it improves outcomes and decreases chances of c-section. 

The ARRIVE trial did not say everybody should be induced at 39 weeks. The results are being misapplied and distilled down to research shows induction at 39 weeks decreases risks of meconium aspiration, NICU admittance, or C-section. 

If you look at the actual data from the ARRIVE trial, there was no difference between groups in admission to the NICU or meconium aspiration, and they also found that inducing labor at 39 weeks did not improve the primary outcome of death or serious complications for babies. 

And it’s an unfortunate confluence because women get so uncomfortable, they can’t work, they don’t have good support at home. And then the provider says, “Well, we have this study that says it’s a good idea anyway,” and then the induction makes sense for everybody. 

Most people at 39 weeks don’t have a ripe cervix. Let’s say your cervix is very closed, thick, or high. The induction begins with Cytotec (same thing as Miso) or Cervidil every four hours to help soften the cervix. The cervix will be checked multiple times and then there will be a balloon inserted and inflated. This already puts you at 24 hours on Day One; then you need a Pitocin drip, so you’re already into Day Two of your induction. 

Early inductions can take a very long time: lots of procedures and exams, higher risk of infection, the likelihood of more pain from induced different contractions, need for pain management. Babies don’t always love all these approaches, so you’re on monitors the whole time. If your baby becomes stressed, the attendants will be hyper-focused, as if it is “labor” that is stressing the baby. Monitors may be placed internally to evaluate the baby and to measure contractions. 

Day three – there aren’t many physicians sitting around being fine with three-day inductions and minimal exams. Some hospitals say, “you only let the sun set twice on an induction.”  So when you hit day three, it’s a C-section. It’s incredibly uncommon to go past three days. So this idea that it’s going to decrease C-section rates is a ridiculous gas-lit rewording of research. “Let us control your labor dear first-time pregnant person at 39 weeks when your body is nowhere near ready, in order to prevent a C-section” – it’s also a wild gas-lit rewriting of physiology.  

One of the many things that are wrong is the ignoring of the research on doulas as an intervention. Continuous labor support decreases C-section and long labor by a much higher percentage than induction at 39 weeks. If providers really cared about reducing c-s rates, why don’t they require (or even suggest) doulas? And all the other proven ways to facilitate normal birth and lower the risk of Cesarean: out of hospital birth with a midwife, doula, move during labor, hydrotherapy, patience, allowing 4-5 hours pushing with an epidural. 

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The ARRIVE trial took place at 41 hospitals in the United States. The researchers randomly assigned 3,062 first-time mothers to be induced at 39 weeks and 3,044 to expectant management. 

Expectant management meant you could wait for labor to begin on its own as long as birth occurred by 42 weeks and 2 days, or be induced for medical reasons at any time, or be induced electively after 40 weeks and 5 days.

For mothers, induction at 39 weeks was linked to a lower rate of Cesarean (19%) compared to expectant management (22%) and a lower chance of developing pregnancy-induced high blood pressure (9% versus 14%). 

ARRIVE was NOT a comparison of 3,044 spontaneous labors vs 3,062 inductions at 39 weeks. Women in the expectant management group experienced a mix of spontaneous labor, induced labor for medical reasons, and electively induced labor. 

For these 6000 women, they found a 3.6% difference in c-s.  The study does not tell us what the c-sections were for.  

The burning question remains: “How many women in the expectant-management group were induced?” Most women would likely have gone into labor spontaneously by 41 weeks. A large percentage of women in the expectant-management group likely underwent unnecessary induction with an unfavorable cervix. Trial investigators tell us that only 135 women in the expectant-management group were “electively” induced, but others were induced for medical reasons. The lack of a definition for what was considered a medical indication for induction and what wasn’t calls the comparison into question. 

No matter what studies show us about risk factors beyond a number of weeks gestation, the problem goes back to the dating of the pregnancy. If we are starting out with a due date that is probably 5 days off, then our evidence for inducing at 39 or 40 weeks is already off. Thus, even if evidence shows risks of stillbirth after 41 + 2 weeks, we are dating that 41 weeks wrong.  

Higher pre-eclampsia at 41+2 is the only thing ARRIVE proves. And even if research suggests inducing at 41+2 can reduce stillbirth/improve outcomes, what about the fact that we are NOT DATING PROPERLY?

The researchers say that the risk of Cesarean goes up the longer a pregnancy continues. Longer pregnancies do mean more opportunities for potential complications to show up and an increasing willingness by providers to perform a Cesarean. On the flip side, research also says that the risk of cesarean goes up with induction on an unripe cervix

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