What OBs say to other OBs @ ACOG’s 2018 Annual Meeting: Claim that elective induction @ 39 weeks will reduce the US cesarean rate

by faithgibson on November 15, 2018

in Cesarean Politics, Contemporary Childbirth Politics

What obstetrical doctors say to other doctors about routine induction and claims that this policy will DECREASE the CS rate:

Post of two reports supporting new “”Gold Standard” for American Obstetrics as routine induction @ 39 weeks for all healthy women with normal pregnancies (those with complications or high risk pregnancies will be delivered based on medical decision by the  patient’s obstetrician)
AUSTIN, Texas — The current rate of cesarean delivery in the United States is too high, delegates will hear at the upcoming American College of Obstetricians and Gynecologists (ACOG) 2018 Annual Meeting.
An “epidemic” of cesarean delivery is underway, according to Aaron Caughey, MD, PhD, chair of the Department of Obstetrics and Gynecology and associate dean for Women’s Health Research and Policy at the Oregon Health & Science University School of Medicine in Portland, who will give a talk on how groups across the country are working to decrease the number of cesarean deliveries.
During his presentation, he will examine existing data that refute the claim that “cesareans are higher with induction of labor, and will summarize recent preliminary findings from the ARRIVE trial [NCT01990612] that suggest that induction of labor at an earlier gestational age may actually reduce the risk of cesarean,” Caughey told Medscape Medical News.
The theme of this year’s meeting is medical and surgical innovations in healthcare.
Advances in healthcare will be evident throughout the meeting, including in the way research and ideas are presented, said Sandra Carson, MD, vice president of education for the ACOG and lead organizer of the meeting.

Lively Debate Over Cesarean Risk After Induction of Labor

Tara Haelle
May 04, 2018
AUSTIN — Recent evidence casts doubt on the long-held belief that induction of labor increases the risk for cesarean delivery, said Aaron Caughey, MD, PhD, chair of the Department of Obstetrics and Gynecology at the Oregon Health & Science University in Portland.
However, because culture and labor-floor management are different at different institutions, providers need to carefully assess the evidence before establishing the practices that will lead to the best outcomes at their hospital.
“There are no simple answers,” Caughey said here at the American College of Obstetricians and Gynecologists (ACOG) 2018 Annual Meeting, where he discussed the myths, facts, and misconceptions about the induction of labor.
It’s time for long conversations, and probably some struggles, about the benefits and risks of induction of labor after 39 weeks, he explained.
The elective induction of labor before 39 weeks is inconsistent with ACOG recommendations and the standard of care. But once a woman reaches 39 weeks, clinical judgment and institutional culture end up playing a substantial role in the decision to induce.
Caughey described the ARRIVE trial (NCT01990612), which made waves when it was presented at the Society for Maternal-Fetal Medicine’s 38th Annual Pregnancy Meeting earlier this year, as reported by Medscape Medical News.

ARRIVE Trial Controversy

The 6106 ARRIVE participants — all at 39 weeks to 39 weeks and 4 days of gestation — were randomized to induction of labor or expectant management.
Cesarean deliveries were less common in the induction group than in the expectant management group (18.6% vs 22.2%), as were pre-eclampsia or gestational hypertension (9.1% vs 14.1%). Other outcomes were comparable or nonsignificant.
Infant outcomes were similar in the two groups, except the need for respiratory support within the first 72 hours was lower in the induction group than in the expectant management group (3.0% vs 4.2%). Previous research has shown that the composite risk for perinatal death begins to increase with expectant management around 39 weeks.
But these findings — from one not-yet-published study — should be interpreted with caution, Caughey said.
The bottom line is that there’s an increasing body of evidence to suggest that our bias that induction of labor increases the risk of cesarean delivery is not true.
Prospective randomized controlled trials have shown lower rates of cesarean delivery with the induction of labor. And although some retrospective studies have shown higher rates, other retrospective studies, using appropriate comparison groups and statistical adjustment, have shown no difference or slightly lower rates.
But providers should not necessarily start offering every woman past 39 weeks an elective induction of labor.
“We should not be saying to women, ‘we might save your baby’s life by delivering at 39 weeks’,” Caughey explained. “That would be incredibly over-reaching from the data. It would cause chaos and mayhem.”
Even if the ARRIVE results are published and replicated, providers must consider other factors, he pointed out.
“Can you imagine today if you started offering elective inductions of labor” to every woman past 39 weeks? he asked. “What would happen if your labor floor is full of women being electively induced at 39 weeks and someone comes in with a VBAC and has to be turned away?”
Evidence on late-term induction of labor is evolving, so clinicians — when deciding when to offer inductions — need to weigh maternal preferences, risk for maternal complications, risk for neonatal complications, risk for cesarean delivery, overall costs, labor-floor management, and the differences between research protocols and actual practice.
“The bottom line is that there’s an increasing body of evidence to suggest that our bias that induction of labor increases the risk of cesarean delivery is not true,” Caughey told Medscape Medical News. “That being said, there are many practice settings where it might, so you have to take those data, go back to your home institution, and have tough conversations with other providers about your local culture and how you practice.”

Consistent, Equitable Care

If it is determined that induction is unlikely to increase cesarean delivery rates at a particular institution, those providers need to figure out if and how they will offer induction of labor to women at 39 weeks to 40 weeks and 6 days of gestation, which is still considered elective.
“Would you offer it? Would you honor

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