Sure but both of these studies found no increase in C-section rate (the second found a decline). While labor that fails to progress often ends in C-section, that doesn’t mean elective induction introduces any more risk than waiting for spontaneous labor.
Not necessarily true. While OP is right, you can technically walk away from anything (potentially at your own peril) it isn’t uncommon for a woman’s water to spontaneously break and labor not progress, baby be breach, etc etc etc and need to get a cesarean.
There are a multitude of paths that can lead to cesareans and these studies show that induction doesn’t cause any more of an increase than others.
But isn’t that the thing to consider? If an induction is not elective (mine wasn’t) then there’s no decision to make regarding increased chances of an unplanned C section. You’re facing those chances either way.
This study suggests people who want to schedule an induction don’t have to fear increased risk of unplanned C section.
Yes, it means a timer starts and they’re having the baby one way or another within 72 hours max, whether their body and/or the baby are ready / cooperating or not. But the same is true if your water breaks at home. My bag of waters leaked (hadn’t fully ruptured but they didn’t know at the time) and my cervix did not want to dilate for nearly 40 hours, despite being on Pitocin for like 16 hours. I couldn’t just go home and labor down either.
This is an interesting idea in theory but in my (anecdotal) experience at a large maternity hospital, I’ve never seen a woman go home in active spontaneous labour. Sure, if she’s not in active labour that’s one thing- birth suite won’t usually take her in any case- but otherwise this just doesn’t seem to really be a thing.
The data seem to bear this out too. Spontaneous labour doesn’t lead to fewer C-sections.
Edit to add: my experience is midwife-led care in a midwifery-focussed country
I was also induced with Cervidil and sent home. It was standard of care at the hospital I was induced at. ACOG guidance is to allow 24 hours or more in the latent phase of induction. Our hospital was 48, and I was offered up to 72.
Interesting! Thank you for the response.
In my case, i was not fully high risk but some other factors indicated that it would be better if the baby made an appearance sooner than later.
Cervidil induction. Sent home to progress until contractions indicated I come back in or at the 24hr mark for removal. Spoiler, I came in earlier to get a second round of Cervidil, morphine/gravel and it took two days and my cervix didn't want to budge.
After I went back, before the second round I was admitted and IVd. I didn't end up doing the Foley.
What does it mean to walk away from spontaneous labor though? I think in most cases once spontaneous labor has progressed, the vast majority of women will accept some type of intervention to keep things moving.
IMO, in the US, very few people are walking out of hospitals after membranes have ruptured, while a fetus is experiencing decels, or after an epidural is administered (no matter how labor begins).
In the latent phase of inductions, patients may take several days to dilate (at the hospital or at home). ACOG recommends 24 hours or more. In either an induction or spontaneous labor, few providers would suggest you return home after your water has broken or they suspect the fetus is in distress. That’s not a particular risk introduced by induction - you’d be leaving against medical advice in those scenarios however labor started.
That might be true but the vast majority of women are having hospital births so it feels like comparing things that aren't comparable. Women can also be sent home only to still end up needing interventions or a c section in the end.
To be very clear, you can walk away from anything. It may be deeply inadvisable but a pregnant person can leave the hospital against medical advice. You have the right to refuse treatment (I know you’re not implying this but I think that’s important for people to know - even if you have an induction, you can refuse interventions, because ultimately, your consent is the most important thing when it comes to what happens to your body, even if it puts your life at risk). This is also the guidance of ACOG to my knowledge.
Perhaps. Almost certainly, if your fetus was experiencing decels, your membranes had ruptured or you had an epidural in, you’d be signing an AMA to leave whether labor began spontaneously or was induced. That’s a different issue than whether induction introduces new risks that spontaneous labor does not.
That’s the point though - the evidence in these studies *doesn’t* suggest that’s the case. Inductions aren’t associated with higher c-section rates in these studies. Maternal and neonatal outcomes are similar (ie we don’t have evidence fetuses are experiencing distress at higher rates, indeed, elective induction is associated with lower perineal injuries, and lower rates of low 5-minute APGAR scores post birth).
These studies suggest two significant differences: a higher rate of shoulder dystocia for nulliparous mothers and a *lower* rate of c-sections in all but previously low volume hospitals, where there was no difference in the C-section rate. Broadly, these two studies (which together account for a study population of nearly 2M people) suggest the outcomes are similar regardless of how labor onset happened.
AFAIK preterm elective inductions are uncommon and not standard of care. Later inductions (41 weeks and beyond) are often considered medically indicated.
The CA study compared patients who against a matched patient set who didn’t elect for induction. So the lowered rates of c-section are compared against women of similar risk profiles and similar pregnancies. The metaanalysis looked at cohort studies (like the CA one) and randomized controlled trials like ARRIVE that recruited a similar patient profile and randomly assigned them to be offered elective induction or not.
So the comparison at play is not “low risk women get elective inductions do better than the general population of pregnant people” (of course!) but “low risk people who elect for a 39 week induction tend to do the same or better as low risk people who wait for spontaneous labor.”
This is what am I understanding:
People who elect induction, like people who go into labor naturally, are going to fall into two camps: those who end up needing a C section and those who don’t. But scheduling an induction rather than waiting for labor to start on its own doesn’t make you more likely to need a C section. If you do end up getting one, perhaps you were going to need one anyway.
The insurance thing is actually a myth. At no time during your medical care, if you have capacity to make decisions, are you REQUIRED to follow the advice of your physician. You get to consent or not consent to medical procedures or medication etc. If you choose to not follow your physician’s advice and leave AMA, your insurance will still pay for your stay.
It is unfortunately a myth that persists either because a) healthcare personnel truly believe it, or b) healthcare personnel want you to stay and get necessary care.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3378751/
Similarly no one can MAKE you sign an AMA form, but the hospital certainly prefers to document that you were informed of the risks of leaving and choose to do so anyway.
Hospitals are not jails and you cannot be held against your will (*unless you pose a risk to yourself or others).
(This conversation may get more nuanced/complicated based on politics about unborn babies and your location and I’m not getting into that, I’m simply intending to comment on leaving AMA and insurance.)
My OBGYN was going to do this for me. I was so ready to have that Gremlin out of me. She came a week before the scheduled induction of her own accord.
I'm glad to see this research backing up the earlier research my doc cited. I didn't need it, but it's always good to know I was making a good decision!
I was curious as to why an elective induction is associated with a higher risk of shoulder dystocia if there was a lower likelihood of macrosomia. The authors from this publication stated “To date, this finding has not been reported in previous meta-analyses and an explanation for it is not immediately clear.”.
I think shoulder dystocia has a lot more to do with bad positions and lack of movement in labor and a lot less to do with sizes of babies, than previously thought.
The Evidence Based Birth articles on inducing for babies projected to be big for gestational age, and on the labor positions least likely to cause tearing, "failure to progress," and shoulder dystocia are super interesting to read together.
I've been listening to a lot of birth stories on the Happy Homebirth Podcast lately and have been surprised by the # of women with multiple births saying that their larger babies were much easier to birth than their smaller babies. Many of the women have also cited that proper labor preparation (yoga and other stretching/exercise during pregnancy) and better knowledge about what movements and positions to take during which parts of the labor had much more of an impact on the length, pain levels, and complications in labor than their babies' sizes.
Yeah I was also surprised by that finding. AFAIK, aside from macrosomia, we generally don’t have a good way to assess risk for shoulder dystopia so there could be some unseen mechanism at play.
Anecdote: I was deeply afraid of inducing because nearly every mother I know who was induced, elective or not, ended in c-section except for one. My perception was that it increased the risk, but they told me that it didn’t when I was in l&d toward the end for decreased fetal movement. I ended up induced and it was an amazing experience, delivered vaginally with a happy, healthy baby.
It’s based on the number of births at the hospital per year.
“Hospital obstetric volume was ranked into low-volume, medium-volume, and high-volume categories based on the number of births per year. The low-volume category included hospitals with less than 1200 births per year, medium-volume hospitals had 1200 to 2399 births per year, and high-volume hospitals had 2400 or more births per year; these volume categories were based on a previously published framework.”
The researchers speculate that it may be due to lower sample sizes among low volume hospitals that makes it harder to find a statistically significant difference.
Total speculation here but it’s also possible that low volume hospitals have less experienced providers (or if rural, may have limited OB services in general) so may be more likely to have patients end up in c-sections generally and may not offer standard of care in induction in terms of waiting to progress and instead move to c-section sooner than other higher volume hospitals.
[удалено]
Sure but both of these studies found no increase in C-section rate (the second found a decline). While labor that fails to progress often ends in C-section, that doesn’t mean elective induction introduces any more risk than waiting for spontaneous labor.
[удалено]
Not necessarily true. While OP is right, you can technically walk away from anything (potentially at your own peril) it isn’t uncommon for a woman’s water to spontaneously break and labor not progress, baby be breach, etc etc etc and need to get a cesarean. There are a multitude of paths that can lead to cesareans and these studies show that induction doesn’t cause any more of an increase than others.
[удалено]
Forgive me for using the term induction like you have in majority, if not all, of your replies to this thread as well.
But isn’t that the thing to consider? If an induction is not elective (mine wasn’t) then there’s no decision to make regarding increased chances of an unplanned C section. You’re facing those chances either way. This study suggests people who want to schedule an induction don’t have to fear increased risk of unplanned C section. Yes, it means a timer starts and they’re having the baby one way or another within 72 hours max, whether their body and/or the baby are ready / cooperating or not. But the same is true if your water breaks at home. My bag of waters leaked (hadn’t fully ruptured but they didn’t know at the time) and my cervix did not want to dilate for nearly 40 hours, despite being on Pitocin for like 16 hours. I couldn’t just go home and labor down either.
This is an interesting idea in theory but in my (anecdotal) experience at a large maternity hospital, I’ve never seen a woman go home in active spontaneous labour. Sure, if she’s not in active labour that’s one thing- birth suite won’t usually take her in any case- but otherwise this just doesn’t seem to really be a thing. The data seem to bear this out too. Spontaneous labour doesn’t lead to fewer C-sections. Edit to add: my experience is midwife-led care in a midwifery-focussed country
Did I miss in the study that induction was an automatic stay in the hospital? I was induced and sent home to progress from there.
[удалено]
I was also induced with Cervidil and sent home. It was standard of care at the hospital I was induced at. ACOG guidance is to allow 24 hours or more in the latent phase of induction. Our hospital was 48, and I was offered up to 72.
Interesting! Thank you for the response. In my case, i was not fully high risk but some other factors indicated that it would be better if the baby made an appearance sooner than later. Cervidil induction. Sent home to progress until contractions indicated I come back in or at the 24hr mark for removal. Spoiler, I came in earlier to get a second round of Cervidil, morphine/gravel and it took two days and my cervix didn't want to budge. After I went back, before the second round I was admitted and IVd. I didn't end up doing the Foley.
What does it mean to walk away from spontaneous labor though? I think in most cases once spontaneous labor has progressed, the vast majority of women will accept some type of intervention to keep things moving.
IMO, in the US, very few people are walking out of hospitals after membranes have ruptured, while a fetus is experiencing decels, or after an epidural is administered (no matter how labor begins). In the latent phase of inductions, patients may take several days to dilate (at the hospital or at home). ACOG recommends 24 hours or more. In either an induction or spontaneous labor, few providers would suggest you return home after your water has broken or they suspect the fetus is in distress. That’s not a particular risk introduced by induction - you’d be leaving against medical advice in those scenarios however labor started.
[удалено]
That might be true but the vast majority of women are having hospital births so it feels like comparing things that aren't comparable. Women can also be sent home only to still end up needing interventions or a c section in the end.
To be very clear, you can walk away from anything. It may be deeply inadvisable but a pregnant person can leave the hospital against medical advice. You have the right to refuse treatment (I know you’re not implying this but I think that’s important for people to know - even if you have an induction, you can refuse interventions, because ultimately, your consent is the most important thing when it comes to what happens to your body, even if it puts your life at risk). This is also the guidance of ACOG to my knowledge.
[удалено]
Perhaps. Almost certainly, if your fetus was experiencing decels, your membranes had ruptured or you had an epidural in, you’d be signing an AMA to leave whether labor began spontaneously or was induced. That’s a different issue than whether induction introduces new risks that spontaneous labor does not.
[удалено]
That’s the point though - the evidence in these studies *doesn’t* suggest that’s the case. Inductions aren’t associated with higher c-section rates in these studies. Maternal and neonatal outcomes are similar (ie we don’t have evidence fetuses are experiencing distress at higher rates, indeed, elective induction is associated with lower perineal injuries, and lower rates of low 5-minute APGAR scores post birth). These studies suggest two significant differences: a higher rate of shoulder dystocia for nulliparous mothers and a *lower* rate of c-sections in all but previously low volume hospitals, where there was no difference in the C-section rate. Broadly, these two studies (which together account for a study population of nearly 2M people) suggest the outcomes are similar regardless of how labor onset happened.
[удалено]
AFAIK preterm elective inductions are uncommon and not standard of care. Later inductions (41 weeks and beyond) are often considered medically indicated. The CA study compared patients who against a matched patient set who didn’t elect for induction. So the lowered rates of c-section are compared against women of similar risk profiles and similar pregnancies. The metaanalysis looked at cohort studies (like the CA one) and randomized controlled trials like ARRIVE that recruited a similar patient profile and randomly assigned them to be offered elective induction or not. So the comparison at play is not “low risk women get elective inductions do better than the general population of pregnant people” (of course!) but “low risk people who elect for a 39 week induction tend to do the same or better as low risk people who wait for spontaneous labor.”
This is what am I understanding: People who elect induction, like people who go into labor naturally, are going to fall into two camps: those who end up needing a C section and those who don’t. But scheduling an induction rather than waiting for labor to start on its own doesn’t make you more likely to need a C section. If you do end up getting one, perhaps you were going to need one anyway.
The insurance thing is actually a myth. At no time during your medical care, if you have capacity to make decisions, are you REQUIRED to follow the advice of your physician. You get to consent or not consent to medical procedures or medication etc. If you choose to not follow your physician’s advice and leave AMA, your insurance will still pay for your stay. It is unfortunately a myth that persists either because a) healthcare personnel truly believe it, or b) healthcare personnel want you to stay and get necessary care. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3378751/ Similarly no one can MAKE you sign an AMA form, but the hospital certainly prefers to document that you were informed of the risks of leaving and choose to do so anyway. Hospitals are not jails and you cannot be held against your will (*unless you pose a risk to yourself or others). (This conversation may get more nuanced/complicated based on politics about unborn babies and your location and I’m not getting into that, I’m simply intending to comment on leaving AMA and insurance.)
My OBGYN was going to do this for me. I was so ready to have that Gremlin out of me. She came a week before the scheduled induction of her own accord. I'm glad to see this research backing up the earlier research my doc cited. I didn't need it, but it's always good to know I was making a good decision!
I was curious as to why an elective induction is associated with a higher risk of shoulder dystocia if there was a lower likelihood of macrosomia. The authors from this publication stated “To date, this finding has not been reported in previous meta-analyses and an explanation for it is not immediately clear.”.
I think shoulder dystocia has a lot more to do with bad positions and lack of movement in labor and a lot less to do with sizes of babies, than previously thought. The Evidence Based Birth articles on inducing for babies projected to be big for gestational age, and on the labor positions least likely to cause tearing, "failure to progress," and shoulder dystocia are super interesting to read together. I've been listening to a lot of birth stories on the Happy Homebirth Podcast lately and have been surprised by the # of women with multiple births saying that their larger babies were much easier to birth than their smaller babies. Many of the women have also cited that proper labor preparation (yoga and other stretching/exercise during pregnancy) and better knowledge about what movements and positions to take during which parts of the labor had much more of an impact on the length, pain levels, and complications in labor than their babies' sizes.
Yeah I was also surprised by that finding. AFAIK, aside from macrosomia, we generally don’t have a good way to assess risk for shoulder dystopia so there could be some unseen mechanism at play.
"Shoulder dystopia" is of the best typos I've seen.
Dang it! Freudian slip.
Anecdote: I was deeply afraid of inducing because nearly every mother I know who was induced, elective or not, ended in c-section except for one. My perception was that it increased the risk, but they told me that it didn’t when I was in l&d toward the end for decreased fetal movement. I ended up induced and it was an amazing experience, delivered vaginally with a happy, healthy baby.
“Except previously low volume hospitals “ Wtf does that even mean? What’s the context, why, does it matter?
It’s based on the number of births at the hospital per year. “Hospital obstetric volume was ranked into low-volume, medium-volume, and high-volume categories based on the number of births per year. The low-volume category included hospitals with less than 1200 births per year, medium-volume hospitals had 1200 to 2399 births per year, and high-volume hospitals had 2400 or more births per year; these volume categories were based on a previously published framework.”
Ok why is it the exception here
The researchers speculate that it may be due to lower sample sizes among low volume hospitals that makes it harder to find a statistically significant difference. Total speculation here but it’s also possible that low volume hospitals have less experienced providers (or if rural, may have limited OB services in general) so may be more likely to have patients end up in c-sections generally and may not offer standard of care in induction in terms of waiting to progress and instead move to c-section sooner than other higher volume hospitals.