Induction of labour: if, and when, to induce

In this blog for pregnant women and those supporting them, Associate Professor Philippa Middleton and co-authors discuss their recently updated Cochrane Review looking at the effects for women and their babies of inducing labour towards the end of pregnancy.

Why is timing of birth important, and controversial?

Women usually give birth around 40 weeks. For some the pregnancy continues longer, which can slightly increase the risk of the baby dying – before birth (stillbirth), or shortly after being born (early neonatal death).  If women give birth before 40 weeks, their unborn baby may potentially miss out on some growth and development, particularly optimal brain development.

Many women want to give birth naturally (with spontaneous labour), but if there are concerns for their babies’ or their own health, they may be offered an induction in late pregnancy, usually around or after 40 weeks. However induction practices differ between maternity services, so having policies backed by good evidence will help guide policy and practice.

What is induction?

Induction usually involves breaking the women’s waters, and/or use of drugs like prostaglandins or oxytocin, to bring on contractions before labour begins on its own. In many high-income countries, three out of every 10 pregnancies are induced.  There are concerns from women and health professionals that not all of these inductions are necessary.

Why and when can induction help some babies?

Our recently published Cochrane Review Induction of labour at or beyond 37 weeks’ gestation is a designated priority review. We found high-certainty evidence that there were fewer perinatal deaths (four stillbirths or early neonatal deaths with induction, compared with 25 stillbirths or early neonatal deaths when waiting for birth happen). Almost all the deaths occurred after 41 weeks of pregnancy.  There was also high-certainty evidence that fewer babies went to the intensive care unit when there was a policy of induction compared with waiting for labour to happen.

But does induction of labour in late pregnancy lead to a rise in caesarean births?

Our Induction of labour at or beyond 37 weeks’ gestation review also found evidence of moderate certainty that caesareans were probably decreased with induction of labour in late pregnancy compared with waiting for birth to happen. This suggests that reasons other than induction of labour are responsible for the rise in caesarean rates in many countries.

What still needs to be done?

Women’s values and preferences vary, so there needs to be collaborative discussion and shared decision-making about whether and when induction is the best course of action. We still need to know much more about which women and babies are most at risk of harm with prolonged pregnancy (and therefore, who will benefit from induction of labour in late pregnancy).  And we need to know how to quantify and reduce any risks. Together, this will help decrease perinatal deaths, admissions to intensive care, and caesarean sections – without increasing rates of early, or unnecessary, inductions.

Take-home points

If, and when, to induce labour in late pregnancy is controversial and there is variation in policy and practice. A recent Cochrane Review found evidence that when women are induced in late pregnancy, rather than waiting for birth to happen, there are fewer perinatal deaths, fewer babies requiring a visit to intensive care and probably fewer caesareans required. Women’s values and preferences vary, so there needs to be collaborative discussion and shared decision-making about whether and when induction is the best course of action.

Join in the conversation on Twitter with @CochraneUK, @CochranePCG #eehealthchoices or leave a comment on the blog. Please note, we cannot give medical advice and we will not publish comments that link to commercial sites or appear to endorse commercial products.

Reference:

Middleton  P, Shepherd  E, Morris  J, Crowther  CA, Gomersall  JC. Induction of labour at or beyond 37 weeks’ gestation. Cochrane Database of Systematic Reviews 2020, Issue 7. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub5.

Philippa Middleton and the other authors of this blog declare that they have nothing to disclose.

Emily Shepherd

Dr Emily Shepherd

Judith Gomersall

Dr Judith Gomersall

Caroline Crowther

Prof. Caroline Crowther

 

 

 

 

 

Associate Professor Philippa Middleton’s photo and biography appear below. Dr Emily Shepherd and Dr Judith Gomersall are Research Fellows with SAHMRI Women and Kids in South Australia. Professor Caroline Crowther is Professor of Maternal & Perinatal Health at the Liggins Institute, at the University of Auckland in New Zealand.

Editor’s note: In August 2020, the following review was published:

Alfirevic  Z, Gyte  GML, Nogueira Pileggi  V, Plachcinski  R, Osoti  AO, Finucane  EM. Home versus inpatient induction of labour for improving birth outcomes. Cochrane Database of Systematic Reviews 2020, Issue 8. Art. No.: CD007372. DOI: 10.1002/14651858.CD007372.pub4

Page last updated 03 September 2020.



Induction of labour: if, and when, to induce by Philippa Middleton

is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International

3 Comments on this post

  1. Avatar

    This sentence requires a denominator to make sense “four stillbirths or early neonatal deaths with induction, compared with 25 stillbirths or early neonatal deaths when waiting for birth happen” In addition, we also need to know if there are long-term consequences for offspring of shortening the gestation time. Some studies are suggesting that this is the case eg https://pubmed.ncbi.nlm.nih.gov/22753563/ https://pubmed.ncbi.nlm.nih.gov/28154109/ and https://pubmed.ncbi.nlm.nih.gov/25754325/

    Sarah Buckley / Reply
  2. Avatar

    Systematic reviews and meta-analyses have clearly demonstrated reduced neonatal morbidity and mortality when inductions at 37 weeks are performed, yet Dr Emily Shepherd, Dr Judith Gomersall, Prof. Caroline Crowther, Associate Professor Philippa Middleton, seem reluctant in admitting established wait-and-see practices must change!

    Stavros Saripanidis / Reply
    • Avatar

      That’s not what the evidence suggests at all. This review highlights that nearly all IUD’s and NND’s occurred when pregnancy went beyond 41weeks therefore there is no evidence to support offering all women induction at 37 weeks

      Roseann Pailor / (in reply to Stavros Saripanidis) Reply

Leave a Reply

Your email address will not be published. Required fields are marked *

*

UA-49496932-1