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Published:April 10, 2019DOI:https://doi.org/10.1016/j.ajog.2019.04.007
      We appreciate Dr Scialli’s thoughtful comments about our study on elective induction of labor (IOL) at term and his concerns about current obstetric practices that contribute to high rates of intervention in births beyond 39 gestational weeks.
      • Souter V.
      • Painter I.
      • Sitcov K.
      • Caughey A.B.
      Maternal and newborn outcomes with elective induction of labor at term.
      Term elective IOL is 1 of a growing number of optional interventions in maternity care. Unlike many obstetric practices, we have increasing evidence about the impact of induction of labor that we can share with individual patients and that may help inform their birth choices.
      • Grobman W.A.
      • Rice M.M.
      • Reddy U.M.
      • et al.
      Labor induction versus expectant management in low-risk nulliparous women.
      We believe this information is useful for clinicians and patients alike.
      However, Dr Scialli raises a bigger question about whether recent study results reflect unnecessarily high rates of intervention in births at >39 weeks gestation and whether term elective IOL would still appear beneficial in a clinical context in which there was less intervention in labor at later gestational weeks. This is an important question; however, determining whether a cesarean delivery prevented an adverse outcome or was an unnecessary reaction to perceived risk is challenging.
      Relationships between obstetrics interventions and outcomes are not straightforward. Over the last 40 years, induction has more than doubled while cesarean delivery rates have increased dramatically. There is therefore no guarantee that recommending IOL at 39 weeks gestation for all nulliparous women would reduce the national cesarean delivery rate or indeed be acceptable to most pregnant women.
      That being said, there are consistent findings across a variety of settings that term elective IOL, when compared with expectant management, leads to either a reduction or no difference in cesarean deliveries.
      • Caughey A.B.
      • Nicholson J.M.
      • Cheng Y.W.
      • Lyell D.J.
      • Washington A.E.
      Induction of labor and cesarean delivery by gestational age.
      • Caughey A.B.
      • Sundaram V.
      • Kaimal A.J.
      • et al.
      Systematic review: elective induction of labor versus expectant management of pregnancy.
      Additionally, in a recent systematic review, the findings from previous cohort studies that examined this question essentially found a similar effect size to the randomized trials.
      • Grobman W.A.
      • Caughey A.B.
      Elective induction of labor at 39 weeks compared to expectant management: a metaanalysis of cohort studies.
      Thus, although the impact on cesarean delivery in lower intervention settings may have a lower absolute impact, there is no evidence to suggest it may lead to harm. However, going forward, a better understanding of the economic, resource, and long-term implications of elective induction at term will be important areas for investigation.

      References

        • Souter V.
        • Painter I.
        • Sitcov K.
        • Caughey A.B.
        Maternal and newborn outcomes with elective induction of labor at term.
        Am J Obstet Gynecol. 2019; 220: 273.e1-273.e11
        • Grobman W.A.
        • Rice M.M.
        • Reddy U.M.
        • et al.
        Labor induction versus expectant management in low-risk nulliparous women.
        N Engl J Med. 2018; 379: 513-523
        • Caughey A.B.
        • Nicholson J.M.
        • Cheng Y.W.
        • Lyell D.J.
        • Washington A.E.
        Induction of labor and cesarean delivery by gestational age.
        Am J Obstet Gynecol. 2006; 195: 700-705
        • Caughey A.B.
        • Sundaram V.
        • Kaimal A.J.
        • et al.
        Systematic review: elective induction of labor versus expectant management of pregnancy.
        Ann Intern Med. 2009; 151 (W53-63): 252-263
        • Grobman W.A.
        • Caughey A.B.
        Elective induction of labor at 39 weeks compared to expectant management: a metaanalysis of cohort studies.
        Am J Obstet Gynecol. 2019; ([Epub ahead of print.])https://doi.org/10.1016/j.ajog.2019.02.046

      Linked Article

      • Induction of labor at term
        American Journal of Obstetrics & GynecologyVol. 221Issue 1
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          Souter et al1 have presented a careful and comprehensive evaluation of outcomes after elective induction of labor compared with expectant management. These authors have joined the ranks of others who offer labor induction at 39 weeks gestation as a favorable alternative to expectant management. An explanation for the findings of these groups is that expectant management is associated with a higher prevalence of preeclampsia and with larger babies, which are findings that were confirmed in the ARRIVE trial.
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