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For women aged 35 years and older, induction of labor at 39 weeks neither raised nor lowered the rate of cesarean delivery, compared with expectant management, in a randomized clinical trial in the United Kingdom.
Labor induction at or before the due date may be beneficial in older women “because the gestational age at delivery that is associated with the lowest cumulative risk of perinatal death is 38 weeks.” However, induction in general is associated with an increased rate of cesarean delivery.
Previous studies of the relative benefits and harms of labor induction in this age group haven’t shed much light on the issue; they were small, observational in design, and were performed in the 1970s, so their findings may not be applicable to modern obstetric practice, wrote Dr. Kate F. Walker of University of Nottingham, England, and her associates.
They tested the hypothesis that labor induction at 39 weeks would reduce the rate of cesarean delivery in nulliparous women of advanced maternal age in the 35/39 Trial. It involved 619 women aged 35 years and older with singleton, uncomplicated pregnancies who were treated during a 2.5-year period at 39 secondary- and tertiary-care medical centers across the United Kingdom. The study participants were randomly assigned late in their pregnancies to either labor induction at 39 weeks (304 women) or expectant management (314 women).
The study hypothesis was not proven: there was no significant difference in the frequency of cesarean section between the induction group (32%) and the expectant management group (33%), for a relative risk of 0.99.
There also were no significant differences between the two study groups in maternal outcomes or neonatal outcomes (N Engl J Med. 2016 Mar 2;374:813-22. doi: 10.1056/NEJMoa1509117).
The trial did not address whether induction at 39 weeks’ gestation could prevent stillbirth, the researchers reported, but it provides support for the safety of performing a larger trial to test the effects of induction on stillbirths and other adverse neonatal outcomes.
The women assigned to labor induction did not differ from those assigned to expectant management in their subjective assessments of satisfaction with the childbirth experience. However, all the study participants had agreed to randomization. Women who had strong preferences about induction or expectant management, or strong feelings about their involvement in treatment decisions – and who may therefore have had a different take on their childbirth experience if labor were induced – were excluded from the study.
The study was supported by the National Institute for Health Research in the United Kingdom. Dr. Walker reported having no relevant financial disclosures; one of her associates reported ties to Roche Diagnostics, GlaxoSmithKline, General Electric, Chiesi, and Action Medical Research.
The findings of Walker et al. suggest that a fundamental belief that guides our decisions about the timing of delivery – namely, that induction of labor at term increases the risk of cesarean delivery – may not be true after all.
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Dr. William A, Grobman |
However, the authors note that larger studies of the issue are needed to confirm these findings and to further explore the effects of induction on maternal and neonatal outcomes, especially stillbirth and other uncommon adverse outcomes. I am the principal investigator of such a trial (NCT01990612), which is currently underway within the Maternal–Fetal Medicine Units Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
This trial, which has a targeted enrollment of 6,000 women, is designed to identify differences in perinatal outcomes among nulliparous women with uncomplicated singleton pregnancies who are randomly assigned to induction between 39 weeks 0 days and 39 weeks 4 days of gestation or to expectant management. The trial is more than halfway complete.
Dr. William A. Grobman is at Northwestern University, Chicago. He reported having no relevant financial disclosures. These remarks are adapted from an accompanying editorial (N Engl J Med. 2016 March 2. doi: 10.1056/NEJMe1516461).
The findings of Walker et al. suggest that a fundamental belief that guides our decisions about the timing of delivery – namely, that induction of labor at term increases the risk of cesarean delivery – may not be true after all.
|
Dr. William A, Grobman |
However, the authors note that larger studies of the issue are needed to confirm these findings and to further explore the effects of induction on maternal and neonatal outcomes, especially stillbirth and other uncommon adverse outcomes. I am the principal investigator of such a trial (NCT01990612), which is currently underway within the Maternal–Fetal Medicine Units Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
This trial, which has a targeted enrollment of 6,000 women, is designed to identify differences in perinatal outcomes among nulliparous women with uncomplicated singleton pregnancies who are randomly assigned to induction between 39 weeks 0 days and 39 weeks 4 days of gestation or to expectant management. The trial is more than halfway complete.
Dr. William A. Grobman is at Northwestern University, Chicago. He reported having no relevant financial disclosures. These remarks are adapted from an accompanying editorial (N Engl J Med. 2016 March 2. doi: 10.1056/NEJMe1516461).
The findings of Walker et al. suggest that a fundamental belief that guides our decisions about the timing of delivery – namely, that induction of labor at term increases the risk of cesarean delivery – may not be true after all.
|
Dr. William A, Grobman |
However, the authors note that larger studies of the issue are needed to confirm these findings and to further explore the effects of induction on maternal and neonatal outcomes, especially stillbirth and other uncommon adverse outcomes. I am the principal investigator of such a trial (NCT01990612), which is currently underway within the Maternal–Fetal Medicine Units Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
This trial, which has a targeted enrollment of 6,000 women, is designed to identify differences in perinatal outcomes among nulliparous women with uncomplicated singleton pregnancies who are randomly assigned to induction between 39 weeks 0 days and 39 weeks 4 days of gestation or to expectant management. The trial is more than halfway complete.
Dr. William A. Grobman is at Northwestern University, Chicago. He reported having no relevant financial disclosures. These remarks are adapted from an accompanying editorial (N Engl J Med. 2016 March 2. doi: 10.1056/NEJMe1516461).
For women aged 35 years and older, induction of labor at 39 weeks neither raised nor lowered the rate of cesarean delivery, compared with expectant management, in a randomized clinical trial in the United Kingdom.
Labor induction at or before the due date may be beneficial in older women “because the gestational age at delivery that is associated with the lowest cumulative risk of perinatal death is 38 weeks.” However, induction in general is associated with an increased rate of cesarean delivery.
Previous studies of the relative benefits and harms of labor induction in this age group haven’t shed much light on the issue; they were small, observational in design, and were performed in the 1970s, so their findings may not be applicable to modern obstetric practice, wrote Dr. Kate F. Walker of University of Nottingham, England, and her associates.
They tested the hypothesis that labor induction at 39 weeks would reduce the rate of cesarean delivery in nulliparous women of advanced maternal age in the 35/39 Trial. It involved 619 women aged 35 years and older with singleton, uncomplicated pregnancies who were treated during a 2.5-year period at 39 secondary- and tertiary-care medical centers across the United Kingdom. The study participants were randomly assigned late in their pregnancies to either labor induction at 39 weeks (304 women) or expectant management (314 women).
The study hypothesis was not proven: there was no significant difference in the frequency of cesarean section between the induction group (32%) and the expectant management group (33%), for a relative risk of 0.99.
There also were no significant differences between the two study groups in maternal outcomes or neonatal outcomes (N Engl J Med. 2016 Mar 2;374:813-22. doi: 10.1056/NEJMoa1509117).
The trial did not address whether induction at 39 weeks’ gestation could prevent stillbirth, the researchers reported, but it provides support for the safety of performing a larger trial to test the effects of induction on stillbirths and other adverse neonatal outcomes.
The women assigned to labor induction did not differ from those assigned to expectant management in their subjective assessments of satisfaction with the childbirth experience. However, all the study participants had agreed to randomization. Women who had strong preferences about induction or expectant management, or strong feelings about their involvement in treatment decisions – and who may therefore have had a different take on their childbirth experience if labor were induced – were excluded from the study.
The study was supported by the National Institute for Health Research in the United Kingdom. Dr. Walker reported having no relevant financial disclosures; one of her associates reported ties to Roche Diagnostics, GlaxoSmithKline, General Electric, Chiesi, and Action Medical Research.
For women aged 35 years and older, induction of labor at 39 weeks neither raised nor lowered the rate of cesarean delivery, compared with expectant management, in a randomized clinical trial in the United Kingdom.
Labor induction at or before the due date may be beneficial in older women “because the gestational age at delivery that is associated with the lowest cumulative risk of perinatal death is 38 weeks.” However, induction in general is associated with an increased rate of cesarean delivery.
Previous studies of the relative benefits and harms of labor induction in this age group haven’t shed much light on the issue; they were small, observational in design, and were performed in the 1970s, so their findings may not be applicable to modern obstetric practice, wrote Dr. Kate F. Walker of University of Nottingham, England, and her associates.
They tested the hypothesis that labor induction at 39 weeks would reduce the rate of cesarean delivery in nulliparous women of advanced maternal age in the 35/39 Trial. It involved 619 women aged 35 years and older with singleton, uncomplicated pregnancies who were treated during a 2.5-year period at 39 secondary- and tertiary-care medical centers across the United Kingdom. The study participants were randomly assigned late in their pregnancies to either labor induction at 39 weeks (304 women) or expectant management (314 women).
The study hypothesis was not proven: there was no significant difference in the frequency of cesarean section between the induction group (32%) and the expectant management group (33%), for a relative risk of 0.99.
There also were no significant differences between the two study groups in maternal outcomes or neonatal outcomes (N Engl J Med. 2016 Mar 2;374:813-22. doi: 10.1056/NEJMoa1509117).
The trial did not address whether induction at 39 weeks’ gestation could prevent stillbirth, the researchers reported, but it provides support for the safety of performing a larger trial to test the effects of induction on stillbirths and other adverse neonatal outcomes.
The women assigned to labor induction did not differ from those assigned to expectant management in their subjective assessments of satisfaction with the childbirth experience. However, all the study participants had agreed to randomization. Women who had strong preferences about induction or expectant management, or strong feelings about their involvement in treatment decisions – and who may therefore have had a different take on their childbirth experience if labor were induced – were excluded from the study.
The study was supported by the National Institute for Health Research in the United Kingdom. Dr. Walker reported having no relevant financial disclosures; one of her associates reported ties to Roche Diagnostics, GlaxoSmithKline, General Electric, Chiesi, and Action Medical Research.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point: Among women aged 35 years and older, labor induction at 39 weeks didn’t affect the rate of cesarean delivery.
Major finding: There was no significant difference in the frequency of C-section between the induction group (32%) and the expectant management group (33%).
Data source: A multicenter, randomized trial involving 619 older pregnant women in the United Kingdom.
Disclosures: The study was supported by the National Institute for Health Research in the United Kingdom. Dr. Walker reported having no relevant financial disclosures; one of her associates reported ties to Roche Diagnostics, GlaxoSmithKline, General Electric, Chiesi, and Action Medical Research.
