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Consortium
for the Evidence-based practice of Obstetrics --
C.E.O. is dedicated to bringing science-based
maternity care to all childbearing women
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Quotes
and Excerpts from www.eObGynNews.com
and
other respected sources of professional information
on safety, complications & practice trends for obstetricians
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Bibliography, Recommended
Reading and Scientific Citation from obstetrical sources
for the:
Risks
& Complications of Elective Induction
Shoulder Dystocia
/ Factual Basis for Reducing
Practitioner Anxiety
Induction Rate
Doubled in the US from 1990 to 1998; Ob.Gyn.News
May 1, 2002, Vol 37, No 9;
Labor Induction for Macrosomia (big baby)
not Justified – Ob.Gyn.News; Mar 1 2002 Vol
37,
Induction Linked to Doubling of Cesarean
Rate in Nulliparas
(1st
time mothers), Ob.Gyn.News; Jan 1 2003 Vol 38,
No 1;
Multiparas: C-Section, Cervical Ripening
Link Seen –
Women had previously delivered
vaginally, Ob.Gyn.News;
Jun 15 2003 Vol 38, No 12;
Data
Don't Support Postdates Pregnancy Guideline;
ObGynNews,
Mar 1, 2001, Vol 36 No 5
Prolonged Resolution of Dystocia is Well
Tolerated
–
Moderate delays not
tied to fetal academia
ObGynNews, Oct 15, 2002, Vol 37 No
20
Based on observational data & experience,
Scientific Data Doesn't Support Postdates Pregnancy Guidelines Oct 15 2002 • Volume 37 • No 20
Observational data and clinical experience—not
randomized controlled data—have led to the currently accepted guidelines for managing postdates pregnancies.
Yet these guidelines govern the practices of most obstetricians in the United
States ... “There is very little evidence for what we do.
.... There have been two randomized controlled trials comparing the effects of monitoring, fetal testing, and induction on perinatal mortality and morbidity in postdate pregnancies. Both have found no significant difference in adverse outcomes or cesarean section
rate....
“The jury is still out. So the question is ‘When should we begin antenatal surveillance, and should we induce?’”
For many years, obstetricians have believed the truism that the best way to decrease perinatal mortality is to terminate the pregnancy before adverse events occur. Yet whether induction at 41 weeks
increases the risk of an operative delivery without preventing perinatal death is still not clear.
There is also no evidence in the literature that testing between 40 and 42 weeks' gestation improves outcomes, though many obstetricians believe it
does. At 41 weeks, most obstetricians will deliver a baby if the cervix is favorable. “However, this is entirely based on observational data,”
After 42 weeks, observational studies have shown that there is a drop-off in amniotic fluid, which is felt to be a sign of poor renal function in the fetus.
ACOG guidelines—again, based on observational data—maintain that oligohydramnios is an indication for delivery, he added.
If the cervix is unfavorable or the Bishop score is low, immediate delivery may put the woman and baby at risk for a failed induction, he said. In these cases, the obstetrician should use the Foley balloon or
misoprostol [Cytotec].
In his practice, .... prefers to induce around term...
Induction Linked to Doubling of Cesarean
Rate in Nulliparas (1st
time mothers), Ob.Gyn.News; Jan 1 2003 Vol 38,
No 1;
The cesarean delivery rate doubled
when nulliparous [having a 1st baby] were induced.... The
C-section rate was especially high, 31.5%, among nulliparous patients who
were induced despite an unfavorable cervix, defined as having a Bishop score
at induction <5.
......the tracking of 20,000 deliveries
in the Providence Health System (Portland, Ore) offers valuable insight into
risk factors and the route of delivery. In all, 4,635 (64%0 went into
labor spontaneous and had a C-section rate of 11.5%. Among the 2,647 women (36%)
who were induced, theC-section rate was 23.7%.
There's a doubling of the C-section
rate of induced nulliparous women over the spontaneous background rate of
11.5%, ...... [Dr. Johnson] noted that other recent studies have shown a
"fairly consistent" doubling of C-sections among induced nulliparous
women, regardless of the background C-section rate.
Induction of labor in nulliparous
patients should be approached with caution, especially if the cervix is
unfavorable ..... Patients should be informed of this relationship, and
proper
informed consent should be obtained."
Multiparas: C-Section, Cervical Ripening
Link Seen – Women had previously delivered vaginally,
Ob.Gyn.News;
Jun 15 2003 Vol 38, No 12;
The risk of cesareans section is five
times higher in women with at least one previous vaginal delivery who receive
cervical ripening before elective induction, compared with women who have a
spontaneous.
These findings, from a retrospective
study of 1,268 women, suggest that "a patient should not be induced
electively unless her cervix is favorable, said Dr Hoffman of the department of
obstetrics and gynecology at Christiana Care Health Services in Newark,
Delaware. "We probably don't truly create the same parameters that a
woman does through our process of preinduction cervical ripening," he
told this newspaper. "We need to wait for the cervix to become ready."
In primiparas [having a first baby]
elective induction even with a favorable cervix is associated with anywhere from
two or threefold increase in Cesarean section rate," compared with women
who have spontaneous labor, he said.
In the study the Cesarean section rate
was 11.9% among women who had preinduction cervical ripening, 3.3% among the 454
women who were induced with cervical ripening and 2.4% among the 747 women who
went into spontaneous labor.
Dr Hoffman said the rate of elective
inductions is growing rapidly across the country because of both physician and
patient demand for convenience. "Over 20% of pregnancies are not induced,
and probably the most rapid increase is because of elective induction, her said,
adding that more than 40% of obstetric patients without a favorable cervix, as
well as all nulliparous patients, he said.
Nor was there a
significant correlation between longer times to dystocia resolution and
decreasing 5-minute Apgar scores. Of the 8,282 vaginal deliveries studied,
there were 134 cases of shoulder dystocia, representing an incidence
of 1.7%. the mean birth
weight for infants with dystocia was 4,504 g [10#].
The average head-to-body interval was 3 minutes, ranging from 30
seconds to 8 minutes. In a subgroup of 43 cases, there was a nuchal
cord present at delivery, but this was not believed to be associated with
adverse outcomes. Only one infant had an Apgar score of less than 3; no
infant had a 10-minute Apgar score of less than 4.