Sunday, March 30, 2014

Wait for Spontaneous Labor If the Cervix Isn't Ripe

Here is a new study that suggests that it may be better to await spontaneous labor in first-time obese mothers with an unripe cervix, rather than trying to force labor to start regardless of the Bishop's Score.


Am J Obstet Gynecol. 2014 Jan 31. pii: S0002-9378(14)00063-5. doi: 10.1016/j.ajog.2014.01.034. [Epub ahead of print] Risk of cesarean in obese nulliparous women with unfavorable cervix: elective induction vs expectant management at term. Wolfe H1, Timofeev J2, Tefera E3, Desale S3, Driggers RW2. PMID: 24486226
OBJECTIVE: The objective of the study was to examine maternal and neonatal outcomes in obese nulliparous women with an unfavorable cervix undergoing elective induction of labor compared with expectant management after 39.0 weeks. STUDY DESIGN: This was a retrospective analysis of a cohort of nulliparous women with a vertex singleton gestation who delivered at MedStar Washington Hospital Center from 2007 to 2012. Patients with unfavorable cervix between 38.0 and 38.9 weeks (modified Bishop <5) and a body mass index of 30.0 kg/m2 or greater at the time of delivery were included. Women undergoing elective induction between 39.0 and 40.9 weeks' gestation were compared with those who were expectantly managed beyond 39.0 weeks. Outcomes were analyzed using χ2, Student t, or Wilcoxon rank sum tests as appropriate with a significance set at P < .05. RESULTS: Sixty patients meeting inclusion criteria underwent elective induction of labor and were compared with 410 patients expectantly managed beyond 39.0 weeks. The rate of cesarean delivery was significantly higher in the electively induced group (40.0% vs 25.9%, respectively, P = .022). Other maternal outcomes, including operative vaginal delivery, rate of third- or fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage, and a need for a blood transfusion were similar. The neonatal intensive care unit admission rate was higher in the electively induced group (18.3% vs 6.3%, P = .001). Birthweight, umbilical artery pH less than 7.0, and Apgar less than 7 at 5 minutes were similar. CONCLUSION: Elective labor induction at term in obese nulliparous parturients carries an increased risk of cesarean delivery and higher neonatal intensive care unit admission rate as compared with expectant management.


CommanderLogic said...

Hi! Sorry for intruding, but I didn't see a contact email address. I have a question about induction and presumed macrosomia - namely, my doctor is (gently) pressuring me to consider induction, and I want to know if there is any reason OTHER than shoulder dystocia for induction to be considered.

A little background: I am currently 4 months pregnant with my second baby. I started my first pregnancy one pound into the Obese BMI range, had no GD, hypertension, or eclampsia symptoms. Babies run big and late in my family, and baby #1 was no exception, arriving two days after her due date at 9lb15oz. The labor was somewhat induced - my water broke and my labor wasn't progressing. I was on constant fetal monitoring, and was not allowed to move as I wanted as that would move the monitor. At 18 hours, I was put on pitocin, then received an epidural on request. Baby #1 was delivered with a shoulder dystocia, and while macrosomia was undoubtedly a factor, I also want to emphasize that I was induced, not allowed to walk or move during my labor, and delivered in standard on-the-back position, all of which (I discovered later) were also risk factors for dystocia.

Baby #1's arm temporarily displayed a palsy, but fortunately she recovered in about two weeks and shows no sign of palsy.

I researched dystocia recurrence and found that only 1% of women who delivered with dystocia had another dystocia. So I'm not truly concerned about that. But baby #2 is likely to be another biggun, so what is my doctor actually afraid will happen? If anything? Thank you! And thank you for all the other wonderful work you've done here!

Well-Rounded Mama said...

CommanderLogic, I'm sorry you are facing this tough decision. My contact info is listed to the left in "about the author" but I'll answer here.

Your doctor probably is most concerned about another shoulder dystocia, since a previous one is a risk factor for recurrence. How much depends on the study, really. Some show more risk than others. I think the number you quote is a bit low but I'd have to do more digging to know for sure.

You're right; lack of mobility in labor and pushing, being induced, being flat on the back with an epidural...these are all risk factors for SD, and ones that many providers tend to discount. Inducing would tend to produce those same conditions again, so that's a good argument against inducing.

But to be fair, macrosomia is a real risk factor for SD. Yet some of us just make big babies and most of those are born without problems. The problem is that not all are, and no one knows what the best thing is to do about that.

Your doctor is probably quite concerned about being sued (with some reason). Shoulder dystocia is one of the top reasons OBs get sued. They feel that if they can show they "did something" about it proactively, like induce early, they are less likely to be found culpable. And of course, I'm sure the doctor is also truly concerned about possible complications from SD as well.

There's no easy answer to this question. Most of the time, SD does not recur, even when the baby is still big, but there have been cases of recurrence with poor outcomes, so doctors are concerned, and of course, afraid of being sued.

Personally, I make big babies. I was always being pressured to induce early because of the SD fear. In the end I chose to get chiropractic care to make sure my pelvis was as aligned as possible (to make the most room possible) and to choose a provider who was not afraid of big babies and was well-trained in responding to SD if that happened.

However, I also know people that choose to induce. I think it's hard to know what the best course of action in this situation is. Hugs to you as you consider your choices.

Well-Rounded Mama said...

I forgot to mention that another choice is to change providers. It will not be easy to find one who won't pressure you to induce early, given the prior SD, but there are some out there. Midwives tend to be a little less intervention-oriented than doctors, but really it mostly depends on the individual provider. You have to ask a lot of careful questions to really find someone who doesn't freak out about big babies, but there are some out there.

CommanderLogic said...

Thank you so much for the response! I know SD is no trivial matter, and we were extremely lucky that Baby #1's palsy was mild and passed, and also that I had minimal tearing and no further complications.

Yeah, I figured SD (and fear of being sued!) was the main factor here. I feel like I can address that fear with my doctor, I just wanted to be sure there wasn't something else with macrosomia that I was missing - like a significantly higher stillbirth rate or increased maternal mortality rate, and it doesn't look like that's the case in non-GD pregnancies. Next time my doctor suggests induction or scheduled c-section, I'll ask for more detail as to why exactly, and what else we can do instead.

I'm not against medically necessary c-sections, and if I do need one, I'm REALLY glad that I'll have access to that level of care. But I don't want one unless I actually, truly need one, because however routine it is for a hospital's surgeons, it's still a major surgery.

Thanks again!

Well-Rounded Mama said...

Stillbirth is a potential risk for shoulder dystocia, which I'm pretty sure you know already, but which I feel obligated to point out. Nearly all SDs can be resolved before that point, but it IS a potential risk. I have occasionally known of cases of this, although it's quite rare.

But it's a risk of SD, not macrosomia itself, as far as I'm aware. The macrosomia makes the risk for SD go up, but I don't think macrosomia itself is the issue.

I would still put in a plug for considering chiropractic care, if you are open to that. It will help make sure you have the maximum possible room in your pelvis for that baby.

From there, whatever you choose is up to you, but it helps keep open your options. Doctors don't believe it will help, mind, but I am convinced from experience that it does help. Not a guarantee, of course, but a help.

Best wishes whatever you decide!

Anonymous said...

Be VERY careful with the interpretation of this RETROSPECTIVE study--
One very fine detail is the cervical dilatation upon admission in the two groups. They are DIFFERENT! It is clear based on other research, that if two groups of women of the same gestational age are induced, the one with the better Bishop score (and by definition, greater dilatation => higher Bishops)will have better rates of vaginal delivery.

This article does not address RISKS of waiting in full (rates of development of preeclamspia, reasons why women in the expectant group were induced, etc) nor was it designed to do so. Be VERY careful about making broad statements with only part of the story. There are risks and benefits to ALL methods of care, and these should be fully appreciated and understood by ALL parties.

Anonymous said...

PLEASE do not assume that MDs only fear LAWSUITS. Bad outcomes are DEVASTATING for US as well! Most MDs I know are high achievers, went into medicine out of a genuine desire to HELP PEOPLE. Watching a mother lose a baby, a baby lose a mother or someone have a major complication is something we TAKE HOME WITH US, and can sometimes (sometimes unfortunately) change the way we practice. We MDs are NOT always the enemy. Be as open to our concerns as you want us to be about yours--a concerned and caring MD.

Well-Rounded Mama said...

Dear Concerned and Caring MD,

Thank you for your comments. I agree, MDs are not the enemy, and yes, it's important to consider the potential risks of waiting. Of course doctors are devastated by poor outcomes and this colors their decisions. How could it not? My heart goes out to the providers too.

I would still point out that it's also important to consider the risks of inducing. Sometimes only the potential risks of waiting get emphasized to patients, without similar attention to potential risks of the induction itself. Yet I've known women whose babies have died due to the induction itself. And in this study, more induced babies ended up in the NICU.

That's what makes end-of-pregnancy decisions so difficult. There are risks to waiting and there are risks to taking action. So difficult to weigh those two. This is simply sharing one piece of research on that difficult topic.