November 20, 2019

expert reaction to study looking at inducing labour versus ‘wait and see’ approach for late term pregnancies

Research, published in the BMJ, reports that inducing labour in late term pregnancies may be less risky than the ‘wait and see’ approach. 

Prof Andrew Shennan, Professor of Obstetrics and Clinical Director of the South London Clinical Research Network, King’s College London, said:

“Induction of labour is known to improve outcomes and is routinely offered between 41 and 42 weeks.  Risks of still birth were low at 42 weeks (<1 in 200) but none occurred if induction was performed at 41 weeks.  Women can be reassured that earlier induction of labour did not have any additional ill effects including need for caesareans or medical assistance, and is safer for the baby.  Many may now choose this as a reasonable routine option, but drugs and staffing issues to implement this will need consideration.”

Dr Kasia Maksym, UCL EGA Institute for Women’s Health, UCL, said:

“This is a very important piece of research.  Nearly perfect design, would benefit from involving women in the designing process.  There is potential for data to be biased as recruitment was stopped before reaching planned target.  However it was stopped for the reason, the very reason this study was designed for – to answer the question: which management is the safest in prolonged pregnancy.  The result is not unexpected.  The message is clear: there is an intervention, which can reduce risk of perinatal mortality in prolonged pregnancy, without additional risk for mother and baby.”

Prof Christoph Lees, Professor of Obstetrics and Trustee of the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), said:

“This excellent Swedish study comes hot on the heels of a similar Dutch study¹, these studies showing a reduction in perinatal mortality and a reduction in perinatal adverse outcome, respectively.  The findings of this latest contribution are very important; though the primary outcome was not perinatal death the findings of a greater perinatal death rate amongst women randomized to expectant management is compelling, particularly as induction at 41 weeks was also associated with lower rates of neonatal unit admission, pre-eclampsia, SGA and jaundice requiring phototherapy.

“Given that the Caesarean section rate was not increased, there can now surely be no argument against offering induction of labour routinely at 41 weeks, particularly to women in their first pregnancy, whose risk of perinatal death is higher.

“This study raises an urgent issue that should inform how we counsel women who ask us about induction of labour at 41 weeks versus waiting.  This is a question that NHS maternity units should address immediately, as we cannot ignore the evidence that we have in front of us.  The Montgomery ruling in the Supreme Court in 2014 is pertinent here, particularly if a woman were to suffer a stillbirth after 41 weeks: ‘it is not possible to consider a particular medical procedure in isolation from its alternatives. Most decisions about medical care are not simple yes/no answers.  There are choices to be made, arguments for and against each of the options to be considered, and sufficient information must be given so that this can be done’.”

1 Keulen JK, Bruinsma A, Kortekaas JC, et al . Induction of labour at 41 weeks versus expectant management until 42 weeks (INDEX): multicentre, randomised non-inferiority trial. BMJ 2019;364:l344. 10.1136/bmj.l344 30786997

Dr Sarah Stock, Wellcome Trust Clinical Career Development Fellow and Honorary Consultant in Maternal and Fetal Medicine, MRC Centre for Reproductive Health, University of Edinburgh, said:

“This study adds to the growing body of evidence that induction of labour, at or beyond term gestation, is safer for babies, without increasing caesarean section or other complications for mothers.

“This carefully conducted Swedish study suggests that offering pregnant women induction of labour at 41 weeks gestation, rather than waiting until 42 weeks gestation, could reduce baby deaths.

“The trial, which compared two policies of induction of labour, was stopped early because more babies died when women were allocated to a ‘wait and see’ approach, than when women had induction at 41 weeks gestation.  Other benefits of induction at 41 weeks included fewer babies separated from their mothers because of admission to specialist neonatal care, fewer babies with high birth weight, and fewer babies with complications like jaundice.

“Some of the women assigned to induction of labour at 42 weeks had ultrasound scans to check on their babies while waiting for birth; but the study was not large enough to see if this ‘watchful waiting’ approach was any safer.

“It now seems hard to justify denying women the option of induction of labour when they reach 41 weeks gestation.  Maternity services must be adequately resourced and staffed to offer increasing numbers of induction of labour safely, in a setting that works for women.”

‘Induction of labour at 41 weeks versus expectant management and induction of labour at 42 weeks (SWEdish Post-term Induction Study, SWEPIS): multicentre, open label, randomised, superiority trial’ by Ulla-Britt Wennerholm et al. was published in the BMJ at 23:30 UK time on Wednesday 20 November 2019.

DOI: 10.1136/bmj.l6131

Declared interests

Prof Andrew Shennan: “No conflicts.”

Prof Christoph Lees: “Trustee of ISUOG, Head of Fetal Medicine at Imperial College London, Hold research & educational grants and collaborations with Roche, GE, Samsung, Canon.”

Dr Sarah Stock: “Dr Sarah Stock receives grant funding from the National Institute of Healthcare Research Health Technology Assessment (NIHR HTA) for a study of home versus hospital induction of labour (NIHR127569: CHOICE study). Dr Sarah Stock is Chair of the Royal College of Obstetricians and Gynaecologists Stillbirth Clinical Study Group.”

None others received.