Grand Rounds

CMECNE

Induction vs Expectant Management At and Beyond Term – the Cochrane Review

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. List the risk factors for postterm delivery
2. Discuss the results of the Cochrane Review meta-analysis that compared induction to expectant management for low risk women at term and beyond

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from June 4 2018 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

BACKGROUND AND PURPOSE:

Risk factors for postterm pregnancy include obesity, nulliparity and maternal age >30
Postterm pregnancy is associated with risk, especially to the fetus/newborn, while there is potential for adverse outcomes related to interventions associated with induction of labor
Middleton et al. (Cochrane Reviews, 2018) sought to determine whether a policy of labor induction at or beyond term could improve pregnancy outcomes for infant and mother

METHODS:

Database search of randomized controlled trials (RCTs)
Participants: Low-risk pregnant women at or beyond term enrolled in trials comparing induction to expectant management
Policies differed with respect to
- Gestational age used in the policy | Actual method of labor induction | Expectant management protocols (intensity of fetal monitoring)
Majority of trials (75% of participants) adopted a policy of induction at ≥41 weeks gestation
Induction protocols ranged from from 37 to >42 weeks induction policies
- For purposes of this study, gestational ages were collapsed in to 3 groups: (1) Induced at <41 weeks; (2) Induced ≥41 weeks; (3) inductions spanning 37 to 42 weeks
Primary outcome: Perinatal death (intrauterine plus neonatal)
Secondary outcomes
- Adverse maternal and fetal outcomes | Mode of delivery | Health services use (length of stay and labor)

RESULTS:

30 RCTs were included in this review (moderate risk for bias)
Compared with expectant management, labor induction was associated with
- Fewer all-cause perinatal deaths: Risk ratio (RR) 0.33; 95% CI, 0.14 to 0.78 (moderate-quality evidence)
- Fewer stillbirths: RR 0.33; 95% CI, 0.11 to 0.96 (moderate-quality evidence)
- Fewer C-sections: RR 0.92; 95% CI, 0.85 to 0.99 (moderate-quality evidence)
- Increase in operative vaginal births: RR 1.07; 95% CI, 0.99 to 1.16 (moderate-quality evidence)
- Fewer NICU admissions: RR 0.88; 95% CI, 0.77 to 1.01 (moderate-quality evidence)
- Fewer babies had Apgar scores <7 at 5 minutes: RR 0.70; 95% CI, 0.50 to 0.98 (moderate-quality evidence)
There was no differences between groups regardless of gestational age for
- Perineal trauma | Postpartum hemorrhage | length of maternal hospital stay | Neonatal trauma
In cervical state or timing of induction (<41 weeks vs ≥41 weeks) there were no differences in perinatal death, stillbirth, NICU admission, cesarean section or perineal trauma
- More operative deliveries in <41 week group

CONCLUSION:

Adopting a policy of labor induction lead to better pregnancy outcomes for mother and child, including fewer perinatal deaths, fewer C-sections, more operative vaginal births, and fewer NICU visits
According to the authors,

A policy of labour induction was associated with fewer perinatal deaths (with two perinatal deaths in the labour induction policy group compared with 16 perinatal deaths in the expectant management group) (moderate-quality evidence). When restricted to a policy of induction at later gestational ages (> 41 weeks), there were two and 13 perinatal deaths, respectively.

Learn More – Primary Sources:

Induction of labor for improving birth outcomes for women at or beyond term

ACOG Committee Opinion 579: Definition of Term Pregnancy

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