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To induce labour, or wait: further quantifying the choice

Induction of labour (IOL), whether medically indicated or elective, has been a concern for as long as modern obstetric care has focused on optimising both maternal and newborn outcomes. Historically, IOL was used when the mother’s condition warranted it, such as in cases of eclampsia or fetal demise. Current medical indications for IOL are often related to worsening maternal (preeclampsia, diabetes) or fetal conditions (fetal growth restriction or abnormal fetal testing), which frequently occur in the late preterm (34–37 weeks of gestation) or early term (37–39 weeks of gestation) periods. At these earlier gestations, the cervix may be unfavourable and attempting an IOL well before the uterus is ready, results in significant increases in caesarean section (CS) rates (Ehrenthal et al. Obstet Gynecol. 2010;116:35–42); however, more recent studies are not as clear on an increase. Furthermore, certain women in developed countries, with normal pregnancies, want to personalise their deliveries to a particular date and time, which can lead to elective IOL and also a higher CS rate. Bernardes et al. present a novel study which combines two prior randomised controlled trials (RCTs) comparing IOL and expectant management (EM) in two groups of high risk patients with hypertensive disease (Koopmans et al. Lancet. 2009:374:979–88) or suspected fetal growth restriction (Boers et al. BMJ. 2010;341:c7087). These two original studies focused on the most common maternal indications for induction and found that IOL was largely equivalent to EM with respect to CS rates and pregnancy outcomes. Their conclusions were reassuring to providers regarding the safety and ease of IOL. Bernardes et al. focuses on those women who had unfavourable cervical exams as measured by the Bishop score (BS). The BS is the standard vaginal exam performed to describe cervical dilation, effacement, station, consistency, and position. The higher the BS (0–13 points), the more likely the IOL will be successful. In the current study, the most interesting finding, though not unexpected, was that a BS. of two or less (IOL 22.7%, EM 21.2%, Table 5) had a higher CS rate than a BS of 3– 6 (IOL 9.3%, EM 12.0%). This finding should assist clinicians with counselling women with unfavourable cervices about success (or failure) of IOL. Still unanswered by this study is the impact of BS on parity and IOL success. In Table 3 of the current manuscript, in the IOL group, the multiparous women (1.5 days) deliver almost a half day sooner that the nulliparous women (1.9 days). This difference is not seen with the EM patients and may represent a future area of study. A final question is whether or not the fairly homogeneous Dutch population IOL results, will apply to other more diverse populations. One concerning finding was that the rate of low cord blood gases (cord pH < 7.05) was higher in the EM group (4.8%) than in the IOL group (1.7%). This finding was also seen (to a lesser degree) in the group with a cord pH < 7.1. An almost one in 20 chance (4.8%) of having significant acidaemia at birth may be too high and deserves. further examination. In conclusion, Bernardes et al. add an additional piece to the complex puzzle of IOL and ongoing efforts to optimise pregnancy outcomes.