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Outcomes of elective induction of labour compared with expectant management: population based study

BMJ 2012; 344 doi: (Published 10 May 2012) Cite this as: BMJ 2012;344:e2838

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Re: Outcomes of elective induction of labour compared with expectant management: population based study

The authors note that this may be the first study to quantify the benefits of induction of labour in terms of a reduction in perinatal mortality, but it is certainly not the first study to quantify the benefits of delivering babies at an optimum gestational age with the aim of reducing this risk.

In 2006, research by Hankins et al in the U.S. “estimated that delivery at 39 weeks EGA would prevent 2 fetal deaths per 1000 living fetuses. This would translate into the prevention of as many as 6000 intrauterine fetal demises in the United States annually – an impact that far exceeds any other strategy implemented for stillbirth reduction thus far.”(1)

They did not suggest therefore that all women should plan a c-section at 39-40 weeks’ gestation, but that women should be informed about the risk of stillbirth in the absence of spontaneous labour.

Stock et al’s latest analysis of gestational age outcomes provides even more information for women: they may consider expectant management, induction of labour or an elective caesarean. The latter was not discussed in the Scottish research (rather, caesarean delivery is discussed in the context of whether its likelihood is increased or decreased, which is helpful for women who want to avoid surgery), but as Hankins et al concluded in 2006, it “is reasonable to inform the pregnant woman of the risk of each of the above categories, in addition to counseling her regarding the potential risks of a cesarean section for the current and any subsequent pregnancies. The clinician's role should be to provide the best evidence-based counseling possible to the pregnant woman and to respect her autonomy and decision-making capabilities when considering route of delivery.”

My concern is that all too often stillbirth is not seriously considered in “low risk” pregnancies, and therefore women are not properly informed about it. Worse still, many hospitals are so focused on meeting caesarean rate reduction targets that mother’s choices are limited and mistakes are made,(2) leaving families and the NHS with huge physical, psychological and financial costs.

(1) Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Hankins GD, Clark SM, Munn MB. Semin Perinatol. 2006 Oct;30(5):276-87.

(2) “King’s Lynn: QEH apologies over baby death,” Lynn News, May 12, 2012.

Competing interests: Co-author of Choosing Cesarean, A Natural Birth Plan

13 May 2012
Pauline M Hull
Author and Editor
Surrey, UK