Routine induction in late-term pregnancies: follow-up of a Danish induction of labour paradigm

Rydahl, Eva; Declercq, Eugene; Juhl, Mette; Maimburg, Rikke Damkjær

doi:10.1136/bmjopen-2019-032815

Cited by 18 publications

(19 citation statements)

References 39 publications

(59 reference statements)

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“…A recent attempt to extrapolate unidirectional trend curves appears to be unsuited to evaluate the influence of induction and implied at total miss of the significant increase in stillbirths over last 6 years. 4 On the other hand, our results are in line with the newly published randomised Swedish study suggesting significantly higher stillbirth rates with postponing induction to 42 weeks instead of at 41 weeks of gestation. 3 Strengths and limitations of study The main limitation of this study is its ecological design implying that even a strong correlation is not an ultimate prove of a causal relationship between induction regimen and stillbirth rates.…”

Section: Implication Of Findingssupporting

confidence: 91%

“…Recently, it has been questioned whether an association between induction regime and stillbirth rates exists at all. 4 One of the challenges with a more frequent and earlier induction regimen, is the demand of an expanded staff to take Open access care of these inductions, needs which often conflict with attempts to reduce staff as maternity wards are merged and centralised in order to ensure, for example, at site neonatal care facilities. This study aimed to analyse induction frequencies and national stillbirth rates from 41 completed weeks during the period 2007-2018.…”

Section: Introductionmentioning

confidence: 99%

“…Recently, it has been questioned whether an association between induction regime and stillbirth rates exists at all. 4 …”

Section: Introductionmentioning

confidence: 99%

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Are the Danish stillbirth rates still record low? A nationwide ecological study

et al. 2020

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ObjectivesAfter introduction of a more proactive post-term induction practice, stillbirth rates have decreased substantially throughout the first decade of this century in Denmark. The aim was to follow up on induction and stillbirth rates in Denmark.DesignHistorical ecological study.ParticipantsWe included all delivering women in Denmark during the period 2007–2018.InterventionInduction rates from 41 weeks of gestation.Main outcome measureStillbirth rates from 41+0 weeks.ResultsOf 739 570 delivered children, 179 734 (24.3%) were born from 41+0 weeks. The proportion of deliveries after 41 weeks which were induced increased from 25.4% in 2007 to 44.4% in 2012. From 2012 to 2015, the induction rates decreased from 44.4% to 39.4%. After 2015 rates were stable.During the same period, stillbirth rates decreased from 1.30 in 2007/2008 to 0.38 per 1000 newborn in 2011/12; -54%. From 2012, however, the rates were doubled from 0.38 per 1000 in 2011/2012 to 0.74 per 1000 in 2015/2018; RR 1.97 (95% CI 1.02 to 3.81), p=0.033.Changes in the included potential confounders cannot explain neither the substantial fall in stillbirth rates from 2007/2008 to 2011/2012, nor the doubling in stillbirth rates after 41 weeks since 2012.During the whole study period, the cumulated risk of intrauterine foetal death increased from week 41+0 to 41+6 from 0.16 to 1.25 per 1000 ongoing pregnancies or 7.8 folds. Going beyond 42 weeks further increased the risk to 2.46 per 1000 ongoing pregnancies.ConclusionWe found a consistent inverse correlation between the proportion of women with induction of labour after 41 weeks of gestation and the stillbirth rates during the same period and same gestational ages. This Danish update on post-term inductions and corresponding stillbirth rates thus confirm previous findings suggesting a causal link between these two parameters.

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Section: Implication Of Findingssupporting

confidence: 91%

Section: Introductionmentioning

confidence: 99%

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Are the Danish stillbirth rates still record low? A nationwide ecological study

et al. 2020

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“…Several large observational studies are also in line with our findings [ 31 , 32 ]. However, other observational studies are not [ 33 , 34 ]. The Cochrane reviews included RCTs with different time frames of comparison, and most RCTs had upper limits of expectant management that went far beyond 42 weeks, which could at least partly explain the higher risk of perinatal mortality with a policy of expectant management [ 8 , 9 ].…”

Section: Discussionmentioning

confidence: 99%

Induction of labour at 41 weeks or expectant management until 42 weeks: A systematic review and an individual participant data meta-analysis of randomised trials

et al. 2020

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Background The risk of perinatal death and severe neonatal morbidity increases gradually after 41 weeks of pregnancy. Several randomised controlled trials (RCTs) have assessed if induction of labour (IOL) in uncomplicated pregnancies at 41 weeks will improve perinatal outcomes. We performed an individual participant data meta-analysis (IPD-MA) on this subject. Methods and findings We searched PubMed, Excerpta Medica dataBASE (Embase), The Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and PsycINFO on February 21, 2020 for RCTs comparing IOL at 41 weeks with expectant management until 42 weeks in women with uncomplicated pregnancies. Individual participant data (IPD) were sought from eligible RCTs. Primary outcome was a composite of severe adverse perinatal outcomes: mortality and severe neonatal morbidity. Additional outcomes included neonatal admission, mode of delivery, perineal lacerations, and postpartum haemorrhage. Prespecified subgroup analyses were conducted for parity (nulliparous/multiparous), maternal age (<35/≥35 years), and body mass index (BMI) (<30/≥30). Aggregate data meta-analysis (MA) was performed to include data from RCTs for which IPD was not available. From 89 full-text articles, we identified three eligible RCTs (n = 5,161), and two contributed with IPD (n = 4,561). Baseline characteristics were similar between the groups regarding age, parity, BMI, and higher level of education. IOL resulted overall in a decrease of severe adverse perinatal outcome (0.4% [10/2,281] versus 1.0% [23/2,280]; relative risk [RR] 0.43 [95% confidence interval [CI] 0.21 to 0.91], p-value 0.027, risk difference [RD] −57/10,000 [95% CI −106/10,000 to −8/10,000], I2 0%). The number needed to treat (NNT) was 175 (95% CI 94 to 1,267). Perinatal deaths occurred in one (<0.1%) versus eight (0.4%) pregnancies (Peto odds ratio [OR] 0.21 [95% CI 0.06 to 0.78], p-value 0.019, RD −31/10,000, [95% CI −56/10,000 to −5/10,000], I2 0%, NNT 326, [95% CI 177 to 2,014]) and admission to a neonatal care unit ≥4 days occurred in 1.1% (24/2,280) versus 1.9% (46/2,273), (RR 0.52 [95% CI 0.32 to 0.85], p-value 0.009, RD −97/10,000 [95% CI −169/10,000 to −26/10,000], I2 0%, NNT 103 [95% CI 59 to 385]). There was no difference in the rate of cesarean delivery (10.5% versus 10.7%; RR 0.98, [95% CI 0.83 to 1.16], p-value 0.81) nor in other important perinatal, delivery, and maternal outcomes. MA on aggregate data showed similar results. Prespecified subgroup analyses for the primary outcome showed a significant difference in the treatment effect (p = 0.01 for interaction) for parity, but not for maternal age or BMI. The risk of severe adverse perinatal outcome was decreased for nulliparous women in the IOL group (0.3% [4/1,219] versus 1.6% [20/1,264]; RR 0.20 [95% CI 0.07 to 0.60], p-value 0.004, RD −127/10,000, [95% CI −204/10,000 to −50/10,000], I2 0%, NNT 79 [95% CI 49 to 201]) but not for multiparous women (0.6% [6/1,219] versus 0.3% [3/1,264]; RR 1.59 [95% CI 0.15 to 17.30], p-value 0.35, RD 27/10,000, [95% CI −29/10,000 to 84/10,000], I2 55%). A limitation of this IPD-MA was the risk of overestimation of the effect on perinatal mortality due to early stopping of the largest included trial for safety reasons after the advice of the Data and Safety Monitoring Board. Furthermore, only two RCTs were eligible for the IPD-MA; thus, the possibility to assess severe adverse neonatal outcomes with few events was limited. Conclusions In this study, we found that, overall, IOL at 41 weeks improved perinatal outcome compared with expectant management until 42 weeks without increasing the cesarean delivery rate. This benefit is shown only in nulliparous women, whereas for multiparous women, the incidence of mortality and morbidity was too low to demonstrate any effect. The magnitude of risk reduction of perinatal mortality remains uncertain. Women with pregnancies approaching 41 weeks should be informed on the risk differences according to parity so that they are able to make an informed choice for IOL at 41 weeks or expectant management until 42 weeks. Study Registration: PROSPERO CRD42020163174

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“…Danskene fremskyndet igangsetting av fødsel fra svangerskapsuke 42 til midten av svangerskapsuke 41. I en studie som evaluerte effekten av dette tiltaket, fant man ingen reduksjon i dødfødsler, neonatale dødsfall eller nyfødte med lav apgarscore (9). Derimot fant man en økning i antall uterusrupturer.…”

Section: Uheldige Effekterunclassified

Igangsetting av alle fødsler i svangerskapsuke 41 er uhensiktsmessig

Haavaldsen¹,

Eskild²,

Morken³

2020

Tidsskriftet

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Camilla Haavaldsen er ph.d., spesialist i fødselshjelp og kvinnesykdommer og postdok ved Kvinneklinikken ved Akershus universitetssykehus. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter. ANNE ESKILD Anne Eskild er ph.d., spesialist i fødselshjelp og kvinnesykdommer, overlege og avdelingsleder ved Kvinneklinikken ved Akershus universitetssykehus og professor ved Universitetet i Oslo. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter. NILS-HALVDAN MORKEN Nils-Halvdan Morken er ph.d., spesialist i fødselshjelp og kvinnesykdommer, overlege ved Kvinneklinikken ved Haukeland universitetssjukehus og professor ved Universitetet i Bergen. Han er nestleder i Norsk gynekologisk forening. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter.

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Routine induction in late-term pregnancies: follow-up of a Danish induction of labour paradigm

Cited by 18 publications

References 39 publications

Are the Danish stillbirth rates still record low? A nationwide ecological study

Are the Danish stillbirth rates still record low? A nationwide ecological study

Induction of labour at 41 weeks or expectant management until 42 weeks: A systematic review and an individual participant data meta-analysis of randomised trials

Igangsetting av alle fødsler i svangerskapsuke 41 er uhensiktsmessig

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