One of the most common questions I get as people move to the end of pregnancy is Should I have a labor induction? Labor induction did not used to be the norm, but it increasingly is. In many medical practices, it is now routine to schedule labor induction at 39 weeks of pregnancy for virtually all patients.
A big reason for this change is something called the ARRIVE trial, which was designed to test whether routine induction would increase the risk of cesarean section. The results were published in 2018, and they showed that labor induction did not drive C-section rates. In the wake of the trial, with that concern limited, many more doctors began recommending inductions as routine.
But this doesn’t work for everyone — some people would rather not be induced, and some researchers have argued that the results from ARRIVE actually do not hold up in the real world. Today on the podcast, I bring on my friend Dr. Nathan Fox so we can dive into data and decision-making on this tough question. Dr. Fox is a maternal fetal medicine specialist in New York and my co-author on our new book, The Unexpected, which is out in April.
To spark your interest, here are three highlights from the conversation:
How do doctors know if you need an induction?
Emily:
What are the kinds of things that would make you want to induce versus wait?
Dr. Nathan Fox:
Basically, since there was this idea that if you induce labor you’re increasing the risk of C-section, we would always weigh the benefits of induction versus this risk of C-section. So for example, if I was worried about an increased risk of stillbirth or if I was worried about the mother having an infection or if I was worried because her blood pressure’s going up and she may or may not have preeclampsia, which is unsafe. So we’re balancing the risk of inducing, which is C-section, versus the risk of not inducing or staying pregnant, which could be something bad to the mother or baby. And based on the specifics of the situation, or the condition, we make a decision: all right, we shouldn’t induce, will we wait longer? Will we not wait longer?
And that’s how we did it then, but people started to question that basic fact — that C-section is increased by being induced. And the first way they did it is they went back and looked at the same data that they used to conclude that induction increases the risk of C-section, but they looked at it differently. Instead of looking at women who are in labor versus induced, they looked at a week earlier, people who were induced versus people told to go home. And when they did it, again, retrospective observational, even in those studies, when they reexamined it in a way that makes more sense clinically, they saw no difference in the rate of C-section between the groups.
And that’s actually what prompted the ARRIVE trial. They said, “Whoa, wait a second. When we look at the data in a more logical way, or a more clinical way, this may be wrong. We may have been telling people the wrong thing for all these years. We need to do this in a really well-designed prospective trial.”
When is the best time for an elective induction?
Dr. Fox:
I don’t think it’s unreasonable to say, “I think the best strategy is to induce everybody at 39 weeks because it does not increase the risk of C-section” and because it might lower the risk of that. Okay, but that doesn’t mean it’s the right answer for everyone, because again, there’s logistical issues. There are patient preference issues. “I don’t want to be induced at 39 weeks, I don’t want to have a 24-hour labor. I want to wait and go into labor of my own.”
So what I tell people typically is any time between 39 and 41 weeks, and maybe for some people 42 weeks, is a reasonable time to be induced. And there’s benefits to going earlier, towards 39 weeks, and there’s benefits to waiting longer, towards 41 weeks. And unless there’s a real medical issue at hand, no one could say that one benefits are better than the other benefits.
If you’re someone who wants to be done as soon as humanly possible — you don’t feel well, you’ve got people coming in town, whatever it is; you want to be delivered at 39 weeks — I’ll say, “Fine, if we can get a room. Just be prepared for a long induction, God bless.” And if they want to wait till 41 weeks, the downside is, well, you’re pregnant for two weeks more, you may not go into labor, and you may end up with an induction anyway, and there’s small risks to you and to the baby, very slight. I don’t try to scare people or anything, but there’s very small risks of waiting longer in pregnancy. And that’s it. And most people will tell you what they want, most people will show you their cards. It’s not that hard.
How do you talk to your doctor about a possible induction?
Dr. Fox:
I would say that one of the important aspects about induction is asking, “Why are you recommending this?” Right? Are you recommending it just because I’m 39 weeks and I’ve hit a certain number, but everything is going perfectly fine, in which case I think there’s a lot of room for waiting and pushback — like maybe I don’t want to induce, versus are you recommending it because you have a specific concern for me or my baby about waiting on top of just the, I’m getting more pregnant? Meaning, is it because I’m 45 years old and you’re worried about a risk of a stillbirth? Is it because I have diabetes and you’re worried about a risk of a stillbirth? Is it because my blood pressure’s creeping up and you’re worried about me getting severe hypertension? That’s a very different reasoning than “just because.”
And again, just like patients will tell you what they think, doctors and midwives will tell you what they think. We’re not secretive. Our personalities come out, our opinions come out, and you want to get a sense. Ideally, these conversations should happen early in pregnancy — not specifically about induction, but just in general, because you’ll get a sense, is this a person I trust. And if it’s a person I trust, then probably this conversation will be very easy because you’ll already have that rapport. If you’re not sure if you trust this person, that’s not a good place to be.
Emily:
I wish I had had that advice with my first pregnancy, because I remember getting to the end and telling the doctor, “I’m planning not to have an epidural.” And they were like, “Oh, yeah, we’ll see how that goes.” And I was like, “Oh, we should have touched on this earlier.”
Dr. Fox:
It is true that, at least in our hospital, 90% of women get epidurals. That’s just sort of the numbers, but if you’re going to be in the 10%, I think that’s awesome. As I say, your labor won’t hurt me one bit, so whatever works, great. I think it’s terrific.
Full transcript
This transcript was automatically generated and may contain small errors.
One of the most common questions I get about the end of pregnancy is whether it’s a good idea to have a labor induction. For those of you who are wondering what this is, for many people at the end of pregnancy, they go into labor on their own. That’s called a spontaneous labor. But sometimes it makes sense to induce labor, to encourage labor, to start using a combination of medications. Over the past several years, there has been a push towards more of these labor inductions, and for many more people, they are being offered or even actively encouraged to induce labor at the end of their pregnancy. For some people, this is really welcome. A lot of the feelings of pregnancy are about giving up control, but the possibility of having some of that control back, at least for a little while, of being able to pick when you have your birth, that seems appealing. It’s easier to plan around. But for other people, this isn’t what they want. They were thinking of their labor experience as something that would start on its own, and being offered or strongly encouraged towards an induction makes them uncomfortable.
The reason this has changed so much in the last few years is because of something called the ARRIVE trial, which we’ll explain at much more length in this episode. But the most important baseline thing to understand is that this is a randomized controlled trial. It was designed to test whether labor induction made C-sections more likely. That was one of the concerns about labor induction. And what the trial showed is that it didn’t. The group that had their labor induced was no more likely to have C-sections than the group that didn’t have their labor induced. And a result of that is that many more providers became comfortable with the idea of labor inductions, and as they became more comfortable, we started to move towards a world in which maybe everyone should have a labor induction. After all, it’s easier to plan. It’s easier to schedule.
This landscape, this moving landscape, has caused a lot of tension, a lot of discomfort for a lot of women. And today I’m going to talk with Dr. Nate Fox about induction, about this trial, about what we should learn from this trial, what we shouldn’t learn from the trial, about the limits of evidence in general, and also about how we bring our own preferences to our care. We talk about the risks of induction versus the risk of waiting, and we really try to get into how people can make this decision in the most informed way for themselves.
A quick note. Nate and I talk about ACOG, which stands for the American College of Obstetrics and Gynecology, just to be clear on that one.
After the break, Dr. Nate Fox.
It is true that patients 11 through 20 had a higher rate of C-section than patients one through 10. And so the conclusion people made is, “Okay, people who are getting induced have a higher rate of C-section than those who come in spontaneous labor.” True statement. The problem is, clinically, if I’m seeing someone and making a decision about whether to induce them or not, the alternative to being induced is not you shall be in labor, it is go home. And so we don’t really have an opportunity, clinically, to decide whether someone should be induced or be in labor. We have a decision whether to induce them or not induce them, which means I’m going to send you home and come back when you’re in labor, or in a week or whatever. And so that was not advertised as part of the conclusion that induction increases the risk of labor. And so when they-
Instead of looking at women who are in labor versus induced, they looked at a week earlier, people who were induced versus people told to go home. And when they did it, again, retrospective observational, even in those studies, when they reexamined it in a way that makes more sense clinically, they saw no difference in the rate of C-section between the groups. And that’s actually what prompted the ARRIVE trial. They said, “Whoa, wait a second. When we look at the data in a more logical way, or a more clinical way, this may be wrong. We may have been telling people the wrong thing for all these years. We need to do this in a really well-designed prospective trial.” And that’s what led to the ARRIVE trial.
Then they did it for women who had hypertension. And the same thing, if you induce them, you don’t increase the risk. Then they did it for women who are over 35, and if you induce them you don’t increase risk. Meaning there was more and more mounting evidence, at least in smaller populations, that maybe this is incorrect. And the reason you would want to know that is number one, just in terms of counseling, and number two, it may change, it may tip the scales. You may need less of a risk of waiting to push you over the edge to induce if you’re not worried about the risk of induction. Maybe even to the point, and I’m not suggesting that you need to do this, but maybe to the point that you should just induce everyone. I mean that’s sort of the possible conclusion from something like this.
They actually, of course, as always at a trial like this, they weren’t forced to make the choice they were randomized into, but in the end, because of this encouragement, groups did have very different induction rates. And the results, what the authors find is that infant outcomes very similar in both groups. And if anything, there is a slightly lower C-section rate in the group that was induced. So both groups are actually very low, which we’ll come back to. It’s about eight to 11% of births are C-sections, that’s relative to a US rate of about 30%. But on face value, this trial really puts a wrench into the idea that labor inductions increase the risk of C-sections. So when this came out, did you just say, “I told you so?”
But whether it’s a problem to induce for that reason, that was a real question. So we weren’t doing a ton of that in my practice to begin with, and so it didn’t really impact us. The main thing after the ARRIVE trial, I would say, is it really made conversations about induction easier. Because it used to be, I would say, listen, we’re going to induce you. I hope it doesn’t increase your risk of C-section. But even if it does, listen, we really got to do it because of this concern or that concern or this reason or that reason. But now I can tell people, “I think you should be induced”, because of this reason or this reason or this reason. And just so you know, this really should not increase your risk of a C-section. And that makes it much more palatable for people on the receiving end of that kind of counseling.
And so, even if I wanted to induce everyone electively at 39 weeks, my hospital wouldn’t let me. They’d be like, dude, we don’t have room. We can’t do it.” And so, it doesn’t come into play in our practice, and maybe smaller hospitals, which have a lot of space and it doesn’t really make a difference. Yes, potentially, but in our practice it’s just not relevant. Which is also part of the reason, when people are saying… Whenever big studies come out, it’s not the I told you sos, but what happens is a big study comes out and within 15 minutes every expert in every society feels like they have to put this long-winded statement about it, and what is the conclusion? It’s like anything, and it’s frankly kind of annoying. It’s sort of like the race to be better. I’m going to get on this first, I’m going to get on this first, like I got this scoop.
But the problem is people make these recommendations like, “Oh, since it doesn’t increase the risk of C-section and since there was a slightly lower risk and no hypertension, I think everybody should be induced.” It’s like watching SportsCenter and someone’s like, “Oh, we got to trade this guy because they missed a free throw.” And it’s literally the same thing, but people don’t think that through. If we induce everyone, we can’t deliver anybody. We don’t have enough labor rooms in this country to do that. And so, these things have to be much more thoughtful in how to deal with new data.
So I want to talk a little bit about the limitations of the study before we talk about some of this issue about how this changed practice is important, but to talk about the limitations. So I’m interested, I can tell you for me, I think the most significant limitations on this study are, number one, the kind of low-risk women with their first child restriction and the question of whether that applies more broadly. And the second, is that the overall C-section rate in this cohort is really low relative to the US rate overall, and that makes me worried that this did not reflect the broader swath of the US population.
I agree that you can’t apply these numbers to higher-risk cohorts, but I would retort with two things. Number one, in the higher-risk cohorts, it seems to be the same. If you look at other higher-risk cohorts, it does not seem to increase the risk of C-section. And the only difference is that they may have a higher risk overall, whether they’re get induced or they wait. Meaning of, let’s say, it’s about 10% of the youngest, healthiest of patients, great. And if you take a different cohort, maybe it’s 20% ,and another one it might be 30%, but it does not seem to differ whether you induce them or wait. And that seems to be what the data shows. I think the biggest problem, not problem, but the biggest misinterpretation of this study is that this is what’s going to be everywhere in the country. Because this is, you’re talking about major academic medical centers with lots of resources, 24-hour OB residents and attendings, and anesthesiologists, and a lot of nurses, and they know they’re being studied so they’re doing their inductions very cautiously and patiently, sort of the quote right way.
But if you try to replicate this in every hospital in the US, there’s a lot more pressures. Like I said, what they’re like, “Dude, we are cramped with rooms.”
If they say, “You know what? People say inductions don’t increase the risk of C-sections, but I don’t buy it. I don’t know, I’m sectioning everybody by 4:00 or 5:00 PM the next day. 12 hours later, and so I haven’t found that”, then probably you’re getting a less patient form of an induction and maybe it will increase the risk for you. And I think that’s really the best way to sort this out on your own.
But the other thing that comes out, is people will now say, “My doctor told me that they always induce at 39 weeks, that is now standard practice.” Or people will say, “My doctor told me that ACOG recommends that everyone be induced at 39 weeks.” And some people don’t want that. And it was sort of interesting to hear your answer at the beginning about how isn’t you’re practicing, because there is a really, really important distinction between telling a patient there are some reasons to induce, and by the way, there isn’t this downside on the other side, and telling somebody we really, like ACOG is saying, you got to get the baby out or you might have a stillbirth, which is what some of these guys are hearing.
But if you sort look at things as black and white, okay, you could have one study that says, black and white, you shouldn’t be induced before 39 weeks with a reason. And another study that says black and white, you should be induced at 39 weeks, but you have to take everything and all of the data together into context. So I don’t think it’s unreasonable to say, “I think the best strategy is to induce everybody at 39 weeks because it does not increase the risk of C-section”, and because it might lower the risk or lower the risk of that. Okay, but that doesn’t mean it’s the right answer for everyone, because again, there’s logistical issues like we mentioned before. There are patient preference issues. I don’t want to be induced at 39 weeks, I don’t want to have a 24-hour labor. I want to wait and go into labor of my own A, so it’s shorter, B, because I think it’ll make my chance of needing an epidural lower, or C, because it’ll just make me feel more in touch with, whatever the reason is.
Those are all quite reasonable thought processes. And unless there’s some reason not to wait past 39 weeks, that should be an option. So what I tell people typically is any time between 39 and 41 weeks, and maybe for some people 42 weeks, is a reasonable time to be induced. And there’s benefits to going earlier, towards 39 weeks, and there’s benefits to waiting longer, towards 41 weeks. And unless there’s a real medical issue at hand, no one could say that one benefits are better than the other benefits.
And so I tell people, typically, again, unless there’s a reason to deliver earlier or for a specific time, I’m very comfortable 39 to 41 weeks. If you’re someone who wants to be done as soon as humanly possible, you don’t feel well, you’ve got people coming in town, whatever it is, you want to be delivered at 39 weeks, I’ll say, “Fine, if we can get a room. Just be prepared for long induction, God bless.” And if they want to wait till 41 weeks, the downside is well, you’re pregnant for two weeks more, you may not go into labor and you may end up with an induction anyways, and there’s small risks to you and to the baby, very slight. I don’t try to scare people or anything, but they are, there’s very small risks of waiting longer in pregnancy. And that’s it. And most people will tell you what they want, most people will show you their cards. It’s not that hard.
Obviously, I can’t force you to be induced, but I would be firm. I would say, “I think you’re making a mistake. Here is why.” And I would explain the reason why. But if you’re within a timeframe that I think is reasonable, like you said, well, I don’t want to be induced at 39 weeks, I want to wait until as close to possible as 41 weeks or go a little bit past, then my job is talk to you about the pluses and minuses and then let you make a choice. And that’s reasonable. And I think that a lot of either patients want something different ,or a lot of doctors do something different, where they’re on the one hand either too dogmatic and they just give people black and white, or they can’t make up their damn mind and people are left with like, “Well, you’re the doctor, what do you think?” Some people just won’t give an opinion, which I think is also a mistake.
It could happen at any point in pregnancy, but that risk is present if you’re still pregnant, and it’s absent if you’ve delivered. And so even though that risk is very, very small, fortunately, well less than 1%, it is on the table. And so for some people, they’re like, “Listen, everything’s good today, I want the baby out.” And again, that’s not unreasonable. It’s not a recommendation because the likelihood of something bad happening between 39 and 41 weeks is so low, especially if someone is monitoring how the baby’s moving or they come to the office, they have a test, whatever it is that they’re getting prenatal care in some capacity. The chance is so, so low that it’s not recommended that everybody has to be induced, but it is a potential risk.
And so for that reason, some people are more adamant about delivering at 39 weeks, just to make that minuscule risk a more minuscule risk. There’s also a risk of developing hypertension as you move on in pregnancy, like gestational hypertension, preeclampsia, that does not tend to be a life-threatening thing for the mother or baby if it’s, again, followed and watched and treated, and all these things. So the bigger driving force tends to be that possibility of stillbirth versus you’re not increasing the risk to the baby after birth, of things like prematurity.
But yes, people’s own fears and anxiety, sometimes it’s a cousin of mine had a stillbirth, right? So if a cousin of mine had a stillbirth, I’m not at increased risk of having a stillbirth, but it’s on my mind a lot more than someone who’s never really had that in their world, thank God. And so, people’s anxieties in general definitely play into that decision about when they want to deliver. I would say, for most people, it’s not pressing in their mind, fortunately. That would be very daunting to be pregnant if it’s always pressing in someone’s mind, but occasionally is, but that is sort of the risk, the unspoken risk, that people try not to say out loud too much. Because once you drop stillbirth during a prenatal visit, it changes everything afterwards. It’s very hard to talk about it but not talk about it at the same time.
And again, just like patients will tell you what they think, doctors and midwives will tell you what they think. We’re not secretive. Our personalities come out, our opinions come out, and you want to get a sense. Ideally, these conversations should happen early in pregnancy, not specifically about induction, but just in general, because you’ll get a sense, is this a person I trust. And if it’s a person I trust, then probably this conversation will be very easy because you’ll already have that rapport. If you’re not sure if you trust this person, that’s not a good place to be.
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