To Induce or Not To Induce-That Is the Question

A patient with group B strep presents requesting induction at 38 weeks. Three of her previous pregnancies resulted in precipitous delivery at or before 38 weeks. The patient expresses fears of possible intrapartum GBS fetal infection and other anxieties. While balancing possible inadequately treated GBS and uncontrolled precipitous delivery versus prematurity at 38 weeks, you believe your patient would be a candidate for early induction. The hospital’s quality improvement committee disagrees, and argues that your patient does not meet the requirements for exemption to the American Academy of Obstetricians and Gynecologist’s 39 week induction rule.

Should the patient in question be granted her request? Should the patient’s desires/fears play a role in making such a decision? How risky is induction at 38 weeks compared to risk of infection? And what, exactly, is the guideline for early induction?

This case was recently presented on OBGYN.net’s forum for medical professionals, and clinicians around the country shared their thoughts and clinical experience. But what does ACOG say about the 39 week rule and what are the real risks?

In 2009, ACOG revised its practice guideline as the rate of inductions performed in the United States rose to more than 22% of all pregnancies. Recognizing the need for inductions under certain circumstances as well as the need to keep the number of inductions in check, ACOG noted in the practice guidelines: “induction of labor has merit as a therapeutic option when the benefits of expeditious delivery outweigh the risks of continuing the pregnancy. The benefits of labor induction must be weighed against the potential maternal and fetal risks associated with this procedure.”

Although each patient and their specific circumstances are different and should be analyzed to make appropriate decisions, ACOG has compiled a list of maternal and fetal situations that would indicate need for performing inductions. These circumstances include:

• Abruptio placentae
• Chorioamnionitis
• Fetal demise
• Gestational hypertension
• Preeclampsia, eclampsia
• Premature rupture of membranes
• Postterm pregnancy
• Maternal medical conditions (eg, diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension, antiphospholipid syndrome)
• Fetal compromise (eg, severe fetal growth restriction, isoimmunization, oligohydramnios)

ACOG also acknowledges that some logistics may influence the need for induction, including patient’s distance to the hospital, risk of rapid labor, or psychosocial indications. It is important to note that ACOG has specifically stated that “a mature fetal lung maturity test result before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is not an indication for delivery.”

In weighing the “benefits of expeditious delivery” versus “the risks of continuing the pregnancy,” what does the data show? The Center for Disease Control notes that a pregnant woman who tests positive for group B strep and receives antibiotics during labor will only have a 1 in 4,000 chance that of delivering a baby with group B strep disease. Meanwhile, in a comment on the forum, a clinician posted a comparison of the risks associated with birth at 38 weeks as opposed to 39 weeks. According to research, he noted, babies born at 38 weeks have a great chance of having respiratory distress syndrome than those born at 39 weeks (5.5% versus 3.4%, respectively). Earlier induction also has been associated with increased NICU admissions, increased transient tachypnea of the newborn, and increased suspected or proven sepsis. The data seem to indicate that the benefits of earlier delivery in such a case may not outweigh the risks. However, as one clinician on the forum noted, medicine is as much an art as it is science, and to some extent, a clinician must follow their instincts and do what they believe will be right for that particular patient.

Ultimately, the doctor in this case chose to induce at 38 weeks, and both mother and baby were fine.

Further Reading:

Gyamfi-Bannerman C. The scope of the problem: the epidemiology of late preterm and early-term birth. Semin Perinatol. 2011 Oct;35(5):246-8.
Murthy K, Grobman WA, Lee TA, Holl JL. Trends in induction of labor at early-term gestation. Am J Obstet Gynecol. 2011 May;204(5):435.e1-6.
Ohnsorg T, Schiff J. Preventing elective induction before 39 weeks. Minn Med. 2010 Nov;93(11):44-6.
Spong CY, Mercer BM, D’alton M, et al. Timing of indicated late-preterm and early-term birth. Obstet Gynecol. 2011 Aug;118(2 Pt 1):323-33.
Tita AT, Landon MB, Spong CY, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med. 2009 Jan 8;360(2):111-20.

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