Kate Johnson

May 23, 2013

NEW ORLEANS, Louisiana — Policies restricting nonmedically indicated labor inductions are now in place in the majority of hospitals in the United States, and early signs are that they have the desired effect, according to several new studies.

"The national movement to eliminate non-medically indicated delivery at less than 39 weeks of gestation has prompted many hospitals to adopt specific policies against this practice," reported Nathaniel DeNicola, MD, from the University of Pennsylvania, in Philadelphia.

His survey, presented here at the American Congress of Obstetricians and Gynecologists (ACOG) 61st Annual Clinical Meeting, found that nearly two thirds of more than 2600 hospitals are on the bandwagon.

The majority, 67%, have a formal policy against nonmedically indicated labor induction, and among those without a formal policy, just over half said it was against their standard of care.

Dr. DeNicola found that 69% of formal hospital policies were hard-stop, meaning strictly enforced, as opposed to soft-stop or strongly discouraged.

"This represents a major step in promoting maternal and perinatal health," he said.

For Andrew Healy, MD, medical director of obstetrics at Baystate Medical Center, in Springfield, Massachusetts, the hard-stop policy has resulted in the expected, and even some unexpected, benefits.

This represents a major step in promoting maternal and perinatal health.

"Something we didn't even anticipate as a benefit of this policy, but was a delightful surprise to see, was a decreased admission rate to the neonatal intensive care unit," Dr. Healy told Medscape Medical News at the meeting.

Angela Silber, MD, director of maternal-fetal medicine at Summa Akron City Hospital, in Ohio, said she found a similar decrease in neonatal intensive care unit (NICU) admissions after a hard-stop policy was implemented at her hospital. "You have less of the early term admissions for things that are not life-threatening, but still disruptive of the neonatal period that will affect breast-feeding and maternal-neonatal bonding," she said in an interview.

Both Dr. Silber and Dr. Healy presented studies at the meeting showing a range of benefits from their hospitals' new hard-stop policies.

"Before we had a policy against elective induction, but it wasn't being enforced," explained Dr. Healy. "We were seeing our c-section rate go up and patients on labor and delivery being induced for 2 and 3 days. We have also had an increase in the number of accreta cases, which is abnormal placentation in women who have typically had multiple c-sections; so, we're really trying to keep our c-section rate down."

Hard-Stop Policy Better Than Soft-Stop

Dr. Healy's study comparing 9515 singleton births before the policy and 2641 singletons after the policy found a significant decrease of 5.9 hours in the median time to delivery (P = .002).

The cesarean section rate for elective inductions also decreased from 16% before the policy to 7% after (P = .05).

NICU admission rates decreased by a third, he said. "Before the policy, 3% of term babies got admitted to the NICU and after the policy that went down to 2%" (P = .02).

"We didn't see any increase in the stillbirth rate, which is reassuring to all of us," Dr. Healy added.

Dr. Silber's similar pre- and postpolicy comparison also found a decrease in stillbirths and NICU admissions at her hospital.

Comparing 9806 singleton deliveries before the policy and 6041 singletons after, the number of stillbirths decreased significantly from 16 to 3 ( P = .023), with a trend toward significance in the reduction of NICU admissions (from 867 to 587; P = .06).

There was no significant difference in macrosomia rates (P = .718).

Other data from the study, which has not yet been fully compiled, shows a decrease in cesarean sections as well as postpartum hemorrhage, she added.

"Previously it was seen as not detrimental to a baby to be born at 37 or 38 weeks," she said, citing reasons such as patient discomfort, physician anxiety, and convenience as reasons for inductions.

Now, she says, her hospital may actually extend its hard-stop policy further to include patients beyond 39 weeks if they have an unfavorable cervix.

"And we're even considering stopping elective inductions completely — it's just a matter of time."

The researchers from all 3 studies have disclosed no relevant financial relationships.

American Congress of Obstetricians and Gynecologists (ACOG) 61st Annual Clinical Meeting: Abstracts 42 and 50. Presented May 6, 2013, and Abstract 44. Presented May 7, 2013.


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