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Induction Triples the Risk for Cesareans in First-Time Moms
Here is the abstract of a recent study (Thorsell 2011) on how induction of labor increases cesarean rates, especially in first-time mothers with an unripe cervix.
This is yet another reason why the very high induction rate in women of size plays such a strong role in the higher cesarean rate in "obese" women.
[For example, in Abenhaim and Benjamin, 2011 about 50% of "morbidly obese" women were induced; double the 24% rate in "normal BMI" women. In addition, more than half of the "morbidly obese" women had a very unripe cervix (dilation of 2 or less) upon admission. Is a high cesarean rate in this group therefore any surprise?]
In the Thorsell 2011 study (abstract below), first-time mothers with an unripe cervix who were induced had a 42% c-section rate in labor. Yes, you read that correctly; nearly half ended up with a cesarean. After controlling for other factors, inducing labor in a first-time mother with an unripe cervix tripled her risk for a cesarean.
The effect was much less strong in multips, whose cesarean rate after induction was a more modest 14%. Yet, after controlling for variables, their risk was still nearly doubled. So while the total numerical rate was much lower in multips, the odds ratio was still considerably increased.
Of course, it's important to point out that induction, even in a first-time mother, results in more vaginal births than cesareans. If you are induced, it doesn't mean that a cesarean will automatically follow; you still have a reasonable chance for a vaginal birth, especially if your cervix is ripe first or if you've had a previous vaginal birth.
But the risk for cesarean is greatly increased when labor is induced, and especially so in a first-time mother whose cervix is not very ripe.
How many of these cesareans could be avoided just by being a little more patient?
And how many cesareans in women of size could be avoided by refraining from induction until the cervix is very ripe, or by awaiting spontaneous labor as much as possible?
Source
This is yet another reason why the very high induction rate in women of size plays such a strong role in the higher cesarean rate in "obese" women.
[For example, in Abenhaim and Benjamin, 2011 about 50% of "morbidly obese" women were induced; double the 24% rate in "normal BMI" women. In addition, more than half of the "morbidly obese" women had a very unripe cervix (dilation of 2 or less) upon admission. Is a high cesarean rate in this group therefore any surprise?]
In the Thorsell 2011 study (abstract below), first-time mothers with an unripe cervix who were induced had a 42% c-section rate in labor. Yes, you read that correctly; nearly half ended up with a cesarean. After controlling for other factors, inducing labor in a first-time mother with an unripe cervix tripled her risk for a cesarean.
The effect was much less strong in multips, whose cesarean rate after induction was a more modest 14%. Yet, after controlling for variables, their risk was still nearly doubled. So while the total numerical rate was much lower in multips, the odds ratio was still considerably increased.
Of course, it's important to point out that induction, even in a first-time mother, results in more vaginal births than cesareans. If you are induced, it doesn't mean that a cesarean will automatically follow; you still have a reasonable chance for a vaginal birth, especially if your cervix is ripe first or if you've had a previous vaginal birth.
But the risk for cesarean is greatly increased when labor is induced, and especially so in a first-time mother whose cervix is not very ripe.
How many of these cesareans could be avoided just by being a little more patient?
And how many cesareans in women of size could be avoided by refraining from induction until the cervix is very ripe, or by awaiting spontaneous labor as much as possible?
Acta Obstet Gynecol Scand. 2011 Jun 17. Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women. Thorsell M, Lyrenäs S, Andolf E, Kaijser M. PMID: 21679162
Source
Division of Obstetrics and Gynecology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden, and Clinical Epidemiology Unit, Department of Medicine at Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
Abstract
Objective. To assess the risk for emergency cesarean section among women who were induced to labor in gestational week ≥ 41 and to evaluate if parity and mode of induction affected this association.
Design. Hospital based retrospective cohort study.
Population: Singleton pregnancies delivered after ≥41 gestational weeks at Danderyd Hospital, Stockholm, Sweden during 2002-2006.
Material and Methods. Of 23 030 singleton pregnancies meeting the entry criteria, 881 were induced with Bishop score of < 7. Obstetric outcome was assessed through linkage with the Swedish Medical Birth Registry and a local obstetrical database containing information from patients' medical files. Results were adjusted for BMI, age and the use of epidural analgesia.
Main outcome measure. Risk for emergency cesarean section.
Results. Among women who were induced, the proportions delivered by emergency cesarean section were 42% for nulliparous and 14% for multiparous. Compared to spontaneous onset, this corresponded to a more than threefold increase in risk for nulliparous women (OR 3.34, 95% CI 2.77-4.04) and an almost twofold increase in risk for multiparous women (OR 1.94, 95% CI 1.24-3.02). There was no significant difference in risk for emergency cesarean section between the two methods of induction (PGE(2) and transcervical catheter).
Conclusion. Compared to spontaneous onset of delivery, induction of labor is associated with an increased risk for emergency cesarean section both among nulliparous and multiparous women. When labor is induced the high risk for emergency cesarean must be kept in mind.
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