ARRIVE trial results - elective induction of labor at 39 weeks

Specialties CNM

Published

You are reading page 2 of ARRIVE trial results - elective induction of labor at 39 weeks

Specializes in Nurse-Midwife.

Thanks for all your comments and perspectives.

I realize that I must be living in an area where induction practices have been modified to allow for longer onset of labor, diagnoses of 'failed induction' and stricter criteria for Bishop scores prior to initiating oxytocin. It is pretty uniformly practiced in my area that a nullip must have a Bishop of >10 before starting oxytocin. There are only a few providers that try to circumvent this - so yes, labors (well, cervical ripening) take a loooooooong time, but no one is put on a clock and sectioned after 24 or even 48 hours of ripening. That is just not happening. It is also more universally practiced in my local hospitals/medical centers to diagnose active labor at 6 cm dilatation, and not before. I haven't worked in a facility that worships the Friedman curve, or anything close to it. There's a random provider (physician) here and there who might be doing this - but they are usually in solo or private practice, kind of out there on their own, they are becoming few and far between.

I have to be careful to not assume that this is true elsewhere, because I'm hearing from many others that induction of labor is still in the dark ages in many places.

If I worked in a freestanding birth center I would probably not see any reason to change the way I practiced, either! Birth center clients are usually committed to natural, physiologic, spontaneous labor and birth - and very motivated to acheive that.

I work in a hospital-based practice, and have patients requesting inductions all the time. Our midwifery practice is not restricted to patients who only desire natural birth, so this creates a lot of diversity in desires for a labor and birth experience. The hospital system discourages elective IOL - in fact our guidlelines effectively prohibit it - no cervical ripening until 40+6. Medically indicated IOLs can be performed at various gestional ages based on clinical criteria.

For me, I want to accommodate choices that my patients make for themselves, based on shared decision making and informed consent. One of the hardest things for me to have learned is to accept and support choices made by my patients that I would not make for myself. Some of the choices they make come with increased risks, some with decreased risks, some just conflict with my own ideas of what an ideal birth experience is **for me**.

Example: I never wanted an epidural for labor - but I work with patients all the time who opt for epidurals, and are happy they made that choice for themselves. (There are patients who dislike the epidural experience, usually when it doesn't work, but that's a method failure in a way.) I'm delighted to work with patients who get the experience they want. Same with patients who want to give birth underwater, I'm happy to support that, if that is what they are opting for themselves. I induce patients with medical necessity, and I support the labor process and promote a positive labor and birth experience to the best of my ability when induction is indicated. I don't know any midwifery practice that functions in that old school 24-hours-to-birth after starting IOL - it seems that a midwifery managed IOL would result in lower cesearean rates, just as spontaneous labors do. (Maybe another study is indicated?)

I'm getting long-winded. Do any of you have patients requesting induction of labor by 39 weeks? How would you counsel them? I'm having a hard time not supporting this choice - it appears to not increase risk for cesarean birth. I really like that.

Also, I don't think swarms of women will be requesting elective IOL - only a few. And actually, after describing the risks and the process (this will take DAAAAAAYS), probably fewer. But right now I have no way to provide that option to any patient, due to institutional protocols against it.

Specializes in Nurse-Midwife.
I don't think it was that many hospitals. There are only about 6 or 8 NIH MFMU sites, and each site only recruits at one or two large hospitals, as far as I know.

I just looked it up, there are 12 MFMU sites, sorry.

"The multicenter ARRIVE study involved 6106 women who were randomly assigned in their 38th gestational week to induction or expectant management at 39 weeks, 0 to 4 days. The women, from 41 hospitals across the United States, were nulliparous with a live singleton fetus in vertex position in an uncomplicated pregnancy and without contraindications for a lady partsl delivery."

This is from a Medscape article regarding the ARRIVE study (where I could pull it up the most quickly).

klone, MSN, RN

14,790 Posts

Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

I stand corrected, thank you! When Denver was an MFMU site, they only worked at two hospitals (UCH and Denver Health). I erroneously assumed that's what they did everywhere.

Specializes in OB.
Also, I don't think swarms of women will be requesting elective IOL - only a few. And actually, after describing the risks and the process (this will take DAAAAAAYS), probably fewer. But right now I have no way to provide that option to any patient, due to institutional protocols against it.

I think that was another big takeaway from the study---that about 75% of the women who qualified for the study declined to enroll. Some perhaps just didn't like the idea of being in a study, period, but we can gather from that stat that a large number of women truly are not interested in elective IOL at 39 weeks.

I think that this study will do one main thing---it will give providers who already practice in an overly medicalized, interventive manner some fodder to continue doing so and defend their practices. I really don't think that any provider who is judicious with recommending IOL will suddenly be swayed enough by this so-so study to completely change their practice.

Specializes in Midwife, OBGYN.

Following this thread, but I was sent the following breakdown of the study from my birth workers group from Science and Sensibility helpful in understanding the overall aims and outcomes of the study itself. I think she does a good job of laying out the study.

Science & Sensibility : Blogs : Preventive Induction of Labor: Does Mother Nature Know Best? - Henci Goer Examines the ARRIVE Study

I especially like her quote at the end:

"Mother Nature is, indeed, a terrible obstetrician, but that's not a bad thing because she's a great midwife."

Specializes in Nurse-Midwife.

"Mother Nature is, indeed, a terrible obstetrician, but that's not a bad thing because she's a great midwife."

It seems like she's mixing metaphors a little bit. What do you think this means?

Specializes in Midwife, OBGYN.
"Mother Nature is, indeed, a terrible obstetrician, but that's not a bad thing because she's a great midwife."

It seems like she's mixing metaphors a little bit. What do you think this means?

In this context, I believe the author is referring to the fact that an OBGYN (though not all -there are of course more interventionist leaning midwives and more holistic OBGYNs, that depends on where they practice and who they had interactions with over the course of their training) generally has a more interventionist mindsent while a midwife goes with a more holistic approach to childbirth hence more in line with how Mother Nature approaches child birth, to allow childbirth to naturally run its course with the least amount of interference from us as providers.

Before i started midwifery school, one of my mentors who was a LPM told me to remember that as a midwife sometimes the best action that you can take is to do nothing and be patient to allow birth to progress in its own time.

But I do see what you are trying to say, if I were to put what the author said in my own words I would change the quote to say, "Mother Nature is not a obstetrician, she is by her nature, a great midwife instead."

+ Add a Comment