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Intrapartum interventions and outcomes for women and children following induction of labour at term in uncomplicated pregnancies: a 16-year population-based linked data study
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  • Published on:
    Due to selection bias, this study does not show a relationship between non-medical induction of labour at term and adverse outcomes
    • Bradley de Vries, Obstetrician and clinical researcher Sydney Institute for Women, Children and their Families

    I would like to congratulate Hannah Dahlen and colleagues on their recent publication in BMJ Open (1), particularly with respect to their follow-up of longer-term outcomes for infants born following induction of labour between 37 and 41 completed weeks gestational age compared with women who had a spontaneous onset of labour.
    Dahlen et al found that adverse maternal outcomes including caesarean section, instrumental birth, epidural use (potentially indicating a more painful and/or longer labour), episiotomy and post-partum haemorrhage were more common among women with an induced labour compared with women who went into spontaneous labour.
    They list absence of an intention-to-treat analysis as a weakness in the study design, but go on to say, “the data sources have a good track record of accuracy, so we do not believe these errors are likely to be large, or that they would have significantly influenced the direction of effect of the outcomes.”
    However, even if the data were perfectly accurate, the lack of intention-to-treat analysis causes a selection bias to an extent which makes it impossible to assess the impact of non-medically indicated induction of labour on maternal, neonatal, and child outcomes.
    In a randomised trial of planned induction of labour at a given gestational age, an intention-to-treat analysis will include all randomised women, including those who went on to have a later medically indicated induction of labour. Similarly, in an o...

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    Conflict of Interest:
    None declared.
  • Published on:
    Comments regarding the data and conclusions reached.
    • Kara E Thompson, Obstetrician and Gynaecologist .
    • Other Contributors:
      • Nisha Khot, Obstetrician and Gynaecologist

    Dear Professor Dahlen et al

    Thank you for your research regarding this retrospective population linked data in NSW.

    We wish to make a number of comments regarding the methods and conclusions reached.

    Firstly, the premise of retrospectively comparing birth outcomes for induction versus spontaneous labour at a particular gestation is an erroneous one. It is not possible to elect to go into spontaneous labour. The only option available to women is elect to have an induction at a certain gestation, or to continue with the pregnancy, i.e. expectant management. Expectant management may include the pregnancy going post-dates, requiring an IOL at a later gestation, or the development of complications that are known to increase beyond 40 weeks including preeclampsia, placental insufficiency, stillbirth and macrosomia.

    It is for this simple reason that prospective RCT data that compares IOL at 39-40 weeks versus expectant management demonstrate a clear reduction in the rate of caesarean section, third and fourth degree perineal tears, and a reduction in perinatal adverse outcomes.

    It is not possible with your data to make any comment regarding the outcomes of IOL for no medical reason versus expectant management. Given, in reality, this is the only choice that women are able to make, we do not believe that your conclusion, that women may have an increased rate of caesarean section and adverse outcomes if they elect for an IOL, is supported at all...

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    Conflict of Interest:
    None declared.