No time for complacency: labor inductions, cesarean deliveries, and the definition of "term".

Y ago, after a successful day in the operating room, a respected gynecology attending physician would often remind us residents, “This is no time for complacency. ” There were still potential hazards ahead: postoperative complications, uncertain longer term outcomes, the next week’s case. Complacency, defined by Webster’s dictionary as “self satisfaction especially when accompanied by unawareness of actual dangers or deficiencies,”1 is an understandable phenomenon in obstetrics and gynecology. In the field of obstetrics, modern surgical and anesthetic techniques and huge advances in neonatal care have reduced the perils of childbirth dramatically for women and their newborns. Maternal and neonatal outcomes are good in the vast majority of term (37–41 week) deliveries, whether vaginal or cesarean, whether labor is spontaneous or induced, whether delivery is indicated or elective, and whether it occurs at 37 or 40 weeks. A generalized, liberal view of the use of obstetric interventions and their appropriate timing is becoming apparent among both providers and patients. Inductions of labor have increased from 9.5% in 1990 to 22.5% in 2006,2 driven by a rise in elective inductions.3 Particularly in nulliparous women, induction of labor increases risk of cesarean delivery.3 The cesarean delivery rate in the United States has reached an all-time high of 32%,4 and the excess risks of maternal complications and neonatal respiratory morbidity associated with surgical delivery are well-documented. The average gestational age at birth has decreased to 39 weeks, and this is explained, in part, by lowered thresholds to effect delivery in late preterm pregnancies and an increase in deliveries between 37 and 39 weeks.5 Obstetric care providers may time an induction of labor or repeat cesarean delivery to balance patient-care responsibilities, accommodate patients’ schedules, or avoid the presumed legal risk of expectant management. Many women believe that delivering a few weeks early is just as safe as delivering on the projected due date6 and may request delivery for any number of reasons of comfort or convenience. However, we must remember that incautious use and timing of interventions—particularly in elective cases—can lead to unnecessarily poorer outcomes for women and newborns. In this issue, Ehrenthal and colleagues (see p. 35)7 report results of a retrospective study of more than 7,800 nulliparous women delivered at term (37 weeks or greater) in a single institution between 2003 and 2006. Their finding that cesarean delivery rates were approximately twofold higher in those women whose labor was induced compared with women with spontaneous labor is not particularly surprising. However, a number of pieces of information in this report are surprising—even alarming. In their institution during this timeframe, almost 44% of nulliparous women underwent labor induction, and 40% of these inductions were elective. Thirty-seven percent of elective inductions were in women with an unfavorable cervix. Even in a subsample of 4,623 low-risk nulliparas, 29.2% had induced labor (the proportion that were elective was not reported). CalculaSee related articles on pages 35 and 136.