Summary: In this video, Dr. Bobby Lazzara looks at the question of whether reducing term births before 39 weeks' gestation leads to a significant increase in the rate of stillbirths and how it may impact practice. Lazzara cites the following two sources in the video:

1. Nicholson, James M., et al. (2016), "US term stillbirth rates and the 39-week rule: a cause for concern?" American Journal of Obstetrics and Gynecology 214(5):621.e1-621.e9.

2. Lockwood, Charles J. (2016), "Fewer elective early term deliveries, more stillbirths?" Contemporary OB/GYN (Published online, 01 May 2016).

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Summary: This large, comprehensive, meta-analysis of 157 randomized controlled trials provides the most compelling evidence yet that induction of labor actually lowers the risk of cesarean delivery. In fact, the authors found that the use of induction vs. expectant management reduced the overall risk of term and postterm cesarean delivery by 12% for nearly every possible indication, including no indication, in both high and low risk pregnancies, and even in situations where cervical status was unfavorable. The study noted other benefits of induction, as well, including reduced risks of fetal death and admission to a neonatal intensive care unit. Induction was shown to have no impact on maternal death.
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Summary: This large review by USA physicians, funded by AHRQ, supports the concept that non-indicated (elective) term labor induction—when compared to expectant management to a later gestational age—might provide more benefit than harm. One of the main conclusions of this review was that non-indicated labor induction in the early-term and mid-term periods needs further study. Ideally, studies should be done using prospective randomized clinical trial (RCT) format.
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Summary: This paper suggests that delivery at 39 weeks' gestation, as compared to delivery in the 37th or 38th week, in both high and low risk pregnancies would result in an increased number of perinatal deaths. Decisions regarding the "optimal time for delivery" should include the risk of remaining undelivered beyond the early-term period.

Dr. Nicholson's Comments: This article has a surprising finding: the risk of term IUFD is lowest in the 37th and 38th week. Granted, this is a study of "what is" and its findings cannot be used to conclude that encouraging delivery in the 38th week of gestation would decrease either term stillbirth rates or perinatal mortality rates. However, it means that it is possible that the current campaign to restrict "non-indicated" labor induction might be increasing the incidence of term IUFD (stillbirth). Increases in the incidence of term stillbirth have been found in some retrospective studies (Ehrenthal et al. 2011, "Neonatal Outcomes After Implementation of Guidelines Limiting Elective Delivery Before 39 Weeks of Gestation"; Stock et al. 2012, "Outcomes of elective induction of labour compared with expectant management: population based study"), but not in others. This article should be a wake-up call of sorts, and should stimulate reconsideration of the current restrictions being placed on pre-39 week non-indicated labor induction. In addition, the article should stimulate the intentional study of the actual impact of pre-39 week non-indicated labor induction on birth outcomes. Perhaps the NICHD could generate a specific RFA. In any case, the AMOR-IPAT studies, and the approach discussed on this website, suggest that pre-39 week non-indicted risk-based labor induction might be beneficial. In light of this new study, the fact that published AMOR-IPAT articles, and most of the articles that support the potential benefit of non-indicated labor induction, are being ignored by the obstetrical community (MFM, ACOG), is unacceptable.
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Summary: This paper suggests that the use of non-indicated labor induction for impending macrosomia might lower risk of cesarean delivery.
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Summary: This paper suggests that the use of non-indicated labor induction might lower the risk of term stillbirth.
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Summary: This large review by Scottish physicians also suggested that non-indicated labor induction might be more beneficial than harmful.
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Summary: This paper indicates that a policy limiting elective delivery before 39 weeks of gestation was followed by changes in the timing of term deliveries. This was associated with a small reduction in NICU admissions; however, macrosomia and stillbirth increased.

Dr. Nicholson's Comments: In the setting of restriction of pre-39 week non-indicated labor induction, the rate of early-term still birth increased from 2.5 per 10,000 to 9.1 per 10,000. This increase means that some babies may have died that would not have died if the strict restrictions had not been put in place. The potential that this finding might reflect truth is very disturbing. Although rates of NICU admission decreased from 9.29% to 8.55%, these data include babies born after elective cesarean delivery. It is unlikely that if the analysis had been restricted only to labor induction situations that this difference would have been significant, and it is possible that the actual trend might have been reversed—i.e., that restricting early term labor induction might have led to an increase in term NICU admission in non-CS cases.
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Summary: This Letter to the Editor questions the efficacy of a recent proposal to subcategorize term pregnancy into three distinct categories based only on gestational age. The letter argues that doing so would provide an oversimplified construct for stratifying term pregnancy, and further warns that there is a chance that the proposed stratification, especially if combined with untested applications, may cause more harm than good.
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