An American obstetrician has offered further insight into the results of the controversial ARRIVE Trial, which considered early induction of labour for healthy women. In a letter written to the American Journal of Obstetrics and Gynecology, Andrew Scialli, Clinical Professor of Obstetrics and Gynecology at George Washington University School of Medicine, offers the following thought:
“The studies in this area are limited by the expectant management group being managed by modern obstetricians, whose inclination for intervention may be higher than is optimal. Larger babies mean longer labors, which may tax the patience of the modern obstetricians, and preeclampsia is alarming to some practitioners who may not be willing to stabilize the patient and wait for the uterus to respond to oxytocin. As gestation advances, there may be less amniotic fluid with consequent benign variable decelerations that are over-interpreted as fetal hypoxemia.” (Scialli 2019).
What an important point, and one which illustrates how vital it is not just to look at the results of research but at the wider context of research and practice, as well as the way in which evidence is generated and the belief systems of those who undertake and participate in such research.
I have to declare a bit of a bias towards such a viewpoint here. I wrote something a bit similar in Inducing Labour: making informed decisions, where I noted that,
“just as Michel Odent once observed that all we could really learn from the Canadian term breech trial was that having “a breech birth in a conventional hospital and in the presence of an obstetrician is dangerous” (Odent 2003: 11), we might consider that the reviews which claimed to show that induction reduces the chance of caesarean teach us that awaiting spontaneous labour while in the care of an obstetrician may increase the risk of being advised to have a caesarean section, which may or may not have been genuinely warranted.” (Wickham 2018).
Scialli’s suggested solution was a careful review of why the caesareans were done, and this is not dissimilar to the work done by Menticoglou and Hall (2002) who questioned a policy of routine induction several years ago. It is clear that, while we need randomised controlled trials in order to evaluate the effects of an intervention, we need clear thinking and other types of analysis in order to put those results into a wider context and determine whether or not they have relevance for the individual woman in front of us. And then, it’s up to her to make the decision that is right for her.
Scialli happily claims to be an obstetrician of a certain vintage, and concludes by adding that, “The current high induction and cesarean rates in modern obstetrics have not given us better babies, and we would do well to be concerned about effects on maternal morbidity and mortality.” (Scialli 2019).
Thank goodness for those who can offer a wider perspective.
Menticoglou SM and Hall PF (2002). Routine induction of labour at 41 weeks gestation: nonsensus consensus. BJOG: An International Journal of Obstetrics and Gynaecology, 109(5): 485-91.
Scialli AR, Induction of Labor at Term, American Journal of Obstetrics and Gynecology (2019), doi: https://doi.org/10.1016/j.ajog.2019.04.006.