Latest / Wellness, Actually with Emily Oster & Perry Wilson, MD / Choosing to Induce: How a randomized trial gave birth to a new era in obstetrics

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Choosing to Induce: How a randomized trial gave birth to a new era in obstetrics · Wellness, Actually with Emily Oster & Perry Wilson, MD

• 0:00
  Speaker 1: This is parent data. I'm Emily Oster.
• 0:04
  Speaker 2: One of the most common questions I get about the
• 0:06
  Speaker 2: end of pregnancy is whether it's a good idea to
• 0:09
  Speaker 2: have a labor.
• 0:09
  Speaker 1: Induction for those of you who are wondering.
• 0:14
  Speaker 3: What this is.
• 0:15
  Speaker 2: For many people at the end of pregnancy, they go
• 0:17
  Speaker 2: into labor on their own. That's called the spontaneous labor,
• 0:21
  Speaker 2: but sometimes it makes sense to induce labor, to encourage
• 0:25
  Speaker 2: labor to start using a combination of medications. Over the
• 0:30
  Speaker 2: past several years.
• 0:32
  Speaker 1: There has been a push towards more of these labor inductions.
• 0:37
  Speaker 2: And for many more people they are being offered or
• 0:41
  Speaker 2: even actively encouraged to induce labor at the end of
• 0:45
  Speaker 2: their pregnancy. For some people, this is really welcome. A
• 0:49
  Speaker 2: lot of the feelings of pregnancy are about giving up control,
• 0:52
  Speaker 2: but the possibility of having some of that control back,
• 0:55
  Speaker 2: at least for a little while, of being able to
• 0:57
  Speaker 2: pick when you have your birth, that seems appealing.
• 1:01
  Speaker 1: It's easier to plan around. But for other people this
• 1:05
  Speaker 1: isn't what they want.
• 1:06
  Speaker 2: They were thinking of their labor experience as something that
• 1:09
  Speaker 2: would start on its own, and being offered or strongly
• 1:14
  Speaker 2: encouraged towards an induction makes them uncomfortable. The reason this
• 1:19
  Speaker 2: has changed so much in the last few years is
• 1:22
  Speaker 2: because of something called the Arrived trial, which will explain
• 1:25
  Speaker 2: at much more length in this episode, But the most
• 1:29
  Speaker 2: important baseline thing to understand is that this is a
• 1:32
  Speaker 2: randomized controlled trial. It was designed to test whether labor
• 1:37
  Speaker 2: induction made c sections more likely. That was one of
• 1:41
  Speaker 2: the concerns about labor induction, and what the trial showed
• 1:44
  Speaker 2: is that it didn't. The group that had their labor
• 1:47
  Speaker 2: induced was no more likely to have C sections than
• 1:51
  Speaker 2: the group that didn't have their labor induced. And a
• 1:54
  Speaker 2: result of that is that many more providers became comfortable
• 1:59
  Speaker 2: with the idea of labor inductions. And as they became
• 2:03
  Speaker 2: more comfortable, we started to move towards a world in
• 2:05
  Speaker 2: which maybe everyone should have a labor induction. After all,
• 2:09
  Speaker 2: it's easier to plan, it's easier to schedule. This landscape,
• 2:13
  Speaker 2: this moving landscape, has caused a lot of tension, a
• 2:18
  Speaker 2: lot of discomfort for a lot of women.
• 2:21
  Speaker 1: And today I'm going to talk with doctor Nate Fox
• 2:25
  Speaker 1: about induction, about.
• 2:26
  Speaker 2: This trial, about what we should learn from this trial,
• 2:29
  Speaker 2: what we shouldn't learn from the trial, about the limits
• 2:32
  Speaker 2: of evidence in general, and also about how we bring
• 2:35
  Speaker 2: our own preferences to our care.
• 2:38
  Speaker 1: We talk about the risks of induction versus the risk of.
• 2:41
  Speaker 2: Waiting, and we really try to get into how people
• 2:44
  Speaker 2: can make this decision in the most informed way for themselves.
• 2:49
  Speaker 2: A quick note, Nate and I talk about ACOG, which
• 2:52
  Speaker 2: stands for the American College of Obstetrics and Gynecology.
• 2:56
  Speaker 1: Just to be clear on that one.
• 2:59
  Speaker 2: After the break, Doctor Nate Fox, Hello, Nate, Hey, welcome
• 3:19
  Speaker 2: to Parent Data.
• 3:20
  Speaker 1: Can I ask you to introduce yourself?
• 3:23
  Speaker 3: Yes, you can. Thanks thanks for having me. My name
• 3:25
  Speaker 3: is Nate or doctor Nathan Fox formerly, but that doesn't
• 3:30
  Speaker 3: usually happen. So I am. Let's see, I'm an obgyn
• 3:34
  Speaker 3: and maternal feedal medicine specialist. I am in practice in
• 3:38
  Speaker 3: New York City and I'm originally from the Midwest, which
• 3:42
  Speaker 3: explains my pleasant demeanor. And I live in New Jersey
• 3:46
  Speaker 3: with my wife and I have four children, some in
• 3:49
  Speaker 3: the house, some moved out of the house, and two dogs.
• 3:53
  Speaker 2: So you're also your most important job is you're my
• 3:55
  Speaker 2: co author on our book The Unexpected, which is coming
• 3:59
  Speaker 2: out at the end of April. Would you say that
• 4:01
  Speaker 2: your most is that your most important role?
• 4:04
  Speaker 3: It certainly appears to be the most impressive thing I've
• 4:07
  Speaker 3: done in the past several years if you ask anybody
• 4:09
  Speaker 3: in my life, so like, how the hell did you
• 4:11
  Speaker 3: get roped in with Emily Oster? But yeah, no, it's
• 4:13
  Speaker 3: been awesome. I'm very pleased to do that, and I'm
• 4:16
  Speaker 3: really excited about the book and it's going to be great.
• 4:18
  Speaker 1: I agree.
• 4:20
  Speaker 2: Okay, So today we're going to talk about the Arrived trial,
• 4:23
  Speaker 2: and I actually want to structure the way we're talking
• 4:25
  Speaker 2: about this and sort of before, during, and after, and
• 4:30
  Speaker 2: so to start with the before. So in the years
• 4:34
  Speaker 2: and really the decades before this trial, including when I
• 4:37
  Speaker 2: wrote Expecting Better, I think a lot of people saw
• 4:39
  Speaker 2: induction as part of what they would call the cascade
• 4:43
  Speaker 2: of interventions. I believe that phrase is from Ricky Lake.
• 4:47
  Speaker 3: And the great, the great philosopher rick the.
• 4:50
  Speaker 2: Great philosopher Ricky Lake, and the concern was that labor
• 4:54
  Speaker 2: induction would lead to a stalled labor, which would then
• 4:56
  Speaker 2: ultimately lead to a Cesarean section and from a day
• 5:00
  Speaker 2: at a standpoint, that conclusion, my senses was based on
• 5:03
  Speaker 2: the observation that people with induced labor are more likely
• 5:07
  Speaker 2: to have cesarean sections than those who start labor spontaneously. Obviously,
• 5:13
  Speaker 2: in a lot of cases there are underlying risk factors
• 5:15
  Speaker 2: which drive the decision to induce and make people more
• 5:17
  Speaker 2: likely to need a cesarean.
• 5:19
  Speaker 1: It's very difficult to draw a causal conclusion from that data.
• 5:23
  Speaker 2: So from your standpoint in this kind of pre arrived
• 5:26
  Speaker 2: frial period, how did you think about the consequences of
• 5:29
  Speaker 2: labor induction for C sections.
• 5:31
  Speaker 3: Yeah, it's it's a great question, and it's an interesting topic. Now,
• 5:36
  Speaker 3: it was certainly an interesting topic then, you know, I
• 5:40
  Speaker 3: when you mentioned the term cascade of events, it's it's
• 5:43
  Speaker 3: interesting because a lot of people use that term and
• 5:48
  Speaker 3: what they typically use it to mean as well, once
• 5:52
  Speaker 3: you go to a hospital or go to a doctor,
• 5:54
  Speaker 3: they're going to start doing this, and it's going to
• 5:56
  Speaker 3: lead to that, and it's going to lead to that
• 5:57
  Speaker 3: and ultimately it's going to lead to you know, world
• 6:00
  Speaker 3: destruction or something like that. But labor induction really wasn't
• 6:05
  Speaker 3: part of the cascade because it was really considered itself
• 6:10
  Speaker 3: something you really should not do. It wasn't like because
• 6:13
  Speaker 3: it'll lead to A to B to C. It was like,
• 6:15
  Speaker 3: you should not induce, and during my training and during
• 6:19
  Speaker 3: the beginning part of my practice, the tenant was that
• 6:22
  Speaker 3: we know that if you induce someone's labor, you are
• 6:26
  Speaker 3: going to increase their chance of a cesarean delivery, Like
• 6:29
  Speaker 3: that is the biggest downside.
• 6:32
  Speaker 2: Just to be that was something where it was like,
• 6:34
  Speaker 2: we know that's true. That's something we accept as part
• 6:36
  Speaker 2: of our or at least we think is true.
• 6:39
  Speaker 3: Well, that's what was taught. I disagreed at the time.
• 6:42
  Speaker 3: I'll explain why, and I think that I've been vindicated.
• 6:46
  Speaker 3: But that's what we were taught. That was in the textbooks.
• 6:49
  Speaker 3: That was what you were taught first day of your
• 6:51
  Speaker 3: first you know, internship, Like if you induce labor, you're
• 6:54
  Speaker 3: increasing the risk of C section. That was the biggest downside,
• 6:57
  Speaker 3: and then the other downsides you know, in terms of
• 7:00
  Speaker 3: patient experience, it's going to take longer, which are all true. Fine,
• 7:03
  Speaker 3: but the problem was, and this was a problem at
• 7:06
  Speaker 3: the time, the data was poor or limited, and the
• 7:11
  Speaker 3: reason the day was limited is basically what they did
• 7:14
  Speaker 3: is imagine if I went onto the labor floor and
• 7:16
  Speaker 3: we have a labor board of let's say twenty patients
• 7:19
  Speaker 3: are in labor and I say, all right, patients one
• 7:22
  Speaker 3: through ten, just so you know, all showed up in
• 7:25
  Speaker 3: spontaneous labor, and patients eleven through twenty are here because
• 7:29
  Speaker 3: they're getting induced. It is true that patients eleven through
• 7:33
  Speaker 3: twenty had a higher rate of sea section than patients
• 7:37
  Speaker 3: one through ten. And so the conclusion people made is okay,
• 7:41
  Speaker 3: people who are getting induced have a higher rate of
• 7:44
  Speaker 3: sea section than those who come in spontaneous labor. True statement.
• 7:49
  Speaker 3: The problem is clinically, if I'm seeing someone and making
• 7:53
  Speaker 3: a decision about whether to induce them or not, the
• 7:56
  Speaker 3: alternative to being induced is not you shall be in labor,
• 8:00
  Speaker 3: it is go home, right, And so we don't really
• 8:04
  Speaker 3: have an opportunity clinically to decide whether someone should be
• 8:08
  Speaker 3: induced or be in labor. We have a decision whether
• 8:11
  Speaker 3: to induce them or not induce them, which means I'm
• 8:14
  Speaker 3: going to send you home and come back when you're
• 8:17
  Speaker 3: labor or in a week or whatever. And so that
• 8:20
  Speaker 3: was not advertised as part of the conclusion that induction.
• 8:25
  Speaker 2: Increases the risk of labor and sonate just to pause
• 8:29
  Speaker 2: on that, what are the kinds of things that would
• 8:32
  Speaker 2: make you want to induce.
• 8:34
  Speaker 1: Versus weight right.
• 8:35
  Speaker 3: So basically, since there was this idea that if you
• 8:39
  Speaker 3: induce labor, you're increasing the risk of sea section, we
• 8:42
  Speaker 3: would always weigh the benefits of induction versus this risk
• 8:48
  Speaker 3: of sea section. So, for example, if I was worried
• 8:50
  Speaker 3: about an increased risk of stillbirth, or if I was
• 8:53
  Speaker 3: worried about the mother having an infection, or if I
• 8:56
  Speaker 3: was worried because her blood pressure is going up and
• 8:59
  Speaker 3: she may or not aclamsey, which is unsafe. So we're balancing,
• 9:01
  Speaker 3: all right, the risk of inducing which is c section,
• 9:06
  Speaker 3: versus the risk of not inducing or staying pregnant, which
• 9:10
  Speaker 3: could be something bad to the mother or baby. And
• 9:12
  Speaker 3: based on the specifics of the situation or the condition,
• 9:16
  Speaker 3: we make a decision, all right, we should induce, we
• 9:18
  Speaker 3: shouldn't induce, Will we wait longer, will we not wait longer?
• 9:21
  Speaker 3: And that's sort of that's how we did it then.
• 9:23
  Speaker 3: But people started to question that basic fact that c
• 9:29
  Speaker 3: section is increased by being induced. And the first way
• 9:32
  Speaker 3: they did it is they went back and looked at
• 9:34
  Speaker 3: the same data that they used to conclude that induction
• 9:38
  Speaker 3: increases the risk of sea section, but they looked at
• 9:41
  Speaker 3: it differently. Instead of looking at women who are in
• 9:44
  Speaker 3: labor versus induced. They looked at like a week earlier,
• 9:48
  Speaker 3: people who were induced versus people told to go home,
• 9:51
  Speaker 3: and when they did it again retrospective, observational. Even in
• 9:55
  Speaker 3: those studies, when they re examined it in a way
• 9:57
  Speaker 3: that makes more sense clinically, they saw no difference in
• 10:02
  Speaker 3: the rate of sea section between the groups. And that's
• 10:05
  Speaker 3: actually what prompted the arrived trial. They said, whoa wait
• 10:08
  Speaker 3: a second, when we look at the data in a
• 10:11
  Speaker 3: more logical way or a more clinical way, this may
• 10:17
  Speaker 3: be wrong. We may have been telling people the wrong
• 10:19
  Speaker 3: thing for all these years. We need to do this
• 10:22
  Speaker 3: in a really well designed prospective trial, and that's what
• 10:25
  Speaker 3: led to the arrived trial.
• 10:28
  Speaker 1: So we're going to get the arrived trial in a second.
• 10:31
  Speaker 2: Yeah, but just to like to sort of put a
• 10:35
  Speaker 2: fine point on why this initial data is not good
• 10:38
  Speaker 2: or is not necessarily compelling.
• 10:41
  Speaker 1: It is this issue of you know, you.
• 10:44
  Speaker 2: Mentioned, you know, preclamsya, stillbirth risks, infection risks are characteristics
• 10:49
  Speaker 2: that would push you to say, hey, let's induce now.
• 10:51
  Speaker 1: Let's not wait, let's induce now.
• 10:54
  Speaker 2: Those are characteristics which themselves lead to a higher risk
• 10:58
  Speaker 2: of sea section, for I would guess a bunch of reasons.
• 11:00
  Speaker 2: For example, if labor starts to go get a little
• 11:03
  Speaker 2: more complicated, you're going to be more likely to pull
• 11:05
  Speaker 2: the trigger on a C section because you're worried about
• 11:08
  Speaker 2: other risks or worried about other aspects of the baby.
• 11:11
  Speaker 1: Is that basically these.
• 11:13
  Speaker 3: Issues potentially, I mean, it's sort of you know, when
• 11:17
  Speaker 3: you have a situation where there's concern like preclamcyr or
• 11:21
  Speaker 3: something like that, the reason to induce is not because
• 11:26
  Speaker 3: I want to lower the risk of a sea section, though,
• 11:28
  Speaker 3: it's because I want to lower the risk to the
• 11:30
  Speaker 3: mother and baby. So we say, even if it does
• 11:33
  Speaker 3: increase increase the risk of sea section, we're willing to
• 11:36
  Speaker 3: take that risk because we're helping the other baby. But yes,
• 11:38
  Speaker 3: it is possible that, in fact, it would lower the
• 11:41
  Speaker 3: risk of sea section because we don't know what's going
• 11:42
  Speaker 3: to happen, because no one tends to wait on those patients.
• 11:45
  Speaker 3: But they did start to chip away at this idea
• 11:49
  Speaker 3: of induction increases the risk of sea section, and they
• 11:52
  Speaker 3: did it in sort of subsets, like women with ruptured membranes.
• 11:56
  Speaker 3: There's old, old data that you induce them you don't
• 11:59
  Speaker 3: increase the risk. Then they did it for women who
• 12:01
  Speaker 3: had hypertension, and the same thing. If you induce them,
• 12:04
  Speaker 3: you don't increase the risk. Then they did it for
• 12:05
  Speaker 3: women who are over thirty five, and if you induce them,
• 12:08
  Speaker 3: you don't increase the risk. Meaning there was more and
• 12:10
  Speaker 3: more mounting evidence, at least in smaller populations that maybe
• 12:14
  Speaker 3: this is incorrect. And the reason you would want to
• 12:19
  Speaker 3: know that is number one, just in terms of counseling,
• 12:23
  Speaker 3: and number two, it may change, It may tip the scales,
• 12:27
  Speaker 3: You may need less of a risk of waiting to
• 12:31
  Speaker 3: push you over the edge to induce if you're not
• 12:33
  Speaker 3: worried about the risk of induction, maybe even to the
• 12:36
  Speaker 3: point and I'm not suggesting that you need to do this,
• 12:39
  Speaker 3: but maybe to the point that you should just induce everyone, Right,
• 12:41
  Speaker 3: I mean, that's sort of the possible conclusion from something
• 12:44
  Speaker 3: like this.
• 12:45
  Speaker 2: Yeah, okay, so then we sort of have this kind
• 12:48
  Speaker 2: of suggestive evidence, which the way that I would frame
• 12:51
  Speaker 2: it is, you know, once you limit to people where
• 12:53
  Speaker 2: you know the reason for induction, and the reason for
• 12:55
  Speaker 2: induction isn't something that itself would lead to a risk
• 12:58
  Speaker 2: of CEA section, then you're start to get evidence that
• 13:02
  Speaker 2: it doesn't.
• 13:02
  Speaker 3: Matter or or in general again even in the general population,
• 13:07
  Speaker 3: because they looked at people who are induced electively. And
• 13:10
  Speaker 3: also this is really also talking about first time moms,
• 13:14
  Speaker 3: meaning even back then, way back when, before the arrived trial,
• 13:17
  Speaker 3: if you're taking someone who's already had a baby vaginally, yes,
• 13:22
  Speaker 3: inducing might increase the risk of a sea section, but
• 13:24
  Speaker 3: only by like a couple of percent points, not by
• 13:27
  Speaker 3: a really massive difference.
• 13:29
  Speaker 2: Once you have already had a vaginal birth, it's all
• 13:31
  Speaker 2: like it's all loosened up, so it's just you know,
• 13:33
  Speaker 2: it just slips right out.
• 13:34
  Speaker 3: That's it just walks right out.
• 13:36
  Speaker 1: It was just like they're basically okay, all right. So
• 13:39
  Speaker 1: then we come to the arrived trial. So this is
• 13:42
  Speaker 1: a trial.
• 13:43
  Speaker 2: A large randomized general trial was published in the New
• 13:46
  Speaker 2: England Journal Medicine in twenty eighteen.
• 13:48
  Speaker 1: The aim in this trial is.
• 13:50
  Speaker 2: To evaluate whether routine labor induction at thirty nine weeks
• 13:53
  Speaker 2: of pregnancy makes a sea section more likely. The trial
• 13:57
  Speaker 2: includes about six thousand low risk women having their first
• 14:01
  Speaker 2: child and it randomized them into either induction at thirty
• 14:04
  Speaker 2: nine weeks or expectant management, which is just another word
• 14:08
  Speaker 2: for just sending.
• 14:08
  Speaker 1: Them home and waiting.
• 14:11
  Speaker 2: They actually, of course, like as always at a trial
• 14:13
  Speaker 2: like this, they weren't forced to make the choice they
• 14:15
  Speaker 2: were randomized into. But in the end, because of this encouragement,
• 14:19
  Speaker 2: groups did have very different induction.
• 14:21
  Speaker 1: Rates and the results.
• 14:23
  Speaker 2: What the authors find is that infant outcomes is very
• 14:26
  Speaker 2: similar in both groups, and if anything, there is a
• 14:28
  Speaker 2: slightly lower C section rate in the group that was induced.
• 14:31
  Speaker 1: So both groups.
• 14:32
  Speaker 2: Are actually very low, which we'll come back to. It's
• 14:35
  Speaker 2: about eight to eleven percent of birth star c sections.
• 14:38
  Speaker 2: That's relative to a US rate of about thirty percent.
• 14:41
  Speaker 2: But on face value, this trial really puts a wrench
• 14:46
  Speaker 2: into the idea that labor inductions increase the risk of
• 14:51
  Speaker 2: sea sections.
• 14:52
  Speaker 1: So when this came out, did you just say, I
• 14:55
  Speaker 1: told you so.
• 14:58
  Speaker 3: I'm not a big I told you so guy. But
• 15:00
  Speaker 3: it was definitely yeah, you would think I am no.
• 15:04
  Speaker 3: I mean, you know, it was even even to those
• 15:08
  Speaker 3: of us who were sort of questioning that idea. I
• 15:13
  Speaker 3: think a lot of us were still surprised how much
• 15:16
  Speaker 3: it really didn't seem to matter. And like you said,
• 15:19
  Speaker 3: maybe a slightly lower risk in the group that got induced.
• 15:22
  Speaker 1: I don't pretty it's a small difference.
• 15:24
  Speaker 3: Yeah, I don't make too much of that. As expected,
• 15:28
  Speaker 3: the group that got induced had a slightly lower risk
• 15:30
  Speaker 3: of getting hypertension because as you wait longer in pregnancy,
• 15:34
  Speaker 3: that risk goes up. So that was not a surprise,
• 15:37
  Speaker 3: But the fact that it really did not impact C
• 15:40
  Speaker 3: section rates was. It was definitely surprising to like everybody,
• 15:45
  Speaker 3: but even those of us who are knee deep in
• 15:46
  Speaker 3: it already were still a little bit like, oh, pretty cool.
• 15:50
  Speaker 3: It was a very impressive study and it absolutely changed
• 15:56
  Speaker 3: the way a lot of people think about induction. I
• 15:59
  Speaker 3: think correct, it changed the way I'm sure we'll discuss it.
• 16:03
  Speaker 3: I think some people might go a little too far
• 16:05
  Speaker 3: with this, but whatever, it was impressive. It is impressive.
• 16:09
  Speaker 2: So let me ask you for you, and then I
• 16:11
  Speaker 2: want to talk about the more general question. But for you,
• 16:13
  Speaker 2: did this change how you advise people? Did it change
• 16:16
  Speaker 2: your clinical practice?
• 16:18
  Speaker 4: So?
• 16:19
  Speaker 3: Yes, and no, it didn't ultimately change my clinical practice
• 16:23
  Speaker 3: because before the arrived trial I was talking to people
• 16:29
  Speaker 3: about risk and benefits of induction versus you know, expect
• 16:33
  Speaker 3: to management. But ultimately, since the only reason we would
• 16:37
  Speaker 3: really induce people is because of a medical indication. It
• 16:44
  Speaker 3: didn't really make a big difference, right, we were already
• 16:47
  Speaker 3: inducing people who needed to be induced. The people who
• 16:49
  Speaker 3: it really affects are people who are thinking about what
• 16:51
  Speaker 3: we call elective inductions, like just getting induced because I
• 16:55
  Speaker 3: don't want to be pregnant anymore, which is God bless.
• 16:57
  Speaker 3: That's a very reasonable feeling to have. But whether it's
• 17:01
  Speaker 3: a problem to induce for that reason that was a
• 17:03
  Speaker 3: real question. So we weren't doing a ton of that
• 17:05
  Speaker 3: in my practice to begin with, and so we didn't.
• 17:08
  Speaker 3: Really it didn't really impact us. The main thing after
• 17:11
  Speaker 3: the arrived trial, I would say, is it really made
• 17:15
  Speaker 3: conversations about induction easier. Because it used to be I
• 17:20
  Speaker 3: would say, listen, we're going to induce you. I hope
• 17:24
  Speaker 3: it doesn't increase your risk of sea section. But even
• 17:26
  Speaker 3: if it does, listen, we really got to do it
• 17:28
  Speaker 3: because of this concern or that concern, or this reason
• 17:32
  Speaker 3: or that reason. But now I can tell people I
• 17:36
  Speaker 3: think you should be induced because of this reason or
• 17:39
  Speaker 3: this reason and this reason, and just so you know,
• 17:42
  Speaker 3: this really should not increase your risk of a sea section.
• 17:45
  Speaker 3: And that makes it much more palatable for people on
• 17:49
  Speaker 3: the receiving ends of that kind of counsel link.
• 17:51
  Speaker 2: So it's interesting because I do want to when we
• 17:53
  Speaker 2: talk about sort of how this has changed practice, I
• 17:56
  Speaker 2: actually really want to dive into this elective induction because
• 17:59
  Speaker 2: it sounds, for from your standpoint, like that's just.
• 18:01
  Speaker 1: Not something you do much of that you basically, yeah.
• 18:04
  Speaker 2: That's not a big part of your clinical practice right
• 18:06
  Speaker 2: now or before or after.
• 18:08
  Speaker 3: So I don't I don't have a problem with it,
• 18:10
  Speaker 3: and certainly I would be okay doing it. Like if
• 18:13
  Speaker 3: someone said I'm thirty nine weeks or I'm forty weeks
• 18:16
  Speaker 3: and I want to be induced because you know, I'm done,
• 18:18
  Speaker 3: or whatever it is. I think it's fine that the
• 18:21
  Speaker 3: problem is from a data standpoint, you can justify it again,
• 18:26
  Speaker 3: and you may be able to justify it on everybody
• 18:28
  Speaker 3: if someone's as well, you know, why not induced they
• 18:31
  Speaker 3: don't have hypertension, maybe there's a slightly lower risk ascese section.
• 18:34
  Speaker 3: Like I get it. But the problem is practically, when
• 18:37
  Speaker 3: you induce someone's labor, they're in a labor room for
• 18:41
  Speaker 3: a very long time, and so we just don't have
• 18:44
  Speaker 3: like the space for that. You know, our labor floor
• 18:46
  Speaker 3: is x amount of labor rooms and if the average
• 18:49
  Speaker 3: time of an induction for a first baby is about
• 18:53
  Speaker 3: eighteen hours, somewhere between twelve and twenty four and so
• 18:56
  Speaker 3: someone's in a labor room for twelve to twenty four
• 18:59
  Speaker 3: hours versus someone who comes in and labor on their own,
• 19:02
  Speaker 3: and the average time in a room is six hours,
• 19:04
  Speaker 3: you're gonna need fo you know, three to four times
• 19:07
  Speaker 3: as many rooms to deliver the same number of people.
• 19:10
  Speaker 3: And so even if I wanted to induce everyone electively
• 19:13
  Speaker 3: thirty nine weeks, my hospital wouldn't let me. They'd be dude,
• 19:16
  Speaker 3: we don't have room, like, we can't do it. And
• 19:18
  Speaker 3: so it doesn't it doesn't come into play in our practice,
• 19:22
  Speaker 3: and maybe smaller hospitals which are have a lot of space,
• 19:25
  Speaker 3: and it doesn't really make a difference. Yes, potentially, but
• 19:29
  Speaker 3: in our practice it's just not relevant, which is also
• 19:32
  Speaker 3: part of the reason when people are saying, you know,
• 19:34
  Speaker 3: whatever big studies come out, it's not the I told
• 19:37
  Speaker 3: you so is. But what happens is a big study
• 19:39
  Speaker 3: comes out and within like fifteen minutes, every expert in
• 19:43
  Speaker 3: every society feels like they have to put this like
• 19:45
  Speaker 3: long winded statement about it, and like, what is the conclusion.
• 19:48
  Speaker 3: It's it's like anything, and it's it's frankly kind of annoying,
• 19:51
  Speaker 3: and you know, it's sort of like the race to
• 19:54
  Speaker 3: like be better. You know, I'm gonna get on this first.
• 19:56
  Speaker 3: I'm gonna get on this first, Like I got the scoop.
• 19:58
  Speaker 3: But the problem is people make these recommendations like, oh,
• 20:01
  Speaker 3: you know, since it doesn't increase the risk of se
• 20:03
  Speaker 3: section and since there was a slightly lower risk and
• 20:05
  Speaker 3: no hype pretension, I think everybody should be induced. You know.
• 20:08
  Speaker 3: It's like watching you know, it's like watching Sports Center,
• 20:11
  Speaker 3: you know, and someone's saying, oh, we got to trade
• 20:13
  Speaker 3: this guy because they missed a free throw, and it's
• 20:15
  Speaker 3: it's literally the same thing. But people don't think that through.
• 20:17
  Speaker 3: Like if we induce everyone, we can't deliver anybody. We
• 20:21
  Speaker 3: don't have enough labor rooms in this country to do that,
• 20:23
  Speaker 3: and so these things have to be much more thoughtful
• 20:26
  Speaker 3: and how to you know, how to deal with new data.
• 20:29
  Speaker 2: I just want to say that with my second kid,
• 20:31
  Speaker 2: I had the baby twenty three minutes after arriving at
• 20:35
  Speaker 2: the hospital, So I feel like I was really efficient
• 20:38
  Speaker 2: in my use of the labor.
• 20:39
  Speaker 3: You should get a discount I should get a DIF
• 20:41
  Speaker 3: like a rebate.
• 20:41
  Speaker 1: I want. I want my baby rebate.
• 20:43
  Speaker 2: Yeah, all I got was this baby and it's no
• 20:46
  Speaker 2: rebates at all. So I want to talk a little
• 20:49
  Speaker 2: bit about the limitations of the study before we talk
• 20:52
  Speaker 2: about some of this issue about how it's changed practice important,
• 20:56
  Speaker 2: but to talk about the limitations, so I'm interested. I
• 20:59
  Speaker 2: can tell you for I think the most significant limitations
• 21:02
  Speaker 2: on this study are number one, the kind of low
• 21:05
  Speaker 2: risk women with their first child restriction and the question
• 21:09
  Speaker 2: of whether that applies more broadly.
• 21:11
  Speaker 1: And the second is.
• 21:12
  Speaker 2: That the overall C section rate in this cohort is
• 21:16
  Speaker 2: really low relative to the US rate overall, and that
• 21:20
  Speaker 2: makes me worried that this did not reflect the broader
• 21:24
  Speaker 2: swath of the US population.
• 21:26
  Speaker 3: So you are definitely correct across the board, as you
• 21:31
  Speaker 3: often are. I don't think that ends up being the
• 21:34
  Speaker 3: biggest issue with this study, though, because the low risk
• 21:39
  Speaker 3: women are the ones who we were most concerned about
• 21:42
  Speaker 3: increasing their risk of sea section. Right, So someone's young
• 21:46
  Speaker 3: and healthy and fit and their pregnancy is going great,
• 21:48
  Speaker 3: You're like, hey, you should have the lowest risk of
• 21:50
  Speaker 3: sea section out of anybody. Again, amongst people having their
• 21:53
  Speaker 3: first baby, And so the fear is if I just
• 21:56
  Speaker 3: induce you, maybe I'm going to screw that up, you know,
• 21:58
  Speaker 3: and double your risk of sea sect or something like that.
• 22:01
  Speaker 3: And so I think this study did show that that
• 22:05
  Speaker 3: does not seem to be the case. Meaning, if you
• 22:07
  Speaker 3: are young, low risk, healthy, all these things, it probably
• 22:11
  Speaker 3: does not make a big difference whether you get induced
• 22:13
  Speaker 3: or wait to go into libor on your own. I
• 22:15
  Speaker 3: agree that you can't apply these numbers to higher risk cohorts,
• 22:20
  Speaker 3: but I would retort with two things. Number one, in
• 22:27
  Speaker 3: the higher risk cohorts, it seems to be the same
• 22:30
  Speaker 3: like if you look at other high risk cours, does
• 22:32
  Speaker 3: not seem to increase the risk a seay section. And
• 22:35
  Speaker 3: the only difference is that they may have a higher
• 22:38
  Speaker 3: risk overall whether they get induced or they wait. Meaning
• 22:42
  Speaker 3: of let's say it's about ten percent to the youngest
• 22:44
  Speaker 3: healthiest of patients. Great, and if you take a different court,
• 22:47
  Speaker 3: maybe it's twenty percent, and another one it might be
• 22:50
  Speaker 3: thirty percent. But it does not seem to differ whether
• 22:53
  Speaker 3: you induce them or wait. And that seems to be
• 22:56
  Speaker 3: what the data shows. I think the biggest problem, not problem,
• 23:00
  Speaker 3: but the biggest uh mis interpretation of this study is
• 23:04
  Speaker 3: that this is what's going to be everywhere in the country,
• 23:07
  Speaker 3: because this is you're talking about major academic medical centers
• 23:11
  Speaker 3: with lots of resources, twenty four hour ob residents and
• 23:15
  Speaker 3: attendings and antithesiologists and one you know, and you know
• 23:19
  Speaker 3: a lot of nurses and they know they're being studied,
• 23:22
  Speaker 3: so they're doing their inductions very cautiously and patiently sort
• 23:25
  Speaker 3: of the quote unquote right way. But if you try
• 23:28
  Speaker 3: to like replicate this in every hospital in the US,
• 23:32
  Speaker 3: there's a lot more pressures. Like I said, what if
• 23:34
  Speaker 3: they're like, dude, we are we are cramped with rooms
• 23:37
  Speaker 3: out of Yeah you got like yeah, like move it
• 23:39
  Speaker 3: like move it along, section your patient get or delivered,
• 23:42
  Speaker 3: whatever it is. We got three people waiting for a room.
• 23:45
  Speaker 3: And those are legitimate pressures. And some of them are
• 23:48
  Speaker 3: just doctors practice differently, or nurses practice differently, or patients
• 23:52
  Speaker 3: have different desires. Maybe some of them are sort of
• 23:54
  Speaker 3: only half heartedly in on the induction versus that, and
• 23:58
  Speaker 3: so in practice, those C section rates are not replicated.
• 24:04
  Speaker 3: But it does not mean that inducing increases the risk ever.
• 24:08
  Speaker 3: Else It just means people might not be following the
• 24:10
  Speaker 3: protocol the exact same way they did it, right.
• 24:13
  Speaker 1: Yeah, I mean, I think that's in some ways, that's
• 24:15
  Speaker 1: a little bit.
• 24:16
  Speaker 2: Of an academic distinction, because from the standpoint of a patient,
• 24:19
  Speaker 2: the question is if I have this induction, will it
• 24:21
  Speaker 2: increase my risk of C section? And there's a there's
• 24:24
  Speaker 2: a kind of mechanistic question which is like would it
• 24:26
  Speaker 2: have to as done perfectly?
• 24:28
  Speaker 1: And they think that this trial says is no. And
• 24:31
  Speaker 1: then there's a question of might it in the real.
• 24:33
  Speaker 2: World because you know, they're running out of rooms and
• 24:36
  Speaker 2: and you know, we know that inductions are slower and
• 24:39
  Speaker 2: that you need patients. I don't know if you're somebody
• 24:43
  Speaker 2: told me, like, bring a long book was their main advice.
• 24:46
  Speaker 1: I don't know if that was you.
• 24:47
  Speaker 3: I never, I never, not until I wrote books, did
• 24:49
  Speaker 3: I ever tell people to bring a book.
• 24:51
  Speaker 2: I bring a charger, charger, bring an iPad, a charger
• 24:55
  Speaker 2: and a lot bring a charger. But I think, I mean,
• 24:57
  Speaker 2: I think that is important because it from the standpoint
• 25:00
  Speaker 2: the patient, if you want to ask the question, will
• 25:02
  Speaker 2: being induced to increase my risk of sease? Actually, you
• 25:04
  Speaker 2: do want to think about, you know, does the place
• 25:06
  Speaker 2: that I'm doing this have the capacity to wait, to
• 25:09
  Speaker 2: have the capacity to like have me there for twenty
• 25:11
  Speaker 2: four hours, and that's part of the mechanism and something
• 25:14
  Speaker 2: that doesn't show up much in the trial for a
• 25:16
  Speaker 2: bunch of reasons.
• 25:17
  Speaker 3: I think for people listening from the patient perspective, if
• 25:20
  Speaker 3: you're trying to get a sense of like, how do
• 25:22
  Speaker 3: I know if this applies to me? The simplest way
• 25:25
  Speaker 3: is to ask your doctor or midwife, what are your inductions, like,
• 25:31
  Speaker 3: like what happens? And if in that process they say,
• 25:34
  Speaker 3: you know, we do A, we do B, we do C,
• 25:37
  Speaker 3: and they say things like and we're very patient because
• 25:40
  Speaker 3: it takes a long time, and we know it takes
• 25:42
  Speaker 3: a long time, and we really try to wait as
• 25:44
  Speaker 3: long as we can as long as it's safe. Then
• 25:47
  Speaker 3: probably you're getting an induction that's very similar to what
• 25:51
  Speaker 3: they did in the study, and probably it's not increasing
• 25:54
  Speaker 3: your risk of a C section. If they say, you
• 25:58
  Speaker 3: know what, people say, inductions don't increase to risk a
• 26:00
  Speaker 3: see sections. But I don't buy it. I don't know.
• 26:02
  Speaker 3: I'm sectioning everybody by four or five pm the next day,
• 26:06
  Speaker 3: you know, twelve hours later, and so I haven't found that,
• 26:08
  Speaker 3: then probably you're getting a less patient form of an
• 26:12
  Speaker 3: induction and might be maybe it will increase the risk
• 26:15
  Speaker 3: for you, and I think that's really the best way
• 26:17
  Speaker 3: to sort this out, you know, on your own.
• 26:19
  Speaker 2: Yeah, yeah, And so it's interesting to sort of move
• 26:22
  Speaker 2: now to thinking about this like after period, right, it
• 26:25
  Speaker 2: is like two things that to pull out, So one
• 26:28
  Speaker 2: is actually there. There have been some sort of studies
• 26:33
  Speaker 2: post to this which have like less good data, so
• 26:37
  Speaker 2: they are not their data is not as good as
• 26:39
  Speaker 2: it's not randomized, but have suggested that that there is
• 26:42
  Speaker 2: still a relationship between inductions and safe sections, and maybe
• 26:45
  Speaker 2: that is reflective of the same biases in the data before.
• 26:48
  Speaker 2: Maybe it's reflective of you know, some changes or some
• 26:52
  Speaker 2: of this lack of patients. But the other thing that
• 26:56
  Speaker 2: comes out is people will now say, you know, my
• 26:59
  Speaker 2: doctor told me that they always induce at thirty nine weeks,
• 27:04
  Speaker 2: that that is now standard practice, or people will say,
• 27:07
  Speaker 2: my doctor told me that ACOG recommends that everyone be
• 27:11
  Speaker 2: induced at thirty nine weeks, and some people don't want that.
• 27:15
  Speaker 2: And it was sort of interesting to hear your answer
• 27:17
  Speaker 2: at the beginning about how that isn't how you're practicing,
• 27:22
  Speaker 2: because there is a really really important distinction between telling
• 27:26
  Speaker 2: a patient you know, there are some reasons to induce,
• 27:29
  Speaker 2: and by the way, there isn't this downside on the
• 27:32
  Speaker 2: other side, and telling somebody we really like ACOG is
• 27:36
  Speaker 2: saying you got to get the baby out.
• 27:38
  Speaker 1: Or you might have a stillbirth, which is what some
• 27:40
  Speaker 1: of these guys are hearing.
• 27:41
  Speaker 3: So ACOG does not say that. For the record, they
• 27:43
  Speaker 3: do not say that you have to learn it.
• 27:45
  Speaker 2: They don't say that, but people are hearing from their
• 27:47
  Speaker 2: doctors that ACOG.
• 27:47
  Speaker 3: Says this, right. No, I agree. I think that one
• 27:51
  Speaker 3: of the I gave a lecture recently about it was
• 27:54
  Speaker 3: called when to Go Rogue, sort of like there's recommendations
• 27:57
  Speaker 3: out there and where they just don't make sense and
• 28:00
  Speaker 3: what are the great ones is if you're a low risk,
• 28:02
  Speaker 3: uncomplicated pregnancy and you're seeing one of those doctors who
• 28:07
  Speaker 3: says things like that up until thirty eight weeks and
• 28:11
  Speaker 3: six days, you will be told you absolutely positively cannot
• 28:16
  Speaker 3: be induced because it's dangerous for the baby. It's not allowed,
• 28:20
  Speaker 3: it's illegal, I'm going to lose my hospital privileges. And
• 28:23
  Speaker 3: then when midnight hits and you're thirty nine weeks and
• 28:26
  Speaker 3: zero days, you must be induced. It's absolutely the best
• 28:28
  Speaker 3: thing for you and the baby. Now, there is no
• 28:31
  Speaker 3: biologic plausibility to that. Zero. It makes no sense anyone
• 28:35
  Speaker 3: listening to be like, well, that's stupid. But if you
• 28:37
  Speaker 3: sort of look at things as black and white, okay,
• 28:41
  Speaker 3: you could have one study that says, black and white,
• 28:43
  Speaker 3: you shouldn't be induced before thirty nine weeks with the reason,
• 28:46
  Speaker 3: and another study that says, black and white, you should
• 28:49
  Speaker 3: be induced at thirty nine weeks. But you have to
• 28:52
  Speaker 3: take everything in, all of the data together into context.
• 28:55
  Speaker 3: So I don't think it's unreasonable to say I think
• 29:00
  Speaker 3: think the best strategy is to induce everybody at thirty
• 29:03
  Speaker 3: nine weeks because it does not increase the risk of
• 29:06
  Speaker 3: sea section, and because you know it might lower the
• 29:09
  Speaker 3: risk or lower the risk of that. Okay, but that
• 29:12
  Speaker 3: doesn't mean it's the right answer for everyone, because again
• 29:15
  Speaker 3: there's logistical issues, like we mentioned before, there are patient
• 29:20
  Speaker 3: preference issues. I don't want to be induced at thirty
• 29:22
  Speaker 3: nine weeks. I don't want to have a twenty four
• 29:24
  Speaker 3: hour labor. I want to wait and go into labor
• 29:26
  Speaker 3: my own ASO it's shorter, B because I think it'll
• 29:29
  Speaker 3: make my chance of needing an epidural lower or c
• 29:32
  Speaker 3: because it'll just make me feel more in touch with
• 29:35
  Speaker 3: the labor. Whatever the reason is, those are all quite
• 29:38
  Speaker 3: reasonable thought processes, and unless there's some reason not to
• 29:44
  Speaker 3: wait past thirty nine weeks, that should be an option.
• 29:47
  Speaker 3: So what I tell people typically is any time between
• 29:51
  Speaker 3: thirty nine and forty one weeks, and maybe for some
• 29:55
  Speaker 3: people forty two weeks is a reasonable time to be induced.
• 30:01
  Speaker 3: And there's benefits to going earlier towards thirty nine weeks,
• 30:05
  Speaker 3: and there's benefits to waiting longer towards forty one weeks.
• 30:09
  Speaker 3: And unless there's a real medical issue at hand, you know,
• 30:14
  Speaker 3: no one could say that one benefits are better than
• 30:16
  Speaker 3: the other benefits. And so I tell people typically, again,
• 30:19
  Speaker 3: unless there's a reason to deliver earlier or for a
• 30:22
  Speaker 3: specific time, I'm very comfortable thirty nine to forty one weeks.
• 30:25
  Speaker 3: If you're someone who wants to be done as soon
• 30:27
  Speaker 3: as humanly possible, you don't feel well, you've got people
• 30:32
  Speaker 3: coming in town, whatever it is you want to be delivered.
• 30:33
  Speaker 3: At thirty nine weeks, I'll say fine, if we can
• 30:36
  Speaker 3: get a room, just be prepared for long induction. God
• 30:38
  Speaker 3: bless and if they want to wait till forty one weeks.
• 30:41
  Speaker 3: The downside is, well, you're pregnant for two weeks more,
• 30:45
  Speaker 3: you may not go into labor, and you may end
• 30:46
  Speaker 3: up with an induction anyways, And there's small risks to
• 30:50
  Speaker 3: you and to the baby, very slight. I don't try
• 30:52
  Speaker 3: to scare people or anything, but you know that's they are.
• 30:55
  Speaker 3: There's very small risks of waiting longer pregnancy, and that's it.
• 30:58
  Speaker 3: And most people will tell you what they want. Most
• 31:01
  Speaker 3: people will show you their cards. It's not that hard.
• 31:03
  Speaker 2: Yeah, And I think giving people the space to talk
• 31:06
  Speaker 2: about their preferences and talk about their preferences for their birth,
• 31:10
  Speaker 2: which people have. I mean, when I was pregnant, like
• 31:14
  Speaker 2: I really wanted to go into labor without an induction, I.
• 31:18
  Speaker 1: Did not want to have an epidural.
• 31:20
  Speaker 2: I think it's pretty clear from the data that an
• 31:22
  Speaker 2: induction increases the pain associated with parts of labor, and
• 31:25
  Speaker 2: people are more likely to have epidurals for a bunch
• 31:28
  Speaker 2: of reasons.
• 31:29
  Speaker 3: I think it increases the duration. I don't the pound
• 31:32
  Speaker 3: for pound, the contractions I'm told, well they are, I don't.
• 31:36
  Speaker 3: I've never had an induction or a contraction. But I
• 31:39
  Speaker 3: think the data is that the actual contractions don't hurt
• 31:42
  Speaker 3: more of the differences. You basically start, you slam on
• 31:45
  Speaker 3: the gas at the very beginning versus a very slow
• 31:48
  Speaker 3: uptick to get into labor.
• 31:51
  Speaker 2: Yeah, but for me, this was, you know, it was
• 31:53
  Speaker 2: actually very It was important to avoid an induction or
• 31:57
  Speaker 2: at least do what do what I could. And that
• 32:01
  Speaker 2: I mean, I think those those preferences have value in people,
• 32:03
  Speaker 2: and people differ in what their their preferences are there,
• 32:07
  Speaker 2: and it's that's just that's important.
• 32:08
  Speaker 3: That's something we need to be thinking of one hundred percent. Listen,
• 32:11
  Speaker 3: this is one of the great sort of not secrets,
• 32:14
  Speaker 3: but one of the real arts in medicine. And just
• 32:16
  Speaker 3: as a plug. We do discuss this in the book
• 32:19
  Speaker 3: that on the one hand, you know, like, what's my
• 32:22
  Speaker 3: job as a doctor, and is it to just tell
• 32:26
  Speaker 3: you what's right and tell you what to do, or
• 32:28
  Speaker 3: is it for me to just discuss all the options,
• 32:31
  Speaker 3: lay them out on the table and let you choose
• 32:33
  Speaker 3: like you're at a restaurant choosing from a menu. And
• 32:36
  Speaker 3: I would argue it's really neither of those. It's in between.
• 32:39
  Speaker 3: It's to have a conversation with you about what I
• 32:42
  Speaker 3: think are sort of reasonable brackets, you know, to put
• 32:45
  Speaker 3: around your options, and for me to tell you, like
• 32:49
  Speaker 3: I think this is a bad option because of this,
• 32:52
  Speaker 3: if you're going to make a bad choice, Like if
• 32:54
  Speaker 3: you said, I don't want to be induced because I
• 32:56
  Speaker 3: don't want to get an epidural and I want to
• 32:58
  Speaker 3: go till i'm forty three weeks pregnant, I would have
• 33:00
  Speaker 3: said to you, I think you're making a mistake. Like
• 33:03
  Speaker 3: obviously I can't, you know, force you to be induced,
• 33:05
  Speaker 3: but I would be firm. I would say, I think
• 33:06
  Speaker 3: you're making mistake. Here is why, and I would explain
• 33:10
  Speaker 3: the reason why. But if you're within a time frame
• 33:13
  Speaker 3: that I think is reasonable, like you said, well, I
• 33:14
  Speaker 3: don't want to be induced at thirty nine weeks, I
• 33:16
  Speaker 3: want to wait until as close to possible as forty
• 33:19
  Speaker 3: one weeks. Are go a little bit past than my
• 33:20
  Speaker 3: job is, you know, talk to you about the pluses
• 33:22
  Speaker 3: and minuses and then let you make a choice. And
• 33:24
  Speaker 3: that's reasonable. And I think that a lot of either
• 33:29
  Speaker 3: patients want something different or a lot of doctors do
• 33:32
  Speaker 3: something different, where they're on the one hand, either too
• 33:35
  Speaker 3: dogmatic and they just give people black and white, or
• 33:38
  Speaker 3: they can't make up their damn mind, and people are
• 33:40
  Speaker 3: left with, well, you're the doctor, like what do you think?
• 33:43
  Speaker 3: And some people just won't give an opinion, which I
• 33:45
  Speaker 3: think is also a mistake.
• 33:46
  Speaker 1: Yeah, no, it's interesting.
• 33:47
  Speaker 2: I mean it feels like such a balance, like a
• 33:50
  Speaker 2: hard balance for a practitioner to be kind of simultaneously
• 33:54
  Speaker 2: the menu but an expert an expertly curated menu. Yeah,
• 33:57
  Speaker 2: you know, there's a lot of things on here you
• 33:59
  Speaker 2: can have. But me to tell you, the oysters aren't
• 34:02
  Speaker 2: that great.
• 34:02
  Speaker 1: Today, but you know we do have them.
• 34:03
  Speaker 3: No, but that's really but that's really true. And it's
• 34:06
  Speaker 3: also not sometimes just preference. It's if I said, well,
• 34:09
  Speaker 3: I mean, think of it more this way, like you're
• 34:11
  Speaker 3: allergic to nuts, donat these four things, right, or you're
• 34:14
  Speaker 3: gluten free, don'tat these six things. Or you said that
• 34:17
  Speaker 3: you know this makes you you don't like this spice,
• 34:20
  Speaker 3: don't have this, Meaning that it's more than just giving
• 34:24
  Speaker 3: someone advice, although there is some of that, it's really
• 34:26
  Speaker 3: about saying, Okay, this preference of yours is reasonable and safe,
• 34:31
  Speaker 3: even if it's not let's say typical whatever. Whereas this
• 34:34
  Speaker 3: one is really just not a safe idea, and here's why.
• 34:37
  Speaker 3: And to be able to articulate that is also not easy,
• 34:41
  Speaker 3: because sometimes it's just easier to say, let's do this
• 34:43
  Speaker 3: and like all right, and that some people are okay
• 34:45
  Speaker 3: with that, but many people are not, so Nay.
• 34:48
  Speaker 2: You've talked a couple of times about the possible benefits
• 34:52
  Speaker 2: of induction, and can you just or the possible dangers
• 34:55
  Speaker 2: of waiting longer. Can you just say a little bit
• 34:57
  Speaker 2: more about about what those are?
• 34:59
  Speaker 3: Yeah, I mean, but if you take someone who's thirty
• 35:01
  Speaker 3: nine weeks and low risks, no issues going on, and
• 35:07
  Speaker 3: you deliver the baby on that day, right, whether it's
• 35:10
  Speaker 3: a C section or its induction, whatever it is, the
• 35:12
  Speaker 3: outcomes for the baby are as good or better than
• 35:17
  Speaker 3: if waiting, meaning there isn't an increased risk of prematurity
• 35:22
  Speaker 3: or delivering before it's time or anything like that, whereas
• 35:25
  Speaker 3: earlier in pregnancy that's always a concern. So once you
• 35:28
  Speaker 3: get to thirty nine weeks, you don't really have that
• 35:31
  Speaker 3: benefit to the baby of waiting longer, letting the baby
• 35:34
  Speaker 3: develop further, grow further, things like that, and so that
• 35:39
  Speaker 3: upside is kind of done at thirty nine weeks. But
• 35:42
  Speaker 3: there is a downside of waiting, and it's hard to
• 35:46
  Speaker 3: talk about because it's terrifying and it's also very rare,
• 35:51
  Speaker 3: and that's the risk of stillbirth. Right, a perfectly healthy
• 35:55
  Speaker 3: pregnancy can end up having a baby that passes away
• 35:58
  Speaker 3: inside after thirty nine weeks. It could happen in any
• 36:01
  Speaker 3: point in pregnancy, but that risk is present if you're
• 36:04
  Speaker 3: still pregnant, and it's absent if you've delivered. And so
• 36:09
  Speaker 3: even though that risk is very very small, fortunately you know,
• 36:13
  Speaker 3: well less than one percent, it is on the table.
• 36:17
  Speaker 3: And so for some people they're like, listen, everything's good today,
• 36:22
  Speaker 3: I want the baby out. And again that's not unreasonable.
• 36:26
  Speaker 3: It's not a recommendation because the likelihood of something bad
• 36:30
  Speaker 3: happening between thirty nine and forty one weeks is so low,
• 36:35
  Speaker 3: especially if someone is you know, monitoring how the baby's moving,
• 36:38
  Speaker 3: or they come to the office, they have a test,
• 36:40
  Speaker 3: whatever it is, that they're getting prenatal care in some capacity.
• 36:43
  Speaker 3: The chance is so so low that it's not recommended
• 36:45
  Speaker 3: that everybody has to be induced. But it is a
• 36:48
  Speaker 3: potential risk, and so for that reason, some people are
• 36:52
  Speaker 3: more adamant about delivering at thirty nine weeks, just to
• 36:55
  Speaker 3: make that miniscule risk a more minuscule risk. There's also
• 37:00
  Speaker 3: or risk of developing hypertension as you move on in pregnancy,
• 37:03
  Speaker 3: like just stationial apepretension, preclamsy up. That does not tend
• 37:06
  Speaker 3: to be a life threatening thing for the mother or
• 37:09
  Speaker 3: baby if it's again followed and watched and treated all
• 37:12
  Speaker 3: these things. So the bigger driving force tends to be
• 37:15
  Speaker 3: that possibility is still birth versus you're not increasing the
• 37:20
  Speaker 3: risk to the baby after birth of things like prematurity.
• 37:24
  Speaker 2: And this is just to kind of touch on this
• 37:26
  Speaker 2: because it's something we talk a little bit about in
• 37:28
  Speaker 2: the book. But your prior experiences with pregnancies sometimes play
• 37:33
  Speaker 2: into this choice. So if someone has had a stillbirth
• 37:37
  Speaker 2: or even a pregnancy loss earlier, sometimes those risks, even
• 37:43
  Speaker 2: if they are in practice.
• 37:45
  Speaker 1: Very small, can loom much larger.
• 37:47
  Speaker 2: And so that is a reason why you know, it
• 37:50
  Speaker 2: could make sense for somebody to induce at thirty nine
• 37:53
  Speaker 2: weeks if that's sort of if that's a present a
• 37:55
  Speaker 2: present risk in their minds, even if it is not
• 37:58
  Speaker 2: something that is medically higher risk.
• 38:00
  Speaker 3: Right or sometimes even I mean even earlier, potentially someone
• 38:03
  Speaker 3: has a history of a still birth. Frequently we deliver
• 38:07
  Speaker 3: them before thirty nine weeks, and we take that extra
• 38:09
  Speaker 3: risk after birth of the baby being slightly less mature.
• 38:13
  Speaker 3: I mean at thirty seven or thirty eight weeks, the
• 38:15
  Speaker 3: risks aren't huge, but okay, well, sometimes take that risk
• 38:18
  Speaker 3: because number one, the anxiety overweighting is so great understandably
• 38:23
  Speaker 3: for these women. I mean, it's it's awful the anxiety
• 38:26
  Speaker 3: that they're having at that point. And since we're humble
• 38:30
  Speaker 3: enough to know we don't know everything about everything, And
• 38:33
  Speaker 3: I couldn't possibly tell someone, oh, because your still birth
• 38:37
  Speaker 3: happened for X reason, there's no chance it's going to
• 38:41
  Speaker 3: happen again this pregnancy. That would be very That would
• 38:44
  Speaker 3: be a lot of hubrists for me to say that,
• 38:45
  Speaker 3: And so sometimes even earlier, but yes, people's own fears
• 38:49
  Speaker 3: and anxiety. Sometimes it's a cousin of mine had a
• 38:52
  Speaker 3: still birth, right, so if a cousin of mine had
• 38:54
  Speaker 3: a still birth, there's no I'm not an increased risk
• 38:57
  Speaker 3: of having a still birth, but it's on my mind
• 38:59
  Speaker 3: a lot more than someone who's never really had that
• 39:03
  Speaker 3: in their world, to thank God. And so people's anxieties
• 39:07
  Speaker 3: in general definitely play into that decision about when they
• 39:09
  Speaker 3: want to deliver. I would say for most people, it's
• 39:12
  Speaker 3: not pressing in their mind. Fortunately, that would be very
• 39:17
  Speaker 3: daunting to be pregnant if it's always pressing in someone's mind,
• 39:21
  Speaker 3: but occasionally is. But that is sort of the risk,
• 39:24
  Speaker 3: the unspoken risk that people try not to say out
• 39:27
  Speaker 3: loud too much, because it's just once you drop stillbirth
• 39:30
  Speaker 3: during a prenatal visit, it just it changes everything afterwards.
• 39:35
  Speaker 3: It's very hard to talk about it but not talk
• 39:37
  Speaker 3: about it at the same time.
• 39:40
  Speaker 2: Yeah, all right, So to bring it back to the
• 39:42
  Speaker 2: arrived trial, and we sort of think about takeaways. I
• 39:44
  Speaker 2: think the biggest takeaways for me here and then I'm
• 39:46
  Speaker 2: going to let you give your big takeaways if they disagree.
• 39:50
  Speaker 3: Are or shadowing the book.
• 39:52
  Speaker 2: Number one, this is a really good trial and that
• 39:57
  Speaker 2: in general based on and this is the best evidence
• 40:01
  Speaker 2: we have, and it does not suggest that an induction
• 40:03
  Speaker 2: needs to lead to an increased risk of C section.
• 40:06
  Speaker 2: But my second takeaway is that it also doesn't mean
• 40:10
  Speaker 2: that you have to have an induction at thirty nine weeks,
• 40:13
  Speaker 2: and that it's worth asking. I mean, this is really
• 40:16
  Speaker 2: your point. So I'm stealing it because I got to
• 40:18
  Speaker 2: go first, but that it is worth talking to your
• 40:21
  Speaker 2: provider about. Really, their ability to be patient is the
• 40:26
  Speaker 2: biggest thing I would put out there. Their ability to
• 40:30
  Speaker 2: let the induction take along time.
• 40:32
  Speaker 3: Yeah, I mean my takeaways obviously I agree with all three.
• 40:36
  Speaker 3: I would say that one of the important aspects about
• 40:42
  Speaker 3: induction is asking why are you recommending this? Right? Are
• 40:49
  Speaker 3: you recommending it just because I'm thirty nine weeks and
• 40:51
  Speaker 3: I've hit a certain number but everything is going perfectly fine,
• 40:55
  Speaker 3: in which case I think there's a lot of room
• 40:58
  Speaker 3: for waiting and pushback, like you know, maybe I don't
• 41:00
  Speaker 3: want to me do Versus are you recommending it because
• 41:02
  Speaker 3: you have a specific concern for me or my baby
• 41:07
  Speaker 3: about waiting on top of just the I'm getting more pregnant?
• 41:12
  Speaker 3: Meaning is it because I'm forty five years old and
• 41:16
  Speaker 3: you're worried about a risk of a stillbirth? Is it
• 41:18
  Speaker 3: because I have diabetes and you're worry about a risk
• 41:21
  Speaker 3: of a still birth? Is it because my blood pressure
• 41:23
  Speaker 3: is creeping up and you're worried about me getting severe hypertension.
• 41:25
  Speaker 3: That's a very different reasoning than just because, right, I
• 41:29
  Speaker 3: think having a conversation like you mentioned that I mentioned
• 41:36
  Speaker 3: about the ability to be patient, but also even more
• 41:41
  Speaker 3: generic than that, just tell me what an induction is
• 41:44
  Speaker 3: like with you or at your hospital. And again, just
• 41:48
  Speaker 3: like you know, patients will tell you what they think,
• 41:51
  Speaker 3: doctors and midwise will tell you what they think. We're
• 41:53
  Speaker 3: not secretive, like you know. Our personalities come out, our
• 41:56
  Speaker 3: opinions come out, and you want to get a sense. Ideally,
• 42:00
  Speaker 3: these conversations should happen early in pregnancy, not specifically about induction,
• 42:05
  Speaker 3: but just in general, because you get a sense is
• 42:08
  Speaker 3: this a person I trust? And if it's a person
• 42:10
  Speaker 3: I trust, then probably this conversation will be very easy
• 42:14
  Speaker 3: because you'll already have that rapport. If you're not sure
• 42:17
  Speaker 3: if you trust this person, that's not a good place
• 42:19
  Speaker 3: to be.
• 42:21
  Speaker 2: I wish I had had that advice with my first pregnancy,
• 42:24
  Speaker 2: because I remember getting to the end and telling the doctor, I,
• 42:28
  Speaker 2: don't you know, I'm planning not to have an epidural,
• 42:31
  Speaker 2: and they were like, oh, yeah, we'll see.
• 42:33
  Speaker 1: How that goes.
• 42:34
  Speaker 2: Good luck with that, and I was like, oh, we
• 42:36
  Speaker 2: should should have touched on this earlier.
• 42:38
  Speaker 3: Yeah, but it's but that's I but it's interesting. I
• 42:41
  Speaker 3: mean I tell people that, you know, get at abadua
• 42:43
  Speaker 3: doc abadual, like God Bless, you know, whatever you want
• 42:45
  Speaker 3: to find. It is true that at least in our hospital,
• 42:48
  Speaker 3: ninety percent of women get epidurals. That's just sort of
• 42:51
  Speaker 3: the numbers. But I don't you know, God Bless, if
• 42:53
  Speaker 3: you're gonna be in the ten percent, I think that's awesome.
• 42:56
  Speaker 3: You know, as I say, your labor won't hurt me
• 42:58
  Speaker 3: one bit. So whatever works great, I think it's terrific.
• 43:01
  Speaker 3: There are a few exceptions when I may sort of
• 43:03
  Speaker 3: push someone into epiderble I mean twins. I mean, you know,
• 43:06
  Speaker 3: sort of rare exceptions. Yeah, but it's more important. I
• 43:09
  Speaker 3: mean things like you know, I mean we discuss that
• 43:11
  Speaker 3: attitudes in general about inductional Like if someone has a
• 43:16
  Speaker 3: rule that they induce all our patients at thirty nine weeks,
• 43:19
  Speaker 3: that's something that probably should be like told upfront, you know,
• 43:22
  Speaker 3: at the beginning of pregnancy when you join, because it's
• 43:24
  Speaker 3: not that's not what's recommended. It's fine, it's not unreasonable,
• 43:29
  Speaker 3: but it's not like the only way to do it,
• 43:31
  Speaker 3: and it's not what ACC says. We don't do it.
• 43:33
  Speaker 3: We don't induce everyone in thirty nine weeks, and you
• 43:35
  Speaker 3: know we seem to have not been arrested.
• 43:46
  Speaker 2: Nate.
• 43:46
  Speaker 1: I love to talk to you. I can't wait to
• 43:48
  Speaker 1: talk to you more.
• 43:48
  Speaker 2: We'll do more stuff with our new book, and it's
• 43:51
  Speaker 2: always just a treat. Love it.
• 43:53
  Speaker 3: Thanks for having me, Thanks for bringing me into your world.
• 43:55
  Speaker 3: It's been a wild ride and it's awesome.
• 44:07
  Speaker 1: Thank you again to doctor Nate Fox.
• 44:09
  Speaker 2: You'll be hearing more from him when our book The
• 44:11
  Speaker 2: Unexpected is released in April twenty twenty four. More parent data,
• 44:17
  Speaker 2: including your induction stories after the break.
• 44:40
  Speaker 5: So this is an induction story actually for my second baby,
• 44:44
  Speaker 5: not my first baby. My first baby actually came on
• 44:47
  Speaker 5: his due date, and so in my mind that was
• 44:51
  Speaker 5: like how babies are born. And so when I went
• 44:55
  Speaker 5: in for my thirty eight week appointment, I figured, okay,
• 45:00
  Speaker 5: little buddy, you've got exactly two weeks left because you're
• 45:04
  Speaker 5: going to be born on your due date too.
• 45:07
  Speaker 4: I was really not expecting to have an induction for
• 45:10
  Speaker 4: my whole pregnancy. My plan was to labor for as
• 45:13
  Speaker 4: long as I could without medication, and then getting up
• 45:17
  Speaker 4: adural when I just couldn't take it anymore. For the
• 45:20
  Speaker 4: last six weeks, I was pregnant. My feet itched more
• 45:24
  Speaker 4: than they've ever itched in my entire life. I couldn't sleep,
• 45:26
  Speaker 4: I was strapping ice packs to them. Nothing helped, and
• 45:29
  Speaker 4: my doctors kept testing me for something called colistasis. I
• 45:33
  Speaker 4: never tested positive, but as we got closer to my
• 45:36
  Speaker 4: due date, they basically said, look, if you want to
• 45:38
  Speaker 4: be extra cautious, we could give you an induction.
• 45:42
  Speaker 5: Right before I went into the doctor's office, I got
• 45:45
  Speaker 5: a phone call from my now two and a half
• 45:47
  Speaker 5: year old's school saying that he was having a really
• 45:50
  Speaker 5: tough day and that I needed to come pick him up.
• 45:53
  Speaker 5: And that's when they took my blood pressure and they said,
• 45:57
  Speaker 5: you know, we're really kind of concerned. Blood pressure is
• 46:00
  Speaker 5: higher than we'd like, so we'll tell you what. You
• 46:04
  Speaker 5: sit there and wait, and you know, we'll just take
• 46:08
  Speaker 5: it again in twenty minutes. And in my head, I'm like,
• 46:12
  Speaker 5: I have to go pick up my kid, like I
• 46:14
  Speaker 5: can't wait twenty minutes, and I don't think this is
• 46:17
  Speaker 5: going to help the blood pressure situation.
• 46:19
  Speaker 4: I decided that seems like the safest thing for me
• 46:22
  Speaker 4: and my baby, But I was really terrified of induction.
• 46:25
  Speaker 4: I'd only heard negative stories about it, and I felt
• 46:28
  Speaker 4: like all my plans were just going.
• 46:29
  Speaker 5: To go out the window. And so the doctor came
• 46:31
  Speaker 5: in and was like, I think we need to induce you.
• 46:36
  Speaker 5: And that was not what I wanted to hear. I
• 46:39
  Speaker 5: don't know why it bothered me so much. I guess
• 46:42
  Speaker 5: I was like, I wasn't expecting to have today be
• 46:46
  Speaker 5: the last breakfast with my family of three.
• 46:51
  Speaker 4: One of the first positive things that happened is I
• 46:53
  Speaker 4: felt like I could prepare myself mentally and emotionally for
• 46:58
  Speaker 4: the time I was going to give birth. I went
• 47:01
  Speaker 4: on a nice walk with my husband. I spent hours
• 47:04
  Speaker 4: just listening to music and writing in my journal. And
• 47:07
  Speaker 4: then it was go time.
• 47:08
  Speaker 5: I begged them. I said, look, I need one more
• 47:11
  Speaker 5: night at home with my older kid. I need to
• 47:15
  Speaker 5: tell him where I went. So they gave me that
• 47:19
  Speaker 5: they let me go home. I got that one last night.
• 47:22
  Speaker 5: The next day, I check in all ready to go
• 47:25
  Speaker 5: before they give me the potocin. I go into labor naturally,
• 47:29
  Speaker 5: so the doctors think that that's why my blood pressure
• 47:32
  Speaker 5: was high, because I was going into labor, and it
• 47:38
  Speaker 5: was a really beautiful labor for a really sweet little baby.
• 47:44
  Speaker 4: I ended up having a really positive induction experience. Meeting
• 47:48
  Speaker 4: my daughter for the first time was, without a doubt,
• 47:51
  Speaker 4: the happiest moment of my entire life, and I wouldn't
• 47:53
  Speaker 4: change a thing.
• 47:58
  Speaker 6: For my third pregnancy. After my first two were born
• 48:03
  Speaker 6: a month early, I was told by some male gynecologist,
• 48:09
  Speaker 6: I'm sure that I had an incompetent cervix. So they
• 48:14
  Speaker 6: did curclage and kind of wrapped something I guess around
• 48:19
  Speaker 6: the cervix that would keep the baby in to term,
• 48:23
  Speaker 6: and they worked, and by the time I got to
• 48:27
  Speaker 6: the end of the pregnancy, they were going to induce me.
• 48:31
  Speaker 6: So I went to the hospital and checked myself in,
• 48:35
  Speaker 6: never had to miss a meal, and they took off
• 48:38
  Speaker 6: the circlauge and I went into labor independently. So I
• 48:41
  Speaker 6: had my third child exactly when she was supposed to
• 48:44
  Speaker 6: be born. And now she's the producer of this podcast,
• 48:51
  Speaker 6: You're Welcome.
• 49:03
  Speaker 2: Parent Data is produced by Tamar Avishai with support from
• 49:06
  Speaker 2: the parent Data team and PI Rex. Also special thanks
• 49:10
  Speaker 2: to our house violinist, my daughter Penelope. No Problem.
• 49:13
  Speaker 1: Well, if you have.
• 49:14
  Speaker 2: Thoughts on this episode, please join the conversation on my
• 49:17
  Speaker 2: Instagram at prof Emily Oster and If you want to
• 49:21
  Speaker 2: support the show, become a subscriber to the parent Data
• 49:24
  Speaker 2: newsletter at parentdata dot org, where I write weekly posts
• 49:27
  Speaker 2: on everything to do with parents and data to help
• 49:30
  Speaker 2: you make better, more informed parenting decisions. For example, in
• 49:35
  Speaker 2: April twenty twenty, I wrote a post going through the
• 49:38
  Speaker 2: Arrived trial in much more detail. If you like what
• 49:41
  Speaker 2: you hear, please leave the show or positive review on
• 49:43
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• 49:46
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• 49:51
  Speaker 1: We'll see you next time.