Are you a candidate for an "ARRIVE" induction?

We know you're tired of being pregnant, and you're anxious to hold your baby. Does that mean a planned induction is the best choice for you? Read all about The ARRIVE Trial (A Randomized Trial of Induction Versus Expectant Management) and decide what's best for you!

By Rebecca Dekker, PhD, RN

(this article was abbreviated here. To see full content, read it here.)

(Note: the average age of participants in this trial was 24 years of age.)

Why did researchers conduct the ARRIVE trial?

The researchers carried out the ARRIVE study (A Randomized Trial of Induction Versus Expectant Management) to find out if elective induction of labor (using medicine to start labor without a medical reason) during the 39th week of pregnancy would result in a lower rate of death and serious complications for babies, compared to waiting until at least 40 weeks and 5 days for elective induction (Grobman et al. 2018). They also wanted to see if inductions had an effect on the risk of Cesareans.

Who was in the study?

This was a large study that took place at 41 hospitals in the United States. Researchers screened more than 50,000 people, and here's what they used for their study:

• first time moms with a single, head-down baby

• had no major medical conditions.

• Of 22,533 eligible, 6,106 (27%) agreed to participate

• Group A: 3,062 people to be induced at 39 weeks

• Group B: 3,044 people to expectant management, meaning you wait for labor to begin on its own or up to 40 weeks and 5 days (unless medically needs dictate otherwise)

What did the researchers find?

Group A: (Induced at 39 weeks)

• For babies: no noted improvement in outcome of death or serious complications in labor

• For moms: a marginally lower rate of Cesarean (19% Cesarean rate versus 22%) and pregnancy-induced high blood pressure (9% versus 14%).

• Mothers in the early induction group spent more time in the hospital in labor (30 or more hours VS 16 hours), but less time in the hospital postpartum.

So should everyone be induced at 39 weeks to lower the rate of Cesareans?

Although this study may be helpful with making informed decisions, it does not mean “everyone” should be induced, and professional organizations have not yet made recommendations recommending elective inductions during the 39th week of pregnancy.

The ARRIVE study did find that inducing low-risk, first-time mothers with accurately estimated due dates at 39 weeks may help to lower the Cesarean rate from 22% to 19% if care providers follow the same induction practices as they did in this study. The researchers think this is because the risk of Cesarean goes up the longer a pregnancy continues. Longer pregnancies mean more opportunities for potential complications to show up and an increasing willingness by providers to perform a Cesarean.

The ARRIVE study does not mean that elective induction at 39 weeks lowers the risk of Cesarean for every individual. Some mothers may not benefit from early elective induction, including:

• Those who prefer to avoid medical interventions.

• Those whose care providers have high Cesarean rates with inductions.

• Those choosing midwifery care.

Are there other ways to lower my risk of Cesarean?

Yes! Studies have found larger reductions in the relative risk of Cesarean using other approaches. People randomly assigned to continuous support during labor (such as with a doula) were 25% less likely to have a Cesarean (Bohren et al. 2017). Also, when people are assigned to a less-invasive type of fetal monitoring called hands-on listening (also known as intermittent auscultation), they are 39% less likely to have a Cesarean compared to people assigned to continuous electronic fetal monitoring (Alfirevic et al. 2017). Other comfort measures, such as walking around during labor, staying hydrated, and planning a waterbirth, have also been shown in randomized trials to lower your risk of Cesarean by much more than 16%. So, there are plenty of alternatives for people who want to lower their risk of Cesarean, but don’t want an elective induction.

What do the professional guidelines say?

The American College of Obstetricians and Gynecologists (ACOG) released new practice guidelines that address the ARRIVE trial findings. They conclude that it is reasonable to offer elective induction to low-risk, first-time mothers at 39 weeks of pregnancy. However, they urge care providers to first consider three important factors: the values and preferences of the pregnant woman, the staffing and facility resources available (to assist longer labors), and the protocol for “failed” induction. Specifically, as long as there are no complications, early labor can last 24 hours or more and oxytocin can be given for 12 to 18 hours after breaking the mother’s water before the induction is considered a failure.

The American College of Nurse-Midwives (ACNM) also released a press statement saying that they continue to promote normal healthy physiologic birth and a woman’s right to make decisions during pregnancy. They express concern that many women may not desire elective induction and propose that costs might be better spent on less invasive approaches to reduce Cesareans, such as continuous labor support from a doula.