Induction of labour
===================

* Mark P. Hehir
* Adam Mackie
* Michael S. Robson

Mishanina and colleagues1 have reported that the risk of cesarean delivery associated with induction of labour was 12% lower than with expectant management in a systematic review and meta-analysis encompassing 157 randomized controlled trials (RCTs). Although this study presents a wide-reaching review of trials related to this topic, we are concerned that it sends a message that risks associated with all inductions are equal.

The trials included in the review were highly varied in terms of the indications for induction that were studied. The methods of induction were also not standardized with various methods of pharmacological and mechanical induction carried out. The majority of RCTs included in the review also contained a mix of both nulliparous and multiparous parturients in their study cohort and individual examination of these groups may have yielded different results.

Furthermore, the range of institutional cesarean delivery rates across the trials included in the study was not addressed, and rates of prelabour cesarean delivery were also not examined.

Settling the argument of induction versus expectant management will be difficult. A large-scale RCT where participants are matched according to parity and indication for induction, and have standardized management for both spontaneous and induced labours is lacking in the literature. The challenges in design and implementation of such a trial are apparent; however, we feel it is misleading to encourage clinicians to apply the findings of the present study to all patients regardless of maternal baseline characteristics and the indication for induction.

## Reference

1.  Mishanina E, Rogozinska E, Thatthi T, et al. Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis. CMAJ 2014;186:665–73.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxODYvOS82NjUiO3M6NDoiYXRvbSI7czoyNDoiL2NtYWovMTg2LzE2LzEyNDYuMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)