A Randomized Trial of Induction versus Expectant Management (ARRIVE)
How will results from ARRIVE change birth for women in your community?
Guest post by Nicole Carlson, PhD, CNM
Initial results from A Randomized Trial of Induction Versus Expectant Management (ARRIVE) were announced on February 1, 2018 at the annual meeting of the Society for Maternal Fetal Medicine. These initial results show significant reductions in cesarean births; maternal admissions to intensive care; neonatal respiratory support in first 72 hours following birth; and diagnosis of preeclampsia or gestational hypertension.
What does this mean for the future of labor and birth? Will all women be induced? Will physiological birth require consent? Let’s look at some key points from the study before jumping to conclusions.
- Only the conference abstract and clinical trial guidelines have been made public. This has not yet been published in a peer reviewed journal.
- The Society for Maternal-Fetal Medicine, American College of Nurse-Midwives, and American College of Obstetrics and Gynecology have all stated that elective inductions at less than 41 0/7 weeks in women with unfavorable cervices should still be avoided. Lisa Kane Low, President of ACNM, encouraged maternity care providers to “continue the process of shared decision-making with individual women who may not desire the multiple interventions involved in labor induction.”
- The trial looks at elective induction at 39 weeks versus going past 40 weeks. However, it is possible that the women who were randomized to the expectant management group who did not go into labor spontaneously before 40 5/7 weeks asked for inductions soon after. It is less a matter of induction versus expectant management and more a question of inducing at certain gestational ages.
- The rigorous labor induction protocols used by the trial may not be reproducible by all maternity care providers. Earlier this year, William Grobman et al. (2018) concluded that it is safe for providers to wait up to 15 hours following oxytocin administration and rupture of the membranes before preforming cesarean.
- The women in the trial were also not like most women in United States in that they represented a select group of low-risk women who were willing to have highly medicalized labors and births in academic medical centers. Their maternity care providers were aware that these women were study participants and that one of the important outcomes of the study was the rate of cesarean birth.
The entirety of the study needs to be published before such a recommendation is made, and the above factors and questions need to be considered as it will likely affect room availability, nursing hours, nationwide labor induction protocols, etc. In light of all of these issues, let’s move slowly and cautiously as we consider what ARRIVE means for women in the United States.
Big thank you to Nicole Carlson for sharing this PowerPoint presentation with us on the new ARRIVE trial. Link to PDF: A Randomized Trial of Induction versus Expectant Management
American College of Nurse-Midwives. (2018). ACNM recommends no change in practice in response to study on induction of labor. Retrieved from http://www.midwife.org/induced-labor-study-statement
Carlson, N. S. (2015). Current resources for evidence-based practice, May/June 2015. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(3), E5-E13. doi: 10.1111/1552-6909.12578
Chaillet, N., & Dumont, A. (2007). Evidence-based strategies for reducing cesarean section rates: A meta-analysis. Birth, 34(1), 53-64. doi: 10.1111/j.1523-536X.2006.00146.x
Grobman, W. (2018). LB01: A randomized trial of elective induction of labor at 39 weeks compared with expectant management of low-risk nulliparous women. American Journal of Obstetrics & Gynecology, 218(1), S601. doi: 10.1016/j.ajog.2017.12.016
Grobman, W. A., Bailit, J., Lai, Y., Reddy, U. M., Wapner, R. J., Varner, M. W.,…Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. (2018). Defining failed induction of labor. American Journal of Obstetrics & Gynecology, 218(1), 122 e121-122 e128. doi: 10.1016/j.ajog.2017.11.556
Kawakita, T., Reddy, U. M., Huang, C. C., Auguste, T. C., Bauer, D., & Overcash, R. T. (2017). Predicting vaginal delivery in nulliparous women undergoing induction of labor at term. American Journal of Perinatology. Advance online publication. doi: 10.1055/s-0037-1608847
Main, E. (2018). Comments on the Arrive trial [Press release]. Retrieved from https://www.cmqcc.org/sites/default/files/Arrive%20Trial%20Statement%20Final.pdf
Martin, J. A., Hamilton, B. E., Osterman, M. J., Driscoll, A. K., & Drake, P. (2018). Births: Final data for 2016. National Vital Statistics Reports, 67(1), 1-55. Retrieved fromhttps://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_01.pdf