Consortium for the Evidence-based practice of Obstetrics -- 
C.E.O. is dedicated to bringing science-based 
maternity care to all childbearing women

 Quotes and Excerpts from and 
 other respected sources  of professional information
on safety, complications & practice trends for obstetricians  

Bibliography, Recommended Reading and Scientific Citation from obstetrical sources for the:

Risks & Complications of Elective Induction Shoulder Dystocia
/ Factual Basis for Reducing Practitioner Anxiety 



Induction Rate Doubled in the US from 1990 to 1998; Ob.Gyn.News May 1, 2002, Vol 37, No 9;

Labor Induction for Macrosomia (big baby) not Justified Ob.Gyn.News; Mar 1 2002 Vol 37, 

Induction Linked to Doubling of Cesarean Rate in  Nulliparas (1st time mothers), Ob.Gyn.News; Jan 1 2003 Vol 38, No 1;

Multiparas: C-Section, Cervical Ripening  Link Seen Women had previously delivered vaginally, Ob.Gyn.News; Jun 15 2003 Vol 38, No 12;


Data Don't Support Postdates Pregnancy Guideline; ObGynNews, Mar 1, 2001, Vol 36  No 5

Prolonged Resolution of Dystocia is Well Tolerated Moderate delays not tied to fetal academia
ObGynNews, Oct 15, 2002, Vol 37  No 20  


Induction Rate Doubled in the US from 1990 to 1998; Ob.Gyn.News May 1, 2002, Vol 37, No 9;  

The rate of labor inductions in the United States [more than] doubled in from 1990 to 1998”  “Labor inductions [which does not include the use of  to augment latent or slow labors] increased from 9.5% of all birth nationwide in 1990 to 19.4% in 1998. If women who underwent elective cesarean …. were not included, the overall rate in 1998 would have been almost 23% [this means that inductions when up from 9% to 23% in 8 years] White race, higher education and early prenatal care were each associated with approximately 100% increase in labor induction. Nulliparious (first baby) had a higher rate than multiparious women (2 or more previous babies) (13)  

Labor Induction for Marcosomia Not Justified – Expectant management significantly lowers Cesarean rate; 
Ob.Gyn.News; Mar 1 2002 Vol 37, 

“Labor induction for the sole indication of suspected macrosomia cannot currently be justified, … Instead, these patients should be managed expectantly. Many obstetricians feel that if babies are getting big they have to do something early. Our study shows that, based on the literature, we should leave them alone. The rate of Cesarean delivery was significantly lower with expectant management than with labor induction (9% compared with 17%) … expectant management was associated with a significant increase in the rate of spontaneous vaginal delivery (82% compared with 71%). Apgar scores also did not differ significantly”. (15)  

Based on observational data & experience, Scientific Data Doesn't Support Postdates Pregnancy Guidelines  Oct 15 2002 • Volume 37 • No 20

Observational data and clinical experience—not randomized controlled data—have led to the currently accepted guidelines for managing postdates pregnancies.

Yet these guidelines govern the practices of most obstetricians in the United States ...  “There is very little evidence for what we do.  .... There have been two randomized controlled trials comparing the effects of monitoring, fetal testing, and induction on perinatal mortality and morbidity in postdate pregnancies. Both have found no significant difference in adverse outcomes or cesarean section rate....

“The jury is still out. So the question is ‘When should we begin antenatal surveillance, and should we induce?’”  For many years, obstetricians have believed the truism that the best way to decrease perinatal mortality is to terminate the pregnancy before adverse events occur. Yet
whether induction at 41 weeks increases the risk of an operative delivery without preventing perinatal death is still not clear.

There is also no evidence in the literature that testing between 40 and 42 weeks' gestation improves outcomes, though many obstetricians believe it does. At 41 weeks, most obstetricians will deliver a baby if the cervix is favorable. “However, this is entirely based on observational data,” 

After 42 weeks, observational studies have shown that there is a drop-off in amniotic fluid, which is felt to be a sign of poor renal function in the fetus.  ACOG guidelines—again, based on observational data—maintain that oligohydramnios is an indication for delivery, he added. If the cervix is unfavorable or the Bishop score is low, immediate delivery may put the woman and baby at risk for a failed induction, he said. In these cases, the obstetrician should use the Foley balloon or
misoprostol [Cytotec].  In his practice, ....  prefers to induce around term... 


Induction Linked to Doubling of Cesarean Rate in  Nulliparas (1st time mothers), Ob.Gyn.News; Jan 1 2003 Vol 38, No 1;


The cesarean delivery rate doubled when nulliparous [having a 1st baby] were induced....   The C-section rate was especially high, 31.5%, among nulliparous patients who were induced despite an unfavorable cervix, defined as having a Bishop score at induction <5. 


......the tracking of 20,000 deliveries in the Providence Health System (Portland, Ore) offers valuable insight into risk factors and the route of delivery.  In all, 4,635 (64%0 went into labor spontaneous and had a C-section rate of 11.5%. Among the 2,647 women (36%) who were induced, theC-section rate was 23.7%. 


There's a doubling of the C-section rate of induced nulliparous women over the spontaneous background rate of 11.5%, ...... [Dr. Johnson] noted that other recent studies have shown a "fairly consistent" doubling of C-sections among induced nulliparous women, regardless of the background C-section rate.


Induction of labor in nulliparous patients should be approached with caution, especially if the cervix is unfavorable ..... Patients should be informed of this relationship, and proper informed consent should be obtained."


Multiparas: C-Section, Cervical Ripening  Link Seen – Women had previously delivered vaginally, Ob.Gyn.News; Jun 15 2003 Vol 38, No 12;


The risk of cesareans section is five times higher in women with at least one previous vaginal delivery who receive cervical ripening before elective induction, compared with women who have a spontaneous


These findings, from a retrospective study of 1,268 women, suggest that "a patient should not be induced electively unless her cervix is favorable, said Dr Hoffman of the department of obstetrics and gynecology at Christiana Care Health Services in Newark, Delaware. "We probably don't truly create the same parameters that a woman does through our process of preinduction cervical ripening," he told this newspaper. "We need to wait for the cervix to become ready."


In primiparas [having a first baby] elective induction even with a favorable cervix is associated with anywhere from two or threefold increase in Cesarean section rate," compared with women who have spontaneous labor, he said.


In the study the Cesarean section rate was 11.9% among women who had preinduction cervical ripening, 3.3% among the 454 women who were induced with cervical ripening and 2.4% among the 747 women who went into spontaneous labor. 


Dr Hoffman said the rate of elective inductions is growing rapidly across the country because of both physician and patient demand for convenience. "Over 20% of pregnancies are not induced, and probably the most rapid increase is because of elective induction, her said, adding that more than 40% of obstetric patients without a favorable cervix, as well as all nulliparous patients, he said. 


Prolonged Resolution of Dystocia is Well Tolerated – Moderate delays not tied to fetal academia
ObGynNews, Oct 15, 2002, Vol 37  No 20  

“A moderate delay in childbirth for the sake of resolving shoulder dystocia is not associated with clinically significant increases in umbilical artery academia”   “Few data address the question of safe time thresholds for resolving shoulder dystocia; however, some authors have arbitrarily placed the limit at around 2-3 minutes. On the basis of this study and other data in recent years, "statement of an arbitrary time limit is inappropriate," Dr. Stallings said in an interview. The results suggest that if the fetus is healthy, it will likely be able to tolerate a prolongation of delivery by 4-5 minutes. "It should not be the clinician's first impulse to increase the forces applied in a rushed attempt to deliver the fetus within an arbitrary 2-minute time limit,"  ..”drops in fetal pH levels after the onset of shoulder dystocia probably occur much more gradually than physicians have generally assumed, challenging the notion that shoulder dystocia requires a crash or rushed delivery.

Nor was there a significant correlation between longer times to dystocia resolution and decreasing 5-minute Apgar scores. Of the 8,282 vaginal deliveries studied, there were 134 cases of shoulder dystocia, representing an incidence of 1.7%.   the mean birth weight for infants with dystocia was 4,504 g [10#].  The average head-to-body interval was 3 minutes, ranging from 30 seconds to 8 minutes. In a subgroup of 43 cases, there was a nuchal cord present at delivery, but this was not believed to be associated with adverse outcomes. Only one infant had an Apgar score of less than 3; no infant had a 10-minute Apgar score of less than 4.

A few studies suggest that outcomes following dystocia, even in the case of nuchal cord, depend on whether the cord is clamped and divided. [ a reason not to cut the cord before the birth – use summersault maneuver for  nucal cord instead] "We speculate that, even in the face of shoulder dystocia with a nuchal cord, some cord circulation may continue, and that severing the cord may contribute to fetal hypoxia and hypotension during the time it takes to resolve the dystocia." …” therefore, advise "caution regarding the clamping and cutting of the nuchal cord prior to the initiation of maneuvers."  (26)