1. Perinatal outcomes following an earlier post-term labour induction policy: a historical cohort study Hedegaard M, Lidegaard Ø, Skovlund CW, Mørch LS, Hedegaard M

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3. Scenario A 38-year-old Caucasian woman comes to see you at 37 weeks of her first pregnancy. She has read in the news (http://dailym.ai/1Bpwtir) that “inducing babies at 37 weeks cuts risks of child dying or developing a serious health condition such as cerebral palsy”.http://dailym.ai/1Bpwtir She has an uncomplicated pregnancy and no other medical history. She asks for your advice about timing of delivery and the possibility of induction of labour. How would you counsel her?

4. Background Since 2009, Danish guideline recommends labour induction between 41 +3 and 41 +5 weeks of gestation to ensure delivery by 42 weeks. The change in policy has been associated with a significant reduction in stillbirth (Hedegaard 2014).

5. Background Do you routinely offer induction of labour to women similar to the one in the scenario? If yes, when do you recommend delivery? How does the Danish clinical guideline recommendations compare to your local practice?

6. The Clinical Question Has the change in recommended practice advocating earlier labour induction reduced perinatal morbidity and mortality?

7. Structured question (PICOD) ParticipantsAll babies born at or after 37 weeks gestation in Denmark between 2000-2012 InterventionImplementation of a proactive labour induction practice recommended by Danish clinical guidelines since 2009 ComparisonOutcomes before the implementation of the new guideline (prior to 2009) OutcomesUmbillical cord pH <7.0; Apgar-score <7 at 5 minutes; neonatal death; NICU admission; cerebral palsy; fetal weight <4500g; shoulder dystocia; peripheral nerve injury Study DesignA historical cohort study

8. Methods What are the pitfalls of using a historical cohort study to address this research question? How did the authors address these pitfalls in their methods?

9. How were the participants identified? Born from 2000-2012 (n = 832,935) Excluded: Born before 37 weeks’ gestation (n = 62,009) Born from 37 weeks’ gestation (n = 770,926) Included Planned vaginal delivery (n = 602,219) Medical labour induction (n = 104,107) Elective Caesarean Section (n = 104,107)

10. Results Rate of induced deliveries (black, Y1) and post-term deliveries (blue, Y2)

11. Perinatal outcomes by year (1)

12. Perinatal outcomes by year (2)

13. Results & Discussion Can you briefly summarise the results of this study as a one-sentence take-home message? Has the general media accurately reported the results of this study? (See an example at http://dailym.ai/1Bpwtir) http://dailym.ai/1Bpwtir Would the results of this study influence your management of the woman in the scenario? How would the results of this study influence your daily practice?

14. Authors’ Conclusions Labour induction from 40 weeks increased from 9.5% in 2000 to 29.4% in 2012. During the same period, the perinatal morbidity and mortality decreased, suggesting a positive effect of the more pro-active post-term labour induction practice. Adjustments for maternal age, parity, plurality and smoking did not change the results. NICU admission (+56%) Shoulder dystocia (+32%) Cord pH < 7.0 (-23%) Neonatal death (-46%) Cerebral palsy (-26%) Fetal weight > 4500 g (-32%) Nerve injury (-43%)

15. Suggested reading Jauniaux E, Kilby M. All twins should be delivered before 38 weeks of gestation: FOR. BJOG. 2014 Sep;121(10):1292.BJOG. 2014 Sep;121(10):1292 Saugstad OD. Twins should be delivered before 38 weeks of gestation: AGAINST. BJOG. 2014 Sep;121(10):1293.BJOG. 2014 Sep;121(10):1293 RCOG statement with regards to this paper: http://bit.ly/1C8zW8zhttp://bit.ly/1C8zW8z Hedegaard M, Lidegaard OE, Skovlund CW, Mørch LS, Hedegaard M. Reduction in stillbirths at term after new birth induction paradigm. Results of a national intervention. BMJ Open. 2014 Aug 14;4(8):e005785. doi: 10.1136/bmjopen-2014-005785

16. Authors’ Affiliations Ms. Mette HEDEGAARD 1, MS Dr. Øjvind LIDEGAARD 1, DMSc Ms. Charlotte W. SKOVLUND 1, M.Sc. Ms. Lina S. MØRCH 1, Ph. D. Dr. Morten HEDEGAARD 2, Ph. D. 1) Department of Gynaecology, Rigshospitalet, Faculty of Health Science, University of Copenhagen, Denmark. 2) Department of Obstetrics, Rigshospitalet, Faculty of Health Science, University of Copenhagen, Denmark. Correspondance to: oejvind.lidegaard@regionh.dk