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Clinical inquiries. What are the risks and benefits of elective induction for uncomplicated term pregnancies?
Abstract
Induction of labor is a viable therapeutic option when the benefits of timely delivery outweigh the risks of unnecessary cesarean section or prematurity. Two large retrospective studies support the concept that cesarean section rates and admissions to neonatal intensive care units are higher with elective induction as opposed to expectant management (TABLE). A large population-based study suggests that the higher cesarean section rates in elective induction is present only among nulliparous women; in multiparous women, the rate is the same as expectant management. Contrasting these results are those of a large systematic review, which found lower cesarean section rates in electively induced women. Two more recent studies, a retrospective cohort study and a randomized controlled trial, found a much lower incidence of cesarean section and operative vaginal deliveries among induced vs expectantly managed women at term.
... Whether an induction of labor is elective for an uncomplicated, full term pregnancy or a pregnancy before 39 weeks gestation, there can be added costs and legal risks (Santana and Meyer 2006). Because an elective induction of labor requires cervical ripening, extra ...
... monitoring, and medications to promote uterine contractions, elective inductions always incur added costs which are described in more detail in the Cost Savings section of this report (Santana and Meyer 2006). It has been found that the induction of labor is also associated with healthrelated complications for both the mother and baby (ACOG 2009). ...
To evaluate the effect of implementing hospital policies aimed at reducing elective labor induction and increasing spontaneous labor rates.
PubMed, CINAHL, Cochrane Database of Systematic Reviews, and Dissertation Abstracts International.
Observational studies published from 2000 to 2010 were the only original studies from the past 20 years that met the review criteria. These focused on elective induction, labor induction policies, pre- and postimplementation of labor induction policy outcomes, and cesarean and maternal/neonatal morbidity rates.
Six retrospective and three prospective observational studies regarding implementation of labor induction policies were reviewed for types of intervention guidelines implemented and outcomes on rates of induction, cesarean, and maternal/neonatal morbidity.
Implementation of elective induction policies resulted in lower induction, cesarean, operative/instrumental vaginal delivery, and maternal/neonatal morbidity rates. Patients spontaneously gave birth before scheduled elective induction date after policies were implemented, thereby resulting in lower rates of elective induction.
Elective labor induction policies should be developed and implemented in all labor and delivery units.
To determine the prevalence of and reasons for induction of labor on maternal request in a setting where aversion to induction of labor is the norm.
Women undergoing induction of labor on maternal request at three maternity centers in Enugu, Nigeria were interviewed by means of pre-tested self-administered questionnaires. The outcomes of labor in these women were also compared with those of a control group consisting of women who had induction of labor for medical reasons.
The prevalence of induction of labor on maternal request was 7.4%. Maternal convenience was the commonest reason for request induction. The outcomes of labor were similar between the subjects and their controls.
Nigerian women are beginning to request induction of labor without medical indications and have comparable outcomes with those who have medical indications. There is need for appropriate regulatory guidelines.
To determine if elective induction (IND) increases the risk of cesarean delivery compared to expectant management (EM).
A randomized clinical trial involving women 39 weeks' gestation, according to strict dating criteria, with a Bishop score of 5 or more in nulliparous patients and 4 or more in multiparous patients. The control group was expectantly managed and delivered for obstetric indications, but not later than 42 weeks' gestation. The study had 80% power to detect a three-fold increase in cesarean delivery.
One-hundred-and-sixteen patients (45 nulliparous) were randomized to IND and 110 (58 nulliparous) to EM. Demographic characteristics were no different between the groups. The cesarean delivery rate in the IND group was 6.9% (8/116) compared to 7.3% (8/110) in the EM group (p = NS). Rates of cesarean delivery for nulliparous patients randomized to IND compared to EM were also not significantly different: 13.3% (6/45) versus 10.3% (6/58) respectively (p = NS). Neonates delivered of IND patients weighed less than those of the EM group (3459 +/- 347 versus 3604 +/- 438, p = 0.006).
In women with favorable Bishop scores, elective induction of labor resulted in no increase in cesarean delivery compared to expectant management.
This study was undertaken to examine associations between induction of labor and maternal and neonatal outcomes among women without an identified indication for induction.
This was a population-based cohort study of 2886 women with induced labor and 9648 women with spontaneous labor who were delivered at 37 to 41 weeks' gestation, all without identified medical and obstetric indications for induction.
Among nulliparous women 19% of women with induced labor versus 10% of those with spontaneous labor underwent cesarean delivery (adjusted relative risk, 1.77; 95% confidence interval, 1.50-2.08). No association was seen in multiparous women (relative risk, 1.07; 95% confidence interval, 0. 81-1.39). Among all women induction was associated with modest increases in instrumental delivery (19% vs 15%; relative risk, 1.20; 95% confidence interval, 1.09-1.32) and shoulder dystocia (3.0% vs 1. 7%; relative risk, 1.32; 95% confidence interval, 1.02-1.69).
Among women who lacked an identified indication for induction of labor, induction was associated with increased likelihood of cesarean delivery for nulliparous but not multiparous women and with modest increases in the risk of instrumental delivery and shoulder dystocia for all women.
Post-term pregnancy (longer than 42 weeks or 294 days) occurs in approximately 10% of all singleton gestations. The adverse outcomes of post-term pregnancy include a substantial increase in perinatal mortality and morbidity. ACOG currently recommends induction of labor for low-risk pregnancy during the 43rd week of gestation. However, that recommendation dates from 1989. Recent reports mandate reconsideration of the management of post-term pregnancy, including reinterpretation of the statistical risk of stillbirth in post-term pregnancies using ongoing (undelivered) rather than delivered pregnancies as the denominator, which shows a far higher risk to post-term fetuses than believed. Recent data also suggest that the risk of cesarean delivery after induction of labor at term is lower than reported, possibly because of improvements in methods for cervical ripening. Those findings provide rationale for earlier labor induction in low-risk pregnancies.
Our objective was to evaluate the risks of maternal and perinatal morbidity associated with induction of labour in uncomplicated term pregnancies. We conducted a retrospective cohort study including 7,430 women, not referred from another institution, with a single baby in vertex presentation, and delivering between 38 and 40 weeks of pregnancy. Among these women, 3,546 were excluded for prelabour pregnancy complications. Relative risks (RR), adjusted for parity, were computed to compare 3,353 women who went into labour spontaneously with 531 women whose labour was induced. Induction of labour was found to be associated with a higher risk of caesarean section [RR = 2.4, 95% CI 1.8, 3.4]. Use of non-epidural [RR = 1.5, 95% CI 1.2, 1.8] and of epidural analgesia [RR = 1.4, 95% CI 1.1, 1.7] was more frequent after labour induction. Resuscitation [RR = 1.2, 95% CI 1.0, 1.5], admission to the intensive care unit [RR = 1.6, 95% CI 1.0, 2.4] and phototherapy [RR = 1.3, 95% CI 1.0, 1.6] were more frequent after induction of labour. Results were similar when controlling simultaneously for parity, maternal age, gestational age, year of delivery, birthweight and the physician in charge of delivery in a logistic regression analysis. The results of this study suggests that induction of labour is associated with a higher risk of caesarean section and of some perinatal adverse outcomes. Induction of labour should be reserved for cases where maternal and perinatal benefits outweigh the risk of these complications.
To determine whether elective induction of labor in nulliparous women is associated with changes in fetomaternal outcome when compared with labor of spontaneous onset. Study Design: All 80 labor wards in Flanders (Northern Belgium) comprised a matched cohort study. From 1996 through 1997, 7683 women with elective induced labor and 7683 women with spontaneous labor were selected according to the following criteria: nulliparity, singleton pregnancy, cephalic presentation, gestational age at the time of delivery of 266 to 287 days, and birth weight between 3000 and 4000 g. Each woman with induced labor and the corresponding woman with spontaneous labor came from the same labor ward, and they had babies of the same sex. Both groups were compared with respect to the incidence of cesarean delivery or instrument delivery and the incidence of transfer to the neonatal ward.
Cesarean delivery (9.9% vs 6.5%), instrumental delivery (31.6% vs 29.1%), epidural analgesia (80% vs 58%), and transfer of the baby to the neonatal ward (10.7% vs 9.4%) were significantly more common (P <.01) when labor was induced electively. The difference in cesarean delivery was due to significantly more first-stage dystocia in the induced group. The difference in neonatal admission could be attributed to a higher admission rate for maternal convenience when the women had a cesarean delivery.
When compared with labor of spontaneous onset, elective labor induction in nulliparous women is associated with significantly more operative deliveries. Nulliparous women should be informed about this before they submit to elective induction.
To compare routine labor induction with expectant management for patients who reach or exceed 41 weeks' gestation.
Computerized databases, references in published studies, and textbook chapters in all languages were used to identify randomized controlled trials (RCTs) evaluating induction and expectant management of labor for postterm pregnancies.
We identified RCTs that compared induction and expectant management for uncomplicated, singleton, live pregnancies of at least 41 weeks' gestation and evaluated at least one of the following: perinatal mortality, mode of delivery, meconium-stained fluid, meconium aspiration syndrome, meconium below the cords, fetal heart rate (FHR) abnormalities during labor, cesarean deliveries for FHR abnormalities, abnormal Apgar scores, and neonatal intensive care unit (NICU) admissions. The primary outcomes assessed were cesarean delivery rate and perinatal mortality.
Sixteen studies met inclusion criteria for this review. For each study with binary outcomes, an odds ratio (OR) with 95% confidence intervals (CIs) was calculated for selected outcomes. Estimates of ORs for dichotomous outcomes were calculated using fixed and random-effects models. Homogeneity was tested across the studies. Compared with women allocated to expectant management, those who underwent labor induction had lower cesarean delivery rates (20.1% versus 22.0%) (OR 0.88; 95% CI 0.78, 0.99). Although subjects whose labor was induced experienced a lower perinatal mortality rate (0.09% versus 0.33%) (OR 0.41; 95% CI 0.14, 1.18), this difference was not statistically significant. Similarly, no significant differences were noted for NICU admission rates, meconium aspiration, meconium below the cords, or abnormal Apgar scores.
A policy of labor induction at 41 weeks' gestation for otherwise uncomplicated singleton pregnancies reduces cesarean delivery rates without compromising perinatal outcomes.
The purpose of this study was to determine whether exposure to an alternative method of care, called the active management of risk in pregnancy at term, was associated with a lower group cesarean delivery rate.
Active management of risk in pregnancy at term used risk factors for cesarean delivery to guide an increased use of labor induction. A retrospective cohort design was used to compare clinical outcomes of 100 pregnant women who were exposed to active management of risk in pregnancy at term to 300 randomly selected subjects who received standard management.
The 2 groups had comparable levels of prenatal risk. The group exposed to the active management of risk in pregnancy at term exposure group encountered a higher induction rate (63% vs 25.7%; P < .001) and a lower cesarean delivery rate (4% vs 16.7%; P = .01). Findings were similar for both nulliparous and multiparous subgroups. Active management of risk in pregnancy at term exposure was not associated with higher rates of other major birth outcomes.
Exposure to the active management of risk in pregnancy at term exposure was associated with a significantly lower group cesarean delivery rate. A prospective randomized trial that involved active management of risk in pregnancy at term exposure is needed to further explore this association.