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Maternal and newborn outcomes with elective induction of labor at term

Published:February 01, 2019DOI:https://doi.org/10.1016/j.ajog.2019.01.223

      Background

      A growing body of evidence supports improved or not worsened birth outcomes with nonmedically indicated induction of labor at 39 weeks gestation compared with expectant management. This evidence includes 2 recent randomized control trials. However, concern has been raised as to whether these studies are applicable to a broader US pregnant population.

      Objective

      Our goal was to compare outcomes for electively induced births at ≥39 weeks gestation with those that were not electively induced.

      Study Design

      We conducted a retrospective cohort study using chart-abstracted data on births from January 1, 2012, to December 31, 2017, at 21 hospitals in the Northwest United States. The study was restricted to singleton cephalic hospital births at 39+0–42+6 weeks gestation. Exclusions included previous cesarean birth, missing data for delivery type or gestational week at birth, antepartum stillbirth, cesarean birth without any attempt at vaginal birth, fetal anomaly, gestational diabetes mellitus, prepregnancy diabetes mellitus, and prepregnancy hypertension. The rate of cesarean birth for elective inductions at both 39 and 40 weeks gestation was compared with the rate in all other on-going pregnancies in the same gestational week. Maternal outcomes (operative vaginal birth, shoulder dystocia, 3rd- or 4th-degree perineal laceration, pregnancy-related hypertension, and postpartum hemorrhage) and newborn infant outcomes (macrosomia, 5-minute Apgar <7, resuscitation at delivery, intubation, respiratory complications, and neonatal intensive care unit admission) were also compared between elective inductions and on-going pregnancies at 39 and 40 weeks gestation. Logistic regression modeling was used to produce odds ratios for outcomes with adjustment for maternal age and body mass index. Results were stratified by parity and gestational week at birth. Duration of hospital stay (admission to delivery, delivery to discharge, and total stay) were compared between elective inductions and on-going pregnancies.

      Results

      A total of 55,694 births were included in the study cohort: 4002 elective inductions at ≥39+0 weeks gestation and 51,692 births at 39+0–42+6 weeks gestation that were not electively induced. In nulliparous women, elective induction at 39 weeks gestation was associated with a decreased likelihood of cesarean birth (14.7% vs 23.2%; adjusted odds ratio, 0.61; 95% confidence interval, 0.41–0.89) and an increased rate of operative vaginal birth (18.5% vs 10.8%; adjusted odds ratio, 1.8; 95% confidence interval, 1.28–2.54) compared with on-going pregnancies. In multiparous women, cesarean birth rates were similar in the elective inductions and on-going pregnancies. Elective induction at 39 weeks gestation was associated with a decreased likelihood of pregnancy-related hypertension in nulliparous (2.2% vs 7.3%; adjusted odds ratio, 0.28; 95% confidence interval, 0.11–0.68) and multiparous women (0.9% vs 3.5%; adjusted odds ratio, 0.24; 95% confidence interval, 0.15–0.38). Term elective induction was not associated with any statistically significant increase in adverse newborn infant outcomes. Elective induction of labor at 39 weeks gestation was associated with increased time from admission to delivery for both nulliparous (1.3 hours; 95% confidence interval, 0.2–2.3) and multiparous women (3.4 hours; 95% confidence interval, 3.2–3.6).

      Conclusion

      Elective induction of labor at 39 weeks gestation is associated with a decrease in cesarean birth in nulliparous women, decreased pregnancy-related hypertension in multiparous and nulliparous women, and increased time in labor and delivery. How to use this information remains the challenge.

      Key words

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      Linked Article

      • Induction of labor at term
        American Journal of Obstetrics & GynecologyVol. 221Issue 1
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          Souter et al1 have presented a careful and comprehensive evaluation of outcomes after elective induction of labor compared with expectant management. These authors have joined the ranks of others who offer labor induction at 39 weeks gestation as a favorable alternative to expectant management. An explanation for the findings of these groups is that expectant management is associated with a higher prevalence of preeclampsia and with larger babies, which are findings that were confirmed in the ARRIVE trial.
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        American Journal of Obstetrics & GynecologyVol. 221Issue 1
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          We appreciate Dr Scialli’s thoughtful comments about our study on elective induction of labor (IOL) at term and his concerns about current obstetric practices that contribute to high rates of intervention in births beyond 39 gestational weeks.1
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