Cost of Elective Labor Induction Compared With Expectant Management in Nulliparous Women

Objective Findings of the recent ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial, showing reduced cesarean risk with elective labor induction among low-risk nulliparous women at 39 weeks' gestation, have the potential to change interventional delivery practices but require examination in wider populations. The aim of this study was to identify whether term induction of labor was associated with reduced cesarean delivery risk among women with obesity, evaluating several maternal characteristics associated with obesity, induction, and cesarean risk. Study Design We studied administrative records for 66,280 singleton, term births to women with a body mass index ≥30, without a prior cesarean delivery, in New York City from 2008 to 2013. We examined elective inductions in 39 and 40 weeks' gestation and calculated adjusted risk ratios for cesarean delivery risk, stratified by parity and maternal age. We additionally evaluated medically indicated inductions at 37 to 40 weeks among women with obesity and diabetic or hypertensive disorders, comorbidities that are strongly associated with obesity. Results Elective induction of labor was associated with a 25% (95% confidence interval: 19–30%) lower adjusted risk of cesarean delivery as compared with expectant management at 39 weeks of gestation and no change in risk at 40 weeks. Patterns were similar when stratified by parity and maternal age. Risk reductions in week 39 were largest among women with a prior vaginal delivery. Women with comorbidities had reduced cesarean risk with early term induction and in 39 weeks. Conclusion Labor induction at 39 weeks was consistently associated with reduced risk of cesarean delivery among women with obesity regardless of parity, age, or comorbidity status. Cesarean delivery findings from induction trials at 39 weeks among low-risk nulliparous women may generalize more broadly across the U.S. obstetric population, with potentially larger benefit among women with a prior vaginal delivery. Key Points

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Faculty Opinions recommendation of Duration of labor induction in nulliparous women at term: how long is long enough?

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1118884.574989 ◽

2008 ◽

Author(s):

John Svigos ◽

Alison Munt

Keyword(s):

Labor Induction ◽

Nulliparous Women

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Uterine Cervical Change at Term Examined Using Ultrasound Elastography: A Longitudinal Study

Journal of Clinical Medicine ◽

10.3390/jcm10010075 ◽

2020 ◽

Vol 10 (1) ◽

pp. 75

Author(s):

Hyun Soo Park ◽

Hayan Kwon ◽

Ja-Young Kwon ◽

Yun Ji Jung ◽

Hyun-Joo Seol ◽

...

Keyword(s):

Longitudinal Study ◽

Cervical Length ◽

Labor Induction ◽

Ultrasound Elastography ◽

Antenatal Visit ◽

Mean Values ◽

Nulliparous Women ◽

Hardness Ratio ◽

Cesarean Delivery Rate ◽

Time Of Admission

The aim of the study was to investigate if there are changes in elastographic parameters in the cervix at term around the time of delivery and if there are differences in the parameters between women with spontaneous labor and those without labor (labor induction). Nulliparous women at 36 weeks of gestation eligible for vaginal delivery were enrolled. Cervical elastography was performed and cervical length were measured using the E-CervixTM system (WS80A Ultrasound System, Samsung Medison, Seoul, Korea) at each weekly antenatal visit until admission for spontaneous labor or labor induction. E-Cervix parameters of interest included elasticity contrast index (ECI), internal os strain mean level (IOS), external os strain mean level (EOS), IOS/EOS strain mean ratio, strain mean level, and hardness ratio. Regression analysis was performed using days from elastographic measurement at each visit to admission for delivery and the presence or absence of labor against cervical length, and each E-Cervix parameter fitted to a linear model for longitudinal data measured repeatedly. A total of 96 women were included in the analysis, (spontaneous labor, n = 39; labor induction, n = 57). Baseline characteristics were not different between the two groups except for cesarean delivery rate. Cervical length decreased with advancing gestation and was different between the two groups. Most elastographic parameters including ECI, IOS, EOS, strain mean, and hardness ratio were significantly different between the two groups. In addition, ECI, IOS, and strain mean values significantly increased with advancing gestation. Our longitudinal study using ultrasound elastography indicated that E-cervix parameters tended to change linearly at term near the time of admission for delivery and that there were differences in E-Cervix parameters according to the presence or absence of labor.

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47 A Double-Blinded Randomized Controlled Trial on Increased Intravenous Hydration in Nulliparous Women Undergoing Labor Induction

American Journal of Obstetrics and Gynecology ◽

10.1016/j.ajog.2020.12.012 ◽

2021 ◽

Vol 224 (2) ◽

pp. S33-S34

Author(s):

Jennifer Duffy ◽

Erica Wu ◽

Alex Fong ◽

Thomas J. Garite ◽

Vineet Shrivastava

Keyword(s):

Randomized Controlled Trial ◽

Controlled Trial ◽

Labor Induction ◽

Randomized Controlled ◽

Nulliparous Women ◽

Intravenous Hydration ◽

Double Blinded

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Labor Induction vs. Expectant Management of Low-Risk Pregnancy

New England Journal of Medicine ◽

10.1056/nejmc1812323 ◽

2018 ◽

Vol 379 (23) ◽

pp. 2277-2279 ◽

Cited By ~ 2

Keyword(s):

Expectant Management ◽

Labor Induction ◽

Low Risk ◽

Risk Pregnancy ◽

Low Risk Pregnancy

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Reduction of maternal and neonatal harm through prevention of the primary Cesarean section

University of Western Ontario Medical Journal ◽

10.5206/uwomj.v85i2.2222 ◽

2016 ◽

Vol 85 (2) ◽

pp. 19-21

Author(s):

Andrew Welton

Keyword(s):

Cesarean Section ◽

Vaginal Delivery ◽

Common Knowledge ◽

Multiple Pregnancy ◽

Expectant Management ◽

Breech Presentation ◽

Active Phase ◽

External Cephalic Version ◽

Second Stage ◽

Nulliparous Women

While there are clear life-saving indications for Cesarean section (C-section), rates of this procedure have seen a continued rise without a concomitant improvement in maternal or neonatal outcomes. There is some evidence that outcomes may actually be worse for low-risk C-sections versus vaginal delivery. However, this is not necessarily common knowledge for healthcare providers, and therefore, their patients. Measures to safely reduce the C-section rate target management of labour arrest and specific indications for progression to C-section. In the active phase of the first stage of labour, C-section should be considered only in cases of failure to progress after 4 hours of adequate uterine contraction, or 6 hours of inadequate contraction. In the second stage of labour, expectant management of 3 hours of pushing in nulliparous women and 2 hours in multiparous women is safe and appropriate. Furthermore, manual rotation and operative vaginal delivery in the second stage are reasonable alternatives to C-section. Expectant management is also appropriate for certain non-reassuring fetal heart rate tracings. In post-dates pregnancies, induction of labour reduces both rates of C-section and neonatal mortality. Finally, evidence supports the use of external cephalic version in breech presentation as well as a more conservative approach to suspected macrosomia and multiple pregnancy. Taken together, these measures target the most common indications for progression to C-section and can allow us to safely reduce the C-section rate. Educating patients and physicians on the risks of the procedure and reasonable alternatives can improve outcomes for mothers and neonates.

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