Elective induction of labor at 39 weeks compared with expectant management

a meta-analysis of cohort studies

William A. Grobman, Aaron Caughey

Research output: Contribution to journalReview article

4 Citations (Scopus)

Abstract

Background: Elective induction of labor at 39 weeks among low-risk nulliparous women has reduced the chance of cesarean and other adverse maternal and perinatal outcomes in a randomized trial, although its clinical effectiveness in nonresearch settings remains uncertain. Objective: To perform a systematic review of observational studies that compared elective induction of labor at 39 weeks among nulliparous women with expectant management and to use meta-analytic techniques to estimate the association of elective induction with cesarean delivery, as well as other maternal and perinatal outcomes. Study Design: Studies were eligible for this meta-analysis only if they: (1) were observational; (2) compared women undergoing labor induction at 39 weeks with women undergoing expectant management beyond that gestational age; (3) included women in the induction group only if they had no other indication for labor induction at 39 weeks; and (4) provided data specifically for nulliparous women. The predefined primary outcome was cesarean delivery, and secondary outcomes representing other maternal and perinatal morbidities also were evaluated. Outcome data from different studies were combined to estimate pooled relative risks with 95% confidence intervals using random-effects models. Results: Of 375 studies identified by the initial search, 6 cohort studies, which included 66,019 women undergoing elective labor induction at 39 weeks and 584,390 undergoing expectant management, met inclusion criteria. Elective induction of labor at 39 weeks was associated with a significantly lower frequency of cesarean delivery (26.4% vs 29.1%; relative risk, 0.83; 95% confidence interval, 0.74–0.93), as well as of peripartum infection (2.8% vs 5.2%; relative risk, 0.53; 95% confidence interval, 0.39–0.72). Neonates of women in the induction group were less likely to have respiratory morbidity (0.7% vs 1.5%; relative risk, 0.71; 95% confidence interval, 0.59–0.85); meconium aspiration syndrome (0.7% vs 3.0%; relative risk, 0.49; 95% confidence interval, 0.26–0.92); and neonatal intensive care unit admission (3.5% vs 5.5%; relative risk, 0.80; 95% confidence interval, 0.72–0.88). There also was a lower risk of perinatal mortality (0.04% vs 0.2%; relative risk, 0.27; 95% confidence interval, 0.09–0.76). Conclusion: This meta-analysis of 6 cohort studies demonstrates that elective induction of labor at 39 weeks, compared with expectant management beyond that gestational age, was associated with a significantly lower risk of cesarean delivery, maternal peripartum infection, and perinatal adverse outcomes, including respiratory morbidity, intensive care unit admission, and mortality.

Original languageEnglish (US)
JournalAmerican journal of obstetrics and gynecology
DOIs
StatePublished - Jan 1 2019

Fingerprint

Induced Labor
Meta-Analysis
Cohort Studies
Confidence Intervals
Mothers
Peripartum Period
Morbidity
Gestational Age
Meconium Aspiration Syndrome
Perinatal Mortality
Neonatal Intensive Care Units
Infection
Observational Studies
Intensive Care Units
Newborn Infant

Keywords

  • cesarean delivery
  • elective labor induction
  • labor induction
  • low risk
  • maternal complications
  • nulliparity
  • nulliparous
  • observational studies
  • perinatal complications

ASJC Scopus subject areas

  • Obstetrics and Gynecology

Cite this

@article{2da9be2f7e3b46278aa20d24bf054ffd,
title = "Elective induction of labor at 39 weeks compared with expectant management: a meta-analysis of cohort studies",
abstract = "Background: Elective induction of labor at 39 weeks among low-risk nulliparous women has reduced the chance of cesarean and other adverse maternal and perinatal outcomes in a randomized trial, although its clinical effectiveness in nonresearch settings remains uncertain. Objective: To perform a systematic review of observational studies that compared elective induction of labor at 39 weeks among nulliparous women with expectant management and to use meta-analytic techniques to estimate the association of elective induction with cesarean delivery, as well as other maternal and perinatal outcomes. Study Design: Studies were eligible for this meta-analysis only if they: (1) were observational; (2) compared women undergoing labor induction at 39 weeks with women undergoing expectant management beyond that gestational age; (3) included women in the induction group only if they had no other indication for labor induction at 39 weeks; and (4) provided data specifically for nulliparous women. The predefined primary outcome was cesarean delivery, and secondary outcomes representing other maternal and perinatal morbidities also were evaluated. Outcome data from different studies were combined to estimate pooled relative risks with 95{\%} confidence intervals using random-effects models. Results: Of 375 studies identified by the initial search, 6 cohort studies, which included 66,019 women undergoing elective labor induction at 39 weeks and 584,390 undergoing expectant management, met inclusion criteria. Elective induction of labor at 39 weeks was associated with a significantly lower frequency of cesarean delivery (26.4{\%} vs 29.1{\%}; relative risk, 0.83; 95{\%} confidence interval, 0.74–0.93), as well as of peripartum infection (2.8{\%} vs 5.2{\%}; relative risk, 0.53; 95{\%} confidence interval, 0.39–0.72). Neonates of women in the induction group were less likely to have respiratory morbidity (0.7{\%} vs 1.5{\%}; relative risk, 0.71; 95{\%} confidence interval, 0.59–0.85); meconium aspiration syndrome (0.7{\%} vs 3.0{\%}; relative risk, 0.49; 95{\%} confidence interval, 0.26–0.92); and neonatal intensive care unit admission (3.5{\%} vs 5.5{\%}; relative risk, 0.80; 95{\%} confidence interval, 0.72–0.88). There also was a lower risk of perinatal mortality (0.04{\%} vs 0.2{\%}; relative risk, 0.27; 95{\%} confidence interval, 0.09–0.76). Conclusion: This meta-analysis of 6 cohort studies demonstrates that elective induction of labor at 39 weeks, compared with expectant management beyond that gestational age, was associated with a significantly lower risk of cesarean delivery, maternal peripartum infection, and perinatal adverse outcomes, including respiratory morbidity, intensive care unit admission, and mortality.",
keywords = "cesarean delivery, elective labor induction, labor induction, low risk, maternal complications, nulliparity, nulliparous, observational studies, perinatal complications",
author = "Grobman, {William A.} and Aaron Caughey",
year = "2019",
month = "1",
day = "1",
doi = "10.1016/j.ajog.2019.02.046",
language = "English (US)",
journal = "American Journal of Obstetrics and Gynecology",
issn = "0002-9378",
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TY - JOUR

T1 - Elective induction of labor at 39 weeks compared with expectant management

T2 - a meta-analysis of cohort studies

AU - Grobman, William A.

AU - Caughey, Aaron

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Background: Elective induction of labor at 39 weeks among low-risk nulliparous women has reduced the chance of cesarean and other adverse maternal and perinatal outcomes in a randomized trial, although its clinical effectiveness in nonresearch settings remains uncertain. Objective: To perform a systematic review of observational studies that compared elective induction of labor at 39 weeks among nulliparous women with expectant management and to use meta-analytic techniques to estimate the association of elective induction with cesarean delivery, as well as other maternal and perinatal outcomes. Study Design: Studies were eligible for this meta-analysis only if they: (1) were observational; (2) compared women undergoing labor induction at 39 weeks with women undergoing expectant management beyond that gestational age; (3) included women in the induction group only if they had no other indication for labor induction at 39 weeks; and (4) provided data specifically for nulliparous women. The predefined primary outcome was cesarean delivery, and secondary outcomes representing other maternal and perinatal morbidities also were evaluated. Outcome data from different studies were combined to estimate pooled relative risks with 95% confidence intervals using random-effects models. Results: Of 375 studies identified by the initial search, 6 cohort studies, which included 66,019 women undergoing elective labor induction at 39 weeks and 584,390 undergoing expectant management, met inclusion criteria. Elective induction of labor at 39 weeks was associated with a significantly lower frequency of cesarean delivery (26.4% vs 29.1%; relative risk, 0.83; 95% confidence interval, 0.74–0.93), as well as of peripartum infection (2.8% vs 5.2%; relative risk, 0.53; 95% confidence interval, 0.39–0.72). Neonates of women in the induction group were less likely to have respiratory morbidity (0.7% vs 1.5%; relative risk, 0.71; 95% confidence interval, 0.59–0.85); meconium aspiration syndrome (0.7% vs 3.0%; relative risk, 0.49; 95% confidence interval, 0.26–0.92); and neonatal intensive care unit admission (3.5% vs 5.5%; relative risk, 0.80; 95% confidence interval, 0.72–0.88). There also was a lower risk of perinatal mortality (0.04% vs 0.2%; relative risk, 0.27; 95% confidence interval, 0.09–0.76). Conclusion: This meta-analysis of 6 cohort studies demonstrates that elective induction of labor at 39 weeks, compared with expectant management beyond that gestational age, was associated with a significantly lower risk of cesarean delivery, maternal peripartum infection, and perinatal adverse outcomes, including respiratory morbidity, intensive care unit admission, and mortality.

AB - Background: Elective induction of labor at 39 weeks among low-risk nulliparous women has reduced the chance of cesarean and other adverse maternal and perinatal outcomes in a randomized trial, although its clinical effectiveness in nonresearch settings remains uncertain. Objective: To perform a systematic review of observational studies that compared elective induction of labor at 39 weeks among nulliparous women with expectant management and to use meta-analytic techniques to estimate the association of elective induction with cesarean delivery, as well as other maternal and perinatal outcomes. Study Design: Studies were eligible for this meta-analysis only if they: (1) were observational; (2) compared women undergoing labor induction at 39 weeks with women undergoing expectant management beyond that gestational age; (3) included women in the induction group only if they had no other indication for labor induction at 39 weeks; and (4) provided data specifically for nulliparous women. The predefined primary outcome was cesarean delivery, and secondary outcomes representing other maternal and perinatal morbidities also were evaluated. Outcome data from different studies were combined to estimate pooled relative risks with 95% confidence intervals using random-effects models. Results: Of 375 studies identified by the initial search, 6 cohort studies, which included 66,019 women undergoing elective labor induction at 39 weeks and 584,390 undergoing expectant management, met inclusion criteria. Elective induction of labor at 39 weeks was associated with a significantly lower frequency of cesarean delivery (26.4% vs 29.1%; relative risk, 0.83; 95% confidence interval, 0.74–0.93), as well as of peripartum infection (2.8% vs 5.2%; relative risk, 0.53; 95% confidence interval, 0.39–0.72). Neonates of women in the induction group were less likely to have respiratory morbidity (0.7% vs 1.5%; relative risk, 0.71; 95% confidence interval, 0.59–0.85); meconium aspiration syndrome (0.7% vs 3.0%; relative risk, 0.49; 95% confidence interval, 0.26–0.92); and neonatal intensive care unit admission (3.5% vs 5.5%; relative risk, 0.80; 95% confidence interval, 0.72–0.88). There also was a lower risk of perinatal mortality (0.04% vs 0.2%; relative risk, 0.27; 95% confidence interval, 0.09–0.76). Conclusion: This meta-analysis of 6 cohort studies demonstrates that elective induction of labor at 39 weeks, compared with expectant management beyond that gestational age, was associated with a significantly lower risk of cesarean delivery, maternal peripartum infection, and perinatal adverse outcomes, including respiratory morbidity, intensive care unit admission, and mortality.

KW - cesarean delivery

KW - elective labor induction

KW - labor induction

KW - low risk

KW - maternal complications

KW - nulliparity

KW - nulliparous

KW - observational studies

KW - perinatal complications

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DO - 10.1016/j.ajog.2019.02.046

M3 - Review article

JO - American Journal of Obstetrics and Gynecology

JF - American Journal of Obstetrics and Gynecology

SN - 0002-9378

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