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OBSTETRICS
Cite this article as: Gibson KS, Waters TP, Bailit JL. Maternal and neonatal outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol
2014;211:249.e1-16.
supporting this teaching compared induction of labor with spontaneous labor,4 rather than the true clinical
alternative of expectant management.5
Several studies have presented information refuting the association of induction with increased cesarean delivery.6-9
Two large prospective multicenter studies
of late term (41 weeks gestational age)
pregnancies found no difference6,7 or a
decreased rate of cesarean delivery8 in
elective inductions vs expectant management. A metaanalysis reported an absolute
risk reduction in cesarean delivery rate
with elective induction of 1.9% (95%
condence interval [CI], 0.2e3.7%) for
late term and postterm pregnancies.9
Similar ndings have been reported
across different obstetric cohorts,
including those with hypertensive disease,10 fetal growth restriction,11 and
diabetes.12,13
Three recent retrospective analyses
found no increase in operative delivery
with induction of labor14 and a decrease in
the cesarean delivery rate among nulliparous women delivering at 39-42 weeks
gestational age15 and all women delivering
in the term period (37-40 weeks).16 Cheng
et al15 also reported improvement in other
associated neonatal morbidities including
meconium aspiration, 5-minute Apgar
<7, infection, ventilator use, composite
morbidity, and neonatal intensive care
unit (ICU) admission with induction at 39
weeks gestation. Using discharge and
birth certicate data, Darney et al16 also
recently found a reduction in cesarean
deliveries with induction of labor
compared to expectant management at
37, 38, 39, and 40 weeks of gestation.
Importantly, Darney et al16 also reported
no increase in neonatal ICU admission or
respiratory distress with elective induction
of labor, including those performed at 37
and 38 weeks of pregnancy.
To date, few studies have evaluated
maternal and neonatal outcomes with
elective induction of labor encompassing
all of the term period in a low-risk obstetric population.16,17 Only 2 small,
single-site studies included data on
249.e1
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FIGURE
M ATERIALS
The selection of our low-risk term cohort and the distribution of our final cohort into those electively
induced or expectantly managed by week of pregnancy.
HIV, human immunodeficiency virus.
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.
AND
M ETHODS
Study population
We selected our study cohort from the
database of the Consortium on Safe Labor, a study conducted by the Eunice
Kennedy Shriver National Institute of
Child Health and Human Development
(NICHD), National Institutes of Health.22
In brief, this was a retrospective crosssectional study involving deliveries from
2002 through 2008 from 12 clinical centers and 19 hospitals representing 9
American Congress of Obstetricians and
Gynecologists (ACOG) districts. The
population was then standardized by
assigning a weight to each subject using
ACOG district, maternal race/ethnicity,
parity, and plurality based on 2004 national data.22,23 Institutional review board
approval was obtained for this analysis.
The Figure presents the ow diagram
for our cohort selection. From the initial
data set of all nulliparous and multiparous women presenting for delivery,
we started with the rst singleton pregnancy for each woman (233,736). We
then limited the group to term gestations
of 37-42 weeks gestational age (178,575)
and in vertex presentation (155,848).
To limit confounding, we excluded
all those with a prior uterine scar or
planned (elective) cesarean delivery
(136,014). Finally, we excluded those
with chronic maternal conditions that
may lead to indicated delivery, including
diabetes mellitus, chronic hypertension,
cardiovascular disease, placental previa,
or human immunodeciency viruse
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positive status. Women who developed a
pregnancy-related complication such as
preeclampsia, gestational hypertension,
abruption, or fetal compromise were
included in the nal cohort of 131,243
low-risk women. If these complications
developed antepartum, the patients were
no longer a candidate for an elective induction of labor, and they were included
only in the expectant management arm
of the study. We then identied women
with an elective induction of labor.24 A
predened variable for induction of labor
was coded when either the patients
electronic medical record indicated that
there was an induction and/or a method
or start time for induction. This variable
did not include women receiving only
labor augmentation or those without at
least 2 vaginal examinations in the labor
progression database. Inductions were
categorized as indicated, elective, and
no recorded indication. Indications
for induction included all potential
maternal, fetal, or obstetric complications of pregnancy. If a site indicated that
the induction was elective, no other indications for induction were provided,
and there were no other obstetric, fetal,
or maternal conditions complicating the
pregnancy, then the induction was
designated elective. All other deliveries,
including the no recorded indication
category were included in the expectant
management group. Method of labor
induction included all methods for cervical ripening and induction with multiple methods was allowed.
Study outcomes
Subjects were divided by week of gestational age at delivery (Figure). Those
with an induction of labor coded as
elective were the cases at each week of
gestation (elective induction of labor).
Those not electively induced and who
delivered after that week of gestation
were considered to be expectantly managed in that week of gestation. For
example, the women who delivered in
their 37th week of gestation after an
elective induction were compared to
those who delivered in their 38th week
as they had been expectantly managed in
their 37th week. Mode of delivery was
categorized as a nonoperative vaginal
Research
TABLE 1
Demographic characteristics
Variable
Total (131,243)
Nulliparous
(64,376)
Parous
(66,867)
No.
No.
No.
Maternal age, y
19
14,012
10.7
12,270
19.1
1742
2.6
20-34
100,875
76.9
47,122
73.2
53,753
80.4
35
16,193
12.3
4917
7.6
11,276
16.9
163
0.1
67
0.1
96
0.1
African American
26,263
20.0
13,050
20.3
13,213
19.8
Caucasian
67,885
51.7
32,612
50.7
35,273
52.8
Hispanic
22,080
16.8
10,325
16.0
11,755
17.6
Missing
Race/ethnicity
Asian
5718
4.4
3406
5.3
2312
3.5
Other
9297
7.1
4983
7.7
4314
6.5
Normal/underweight (<25.0)
16,330
12.4
8543
13.3
7787
11.6
Overweight (25.0-29.9)
43,735
33.3
21,972
34.1
21,763
32.5
Obese (30.0-34.9)
28,590
21.8
13,500
21.0
15,090
22.6
18,972
14.5
8815
13.7
10,157
15.2
Missing
23,616
18.0
11,546
17.9
12,070
18.0
Private
75,200
57.3
36,491
56.7
38,709
57.9
Public
38,732
29.5
19,056
29.6
19,676
29.4
1517
1.2
750
1.2
767
1.1
15,794
12.0
8079
12.6
7715
11.5
University teaching
52,769
40.2
27,763
43.1
25,006
37.4
Community teaching
66,605
50.8
31,943
49.6
34,662
51.8
Community nonteaching
11,869
9.0
4670
7.3
7199
10.8
4
55,311
42.1
27,930
43.4
27,381
41.0
>4
75,932
57.9
36,446
56.6
39,486
59.0
37
12,470
9.5
5593
8.7
6877
10.3
38
27,449
20.9
12,213
19.0
15,236
22.8
39
44,970
34.3
19,965
31.0
25,005
37.4
40
34,262
26.1
19,158
29.8
15,104
22.6
41
12,092
9.2
7447
11.6
4645
6.9
Insurance
Self-pay
Other/missing
Hospital type
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.
(continued)
249.e3
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TABLE 1
Variable
Total (131,243)
Nulliparous
(64,376)
Parous
(66,867)
No.
No.
No.
Elective induction, wk
37
224
0.2
72
0.1
152
0.2
38
1344
1.0
404
0.6
940
1.4
39
7563
5.8
1576
2.5
5987
9.0
40
4111
3.1
2124
3.3
1987
3.0
Statistical analysis
Given that this is a descriptive analysis
with very large sample size, power calculations were not performed. The c2
and t tests were used where appropriate.
Demographic factors were controlled for
with logistic regression. Centers with
>5% missing data for an outcome were
removed from the analysis on that specic outcome. We performed all analyses
using statistical software (SAS, version
9.3; SAS Institute Inc, Cary, NC).
R ESULTS
Patients
Our low-risk patient population included
131,243 women. Table 1 presents the
maternal demographic characteristics for
Study outcomes
Table 2 presents the ndings of the primary outcome, mode of delivery.
Nonoperative vaginal delivery occurred
more often in the electively induced
group when compared to the expectantly
managed group at each week of gestation. Additionally, the frequency of both
operative vaginal delivery and cesarean
delivery was signicantly lower for the
electively induced group at each gestational age in both nulliparous and
multiparous patients with either a
favorable or unfavorable cervical status
on admission. The odds of a cesarean
delivery after an elective induction of
labor vs expectant management were
lower at each week of gestation after
controlling for possible confounding
factors in a logistic regression. (Adjusted
odds ratio for births at 37 weeks in
nulliparous patients with an unfavorable
cervix 0.40 [95% CI, 0.18e0.88]; 38
weeks 0.65 [95% CI, 0.49e0.85]; 39
weeks 0.47 [95% CI, 0.38e0.57]; 40
weeks 0.69 [95% CI, 0.59e0.81]; in
multiparous patients with a favorable
cervix at: 38 weeks 0.42 [95% CI,
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Research
TABLE 2
Mode of delivery by week of elective induction of labor compared to those expectantly managed by parity and
modified Bishop score
Nulliparous
Nonoperative vaginal delivery
Wk
37
eIOL
eIOL
Exp
No.
33/43
No.
aOR
95% CI
Wk
76.7
12,381/21,520
57.5
37
Exp
No.
No.
aOR
95% CI
24/28
85.7
24,503/33,486
73.2
38
190/285
66.7
9597/17,099
56.1
38
89/110
80.9
18,986/26,352
71.7
39
420/602
69.8
5524/10,404
53.1
39
720/955
75.4
9830/14,201
69.2
40
629/1094
57.5
1759/3509
50.1
40
634/917
69.1
2205/3292
67.0
No.
Exp
%
eIOL
No.
aOR
95% CI
Wk
No.
Exp
%
No.
aOR
95% CI
37
2/43
4.7
1786/21,520
8.3
0.444
0.106e1.861
37
3/28
10.7
4040/33,486
12.1
0.809
0.242e2.707
38
14/285
4.9
1449/17,099
8.5
0.493
0.285e0.854
38
12/110
10.9
3224/26,352
12.2
0.769
0.418e1.412
39
40/602
6.6
40
112/1094
10.2
876/10,404
8.4
0.522
0.373e0.732
39
157/955
16.4
1756/14,201
12.4
1.011
0.841e1.215
268/3509
7.6
0.865
0.669e1.120
40
167/917
18.2
392/3292
11.9
1.144
0.919e1.424
No.
aOR
95% CI
Cesarean delivery
Nulliparous and unfavorable
eIOL
Wk
No.
Exp
eIOL
No.
aOR
95% CI
Wk
No.
Exp
%
37
8/43
18.6
7353/21,520
34.2
0.402
0.183e0.884
37
1/28
3.6
4943/33,486
14.8
0.164
0.022e1.228
38
81/285
28.4
6053/17,099
35.4
0.647
0.494e0.847
38
9/110
8.2
4142/26,352
15.7
0.430
0.213e0.864
39
142/602
23.6
4004/10,404
38.5
0.466
0.381e0.569
39
78/955
8.2
2615/14,201
18.4
0.497
0.389e0.633
40
353/1094
32.3
1482/3509
42.3
0.689
0.588e0.807
40
116/917
12.7
695/3292
21.1
0.694
0.551e0.874
Multiparous
Nonoperative vaginal delivery
Multiparous and unfavorable
eIOL
Wk
No.
Exp
eIOL
No.
aOR
95% CI
Wk
Exp
No.
No.
aOR
95% CI
37
83/85
97.7
17,334/19,782
87.6
37
62/64
96.9
33,345/35,572
93.7
38
439/474
92.6
12,961/14,815
87.5
38
413/429
96.3
24,638/26,400
93.3
39
2006/2197
61.3
6036/7033
85.8
39
3446/3677
93.7
10,042/10,830
92.7
40
820/912
89.9
1716/2033
84.4
40
885/959
92.3
1963/2121
92.6
No.
Exp
eIOL
No.
aOR
95% CI
Wk
No.
Exp
%
No.
aOR
95% CI
37
0/85
0.0
733/19,782
3.7
37
2/64
3.1
1286/35,572
3.6
0.788
0.192e3.238
38
12/474
2.5
561/14,815
3.8
0.550
0.307e0.985
38
12/429
2.8
1010/26,400
3.8
0.610
0.342e1.089
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.
(continued)
249.e5
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TABLE 2
Mode of delivery by week of elective induction of labor compared to those expectantly managed by parity and
modified Bishop score (continued)
Operative vaginal delivery
Multiparous and unfavorable
eIOL
Exp
eIOL
Exp
Wk
No.
No.
aOR
95% CI
Wk
No.
39
125/2197
5.7
246/7033
3.5
1.139
0.879e1.477
39
204/3677
5.6
40
46/912
5.0
67/2033
3.3
1.091
0.701e1.698
40
58/959
6.1
No.
aOR
95% CI
402/10,830
3.7
1.242
1.017e1.516
67/2121
3.2
1.694
1.123e2.555
Cesarean delivery
Multiparous and unfavorable
eIOL
Wk
No.
Exp
%
No.
eIOL
%
aOR
95% CI
Wk
8.7
0.265
0.064e1.088
37
No.
Exp
%
No.
aOR
95% CI
0/64
0.0
941/35,572
2.7
37
2/85
2.4
1715/19,782
38
23/474
4.9
1293/14,815
8.7
0.553
0.360e0.850
38
4/429
0.9
752/26,400
2.9
0.421
0.156e1.137
39
66/2197
3.0
751/7033
10.7
0.346
0.262e0.456
39
27/3677
0.7
386/10,830
3.6
0.352
0.231e0.534
40
46/912
5.0
250/2033
12.3
0.437
0.307e0.622
40
16/959
1.7
4.3
0.536
0.297e0.968
91/2121A48
aOR is of the outcome compared to vaginal delivery for eIOL with expectant as the referent controlling for maternal age, race/ethnicity, body mass index at delivery, insurance, and type of hospital.
aOR, adjusted odds ratio; CI, confidence interval; eIOL, elective induction of labor; exp, expectant management.
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.
C OMMENT
Using a cohort of low-risk pregnancies
within the Consortium on Safe Labor
database, we examined maternal and
neonatal outcomes for women who were
electively induced compared to those
expectantly managed at each week of
term gestation. For our primary outcome
of mode of delivery, we observed a
reduction in cesarean section with elective induction, regardless of week of
gestation, parity, or cervical examination.
For secondary outcomes including maternal and neonatal morbidity, no
outcome was shown to be worse with
elective induction. Conversely, several
maternal outcomes including infectious
morbidity, obstetrical lacerations, and
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shoulder dystocia were reduced with induction of labor. For those electively
induced, we observed a reduction in
composite neonatal morbidities with induction of labor at 38, 39, and 40 weeks
gestation.
For decades, induction of labor was
reported to be associated with adverse
maternal and fetal outcomes, particularly for nulliparous women with an
unfavorable cervical examination <39
weeks gestation.4 However, many of
these investigations did not compare
induction to the only other clinical option: expectant management. In this
analysis, we chose to compare women
electively induced at a given week of
gestation to those managed until the
next week of pregnancy or later as this
attempts to capture both the risks and
benets of either choice. Our primary
nding of a decreased odds of cesarean
delivery with elective induction corroborate the ndings of more recent investigations5-18 that were based on
administrative data and birth certicate
registries. The data reported herein
move this area of study forward as the
Consortium on Safe Labor data set is
large with detailed medical record data,
including cervical examinations, allowing for analysis of morbidity by week
of gestation and by cervical ripeness
at delivery admission. Additionally, we
observed that induction of labor was
associated with a lower risk of maternal
infectious complications, shoulder dystocia, and neonatal composite morbidities. These data paint a consistent
picture that induction is potentially
associated with several other improvements in outcomes for mom and baby,
throughout the term period.
Prior publications have reported on
newborn morbidities by week of delivery19-21 and have consistently found
lower neonatal morbidities with increasing week of gestation at term.
However in these analyses morbidities
are only attributed to the week of birth
without consideration of other potential
causes, including the risks of waiting for
a later gestational age. Obstetric complications can occur while a patient is
attempting to obtain a later gestational
age including: abruption, cord prolapse,
Research
TABLE 3
Wk
Exp
%
No.
aOR
95% CI
37
No.
1/65
1.5
2990/42,230
7.1
0.211
0.029e1.521
38
12/368
3.3
2357/33,215
7.1
0.414
0.232e0.740
39
119/1401
8.5
1300/18,535
7.0
1.010
0.827e1.233
40
127/1569
8.1
317/5095
6.2
0.987
0.784e1.243
Exp
Wk
No.
No.
aOR
95% CI
37
0/72
0.0
97/44,728
0.2
38
0/399
0.0
69/35,117
0.2
39
0/1.566
0.0
45/19,600
0.2
40
4/2060
0.2
11/5124
0.2
0.984
0.273e3.552
Maternal infections
eIOL
Wk
No.
Exp
%
No.
aOR
95% CI
37
4/68
5.9
7155/46,978
15.2
0.345
0.125e0.952
38
23/382
6.0
5886/37,109
15.9
0.347
0.227e0.530
39
97/1540
6.3
3591/20,844
17.2
0.405
0.328e0.500
40
152/1881
8.1
1092/5600
19.5
0.454
0.377e0.546
No.
5/72
Exp
%
6.9
No.
aOR
95% CI
6206/58,783
10.6
0.767
0.308e1.910
38
35/404
8.7
4997/46,570
10.7
0.969
0.683e1.377
39
173/1576
11.0
2902/26,605
10.9
0.896
0.759e1.057
40
235/2124
11.1
790/7447
10.6
0.978
0.829e1.153
Shoulder dystocia
eIOL
Wk
No.
Exp
%
No.
aOR
95% CI
37
0/72
0.0
697/56,479
1.2
38
2/404
0.5
580/44,671
1.3
0.357
0.088e1.439
39
27/1576
1.7
341/25,402
1.3
1.292
0.865e1.929
40
29/2124
1.4
95/6997
1.4
1.134
0.732e1.757
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.
(continued)
249.e7
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TABLE 3
Multiparous
Wk
Exp
No.
No.
aOR
95% CI
37
9/132
6.8
3269/44,661
7.3
0.896
0.453e1.772
38
51/822
6.2
2382/33,184
7.2
0.703
0.526e0.939
39
597/5568
10.7
802/13,839
5.8
1.360
1.199e1.542
40
121/1571
7.7
165/3152
5.2
1.069
0.810e1.412
Exp
Wk
No.
No.
aOR
95% CI
37
1/149
0.4
140/46,345
0.3
3.596
0.482e26.832
38
1/932
0.1
107/34,119
0.3
0.755
0.104e5.498
39
9/5971
0.2
49/13,797
0.4
1.602
0.679e3.779
40
1/1935
0.1
15/2948
0.5
0.402
0.050e3.206
Maternal infections
eIOL
Wk
No.
Exp
%
No.
aOR
95% CI
37
1/141
0.7
1561/49,079
3.2
0.214
0.030e1.536
38
5/883
0.6
1211/36,637
3.3
0.196
0.081e0.475
39
47/5864
0.8
632/15,520
4.1
0.340
0.248e0.466
40
32/1798
1.8
151/3516
4.3
0.717
0.474e1.083
No.
Exp
%
No.
aOR
95% CI
37
5/152
3.3
1687/59,990
2.8
1.279
0.523e3.129
38
21/940
2.2
1286/44,754
2.9
0.846
0.546e1.312
39
116/5987
1.9
601/19,749
3.0
0.612
0.491e0.764
40
43/1987
2.2
136/4645
2.9
0.669
0.457e0.977
Shoulder dystocia
eIOL
Wk
No.
Exp
%
No.
aOR
95% CI
37
0/152
0.0
1084/57,306
1.9
38
8/940
0.9
878/42,710
2.1
0.424
0.211
0.856
39
114/5987
1.9
419/18,635
2.3
0.981
0.776
1.240
40
48/1987
2.4
93/4286
2.2
1.194
0.809
1.761
aOR is of the outcome compared to vaginal delivery for eIOL with expectant as the referent controlling for maternal age, race/
ethnicity, body mass index at delivery, insurance, type of hospital, and modified Bishop score.
aOR, adjusted odds ratio; CI, confidence interval; eIOL, elective induction of labor; exp, expectant management.
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.
Obstetrics
ajog.org
at 39 weeks gestation. We hope this
prospective trial will add clarity to the
issue of mode of delivery in the full term
period, though we believe this paper and
the paper by Darney et al16 demonstrate
the need to consider lowering gestational
age at study entry to earlier in the term
period.
Finally, the interpretation of our
ndings warrants caution. These data do
not attempt to dene what the best gestational age is for delivery at term. Rather,
we submit that our results demonstrate
that when maternal and newborn outcomes are analyzed through the prism of
the true clinical alternatives of induction
or waiting, the ndings may be drastically different than what has been reported previously. Clearly, these data
suggest that outcomes for mom and
baby are complex with competing interests. Evaluations that only consider
differences in observed neonatal morbidities by week of delivery paint an
incomplete picture as they do not account for the risks of waiting. As such,
we propose that the decision of timing of
delivery or best gestational age for delivery has not been fully answered by
current data or analyses. As the majority
of women in the United States deliver at
term, they deserve better data and analysis including large randomized trials,
which are powered to accurately account
for the potential risks and benets
of delivery vs non delivery for both
patients.
ACKNOWLEDGMENTS
The authors would like to thank S. Katherine
Laughon, MD, MS (Eunice Kennedy Shriver
National Institute of Child Health and Human
Development, National Institutes of Health,
Bethesda, MD) and Jun Zhang, PhD (Ministry of
Education and Shanghai Key Laboratory of
Childrens Environmental Health, Xinhua Hospital, Shanghai Jiaotong University School of
Medicine, Shanghai, China) for their assistance
in study design, data analysis, and manuscript
editing. Additionally, we would like to thank
Stephen Myers, DO (Division of Maternal Fetal
Medicine, Department of Obstetrics and Gynecology, MetroHealth Medical CentereCase
Western Reserve University, Cleveland, OH), for
his intellectual contribution to this topic.
The Consortium on Safe Labor was funded by
the Intramural Research Program of the Eunice
Kennedy Shriver National Institute of Child Health
Research
TABLE 4
Wk
Exp
%
No.
aOR
95% CI
37
No.
5/72
6.9
5033/58,783
%
8.6
0.782
0.314e1.947
38
16/404
4.0
4049/46,570
8.7
0.433
0.262e0.716
39
109/1576
6.9
2451/26,605
9.2
0.750
0.613e0.917
40
137/2124
6.5
743/7447
10.0
0.652
0.535e0.795
Exp
No.
1/72
No.
aOR
95% CI
1.4
1799/54,455
3.3
0.371
0.051e2.674
38
7/398
1.8
1467/43,110
3.4
0.465
0.219e0.986
39
30/1553
1.9
863/24,508
3.5
0.540
0.373e0.783
40
46/1963
2.3
265/6833
0.9
0.589
0.423e0.821
Perinatal death
eIOL
Exp
Wk
No.
No.
aOR
95% CI
37
0/72
0.0
202/56,479
0.4
38
0/404
0.0
158/44,671
0.4
39
2/1576
0.1
88/25,402
0.4
0.348
0.085e1.424
40
6/2124
0.3
17/6997
0.2
1.091
0.398e2.992
Multiparous
Wk
Exp
No.
No.
aOR
95% CI
9/152
5.9
3120/59,990
5.2
1.197
0.608e2.354
38
44/940
4.7
2213/44,754
4.9
0.981
0.721e1.334
39
179/5987
3.0
988/19,749
5.0
0.590
0.494e0.705
40
75/1987
3.8
232/4645
5.0
0.756
0.564e1.012
37
No.
Exp
%
No.
aOR
95% CI
37
8/145
5.5
1107/55,284
2.0
2.897
1.412e5.945
38
14/898
1.6
797/41,306
1.9
0.827
0.484e1.413
39
60/5884
1.0
365/18,037
2.0
0.574
0.424e0.778
40
27/1869
1.5
93/4198
2.2
0.685
0.424e1.109
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.
(continued)
249.e9
Research
Obstetrics
ajog.org
TABLE 4
Perinatal death
eIOL
Wk
No.
Exp
%
No.
aOR
95% CI
37
0/152
0.0
195/57,306
0.3
38
0/940
0.0
122/42,710
0.3
39
11/5987
0.2
57/18,635
0.3
0.781
0.376e1.625
40
3/1987
0.2
14/4286
0.3
0.630
0.163e2.429
aOR is of the outcome compared to vaginal delivery for eIOL with expectant as the referent controlling for maternal age, race/
ethnicity, body mass index at delivery, insurance, type of hospital, and modified Bishop score.
aOR, adjusted odds ratio; CI, confidence interval; eIOL, elective induction of labor; exp, expectant management.
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.
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Timing of elective repeat cesarean delivery at
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Delivery indications at late-preterm gestations
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23. Martin JA, Hamilton BE, Sutton PD,
Ventura SJ, Menacker F, Kirmeyer S. Births: nal
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e1-9.
Obstetrics
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Research
A PPENDIX
SUPPLEMENTAL TABLE 1
Mode of delivery by week of elective induction of labor compared to those expectantly managed within the same
week of delivery by parity and modified Bishop score
Nulliparous
Nonoperative vaginal delivery
Nulliparous and unfavorable
eIOL
Wk
Exp
No.
eIOL
No.
aOR
95% CI
Wk
Exp
No.
No.
aOR
95% CI
37
33/43
76.7
1502/3288
65.7
37
24/28
85.7
2366/2932
80.7
38
190/285
66.7
2594/4136
62.7
38
89/110
80.9
5428/7024
77.3
39
420/602
69.8
3653/6093
60.0
39
720/955
75.4
8436/11,196
75.4
40
629/1094
57.5
3136/5801
54.1
40
634/917
69.1
6991/9992
70.0
Exp
No.
eIOL
No.
aOR
95% CI
Wk
No.
Exp
%
No.
aOR
95% CI
37
2/43
4.7
161/2288
7.0
0.562
0.132e2.402
37
3/28
10.7
324/2932
11.1
0.978
0.290e3.301
38
14/285
4.9
323/4136
7.8
0.531
0.302e0.931
38
12/110
10.9
804/7024
11.5
0.863
0.468e1.594
39
40/602
6.6
533/6093
8.8
0.583
0.414e0.821
39
157/955
16.4
1311/11,196
11.7
1.209
1.002e1.458
40
112/1094
10.2
496/5801
8.6
0.830
0.655e1.050
40
167/917
18.2
1197/9992
12.0
1.215
1.006e1.467
Cesarean delivery
Nulliparous and unfavorable
eIOL
eIOL
No.
No.
Exp
aOR
95% CI
Wk
aOR
95% CI
37
8/43
18.6
625/2288
27.3
0.558
0.250e1.241
37
1/28
3.6
242/2932
8.3
0.327
0.043e2.459
38
81/285
28.4
1219/4136
29.5
0.848
0.641e1.122
38
9/110
8.2
792/7024
11.3
0.593
0.293e1.200
39
142/602
23.6
1907/6093
31.3
0.632
0.514e0.776
39
78/955
8.2
1449/11,196
12.9
0.735
0.574e0.942
40
353/1094
32.3
2169/5801
37.4
0.844
0.727e0.981
40
116/917
12.7
1804/9992
18.0
0.858
0.694e1.062
Wk
No.
Exp
No.
Multiparous
Nonoperative vaginal delivery
Wk
eIOL
eIOL
No.
Exp
No.
Exp
No.
aOR
95% CI
Wk
aOR
95% CI
37
83/85
97.7
2142/2437
87.9
37
62/64
96.9
3660/3850
95.1
38
439/474
92.6
3934/4493
87.6
38
413/429
96.3
8294/8743
94.9
39
2006/2197
61.3
4919/5585
88.1
39
3446/3677
93.7
11,150/11,893
93.8
40
820/912
89.9
3500/4088
85.6
40
885/959
92.3
7194/7750
92.8
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.
No.
e
(continued)
249.e11
Research
Obstetrics
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SUPPLEMENTAL TABLE 1
Mode of delivery by week of elective induction of labor compared to those expectantly managed within the same
week of delivery by parity and modified Bishop score (continued)
Operative vaginal delivery
Multiparous and unfavorable
eIOL
Wk
No.
Exp
%
No.
aOR
95% CI
Wk
Exp
No.
No.
aOR
95% CI
37
0/85
0.0
79/2437
3.2
37
2/64
3.1
104/3850
2.7
1.012
0.243e4.210
38
12/474
2.5
160/4493
3.6
0.566
0.309e1.035
38
12/429
2.8
264/8743
3.0
0.738
0.408e1.334
39
125/2197
5.7
190/5585
3.4
1.320
1.006e1.733
39
204/3677
5.6
404/11,893
3.4
1.291
1.065e1.564
40
46/912
5.0
133/4088
3.3
1.220
0.832e1.791
40
58/959
6.1
277/7750
3.6
1.476
1.077e2.023
aOR
95% CI
Cesarean delivery
Multiparous and unfavorable
eIOL
Wk
No.
Exp
%
No.
eIOL
%
aOR
95% CI
Wk
No.
Exp
%
No.
37
2/85
2.4
216/2437
8.9
0.283
0.068e1.173
37
0/64
0.0
86/3850
2.2
38
23/474
4.9
399/4493
8.9
0.486
0.313e0.755
38
4/429
0.9
185/8743
2.1
0.472
0.173e1.290
39
66/2197
3.0
476/5585
8.5
0.371
0.279e0.494
39
27/3677
0.7
339/11,893
2.9
0.437
0.288e0.664
40
46/912
5.0
455/4088
11.1
0.478
0.343e0.664
40
16/959
1.7
279/7750
3.6
0.664
0.392e1.123
aOR is of the outcome compared to vaginal delivery for eIOL with expectant as the referent controlling for maternal age, race/ethnicity, body mass index at delivery, insurance, and type of hospital.
aOR, adjusted odds ratio; CI, confidence interval; eIOL, elective induction of labor; exp, expectant management.
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.
Obstetrics
ajog.org
Research
SUPPLEMENTAL TABLE 2
Secondary maternal outcomes by week of elective induction of labor compared to those expectantly managed
within the same week of delivery divided by parity
Nulliparous
Wk
Exp
%
No.
aOR
95% CI
37
No.
1/65
1.5
332/4092
8.1
0.196
0.027e1.424
38
12/368
3.3
621/8647
7.2
0.481
0.266e0.867
39
119/1401
8.5
938/13,279
7.1
0.990
0.808e1.213
40
127/1569
8.1
856/11,871
7.2
0.827
0.674e1.013
Exp
Wk
No.
No.
aOR
95% CI
37
0/72
0.0
19/4432
0.4
38
0/399
0.0
28/9212
0.3
39
0/1.566
0.0
24/13,951
0.2
40
4/2060
0.2
30/12,416
0.2
0.803
0.271e2.378
aOR
95% CI
Maternal infections
eIOL
Wk
Exp
No.
No.
37
4/68
5.9
545/4514
12.1
0.436
0.157e1.211
38
23/382
6.0
1246/9487
13.1
0.440
0.286e0.677
39
97/1540
6.3
2198/14,725
14.9
0.466
0.377e0.577
40
152/1881
8.1
2347/13,363
17.6
0.495
0.415e0.590
aOR
95% CI
7.8
1.001
0.399e2.511
Exp
No.
5/72
No.
6.9
433/5521
38
35/404
8.7
1174/11,809
9.9
1.014
0.709e1.450
39
173/1576
11.0
1922/18,389
10.5
1.029
0.869e1.218
40
235/2124
11.1
1877/17,034
11.0
0.997
0.858e1.157
Shoulder dystocia
eIOL
Wk
Exp
No.
No.
aOR
95% CI
37
0/72
0.0
43/5315
0.8
38
2/404
0.5
115/11,404
1.0
0.412
0.100e1.693
39
27/1576
1.7
212/17,693
1.2
1.472
0.973e2.226
40
29/2124
1.4
217/16,281
1.3
1.080
0.722e1.616
Multiparous
Wk
No.
Exp
%
No.
aOR
95% CI
37
9/132
6.8
459/5151
8.9
0.730
0.365e1.459
38
51/822
6.2
836/10,655
7.9
0.664
0.493e0.895
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.
(continued)
249.e13
Research
Obstetrics
ajog.org
SUPPLEMENTAL TABLE 2
Secondary maternal outcomes by week of elective induction of labor compared to those expectantly managed
within the same week of delivery divided by parity (continued)
Multiparous
Exp
Wk
No.
No.
aOR
95% CI
39
597/5568
10.7
983/13,777
7.1
1.024
0.911e1.152
40
121/1571
7.7
516/9116
5.7
0.967
0.772e1.211
Exp
Wk
No.
No.
aOR
95% CI
37
1/149
0.4
22/5573
0.4
1.827
0.221e15.128
38
1/932
0.1
32/11,294
0.3
0.751
0.098e5.776
39
9/5971
0.2
49/14,351
0.3
1.009
0.442e2.305
40
1/1935
0.1
33/8914
0.4
0.295
0.039e2.210
Maternal infections
eIOL
Wk
37
No.
1/141
Exp
%
No.
aOR
95% CI
0.7
205/5536
3.7
0.191
0.026e1.374
38
5/883
0.6
345/11,559
3.0
0.186
0.076e0.454
39
47/5864
0.8
532/15,253
3.5
0.329
0.240e0.451
40
32/1798
1.8
449/10,206
4.4
0.531
0.365e0.772
No.
aOR
95% CI
37
5/152
3.3
158/6725
2.4
1.676
0.672e4.179
38
21/940
2.2
380/14,296
2.7
0.988
0.629e1.553
39
116/5987
1.9
569/19,018
3.0
0.729
0.584e0.911
40
43/1987
2.2
422/13,117
2.2
0.667
0.479e0.929
aOR
95% CI
0.7
Wk
No.
Exp
Shoulder dystocia
eIOL
Wk
37
No.
0/152
Exp
%
0.0
No.
43/6459
38
8/940
0.9
198/13,656
1.5
0.615
0.300e1.264
39
114/5987
1.9
345/18,088
1.9
1.206
0.951e1.531
40
48/1987
2.4
278/12,362
2.3
1.190
0.856e1.653
aOR, adjusted odds ratio; CI, confidence interval; eIOL, elective induction of labor; exp, expectant management.
aOR is of the outcome compared to vaginal delivery for eIOL with expectant as the referent controlling for maternal age, race/ethnicity, body mass index at delivery, insurance, type of hospital, and
modified Bishop score.
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.
Obstetrics
ajog.org
Research
SUPPLEMENTAL TABLE 3
Secondary neonatal outcomes by week of elective induction of labor compared to those expectantly managed
within the same week of delivery divided by parity
Nulliparous
Wk
Exp
No.
No.
aOR
95% CI
11.2
0.528
0.210e1.325
968/11,809
8.2
0.436
0.262e0.724
6.9
1489/18,389
8.1
0.837
0.682e1.028
6.5
1571/17,034
9.2
0.666
0.553e0.802
37
5/72
6.9
619/5521
38
16/404
4.0
39
109/1576
40
137/2124
Exp
No.
1/72
No.
aOR
95% CI
1.4
240/5127
4.7
0.246
0.034e1.788
38
7/398
1.8
325/10,947
3.0
0.526
0.245e1.130
39
30/1553
1.9
574/17,049
3.4
0.561
0.385e0.816
40
46/1963
2.3
552/15,712
3.5
0.611
0.447e0.835
Perinatal death
eIOL
Exp
Wk
No.
No.
aOR
95% CI
37
0/72
0.0
37/5315
0.7
38
0/404
0.0
44/11,404
0.4
39
2/1576
0.1
68/17,693
0.4
0.303
0.074e1.246
40
6/2124
0.3
65/16,281
0.4
0.507
0.214e1.198
Multiparous
Wk
Exp
No.
37
9/152
No.
5.9
609/6725
aOR
95% CI
9.1
0.612
0.309e1.210
38
44/940
4.7
863/14,295
6.0
0.755
0.551e1.034
39
179/5987
3.0
1046/19,018
5.5
0.508
0.427e0.604
40
75/1987
3.8
681/13,117
5.2
0.650
0.503e0.840
No.
Exp
%
No.
aOR
95% CI
37
8/145
5.5
284/6191
1.6
1.153
0.556e2.392
38
14/898
1.6
296/13,080
2.3
0.637
0.368e1.102
39
60/5884
1.0
372/17,385
2.1
0.471
0.350e0.632
40
27/1869
1.5
245/11,980
2.1
0.739
0.484e1.127
Perinatal death
eIOL
Wk
No.
Exp
%
No.
aOR
95% CI
37
0/152
0.0
61/6459
0.9
38
0/940
0.0
73/13,656
0.5
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.
(continued)
249.e15
Research
Obstetrics
ajog.org
SUPPLEMENTAL TABLE 3
Secondary neonatal outcomes by week of elective induction of labor compared to those expectantly managed
within the same week of delivery divided by parity (continued)
Perinatal death
eIOL
Exp
Wk
No.
No.
aOR
95% CI
39
11/5987
0.2
54/18,088
0.3
0.557
0.274e1.130
40
3/1987
0.2
40/12,362
0.3
0.385
0.113e1.314
aOR is of the outcome compared to vaginal delivery for eIOL with expectant as the referent controlling for maternal age, race/ethnicity, body mass index at delivery, insurance, type of hospital, and
modified Bishop score.
aOR, adjusted odds ratio; CI, confidence interval; eIOL, elective induction of labor; exp, expectant management.
Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.