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Research

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OBSTETRICS

Maternal and neonatal outcomes in


electively induced low-risk term pregnancies
Kelly S. Gibson, MD; Thaddeus P. Waters, MD; Jennifer L. Bailit, MD, MPH
OBJECTIVE: Elective induction of labor has been discouraged over

concerns regarding increased complications. We evaluated the mode


of delivery and maternal and neonatal morbidities in low-risk patients
whose labor was electively induced or expectantly managed at term.
STUDY DESIGN: This was a retrospective cross-sectional study from

12 US institutions (19 hospitals), 2002 through 2008 (Safe Labor


Consortium). Healthy women with viable, vertex singleton pregnancies
at 37-41 weeks of gestation were included. Women electively induced
in each week were compared with women managed expectantly. The
primary outcome was mode of delivery.
RESULTS: Of 131,243 low-risk deliveries, 13,242 (10.1%) were

electively induced. The risk of cesarean delivery was lower at each


week of gestation with elective induction vs expectant management
regardless of parity and modified Bishop score (for unfavorable
nulliparous patients at: 37 weeks 18.6% vs 34.2%, adjusted odds

ratio, 0.40; [95% confidence interval, 0.18e0.88]; 38 weeks


28.4% vs 35.4%, 0.65 [0.49e0.85]; 39 weeks 23.6% vs 38.5%,
0.47 [0.38e0.57]; 40 weeks 32.3% vs 42.3%, 0.70 [0.59e0.81]).
Maternal infections were significantly lower with elective inductions.
Major, minor, and respiratory neonatal morbidity composites were
lower with elective inductions at 38 weeks (for nulliparous patients
at: 38 weeks adjusted odds ratio, 0.43; [95% confidence interval,
0.26e0.72]; 39 weeks 0.75 [0.61e0.92]; 40 weeks 0.65
[0.54e0.80]).
CONCLUSION: Elective induction of labor at term is associated with

decreased risks of cesarean delivery and other maternal and neonatal


morbidities compared with expectant management regardless of parity
or cervical status on admission.
Key words: elective induction of labor, expectant management,
induction and cesarean

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.

onventional obstetric teaching,


based on early studies of induction
of labor, suggested that an elective induction of labor is associated with
increased maternal morbidities such as
cesarean section, length of labor, and
infection.1-3 However, publications
From the Division of Maternal Fetal Medicine,
Department of Obstetrics and Gynecology,
MetroHealth Medical CentereCase Western
Reserve University, Cleveland, OH (Drs Gibson
and Bailit), and Division of Maternal Fetal
Medicine, Department of Obstetrics and
Gynecology, Loyola University Medical Center,
Maywood, IL (Dr Waters).
Received Oct. 30, 2013; revised Feb. 13, 2014;
accepted March 10, 2014.
The authors report no conict of interest.
Reprints: Kelly S. Gibson, MD, Division of
Maternal Fetal Medicine, Department of
Obstetrics and Gynecology, MetroHealth
Medical Center, 2500 MetroHealth Dr.,
Cleveland, OH 44109. kgibson@metrohealth.
org
0002-9378/free
2014 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2014.03.016

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

SEPTEMBER 2014 American Journal of Obstetrics & Gynecology

249.e1

Research

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FIGURE

Flow diagram of cohort selection and distribution of subjects by week of


pregnancy

are crucial. As previous investigations


have noted a consistent pattern of a
reduction in cesarean delivery with induction of labor as early as 37 weeks
of gestation without a reciprocal increase
in neonatal morbidity, it is imperative
for additional investigations to either
conrm or refute this observation.
Therefore, we sought to evaluate the
mode of delivery and maternal and
neonatal morbidities in low-risk patients
whose labor was electively induced or
expectantly managed at term using a
national obstetric records database that
contained detailed information regarding
maternal medical history, indications for
induction, and cervical examinations.

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.

cervical status,17,18 while the majority of


the available literature did not have this
important obstetric variable available for
their analyses. As national attention has
identied >39 weeks as the optimal time

for delivery for low-risk women due to


a reported decrease in neonatal risks,
specically respiratory morbidity,19-21 a
comprehensive evaluation of the risks
and benets of elective delivery by week

249.e2 American Journal of Obstetrics & Gynecology SEPTEMBER 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

Morbid obesity (>35.0)

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

BMI at delivery, kg/m2

Insurance

Self-pay
Other/missing
Hospital type

Modified Bishop score

Gestational age at delivery, wk

Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.

(continued)

SEPTEMBER 2014 American Journal of Obstetrics & Gynecology

249.e3

Research

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TABLE 1

Demographic characteristics (continued)

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

BMI, body mass index.


Gibson. Outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014.

delivery, an operative vaginal delivery


(requiring vacuum or forceps assistance), or cesarean section.
Given the limitations of pregnancy
dating and the size of our data set, we
chose to evaluate gestational age by week
rather than day. We acknowledge that
many women who are expectantly managed may have either a spontaneous
labor or indicated induction in the same
week. Therefore, we did a secondary
analysis comparing those with elective
induction of labor to those expectantly
managed, but ultimately delivering
within the same week.
The primary outcome of interest was
mode of delivery. Secondary outcomes
included composites for maternal and
neonatal comorbidities. Maternal outcomes included bleeding (blood products, abruption, postpartum hemorrhage,
uterine rupture, hysterectomy), maternal
ICU admission or death, infections
(intrapartum fevers, chorioamnionitis,
endomyometritis, wound separation),
lacerations (third- or fourth-degree perineal, sulcal, or cervical), and shoulder
dystocia. Neonatal outcomes included a
composite of major comorbidities (birth
injuries, sepsis, pneumonia, intraventricular hemorrhage, aspiration, hypoxic
ischemic encephalopathy, respiratory
distress syndrome, seizures, oliguria,
myocardial injury, ventilator use, continuous positive airway pressure use, transient tachypnea of the newborn,
transfusions, or surfactant use), a composite of respiratory morbidities (oxygen
use, continuous positive airway pressure

use, transient tachypnea of the newborn,


or surfactant administration), or perinatal
death (intrauterine fetal demise or neonatal demise).
To adjust for possible confounding
factors on successful induction of labor
and maternal and neonatal outcomes,
logistic regression was performed. We
controlled for maternal age, race/
ethnicity, parity, body mass index at delivery, insurance status, type of hospital,
and modied Bishop score at delivery
admission. As only 51% (67,257) of patients had all 5 components of the Bishop
score reported, while 84% (110,432) had
information on cervical dilation, effacement, and station available, we used a
modied Bishop score to determine cervical ripeness. We dened an unripe cervix as a modied Bishop score 4.24

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

249.e4 American Journal of Obstetrics & Gynecology SEPTEMBER 2014

the entire cohort and by maternal parity.


Our patients were nearly half nulliparous
with 88% being younger than 35 years at
delivery. The majority were Caucasian
(51.7%) and overweight or obese (mean
body mass index: 30.3  5.8 kg/m2).
Only 1.2% of patients were self-paying
with >90% delivering at a teaching
hospital (40.2% university and 50.8%
community teaching hospitals). In all,
57% had a favorable cervix on admission.
On average, subjects delivered at 39.3 
1.1 weeks gestational age.
The distribution of elective deliveries
by week of gestation and parity is also
presented in Table 1. Ten percent of the
total cohort (n 13,242) had an elective
induction of labor with 57% of all elective inductions performed in the 39th
week of gestation. The majority of elective inductions were parous (68%),
particularly at 37, 38, and 39 weeks of
gestation. The Figure shows the number
of electively induced deliveries, nonelectively induced deliveries and expectantly managed subjects for each week
of gestation.

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

Nulliparous and unfavorable

Nulliparous and favorable

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

Operative vaginal delivery


Nulliparous and unfavorable
eIOL
Wk

No.

Nulliparous and favorable

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.

Nulliparous and favorable

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.

Multiparous and favorable

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

Operative vaginal delivery


Multiparous and unfavorable
eIOL
Wk

No.

Multiparous and favorable

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)

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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

Multiparous and favorable

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.

Multiparous and favorable

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.

0.16e1.14]; 39 weeks 0.35 [95% CI,


0.23e0.53]; 40 weeks 0.54 [95% CI,
0.30e0.97].) The comparison of the
primary outcome for those electively
induced compared to those who delivered within the same week (without
elective induction) demonstrated similar
ndings (Supplemental Table 1).
As the decision to deliver a patient, or
allow a pregnancy to continue until
indicated delivery or spontaneous labor
occurs, encompasses many potential
outcomes for the mother and neonate,
we next evaluated several secondary maternal and neonatal outcomes (Tables 3
and 4). The risk of maternal bleeding
complications, ICU admissions, or death
was overall similar between the 2 groups
after adjustment for confounding factors.
Elective induction of labor appeared to be
protective against maternal infection at
each week of gestation for both nulliparous and multiparous patients (nulliparous patients at: 37 weeks adjusted
odds ratio, 0.35 [95% CI, 0.13e0.95]; 38
weeks 0.35 [95% CI, 0.23e0.53]; 39
weeks 0.41 [95% CI, 0.33e0.50]; 40
weeks 0.45 [95% CI, 0.38e0.55]; in
multiparous patients at: 37 weeks 0.21

[95% CI, 0.03e1.54]; 38 weeks 0.20


[95% CI, 0.08e0.48]; 39 weeks 0.34
[95% CI, 0.25e0.47]; 40 weeks 0.72
[95% CI, 0.47e1.08]). The frequency of
a signicant obstetrical laceration was
lower with elective induction in nulliparous patients at 37 and 38 weeks and in
multiparous patients at 39 and 40 weeks,
but only signicant for the multiparous
patients after adjustment. Elective induction was protective against shoulder
dystocia at 38 weeks of gestation for
multiparous patients. These results are
similar to the ndings for women electively induced compared to those delivering in the same week (Supplemental
Table 2).
The risk of adverse outcomes for the
neonate is presented in Table 4. There
were no signicant differences in the frequency of composite neonatal morbidity
for electively induced women at 37 weeks
compared to the expectantly managed
group. By 38 weeks, elective induction was
associated with a reduction in composite
neonatal morbidity in nulliparous patients and a trend toward reduction in
multiparous patients. Similar results were
observed for only respiratory morbidities.

249.e6 American Journal of Obstetrics & Gynecology SEPTEMBER 2014

The comparison of neonatal morbidities


for those who delivered within the same
week as those who were electively induced
is presented in Supplemental Table 3.
There was a higher composite neonatal
morbidity for subjects who delivered
without elective induction, but still within
the same week compared to those electively induced. Similar results were
observed for respiratory morbidities.

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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ajog.org
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

Secondary outcomes of maternal morbidity by week of elective induction


of labor compared to those expectantly managed divided by parity
Nulliparous

Maternal bleeding complications


eIOL

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

Maternal intensive care admission or death


eIOL

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

Third- or fourth-degree perineal or sulcal lacerations


eIOL
Wk
37

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.

infection, prolonged rupture of the


membranes, and maternal hypertensive
disease. These and other conditions have
their own associated maternal and

(continued)

neonatal morbidities as well as the


burden of time on labor and delivery
units and the costs of associated interventions. Our nding of a reduction

SEPTEMBER 2014 American Journal of Obstetrics & Gynecology

249.e7

Research

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TABLE 3

Secondary outcomes of maternal morbidity by week of elective induction


of labor compared to those expectantly managed divided by parity
(continued)

Multiparous

Maternal bleeding complications


eIOL

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

Maternal intensive care admission or death


eIOL

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

Third- or fourth-degree perineal or sulcal lacerations


eIOL
Wk

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.

249.e8 American Journal of Obstetrics & Gynecology SEPTEMBER 2014

in maternal and neonatal morbidities


with elective induction suggests that
expectant management of a term pregnancy is not a risk-free proposition. We
hypothesize this observation may be
related to the potential complications
that can occur for any gravid while
waiting for labor or a later gestational
age.
Our data have several limitations.
First, while we attempted to compare
elective induction vs expectantly managed women, this was not a randomized
trial. This study uses a cross-sectional
data set to address a longitudinal question. We attempted to control for known
confounding variables in our multivariate analysis, yet unmeasured factors
or potential selection bias such as the
asynchronous timing of the cervical examinations on delivery admission may
be possible. It may be that only women
who were considered more likely to
be successfully induced were electively
induced, and women who were considered unlikely to be successful were not
(healthy user bias). Therefore, we may
only be observing that clinicians are
astute at determining which women are
low risk and will be successfully induced.
However, as this analysis is based on
medical records data (and not administrative data), we use the best data
possible short of having an observer at
each delivery. Additionally, our elective
induction cohort at 37 weeks may be too
small to draw rm conclusions about
risks or benets, but the ndings are
consistent with the rest of the data at
later weeks.
We observed a lower neonatal
morbidity in those electively induced
with increasing week of gestation,
consistent with papers that have evaluated neonatal morbidity by delivery age
alone.19-21 Yet, our data highlight that
this observation can lead to misleading
conclusions about the best gestational
age for delivery when the risks of
expectant management are excluded
from the analysis. In light of the ndings
from retrospective studies such as this
paper, the NICHD and the MaternalFetal Medicine Units Network is beginning a randomized trial of induction
versus expectant management (ARRIVE)

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

Secondary outcomes of neonatal morbidity by week of elective induction


of labor compared to those expectantly managed divided by parity
Nulliparous

Neonatal complication composite


eIOL

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

Neonatal respiratory complications


eIOL
Wk
37

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

Neonatal complication composite


eIOL

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

Neonatal respiratory complications


eIOL
Wk

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.

and Human Development (NICHD), National


Institutes of Health, through Contract No.
HHSN267200603425C. Institutions involved in
the Consortium include, in alphabetical order:
Baystate Medical Center, Springeld, MA;
Cedars-Sinai Medical Center Burnes Allen

(continued)

Research Center, Los Angeles, CA; Christiana


Care Health System, Newark, DE; EMMES
Corporation, Rockville, MD (Data Coordinating
Center); Georgetown University Hospital, MedStar Health, Washington, DC; Indiana University
Clarian Health, Indianapolis, IN; Intermountain

SEPTEMBER 2014 American Journal of Obstetrics & Gynecology

249.e9

Research

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ajog.org

TABLE 4

Secondary outcomes of neonatal morbidity by week of elective induction


of labor compared to those expectantly managed divided by parity
(continued)

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.

Healthcare and the University of Utah, Salt Lake


City, UT; Maimonides Medical Center, Brooklyn,
NY; MetroHealth Medical Center, Cleveland,
OH; Summa Health System, Akron City Hospital, Akron, OH; University of Illinois at Chicago,
Chicago, IL; University of Miami, Miami, FL; and
University of Texas Health Science Center at
Houston, Houston, TX. The named authors
alone are responsible for the views expressed in
this manuscript, which does not necessarily
represent the decisions or the stated policy of
the NICHD.

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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

Nulliparous and favorable

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

Operative vaginal delivery


Nulliparous and unfavorable
eIOL
Wk

Nulliparous and favorable

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

Nulliparous and favorable

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

Multiparous and unfavorable

Multiparous and favorable

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)

SEPTEMBER 2014 American Journal of Obstetrics & Gynecology

249.e11

Research

Obstetrics

ajog.org

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.

Multiparous and favorable


eIOL

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.

Multiparous and favorable

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.

249.e12 American Journal of Obstetrics & Gynecology SEPTEMBER 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

Maternal bleeding complications


eIOL

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

Maternal intensive care admission or death


eIOL

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

Third- or fourth-degree perineal or sulcal lacerations


eIOL
Wk
37

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

Maternal bleeding complications


eIOL

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)

SEPTEMBER 2014 American Journal of Obstetrics & Gynecology

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

Maternal bleeding complications


eIOL

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

Maternal intensive care admission or death


eIOL

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

Third- or fourth-degree perineal or sulcal lacerations


eIOL
%

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.

249.e14 American Journal of Obstetrics & Gynecology SEPTEMBER 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

Neonatal complication composite


eIOL

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

Neonatal respiratory complications


eIOL
Wk
37

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

Neonatal complication composite


eIOL

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

Neonatal respiratory complications


eIOL
Wk

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)

SEPTEMBER 2014 American Journal of Obstetrics & Gynecology

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.

249.e16 American Journal of Obstetrics & Gynecology SEPTEMBER 2014

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