Elective induction of labour at 39 weeks in low-risk nulliparous women versus expectant management: a pilot randomized control trial
DOI:
https://doi.org/10.18203/2320-1770.ijrcog20260183Keywords:
Cesarean delivery, Induction of labor, Maternal infection, NICU admission, PPHAbstract
Background: Elective induction of labor (EIOL) is a debated topic, but recent evidence suggests potential benefits. The ARRIVE trial found that e IOL at 390/7 to 394/7 weeks in low-risk nulliparous women significantly reduced cesarean delivery rates (18.6% vs. 22.2%) and composite perinatal morbidity (4.3% vs. 5.4%).3 This aligns with other studies showing that continuing pregnancy beyond 39 weeks increases maternal/fetal risks. Given that race/ethnicity influences pregnancy duration and outcomes, the current research gap is the lack of specific data on e IOL at 39 weeks in the Indian population
Methods: This open-label randomized trial at RIMS, Ranchi (March 2021-October 2022) compared EIOL to Expectant Management (EM) in 60 low-risk nulliparous Indian women (n=30 per group), with the primary outcome being the rate of cesarean delivery. Participants were randomized at 38 weeks and the e IOL group was induced between 39 and 395/7 weeks using dinoprostone/oxytocin.
Results: The present randomized, open-label trial conducted on low-risk nulliparous Indian women compared EIOL at 39 weeks with expectant management (EM), analyzing 27 participants in each final group. The primary finding demonstrated that e IOL significantly reduced the Cesarean Delivery rate (37% vs. 66.7% in EM, p=0.038) and led to a shorter postpartum hospital stay. While baseline characteristics were comparable, the EM group developed more complications (e.g., preeclampsia, non-reassuring FHR) leading to higher intervention rates. Although secondary neonatal outcomes (e.g., perinatal death, NICU admission) showed a favorable trend for e IOL, these differences were not statistically significant.
Conclusions: This pilot RCT in India found that EIOL at 39 weeks significantly reduced the cesarean delivery rate (33.3% vs. 60% in expectant management, p=0.038), suggesting one CS is avoided per four inductions. EIOL was safe, showing no increase in adverse maternal outcomes (PPH, infection) and even shorter hospital stays, while maintaining positive neonatal outcomes. The study supports EIOL as a safe, effective strategy to lower CS rates in low-resource settings.
Metrics
References
American College of Obstetricians and Gynaecologists. ACOG Practice Bulletin No. 107: Induction of labor. Obstet Gynecol. 2009;114(1):386-97. DOI: https://doi.org/10.1097/AOG.0b013e3181b48ef5
Stock SJ, Ferguson E, Duffy A, Ford I, Chalmers J, Norman JE. Outcomes of elective induction of labour compared with expectant management: population based study. BMJ. 2012;344:2838. DOI: https://doi.org/10.1136/bmj.e2838
Grobman WA, Rice MM, Reddy UM. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med. 2018;379(6):513-23. DOI: https://doi.org/10.1056/NEJMoa1800566
Grobman WA, Caughey AB. Elective induction of labor at 39 weeks compared with expectant management: a meta-analysis of cohort studies. Am J Obstet Gynecol. 2019;221(4):304-10. DOI: https://doi.org/10.1016/j.ajog.2019.02.046
Balchin I, Whittaker JC, Patel RR. Racial variation in the association between gestational age and perinatal mortality: prospective study. BMJ. 2007;334(7598):833. DOI: https://doi.org/10.1136/bmj.39132.482025.80
Mathai M, Thomas S, Peedicayil A. Growth pattern of the Indian foetus. Int J Gynaecol Obstet. 1995;48(1):21-4. DOI: https://doi.org/10.1016/0020-7292(94)02237-2
Caughey AB, Sundaram V, Kaimal AJ. Systematic review: elective induction of labor versus expectant management of pregnancy. Ann Intern Med. 2009;151(4):252-63. DOI: https://doi.org/10.7326/0003-4819-151-4-200908180-00007
Johnson DP, Davis NR, Brown AJ. Risk of cesarean delivery after induction at term in nulliparous women with an unfavorable cervix. Am J Obstet Gynecol. 2003;188(6):1565-72. DOI: https://doi.org/10.1067/mob.2003.458
Vrouenraets FP, Roumen FJ, Dehing CJ, van der Post JA, Mol BW, Veersema S. Bishop score and risk of cesarean delivery after induction of labor in nulliparous women. Obstet Gynecol. 2005;105(4):690-7. DOI: https://doi.org/10.1097/01.AOG.0000152338.76759.38
Keulen JK, Bruinsma A, Kortekaas JC. Induction of labour at 41 weeks versus expectant management until 42 weeks (INDEX): multicentre, randomised non-inferiority trial. BMJ. 2019;364:l344. DOI: https://doi.org/10.1136/bmj.l344
Middleton P, Shepherd E, Morris J, Crowther CA, Gomersall JC. Induction of labour at or beyond 37 weeks' gestation. Cochrane Database Syst Rev. 2020;7(7):4945. DOI: https://doi.org/10.1002/14651858.CD004945.pub5
Beigh SK. Comparison of caesarean section rate and maternal complications in elective induction versus spontaneous labor. Int J Reprod, Contr, Obst Gynecol. 2021;10(11):4142-7. DOI: https://doi.org/10.18203/2320-1770.ijrcog20214340
Wagner SM, Sandoval G, Grobman WA. Labor induction at 39 weeks compared with expectant management in low-risk parous women. Am J Perinatol. 2022;2:986. DOI: https://doi.org/10.1055/s-0040-1716711
Souter V, Painter I, Sitcov K, Caughey AB. Maternal and newborn outcomes with elective induction of labor at term. Am J Obstet Gynecol. 2019;220(3):273. DOI: https://doi.org/10.1016/j.ajog.2019.01.223
Miller NR, Cypher RL, Foglia LM, Pates JA, Nielsen PE. Elective induction of labor compared with expectant management of nulliparous women at 39 weeks of gestation: a randomized controlled trial. Obstet Gynecol. 2015;126(6):1258-64. DOI: https://doi.org/10.1097/AOG.0000000000001154
Begum J, Samal R. Outcomes of elective induction of labor compared with expectant management in nulliparous women with unfavorable cervix. J South Asian Feder Obs Gyn. 2018;10(4):233-6. DOI: https://doi.org/10.5005/jp-journals-10006-1552