Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Provider, Education; Hospital, Chart audit and feedback, Elective induction policy, Guideline change and implementation, Quality improvement , HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Chart Audit and Feedback, Elective Induction Policy, Guideline Change and Implementation, Quality Improvement

Intervention Description: At a large Southern US women's hospital, new measures were made to reduce the rates of cesarian delivery at the facility. Endeavors were led by nurse / doctor leaders (VP & chief of staff). These included monitoring, benchmarking & disseminating information about CD at the facility; new protocols for oxytocin administration; Bishop's score assessment; elective CD performed only at 39 weeks; new protocols and intrapartum alternative positioning devices, the process of laboring down, and closed glottis pushing attempts in second-stage labor.

Intervention Results: Collectively, these interdisciplinary interventions have resulted in significant decreases in overall cesarean birth rates and comparable significant reductions in the NTSV cesarean rates.

Conclusion: Concerted efforts to reduce rates of nonmedically indicated cesarean birth have resulted in the development and implementation of comprehensive action plans aimed at effecting reductions and enhancing overall obstetric quality care.

Setting: One large obstetric hospital in the Southern USA

Population of Focus: NTSV births

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy, , HOSPITAL

Intervention Description: To assess adverse perinatal outcomes and caesarean section of low-risk women receiving elective induction of labour at 41 weeks or expectant management until 42 weeks according to their preferred and actual management strategy.

Intervention Results: From 2012–2016, 3642 women out of 6088 eligible women for the INDEX RCT, participated in the cohort study for observational data collection (induction of labour n = 372; expectant management n = 2174; unknown preference/management strategy n = 1096). Adverse perinatal outcome occurred in 1.1 % (4/372) in the induction group versus 1.9 % (42/2174) in the expectant group (adjRR 0.56; 95 %CI: 0.17–1.79), with severe adverse perinatal outcome occurring in 0.3 % (1/372) versus 1.0 % (22/2174), respectively (adjRR 0.39; 95 % CI: 0.05–2.88). There were no stillbirths among all 3642 women; one neonatal death occurred in the unknown preference/management group. Caesarean section rates were 10.5 % (39/372) after induction and 8.9 % (193/2174) after expectant management (adjRR 1.32; 95 % CI: 0.95–1.84). A higher incidence of adverse perinatal outcome was observed in nulliparous compared to multiparous women. Nulliparous 1.8 % (3/170) in the induction group versus 2.6 % (30/1134) in the expectant management group (adjRR 0.58; 95 % CI 0.14–2.41), multiparous 0.5 % (1/201) versus 1.1 % (

Conclusion: In this cohort study among low-risk women receiving the policy of their preference in late-term pregnancy, a non-significant difference was found between induction of labour at 41 weeks and expectant management until 42 weeks in absolute risks of composite adverse (1.1 % versus 1.9 %) and severe adverse (0.3 % versus 1.0 %) perinatal outcome. The risks in this cohort study were lower than in the trial setting. There were no stillbirths among all 3642 women. Caesarean section rates were comparable.

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy, , HOSPITAL

Intervention Description: To determine the impact of offering elective labour induction at 39 weeks gestation on perinatal and maternal outcomes in nulliparous people with low-risk pregnancies.

Intervention Results: A total of 174 patients were included. Of these patients, 56 (32.2%) underwent elective induction of labour between 390 and 396 weeks gestation over the period of June 2020 to December 2021, whereas 118 (67.8%) were expectantly managed from 390 weeks gestation over the period of September 2018 to March 2020. Compared with expectant management, those in the 39+ weeks induction group had a significantly lower risk of cesarean delivery (odds ratio [OR] 0.39; 95% confidence interval [CI] 0.15–0.99), composite adverse maternal outcomes (OR 0.34; 95% CI 0.12–0.97), and composite adverse perinatal outcomes (OR 0.26; 95% CI 0.074–0.92).

Conclusion: Our results suggest that elective induction of labour at 39 weeks gestation and over in low-risk nulliparous people is associated with lower risks of cesarean delivery, composite adverse maternal outcomes, and composite adverse perinatal outcomes than expectant

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy, HOSPITAL, Policy/Guideline (Hospital)

Intervention Description: To determine if there were changes in obstetrical practices and perinatal outcomes in the United States after the ARRIVE trial publication.

Intervention Results: There were 1,966,870 births in the pre-ARRIVE group and 609,322 in the post-ARRIVE group. The groups differed in age, race, body mass index, marital status, infertility treatment, and smoking history (P<.001). After adjusting for these differences, the post-ARRIVE group was more likely to undergo induction (36.1% vs 30.2%; adjusted odds ratio, 1.36 [1.36–1.37]) and deliver by 39+6 weeks of pregnancy (42.8% vs 39.9%; adjusted odds ratio, 1.14 [1.14–1.15]). The post-ARRIVE group had a significantly lower rate of cesarean delivery than the pre-ARRIVE group (27.3 % vs 27.9%; adjusted odds ratio, 0.94 [0.93–0.94]). Patients in the post-ARRIVE group were more likely to receive a blood transfusion (0.4% vs 0.3%; adjusted odds ratio, 1.43 [1.36–1.50]) and be admitted to medical intensive care unit (0.09% vs 0.08%; adjusted odds ratio, 1.20 [1.09–1.33]). Neonates in the post-ARRIVE group were more likely to need assisted ventilation at birth (3.5% vs 2.8%; adjusted odds ratio, 1.28 [1.26–1.30]) and >6 hours (0.6% vs 0.5%; adjusted odds ratio, 1.36 [1.31–1.41]). The neonates in the post-ARRIVE group were more likely to have low 5-minute APGAR scores (0.4% vs 0.3%; adjusted odds ratio, 0.91 [0.86–0.95]). Neonatal intensive care unit admission did not differ between the 2 groups (4.9% vs 4.9%; adjusted odds ratio, 1.01 [0.99–1.03]). There were no differences in neonatal seizures (0.04% vs 0.04%; adjusted odds ratio, 0.97 [0.84–1.13]), and surfactant use (0.08% vs 0.07%; adjusted odds ratio, 1.05 [0.94–1.17]) between the 2 groups.

Conclusion: There were more inductions of labor, more deliveries at 39 weeks’ gestation, and fewer cesarean deliveries in the year after the ARRIVE trial publication. The small but statistically significant increase in some adverse maternal and neonatal outcomes should be explored to determine if they are related with concurrent changes in obstetrical practices.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Elective Induction Policy

Intervention Description: In this multicenter trial, 6,106 low-risk nulliparous women were randomly assigned to either expectant management (3044) or labor induction (3062) at 39 weeks 0 days to 39 weeks 4 days.. The primary outcome was a composite of perinatal death or severe neonatal complications; the principal secondary outcome was cesarean delivery.

Intervention Results: A total of 3062 women were assigned to labor induction, and 3044 were assigned to expectant management. The primary outcome occurred in 4.3% of neonates in the induction group and in 5.4% in the expectant-management group (relative risk, 0.80; 95% confidence interval [CI], 0.64 to 1.00). The frequency of cesarean delivery was significantly lower in the induction group than in the expectant-management group (18.6% vs. 22.2%; relative risk, 0.84; 95% CI, 0.76 to 0.93).

Conclusion: Induction of labor at 39 weeks in low-risk nulliparous women did not result in a significantly lower frequency of a composite adverse perinatal outcome, but it did result in a significantly lower frequency of cesarean delivery. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ARRIVE ClinicalTrials.gov number, NCT01990612 .).

Setting: 41 hospitals participating in the Maternal–Fetal Medicine Units Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Population of Focus: Low risk nulliparous women

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Peer-Review of Provider Decisions, Elective Induction Policy, Guideline Change and Implementation, PATIENT_CONSUMER, Intensive Therapy, Psychoeducation

Intervention Description: We conducted a retrospective study was conducted in the Centre Hospitalier Universitaire Vaudois (CHUV) including all births between the 1st January 1997 and 31st December 2011 to analyze the cesarean section (CS) rate using the different groups of the Robson classification in a Swiss maternity hospital.

Intervention Results: The overall CS rate was 29 %, mainly related to group 5 (multiparous with previous CS) and group 2 (nulliparous women induced or who had CS before labor). The study also shows that induction of labor on maternal request in nulliparous at term (group 2a) increased significantly the risk of CS compared to induction of labor for medical reason (p<0.001).

Conclusion: The Robson classification system appears as a simple tool for monitoring CS rates. The main strategies for reducing CS rates will be through better selection of women for VBAC (vaginal birth after caesarean) and limitation of induction of labor, especially in nulliparous women.

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy, HOSPITAL

Intervention Description: This article evaluates the impact of adopting a practice of elective induction of labor (eIOL) at 39 weeks among nulliparous, term, singleton, vertex (NTSV) pregnancies in a statewide collaborative.

Intervention Results: When compared with all expectantly managed women, eIOL was associated with a higher cesarean birth rate (30.1 vs. 23.6%, p < 0.001). When compared with a propensity score-matched cohort, eIOL was not associated with a difference in cesarean birth rate (30.1 vs. 30.7%, p = 0.697). Time from admission to delivery was longer for the eIOL cohort compared with the unmatched (24.7 ± 12.3 vs. 16.3 ± 11.3 hours, p < 0.001) and matched (24.7 ± 12.3 vs. 20.1 ± 12.0 hours, p < 0.001) cohorts. Expectantly managed women were less likely to have a postpartum hemorrhage (8.3 vs. 10.1%, p = 0.02) or operative delivery (9.3 vs. 11.4%, p = 0.029), whereas women who underwent an eIOL were less likely to have a hypertensive disorder of pregnancy (5.5 vs. 9.2%, p < 0.001).

Conclusion: eIOL at 39 weeks may not be associated with a reduced NTSV cesarean delivery rate.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Elective Induction Policy, Guideline Change and Implementation, Quality Improvement, POPULATION-BASED SYSTEMS, NATIONAL, Policy/Guideline (National)

Intervention Description: Estimate the frequency of failure to follow the French consensus guidelines for elective induction, and assess how failure affects the rate of cesarean delivery.

Intervention Results: Women with electively induced and spontaneous labor had identical cesarean rates (4.1%). The guidelines were not followed in 23.2% of elective inductions. The risk of cesarean was higher after induction with a Bishop score <5, than after spontaneous labor (adjusted OR = 4.1, 95% CI [1.3–12.9]), while elective induction with a favourable cervix did not increase the cesarean risk. In nulliparas, failure to follow the guidelines tripled the risk of cesarean (adjusted OR = 3.2 [1.0–10.2]). On the other hand, elective induction of labor for women with a favourable cervix did not increase the risk of cesarean over the risk with spontaneous labor.

Conclusion: Elective induction does not appear to increase the cesarean rate when the guidelines are met. Electively inducing labor with a low Bishop score increased the risk of cesarean, especially in nulliparas.

Study Design: Retrospective cohort

Setting: 138 maternity units

Population of Focus: Nulliparous women who gave birth between June 2001 and May 20022

Data Source: Not specified

Sample Size: Total (n=2,052) Intervention (n=69) Control (n=1,983)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy, HOSPITAL

Intervention Description: The purpose of our study is to compare the maternal and neonatal outcomes of induction of labor (IOL) versus expectant management at 39 weeks of gestation.

Intervention Results: IOL and expectant group had similar cesarean delivery rate (18.2% vs. 15.9%, p = 0.570). The delivery time from admission was longer in IOL group (834 ± 527 vs. 717 ± 469 min, p = 0.040). The IOL group was less likely to have Apgar score at 5 min < 7 than in expectant group (0.8% vs. 5.4%, p = 0.023). Multivariate analysis showed that IOL at 39 weeks was not an independent risk factor for cesarean delivery (relative risk 0.64, 95% confidence interval: 0.28–1.45, p = 0.280). Maternal and neonatal adverse outcomes, including cesarean delivery rate, were similar to women in IOL at 39 weeks of gestation compared to expectant management in nulliparous women.

Conclusion: IOL at 39 weeks of gestation could be recommended even when the indication of IOL is not definite.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Elective Induction Policy

Intervention Description: A retrospective cohort in a single institution was used to investigate the difference in the cesarean delivery rate between induction of labor and spontaneous labor among nulliparous, term, singleton, and vertex-presenting (NTVS) women. Of the 5,997 deliveries analyzed, 2,283 were spontaneous labor deliveries and 2,017 were labor inductions (446 were elective and 1,571 were medically indicated). The 7-year study took place between January 2012 and December 2018.

Intervention Results: A statistically significant difference was found in cesarean delivery rate between those women whose labor was induced and those whose labor began spontaneously, at each term gestational age of labor initiation (P < 0.001). The proportion of indications for induction was described (i.e. elective vs. medically-indicated), and no difference was found for neonatal morbidity between the groups analyzed, using the 5-minute Apgar score as the perinatal outcome measure.

Conclusion: A comparison was made between spontaneous and induced labor regarding the resultant cesarean delivery rate, and a significant difference was found favoring spontaneous labor. This should be considered when electing to deliver using an induction methodology for nulliparous women, especially when there are no medical indications for it.

Setting: Advocate Aurora Health Illinois Masonic Medical Center

Population of Focus: Nulliparous, term, singleton, and vertex-presenting women

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy, HOSPITAL

Intervention Description: The purpose of this study was to compare the cesarean birth rate for women with pregnancies at 39.0 weeks’ gestation or later admitted for spontaneous labor or medically indicated induction of labor (IOL) with that of women receiving elective IOL at term.

Intervention Results: A total of 1528 women were included in this study. Among these, 158 received elective IOL, and 1370 did not. The cesarean birth rates (31.0% vs 23.9%, elective induction of labor vs expectant management, respectively, P = .048), neonatal intensive care admissions (9.5% vs 7.6%, P = .41), and Apgar scores were similar among women in both management groups, respectively (P = .08). Accounting for other potential risk factors, the odds of having cesarean birth were not statistically different between management groups (adjusted odds ratio, 0.73; 95% CI, 0.5-1.1; P = .09). There were 2 fetal deaths among women whose labor was not electively induced. In the total cohort, women who were older, who had higher body mass index (BMI), and who identified as non-Hispanic Black had an increased odds of experiencing a cesarean birth. The associations between women in management groups and cesarean birth were not modified by age, BMI, race, or ethnicity (P = .33, .67, and .87, respectively).

Conclusion: Elective IOL was not associated with lower cesarean rates in this study. Further research is needed before implementing clinical practice changes that encourage more use of IOL

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Chart Audit and Feedback, Elective Induction Policy, Guideline Change and Implementation

Intervention Description: To examine the effect of implementation of guidelines for induction of labor on the process of care and outcome measures.

Intervention Results: Among nulliparous women, there was a reduction in the number of women who were admitted with cervical score of < or = 4 (24%, 40%, and 54% in 1997, 1996, and 1995, respectively; p=0.0001), an increase in the number of women who had amniotomy on admission (32%, 25% and 12% in 1997, 1996, and 1995, respectively; p=0.0001) and a shorter induction-delivery interval. No change in outcome measures was noted among multiparous women despite reduced dose of prostaglandin E2 used for induction of labor. A marginal reduction of both Cesarean section and failed induction rates were noted in both nulliparae and multiparae. Level of compliance improved with successive rounds of audit.

Conclusion: Explicit guidelines do improve clinical practice, when introduced and monitored in the context of rigorous evaluations. However, the size of improvement could vary.

Study Design: Time trend analysis

Setting: 1 private hospital

Population of Focus: Nulliparous women who gave birth between January 1995 and November 1997 with scheduled induction of labor and for whom completed medical forms were available

Data Source: Not specified

Sample Size: Total (n=531) Pre-intervention (n=168) Post-intervention (n=164)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Elective Induction Policy, Guideline Change and Implementation, Policy/Guideline (Hospital)

Intervention Description: To assess the cesarean delivery (CD) rate among low-risk pregnancies before and after implementation of a hospital-based program in Canada.

Intervention Results: At the intervention hospital, 30.3% (964/3181) of women underwent CD in 2009–2010, compared with 26.4% (803/3045) in 2012–2013 (difference −3.9%, P<0.001). By contrast, no significant difference was recorded in control hospitals (28.1% [23 694/84 361] vs 28.2% [23 683/83 895]; difference 0.1%, P=0.5157).

Conclusion: Implementation of the CARE strategy reduced rates of cesarean delivery among the target population.

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy, Policy/Guideline (Hospital), HOSPITAL

Intervention Description: Induction of labour (IOL) is a common obstetric intervention. When planning IOL, especially in women at risk for complications at delivery, the aim should be for delivery to occur when senior staff are available to optimise safe care.

Intervention Results: The rate of deliveries occurring in-hours were higher following the intervention; n = 118/285 (45.6%) pre-intervention versus n = 251/470 (53.4%) post-intervention; adjusted OR = 1.47, 95% CI = 1.07–2.01, p = 0.02). The percentage of caesarean sections (CS) occurring in-hours was significantly lower in the pre-intervention group n = 71/153 (28.3%) compared with the post intervention group = 35/132(46.4%) (p < 0.001)). The rate of CS was higher in the pre intervention n = 132/285(46.3%) compared with the post intervention group n = 153/470 (32.4%)).

Conclusion: The change in induction procedures was associated with a significantly higher rate of births occurring in-hours and a lower rate of overall of CS. This policy change led to a better pattern of timing of birth for nulliparous women undergoing IOL.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Elective Induction Policy

Intervention Description: In this retrospective cohort study, chart-abstracted data on births was used to compare outcomes for electively induced births at ≥39 weeks gestation with those that were not electively induced. The study was restricted to singleton cephalic hospital births at 39+0–42+6 weeks gestation. A total of 55,694 births were included in the study cohort.

Intervention Results: A total of 55,694 births were included in the study cohort: 4002 elective inductions at ≥39+0 weeks gestation and 51,692 births at 39+0-42+6 weeks gestation that were not electively induced. In nulliparous women, elective induction at 39 weeks gestation was associated with a decreased likelihood of cesarean birth (14.7% vs 23.2%; adjusted odds ratio, 0.61; 95% confidence interval, 0.41-0.89) and an increased rate of operative vaginal birth (18.5% vs 10.8%; adjusted odds ratio, 1.8; 95% confidence interval, 1.28-2.54) compared with on-going pregnancies. In multiparous women, cesarean birth rates were similar in the elective inductions and on-going pregnancies. Elective induction at 39 weeks gestation was associated with a decreased likelihood of pregnancy-related hypertension in nulliparous (2.2% vs 7.3%; adjusted odds ratio, 0.28; 95% confidence interval, 0.11-0.68) and multiparous women (0.9% vs 3.5%; adjusted odds ratio, 0.24; 95% confidence interval, 0.15-0.38). Term elective induction was not associated with any statistically significant increase in adverse newborn infant outcomes. Elective induction of labor at 39 weeks gestation was associated with increased time from admission to delivery for both nulliparous (1.3 hours; 95% confidence interval, 0.2-2.3) and multiparous women (3.4 hours; 95% confidence interval, 3.2-3.6).

Conclusion: Elective induction of labor at 39 weeks gestation is associated with a decrease in cesarean birth in nulliparous women, decreased pregnancy-related hypertension in multiparous and nulliparous women, and increased time in labor and delivery. How to use this information remains the challenge.

Setting: 21 hospitals in the Northwest United States

Population of Focus: Women with singleton cephalic hospital births at 39+0–42+6 weeks gestation.

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy, HOSPITAL

Intervention Description: This study compared the outcomes in a cohort of consecutive pregnant women, who fulfilled the criteria of the ARRIVE trial and were managed expectantly in an Italian referral academic hospital, with those reported in the expectant and induction arms of the ARRIVE trial.

Intervention Results: A total of 1696 patients met the established criteria at recruitment. Of these, 343 spontaneously delivered in <39 weeks, 82 delivered because of maternal indication, and 37 for fetal indication. A total of 1234 pregnant women were eligible for comparison with the elective induction and the expectant management groups of the ARRIVE trial. The socioeconomic status was significantly better, maternal age was significantly higher, and body mass index was significantly lower in our cohort. Cesarean section rate in our cohort was lower than that of the expectant group of the ARRIVE trial (18.7 vs. 22.2%; p = 0.02) and similar to that of the elective induction group (18.7 vs. 18.6%). A new diagnosis of hypertensive disorders during expectant management was noted in 1.6% in our cohort vs. 14.1% in the ARRIVE arm. Among the different obstetric outcomes, only the prevalence of postpartum hemorrhage was not significantly lower in our cohort. The primary perinatal composite outcome was significantly better in our cohort than in both arms of the ARRIVE trial (2.1 vs. 5.4% in the expectant group and 4.3% in the induction group). We did not record cases with an Apgar score ≤ 3 or hypoxic-ischemic encephalopathy.

Conclusion: In our cohort, expectant management in low-risk pregnancies with late preterm screening of feto-maternal well-being seemed to achieve better maternal and perinatal outcomes than a universal policy of induction at 39 weeks. The results of the ARRIVE trial should be carefully evaluated in different demographic and clinical settings and cannot be extended to the general population.