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Obstetrics & Gynecology:
Original Research

Risk of Cesarean Delivery With Elective Induction of Labor at Term in Nulliparous Women

SEYB, STACY T. MD; BERKA, RONALD J. MD; SOCOL, MICHAEL L. MD; DOOLEY, SHARON L. MD, MPH

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Author Information

Department of Obstetrics and Gynecology, Northwestern University Medical School, Northwestern Memorial Hospital, Chicago, Illinois.

Address reprint requests to: Stacy T. Seyb, MD 2525 South Downing Street, #11B Denver, CO 80210 E-mail: stacyseyb@centura.org

Received November 9, 1998. Received in revised form March 5, 1999. Accepted March 18, 1999.

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Abstract

Objective: To quantify the risk of cesarean delivery associated with elective induction of labor in nulliparous women at term.

Methods: We performed a cohort study on a major urban obstetric service that serves predominantly private obstetric practices. All term, nulliparous women with vertex, singleton gestations who labored during an 8-month period (n = 1561) were divided into three groups: spontaneous labor, elective induction, and medical induction. The risk of cesarean delivery in the induction groups was determined using stepwise logistic regression to control for potential confounding factors.

Results: Women experiencing spontaneous labor had a 7.8% cesarean delivery rate, whereas women undergoing elective labor induction had a 17.5% cesarean delivery rate (adjusted odds ratio [OR] 1.89; 95% confidence interval [CI] 1.12, 3.18) and women undergoing medically indicated labor induction had a 17.7% cesarean delivery rate (OR 1.69; 95% CI 1.13, 2.54). Other variables that remained significant risk factors for cesarean delivery in the model included: epidural placement at less than 4 cm dilatation (OR 4.66; 95% CI 2.25, 9.66), epidural placement after 4 cm dilatation (OR 2.18; 95% CI 1.06, 4.48), chorioamnionitis (OR 4.61; 95% CI 2.89, 7.35), birth weight greater than 4000 g (OR 2.59; 95% CI 1.69, 3.97), maternal body mass index greater than 26 kg/m2 (OR 2.36; 95% CI 1.61, 3.47), Asian race (OR 2.35; 95% CI 1.04, 5.34), and magnesium sulfate use (OR 2.18; 95% CI 1.04, 4.55).

Conclusion: Elective induction of labor is associated with a significantly increased risk of cesarean delivery in nulliparous women. Avoiding labor induction in settings of unproved benefit may aid efforts to reduce the primary cesarean delivery rate.

The cesarean delivery rate in the United States peaked at 24.7% in 1988.1 Strategies including vaginal birth after cesarean (VBAC) delivery and the use of alternative management schemes for dystocia helped reduce the national cesarean delivery rate to 20.7% in 1996.2 However, evolving trends in obstetric practice may counteract efforts to further reduce the cesarean delivery rate. One such trend is the frequency of labor induction, which rose 77% nationally from 1989 to 1995.3

It is generally acknowledged that induction of labor for medical indications is associated with an increased risk of cesarean delivery. It is unclear whether there is a similar increase in risk associated with elective induction because previous investigations have been retrospective or lacked statistical power.4–11 Because the increase in the use of labor induction is likely attributable to more liberal indications for induction rather than to proved maternal or fetal benefit, it is important to resolve this question.

We conducted this cohort study to quantify the risk of cesarean delivery associated with elective induction of labor at term compared with the risk associated with spontaneous labor. Women undergoing labor induction for medical indications were included for comparison. The study was limited to nulliparous women because they have the highest background rate of cesarean delivery.

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Materials and Methods

All term, nulliparous women admitted to the labor and delivery unit at Prentice Women's Hospital of Northwestern Memorial Hospital from November 1, 1996 through June 30, 1997 were candidates for this study. The cohort was composed of women laboring with a singleton fetus in the vertex presentation at 37 weeks' gestation or later. Women undergoing cesarean delivery without labor were excluded.

Members of the cohort were classified by admitting labor status to form three groups: medical induction, elective induction, or spontaneous labor. The indications and criteria for inclusion in the medical induction group are summarized in Table 1. The elective induction group was composed of women whose induction was stated as elective or who did not meet any defining criterion for a medical induction. Table 2 presents the indications cited by the admitting physician for women who were classified as undergoing an elective induction of labor. The spontaneous labor group consisted of those women who were diagnosed as being in labor at admission. The criteria used to diagnose spontaneous labor were regular, painful uterine contractions together with either complete cervical effacement or rupture of membranes.12

Table 1
Table 1
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Table 2
Table 2
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Premature rupture of membranes (PROM) at term was defined as rupture of membranes before the onset of labor. It is a common practice at our institution to administer oxytocin before performing a digital cervical examination on women with term PROM. For the purpose of this study, women with PROM were assigned to the medical induction group if they experienced a contraction frequency of less than every 10 minutes and exhibited no other signs of labor such as bloody show for 4 hours before initiation of oxytocin.

The Northwestern University Institutional Review Board approved this study. Candidates for the induction groups were identified on admission to labor and delivery. Women experiencing spontaneous labor were identified either on admission or by daily review of admission logs. Lists were cross-referenced with the hospital perinatal database to ensure complete ascertainment. Information was collected both at the time of admission and by subsequent review of prenatal records and hospital charts. The data collected included: maternal age, self-identified race, managing service, gestational age, and maternal height and best-determined prepregnancy weight for calculating body mass index (BMI). The nursing and physician progress notes were used to determine results of the initial cervical examination and those at the time of epidural placement. Magnesium sulfate for seizure prophylaxis in women with preeclampsia was considered to have been used in labor if it was initiated before completion of the first stage of labor. Chorioamnionitis was diagnosed if the managing physician instituted antibiotic therapy in the presence of clinical signs. A postpartum complication was defined as hemorrhage that required transfusion or a problem that prolonged hospitalization beyond the routine stay of 2 days for a vaginal delivery or 4 days for a cesarean delivery. Delivery information included route of delivery, indication for cesarean delivery, birth weight, Apgar scores, umbilical artery (UA) cord blood gases, presence of meconium, and neonatal intensive care unit (NICU) admission.

The admission time was determined to be the nursing admit time for patients presenting from outside the hospital or the time of the first recorded nursing note for transferred inpatients. Time on labor and delivery in hours was calculated by subtracting the time of admission from the delivery time. Postpartum stay was the integer obtained by subtracting the date of admission to the postpartum unit from the date of discharge.

The attending physician or nurse-midwife, in conjunction with the resident physicians, made all decisions regarding labor management. Cervical ripening, when indicated, was performed with laminaria or extra-amniotic saline infusion.13 Labor induction was accomplished using oxytocin with or without amniotomy. The prevailing practice for epidural analgesia during the study period was a continuous infusion of low-dose bupivacaine (0.125% or less) with fentanyl.

Information for cost analysis was obtained from the hospital finance department. These estimates are derived from an in-depth cost-accounting method using relative value units that break down, to a procedural level, the cost of providing care. Direct, support, and overhead costs are all included.14 A detailed profile of the cost of providing care was then generated for each admission.

Pilot data were gathered over a 1-month period on 224 nulliparous women to perform a power calculation. A ratio of spontaneous labor to elective induction of 10:1 was observed, with cesarean delivery rates of 9% and 18%, respectively. The estimated sample size needed to detect a two-fold difference in the cesarean rate with α = .05 and a power of 80% was calculated as 1220 women in spontaneous labor and 122 undergoing elective induction. The pilot data were not included in the study analyses.

Statistical analyses were performed using SAS 6.10 (SAS Institute, Cary, NC). Analyses included analysis of variance with Scheffe test for differences between groups, χ2, and χ2 for trend, as appropriate. A stepwise multiple logistic regression analysis was used to create a final model of risk factors for cesarean delivery, with P < .05 for entry of a variable into the model.

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Results

During the study period, 1917 nulliparous women were delivered on our labor and delivery service. After excluding those with multiple gestation, malpresentation, preterm delivery, and planned cesarean delivery, 1561 women qualified for inclusion in the study cohort. Data were complete for all variables except that time on labor and delivery was missing for one woman; race, gestational age, and cost data were missing for two women; epidural use was missing for four women; and BMI could not be calculated for 18 women.

The pregnancies included in the spontaneous labor, elective induction, and medical induction groups are described in Table 3. Compared with women in spontaneous labor, those undergoing elective induction tended to be older, white, and to have a private obstetrician. Women being electively induced declined epidural analgesia less frequently and tended to have a higher mean birth weight. The mean gestational age in the medical induction group is higher because the pregnancies were induced for postdates (over 41 weeks' gestation), and the higher rate of magnesium sulfate use in this group is due to preeclampsia. The mean BMI of the medical induction group was higher than in the other two groups, and this slight difference achieved statistical significance.

Table 3
Table 3
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Results of the cervical examinations upon admission for each of the groups are shown in Table 4. The missing examinations are predominantly due to women with PROM. As expected, cervical dilatation and effacement in the spontaneous labor group were more advanced than in the induction groups, which is consistent with established labor. Cervical ripening was used for 55 women (18.7%) in the medical induction group and for 21 women (14.7%) in the elective induction group.

Table 4
Table 4
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The cesarean delivery rate in the spontaneous labor group was 7.8%. The rates in the medical and elective induction groups were 17.7% and 17.5%, respectively. The unadjusted relative risk for each variable is listed in Table 5. Factors associated with a significantly increased risk for cesarean delivery include: elective or medical induction, maternal BMI greater than 26 kg/m2, gestational age of 40 weeks or greater, birth weight greater than 4000 g, PROM, epidural use, magnesium sulfate use in labor, and chorioamnionitis. The risk factors that remained significant in the final regression model are shown in Table 6. Controlling for the significant confounding variables, elective induction and medical induction continued to be associated with a significantly increased risk of cesarean delivery, with adjusted odds ratios of 1.89 and 1.69, respectively. Asian race, maternal BMI greater than 26 kg/m2, birth weight greater than 4000 g, epidural analgesia (especially if placed before 4 cm dilatation), magnesium sulfate use, and chorioamnionitis all demonstrated independent effects in the final model.

Table 5
Table 5
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Table 6
Table 6
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The indications for cesarean delivery in each labor group are listed in Table 7. The most common indication for cesarean delivery was labor dystocia, and the cesarean delivery rate for this indication was substantially higher in both induction groups. Among the elective induction group, there was a significant trend toward decreasing cesarean delivery rates with advancing cervical effacement (P < .001), but not with advancing cervical dilatation (P = 0.98).

Table 7
Table 7
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Induction of labor required significantly more time on labor and delivery and was associated with a longer postpartum stay, but there was no significant increase in postpartum complications. Mean hours on labor and delivery were lowest in the spontaneous labor group (8.7), intermediate in the elective induction group (11.6), and highest in the patients having medical induction (15.3) (P < .05 between all groups). Mean days of postpartum stay were slightly lower in the spontaneous labor group (1.8) than in the two induction groups (both 2.0; P < .05). There were no proportional differences between the groups of women experiencing postpartum complications. Neonatal outcomes were not significantly different with respect to the incidence of meconium, Apgar scores at 1 and 5 minutes, UA cord blood pH, and NICU admissions (data not shown).

Cost analysis of the three groups is presented in Figure 1 as a relative comparison of the elective and medical induction groups with spontaneous labor, which incurred the least cost. The total cost associated with hospitalization for women undergoing elective induction and medical induction was increased by 17.4% and 29.1%, respectively. Induction of labor was associated with a cost increase in all expense categories, but the greatest increase was associated with the costs of labor and delivery.

Figure 1
Figure 1
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Discussion

Elective induction of labor in term nulliparous women, as practiced in our institution, was found to be an important risk factor for cesarean delivery. Women undergoing elective induction had a 17.5% rate of cesarean delivery, whereas those in whom labor began spontaneously had a cesarean delivery rate of 7.8%. The cesarean delivery rate was 17.7% for those women who underwent an induction for medical indications. Dystocia was the most common indication for cesarean delivery in all three groups, as it is for all primary cesarean deliveries in the United States.15 Furthermore, the increase in dystocia in both induction groups accounted for most of the difference in cesarean deliveries relative to the spontaneous labor group. This association of dystocia with induced labor is consistent with the numerous trials of various cervical ripening agents, which have not conclusively demonstrated an impact on the cesarean delivery rate.16

Of previous investigations focusing on the risk of elective induction, only one retrospective study used a nulliparous sample size similar to ours.4 This report did not rigorously discriminate between medical and elective indications for labor induction and even categorized patients induced for postdates as elective inductions. The only control for possible confounding was by subgroup matching with univariate statistical analysis of variables. Despite these limitations, the outcomes for nulliparous women were similar to our findings, with cesarean delivery rates of 10% and 17% in the spontaneous labor and elective induction groups, respectively. Other reports that we identified, including three prospective5–7 and three retrospective8–10 studies, used sample sizes inadequate to demonstrate a difference in cesarean rates or did not discriminate between the outcomes of nulliparous and parous women. Additionally, most of these studies may not be representative of contemporary practice based upon relatively lower rates of epidural use.

Prysak and Castronova11 recently concluded that elective induction caused no increased risk of cesarean delivery. They used a retrospective study design by selecting electively induced women from a scheduling book and matching for age, parity, and pay status with women who delivered after spontaneous labor who were identified from their delivery log. All women with “high-risk factors” were eliminated from both groups. Among the nulliparous women in their study, the cesarean delivery rate was 9.5% (20 of 210) after spontaneous labor compared with 15.7% (33 of 210) after elective induction. This difference approached significance (P = .056), but the authors were unable to show an independent effect of induction in the final regression model. Although their study design differed substantially from ours and they did not indicate how the analysis by logistic regression was modified to account for matching, we speculate that the most likely reason for the difference in results was their lack of power.

We found that both elective and medically indicated labor inductions remained significant risk factors for cesarean delivery in a multivariate model controlling for all other significant effects. Most of the other variables identified in our model have been reported previously as risk factors for cesarean delivery.17–22 Most significantly, the adjusted risk of cesarean delivery with placement of an epidural at 4 cm dilatation or greater was 2.2, and this risk increased to 4.7 if the epidural was placed earlier in labor. These findings are consistent with the results of several other studies23–28; however, none of these studies, including ours, allows certainty regarding causality. Using these results to justify denying epidural anesthesia to nulliparous women is inappropriate, but it is prudent to consider a practice of delaying epidural placement until after 4 cm of dilatation.

The costs of elective induction are both immediate and long term. We found that the total hospital cost of providing care for nulliparous women undergoing elective induction is 17% higher than what is required for nulliparous women in spontaneous labor. This is largely due to the requirement for more labor and delivery resources and more frequent cesarean delivery. Although not the subject of this study, downstream costs are also of concern because nulliparous women are more likely to repeat childbearing, and the VBAC rate for the United States is only 28.3%.2 It is widely acknowledged that the most effective way to reduce the overall cesarean rate is to prevent primary cesarean deliveries.

It is probably not realistic to expect to achieve the cesarean delivery rate associated with spontaneous labor in all nulliparous women. A certain proportion will not experience spontaneous labor before a medical indication for induction is encountered. However, it appears that overuse of induction incurs risk. Women classified in the elective induction group in our study included some with a relatively unfavorable cervix who were being induced for indications not associated with fetal jeopardy, for example, after 40 weeks' gestation but not yet postdates. We submit that this practice at our institution is likely representative of a national trend toward more liberal indications for induction. In this light, our finding of an unadjusted risk of 2.5 for cesarean delivery associated with elective induction has important implications because it represents the actual risk of induction as practiced.

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American Journal of Obstetrics and Gynecology
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European Journal of Obstetrics Gynecology and Reproductive Biology
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Obstetrics and Gynecology
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Journal of Family Practice
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Journal of Reproductive Medicine
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Acta Obstetricia Et Gynecologica Scandinavica
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American Journal of Obstetrics and Gynecology
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Dublin, S; Lydon-Rochelle, M; Kaplan, RC; Watts, DH; Critchlow, CW
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Journal of Korean Medical Science
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Park, KH
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American Journal of Obstetrics and Gynecology
Active management of risk in nulliparous pregnancy at term: association between a higher preventive labor induction rate and improved birth outcomes
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American Journal of Obstetrics and Gynecology
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Ultrasound in Obstetrics & Gynecology
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Paediatric and Perinatal Epidemiology
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Chen, JS; Ford, JB; Ampt, A; Simpson, JM; Roberts, CL
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American Journal of Obstetrics and Gynecology
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Archives of Gynecology and Obstetrics
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Does Enhanced "Bundling" Criteria Improve Outcomes? A Comparative Study of Elective Inductions
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Journal of Reproductive Medicine, 58(): 402-410.

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Patient-requested Neuraxial Analgesia for Labor: Impact on Rates of Cesarean and Instrumental Vaginal Delivery
Marucci, M; Cinnella, G; Perchiazzi, G; Brienza, N; Fiore, T
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Term Labor Induction Compared With Expectant Management
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© 1999 The American College of Obstetricians and Gynecologists

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