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Systematic Review: Elective Induction of Labor Versus Expectant Management of Pregnancy
- Aaron B. Caughey, MD, MPP, MPH, PhD;
- Vandana Sundaram, MPH;
- Anjali J. Kaimal, MD;
- Allison Gienger, BA;
- Yvonne W. Cheng, MD, MPH;
- Kathryn M. McDonald, MM;
- Brian L. Shaffer, MD;
- Douglas K. Owens, MD, MS; and
- Dena M. Bravata, MD, MS
- From Stanford University, Stanford; University of California, San Francisco, San Francisco; and Veterans Affairs Palo Alto Healthcare System, Palo Alto, California.
Abstract
Background: The rates of induction of labor and elective induction of labor are increasing. Whether elective induction of labor improves outcomes or simply leads to greater complications and health care costs is commonly debated in the literature.
Purpose: To compare the benefits and harms of elective induction of labor and expectant management of pregnancy.
Data Sources: MEDLINE (through February 2009), Web of Science, CINAHL, Cochrane Central Register of Controlled Trials (through March 2009), bibliographies of included studies, and previous systematic reviews.
Study Selection: Experimental and observational studies of elective induction of labor reported in English.
Data Extraction: Two authors abstracted study design; patient characteristics; quality criteria; and outcomes, including cesarean delivery and maternal and neonatal morbidity.
Data Synthesis: Of 6117 potentially relevant articles, 36 met inclusion criteria: 11 randomized, controlled trials (RCTs) and 25 observational studies. Overall, expectant management of pregnancy was associated with a higher odds ratio (OR) of cesarean delivery than was elective induction of labor (OR, 1.22 [95% CI, 1.07 to 1.39]; absolute risk difference, 1.9 percentage points [CI, 0.2 to 3.7 percentage points]) in 9 RCTs. Women at or beyond 41 completed weeks of gestation who were managed expectantly had a higher risk for cesarean delivery (OR, 1.21 [CI, 1.01 to 1.46]), but this difference was not statistically significant in women at less than 41 completed weeks of gestation (OR, 1.73 [CI, 0.67 to 4.5]). Women who were expectantly managed were more likely to have meconium-stained amniotic fluid than those who were electively induced (OR, 2.04 [CI, 1.34 to 3.09]).
Limitations: There were no recent RCTs of elective induction of labor at less than 41 weeks of gestation. The 2 studies conducted at less than 41 weeks of gestation were of poor quality and were not generalizable to current practice.
Conclusion: RCTs suggest that elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid. There are concerns about the translation of these findings into actual practice; thus, future studies should examine elective induction of labor in settings where most obstetric care is provided.
Article and Author Information
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Disclaimer: Views expressed here are those of the authors and do not necessarily reflect those of the Department of Veterans Affairs. This manuscript is based on the evidence report on elective induction of labor which is pending publication by AHRQ. Dr. Caughey and Ms. Sundaram had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
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Grant Support: This report is based on research conducted by the Stanford-UCSF Evidence-based Practice Center under contract 290-02-0017 from AHRQ. Dr. Owens and Ms. Sundaram were supported in part by the Health Services Research and Development Service, Department of Veterans Affairs.
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Acknowledgment: The authors thank Christopher Stave, Teresa Sparks, Jason F. Lee, Luchin Wong, and Susan H. Tran for their contributions to this work.
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Potential Financial Conflicts of Interest: None disclosed.
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Requests for Single Reprints: Aaron B. Caughey, MD, PhD, Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 505 Parnassus Avenue, M-1495, Box 0132, San Francisco, CA 94143; e-mail, abcmd{at}berkeley.edu.
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Current Author Addresses: Drs. Caughey, Kaimal, Cheng, and Shaffer: Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 505 Parnassus Avenue, M-1495, Box 0132, San Francisco, CA 94143.
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Ms. Sundaram, Ms. Gienger, Ms. McDonald, and Drs. Owens and Bravata: Center for Primary Care and Outcomes Research, Stanford University, 117 Encina Commons, Stanford, CA 94305-6019.
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