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Routine induction reduces cesarean rate

J Fam Pract. 2003 November;52(11):828-848
By
Samina Yunus, MD
Warren Newton, MD, MPH
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  • BACKGROUND: Pregnancies lasting beyond 41 weeks are common, but management remains controversial. This meta-analysis compared the outcomes of routine induction of labor and expectant management for uncomplicated pregnancies after 41 weeks.
  • POPULATION STUDIED: A total of 6588 subjects were enrolled in 16 trials from 10 countries over 33 years. Five of these trials took place in countries with significant higher rates of maternal and perinatal mortality than the United States. Only trials limited to uncomplicated singleton pregnancies were included; in practice, the estimated gestational age at randomization ranged from 41 to 42 weeks. No information was given about subjects’ age, obstetric risk factors, and Bishop score.
  • STUDY DESIGN AND VALIDITY: The investigators searched for randomized trials comparing routine labor induction vs expectant management for pregnancies of at least 41 weeks gestation with clearly documented outcome data. The search included electronic databases, review articles, textbook chapters, PubMed, MEDLINE, and Cochrane databases from 1966–2002 without language restriction. Data were extracted by 2 investigators independently, with differences resolved by consensus; similarly, study quality was scored by 2 investigators blinded to investigators and institutions.
  • OUTCOMES MEASURED: The primary outcomes were cesarean delivery rate and perinatal mortality. Secondary outcomes included meconium-stained fluid, meconium aspiration syndrome, meconium below the cords, fetal heart rate abnormalities during labor, cesarean delivery for fetal heart rate abnormalities, abnormal Apgar scores, and neonatal intensive care unit admissions. Outcomes important in the US context such as cost, patient satisfaction, and provider satisfaction were not addressed.
  • RESULTS: For most analyses, investigators found no evidence of heterogeneity. Women who underwent labor induction had lower cesarean delivery rates (20% vs 22%; odds ratio [OR]=0.88; 95% confidence interval [CI], 0.78–0.99; number needed to treat=50), as well as a lower rate of meconium-stained fluid (OR=0.75; 95% CI, 0.66–0.84) and caesarean section for fetal heart rate abnormalities (OR=0.77; 95% CI, 0.61–0.96).
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PRACTICE RECOMMENDATIONS

A strategy of routine induction at or just after 41 weeks for uncomplicated pregnancies reduces cesarean sections without improving or adversely affecting neonatal outcomes. Family physicians should provide this information to their patients and continue to look for studies that provide clinical detail and directly compare the strategy of routine induction after 41 weeks with expectant management and induction after 42 weeks.

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