Labor induction and an unripe cervix: does it result in more C-sections?
In a secondary analysis of two major studies, researchers assessed outcomes in women undergoing induction of labor compared to expectant management with a cervical Bishop score of < 6.
1406 women had a Bishop score of <6 and after random allocation, 572 were induced while 600 were monitored expectantly. Analysis showed:
There were no significant differences in overall cesarean rate between induction (15.4%) and the expectant management group (16.5%)
There was no significant difference in the overall composite adverse neonatal outcome, which included at least one of the following:
5 minute Apgar score less than or equal to 6
Arterial umbilical cord pH <7.05
Neonatal intensive care (NICU) admission
Seizures or perinatal death
There were fewer newborns with decreased arterial umbilical cord pH < 7.05 in the induction group (1.7%) compared to those managed expectantly (4.8%) which was statistically significant (95% CI -5.6 to -0.9)
If the arterial umbilical cord pH cut-off was set at 7.01, a similar finding was obtained, with 0.2% of newborns with low pH in the induction group, compared to 2.8% in the expectant management group
The data for this study (Bernardes, et al., BJOG, 2016) was obtained from two multi-centered, controlled randomized trials, HYPITAT and DIGITAT, which included women with gestational hypertension/mild preeclampsia and suspected intrauterine growth restriction (IUGR) respectively. Both studies assessed women who were between 36 and 41 weeks, with a singleton fetus and cephalic presentation. While these original studies demonstrated that induction did not increase cesarean section rates, the question remains whether this was still true when the cervix was unripe.
In near term or term infants, induction does not appear to increase cesarean section rates in women with an unripe cervix
Concerns regarding failed induction with a Bishop score between 3 and 6 may be unwarranted
This study was in high risk women; however, the authors point to a recent retrospective study of 5,090 women indicating similar maternal and neonatal outcomes whether inductions were medically indicated or elective in nature
An overall cesarean section rate of only 15.4% in the induction group justifies the attempt at vaginal delivery, following informed decision making with the patient
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