Grand Rounds

Does Elective Induction Lower Risk for Adverse Obstetrical Outcomes in the Setting of Obesity

BACKGROUND AND PURPOSE:

Standardized guidelines for management of women with BMI ≥30 in pregnancy are not currently available
Gibbs Pickens et al. (Obstetrics & Gynecology, 2017) compared elective induction vs expectant management to assess impact on cesarean delivery and adverse perinatal outcomes in obese women, 39-41 weeks

Retrospective cohort study (2007-2011)
California Linked Patient Discharge Data–Birth Cohort File
Inclusion: Singleton, cephalic, nonanomalous deliveries to obese women, ≥39 weeks
Exclusion: Pre-existing medical conditions, previous cesarean, abnormal placentation, issoimmunization
Multivariable logistic regression models were used, stratified by parity for each week from 39 to 41 weeks
Primary outcome
- Maternal mode of delivery
Secondary outcomes
- Severe maternal morbidity (composite outcome)
- Macrosomia (birth weight ≥4,500 g)
- Shoulder dystocia, brachial plexus injury
- Clinical chorioamnionitis
- Infant mortality, NICU admission, neonatal transfer or extended hospital stay, meconium aspiration syndrome, respiratory distress syndrome (RDS)

165,975 women were included
Among nulliparous, obese women, cesarean section was less common at 39 and 40 weeks in the induction group
Cesarean section was 35.9% in the induction group vs 41.0% in the expectant management group
- 39 weeks: Adjusted odds ratio [OR] 0.82; 95% CI 0.77–0.88
Severe maternal morbidity was less common among nulliparous women undergoing induction (5.6%) vs expectant management (7.6%)
- 39 weeks: Adjusted OR 0.75; 95% CI 0.65–0.87
NICU admission was reduced among nulliparous women undergoing induction (7.9%) when compared to expectant management (10.1%)
- 39 weeks: Adjusted OR 0.79; 95% CI 0.70-0.89
Benefits of induction were also seen in parous women when induction was compared to expectant management (following data at 39 weeks)
- Cesarean delivery less common: 7.0% vs 8.7%
  - OR 0.79; 95% CI 0.73–0.86
- Severe maternal morbidity less common: 3.3% vs 4.0%
  - OR 0.83; 95% CI 0.74–0.94
- NICU admission less common: 5.3% vs 7.4%
  - OR 0.75; 95% CI 0.68–0.82
- Similar findings were found at 40 weeks with reduced odds of cesarean delivery, maternal morbidity, and neonatal intensive care unit admission among both obese nulliparous and parous patients

Elective labor induction in obese women was associated with lower risk for maternal and neonatal morbidity
Authors recommend future research with more rigorous (prospective) study design

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