Grand Rounds
CMECNE

A New Predictive Model for Successful Induction of Labor

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Learning Objectives and CME/Disclosure Information

BACKGROUND AND PURPOSE: 

  • Previous studies to predict induction success are focused on nulliparous women and are weighted towards a favorable cervical exam   
  • Levine et al. (AJOG, 2018) sought to derive and validate an induction prediction model for women with an unfavorable cervix in both nulliparous and multiparous women 

METHODS:

  • Based on a planned secondary analysis of a large randomized trial
  • Foley or Misoprostol for the Management of Induction (FOR MOMI)
    • Study compared time to delivery among 4 induction methods
      • Misoprostol alone | cervical Foley alone | misoprostol & cervical Foley concurrently | cervical Foley & oxytocin concurrently
  • Both nulliparous and multiparous women at full-term (≥37 weeks) with a singleton gestation and intact membranes were included
  • Unfavorable cervix: Bishop score ≤6 and dilation ≤2 cm
  • Multivariable logistic regression was used to construct the prediction model
  • The prediction model was further refined by using an observational cohort of women from the same institution who underwent an induction during the trial period
  • An external validation was performed utilizing a publicly available database (Consortium for Safe Labor)

RESULTS: 

  • The cesarean delivery rates in the derivation and external validation groups were: 27.7% (n = 136/491) and 26.4% (n = 2235/8466) 
  • There were no differences in cesarean rate between the derivation group and external validation group (P = .53) 
  • In multivariable modeling, nulliparity, gestation age ≥40 weeks, BMI at delivery, modified Bishop score, and height were significantly and independently associated with cesarean delivery  
  • A nomogram and calculator were created and found to have an area under the curve (ROC) in the external validation cohort of 0.73 (95% confidence interval, 0.72-0.74) 

CONCLUSION: 

  • A nomogram and user-friendly Web-based calculator that incorporates 5 variables known at the start of induction has been developed and validated 
  • Calculators should not be used in isolation and clinical context should be included in clinical decision making  
  • The calculator should not be used to  
    • Forego medically indicated induction  
    • Lower the threshold for elective primary cesarean delivery 
    • Lower the threshold for cesarean delivery in labor in the absence of other clinical information 
  • The web-based calculator has been developed based on this data and can be found in the ‘Learn More – Primary Sources’  

Learn More – Primary Sources: 

A validated calculator to estimate risk of cesarean after an induction of labor with an unfavorable cervix.

Penn Medicine: Labor Induction Calculator

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Related ObG Topics:

The ARRIVE Trial and Professional Guidance: Elective 39 Week Induction to Reduce the Risk of Cesarean Section
Practical info on evidence based medicine for your women's healthcare practice
Labor induction and an unripe cervix: does it result in more C-sections?
Cochrane Review 2017: Outpatient Cervical Ripening and Labor Induction
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