Am J Perinatol
DOI: 10.1055/s-0043-1776975
SMFM Fellows Research Series

The Relationship between Gestational Weight Gain and Cesarean Delivery among Patients undergoing Induction of Labor

1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
2   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, Virginia
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
Cara Dolin
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
› Author Affiliations
Funding None.


Objective This study aimed to determine the impact of pregnancy weight gain above National Academy of Medicine (NAM) guidelines on cesarean delivery rates following induction.

Study Design This is a secondary analysis of a prospective cohort study of patients who underwent induction at a single tertiary care center between July 2017 and July 2019. Included in the primary study were patients undergoing term (≥37 weeks) labor induction with a singleton gestation, intact membranes, and unfavorable cervical examination (Bishop score of ≤6 and cervical dilation ≤ 2 cm). Eligibility for this analysis was limited to patients with a documented prenatal body mass index (BMI) < 20 weeks' gestation. The primary exposure was gestational weight gain greater than NAM guidelines (WGGG) for a patient's initial BMI category. The primary outcome was cesarean delivery for any indication.

Results Of 1,610 patients included in the original cohort, 1,174 (72.9%) met inclusion criteria for this analysis and 517 (44.0%) of these had weight gain above NAM guidelines. Of the entire cohort, 60.0% were Black and 52.7% had private insurance. In total, 160 patients (31%) with WGGG underwent cesarean compared with 127 patients (19.3%) without WGGG (p < 0.001), which equates to a 59% increased odds of cesarean when controlling for initial BMI category, parity, gestational diabetes, and indication for induction (Adjusted Odds Ratio [aOR] 1.58, 95% confidence interval [CI] 1.17–2.12). Among only nulliparous patients, WGGG was associated with an increased odds of cesarean (26.4 vs. 38.2%, aOR 1.50, 95% CI 1.07–2.10). In multiparous patients, however, there was no difference in cesarean between those with and without WGGG (8.8 vs. 14.1%, aOR 1.85, 95% CI 0.96–3.58).

Conclusion This study demonstrates that weight gain above NAM guidelines is associated with more than a 50% increased odds of cesarean. Patients should be informed of this association as gestational weight gain may be a modifiable risk factor for cesarean delivery.

Key Points

  • Weight gain above NAM guidelines was associated with a 59% increased odds of cesarean delivery.

  • Nulliparous patients with weight gain above NAM guidelines are at higher risk of cesarean delivery.

  • No difference in cesarean delivery among multiparous patients regardless of gestational weight gain.

Publication History

Received: 24 August 2021

Accepted: 22 October 2023

Article published online:
16 November 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 ACOG Practice Bulletin No. 107: Induction of labor. Obstet Gynecol 2009; 114 (2 Pt 1): 386-397
  • 2 Caughey AB, Cahill AG, Guise JM, Rouse DJ. American College of Obstetricians and Gynecologists (College), Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014; 210 (03) 179-193
  • 3 Caughey AB, Nicholson JM, Cheng YW, Lyell DJ, Washington AE. Induction of labor and cesarean delivery by gestational age. Am J Obstet Gynecol 2006; 195 (03) 700-705
  • 4 Beckmann M. Predicting a failed induction. Aust N Z J Obstet Gynaecol 2007; 47 (05) 394-398
  • 5 Crane JM. Factors predicting labor induction success: a critical analysis. Clin Obstet Gynecol 2006; 49 (03) 573-584
  • 6 Crane JM, Delaney T, Butt KD, Bennett KA, Hutchens D, Young DC. Predictors of successful labor induction with oral or vaginal misoprostol. J Matern Fetal Neonatal Med 2004; 15 (05) 319-323
  • 7 Ennen CS, Bofill JA, Magann EF, Bass JD, Chauhan SP, Morrison JC. Risk factors for cesarean delivery in preterm, term and post-term patients undergoing induction of labor with an unfavorable cervix. Gynecol Obstet Invest 2009; 67 (02) 113-117
  • 8 Gunatilake RP, Smrtka MP, Harris B. et al. Predictors of failed trial of labor among women with an extremely obese body mass index. Am J Obstet Gynecol 2013; 209 (06) 562.e1-562.e5
  • 9 Horowitz KM, Feldman D. Fetal growth restriction: risk factors for unplanned primary cesarean delivery. J Matern Fetal Neonatal Med 2015; 28 (18) 2131-2134
  • 10 Michelson KA, Carr DB, Easterling TR. The impact of duration of labor induction on cesarean rate. Am J Obstet Gynecol 2008; 199 (03) 299.e1-299.e4
  • 11 Middleton P, Shepherd E, Crowther CA. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev 2018; 5 (05) CD004945
  • 12 Parkes I, Kabiri D, Hants Y, Ezra Y. The indication for induction of labor impacts the risk of cesarean delivery. J Matern Fetal Neonatal Med 2016; 29 (02) 224-228
  • 13 Teede HJ, Bailey C, Moran LJ. et al. Association of antenatal diet and physical activity-based interventions with gestational weight gain and pregnancy outcomes: a systematic review and meta-analysis. JAMA Intern Med 2022; 182 (02) 106-114
  • 14 Institute of M, National Research Council Committee to Reexamine IOMPWG. The National Academies Collection: Reports funded by National Institutes of Health. In: Rasmussen KM, Yaktine AL. eds. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington (DC): National Academies Press (US) Copyright © 2009; 2009
  • 15 Beaudrot ME, Elchert JA, DeFranco EA. Influence of gestational weight gain and BMI on cesarean delivery risk in adolescent pregnancies. J Perinatol 2016; 36 (08) 612-617
  • 16 Gawade P, Markenson G, Bsat F, Healy A, Pekow P, Plevyak M. Association of gestational weight gain with cesarean delivery rate after labor induction. J Reprod Med 2011; 56 (3-4): 95-102
  • 17 Maier JT, Schalinski E, Gauger U, Hellmeyer L. Antenatal body mass index (BMI) and weight gain in pregnancy - its association with pregnancy and birthing complications. J Perinat Med 2016; 44 (04) 397-404
  • 18 Tolcher MC, Holbert MR, Weaver AL. et al. Predicting cesarean delivery after induction of labor among nulliparous women at term. Obstet Gynecol 2015; 126 (05) 1059-1068
  • 19 Hamm RF, McCoy J, Oladuja A. et al. Maternal morbidity and birth satisfaction after implementation of a validated calculator to predict cesarean delivery during Labor induction. JAMA Netw Open 2020; 3 (11) e2025582
  • 20 Martin JA, Hamilton BE, Osterman MJK, Driscoll AK. Births: final data for 2018. Natl Vital Stat Rep 2019; 68 (13) 1-47
  • 21 Grobman WA, Caughey AB. Elective induction of labor at 39 weeks compared with expectant management: a meta-analysis of cohort studies. Am J Obstet Gynecol 2019; 221 (04) 304-310
  • 22 Rangel Bousquet Carrilho T, , M Rasmussen K, Rodrigues Farias D. et al; Brazilian Maternal and Child Nutrition Consortium. Agreement between self-reported pre-pregnancy weight and measured first-trimester weight in Brazilian women. BMC Pregnancy Childbirth 2020; 20 (01) 734
  • 23 Kominiarek MA, Saade G, Mele L. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Association between gestational weight gain and perinatal outcomes. Obstet Gynecol 2018; 132 (04) 875-881