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Am J Perinatol 2022; 39(02): 154-164
DOI: 10.1055/s-0040-1714422
Original Article

Term Labor Induction and Cesarean Delivery Risk among Obese Women with and without Comorbidities

Kimberly B. Glazer 
1   Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
2   Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
,
Valery A. Danilack 
2   Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
3   Division of Research, Women & Infants Hospital, Providence, Rhode Island
4   Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
,
Alison E. Field
2   Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
,
Erika F. Werner 
2   Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
4   Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
5   Department of Obstetrics and Gynecology, Women and Infants Hospital, Providence, Rhode Island
,
David A. Savitz
2   Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
4   Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
› Author Affiliations Funding None.
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Abstract

Objective Findings of the recent ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial, showing reduced cesarean risk with elective labor induction among low-risk nulliparous women at 39 weeks' gestation, have the potential to change interventional delivery practices but require examination in wider populations. The aim of this study was to identify whether term induction of labor was associated with reduced cesarean delivery risk among women with obesity, evaluating several maternal characteristics associated with obesity, induction, and cesarean risk.

Study Design We studied administrative records for 66,280 singleton, term births to women with a body mass index ≥30, without a prior cesarean delivery, in New York City from 2008 to 2013. We examined elective inductions in 39 and 40 weeks' gestation and calculated adjusted risk ratios for cesarean delivery risk, stratified by parity and maternal age. We additionally evaluated medically indicated inductions at 37 to 40 weeks among women with obesity and diabetic or hypertensive disorders, comorbidities that are strongly associated with obesity.

Results Elective induction of labor was associated with a 25% (95% confidence interval: 19–30%) lower adjusted risk of cesarean delivery as compared with expectant management at 39 weeks of gestation and no change in risk at 40 weeks. Patterns were similar when stratified by parity and maternal age. Risk reductions in week 39 were largest among women with a prior vaginal delivery. Women with comorbidities had reduced cesarean risk with early term induction and in 39 weeks.

Conclusion Labor induction at 39 weeks was consistently associated with reduced risk of cesarean delivery among women with obesity regardless of parity, age, or comorbidity status. Cesarean delivery findings from induction trials at 39 weeks among low-risk nulliparous women may generalize more broadly across the U.S. obstetric population, with potentially larger benefit among women with a prior vaginal delivery.

Key Points

  • We found reduced cesarean risk with induction at 39 weeks.

  • Results were consistent for age and comorbidity subgroups.

  • Risk reductions were largest among multiparous women.

Keywords

ARRIVE - body mass index - cesarean delivery - induction - obesity

Supplementary Material



Publication History

Received: 01 May 2020

Accepted: 16 June 2020

Article published online:
28 July 2020

© 2020. Thieme. All rights reserved.

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  • References

  • 1 Grobman WA, Rice MM, Reddy UM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med 2018; 379 (06) 513-523
    CrossrefPubMedGoogle Scholar
  • 2 Spong CY, Mercer BM, D'alton M, Kilpatrick S, Blackwell S, Saade G. Timing of indicated late-preterm and early-term birth. Obstet Gynecol 2011; 118 (2 Pt 1): 323-333
    CrossrefPubMedGoogle Scholar
  • 3 Souter V, Painter I, Sitcov K, Caughey AB. Maternal and newborn outcomes with elective induction of labor at term. Am J Obstet Gynecol 2019; 220 (03) 273.e1-273.e11
    CrossrefPubMedGoogle Scholar
  • 4 Society of Maternal-Fetal (SMFM) Publications Committee. Electronic address: pubs@smfm.org. SMFM statement on elective induction of labor in low-risk nulliparous women at term: the ARRIVE trial. Am J Obstet Gynecol 2019; 221 (01) B2-B4
    CrossrefPubMedGoogle Scholar
  • 5 ARRIVE Trial: Talking points for members. American College of Nurse-Midwives. Accessed December 12, 2019 at: http://midwife.org/acnm/files/ccLibraryFiles/Filename/000000007103/ARRIVETrialTalkingPoints.pdf
    PubMedGoogle Scholar
  • 6 Carmichael SL, Snowden JM. The ARRIVE trial: interpretation from an epidemiologic perspective. J Midwifery Womens Health 2019; 64 (05) 657-663
    CrossrefPubMedGoogle Scholar
  • 7 Comments on the ARRIVE Trial [press release]. California Maternal Quality Care Collaborative, February 8, 2018 at: https://www.cmqcc.org/sites/default/files/Arrive%20Trial%20Statement%20Final.pdf
    PubMedGoogle Scholar
  • 8 Rogers AJG, Harper LM, Mari G. A conceptual framework for the impact of obesity on risk of cesarean delivery. Am J Obstet Gynecol 2018; 219 (04) 356-363
    CrossrefPubMedGoogle Scholar
  • 9 Carlson NS, Lowe NK. Intrapartum management associated with obesity in nulliparous women. J Midwifery Womens Health 2014; 59 (01) 43-53
    CrossrefPubMedGoogle Scholar
  • 10 Ruhstaller K. Induction of labor in the obese patient. Semin Perinatol 2015; 39 (06) 437-440
    CrossrefPubMedGoogle Scholar
  • 11 Wolfe KB, Rossi RA, Warshak CR. The effect of maternal obesity on the rate of failed induction of labor. Am J Obstet Gynecol 2011; 205 (02) 128.e1-128.e7
    CrossrefPubMedGoogle Scholar
  • 12 Carlson NS, Hernandez TL, Hurt KJ. Parturition dysfunction in obesity: time to target the pathobiology. Reprod Biol Endocrinol 2015; 13: 135
    CrossrefPubMedGoogle Scholar
  • 13 Wispelwey BP, Sheiner E. Cesarean delivery in obese women: a comprehensive review. J Matern Fetal Neonatal Med 2013; 26 (06) 547-551
    CrossrefPubMedGoogle Scholar
  • 14 Grobman WA. Predictors of induction success. Semin Perinatol 2012; 36 (05) 344-347
    CrossrefPubMedGoogle Scholar
  • 15 Subramaniam A, Jauk VC, Goss AR, Alvarez MD, Reese C, Edwards RK. Mode of delivery in women with class III obesity: planned cesarean compared with induction of labor. Am J Obstet Gynecol 2014; 211 (06) 700.e1-700.e9
    CrossrefPubMedGoogle Scholar
  • 16 Headen I, Cohen AK, Mujahid M, Abrams B. The accuracy of self-reported pregnancy-related weight: a systematic review. Obes Rev 2017; 18 (03) 350-369
    CrossrefPubMedGoogle Scholar
  • 17 Dietz P, Bombard J, Mulready-Ward C. et al. Validation of selected items on the 2003 U.S. standard certificate of live birth: New York City and Vermont. Public Health Rep 2015; 130 (01) 60-70
    CrossrefPubMedGoogle Scholar
  • 18 Specifications Manual for Joint Commission National Quality Measures (v2015A). The Joint Commission; Accessed 2015 at: https://manual.jointcommission.org/releases/TJC2015A/TableOfContentsTJC.html
    PubMedGoogle Scholar
  • 19 Lee VR, Darney BG, Snowden JM. et al. Term elective induction of labour and perinatal outcomes in obese women: retrospective cohort study. BJOG 2016; 123 (02) 271-278
    CrossrefPubMedGoogle Scholar
  • 20 Gibbs Pickens CM, Kramer MR, Howards PP, Badell ML, Caughey AB, Hogue CJ. Term elective induction of labor and pregnancy outcomes among obese women and their offspring. Obstet Gynecol 2018; 131 (01) 12-22
    CrossrefPubMedGoogle Scholar
  • 21 Levine LD, Limaye M, Srinivas SK. The utility of ICD9-CM codes in identifying induction of labor. Am J Perinatol 2015; 32 (05) 475-480
    PubMedGoogle Scholar
  • 22 Lydon-Rochelle MT, Holt VL, Cárdenas V. et al. The reporting of pre-existing maternal medical conditions and complications of pregnancy on birth certificates and in hospital discharge data. Am J Obstet Gynecol 2005; 193 (01) 125-134
    CrossrefPubMedGoogle Scholar
  • 23 Lain SJ, Hadfield RM, Raynes-Greenow CH. et al. Quality of data in perinatal population health databases: a systematic review. Med Care 2012; 50 (04) e7-e20
    CrossrefPubMedGoogle Scholar
  • 24 Danilack VA, Triche EW, Dore DD, Muri JH, Phipps MG, Savitz DA. Comparing expectant management and spontaneous labor approaches in studying the effect of labor induction on cesarean delivery. Ann Epidemiol 2016; 26 (06) 405-411.e1
    CrossrefPubMedGoogle Scholar
  • 25 Gregory KD, Korst LM, Gornbein JA, Platt LD. Using administrative data to identify indications for elective primary cesarean delivery. Health Serv Res 2002; 37 (05) 1387-1401
    CrossrefPubMedGoogle Scholar
  • 26 Henry OA, Gregory KD, Hobel CJ, Platt LD. Using ICD-9 codes to identify indications for primary and repeat cesarean sections: agreement with clinical records. Am J Public Health 1995; 85 (8 Pt 1): 1143-1146
    CrossrefPubMedGoogle Scholar
  • 27 Committee opinion: Weight gain during pregnancy. American College of Obstetricians and Gynecologists; Accessed January 2013 at: https://pubmed.ncbi.nlm.nih.gov/23262962/
    PubMedGoogle Scholar
  • 28 Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol 2004; 159 (07) 702-706
    CrossrefPubMedGoogle Scholar
  • 29 Darney BG, Snowden JM, Cheng YW. et al. Elective induction of labor at term compared with expectant management: maternal and neonatal outcomes. Obstet Gynecol 2013; 122 (04) 761-769
    CrossrefPubMedGoogle Scholar
  • 30 Glantz JC. Term labor induction compared with expectant management. Obstet Gynecol 2010; 115 (01) 70-76
    CrossrefPubMedGoogle Scholar
  • 31 Glantz JC. Elective induction of labor at term compared with expectant management: maternal and neonatal outcomes. Obstet Gynecol 2014; 123 (2 Pt 1): 363
    CrossrefPubMedGoogle Scholar
  • 32 Darney BG, Caughey AB. In reply. Obstet Gynecol 2014; 123 (2 Pt 1): 363
    CrossrefPubMedGoogle Scholar
  • 33 American College of Obstetricians and Gynecologists. ACOG committee opinion no. 560: Medically indicated late-preterm and early-term deliveries. Obstet Gynecol 2013; 121 (04) 908-910
    CrossrefPubMedGoogle Scholar
  • 34 Cheng YW, Kaimal AJ, Snowden JM, Nicholson JM, Caughey AB. Induction of labor compared to expectant management in low-risk women and associated perinatal outcomes. Am J Obstet Gynecol 2012; 207 (06) 502.e1-502.e8
    CrossrefPubMedGoogle Scholar
  • 35 Caughey AB, Sundaram V, Kaimal AJ. et al. Systematic review: elective induction of labor versus expectant management of pregnancy. Ann Intern Med 2009; 151 (04) 252-263 , W53-63
    CrossrefPubMedGoogle Scholar
  • 36 Stock SJ, Ferguson E, Duffy A, Ford I, Chalmers J, Norman JE. Outcomes of elective induction of labour compared with expectant management: population based study. BMJ 2012; 344: e2838
    CrossrefPubMedGoogle Scholar
  • 37 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: CD004945
    CrossrefPubMedGoogle Scholar
  • 38 Kawakita T, Iqbal SN, Huang CC, Reddy UM. Nonmedically indicated induction in morbidly obese women is not associated with an increased risk of cesarean delivery. Am J Obstet Gynecol 2017; 217 (04) 451.e1-451.e8
    CrossrefPubMedGoogle Scholar
  • 39 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
    CrossrefPubMedGoogle Scholar
  • 40 Nicholson JM, Caughey AB, Stenson MH. et al. The active management of risk in multiparous pregnancy at term: association between a higher preventive labor induction rate and improved birth outcomes. Am J Obstet Gynecol 2009; 200 (03) 250.e1-250.e13
    CrossrefPubMedGoogle Scholar
  • 41 Heffner LJ, Elkin E, Fretts RC. Impact of labor induction, gestational age, and maternal age on cesarean delivery rates. Obstet Gynecol 2003; 102 (02) 287-293
    PubMedGoogle Scholar
  • 42 Koopmans CM, Bijlenga D, Groen H. et al; HYPITAT study group. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial. Lancet 2009; 374 (9694): 979-988
    CrossrefPubMedGoogle Scholar
  • 43 Melamed N, Ray JG, Geary M. et al. Induction of labor before 40 weeks is associated with lower rate of cesarean delivery in women with gestational diabetes mellitus. Am J Obstet Gynecol 2016; 214 (03) 364.e1-364.e8
    CrossrefPubMedGoogle Scholar
  • 44 Cruz MO, Gao W, Hibbard JU. What is the optimal time for delivery in women with gestational hypertension?. Am J Obstet Gynecol 2012; 207 (03) 214.e1-214.e6
    CrossrefPubMedGoogle Scholar
  • 45 Hutcheon JA, Lisonkova S, Magee LA. et al. Optimal timing of delivery in pregnancies with pre-existing hypertension. BJOG 2011; 118 (01) 49-54
    CrossrefPubMedGoogle Scholar
  • 46 Vrouenraets FP, Roumen FJ, Dehing CJ, van den Akker ES, Aarts MJ, Scheve EJ. Bishop score and risk of cesarean delivery after induction of labor in nulliparous women. Obstet Gynecol 2005; 105 (04) 690-697
    CrossrefPubMedGoogle Scholar
  • 47 Zelig CM, Nichols SF, Dolinsky BM, Hecht MW, Napolitano PG. Interaction between maternal obesity and Bishop score in predicting successful induction of labor in term, nulliparous patients. Am J Perinatol 2013; 30 (01) 75-80
    PubMedGoogle Scholar