Prolonged Pregnancy: Induction of Labor and

Cesarean Births
JAMES M. ALEXANDER, MD, DONALD D. MCINTIRE, PhD, AND
KENNETH J. LEVENO, MD
Objective: To determine the effects of labor induction on
cesarean delivery in post-date pregnancies.
Materials and Methods: A total of 1325 women who
reached 41 weeks gestation between December 1, 1997, and
April 4, 2000, and who were scheduled for induction of labor
at 42 weeks were included in this prospective observational
study. Cesarean delivery rates were compared between those
women who entered spontaneous labor and those who
underwent induction. Women with any medical or obstetric
risk factors were excluded. A power analysis was performed
to determine how many patients would be required to show
no effect of labor induction on cesarean delivery with a of
.8 and an of .05. Approximately 5200 patients would be
required, taking an estimated 28 years to accrue at our
institution.
Results: Admission to delivery was longer (5.7 compared
with 11.1 hours, P .001) and more likely to extend beyond
10 hours (55 compared with 24%, P .001) in the induction
group. Cesarean deliveries were increased in the induced
group (19 compared with 14%, P < .001) due to cesarean for
failure to progress (14 compared with 8%, P < .001). Independent risk factors for cesarean delivery included nulliparity, undilated cervix prior to labor, and epidural analgesia.
Correction for these risk factors using logistic regression
analysis revealed that it was the risk factors, and not induction of labor per se, that increased cesarean delivery.
Conclusion: Risk factors intrinsic to the patient, rather
than labor induction itself, are the cause of excess cesarean
deliveries in women with prolonged pregnancies. (Obstet
Gynecol 2001;97:9115. 2001 by The American College of
Obstetricians and Gynecologists.)

gestations (25% of women who reach 41 weeks). This

increase in induction has intensified a long-standing
obstetric concern that induction of labor leads to an
increase in cesarean births. During the 1990s, there were
at least eight published reports29 that dealt specifically
with the effects of labor induction on cesarean rates and
numerous other reports dealing with pharmacologic
methods of cervical ripening, primarily involving
prostins.10 With few exceptions, these reports dealing
with the effects of labor induction on cesarean delivery
included a heterogeneous group of patients with many
potentially confounding risk factors for cesarean delivery. For example, most reports included a relatively
wide spectrum of gestational ages (eg, 37 41 weeks),
multiple indications for induction such as preeclampsia
(which undoubtedly influences the conduct of the induction), and differing methods of labor stimulation
within a given study cohort. The multiplicity of these
factors makes it difficult to determine if it is the induction of labor per se, or the patient circumstances under
which induction is undertaken, that influence the resulting cesarean rate.
Our purpose was to measure the effects of labor
induction in a homogeneous cohort of women, all of
whom were scheduled for induction within a 6-day
gestational age window (41 to 41-67 days) and in whom
the only complication was prolonged pregnancy. Importantly, induction and labor management were uniform.

The rate of labor induction has been rising steadily in

the United States since at least 1989 when data on this
obstetric practice first became available on the birth
certificate.1 Currently, about one in five pregnant
women undergo labor induction, with the highest rates
of induction occurring in women with the longest

Materials and Methods

From the University of Texas Southwestern Medical Center at Dallas,

Dallas, Texas.

VOL. 97, NO. 6, JUNE 2001

Between December 1, 1997, and April 4, 2000, women

whose pregnancies reached 41 completed weeks were
seen in a special post-term clinic held at Parkland
Hospital. Information about each patients pregnancy,
labor course, and neonatal outcome was prospectively
entered into a computerized database maintained by a
research nurse. This study was limited to women with

0029-7844/01/$20.00
PII S0029-7844(01)01354-0

911

singleton cephalic presentations. Women with an

anomalous fetus, diabetes, prior cesarean delivery, or
other medical or obstetric indications for delivery were
excluded. Gestational age was confirmed to be 41 weeks
if the stated last menses agreed with an ultrasound
examination prior to 26 weeks or the last menses was
supported by fundal height measurements between 18
and 30 weeks gestation.11
The management protocol for women who reach 41
weeks at our institution begins with referral to a specialized clinic staffed by a maternal-fetal medicine specialist (JA). Women identified to be 41 weeks based on
gestational age landmarks or ultrasound were scheduled for a two-stage induction attempt beginning at
41-67 weeks. All women received a cervical examination
by either an MD or MD-supervised midwives and
nurse practitioners during the clinic visit. The first stage
included installation of 0.5 mg prostaglandin E2 gel into
the cervix the afternoon before scheduled induction of
labor with oxytocin (stage 2) the next morning. Women
who did not develop sustained uterine contractions
with intracervical prostaglandin received oxytocin according to a previously published schedule.12 Briefly,
an oxytocin infusion was begun at 6 mU/min and
increased by 6 mU/min every 40 minutes to a maximum of 42 mU/min. Labor management was standardized and included cervical examinations every 23
hours, with amniotomy when cervical dilatation
reached 3 4 cm, followed by internal uterine and fetal
heart rate (FHR) monitoring. The uterine activity goal
for labor stimulation was more than 200 Montevideo
units. Failure to progress was diagnosed and cesarean
delivery performed when cervical dilatation or fetal
descent ceased for 2 4 hours despite adequate uterine
activity.
Statistical analysis was by Pearson chi-square, MantelHaenszel chi-square for trend,13 Student t test, and
multiple logistic regression. The variables entered into
the logistic regression model were selected a priori as
variables known to be related to cesarean delivery.
These included cervical dilation (modeled as zero or
larger), parity (nulliparity to multiparous), epidural
(present or absent), gestational age (a continuous variable of completed integral weeks), and induction (induced or spontaneous). Results are presented as
means standard deviation, number and percent, and
odds ratios (OR) with 95% confidence intervals (CI).
Wilcoxon rank sum methods were used for nonnormally distributed data and are shown as median
values with quartiles. All P values are two-sided and
were considered statistically significant if less than .05.
SAS version 8 (SAS Institute, Cary, NC) was used.

912 Alexander et al

Cesarean, Induction Post-term

Table 1. Demographic Characteristics of Women Who

Entered Labor Before Scheduled Inductions
Compared With Those Who Actually Underwent
Induction of Labor at 42 Weeks Gestation
Characteristics

Spontaneous labor
n 687 (%)

Induction
n 638 (%)

24.4 5.3

24.0 5.3

553 (80)
97 (14)
27 (4)
10 (1)
336 (49)

498 (78)
85 (13)
41 (6)
14 (2)
347 (54)

Maternal age (y)*

Race
Hispanic
Black
White
Other
Nulliparity

P
.16
.14

.05

* Mean standard deviation.

Results
A total of 1325 women with pregnancies 41 to 41-67
weeks were prospectively enrolled in this observational
study. A total of 687 (52%) women entered spontaneous
labor before their scheduled inductions and the remainder underwent labor induction. Shown in Table 1 are
selected demographic characteristics for women who
had spontaneous labor compared with those whose
labor was induced. There were no significant differences except for nulliparity, which was noted for 54% of
induced pregnancies compared with 49% of those with
spontaneous labor. As expected, gestational age at
delivery was approximately 4 days less, on average, in
women who entered spontaneous labor before their
scheduled inductions, compared with those who required labor induction (Table 2). Labor was longer and
epidural analgesia was more frequent in women who
underwent induction than in those with spontaneous
labor. Cesarean delivery was significantly increased in
women with inductions; this increase was limited to
cesareans for failure to progress.

Table 2. Selected Intrapartum Characteristics of Women

Entering Spontaneous Labor Before Scheduled
Induction Compared With Those Undergoing
Scheduled Induction at 42 Weeks Gestation
Characteristics
Gestational age at delivery
(wk)
Epidural analgesia
Admit to delivery (h)*
10 h
Second stage 2 h
Forceps delivery
Total cesarean births
Failure to progress
Fetal distress

Spontaneous labor
n 687 (%)

Induction
n 638 (%)

41-37
159 (23)
5.7 (2.8, 9.7)
164 (24)
39 (6)
51 (7)
97 (14)
54 (8)
25 (4)

42-07

P
.001

200 (31)
.001
11.05 (6.9, 16.4) .001
351 (55)
.001
33 (5)
.69
53 (8)
.55
124 (19)
.001
87 (14)
.001
30 (5)
.33

* Median with 25th and 75th quartiles shown.

Obstetrics & Gynecology

Table 3. Cesarean Birth Rates Stratified by Cervical Dilatation in Women Who Entered Spontaneous Labor Before Scheduled
Induction Compared With Those Who Underwent Induction at 42 Weeks Gestation
Spontaneous labor
cervical dilatation, cm (%)

Cesarean, all
Failure to progress
Fetal distress

Induction
cervical dilatation, cm (%)

0
n 142

1
n 233

2 or greater
n 322

P for trend

0
n 260

1
n 244

2 or greater
n 134

P for trend

28 (20)
14 (10)
7 (5)

41 (18)
22 (10)
13 (6)

28 (9)
18 (6)
5 (2)

0.001
0.07
0.03

79 (30)*
60 (23)
17 (7)

34 (14)
21 (9)
9 (4)

11 (8)
6 (4)
4 (3)

.001
.001
.09

* Significant, P .02 when compared with overall cesareans in women with zero cervical dilatation and spontaneous labor.

Significant, P .001 for zero cervical dilatation.

Table 3 shows the cesarean births stratified by cervical dilatation before the onset of labor. This examination
occurred at the clinic visit where the induction was
scheduled. Using trend analysis, cesarean deliveries
were related significantly to cervical dilatation in both
study groups. Cervical dilatation was used in this
analysis because it was more predictive of cesarean
delivery than cervical effacement or fetal head station
when analyzed using receiver operator characteristic
curves. Further analysis, using chi-square, showed that
the increase in cesarean delivery associated with induction of labor was attributable to the subgroup of induced women with undilated cervices.
Logistic regression was used to adjust for cervical
dilatation, gestational age, nulliparity, and epidural
analgesia (Figure 1). The OR for cesarean delivery
associated with labor induction was 1.1 (95% CI 0.9,
1.2). Unlike labor induction, an undilated cervix, nulli-

Figure 1. Odds ratios for overall cesarean delivery related to induction of labor corrected for nulliparity, cervical dilatation, gestational
age, and epidural analgesia. CI confidence interval.

VOL. 97, NO. 6, JUNE 2001

parity, and epidural analgesia remained significantly

associated with cesarean delivery. A power analysis
was performed to determine how many patients would
be required to show no effect of labor induction on
cesarean delivery with a of .8 and an of .05.
Approximately 5200 patients would be required, taking
an estimated 28 years to accrue at our institution.

Discussion
There are three central findings in this analysis of the
role labor induction plays in cesarean delivery. Induction of labor, compared with spontaneous labors in
demographically comparable study groups, was associated with a 40% increase in overall cesarean delivery
rates (from 14% to 19%) and an increase in cesarean
deliveries for failure to progress, but not fetal distress.
Associated risk factors for cesarean delivery included
an undilated cervix, epidural analgesia, more advanced
gestational age, and nulliparity. Most importantly,
when the analysis was corrected for these confounding
risk factors, labor induction per se was not related to
excess cesarean delivery. This result suggests that it is
the patients circumstances, for example, undilated cervix, that increase the risk of cesarean delivery rather
than the induction itself.
It has long been accepted that induction of labor
increases the risk of cesarean delivery. We were able to
find eight reports published in the last decade that
specifically deal with the effects of labor induction on
cesarean delivery.29 Two of these reports described
randomized trials and the others were retrospective
studies. Hannah et al3 randomized 3407 women with
uncomplicated pregnancies at 41 weeks gestation or
longer to induction of labor or expectant management.
Induction resulted in a lower cesarean rate. However,
the increase in cesarean births in the expectantly managed group was primarily due to abnormal FHR patterns during antepartum fetal testing, making it difficult
to isolate the effect of labor induction, per se, on
cesarean rates. In the other randomized trial, 440 preg-

Alexander et al

Cesarean, Induction Post-term

913

Table 4. Summary of Retrospective Studies Published

During the 1990s Dealing Specifically With the
Effects of Labor Induction on Cesarean Delivery

Author(s)

Year

Women
studied
(N)

Macer et al4
Xenakis et al5
Prysak and Castronova6
Seyb et al7
Yeast et al8
Maslow and Sweeney9

1992
1997
1998
1999
1999
2000

506
597
922
1561
7224
1135

Does induction
increase
cesarean rate?
No
Yes
No
Yes
Yes
Yes

nancies at 41 weeks gestation were randomized, and

induction of labor had no significant effect on cesarean
delivery but the sample size was deemed insufficient to
measure this outcome.2 Shown in Table 4 is a summary
of the six retrospective studies published during the
1990s specifically addressing the effect of labor induction on cesarean delivery.4 9 Induction was linked to
excess cesarean births in four reports and unrelated in
two others. The populations studied were heterogeneous in terms of medical and obstetric complications
as well as demographic factors. Frequently identified
risk factors for induction-related cesarean births included nulliparity,4 9 unfavorable cervical dilatation,4 7,9 and epidural analgesia.4,6 Our results are similar to those of Prysak and Castronova,6 who performed
a case-control study involving 461 pairs of women. The
increased rate of cesarean delivery in women undergoing labor induction was explained by nulliparity and
undilated cervices and not by induction per se.
Our purpose was to attempt to separate the effects of
labor induction on cesarean delivery from the patient
characteristics that intrinsically impact cesarean births.
As previous studies have shown, this objective is difficult to achieve. The complication for which induction is
performed may greatly affect the effectiveness of labor
stimulation and have an impact on the associated
cesarean rate. For example, in the case of hypertensive
disorders due to pregnancy, the clinical exigencies
concerning the severity of this disease would undoubtedly influence the obstetricians readiness to proceed or
abandon labor induction in favor of cesarean delivery.
Similarly, gestational age is a significant modifier of the
success of labor induction with greater success linked to
advancing gestational age. The multiplicity of confounding factors such as these makes it difficult to
ascertain whether induction of labor based on the
patients characteristics account for the associated increase in cesarean deliveries. Our study cohort was
chosen to exclude as many of these confounding factors
as possible and was mostly but not entirely successful.
For example, a 3-day difference in gestational age was

914 Alexander et al

Cesarean, Induction Post-term

statistically linked to the cesarean delivery rate in our

study groups, even though their maximum gestational
age difference could not exceed 6 days. Such small
incremental differences make it difficult to separate the
effects of intrinsic patient characteristics on cesarean
delivery distinct from the induction of labor itself. We
are of the view, however, that the study cohort we
selected was as homogeneous as possible short of a
likely unfeasible randomized trial. Specifically, to perform a randomized trial of induction compared with
expectant management in women with important risk
factors for cesarean delivery including undilated cervix,
nulliparity, and epidural analgesia would require 1728
women. This represents less than 5% of our prolonged
pregnancy study population and would require ascertainment of over 30,000 pregnancies, a 40-year study at
our institution. In the absence of such a randomized
trial, we are left to conclude that patient circumstance,
as opposed to labor induction itself, leads to increased
cesarean delivery in prolonged pregnancy.

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Final data for 1998. National Vital Statistics Reports, vol. 48 no. 3.
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Obstetrics & Gynecology

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Received September 21, 2000.

Received in revised form January 9, 2001.
Accepted January 31, 2001.

Address reprint requests to:

James M. Alexander, MD
Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
5323 Harry Hines Boulevard
Dallas, TX 75235-9032
E-mail: jalexa@mednet.swmed.edu

VOL. 97, NO. 6, JUNE 2001

Copyright 2001 by The American College of Obstetricians and

Gynecologists. Published by Elsevier Science Inc.

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915