The Journal of Maternal-Fetal & Neonatal Medicine

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A comparison of maternal and perinatal outcomes

with vaginal delivery: indicated induction versus
spontaneous labor

Julie R. Whittington, Songthip T. Ounpraseuth, Everett F. Magann, Paul J.

Wendel, Lisa Newton & John C. Morrison

To cite this article: Julie R. Whittington, Songthip T. Ounpraseuth, Everett F. Magann, Paul J.
Wendel, Lisa Newton & John C. Morrison (2020): A comparison of maternal and perinatal outcomes
with vaginal delivery: indicated induction versus spontaneous labor, The Journal of Maternal-Fetal
& Neonatal Medicine, DOI: 10.1080/14767058.2020.1774545

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Published online: 04 Jun 2020.

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THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE
https://doi.org/10.1080/14767058.2020.1774545

ORIGINAL ARTICLE

A comparison of maternal and perinatal outcomes with vaginal delivery:

indicated induction versus spontaneous labor
Julie R. Whittingtona , Songthip T. Ounpraseuthb , Everett F. Maganna , Paul J. Wendela, Lisa
Newtona and John C. Morrisonc

a
Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA; bDepartment of
Biostatistics, University of Arkansas for the Medical Sciences, Little Rock, AR, USA; cDepartment of Obstetrics and Gynecology,
University of Mississippi Medical Center, Jackson, MS, USA

ABSTRACT ARTICLE HISTORY

Objective: To determine if there is a difference in the maternal and perinatal characteristics and Received 5 February 2020
outcomes of women undergoing a medically indicated labor induction and delivering vaginally Revised 11 May 2020
compared to women in spontaneous labor delivering vaginally. Accepted 21 May 2020
Methods: This is a planned secondary analysis of previously published data with additional data
KEYWORDS
collected for a case-control design. Maternal and perinatal characteristics and outcomes of Indicated induction;
women undergoing a medically indicated labor induction of labor and delivering vaginally were spontaneous labor;
compared with the next woman who went into labor spontaneously and delivered vaginally. perinatal outcomes; vaginal
Results: There were 1097 women in the medically indicated labor group and 1096 women in delivery; length of labor
the spontaneous labor group. The medically indicated induction group was younger (p < .0001),
had less women of “other” race (p ¼ .004), were of a lower gravidity and parity (p < .0001), had
a lower Bishops’ score on admission (p < .0001), had a greater proportion of umbilical arterial
cord pH values <7.1 and <7.0 (p < .0001). Additionally, the induction group had longer first and
second stages of labor (p < .0001). While the unadjusted rates of post-partum complications and
NICU admission were higher in the medically indicated labor induction group, only cord gas pH
<7.1 remained statistically significant after adjustment.
Conclusion: Even with successful vaginal delivery of a medically indicated induction of labor,
the risk for adverse outcomes remains elevated.

Brief rationale women undergoing an elective induction of labor with

This study was conducted to determine if medically
indicated induction of labor with vaginal delivery was
associated with adverse maternal or perinatal out-
comes compared to women who had spontaneous
labor and delivered vaginally. Medically indicated
induction of labor with a subsequent vaginal delivery
was associated with longer labor and umbilical artery
pH <7 compared to spontaneous labor.
Introduction
The overall rate of labor induction, elective and indicated,
has risen dramatically from 8.5% in 1990 to 23% in 2009
[1]. Many methods have been used to induce labor
including oxytocin, prostaglandins (orally and vaginally),
amniotomy, and cervical catheters. In a comparison of
women entering labor spontaneously, nulliparous
women were more likely to be delivered by cesarean and
the risk of shoulder dystocia and an instrumental delivery
was increased in both the nulliparous and parous women
[2]. The information available about the maternal and
neonatal characteristics of pregnancies undergoing a
medically indicated induction of labor and delivering
vaginally compared with women in spontaneous labor
who delivered vaginally is scant.
A literature search for the topic spontaneous vagi-
nal delivery compared with an indicated induction of
labor using PubMed and Web of Science was under-
taken. The MeSH terms Spontaneous and Vaginal and
delivery or birth, were combined with pregnancy out-
comes, Apgar scores, admission, cord gases, outcome
assessment, and labor induction, labor, induced or

CONTACT Julie R. Whittington julie.whittington09@gmail.com Department of Obstetrics and Gynecology, University of Arkansas for the Medical
Sciences, 4301 W. Markham St. Slot # 518, Little Rock, 72205 AR, USA

In memoriam and posthumously submitted for Dr. John C. Morrison, who made significant contributions to the paper in data collection, study design,
and manuscript editing.
This work was authored as part of the Contributor’s official duties as an Employee of the United States Government and is therefore a work of the United States Government.
In accordance with 17 U.S.C. 105, no copyright protection is available for such works under U.S. Law.
2 J. R. WHITTINGTON ET AL.
induction, indicated, and non-elective in PubMed. In
Web of Science, the topic words spontaneous and
vaginal, indicated, induced, induction were combined
with the words outcome, Apgar, cord gases, and neo-
natal intensive care unit admission. The search was
limited to published articles with no limitation on the
years searched but was limited to publications in
English only.
The only related studies that were identified were
two investigations of elective inductions compared to
spontaneous labor in low-risk women [3,4]. The inves-
tigators, Guerra et al., found that elective inductions
were associated with a higher postpartum need for
uterotonic drugs, greater risk for an intensive care unit
admission, postpartum hysterectomy, and increased
need for anesthesia/analgesia [3]. In a study by Glantz,
the elective induction group had more intrapartum
interventions, cesarean deliveries, and longer maternal
hospital stays but no difference in adverse neonatal
outcomes [4]. We discovered no studies that com-
pared the maternal and perinatal outcomes of women
with a medically indicated induction of labor who sub-
sequently delivered vaginally with women entering
labor spontaneously and subsequently deliv-
ered vaginally.
The purpose of this investigation was to evaluate
the maternal characteristics and neonatal outcomes of
women who underwent indicated medical induction
of labor and subsequently delivered vaginally com-
pared with women who entered labor spontaneously
and delivered vaginally. We hypothesized that women
who underwent medically indicated induction of labor
and delivered vaginally would have an increased risk
of adverse perinatal outcomes.
Material and methods
This is a planned secondary analysis of pregnancies
undergoing a medically indicated induction of labor at
two University medical centers who subsequently
delivered vaginally over a 24 month period [5]. These
were then compared with women who entered labor
spontaneously and delivered vaginally during that
same time period. The next spontaneous vaginal deliv-
ery was taken from the delivery logs at the two med-
ical centers in a 1:1 ratio. Women who were electively
induced were excluded from both groups. Indicated
inductions of labor were defined as initiated for a
medical reason such as maternal, fetal, or placental
issues. All gestational ages >24 weeks were included
in this study. This study was approved by expedited
review by the Investigational Review Board at the
University of Arkansas for Medical Sciences
(IRB#111916) and the University of Mississippi Medical
Center (IRB#2010-0004). Strengthening the Reporting
of Observational Studies in Epidemiology (STROBE)
guidelines were followed [6].
Initially, bivariate analyses using a chi-square test or
Fisher’s exact test for categorical measures and two-
sample t-test or the Wilcoxon rank-sum test for con-
tinuous variables were used to evaluate the relation-
ship between the maternal characteristics and
maternal/perinatal outcomes between the two groups.
Next, adjusted relative risk (RR) for a neonatal inten-
sive care unit (NICU) admission and having post-par-
tum complications were compared among those
women undergoing an indicated induction versus
spontaneous labor while adjusting for maternal race,
age, BMI at time of induction, parity, dichotomized
Bishop’s score (<6 vs. 6), duration of first stage of
labor, birth weight, gestational age, and 5 min Apgar
score. Post-partum complications included endometri-
tis, wound infection/break down, and blood product
transfusion. The adjusted RRs for both models were
obtained using a modified multivariable Poisson
regression model [7]. While NICU admission and post-
partum complications were our two primary out-
comes, we also examined other secondary outcomes
such as 5 min Apgar score <7, cord gas pH, and cho-
rioamnionitis with a modified multivariable Poisson
regression model. Finally, a general linear model was
used to examine the difference in the duration of first
stage of labor across the groups (induction vs. spon-
taneous vaginal delivery) while adjusting for maternal
age, race/ethnicity, BMI at delivery, parity, levels of
Bishop’s score (0–2, 3–4, 5–6, >6), infant birth weight,
and gestational age. We note that the duration of the
first stage of labor was tested for normality and
departure from normality was minimal. Nonetheless,
we conducted a sensitivity analysis using log-trans-
formation. The results of the multivariable regression
model did not differ from those of the main analysis,
so for clarity, the regression results of the non-trans-
formed outcome are presented. All statistical analyses
were performed using SAS 9.4 (SAS Institute Inc., Cary,
NC, USA) with two-sided test and statistical signifi-
cance level of .05.
Results
There were a total of 1097 women who underwent an
indicated labor induction vs. 1096 women who were
admitted in spontaneous labor and delivered vaginally
from that same data set over the 24 months of
 THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 3

Table 1. Bivariate analysis based on induction or spontaneous vaginal delivery.

Medical induction vaginal delivery Spontaneous vaginal delivery
Variables N ¼ 1097 N ¼ 1096 p-Value
Maternal characteristics
Age, mean ± sd 24.9 ± 5.8 26.7 ± 6.0 <.0001
Race, N (%) .0135
White 339 (31%) 310 (28%) .179c
Black 602 (55%) 580 (53%) .358c
Other 156 (14%) 206 (19%) .004c
BMI at delivery, mean ± sd 32.4 ± 7.9 30.6 ± 6.7 <.0001
Parity, N (%) <.0001
0 457 (42%) 274 (25%) <.0001c
1 316 (29%) 316 (29%) .989c
2 186 (17%) 255 (23%) .0002c
3 137 (12%) 251 (23%) <.0001c
Gravidity <.0001
1 461 (42%) 231 (21%) <.0001c
2 261 (24%) 263 (24%) .9102c
3 375 (34%) 602 (55%) <.0001c
Bishop’s score, mean ± sd 3.7 ± 2.2 8.7 ± 2.6 <.0001
Bishop’s score < 6, N (%) 870 (79.4%) 138 (12.6%) <.0001
Bishop’s score, N (%) <.0001
0–4 715 (65.2%) 62 (5.7%) <.0001c
5–9 374 (34.1%) 583 (53.2%) <.0001c
10–13 7 (0.7) 451 (41.1%) <.0001c
1st stage of labor (hour), mean ± sd 15.1 ± 7.6 6.6 ± 4.3 <.0001
2nd stage of labor (minute), median (25th, 75th quantiles) 34 [20, 57] 18 [10, 35] <.0001a
3rd stage of labor (minute), median (25th, 75th quantiles) 5 [4, 7] 4 [3, 6] .0001a
Chorioamnionitis, N (%) 44 (4.0%) 22 (2.0%) .0061
Post-partum complications, N (%) 44 (4.0%) 25 (2.2%) .0201
Neonatal characteristics/outcomes
Birth weight, mean ± sd 2844.9 ± 833.5 3045.1 ± 662.7 <.0001
Gestational age, mean ± sd 36.7 ± 4.2 37.9 ± 3.1 <.0001
Apgar 1, median (25th, 75th quantiles) 8.5 (7.0, 9.0) 8.0 (7.0, 9.0) .0557a
Apgar 5, median (25th, 75th quantiles) 9.0 (8.0, 9.0) 9.0 (9.0, 9.0) <.0001a
Apgar 5 min < 7, N (%) 129 (11.8%) 51 (4.7%) <.0001
Cord gas pH < 7, N (%) 38 (3.7%) 2 (0.2%) <.0001b
Cord gas pH < 7.1, N (%) 65 (6.3%) 26 (2.4%) <.0001b
NICU admission, N (%) 312 (29.5%) 150 (13.7%) <.0001
a
Results based on Wilcoxon rank-sum test; bResults based on Fisher’s exact test; cDenote p-value based on post-hoc pairwise comparison using chi-
square test.

assessment. The women from the induction group
were younger, had a slightly lower percentage women
in the other race/ethnicity category, were of a lower
gravidity, and parity, had a lower Bishops’ score on
admission, and longer first and second stages of labor.
The women who underwent an indicated labor induc-
tion delivered babies who had lower birth weight,
gestational age at delivery, and 5 min Apgar compared
to those who were admitted in spontaneous labor.
The proportion of umbilical arterial cord pH values
<7.1 and <7.0 were greater in the induction group on
bivariate analysis. Additionally, these women had a
higher percentage of post-partum complications and
their babies were more likely to be admitted into the
NICU (see Table 1 for complete results).
Table 2 provides the results of the multivariable
Poisson regression analyses for our two primary out-
comes (NICU admission and post-partum complica-
tion). After accounting for various maternal and infant
characteristics, the likelihood of post-partum complica-
tion or NICU admission were not statistically signifi-
cant among women who had a spontaneous vaginal
delivery or vaginal delivery after an indicated labor
induction. Black women were 32% less likely to have
been admitted to a NICU compared to White women.
Additionally, mothers with Bishop’s score <6 were
28% more likely to have had a NICU admission than
mothers with Bishop’s score  6 (p ¼ .044). While the
relative risk of NICU admission decreased by 35% with
each 500 g increase in infant birth weight, the likeli-
hood of having a NICU admission increases by 2.4%
and post-partum complications increase by 3.6% with
each additional hour during the first stage of labor.
Also, mothers who delivered infants whose 5 min
Apgar scores were  7 decreased their likelihood of
having a post-partum complication by 76%.
Table 3 presents the adjusted relative risks models
for our selected secondary outcomes including 5 min
Apgar score <7, cord gas pH <7.1, and chorioamnio-
nitis. There were not statistical differences between
women who had a spontaneous vaginal delivery or
vaginal delivery after an indicated labor induction in
terms of 5 min Apgar score <7 or chorioamnionitis.
However, those women with indicated labor induction
4 J. R. WHITTINGTON ET AL.

Table 2. Adjusted relative risk of primary outcomes (NICU admission and post-partum complications) based
on modified Poisson regression model.
NICU admission Post-partum complications
Relative risk
Predictors [95% CI] p-Value Relative risk [95% CI] p-Value
Onset of labor (ref: spontaneous) 1.230 [0.989, 1.529] .062 0.992 [0.492, 2.002] .982
Maternal age 0.988 [0.973, 1.004] .144 0.967 [0.920, 1.016] .186
Maternal race (ref: White)
Black 0.681 [0.576, 0.806] <.0001 1.280 [0.751, 2.181] .365
Other 0.718 [0.551, 0.937] .015 1.365 [0.675, 2.762] .387
BMI at time of induction 1.000 [0.991, 1.011] .919 0.990 [0.952, 1.029] .614
Parity (ref:  3)
0 1.011 [0.760, 1.345] .940 0.745 [0.370, 1.500] .410
1 0.928 [0.699, 1.233] .607 0.823 [0.408, 1.661] .587
2 1.011 [0.747, 1.369] .942 0.530 [0.226, 1.245] .145
Bishop score (ref:  6) 1.275 [1.010, 1.614] .044 1.083 [0.531, 2.206] .827
First stage of labor (hours) 1.024 [1.012, 1.036] .0001 1.036 [01.010, 1.064] .007
Infant birth weight (500 g unit) 0.654 [0.589, 0.725] <.0001 1.143 [0.876, 1.492] .325
Gestational age 1.021 [0.983, 1.060] .277 0.972 [0.888, 1.063] .530
Apgar 5 min (ref: < 7) 0.940 [0.702, 1.259] .678 0.239 [0.130, 0.441] <.0001

Table 3. Adjusted relative risk of secondary outcomes (5 min Apgar score < 7, cord gas pH, and chorioamnionitis) based on
modified Poisson regression model.
5 min Apgar
score < 7 Cord gas pH < 7.1 Chorioamnionitis
Relative risk Relative risk
Predictors [95% CI] p-Value Relative risk [95% CI] p-Value [95% CI] p-Value
Onset of labor (ref: spontaneous) 1.113 [0.786, 1.578] .547 2.185 [1.194, 4.001] .011 0.964 [0.500, 1.858] .913
Maternal age 0.990 [0.969, 1.012] .371 0.986 [0.942, 1.030] .520 0.9560.904, 1.012] .123
Maternal race (ref: White)
Black 0.792 [0.617, 1.017] .068 0.640 [0.403, 1.016] .059 1.251 [0.705, 2.219] .444
Other 0.860 [0.533, 1.386] .535 0.836 [0.439, 1.595] .587 0.958 [0.429, 2.143] .917
BMI at time of induction 1.005 [0.989, 1.021] .556 1.011 [0.983, 1.040] .434 1.007 [0.973, 1.042] .696
Parity (ref:  3)
0 1.171 [0.805, 1.703] .410 3.326 [1.372, 8.063] .008 15.039 [1.79, 126.2] .013
1 0.978 [0.650, 1.470] .913 2.914 [1.217, 6.978] .016 5.452 [0.665, 44.71] .114
2 1.216 [0.801, 1.848] .359 1.298 [0.464, 3.633] .620 7.323 [0.905, 59.26] .062
Bishop score (ref:  6) 1.183 [0.810, 1.727] .359 0.885 [0.512, 1.529] .661 1.446 [0.752, 2.782] .269
First stage of labor (hours) 1.019 [1.002, 1.036] .029 1.008 [0.980, 1.037] .583 0.999 [0.960, 1.039] .961
Infant birth weight (500g unit) 0.586 [0.466, 0.737] <.001 1.000 [0.810, 1.235] .998 1.324 [1.065, 1.647] .012
Gestational age 0.980 [0.911, 1.054] .585 0.8760.809, 0.948] .001 0.823 [0.764, 0.886] <.001

had 2.185 [95% CI: (1.194, 4.001); p ¼ .011)] the risk of
cord gas pH <7.1 compared to those women who
had a spontaneous vaginal delivery. The adjusted rela-
tive risk of an infant with 5 min Apgar score <7
decreased by 41% while the adjusted relative risk of
chorioamnionitis increase by 32% with each 500 g
increase in infant birth weight. Additionally, the likeli-
hood of an infant with 5 min Apgar score <7 increases
by 1.9% with each additional hour during first stage
of labor.
Finally, the duration of the first stage of labor for
women who had an indicated labor induction
remained, on average, longer than those women who
had a spontaneous vaginal delivery (least squares
mean 13.43 vs. 10.75 h; p < .0001) after adjusting for
maternal age, race/ethnicity, BMI at delivery, parity,
Bishop’s score, birth weight, and gestational age.
Moreover, the length of first stage of labor signifi-
cantly decreased with each increasing level of Bishop’s
score. More specifically, those women with Bishop’s
score 0–2 had an average of 17.7 h of first stage of
labor, Bishop’s score 3–4 had 13.3 h, Bishop’s score
5–6 had 10.1 h, and Bishop’s score >6 had on average
7.3 h. All pairwise comparison of the least squares
means were statistically significant (p < .001) even
after adjustment for multiple comparisons using
Bonferroni correction.
Discussion
Principal findings
There are several notable findings from this study. The
maternal characteristics of the women entering labor
spontaneously were significantly different from the
women who underwent an indicated induction of
labor. The group entering labor spontaneously were
older, had more women in the other race/ethnicity

group, had a lower BMI, had a higher gravidity and
parity, higher Bishop’s scores, and shorter first, second
and third stages of labor. The duration of the first
stage of labor remained significantly longer in the
induction group even after adjusting for various
maternal and infant characteristics. The third stage of
labor was longer in women undergoing indicated
induction; however, this result was not likely clinically
significant as placental delivery was still quick. Women
undergoing indicated inductions were more likely to
have chorioamnionitis and postpartum complications;
however, these results were not statistically significant
after adjusting for various covariates. From a neonatal
standpoint, women in the medically indicated induc-
tion group were more likely to have neonates with
Apgar scores <7 at 5 min and cord blood gas <7.1
and <7.0. However, only cord gas pH <7.1 remained
statistically significant in the adjusted analysis.
Clinical and research implications
Induction of labor is a common obstetric intervention
and is performed daily in Obstetric units worldwide. A
large retrospective study of women electively induced
at 39 weeks compared to women who were not
induced showed no difference in adverse neonatal
outcomes [8]. It is notable that this study involved
lower-risk patients, and therefore cannot be easily
compared to women undergoing medically indicated
induction of labor. Another large retrospective study
of 28,626 women in Australia compared medically
indicated induction, elective induction, and spontan-
eous labor and maternal and neonatal outcomes.
While the focus of this study was not on women who
delivered vaginally, they found both groups who
underwent induction had increased risk of labor
complications.
Other studies have been performed on the indica-
tion for labor induction and whether this impacted
failure rates, including one that showed an increased
risk of induction failure for nulliparous women, older
women, and women with hypertensive disorders [9].
This study did not address neonatal outcomes; how-
ever, or maternal outcomes such as postpartum com-
plications. In a prospective cohort study of 965
women, induction of labor (including elective and
indicated) was not associated with increased blood
loss or postpartum hemorrhage [10]. In contrast with
the ARRIVE trial, a large retrospective cohort study of
402,960 singleton pregnancies did show increased
odds of 5 min Apgar <7 and umbilical artery pH <7.1,
consistent with the findings of our study [11].
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 5
For the practicing obstetrician, the results of our
study are useful in counseling patients that indicated
induction of labor (while required for obstetric man-
agement) may be associated with longer first and
second stages of labor, increased risk of chorioamnio-
nitis, and that there is increased risk of neonatal com-
promise with decreased Apgar scores and cord gas
measurements, even when vaginal delivery is accom-
plished. It is notable that there was no increased risk
of NICU admission or postpartum complications in the
induction group after adjusting for maternal and
infant characteristics. No change in practice patterns is
suggested from this research.
More research is needed on pregnancies with indi-
cated induction of labor compared to both spontan-
eous labor and electively induced labor, with the goal
of finding modifiable risk factors to decrease maternal
postpartum complications and neonatal compromise.
Strengths and limitations
The strengths of this study include a large sample size
and multi-center data collection. Collecting data from
two centers contributes to the generalizability of the
information gained as there is heterogeneity in practice
patterns and induction methods between hospitals.
The main limitation of this study is its retrospective
nature. There is also inherent selection bias in compar-
ing women with medically indicated induction with their
comorbidities compared to women who deliver spontan-
eously. However, this dichotomy exists in practice and;
therefore, these groups should still be compared.
Conclusions
We hypothesized that women who underwent induc-
tion of labor and delivered vaginally would have
increased risk of adverse maternal and neonatal out-
comes compared to women who spontaneously
labored and delivered vaginally. Medically indicated
inductions, as expected, have longer labor, greater risk
of infection, increased risk of adverse neonatal out-
comes (including increased risk of cord pH <7.1), and
more than twice as many NICU admissions. Even with
successful vaginal delivery following medically indi-
cated induction of labor, the risk for adverse outcomes
remains elevated.
Acknowledgments
We would like to thank Donna Eastham, BA, CRS for her
help in editing this manuscript.
6 J. R. WHITTINGTON ET AL.
Disclosure statement
The authors have no financial disclosures or conflicts of
interest and no funding was used for this research.
ORCID
Julie R. Whittington http://orcid.org/0000-0002-6947-2896
Songthip T. Ounpraseuth http://orcid.org/0000-0001-
5623-0444
Everett F. Magann http://orcid.org/0000-0001-6823-7635
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