Induction of labour for improving birth outcomes for women at or beyond term.
BACKGROUND
As a pregnancy continues beyond term the risks of babies dying inside the womb or in the immediate newborn period increase. Whether a policy of labour induction at a predetermined gestational age can reduce this increased risk is the subject of this review.


OBJECTIVE
To evaluate the benefits and harms of a policy of labour induction at term or post-term compared to awaiting spontaneous labour or later induction of labour.


METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2006).


METHODS
Randomized controlled trials conducted in women at or beyond term. The eligible trials were those comparing a policy of labour induction to a policy of awaiting spontaneous onset of labour. Trials comparing cervical ripening methods, membrane stripping/sweeping or nipple stimulation without any commitment to delivery within a certain time were excluded.


METHODS
Two review authors independently evaluated potentially eligible trials and extracted data. Outcomes are analysed in two main categories: gestational age and cervix status.


RESULTS
We included 19 trials reporting on 7984 women. A policy of labour induction at 41 completed weeks or beyond was associated with fewer (all-cause) perinatal deaths (1/2986 versus 9/2953; relative risk (RR) 0.30; 95% confidence interval (CI) 0.09 to 0.99). The risk difference is 0.00 (95% CI 0.01 to 0.00). If deaths due to congenital abnormality are excluded, no deaths remain in the labour induction group and seven deaths remain in the no-induction group. There was no evidence of a statistically significant difference in the risk of caesarean section (RR 0.92; 95% CI 0.76 to 1.12; RR 0.97; 95% CI 0.72 to 1.31) for women induced at 41 and 42 completed weeks respectively. Women induced at 37 to 40 completed weeks were more likely to have a caesarean section with expectant management than those in the labour induction group (RR 0.58; 95% CI 0.34 to 0.99). There were fewer babies with meconium aspiration syndrome (41+: RR 0.29; 95% CI 0.12 to 0.68, four trials, 1325 women; 42+: RR 0.66; 95% CI 0.24 to 1.81, two trials, 388 women).


CONCLUSIONS
A policy of labour induction after 41 completed weeks or later compared to awaiting spontaneous labour either indefinitely or at least one week is associated with fewer perinatal deaths. However, the absolute risk is extremely small. Women should be appropriately counselled on both the relative and absolute risks.
Gülmezoglu
A M
AM
Research Training in Human Reproduction (HRP), UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development,Department of Reproductive Health and Research,World Health Organization, Geneva 27, Switzerland. gulmezoglum@who.int
Crowther
C A
CA
Middleton
P
P
D002585:Cesarean Section; D005260:Female; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D007751:Labor, Induced / Q000009:adverse effects; D011247:Pregnancy; D011273:Pregnancy, Prolonged; D016032:Randomized Controlled Trials as Topic; D012306:Risk