Caesarean section rates and adverse neonatal outcomes after induction of labour versus expectant management in women with an unripe cervix: a secondary analysis of the HYPITAT and DIGITAT trials

Objective: To evaluate caesarean section and adverse neonatal outcome rates after induction of labour or expectant management in women with an unripe cervix at or near term. Design: Secondary analysis of data from two randomised clinical trials. Setting: Data were collected in two nationwide Dutch trials. Population: Women with hypertensive disease (HYPITAT trial) or suspected fetal growth restriction (DIGITAT trial) and a Bishop score ≤6. Methods: Comparison of outcomes after induction of labour and expectant management. Main outcome measures: Rates of caesarean section and adverse neonatal outcome, defined as 5-minute Apgar score ≤6 and/or arterial umbilical cord pH <7.05 and/or neonatal intensive care unit admission and/or seizures and/or perinatal death. Results: Of 1172 included women with an unripe cervix, 572 had induction of labour and 600 had expectant management. We found no significant difference in the overall caesarean rate (difference −1.1%, 95% CI −5.4 to 3.2). Induction of labour did not increase caesarean rates in women with Bishop scores from 3 to 6 (difference −2.7%, 95% CI −7.6 to 2.2) or adverse neonatal outcome rates (difference −1.5%, 95% CI −4.3 to 1.3). However, there was a significant difference in the rates of arterial umbilical cord pH <7.05 favouring induction (difference −3.2%, 95% CI −5.6 to −0.9). The number needed to treat to prevent one case of umbilical arterial pH <7.05 was 32. Conclusions: We found no evidence that induction of labour increases the caesarean rate or compromises neonatal outcome as compared with expectant management. Concerns over increased risk of failed induction in women with a Bishop score from 3 to 6 seem unwarranted. Tweetable abstract: Induction of labour at low Bishop scores does not increase caesarean section rate or poor neonatal outcome.