Effect of Elective Induction at 39 Weeks in Low-Risk Nulliparous Women on Cesarean Delivery Rates

Abstract

Introduction: The ARRIVE trial suggested that elective induction at 39 weeks in low-risk nulliparas does not increase cesarean delivery and may reduce perinatal complications. This review synthesizes subsequent real-world evidence.
Methods: Systematic review of observational studies and one large randomized trial comparing elective induction at 39 weeks versus expectant management in low-risk nulliparas (no medical or obstetric indications). Primary outcome: cesarean delivery rate.
Results: Fourteen observational studies (n=450,000) plus the ARRIVE trial (n=6,100) were included. Meta-analysis of observational data showed no significant difference in cesarean rate (relative risk 0.96) but higher induction failure (12% vs. 4%). ARRIVE showed lower cesarean rate with induction (19% vs. 22%). Pooled effect was a non-significant risk ratio of 0.93.
Discussion: Real-world studies do not replicate the modest cesarean reduction seen in ARRIVE, possibly due to different induction protocols and patient selection. The absolute risk of perinatal complications is very low regardless.
Conclusions: Elective induction at 39 weeks in low-risk nulliparas does not increase cesarean delivery risk. The decision should incorporate patient preference and local induction resources rather than aiming to lower cesarean rates.