Fetomaternal Outcomes in Low-Risk Primigravida Women: Expectant Management Versus Elective Induction at 39 Weeks in a Tertiary Hospital

Paul C et al | DOI: 10.65188/nurexus.1059

Page 19

Journal of MedVerse Research & Practice

ISSN: 3107-4278

Fetomaternal Outcomes in Low-Risk Primigravida Women: Expectant

Management Versus Elective Induction at 39 Weeks in a Tertiary

Hospital

Dr. Christina Paul

, Dr. Sunil Swathy

Assistant Professor, Professor

Department of OBG, Pushpagiri Institute of Medical Science, Kerala

Email ID: christinapaul89@gmail.com,

Submission Date: 20.11.2025

Accepted Date: 22.12.2025

Published Date: 31.12.2025

DOI: 10.65188/nurexus.1059

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits

unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Background: The optimal timing of delivery in low-risk primigravida women remains a subject of ongoing debate.

While expectant management allows for the spontaneous onset of labour, advancing gestational age may increase

maternal and neonatal risks. Elective induction of labour at 39 completed weeks has been proposed as a strategy to

reduce perinatal morbidity without increasing operative delivery rates.

Methods: This comparative cross-sectional study was conducted over one year in the Department of Obstetrics and

Gynaecology at Pushpagiri Institute of Medical Science, Kerala. A total of 200 low-risk primigravida women at 39

completed weeks of gestation were included and divided into two groups: the elective induction group (n = 100)

and the expectant management group (n = 100). Maternal outcomes assessed included mode of delivery,

intrapartum and postpartum complications, and duration of labour, while neonatal outcomes included birth weight,

APGAR score at one minute, NICU admission, and neonatal morbidity. Data were analyzed using appropriate

statistical methods, with a p-value of less than 0.05 considered statistically significant.

Results: Maternal baseline characteristics were comparable between the two groups. The caesarean section rate did

not differ significantly between the elective induction and expectant management groups. The incidence of

meconium-stained amniotic fluid, low APGAR scores at one minute, and NICU admissions was higher in the

expectant management group. Neonates in the expectant management group also had a higher mean birth weight.

Conclusion: Elective induction of labour at 39 completed weeks in low-risk primigravida women is a safe

approach that does not increase caesarean section rates and may improve selected neonatal outcomes when

compared with expectant management.

Keywords: Elective induction of labour; Expectant management; Low-risk primigravida; Fetomaternal outcome;

39 weeks gestation; Caesarean section

Introduction

The timing of childbirth plays a critical role in determining both maternal and neonatal outcomes.

Deliveries occurring at either extreme of gestational age are associated with increased morbidity and

mortality. While preterm birth is a major contributor to neonatal complications, prolongation of

pregnancy beyond term is linked with a progressive rise in maternal, fetal, and perinatal risks. As

gestational age advances, placental efficiency gradually declines, increasing the likelihood of fetal

compromise, oligohydramnios, meconium passage, and adverse obstetric events [1].

In low-risk pregnancies, particularly among primigravida women, expectant management until the

spontaneous onset of labour has traditionally been considered safe and appropriate [2]. However,

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continuation of pregnancy beyond 39 weeks may be associated with a higher incidence of obstetric

interventions, operative vaginal delivery, caesarean section, hypertensive disorders, meconium-stained

amniotic fluid, and neonatal morbidity [3]. Maternal anxiety also tends to increase with advancing

gestation, often influencing clinical decision-making and intervention rates. Elective induction of labour

at 39 completed weeks has gained increasing attention as a strategy to mitigate risks associated with

prolonged gestation without adversely affecting delivery outcomes. Emerging evidence suggests that

planned induction at this gestational age in low-risk nulliparous women may reduce perinatal

complications and maternal morbidity while not increasing, and in some studies reducing, the rate of

caesarean delivery [4]. Induction at 39 weeks may also limit fetal overgrowth, thereby decreasing the risk

of macrosomia, shoulder dystocia, birth trauma, and related neonatal complications. Additionally, elective

induction may reduce the risk of stillbirth and complications related to placental ageing and meconium

aspiration [5].

Despite these potential benefits, induction of labour continues to raise concerns regarding failed

induction, prolonged labour, increased requirement for augmentation, uterine tachysystole, abnormal fetal

heart rate patterns, and maternal discomfort [6]. These concerns are particularly relevant in nulliparous

women with an unfavourable cervix, where induction has historically been associated with higher

operative delivery rates, although recent studies have challenged this perception [7].

In tertiary care settings, especially within resource-conscious healthcare systems, decisions regarding

elective induction versus expectant management must be guided by robust evidence tailored to local

populations. Low-risk primigravida women represent a distinct group in whom balancing maternal

preferences, fetal well-being, and obstetric safety is essential. Expectant management up to 41 weeks

allows for spontaneous onset of labour but may eventually necessitate induction or operative delivery due

to emerging obstetric indications [8]. Kerala, with its high institutional delivery rates and well-established

maternal healthcare infrastructure, provides an ideal setting to evaluate this clinical question. Generating

region-specific evidence is essential to guide obstetric practice, support informed patient counselling, and

optimize fetomaternal outcomes.

Materials and Methods

This comparative cross-sectional study was conducted to evaluate and compare fetomaternal outcomes

among low-risk primigravida women who underwent elective induction of labour at 39 completed weeks

of gestation and those managed expectantly. The study was carried out over a period of one year after

obtaining approval from the Institutional Research and Ethics Committee. The study was conducted in the

Department of Obstetrics and Gynaecology at Pushpagiri Institute of Medical Sciences, Kerala, a tertiary

care referral hospital serving a large obstetric population.

The sample size was calculated based on a previous study by Yogindra M. Kabadi et al., which reported a

neonatal intensive care unit admission rate of 20 percent among neonates born to expectantly managed

women. Using the formula n = 4pq/d², where p was taken as 20, q as 80, and precision d as 20 percent of

p (4), the calculated sample size was 400. As the study population was finite, a correction factor was

applied using the formula F = 1/(1 + n/N), where N represented the average annual NICU admissions of

200. The correction factor obtained was 0.33, resulting in a final sample size of 133 participants in each

group. Thus, a total of 266 low-risk primigravida women were included in the study.

The study population consisted of primigravida women attending the antenatal clinic or admitted to the

labour ward at 39 completed weeks of gestation. A low-risk nulliparous woman was operationally defined

as a primigravida with reliable gestational dating, carrying a singleton live intrauterine fetus in cephalic

Paul C et al | DOI: 10.65188/nurexus.1059

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presentation, and without any associated medical or obstetric complications. Women with gestational

hypertension, gestational diabetes mellitus, hypothyroidism, cardiac, respiratory, neurological, or other

systemic disorders were excluded. Obstetric exclusions included fetal macrosomia, intrauterine growth

restriction, amniotic fluid abnormalities, placental abnormalities, and abnormal Doppler findings.

Participants were divided into two groups based on the management strategy. Group A comprised low-

risk nulliparous women who underwent elective induction of labour at 39 completed weeks and were

followed up until delivery and discharge. Group B included low-risk nulliparous women who were

managed expectantly at 39 completed weeks and followed until spontaneous or indicated delivery and

throughout their hospital stay. Inclusion criteria were maternal age between 18 and 35 years, body mass

index between 18.5 and 25 kg/m², reliable gestational dating, singleton pregnancy, and cephalic

presentation. Women with multiple gestation, multiparity, unreliable gestational age, non-vertex

presentation, placenta previa or accreta, medical disorders, fetal compromise, congenital anomalies,

amniotic fluid or placental abnormalities, or clinically contracted pelvis were excluded.

After obtaining written informed consent, eligible participants were enrolled at 39 completed weeks of

gestation. A detailed history was recorded, followed by general physical, systemic, and obstetric

examinations. Pelvic examination was performed to assess cervical status and determine the Modified

Bishop score. Participants were monitored throughout labour, delivery, and the postpartum period.

Maternal variables documented included age, body mass index, gestational weight gain, Bishop score,

mode and indication of induction, intrapartum findings including nature of liquor, mode of delivery,

intrapartum complications, estimated blood loss, need for blood transfusion, postpartum complications,

duration of labour, and length of hospital stay. Neonatal outcomes assessed included birth weight,

APGAR score at one minute, requirement and indication for NICU admission, need for respiratory

support, neonatal morbidity, stillbirth, neonatal mortality, and duration of neonatal hospital stay.

The present study was approved by the Institutional Ethics Committee of Pushpagiri Institute of Medical

Science, Kerala (Ref No: IEC/PIMS-KL/2023/70518). A detailed Participant Information Sheet was

provided to all participants, and written informed consent was obtained prior to their inclusion in the

study.

All data were entered into Microsoft Excel and analysed using the Statistical Package for Social Sciences

software. Descriptive statistics were used to summarize demographic and clinical variables. Categorical

data were expressed as frequencies and percentages, and continuous variables as mean and standard

deviation. Appropriate statistical tests were applied to compare outcomes between the two groups, and a

p-value of less than 0.05 was considered statistically significant.

Results

Table 1. Baseline Maternal Characteristics of Study Participants (n=200)

Variable

Elective Induction

(n=100)

Expectant Management

(n=100)

p value

Mean maternal age (years)

25.8 ± 3.2

26.1 ± 3.4

0.54

Mean BMI (kg/m²)

22.4 ± 1.8

22.6 ± 1.9

0.47

Mean Bishop score at admission

5.6 ± 1.2

5.4 ± 1.3

0.29

The two groups were comparable with respect to maternal age, body mass index, and cervical status at

admission. No statistically significant difference was observed between the elective induction and

expectant management groups, indicating baseline homogeneity.

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Table 2. Mode of Delivery in the Two Study Groups (n=200)

Mode of delivery

Elective Induction (n=100)

Expectant Management (n=100)

p value

Vaginal delivery

72 (72%)

65 (65%)

0.28

Instrumental delivery

10 (10%)

12 (12%)

0.65

Caesarean section

18 (18%)

23 (23%)

0.37

Vaginal delivery was the most common mode of delivery in both groups. Although the caesarean section

rate was lower in the elective induction group compared to the expectant management group, the

difference was not statistically significant.

Table 3. Intrapartum and Maternal Outcomes(n=200)

Maternal outcome

Elective Induction

(n=100)

Expectant Management

(n=100)

p value

Meconium-stained liquor

14 (14%)

26 (26%)

0.03

Non-reassuring CTG

12 (12%)

20 (20%)

0.12

Postpartum hemorrhage

6 (6%)

8 (8%)

0.58

Prolonged labour

15 (15%)

22 (22%)

0.19

Meconium-stained amniotic fluid was significantly more frequent in the expectant management group.

Other maternal complications, including non-reassuring cardiotocography, postpartum hemorrhage, and

prolonged labour, were more common in the expectant group but did not reach statistical significance.

Table 4. Neonatal Outcomes (n=200)

Neonatal outcome

Elective Induction (n=100)

Expectant Management (n=100)

p value

Mean birth weight (kg)

3.05 ± 0.38

3.24 ± 0.42

0.01

APGAR <7 at 1 min

6 (6%)

14 (14%)

0.04

NICU admission

10 (10%)

22 (22%)

0.02

Neonates in the expectant management group had a significantly higher mean birth weight. Lower

APGAR scores at one minute and NICU admissions were significantly more frequent among neonates

born to women managed expectantly.

Table 5. Indications for NICU Admission

Indication

Elective Induction (n=10)

Expectant Management (n=22)

Respiratory distress

4 (40%)

9 (41%)

Meconium aspiration

2 (20%)

6 (27%)

Hypoglycemia

2 (20%)

4 (18%)

Sepsis

1 (10%)

2 (9%)

Birth asphyxia

1 (10%)

1 (5%)

Respiratory distress was the most common indication for NICU admission in both groups. Meconium

aspiration syndrome was more frequently observed among neonates in the expectant management group,

reflecting the higher incidence of meconium-stained liquor with advancing gestation.

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Figure 1: Comparison of NICU admissions between study groups

The chart demonstrates a higher proportion of NICU admissions among neonates born to women

managed expectantly compared to those who underwent elective induction at 39 completed weeks. This

visual representation supports the observed trend of increased neonatal morbidity with expectant

management in the study population.

Discussion

In the present study, fetomaternal outcomes were compared between low-risk primigravida women

who underwent elective induction of labour at 39 completed weeks and those managed expectantly.

The findings suggest that elective induction at 39 weeks is not associated with an increase in adverse

maternal outcomes and may confer benefits in terms of neonatal morbidity. The baseline maternal

characteristics, including maternal age, body mass index, and cervical status at admission, were

comparable between the two groups, ensuring uniformity and reducing confounding. Similar baseline

comparability was reported in the ARRIVE trial conducted by Grobman et al., which evaluated

elective induction of labour at 39 weeks in low-risk nulliparous women and established the safety of

this approach [9].

In the present study, vaginal delivery was the predominant mode of delivery in both groups, with a

lower caesarean section rate observed among women who underwent elective induction. Although this

difference was not statistically significant, the trend aligns with findings reported by Grobman et al.,

who demonstrated a significantly lower caesarean section rate in the induction group [9]. Walker et al.

also reported that elective induction at 39 weeks did not increase operative delivery rates and was

associated with favourable maternal outcomes [10]. Indian studies by Yogindra M. Kabadi et al. and

Ghosh et al. similarly observed no increase in caesarean section rates with elective induction in low-

risk primigravida women [11,12].

A significantly higher incidence of meconium-stained amniotic fluid was observed in the expectant

management group in the present study. Darney et al. demonstrated that the risk of meconium passage

increases with advancing gestational age beyond 39 weeks [13]. Caughey et al. also reported a

progressive rise in intrapartum complications, including meconium-stained liquor, with prolonged

pregnancy [14]. These findings support the role of elective induction in reducing meconium-related

neonatal complications.

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Neonatal outcomes in the present study favoured elective induction, with lower rates of low APGAR

scores at one minute and reduced NICU admissions. Stock et al. reported a reduction in perinatal

morbidity when delivery occurred at 39 weeks compared to ongoing pregnancy [15]. Similarly,

Kabadi et al. observed higher NICU admission rates among neonates born to expectantly managed

mothers, primarily due to respiratory distress and meconium aspiration [11].

The mean birth weight was higher in the expectant management group, reflecting the effect of

advancing gestation on fetal growth. Cheng et al. reported an increased risk of fetal macrosomia and

associated birth complications with continuation of pregnancy beyond 39 weeks [16]. Increased birth

weight has been linked to higher rates of shoulder dystocia and birth trauma, as highlighted by Rouse

et al. [17].

Respiratory distress was the most common indication for NICU admission in both groups, with a

higher frequency in the expectant management group. Tita et al. reported that prolonged gestation is

associated with increased neonatal respiratory morbidity and perinatal complications [18]. Wood et al.

further emphasized that early-term delivery at 39 weeks may reduce neonatal morbidity without

increasing maternal risk [19]. The findings of this study are consistent with existing literature

suggesting that elective induction of labour at 39 completed weeks in low-risk primigravida women is

a safe and effective strategy. In tertiary care settings, elective induction may reduce neonatal

morbidity while maintaining acceptable maternal outcomes. These findings support the incorporation

of individualized counselling and evidence-based decision-making when managing low-risk

pregnancies approaching term.

Conclusion

The present study demonstrates that elective induction of labour at 39 completed weeks in low-risk

primigravida women is a safe and effective alternative to expectant management. Elective induction

was not associated with an increased rate of primary caesarean section or adverse maternal outcomes,

while neonatal outcomes showed improvement in terms of reduced meconium-stained amniotic fluid,

fewer low APGAR scores at one minute, and lower NICU admission rates compared to expectant

management. These findings suggest that planned delivery at 39 weeks may help minimize perinatal

risks related to advancing gestation without increasing maternal morbidity. In well-equipped tertiary

care settings, elective induction at 39 weeks can be considered a reasonable and evidence-based option

for low-risk primigravida women, supporting informed decision-making and individualized obstetric

care.

Conflict of interest: Nil

Source Of Fund: Nil

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