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

Paul, Christina; Swathy, Sunil

doi:10.65188/nurexus.1059

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ORIGINAL ARTICLE

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

1

, Dr. Sunil Swathy

2

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

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, continuation of pregnancy

beyond 39 weeks may be associated with a higher incidence of obstetric interventions, operative vaginal

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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

Study Design

This hospital-based diagnostic accuracy study was conducted to evaluate the role of C-reactive protein

(CRP) in identifying serious bacterial infections among children presenting with fever without an

identifiable focus.

Study Setting and Duration

The study was carried out in the Department of Pediatrics at Dr. D.Y. Patil Vidyapeeth, Pune, over a

period of 18 months. Both the Pediatric Outpatient Department and Pediatric Wards were included in the

study following approval from the Institutional Ethics Committee.

Study Population

The study population comprised children aged 1 to 36 months presenting with fever without focus. A total

of 100 eligible children attending the outpatient department or admitted to the pediatric wards during the

study period were enrolled consecutively.

Sample Size

A total of 100 children were included in the study. The sample size was calculated based on diagnostic

accuracy parameters considering the expected sensitivity and specificity of C-reactive protein, with a 95%

confidence level and an allowable error of 15%.

Inclusion Criteria

Children aged between 1 and 36 months presenting with fever lasting more than 12 hours and up to seven

days, with a documented body temperature greater than 39°C and no identifiable source of infection

following detailed clinical examination, were included in the study.

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Exclusion Criteria

Children who had received antibiotics or vaccinations prior to presentation, those with known

immunological disorders or immunodeficiency states, and children whose parents or legal guardians

declined consent were excluded from the study.

Data Collection Tool

After obtaining written informed consent from parents or legal guardians, demographic details, clinical

history, physical examination findings, and laboratory investigations were recorded using a structured

case record proforma. Venous blood samples were collected under strict aseptic precautions for complete

blood count, total white blood cell count, absolute neutrophil count, erythrocyte sedimentation rate (ESR),

C-reactive protein (CRP), and blood culture. Blood culture was considered the reference standard for

confirming serious bacterial infection. C-reactive protein estimation was performed using the slide

agglutination method. Initially, qualitative testing was carried out to identify elevated CRP levels,

followed by semi-quantitative estimation using serial serum dilutions. The highest dilution demonstrating

visible agglutination was recorded as the CRP concentration in mg/dL. All clinical and laboratory

findings were documented systematically in the study proforma.

Ethical Considerations

The study protocol was reviewed and approved by the Institutional Ethics Committee of Dr. D.Y. Patil

Vidyapeeth before commencement of the study. Written informed consent was obtained from the parents

or legal guardians of all participating children prior to enrolment. Participant confidentiality was

maintained by assigning unique identification numbers, and all collected information was used solely for

research purposes.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using the Statistical Package for the Social Sciences

(SPSS) software version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as

mean ± standard deviation, whereas categorical variables were presented as frequencies and percentages.

Diagnostic performance of C-reactive protein was evaluated by calculating sensitivity, specificity,

positive predictive value, negative predictive value, and overall diagnostic accuracy, considering blood

culture as the reference standard. Receiver Operating Characteristic (ROC) curve analysis was performed

to determine the optimal CRP cut-off value for predicting serious bacterial infection. Agreement between

CRP results and blood culture findings was assessed using appropriate statistical tests. 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. 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

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[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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