IMPACT OF INDUCTION VERSUS EXPECTANT MANAGEMENT ON PERINATAL OUTCOMES IN POST-TERM PREGNANCY: A SYSTEMATIC REVIEW OF MATERNAL COMPLICATIONS, NEONATAL MORBIDITY, AND OPERATIVE DELIVERY RATES

Abstract

Background: The pregnancy that is carried beyond the 41 weeks of pregnancy is defined as post-term pregnancy, which is linked to high risks of unfavorable maternal and neonatal outcomes. The induction of labor (IOL) is a widely suggested option to address such risks, although expectancy management (EM) is also an option when the fetus is not in distress at the moment. Previous studies have found mixed results on the effectiveness of IOL versus EM in reducing complications such as cesarean section rates, neonatal morbidity and maternal outcomes. A careful consideration of these interventions is important in deciding a best management strategy.

Objectives: To assess and compare the impact of induction versus expectant management on outcome to mother and neonate, as rates of operative delivery, rates of neonatal morbidity, and rates of maternal complications in post-term pregnancy.

Methods: A systematic review and meta-analysis were done using randomized controlled trials comparing induction of labor vs. expectation management in post term pregnancies (>41 weeks). PubMed, Cochrane Library, and ClinicalTrials.gov were searched electronically since beginning to 2025. Articles were included when they compared induction of labor (IOL) and expectancy management in non-term pregnancies (more than 41 weeks). The main outcomes measured were cesarean rates, neonatal morbidity (1-minute and 5-minute Apgar scores, aspiration of meconium and perinatal mortality), and maternal morbidity. Random-effects models were used to synthesize the data to obtain pooled risk ratios (RRs) and 95% confidence intervals (CIs).

Results: A total of 10 RCTs met the inclusion criteria with more than 5,000 post term pregnancies. Meta-analysis demonstrated that induction of labor was associated with a significantly lower risk of cesarean section compared with expectant management (RR = 0.82, 95% CI 0.75–0.91; I² = 49%), lower rates of neonatal complications, and that of meconium aspiration (RR = 0.67, 95% CI: 0.52-0.86) than expectancy management. Neonatal morbidity (as defined by Apgar scores <7 at 1 minute) was also considerably lower in the induction group (RR= 0.75 (0.60-0.93)). Maternal complications such as postpartum hemorrhage did not significantly vary with each group. There was however a reduced length of labor associated with induction (mean difference = -2.4 hours, 95% CI: -3.0 to -1.8 hours).

Conclusion: Induction of labor at or beyond 41 weeks of gestation is associated with a significant reduction in cesarean section rate, neonatal morbidity, and operative delivery rate without a significant increase in maternal complications. These findings support the use of induction of labor may be considered as a preferred management strategy in post-term pregnancies; in the management of post-term pregnancies, especially in the case of an unfavorable cervix. Further studies targeting specific subsets of women including those with high-risk factors are necessary to optimize management strategies.