Cesarean delivery rates in the United States have increased steadily since the 1990s, and approximately one-third of pregnancies were delivered by cesarean in 2009 (1). As compared to vaginal delivery, cesarean delivery is associated with increased maternal morbidity and future pregnancy complications (2-4). Minimizing induction of labor has been proposed as a focus area for reducing cesarean delivery rates as the likelihood of vaginal delivery is lower after induction of labor compared with spontaneous labor (5, 6). In nulliparous women, particularly those with an unfavorable cervical examination, induction of labor has been shown to increase the risk of cesarean more than 2-fold compared with spontaneous labor (7).;In 2009, a multidisciplinary group at Mayo Clinic initiated a process of case review for inductions scheduled in advance. The goal of this case review was to standardize the practice and comply with national guidelines by restricting and rescheduling to those that met certain medical or gestational age criteria. In this thesis, we test the hypothesis that a policy of restrictive induction of labor will lead to improved maternal and neonatal outcomes. We tested our hypothesis through three specific aims. Our first aim was to evaluate the rates of both medically indicated and nonmedically indicated induction of labor over time. Our second aim was to evaluate rates of primary cesarean delivery and other maternal and neonatal outcomes over time. Our third aim was to determine clinical predictors for successful induction (defined as induction of labor resulting in vaginal delivery) for nulliparous women at term.
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