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\begin{document}

\title{Induction of labour at term compared with expectant management in women
over 40 years of age: a retrospective study.}



\author[1]{Elena Marin}%
\author[1]{Vanesa Rodríguez Fernández}%
\author[1]{Laura González Rodríguez}%
\author[1]{Carlos López Ramón y Cajal }%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{June 07, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Objective To compare maternal and neonatal outcomes of induction of
labour at term to those of expectant management in women over 40 years
of age. Design Retrospective cohort study. Setting Data were derived
from the Hospital \selectlanguage{ngerman}Álvaro Cunqueiro birth cohort (Vigo). Population Women
at \selectlanguage{english}[?]40 years of age and \selectlanguage{english}[?]39 weeks of gestation that delivered from 1
January 2012 to 31 December 2017. Methods Women were classified into two
groups: expectant management group (women who delivered from 1 January
2012 to 31 December 2014) and nonmedically indicated induction of labour
group (women who delivered from 1 January 2015 to 31 December 2017).
These two groups were described and compared. Main outcome measures The
primary outcome was the route of delivery. Perinatal results were also
studied. Results There was a total of 603 pregnant women in the
expectant management group compared to 634 women in the induction group.
The rate of cesarean section did not increase in the maternal age-based
labour induction group compared to the expectant management group.
Subgroup analysis did not demonstrate an increased risk by parity. Women
in the expectant management group were more likely to require neonatal
intensive care unit admission and need pediatric support. Conclusion
Compared to expectant management, induction of labour at 39 weeks of
gestation results in significantly better neonatal outcomes without
increasing the cesarean section rates in older women. Tweetable abstract
Induction of labour in women over 40 years of age associates better
perinatal outcomes without increasing the rate of caesarean sections.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{Title page}

\textbf{TITLE:} Induction of labour at term compared with expectant
management in women over 40 years of age: a retrospective study.

Elena MAR\selectlanguage{ngerman}ÍN ORTIZ MD\textsuperscript{1}, Vanesa RODRÍGUEZ FERNÁNDEZ MD
PhD\textsuperscript{1}, Laura GONZÁLEZ RODRÍGUEZ MD\textsuperscript{1},
Carlos N. LÓPEZ RAMÓN Y CAJAL MD PhD\textsuperscript{1}.

1.Department of Obstetrics and Gynecology, Hospital Álvaro Cunqueiro,
Vigo, Pontevedra, Spain

\textbf{Corresponding author's contact information} :

Elena Marín Ortiz

\emph{Elena.marinortiz@gmail.com}

+34 650033899

Hospital Álvaro Cunqueiro.

Estrada Clara Campoamor 341, 36213. Vigo. Spain.

\textbf{Running head:}

Advanced maternal age and induction of labour.

\textbf{Word count}

Abstract: 260 words

Main Text: 2162 words

\textbf{Objective}

To compare maternal and neonatal outcomes of induction of labour at term
to those of expectant management in women over 40 years of age.

\textbf{Design}

Retrospective cohort study.

\textbf{Setting}

Data were derived from the Hospital Álvaro Cunqueiro birth cohort
(Vigo).

\textbf{Population}

Women at \selectlanguage{english}[?]40 years of age and \selectlanguage{english}[?] 39 weeks of gestation that delivered
from 1 January 2012 to 31 December 2017.

\textbf{Methods}

Women were classified into two groups: expectant management group (women
who delivered from 1 January 2012 to 31 December 2014) and nonmedically
indicated induction of labour group (women who delivered from 1 January
2015 to 31 December 2017). These two groups were described and compared.

\textbf{Main outcome measures}

The primary outcome was the route of delivery. Perinatal results were
also studied.

\textbf{Results}

There was a total of 603 pregnant women in the expectant management
group compared to 634 women in the induction group. The rate of cesarean
section did not increase in the maternal age-based labour induction
group compared to the expectant management group. Subgroup analysis did
not demonstrate an increased risk by parity. Women in the expectant
management group were more likely to require neonatal intensive care
unit admission and need pediatric support.

\textbf{Conclusion}

Compared to expectant management, induction of labour at 39 weeks of
gestation results in significantly better neonatal outcomes without
increasing the cesarean section rates in older women.

\textbf{Tweetable abstract}

Induction of labour in women over 40 years of age associates better
perinatal outcomes without increasing the rate of caesarean sections.

\textbf{Keywords}

Advanced maternal age, induction of labor, cesarean section, neonatal
outcomes.

\textbf{Main text}

\textbf{Introduction}

The birth rate of women aged 40 years or older has been rising steadily.
Delaying childbearing is an ongoing and universal phenomenon. In Spain,
the average age of women at childbirth remained at 32.2 years in 2019.
In the last 10 years, the number of births to women aged 40 years and
older has increased by 63.1\%. In 2008, 4.2\% of births were to women
with maternal age \selectlanguage{english}? 40 years, while in 2019, this percentage increased
to 9.7\%.\textsuperscript{1}

Advanced maternal age has been historically defined as \selectlanguage{english}[?]35 years at the
time of delivery and is widely associated with adverse obstetric
outcomes. The risks of hypertensive disorders, gestational diabetes
mellitus, placenta previa, placental abruption, and stillbirth are
higher among women aged 35 years or older than among younger
women.\textsuperscript{2-6}

The incidence of stillbirth at 39--40 weeks of gestation is 2 in 1000
for women \selectlanguage{english}[?] 40 years of age compared with 1 in 1000 for women
\textless{} 35 years old. Women \selectlanguage{english}[?] 40 years of age have a similar
stillbirth risk at 39 weeks of gestation to younger women at 41 weeks of
gestation.4 Induction of labour in older mothers is widely practiced as
an intervention to reduce the risk of late
stillbirth.\textsuperscript{5,6} A survey showed that 37\% of
obstetricians offer induction of labour at term to women aged 40--44
years and 55\% to those \selectlanguage{english}[?] 45 years.\textsuperscript{7} Studies suggest
that there is a low threshold to perform a caesarean section in older
women.\textsuperscript{5,6}

Nonmedically indicated induction of labour compared with spontaneous
labour is associated with an increased risk of caesarean delivery,
especially in nulliparous women. However, spontaneous labour may not be
an ideal comparison. Detailed data regarding the outcomes of
nonmedically indicated induction of labour are still limited. As of 1
January 2015, the Gynaecology and Obstetrics service of the Alvaro
Cunqueiro Hospital offered induction of labour to women aged \selectlanguage{english}[?] 40 from
the 39th week of gestation onwards. The objective of this study was to
compare maternal and neonatal outcomes of nonmedically indicated
induction of labour at term to those of expectant management in women
over 40 years of age.

\textbf{Material and methods}

Study design

This is a retrospective cohort study that included all women at \selectlanguage{english}[?] 40
years of age and \selectlanguage{english}[?] 39 weeks of gestation that delivered in the city of
Vigo from 1 January 2012 to 31 December 2017. Data were derived from the
Hospital Alvaro Cunqueiro birth cohort, an electronic database created
from gestational, birth, and neonatal data from hospitalisations in the
Vigo delivery room.

Women aged \selectlanguage{english}[?] 40 years with singleton pregnancies were included in the
database. Women with \textless{} 39 weeks of gestation and those with
multiple gestations were excluded. In January 2015, the gynaecology and
obstetrics service of Vigo implemented the protocol for induction of
labour due to advanced maternal age; therefore, patients were divided
according to the management of labour at term. We compared expectant
management (women who delivered from 1 January 2012 to 31 December 2014)
to nonmedically indicated induction of labour (women who delivered from
1 January 2015 to 31 December 2017).

The primary outcome was the caesarean delivery rate. The secondary
maternal outcomes were delivery methods other than caesarean section
(that is, assisted vaginal delivery with the use of forceps or vacuum),
the onset of labour (that is, spontaneous labour, elective caesarean
section, or induction of labour), the indication for induction of
labour, the method of labour induction, the indications for caesarean
section, and intrapartum complications (that is, intrapartum fever or
stained amniotic fluid).

The secondary neonatal outcomes were stillbirth, birth weight, the
5-minute Apgar score, the arterial cord pH value, paediatric birth
support, degree of neonatal resuscitation, and admission to a neonatal
intensive care unit (NICU). To analyse the type of paediatric support at
birth, the participants were divided into 3 groups: group 1 included
those new-borns who did not require paediatric assistance at birth;
group 2 included new-borns who required suctioning; group 3 included
those who required the three most advanced degrees of resuscitation,
suctioning and oxygen administration, and use of ambu and intubation.

Basic demographic characteristics and obstetric and clinical outcomes
were examined: parity, smoking status, assisted conception, gestational
age at delivery, history of pregestational diabetes mellitus,
gestational diabetes mellitus, chronic hypertension, and any new
hypertensive disorder during pregnancy (namely, preeclampsia or
gestational hypertension), and pre-pregnancy medical pathology.

\textbf{Statistical analyses}

Data were analysed with SPSS 19.0. Qualitative variables were reported
as absolute frequency and percentage, while quantitative variables were
reported as the mean and standard deviation or the median and
interquartile range if they did not fit a normal distribution. The
Kolmogorov--Smirnov test was used for normality testing. A univariate
analysis was performed to determine whether there were differences
between the two study groups. For the relationship with qualitative
variables, the Chi-square test was used, while for the comparison of
quantitative variables, the parametric t-test or the non-parametric
Mann-Whitney test was applied. Differences were considered statistically
significant at p \textless{} 0.05. Ethics committee approval for this
study was obtained from the Ethics and Clinical Research Committee of
Galicia (approval number 2020/617).

\textbf{Results}

From 1 January 2012 to 31 December 2017, there were 1,776 women aged \selectlanguage{english}[?]
40 years who delivered at Alvaro Cunqueiro Hospital. Women who had
multiple gestations and women delivering at \textless{} 39 weeks of
gestation were excluded. There were a total of 603 pregnant women in the
expectant management group compared to 634 women in the induction group.
Baseline characteristics were similar between the two groups (Table 1).
The delivery outcomes are shown in Table 2. There was no significant
difference in the rate of caesarean section between the induction and
expectant management groups (24\% vs. 24.4\%) (p=0,971). The risk of
urgent intrapartum caesarean section was 44.1\% in the induction group
versus 33.1\% in the expectant management group; these differences were
not significant (p=0,127).

A secondary analysis showed that in the group of women without any
previous surgical or vaginal delivery, the distribution according to the
type of labour did not show statistically significant differences
between groups (p= 0,109). The rate of successful trial of labour after
caesarean (TOLAC) was 57.3\% in the expectant management group and
51.2\% in the induction group. These differences were not statistically
significant (p=0,247). There were significant between-group differences
in the frequency of stained amniotic fluid (147 of 603 in the expectant
management group {[}24.4\%{]} versus 89/634 in the induction of labour
group {[}10.9\%{]} ).

The neonatal outcomes are presented in Table 3. No statistically
significant differences were found for the Apgar value at 5 min and
umbilical artery pH value. There were two cases of stillbirth in the
expectant management group, and no intrauterine foetal deaths were
registered in the induction group. These differences were not
statistically significant (P =0,147). The expectant management group
needed more advanced paediatric support at birth than the labour
induction group. (Table 4). The rate of admission to the NICU was lower
in the labour induction group (p=0,000) than that in the expectant
management group.

\textbf{Discussion}

Principal findings

This study analysed expectant management versus induction of labour at
39 weeks of gestation in women 40 years of age or older at the time of
delivery. In older women, active labour management resulted in better
perinatal outcomes without increasing the caesarean section rate and
with similar vaginal delivery rates compared to expectant management.

Results in the context of what is known

The number of published studies on pregnant women of advanced maternal
age is scarce. Most of the studies on induction of labour at term
involved women with established complications, such as hypertensive
disorders\textsuperscript{8} rupture of membranes\textsuperscript{9},
foetal growth restriction\textsuperscript{10,11},
diabetes\textsuperscript{12}, or foetal macrosomia\textsuperscript{13}.
The 35/39 study was a randomised clinical trial designed to test the
hypothesis that induction of labour at 39 weeks of gestation would
reduce the rate of caesarean delivery among nulliparous women of
advanced maternal age. Their data showed that induction of labour at 39
weeks of gestation, as compared with expectant management, did not
increase caesarean delivery.\textsuperscript{14}

The study by Knight et al included a total of 77,327 women aged 35
years. They found no statistically significant difference in the
caesarean section rate between the 39-week labour induction groups and
the expectant management group (Adjusted relative risk: 1.04, confidence
interval {[}CI{]} 95\%: 0.99--1.01).\textsuperscript{15} In 2019, a
retrospective cohort study including 35-year-old nulliparas with
singleton gestations at term comparing elective induction at 37, 38, 39
and 40 weeks' gestation and those with expectant management at the same
number of weeks found that induction at 39 weeks' gestation was
associated with decreased odds of caesarean section delivery (Ora 0.69;
CI95\%, 0.53-0.91).\textsuperscript{16} Our data supported previous
studies and found no statistically significant difference in the type of
delivery between the expectant management group and the induction at 39
weeks group. In the secondary analysis of the type of delivery according
to parity, we found no significant differences in the route of delivery
among the groups studied. In the expectant management group, the
subgroup of women aged 40 years at 39 weeks of gestation and without any
previous type of delivery (vaginal or caesarean) included 227 patients,
of whom 24.2\% had vaginal deliveries and 41.4\% had operative vaginal
deliveries. This meant that 65.6\% of deliveries were vaginal delivery
versus 34.4\% of deliveries by caesarean section. In the active
management group, the group of patients with the same characteristics
was made up of 252 women, of which 69\% delivered vaginally (32.9\%
vaginal delivery and 36.1\% operative vaginal delivery) as opposed to
31\% of deliveries by caesarean section.

Our data showed a rate of successful TOLAC similar to the 62.3\%
reported in previous studies.\textsuperscript{17}

Another main finding was better neonatal outcomes in the labour
induction group than in the expectant management group. The need for
paediatric support at birth, the type of neonatal resuscitation
measures, and the NICU admission rates were lower in the labour
induction group than in the expectant management group. These data
support the results of study lines in which perinatal outcomes improved
with elective induction at 39 weeks of gestation.\textsuperscript{16,18}

Finally, another result to highlight is the 0\% stillbirth in the active
management group versus the two intrauterine foetal deaths recorded in
the expectant management group. These differences were not statistically
significant because intrauterine foetal death is a rare adverse outcome,
and a large sample size would be needed to find significant differences
between the groups.

Research implications

There is a continuous risk for both the mother and baby with increasing
maternal age, with numerous studies reporting multiple adverse foetal
and maternal outcomes associated with advanced maternal age. Women \selectlanguage{english}[?] 40
years of age had a similar stillbirth risk at 39 weeks of gestation with
younger women at 41 weeks of gestation. Induction of labour at 39 weeks
of gestation reduced these adverse outcomes. However, at present, there
are insufficient data available on the effect such a policy would have
on caesarean rates and perinatal outcomes, specifically in older women.
Our study analysed the effect of labour induction compared with
expectant management in women over 40 years of age. Our results provided
data on intrapartum complications, mode of delivery, neonatal morbidity,
and late stillbirth.

Strengths and limitations

Our study has several limitations. The definition of advanced maternal
age in the literature varies with publications using different criteria.
The definition used in our study aligns with the hospital's definition
of \selectlanguage{english}[?]40 years. The major limitation of our study was its retrospective
nature. The retrospective dataset was subject to incomplete data entry
and variation in practice. Despite our limitations, there are only a few
studies in the literature that evaluated obstetric and perinatal
outcomes according to active or expectant management in pregnant women
of advanced maternal age and consider parity within their data.

\textbf{Conclusion}

In conclusion, induction of labour at 39 weeks of gestation compared to
expectant management in women of advanced maternal age results in
significantly better neonatal outcomes without increasing the caesarean
section rate. Hence, it is important that advanced maternal age pregnant
women be informed of the risks involved in delaying childbearing until
the fourth decade of life. Further studies on this topic are necessary
to develop new policies for clinical care in this group of pregnant
women.

\textbf{Disclosure of interest}

The authors declare that we are free of any personal or commercial
association that may constitute a conflict of interest. Ethical
principles of research have also been respected.

\textbf{Contribution to authorship}

All the authors contributed to the content and development of the
article. All authors reviewed and agreed to the final version of this
manuscript.

\textbf{Details of ethics approval}

Ethics committee approval for this study was obtained from the Ethics
and Clinical Research Committee of Galicia (approval number 2020/617, 20
May 2021).

\textbf{Funding}

The research has no financial support.

\textbf{Acknowledgements}

We would like to thank the women who participated in the study and to
midwives and doctors who enter detail data, diagnoses and procedures in
their everyday practice to forming the Hospital Alvaro Cunqueiro birth
cohort.

\textbf{References}

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\textbf{Tables}

\textbf{Table 1. Baseline Characteristics of the Participants}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Variable\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Expectant management group (N = 603)\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Induction of labor group (N = 634)\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
P value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Maternal age at delivery (years)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Mean Range\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
41 40-50\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
41 40-50\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Parity no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Nulliparous Multiparous\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
227 (37,65) 376 (62,35)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
252 (39,75) 382 (60,25)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Current smoker no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
32 (5,3)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
25 (3,9)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,250\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Medical history no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Yes No\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
99 (16,4) 504 (83,6)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
118 (18,6) 516 (81,4)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Assisted reproductive technology no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,181\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Artificial insemination In vitro fertilization Ovodon\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
10 (1,65) 46 (7,62) 34 (35,63)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9 (1,42) 54 (8,51) 55 (8,67)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Hypertension disorders no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,601\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Pregestational Gestational Preeclampsia\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4 (0,7) 6 (1) 1 (0,1)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6 (0,9) 4 (0,6) 1 (0,1)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Diabetes Mellitus no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,070\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Pregestational Gestational with diet Gestational with insulin\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0 76 (12,6) 4 (0,7)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0 65 (10,3) 10 (1,6)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2. Maternal outcomes}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Variable\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Expectant management group N = 603)\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Induction of labor group (N = 634)\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
P value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Gestational age at the time of delivery\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Mean Range\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
40+2 39-42\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
39+3 39-42+1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Onset of the birth process no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Spontaneous labor Induced labor Elective cesarean section\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
357 (59) 211 (35,2) 35 (5,8)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
100 (15,8) 509 (80,4) 25 (3,9)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Indication for induction of labor no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textgreater{}41 wk of gestation Term prelabor rupture of membranes
Others Posity amnioscopy Oligoamnios Advanced maternal age\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
72 (34.1) 61 (28.9) 26 (12.3\%) 14 (6.6) 13 (6.2) 0 (0)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
10 (2) 26 (5.1) 13 (2.5) 0 (0,0) 7 (1.4) 437 (85.68)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Amniotic fluid color no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Clear Stained Hemorraghic\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
450 (74,6) 147 (24,4) 6 (1)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
559 (88,2) 89(10,9) 6 (0,9)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Intrapartum fever no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
21 (8,6)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
92 (14,6)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,018\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Epidural use no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
464 (77,5)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
504 (79,9)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,258\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Method of delivery no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Vaginal delivery Assisted vaginal delivery Cesarean section\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
306 (50,7) 150 (24,8) 147 (24,4)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
325 (51,3) 157 (24,8) 152 (24)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
No previous type of delivery. Method of delivery no (\%)*\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
227\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
252\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,109\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Vaginal delivery Assisted vaginal delivery Cesarean section\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
55 (24,2) 94 (41,4) 78 (34,4)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
83 (32,9) 91 (36,1) 78 (31)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Type of cesarean section no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,127\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Programmed Non-urgent intrapartum Urgent\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
33 (22,3) 66 (44,6) 49 (33.1)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
25 (16,4) 60 (39,5) 67 (44.1)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Indication for cesarean section no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
N = 147\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
N = 152\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Suspected fetal distress Active phase arrest Cephalopelvic disproportion
Breech presentation Failure of induction Elective\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
40 (27) 24 (16,2) 15 (10,1) 18 (12,2) 18 (8,1) 11 (7,4)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
54 (34,9) 14 (9,2) 17 (11,2) 14 (9,2) 26 (17,1) 9 (5,9)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Indication for assisted vaginal delivery no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
N = 150\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
N = 157\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Suspected fetal distress Second Stage Protraction Maternal
exhaustion\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
99 (66) 50 (33,3) 1 (0,7)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
128 (81,5) 28 (17,9) 1 (0,6)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{* Patients without any previous surgical or vaginal delivery}

\textbf{Table 3. Neonatal outcomes}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Variable\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Expectant management group (N = 603)\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Induction of labor group (N = 634)\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
P value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Sex no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Male Female\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
285 (47,3) 318 (52,7)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
324 (51,1) 310 (48,9)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Birth weight (g)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Mean Range\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3371,61g 2050g-4630g\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3270,23g 2215g- 4600g\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Apgar score at 5 min\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,317\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Mean Range\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9,85 0-10\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9,91 6-10\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Umbilical-cord- arterial pH\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,083\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Mean Range\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
7,20 0-7,41\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
7,23 6,95-7,46\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Stillbirth no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2 (0,3)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0 (0)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,147\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Required intervention no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
357 (59,3)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
184 (29)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
NICU adminission no. (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
143 (23,7)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
65 (10,3)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,000\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 4.} Groups based on the degree of neonatal resuscitation\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& Group 1* & Group 2** & Group 3***\tabularnewline
\midrule
\endhead
2012-2014 & 245(40,7\%) & 279 (46,3\%) & 78 (13\%)\tabularnewline
2015-2017 & 450 (71\%) & 135 (21,3\%) & 49 (7,7\%)\tabularnewline
\bottomrule
\end{longtable}

Group 1: No pediatric assistance at birth

** Group 2 : suctioning *** Group 3 : suctioning and oxygen
administration, use of ambu and intubation

\selectlanguage{english}
\FloatBarrier
\end{document}

