Elective/maternal request/maternal discomfort
Induction following maternal request alone and in the absence of medical indication accounts for 6-14% of all inductions of labour in the Western world. This is a controversial topic and the guidelines surrounding this entity are nebulous and differ by nation.
According to the 2008 NICE guideline, induction of labour purely due to maternal request should be avoided. However, it states that there may be extenuating social circumstances such as a woman's partner is being deployed for duties during the time of the estimated date of delivery when induction of labour may be considered at or after 40 weeks' gestation (8). The American Congress of Obstetrics and Gynecology (ACOG) supports elective induction of labour without clear medical benefit to mother or fetus, only after fetal lung maturity has been demonstrated or a minimum of 39 weeks of gestation (24).When compared to expectant management, elective induction of labour at 41+o weeks is associated with a decreased rate of caesarean delivery, and meconium- stained amniotic fluid (25). There is a recent RCT of nulliparous women ages 35 and older who were induced between 39+o days and 39+6 days compared to expectant management which showed that no increased rate of caesarean section or maternal and neonatal adverse outcomes (14). Furthermore, a very large retrospective cohort study in Scotland from 1981 to 2007 showed that elective induction between 37+0 weeks and 41+0 weeks reduced perinatal mortality without increasing the rate of caesarean delivery (26). This was confirmed by a recent randomised trial of induction versus expectant management for 6,106 low risk women, in which induced women had lower rates of CS and improved perinatal adverse outcomes (27). The evidence is sufficient to support elective induction although the ethical caveat is that the alternative of ‘expectant management' may carry a variable definition depending upon where one is practising. When feasible or requested, elective induction does not appear to carry added risk to the patient and in most cases appears to have benefit (24, 26, 27).
If avoiding IUFD or poor perinatal outcomes, labour induction is cost-effective when compared to expectant management (26). This cost trade-off7 is clear after 41 weeks in developed nations, which further supports the use of this gestational age cut-off. Globally, costeffectiveness is dependent upon resources, distances to healthcare facilities, coverage of prenatal care, and many other factors that when considered together may support the use of elective induction at gestational ages prior to 41+0 weeks. For instance, elective induction especially in multiparous patients may be beneficial to avoid unattended births if there are great difficulties for patients to be transported to a health facility.