Risk factors for cesarean birth after induction of labor in women with term prelabor rupture of membranes: a retrospective cohort study

Induction of labor (IOL) is widely recommended for women with term prelabor rupture of membranes (PROM) to reduce infectious morbidity and shorten the interval to delivery. Despite clear guideline recommendations, outcomes following IOL remain heterogeneous, and unplanned cesarean birth remains a clinically important concern. Most existing evidence derives from heterogeneous induction populations, and data focusing specifically on intrapartum factors in women with term PROM remain limited. This retrospective cohort study included women with singleton pregnancies who presented with term PROM and subsequently underwent IOL at a tertiary referral center between October 2019 and March 2023. Maternal baseline characteristics, intrapartum factors, and neonatal outcomes were extracted from electronic medical records. Cesarean birth following IOL was defined as the primary outcome. Multivariable logistic regression analysis identified factors independently associated with cesarean birth. Exploratory receiver operating characteristic (ROC) analysis assessed discriminatory ability. Among 600 women included in the analysis, 565 (94.2%) achieved vaginal birth, whereas 35 (5.8%) required cesarean birth following IOL. In multivariable analysis, cesarean birth was independently associated with nulliparity (adjusted odds ratio [aOR] 5.07, 95% confidence interval [CI] 1.14–22.56), higher baseline maternal white blood cell count (aOR 1.21 per 10³/µL, 95% CI 1.10–1.34), lower Bishop score (aOR 0.77, 95% CI 0.67–0.88), non-reassuring fetal heart rate (aOR 2.26, 95% CI 1.06–4.81), and higher birthweight (aOR 3.46 per kg, 95% CI 1.17–10.23). In ROC analysis, the latency period demonstrated the strongest discriminative ability (area under the curve [AUC] 0.74, 95% CI 0.63–0.84), and the multivariable model yielded an AUC of 0.80 (95% CI 0.72–0.88). Although the latency period showed the strongest discriminative performance, it did not remain independently associated with cesarean birth in multivariable regression. Neonatal outcomes were generally comparable between groups, although respiratory distress syndrome occurred more frequently among neonates delivered by cesarean birth. Among women with term PROM undergoing IOL, several readily available maternal and intrapartum factors were associated with cesarean birth. The latency period demonstrated moderate discriminative performance. These findings may help contextualize intrapartum risk, but their application to individualized counseling and shared decision-making requires further validation. Prelabor rupture of membranes at term (PROM) is a common condition in pregnancy. To reduce the risk of infection, induction of labor (IOL) is usually recommended. Although most women give birth vaginally after IOL, some require cesarean birth. Knowing which clinical factors are linked to cesarean birth may help clinicians provide clearer information and support informed discussions with women during labor. In this retrospective cohort study, we examined women with singleton term pregnancies who experienced PROM and underwent IOL at a tertiary hospital in Taiwan. Maternal characteristics, intrapartum findings, and neonatal outcomes were compared between women who achieved vaginal birth and those who required cesarean birth following IOL. Most women achieved vaginal birth after IOL. Cesarean birth was more common among women with higher baseline white blood cell counts measured at hospital admission and those with less favorable cervical status at the start of induction. A longer interval between membrane rupture and the onset of active labor, as well as the presence of non-reassuring fetal heart rate patterns during labor, were also more frequently observed among women who required cesarean birth. Neonates delivered by cesarean birth were slightly heavier and more likely to experience respiratory distress, while other short-term neonatal outcomes were similar between groups. These findings indicate that routinely available intrapartum information can provide meaningful clinical context when counseling women with PROM who are undergoing IOL. Rather than predicting individual outcomes, such information may support shared decision-making and more personalized communication during labor care.