A Randomized Trial of Induction Versus Expectant Management (ARRIVE)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT01990612
Recruitment Status : Completed
First Posted : November 21, 2013
Last Update Posted : July 27, 2018
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
Information provided by (Responsible Party):
The George Washington University Biostatistics Center

Brief Summary:
A randomized clinical trial to assess whether elective induction of labor at 39 weeks of gestation compared with expectant management will improve outcomes.

Condition or disease Intervention/treatment Phase
Labor and Delivery Procedure: Elective Induction of Labor Not Applicable

Detailed Description:
Given the reported increased risks of adverse events in pregnancies extending beyond 39 weeks it has been hypothesized that a policy of planned elective induction at 39 weeks could improve outcomes for the infant and the mother. For multiparous patients, especially those with a favorable cervix, it is perhaps easy to justify an elective induction at 39 weeks given the low risk of cesarean section. However, for nulliparous patients the current evidence, derived mainly from retrospective observational studies, does not allow a clear recommendation. Nevertheless, a trend towards an increased rate of elective labor induction in pregnancies at 39 weeks has been reported, indicating that practitioners are more commonly using elective induction at this gestational age,even as others caution against routine elective induction prior to 41 weeks given the reported increased risk of cesarean delivery. Ultimately, a randomized controlled trial is necessary to satisfactorily understand whether elective induction of labor of nulliparas at 39 weeks improves neonatal and maternal outcomes.

Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 6106 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Intervention Model Description: Randomized trial of 6000 women at 38 weeks 0 days to 38 weeks 6 days randomized to one of two arms: elective induction of labor between 39 weeks 0 days and 39 weeks 4 days; or expectant management (unless a medical indication arises) until at least 40 weeks 5 days.
Masking: None (Open Label)
Primary Purpose: Prevention
Official Title: Induction in Nulliparous Women at 39 Weeks to Prevent Adverse Outcomes: A Randomized Controlled Trial
Study Start Date : March 2014
Actual Primary Completion Date : November 2017
Actual Study Completion Date : January 2018

Arm Intervention/treatment
No Intervention: Expectant Management
Expectant management (unless a medical indication arises) until at least 40 weeks 5 days.
Elective Induction of Labor
Elective induction of labor between 39 weeks 0 days and 39 weeks 4 days
Procedure: Elective Induction of Labor
Women randomized to induction of labor will undergo induction via oxytocin at 39 weeks 0 days to 39 weeks 4 days. Those with an unfavorable cervix (modified Bishop score < 5) will first undergo cervical ripening (method left to the discretion of the patient's physician) in conjunction with or followed by oxytocin stimulation unless a contraindication arises.

Primary Outcome Measures :
  1. composite of severe neonatal morbidity and perinatal mortality [ Time Frame: delivery ]

    Includes any one of:

    • Antepartum, intrapartum, or neonatal death
    • Intubation, CPAP, or high-flow nasal cannula (HFNC) for ventilation or cardiopulmonary resuscitation within the first 72 hours
    • Apgar ≤ 3 at 5 minutes
    • Neonatal encephalopathy as defined by Shankaran et al.
    • Seizures
    • Sepsis (presence of a clinically ill infant in whom systemic infection is suspected with a positive blood, cerebrospinal fluid (CSF), or catheterized/suprapubic urine culture; or, in the absence of positive cultures, clinical evidence of cardiovascular collapse or an X-ray confirming infection)
    • Pneumonia confirmed by X-ray or positive blood culture.
    • Meconium aspiration syndrome
    • Birth trauma (bone fractures, brachial plexus palsy, other neurologic injury, retinal hemorrhage, or facial nerve palsy)
    • Intracranial hemorrhage (intraventricular hemorrhage grades III and IV, subgaleal hematoma, subdural hematoma, or subarachnoid hematoma)
    • Hypotension requiring pressor support

Secondary Outcome Measures :
  1. Cesarean delivery and indication [ Time Frame: delivery ]
  2. Incisional extensions at cesarean section, including J shape or T shape; or cervical traumas [ Time Frame: delivery ]
  3. Operative vaginal delivery and indication [ Time Frame: delivery ]
  4. Chorioamnionitis, defined as a clinical diagnosis before delivery [ Time Frame: before delivery ]
  5. Third or fourth degree perineal laceration [ Time Frame: delivery ]
  6. Maternal death [ Time Frame: delivery ]
  7. Admission to intensive care unit (ICU) [ Time Frame: delivery ]
  8. Preeclampsia/gestational hypertension [ Time Frame: before delivery ]
  9. Postpartum hemorrhage [ Time Frame: delivery ]

    defined as any of the following:

    • Transfusion
    • Non-elective hysterectomy
    • Use of two or more uterotonics other than oxytocin
    • Other surgical interventions such as uterine compression sutures, uterine artery ligation, embolization, hypogastric ligation, or balloon tamponade
    • Curettage

  10. Interval from randomization to delivery [ Time Frame: delivery ]
  11. Gestational age at delivery [ Time Frame: delivery ]
  12. Maternal postpartum infection [ Time Frame: delivery ]

    Defined as any of the following:

    • Clinical diagnosis of endometritis
    • Wound reopened for hematoma, seroma, infection or other reasons
    • Cellulitis requiring antibiotics
    • Pneumonia
    • Pyelonephritis
    • Bacteremia - unknown source
    • Septic pelvic thrombosis

  13. Maternal venous thromboembolism [ Time Frame: delivery ]
    Deep venous thrombosis or pulmonary embolism

  14. Neonatal birth weight [ Time Frame: delivery ]
  15. Duration of respiratory support [ Time Frame: delivery ]
    including ventilator, CPAP, high-flow nasal cannula (HFNC)

  16. Cephalohematoma [ Time Frame: delivery ]
  17. Shoulder dystocia [ Time Frame: delivery ]
  18. Transfusion of blood products or blood [ Time Frame: delivery ]
  19. Hyperbilirubinemia requiring phototherapy or exchange transfusion [ Time Frame: delivery ]
  20. Hypoglycemia [ Time Frame: delivery ]
    glucose < 35 mg/dl and requiring IV therapy

  21. Admission to neonatal intensive care unit (NICU) or intermediate care unit [ Time Frame: delivery ]
  22. Number of hours on the labor and delivery unit [ Time Frame: delivery ]
  23. Maternal postpartum length of hospital stay [ Time Frame: after delivery ]
  24. Neonatal length of hospital stay [ Time Frame: delivery ]

Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.

Ages Eligible for Study:   Child, Adult, Older Adult
Sexes Eligible for Study:   Female
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  1. Nulliparous - no previous pregnancy beyond 20 weeks
  2. Singleton gestation. Twin gestation reduced to singleton, either spontaneously or therapeutically, is not eligible unless the reduction occurred before 14 weeks project gestational age.
  3. Gestational age at randomization between 38 weeks 0 days and 38 weeks 6 days inclusive based on clinical information and evaluation of the earliest ultrasound.

Exclusion Criteria:

  1. Project gestational age at date of first ultrasound is > 20 weeks 6 days
  2. Plan for induction of labor prior to 40 weeks 5 days
  3. Plan for cesarean delivery or contraindication to labor
  4. Breech presentation
  5. Signs of labor (regular painful contractions with cervical change)
  6. Fetal demise or known major fetal anomaly
  7. Heparin or low-molecular weight heparin during the current pregnancy
  8. Placenta previa, accreta, vasa previa
  9. Active vaginal bleeding greater than bloody show
  10. Ruptured membranes
  11. Cerclage in current pregnancy
  12. Known oligohydramnios, defined as AFI < 5 or MVP < 2
  13. Fetal growth restriction, defined as EFW < 10th percentile
  14. Known HIV positivity because of modified delivery plan
  15. Major maternal medical illness associated with increased risk for adverse pregnancy outcome (for example, any diabetes mellitus, lupus, any hypertensive disorder, cardiac disease, renal insufficiency)
  16. Refusal of blood products
  17. Participation in another interventional study that influences management of labor at delivery or perinatal morbidity or mortality
  18. Delivery planned elsewhere at a non-Network site

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT01990612

United States, Alabama
University of Alabama - Birmingham
Birmingham, Alabama, United States, 35233
United States, California
Stanford University
Stanford, California, United States, 94305-5317
United States, Colorado
University of Colorado
Denver, Colorado, United States, 80045
United States, Illinois
Northwestern University-Prentice Hospital
Chicago, Illinois, United States, 60611
United States, New York
Columbia University-St. Luke's Hospital
New York, New York, United States, 10032
United States, North Carolina
University of North Carolina - Chapel Hill
Chapel Hill, North Carolina, United States, 27599
Duke University
Durham, North Carolina, United States, 27710
United States, Ohio
Case Western Reserve University
Cleveland, Ohio, United States, 44109
Ohio State University Hospital
Columbus, Ohio, United States, 43210
United States, Pennsylvania
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania, United States, 19104
Magee Womens Hospital of UPMC
Pittsburgh, Pennsylvania, United States, 15213
United States, Rhode Island
Brown University
Providence, Rhode Island, United States, 02905
United States, Texas
Dept of OB/GYN, Southwestern Medical Center, University of Texas
Dallas, Texas, United States, 75235-9032
University of Texas - Galveston
Galveston, Texas, United States, 77555
University of Texas - Houston
Houston, Texas, United States, 77030
United States, Utah
University of Utah
Salt Lake City, Utah, United States, 84132
Sponsors and Collaborators
The George Washington University Biostatistics Center
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
Study Director: Uma Reddy, MD, MPH Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
Principal Investigator: Elizabeth Thom, PhD The George Washington University Biostatistics Center
Study Chair: William Grobman, MD Northwestern University

Publications automatically indexed to this study by Identifier (NCT Number):
Responsible Party: The George Washington University Biostatistics Center Identifier: NCT01990612     History of Changes
Other Study ID Numbers: HD36801-ARRIVE
UG1HD027869 ( U.S. NIH Grant/Contract )
UG1HD027915 ( U.S. NIH Grant/Contract )
UG1HD034116 ( U.S. NIH Grant/Contract )
UG1HD034208 ( U.S. NIH Grant/Contract )
UG1HD040500 ( U.S. NIH Grant/Contract )
UG1HD040485 ( U.S. NIH Grant/Contract )
UG1HD040544 ( U.S. NIH Grant/Contract )
UG1HD053097 ( U.S. NIH Grant/Contract )
UG1HD040545 ( U.S. NIH Grant/Contract )
UG1HD040560 ( U.S. NIH Grant/Contract )
UG1HD087230 ( U.S. NIH Grant/Contract )
UG1HD087192 ( U.S. NIH Grant/Contract )
UG1HD040512 ( U.S. NIH Grant/Contract )
UG1HD068258 ( U.S. NIH Grant/Contract )
UG1HD068268 ( U.S. NIH Grant/Contract )
First Posted: November 21, 2013    Key Record Dates
Last Update Posted: July 27, 2018
Last Verified: July 2018
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Yes
Plan Description: The dataset will be shared per NIH policy after the completion and publication of the main analyses. Requests for datasets can be sent to

Keywords provided by The George Washington University Biostatistics Center:
Induction of labor
Expectant management of labor
39 weeks gestation