Level 1: Likely reliable evidence

Intrauterine growth restriction (IUGR) is often managed by induction of labor to reduce the risk of neonatal morbidity or stillbirth. However, due to concerns about induction, including a possible increase in cesarean sections, some clinicians prefer expectant management, with close monitoring of fetal status.

The DIGITAT trial compared these two approaches in 650 women with suspected IUGR (BMJ. 2010;341:c7087). Women with singleton pregnancies at 36-41 weeks’ gestational age were randomized to expectant management with fetal monitoring until spontaneous onset of labor vs. labor induction within 48 hours. Monitoring included daily fetal-movement counts and twice-weekly heart-rate tracings, ultrasound, and screening for preeclampsia. Women in the expectant management group could have induction or cesarean delivery if indicated.

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The primary outcome was the composite of four neonatal adverse events: death before hospital discharge, five-minute Apgar score <7, umbilical artery pH <7.05, and admission to neonatal intensive care. The composite outcome occurred in 6.1% of the expectant management group vs. 5.3% of the induction group (not significant). There were no significant differences in Apgar scores, umbilical pH, or intensive care admissions. No fetal or neonatal deaths occurred in either group.

The expectant management group had higher median birth weight (+130 g) and longer median gestational age (+10 days). Labor was induced in 50.6% of the expectant management group. There were no significant differences in rates of instrumental delivery or cesarean section.