Background: Induction of labor (IOL) is a common obstetric intervention, yet it is frequently associated with higher cesarean section (CS) rates, particularly in nulliparous women. Identifying determinants of CS following IOL can guide clinical decision-making and improve outcomes.

Objective: To evaluate maternal, fetal, and obstetric factors influencing CS rates among term nulliparous women undergoing IOL.

Methods: This hospital-based observational case-control study was conducted at Dr. Rajendra Prasad Government Medical College, Kangra at Tanda, Himachal Pradesh. Two hundred nulliparous women with singleton term pregnancies undergoing IOL were enrolled 100 who underwent CS after IOL (Group A) and 100 who delivered vaginally (Group B). Data on demographic parameters, comorbidities, Bishop score, indications for induction, and delivery outcomes were collected. Statistical analysis included chi-square and t-tests, with odds ratios (OR) and 95% confidence intervals (CI) calculated for risk factors.

Results: Mean maternal age and BMI were significantly higher in Group A (27.09 ± 4.34 years, 24.71 ± 3.37 kg/m²) than Group B (25.00 ± 3.88 years, 22.91 ± 2.17 kg/m²) (p = 0.001 and p = 0.002, respectively). Bishop score was significantly lower in Group A (3.78 ± 0.76) versus Group B (4.41 ± 0.95; p = 0.001). Hypertensive disorders (OR 2.60, p = 0.008) and diabetes mellitus (OR 2.25, p = 0.046) were significant predictors of CS. Postdated pregnancy was associated with a reduced CS risk (OR 0.37, p = 0.001). Acute fetal distress (72%) failed induction (19%), and non-progression of labor (9%) were the main CS indications. Neonatal outcomes were comparable, although respiratory distress was more frequent in Group A.