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Objective: To analyze the main indications for induction of labor with vaginal misoprostol in high-risk pregnancies as well as the main variables associated with failed induction in a tertiary center in the metropolitan region of Rio de Janeiro, Brazil., Methods: A retrospective cohort study analyzed the medical records of pregnant women who underwent induction of labor. Inclusion criteria were singleton pregnancy, gestational age ≥ 34 weeks, Bishop score ≤ 6, fetuses in cephalic presentation, and no contraindications for the use of vaginal misoprostol. The labor induction protocol consisted of vaginal misoprostol 25 mcg every 6 hours, with a maximum of eight doses (200 mcg) to ripen the cervix if Bishop's score was ≤ 6., Results: A total of 88 cases of labor induction were analyzed. Main indications for labor induction were preeclampsia and gestational hypertension (N = 28; 31.8%), chronic arterial hypertension (N = 19; 21.6%), and gestational diabetes mellitus (N = 12; 13.6%). We observed that vaginal delivery was associated with the number of vaginal misoprostol doses (P = 0.000348). The most common indications for cesarean section were failure of labor induction (N = 21; 40%) and suspected acute fetal distress (N = 17; 33%). We did not observe a statistical difference between indication of labor induction and mode of delivery. There were no fetal deaths. Six neonates were admitted to the neonatal intensive care unit (NICU), one for respiratory distress, one for preterm delivery, and four for hypoglycemia. There was no statistical difference in the rate of NICU admission between delivery modes (P = 0.692)., Conclusion: The main indication for cesarean section in this study was induction failure, indicating the need to review and continuously monitor the protocol to increase success rates without compromising perinatal outcomes.