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Running head: Labor Induction: Review of Current Practices

Labor Induction: Review of Current Practices

Heather Russell

Western Governors University

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Labor Induction: Review of Current Practices

Introduction

The process of having a baby is constantly evolving. It has moved from a very personal

experience with little medical interference towards a more medically invasive and controlled

procedure. At the early phases of medical intervention in the delivery process, the delivery was

at a mother’s home, attended by a midwife. Now the birthing process is largely hospital-based,

with many medical interventions including continuous fetal monitoring, anesthesia such as

epidurals, labor induction and/or augmentation, elective surgical deliveries, and a medical doctor

making the bulk of the decision about how the delivery process will proceed. Mothers are losing

their voice in the process and labor rarely proceeds in a natural manner, operative deliveries are

increasing, while maternal and fetal outcomes are not improving.

Problem Statement

Pregnant women often are unaware of the implications of labor induction and

augmentation, instead choosing to go along with the doctor’s decision and/or relying on

information from friends and relatives. Decisions are made based on what is convenient, easier

or faster instead of what is best practice. Depending on the delivery setting, the doctor is only

present when something goes wrong or delivery is imminent. The labor itself is primarily

attended by a nurse who acts as the bridge between the doctor and the patient and acts as the

primary caregiver during the labor. By reviewing current literature on labor induction and

augmentation, the nurse can give the pregnant patient the most accurate and up to date research

regarding the safety, efficacy, and outcomes related to labor induction and augmentation. This

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allows the patient to make an informed decision with the help of an educated and experienced

professional.

Search Methods

To provide the most accurate and up-to-date information, the nurse should utilize

information from peer-reviewed journals, professional organizations, and interviews with

respected professionals. Several databases were utilized in the search for information. CINAHL

(Cumulative Index to Nursing and Allied Health Literature), PubMed, Google Scholar, and

AWHONN (The Association of Women's Health, Obstetric and Neonatal Nurses) were my

primary sources for data. Search terms included “labor induction,” “labor augmentation,”

“maternal/fetal outcomes,” “artificial rupture of membranes,” and “indications for labor

augmentation.” Only articles published within the last five years were used to ensure that the

data was current. CINAHL is the primary database for nursing research and a good place to

start. PubMed is another large medical database and resource for peer-reviewed literature and

transcripts from professional conferences and roundtable discussions. AWHONN is the largest

professional organization of obstetric and women’s health nurses and a primary source for

current evidence-based nursing practices. Google Scholar is a Google search engine that focuses

largely on searching journal articles and other scholarly resources. Randomly Googling search

terms is a poor means to obtain data because it is more difficult to sort through and to

authenticate data. Wikipedia is ok for general material and to find more accurate sources, but is

not a reliable source of information since it can be edited by anyone regardless of their

background.

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Search Results

Searching the databases was a familiar task, but narrowing down to a specific focused

topic was more difficult. The search started with a focus on artificial rupture of membranes and

rates of chorioamnionitis, but this yielded no material connecting the two. Searching for

artificial rupture of membranes alone showed several varied articles. Skimming through the

articles, there was many discussing labor induction and its impact on maternal and fetal

outcomes. While this was not the original focus of my search, using different search terms

yielded a new topic of interest with a greater amount of evidence. With a new focus, search

terms included “AROM,” “Latent Labor,” “Elective Induction,” “Labor Augmentation,” and

“Induction Protocols.” This resulted in a range of literature to review, and the topic condensed

to include only studies related to labor patterns and labor induction in primigravida women. The

largest obstacle was finding a relevant topic that was neither too broad nor too narrow, and this

was what made the search more laborious.

Summary of Data

Current practices in managing the labor of a primigravida patient have suggested

protocols in place from the governing professional organizations of AWHONN and ACOG (The

American Congress of Obstetricians and Gynecologists). However each practitioner interprets

them differently and/or chooses to follow their chosen protocol. At times decisions are made

based on the convenience of the care provider or patient. The most significant change in practice

has been a move towards eliminating elective labor inductions prior to 39 weeks of gestation and

only then if a Bishop’s Score is favorable. Many of the studies showed an increase in poor fetal

outcomes when labor is induced before this time, largely due to fetal lung immaturity. A

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secondary concern is the increase in unplanned operative deliveries when labor inductions fail.

Failure can be attributed to a failure of the cervix to dilate, failure of the baby to descend, non-

reassuring fetal heart rhythms, or fetal intolerance to labor. Studies showed a correlation

between elective labor induction and an increase in unplanned operative delivery or delivery

requiring forceps or vacuum extraction. The leading factor to failed inductions was an

unfavorable cervix. If a patient presents with a cervix that is closed, thick and high, they will

require more interventions including cervical ripening compared to the patient who cervix is

already starting to dilate and efface.

It was important to examine what researchers considered a “normal” length for labor in

order to determine when a labor is no longer progressing. Again this becomes a very subjective

decision influenced by the care provider and patient preferences, so it is important to set clear

definitions for determining this. Also important was distinguishing between latent and active

labor. Latent labor was previously considered to occur until a patient reached 4 cm of dilation,

which has since been revised to allow latent labor to be better defined by the rate of dilation,

patient comfort, and contraction strength. Thus now a patient may not be in active labor until

they reach 5-6 cm of dilation. This allows a more flexible timeline for labor and ideally

decreases the rush to augment labor.

Another piece of the puzzle affecting labor progress was at what point should a patient be

admitted to the hospital for labor. This is again a very subjective area. A patient may be

extremely uncomfortable at 1cm dilation or may not even arrive at the hospital until delivery is

imminent. Studies showed that early admission during the latent labor phase lead to an increase

in medical interventions including artificial rupture of membranes, oxytocin administration, and

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operative delivery. Data showed a clear correlation between later labor admission and an

increase in spontaneous vaginal delivery, which is the ideal outcome.

Recommended Best Practices

Ideally a patient should be educated during the pregnancy about how labor progresses

and at what point they should come to the hospital. The patient insisting on elective induction

needs to understand the risks to the fetus and the increased likelihood of operative delivery.

Patients need to realize that without confounding factors, they should wait to go into labor on

their own, and that 40 weeks is not an ultimate deadline. Current research suggests a baby is not

post-term until 42 weeks. Primigravida patients are often nervous and easily influenced by

friends and relatives, so a care provider needs to be open to answering the patient’s questions

and explaining the rationales behind their suggestions. The ultimate goal is a healthy mom and a

healthy baby and research shows that this is most likely when a patient has a term spontaneous

vaginal delivery. The nurse is usually responsible for patient education, triaging laboring

patients, and largely managing the patient’s labor. A nurse who is calm and well-educated with

a good bedside manner can have a strong influence on a nervous patient insisting that something

is wrong or frustrated with the slow progress of their labor. The nurse needs to explain to the

anxious patient in latent labor that admitting them early leads to more medical interventions.

The patient is likely to remain in bed on continuous fetal monitoring instead of being an active

participant in the labor progress. By using a team-based approach and giving the patient a voice

in their care, there is a hope to increase positive maternal and fetal outcomes.

Knowledge Gaps

In searching the literature there was a lack of evidence related to certain practices.

Initially I was looking to see if there was a correlation in artificial rupture of membranes and an

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increase in chorioamnionitis or post-partum infection. Taking into consideration that prolonged

rupture of membranes can lead to infection, more data is needed to support or refute the practice

of AROM. At what point should AROM be considered? Does AROM early in labor lead to an

increase of failed labor and/or operative delivery? Does AROM or labor induction and

augmentation lead to an increase in fetal distress? Managing the labor process is constantly

evolving and changing and is affected by so many external factors, so more clear evidence is

needed to support current practices and interventions