Elective labor inductions: Inducing a disaster?

Clinical Problem

The continuing evolution of technology has led to the demand for new innovations in heath care that are suitable for the changing socioeconomic needs of the fast-paced lifestyle in modern society. The implementation of contemporary medical interventions and resource utilization have improved outcomes and allowed access to more options and flexibility in the management of care.  Although there is always a possibility for complications, critical situations may necessitate the use of risky interventions to improve patient outcomes. Recently, procedures that were once indicated for problem management are now being used electively to provide patient satisfaction and convenience. This is seen very often in maternity units when pregnant women request or agree to unnecessary interventions to induce or augment labor.Image

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Although artificially promoting labor is often indicated in high-risk situations, induction may be implemented in healthy pregnancies for the sake of preference. Inductions are often considered as resourceful, as they can allow birth to occur in a timely manner that is often convenient to the parties involved. Frequently, healthy women will request an induction due to time restraints, or in an effort to alleviate the discomfort and anxiety of waiting in the final days of pregnancy. While it may provide a sense of control and increased patient satisfaction, the overall convenience of labor induction is questionable. Recent risk-reduction initiatives have found an increased incidence of unfavorable outcomes due to complications associated with elective inductions in normal pregnancies that could have otherwise been avoided.

Background of the Problem

The objective in investigating the outcomes of induced labors is to determine if there is a relationship between the use of elective inductions and the rising incidence of C-sections. If research reveals an increased risk for Caesareans, recommendations against unnecessary elective labor inductions may be in order.  The ultimate goal is to decrease the need for C-section, and avoid unnecessary interventions by addressing the root of the problem. With confirmation from the evidence, hospital policies and standards of practice can be revised to reduce preventable complications by promoting non-interventional labor management in the absence of problems (Varney, 2004). Additionally, all parties involved in the management of labor and delivery would be impacted by these conclusions. Not only do the findings suggest changes in the provision of care, it can also serve as a critical foundation for patient education during decision-making and informed consent.

Although “being normal” is a concept that is deeply desired amongst today’s society, is it is a wonder why so many patients and providers alike endorse utilization of interventions indicated for the abnormal patient. The midwifery model of care recognizes that childbirth is in fact a normal, physiological process , and supports conservative management by integrating art with science, and using technology judiciously (Varney, Kriebs, & Gegor, 2004).

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Our culture, however, commonly perceives childbirth as a pathophysiological event that requires intervention of normal processes. Essentially, the trend lies in trying to fix what is not broken, and trying to solve problems that don’t necessarily exist.

Background Questions

Using interventions that alter normal physiologic processes have the potential to instigate a cascade of subsequent interventions. In attempt to maintain relative stability, additional interventions become necessary to promote ideal correspondence to expected outcomes (Simpson & Thorman, 2005). Invariably, interventions may lead to further deviations from normal, facilitating physiologic instability, and increasing the risk of morbidities.

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Despite the “convenient” advantages that are often perceived with electively inducing labor, patients become subjected to no food intake, strict bed rest, continuous monitoring, intravenous fluids, and greater frequency and intensity of contractions (Simpson & Thorman, 2005). This can lead to more maternal discomfort and exhaustion that may prolong the second stage of labor, as well as predispose the need for forceps or vacuum assisted delivery and C-section. Furthermore, fetal distress has been associated with inductions as a result of uterine hyperstimulation, extensive head compression, meconium aspiration, and prolapsed cord (Gabbe, Niebyl, & Simpson, 2007). Non-reassuring fetal heart rates often lead to emergent delivery by Caesarean section (Simpson & Thorman, 2005).

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Additionally, Simpson and Atterbury (2003) identify other potential complications associated with induction such as fetal cephalohematoma, placental separation, uterine hemorrhage, fetal death, and significant pelvic floor injuries with perineal and anal lacerations causing urinary and fecal incontinence. With the abundance of potential complications from induction, patients may develop a sense of fear, anxiety, and loss of control that emphasizes the perception of childbirth as a dangerous pathological process and will often electively choose a C-section. Because many institutions prohibit vaginal birth after Caesarean (VBAC), more women are being obligated to undergo C-sections for subsequent births, further increasing the incidence. Invariably, the more a procedure occurs, the more complications associated with the procedure are likely to result. As health care providers striving to improve patient care and morbidity, even a low complication rate is too many.

With an ultimate goal of enhancing birth outcomes, taking steps to avoid preventable complications is a crucial component to reduce mortality and morbidity in childbirth.

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References

Gabbe, S., Niebyl, J., & Simpson, J., (2007). Obstetrics: Normal and problem pregnancies,

(5th ed.). Philadelphia: Churchill Livingston

Simpson, K., & Atterbury, J., (20030). Trends and issues in labor induction in the United States:

implications for clinical practice. Journal of Obstetrics, Gynecology, & Neonatal Nursing, 32: 767–779

Simpson, K., & Thorman, K., (2003). Obstetric “conveniences”: Elective induction of labor,

Caesarean birth on demand, and other potentially unnecessary interventions. Journal of Perinatal & Neonatal Nursing, 19(2): 134-144

Varney, H., Kriebs, J., & Gegor, C., (2004). Varney’s midwifery, (4th ed.). Sudbury, MA: Jones

and Bartlett Publishers, Inc.