Carole Ann Moleti, MS, MPH, CNM, FNP-BC

Trends and
Abstract In 2005, the rate of induction of labor for all births in the United States calculated from birth certificate data approached 22.3%. In 2006, the Listening To Mothers II Study suggested that induction of labor might be as high as 50% if attempts at self-induction are considered. All induction methods hold some measure of risk for minor and more serious and sometimes even lifethreatening complications for the mother and fetus. This article contains a review of the physiology of labor, accepted pharmacologic and mechanical methods of induction, and data about alternative methods women use for induction, including acupuncture and herbal preparations. Risks and complications for women undergoing labor induction are described, and the role of the nurse in patient education and counseling is discussed. Key Words: Labor induction; Misoprostol; Complementary medicine; Trends; Controversy.
January/February 2009




A small proportion (11%) of mothers said in this survey that they had experienced pressure from care providers to have an induction. 2000). 2002). & Applebaum. 2006). the women in the Listening to Mothers II Study were poorly informed about the risks of labor induction.” Only 48% of the women knew that labor induction could increase the risk of cesarean birth.. Corry. January/February 2009 elective inductions may be seen by providers as a reasonable way to manage the demands on their time. however. Corry. either independent of or coincident with the medical induction (Declercq. functional changes.. 2002). hemorrhage. uterine rupture. The doubling of the elective induction rate has occurred for many reasons. 72% thought that induction might be indicated if the baby appeared to be too large at the end of the pregnancy (Declercq et al. the desire on the part of women and their providers to arrange a convenient time of delivery. Given the ease of use and effectiveness of prostaglandin preparations. and more relaxed attitudes toward marginal indications for induction (Zhang. 2006). What is known is that as pregnancy advances. 2005).Controversies in Labor Induction I n 1990. including the availability of better cervical ripening agents. 55% answered “not sure. because the physiological trigger for the initiation of the biochemical events conducive to cervical ripening has yet to be identified (Arias. 2006). & Applebaum. and 52% of 1573 respondents (United States residents) stated that they had an elective delivery. women who had recently given birth were asked about the circumstances of their birthing experience. Simpson & Thorman. including an increased risk of cesarean. 2006). infection.. which makes scheduled births a more attractive option for staffing and bed utilization (Simpson & Thorman. In the Listening to Mothers II Study (Declercq. Yancey. including MCN 41 . Despite the large numbers of women experiencing induction. When women were asked if induction could cause fetal distress. & Henderson. data compiled by the National Center for Health Statistics showed the rate of induction of labor to be 9. still one half of the women who responded to the Listening to Mothers II Study felt that labor should not be interfered with unless medically necessary. too early. Forty-one percent indicated that their caregiver tried to medically induce labor. Concerns about postmaturity and fear of adverse outcomes and litigation have been reported to contribute to the increased rate of induction (Rayburn & Zhang. carried out in partnership with Harris Interactive and Lamaze International. too early. Sakala. or too late—remains a mystery. Sakala. the frequency of labor induction more than doubled to 22. 2007). By 2005. Why spontaneous labor begins on time.3% (Martin et al. and neonatal respiratory distress due to transient tachypnea of the newborn and iatrogenic prematurity (Eagle. Despite this. and 22% stated that they attempted self-induction. The challenge for care providers is to determine when the benefits of induction outweigh the risks and to ensure that patients and families understand their options and give informed consent.5%. All labor inductions have the potential for minor and life-threatening complications for both the mother and fetus. 2006. Many L&D units now function at maximum capacity. Why labor occurs—whether on time. Virtually all felt that the complications of inductions and cesarean section should be discussed (Declercq et al. 2005). including induction or planned cesarean section. or too late remains a mystery. Physical and Biochemical Events That Trigger Onset of Labor Why does labor start? We still don’t know.

. or previous classical uterine incision (ACOG. 2000. and micro-organisms. mediators. Cunningham et al. but those that exist do not support induction of labor for elective or marginal indications. As the cervix dilates. improving electrical synchrony and coordination of smooth muscle contraction in response to the uterotonins oxytocin and prostaglandins (Cunningham et al. 2001).. 1999)... umbilical cord prolapse. increasing myometrial contractility. and then active labor begins (Cunningham et al. trauma.. particularly after rupture of the membranes. Eagle (2006) found that prenatal methods for estimating gestational age are imprecise. McIntire. They state that in women with unfavorable cervices and reassuring fetal status. Contraindications to labor induction include active genital herpes infection. with a margin of error of ± 2 weeks. One metaanalysis of 16 studies of women whose labor was induced beginning at 41 weeks’ gestation found no statistically significant differences for perinatal mortality rate. 2004a). Delke. which causes an inflammatory reaction. or the sequelae of biochemical reactions.Cervical ripening is considered the most important predictor of the success of labor induction and should be documented along with dating parameters for every woman undergoing induction. and development of the lower uterine segment occur. Olivier. meconium below the cords. or abnormal Apgar scores (Sanchez-Ramos. rather than initiators of labor (Cunningham et al. Therefore. cervical ripening. NICU admission rates. 2001)..g. These are thought to be markers. discussion persists in the literature about when elective induction is appropriate by gestational age for women who have reached or exceeded their EDD. Birth of an infant after term in women with favorable cervices is reasonable. which occurs as collagen breaks down and alters the amounts of glycosamines (hyaluronic acid and relaxin). 2002). 1999) Fetal macrosomia is not considered an indication for elective induction because it has not been shown to alter the risk of maternal or neonatal morbidity. along with cervical ripening. meconium aspiration. 2006) did find significantly lower rates of perinatal mortality in routine labor induction at 41 weeks or beyond. even in the absence of complications (ACOG. transverse lie. some face presentations). and gap junctions enlarge between myometrial cells. Bernstein. stimulating water retention (Arias. it is clear that some units have January/February 2009 . 42 VOLUME 34 | NUMBER 1 The prevalence of early ultrasound dating still has not eliminated the biological fact that some pregnancies last longer than 40 weeks due to variations in menstrual cycle length and time of ovulation (Cunningham et al. 2000. labor induction can be undertaken at 41 weeks with use of cervical ripening agents. placenta or vasa previa. progesterone withdrawal occurs before labor. & Kaunitz. Postmaturity and Elective Labor Induction Indications for the Induction of Labor The current acceptable American College of Obstetricians and Gynecologists (ACOG) indications for elective induction of labor are as follows: • pre-eclampsia/eclampsia (and other hypertensive disorders) • maternal diabetes mellitus • premature rupture of membranes • chorioamnionitis • intrauterine fetal growth restriction • fetal demise • postterm pregnancy (ACOG. the decidual tissue of the endometrium is exposed to vaginal fluids. Moore and Rayburn (2006) stated that prospective studies about this topic are limited. Sanchez-Ramos. Fetal macrosomia does increase the risk of cesarean birth (Irion & Boulvain. 2001). shoulder. 2003). and Leveno (2000) concluded that routine labor induction at 41 weeks’ gestation likely increases labor complications and operative delivery without significantly improving neonatal outcomes. fetal malpresentations that preclude vaginal birth (e. Nevertheless. Crowther. hypoxia. Alexander. & Middleton. Costs of Labor Induction Do labor inductions save money for institutions? The unpredictable nature of obstetrics creates difficulties with staffing and bed availability. or the pregnancy can be managed expectantly by initiating twice-weekly antenatal fetal surveillance (between 41 and 42 weeks’ gestation) and performing non–stress tests and assessment of amniotic fluid volume. the current ACOG recommendations (2004a) allow for flexibility in this regard. & Kaunitz. 2001). In most mammals. 2001). Oxytocin receptors in the myometrium increase. but a different meta-analysis of 19 trials (Gulmezoglu.

It assigns a number from 0 to 2 for graduated measurements of cervical consistency. longer postpartum stays. Prostaglandins Prostaglandins work by blocking progesterone and causing a local inflammatory response. is a potent uterotonic agent (Arias. pitocin. MacKenzie. 1999). the rate fell to 13% (overall rate 15%). 2000). It is a polypeptide hormone produced in the hypothalamus and secreted from the posterior pituitary in a pulsatile fashion. and higher facility charges for repeat surgical deliveries (Sakala. Various protocols are used for pitocin. The most common complication of oxytocin administration is uterine hyperstimulation. Sawai. Sakala (2006) concluded that the current trend toward more elective repeat cesareans and fewer vaginal births after cesarean will incur subsequent costs in future pregnancies due to complications. & O’Brien. Studies that compared the three protocols showed no differences in the percentages of patients with successful inductions. & Grobman. The Bishop Score (1964) is the accepted method of assigning cervical ripening. Poma. Wing (2008) concluded that there are insufficient data to support a policy of routine elective induction of labor at term. Excessive doses of oxytocin can exhaust uterine smooth muscle. including low-dose. risk-averse patients and care providers began to opt for elective repeat cesareans.000 excess cesarean births at a cost of nearly $100 million a year (Kaufman. Berka. a policy of routine elective induction at term could result in more than 12. TambyRaja. 2008). & Hale. although the percentage of successful inductions was lower for aggressively managed nulliparous women than for other patient and protocol groups. One additional factor complicating the debate on elective induction of labor is the concurrent trend that discourages women from attempting a trial of labor after a previous low transverse cesarean birth (ACOG. 2000). 2002). Xenakis. When assessing readiness for labor induction. 2009). 2000). MCN 43 . After a comprehensive review of the literature. the cesarean rate was 34%. 2006). 2002). The economic analyses conducted regarding labor inductions have shown that the inductions most costly to the healthcare system are those performed in nulliparas with unfavorable cervices at 39 weeks’ gestation.4% higher than that for spontaneous labors. which is generally reversed by discontinuance of the infusion because its half-life is approximately 10 to 12 minutes (Arias. Pharmacologic Preparations Used for the Induction of Labor Oxytocin Cervical Ripening Cervical ripening is considered the most important predictor of the success of labor induction and should be documented. In 2006. synthetic prostaglandin E2 preparations cause cervical ripening. and pulsatile regimens. along with confirmation of dating parameters. 2000. but there was still an overall added expenditure and additional cesarean deliveries (Zhang et al. the provider assesses the Bishop score and then generally considers which method of elective induction will be used (Krammer. Its synthetic analog. despite the fact that oxytocin is still considered safe for induction in women with a scarred uterus (ACOG. Urinary output and specific gravity should be monitored carefully when more than 3 L of highly concentrated pitocin (40 mU/min) in hypotonic solutions are infused (Feeny. If the nullipara had a favorable cervix. high-dose. examined in this fashion. 2006). for all patients undergoing induction (Wing. the cost was halved. but for women with Bishop Scores of > 3. Gastrointestinal side effects and fever are uncommon with vaginal administration (Arias. Because elective inductions carry a higher risk of ultimate cesarean birth. Care must be taken to consider the total intrapartal dose when rapidly infusing postdelivery pitocin to correct uterine atony. facement. In addition to uterotonic effects. Sakala (2006) postulated that there might be hospital and provider incentives if more elective births are done due to the increased amount of reimbursement for cesarean births. Socol. 2005). 1994). Bailit. See the article in this special issue of MCN by Simpson and Knox to learn more about oxytocin as a high-alert medication (Simpson & Knox. Williams. 2004b). respiratory distress syndrome from iatrogenic prematurity. when ACOG recommended that women with previous cesarean births not receive sequential oxytocin and prostaglandins for labor induction because of an increased incidence of uterine rupture. position. 1995. the cesarean section rate was 20%. Pager. & Lopez Bernal. 2000). Wendel. Rodriquez-Linares. Conway. and efJanuary/February 2009 Oxytocin is the most common drug used for the induction of labor.. Some researchers suggest use of the regimen that provides the lowest total dose of oxytocin to minimize the risk of side effects (Arias. and transient tachypnea of the newborn.chosen to manage this issue by planning more of their births through elective inductions (Simpson & Thorman. 1982. Piper. if success is defined as achieving a vaginal birth while avoiding excess costs and admission to a special care nursery for sepsis. dilatation. 2008). In multiparas with a Bishop Score <3. and Dooley (1999) examined these cost issues and found that the cost associated with elective inductions is 17. predisposing to postpartum hemorrhage (Phaneuf. Wing. and Langer (1997) found that in nulliparas with a Bishop Score < 3. Willcourt. but dropped to 20% when the Bishop Score was > 3 (overall rate 29%). Its antidiuretic effect also can cause water intoxication and hyponatremia. Seyb.

2008). is no stronger than for other prostaglandin preparations. The cost of one tablet is less than $1 per 100 mcg (Wing. precautions. 2003). blue cohosh. 2003). abruption. can cause precipitate la44 VOLUME 34 | NUMBER 1 Herbal and Homeopathic Preparations Used for Labor Induction Women use complementary and alternative medicine more frequently than men. These same authors found that the cesarean birth rate for failed induction after misoprostol was not significantly reduced compared to the other prostaglandins or oxytocin. and postpartum hemorrhage.Nurses should ask patients about their use of herbal or homeopathic methods for labor induction. because it might increase the risk of uterine rupture (Hofmeyer & Gulmezoglu. ACOG (2003b) recommends that prostaglandins not be used in women with uterine scars from a previous myomectomy or cesarean birth. It costs about $150 per insert.5 mL gel for intracervical installation. for attention must be paid to correct dosing. For this reason. however. but the advantage is that it can easily be removed from the vaginal fornix if uterine hyperstimulation occurs. 2008). dosage.5 mg dinoprostone in 2. • Prepidil gel (Pharmacia and Upjohn). is FDA approved for prevention of nonsteroidal anti-inflammatory drug-related gastric ulcers. but there is an increased risk of hyperstimulation and possibly uterine rupture (Hofmeyr & Gulmezoglu. In 25 trials that involved 3. bor. Controversies Surrounding the Use of Prostaglandin for Labor Induction A ripened cervix is more receptive to oxytocin stimulation. and safety for this drug and stated that information on informed consent for misoprostol use and women’s views of the drug are “conspicuously lacking” (Hofmeyer & Gulmezoglu. nonreassuring fetal heart rate (FHR) patterns. a dose of 50 mcg can be considered in some situations. but a preparation should occur in the pharmacy and tablet fragments should be weighed to ensure dosage accuracy. 2008). Three prostaglandin preparations are in use: • Dinoprostone. The recommended dose of misoprostol is 25 mcg intravaginally every 3 to 6 hr. Physicians in the United States. The maximum cumulative dose should not exceed three within a 24-hr period. It is listed as Category X (not to be used) in pregnancy. but there is no way to remove it in the event of hyperstimulation or fetal distress. although exactly how often these remedies are used is not known (Barnes. • Misoprostol (Cytotec/Searle) is prostaglandin E1 analog available as 100-mcg and 200-mcg tablets.651 subjects. 2003). ACOG (2003b) also states that all women undergoing induction with prostaglandins must be hospitalized with continuous electronic monitoring of the fetal heart and uterine activity. 2008). 2003.. 2008). 10 mg. Prostaglandins are often used as first-line agents for labor inductions to soften the cervix. Hofmeyer and Gulmezoglu (2003) recommended further research to establish the ideal route of administration. and misoprostol is comparable. They can be broken into 25-mcg or 50-mcg aliquots. and emergency instructions. The risk of maternal or fetal death among Cervidil. Common methods include black cohosh. and uterine rupture. Cytotec. intrapartum. or Cervidil (Forest Pharmaceuticals). an often uncomfortable and difficult procedure to perform in an effort to remove this gel.. The potent uterotonic side effects of prostaglandins and attendant hyperstimulation. may use FDA-approved drugs for “off label” indications. Wing. It costs less than Cervidil (about $75/application). Evidence for its use. Prepidil. a brand of misoprostol. PowellJanuary/February 2009 . Oxytocin should not be given within 4 hr of the last misoprostol dose (Wing. Oxytocin may be initiated 30 to 60 min after removal of the insert (SanchezRamos et al. oil of evening primrose. has not been found to be effective (Wing. however. and castor oil. 2003). however. The time interval between the final dose and oxytocin administration should be at least 6 hr (Sanchez-Ramos et al. and has been shown to need fewer serial inductions (Wing. contains 0. Clinicians were advised in this study to be concerned about this apparent increase in uterine hyperstimulation. is a timed-release suppository left in place for 12 hr. aside from cost savings and rapidity of action. misoprostol was shown to be more effective and had more rapid onset of action. requires a lower dose of oxytocin. Vaginal lavage. There was an increased rate of uterine hyperstimulation with FHR changes and meconium-stained amnionic fluid.

McFarlin. Natural Medicines: Comprehensive Database. and extra-amnionic saline infusions have been used to stimulate endogenous prostaglandin secretion and/or manually dilate the cervix. three per day for up to 1 week. Artificial rupture of the membranes (amniotomy) is thought to augment labor because of prostaglandin release. but it has not been shown to be a reliable method for labor induction (Kavanaugh. diarrhea. Sexual intercourse has been thought to stimulate uterine contractions because of prostaglandins in semen and because of the physical stimulation of contractions after orgasm. Weed (1986) published the most well-known volume on herbal agents known to be used by women to induce labor on their own. Ten drops under the tongue is the dosage that has been known to have a noticeable effect on the cervix within an hour (Weed. The homeopathic form is Caulophyllum 200x. it is a Gossopium bark tea infusion that women take in sips (Weed. 1986). abruption. • Black cohosh exerts estrogenic effects and is used for cervical ripening. & Thomas. Acupuncture for Labor Induction Acupuncture has been used for labor induction and has appeared in literature documenting its effectiveness. Of those methods. Oxytocin has been found to be more effective after amniotomy (Howarth & Both. 2001). overdoses could be similar to those found with overdose of oxytocin (McFarlin et al. serious side effects. 2001). which causes the secretion of endogenous oxytocin. is one of the most commonly used preparations that women use for self-induction. • Castor oil. Like castor oil. 1986). and dehydration. Their effects may be synergistic. 1999). & Nahin. severe gastric cramping. It can act as a vasodilator and is generally not recommended for use in pregnancy due to its abortifacient properties (McFarlin et al. 1986)... & Thomas. January/February 2009 • Regional variations exist in the types of herbs that women seem to use for labor induction. • Bethroot is documented as being used by American Indians. Stripping or sweeping the membranes. at 30-min intervals. 2001b). Finger pressure over the same sites as acupuncture needling and the burning of moxa (mugwort herb) at an orientation toward those sites are techniques used by Chinese midwives to augment labor (Weed. • Oil of Evening Primrose taken in capsule form. It is said to potentiate the effects of prostaglandins (Weed. A retrospective audit of the use of traditional acupuncture by New Zealand midwives showed a decrease in medical inductions and cesarean births over a 12-month period (Duke & Don. which can be placed under the tongue every hour for 4 hr (Weed. Kelly. • Blue cohosh is an herb with oxytoxic effects and is generally used as a tincture. it was administered after spontaneous rupture of the membranes at term and significantly reduced the length of labor and use of oxytocin (Gurardernack. O’Rear. In a randomized controlled trial. Kelly. Because of its oxytocic effect. & Lohse. Herbal and homeopathic agents used for labor induction have medicinal properties and are known to stimulate at least one of the mechanisms known to initiate labor by causing uterine contractions or prostaglandin release. 2001a). and Harman (1999) conducted a national survey of herbal preparations used by nurse midwives for labor stimulation. there is a special concern in women with Group B streptococcus colonization (Boulvain. Gibson. so care must be taken when using multiple preparations. 1986). 1999. Cotton Bark Root has been used in areas where cotton is grown (for its oxytoxic effects). 1999. One-quarter to one-half teaspoon of the tincture is used twice. and emergency instructions. MCN 45 . 2006). has been used by some women for cervical ripening. cervical dilators (laminaria and inflated Foley catheter balloons). Natural Medicines: Comprehensive Database. Women often repeat this dose hourly for up to three doses (Weed. with three to eight drops placed under the tongue every half hour until contractions begin. few have been studied sufficiently to determine their efficacy or safety in pregnancy (Bayles. 2006). precautions. Nipple stimulation. McFann. Mechanical and Physical Methods Used For the Induction of Labor Other methods that women and their providers discuss for inducing labor have been studied. respectively). 2001). such as precipitate labor. usually put into 2 oz of orange juice. Although some modalities show potential for clinical benefit. Kelly. but no randomized controlled trials have been conducted to test its effectiveness (Kavanaugh. 2007). only stripping membranes and Foley catheters have been found in research to be effective (Poma. They found that the most commonly used herbs for labor induction/augmentation were castor oil (Ricinus communis) and blue and black cohosh (Caulophyllum thallictroides and Cimufuga racemosa. 2002). 2007). has been found to be effective in some women. Natural Medicines: Comprehensive Database.Griner. 2001). 1986. & Hole. it acts as a gastrointestinal and uterine stimulant (Weed. 1986). have been reported (Bayles. The risks of these methods is membrane rupture and infection. Forbord. 1986). Patients should be encouraged to discuss their use with their doctor or midwife because attention must be paid to correct dosing. Although it is one of the most commonly used agents for labor induction. and it promotes downward pressure from the presenting part on the cervix.

and sexual intercourse. and women’s health has been powerful.  January/February 2009 . nurses need to be on the front line of educating patients about the issue of induction. and the catheters and monitors that labor induction involves. cultural methods might be passed through families about how to start labor. Nurses also need to be taught more about herbs and other alternative methods known to be used for labor induction. Many of the respondents surveyed in the Listening to Mothers II Study were unaware of any medical indications for their induction. it becomes even more essential for 46 VOLUME 34 | NUMBER 1 nurses to learn more and to teach their patients more about what is known of herbs. the level of instrumentation to the cervix.. • In order to ensure that patients receive accurate and complete information about the risks. anticipatory discussions are necessary so the woman can make an informed decision about the choice of methods and agent. It is incumbent on nurses to learn as much as possible about this phenomenon and use that knowledge for the betterment of patient care. 1995). sexual intercourse. 2008). are used by some women. Implications for Nursing Because so many of the patients they care for are experiencing labor induction. Reasons the women in this survey gave for why they were induced included caregiver concern that the mother was overdue (25%) and the mother’s desire to get the pregnancy over with (19%). and nurses should ask specific questions to find out if any have been used. nurses who care for pregnant and laboring women require more knowledge about all of these methods in order to provide the safest care. and encourages discussion of risks. 10% of “self-inductions” (defined by the participants as walking or exercise. benefits. 2006). and alternatives (Simpson. membrane stripping. and nipple stimulation) and 17% of medical inductions (Declercq et al. and 33% did so because they wanted to avoid a medical induction). An increased risk of maternal and fetal infection has been found when laminaria are used (Krammer et al. When decisions are being considered by midwives or physicians regarding the more invasive mechanical and pharmacologic methods of labor induction. confirms the indications for induction and Bishop Score. and the impact on nursing. nipple stimulation. and providers such as midwives and physicians should be notified if such use has taken place. • Hospital procedures should be in place for resolution of cases in which the nurse feels the best interests of the patient who is being induced are not being addressed. Some women (15%) wanted to control the timing of the birth (Declercq et al. • Natural methods of induction. with or without adjuvant use of herbal preparations. The rate of labor induction has risen dramatically during the past decade.. obstetrical care. especially the risks and benefits for themselves and their babies. and alternatives of induced labor. such as acupuncture. which reinforces the fact that more education for pregnant women about labor induction is required.2001). Although traditional. and medicolegal issues expose women and their babies to medications and interventions with the potential for serious side effects and increased risk of infection. 39% went into labor as a result of one or both of those interventions (58% who attempted self-induction wanted to get the pregnancy over with. 2006). staffing concerns. consideration should be given to obtaining a formal consent and a second opinion before labor is induced. Suggested Clinical Implications • It is unknown whether women and families would desire elective induction if they understood the potency and possible side effects of the medications. Options such as expectant management with antenatal testing should be offered as a reasonable alternative and supported if the patient desires to avoid other interventions. A sample consent form for cervical ripening and labor induction can be found in the Association of Women’s Health. Because some of the herbs can actually potentiate the pharmacological agents that might be used in a hospital to induce labor. The women also stated that caregiver concern about the baby growing too large contributed to Women require more education about all aspects of labor induction. • The desire to rush the process of labor and birth for convenience. Obstetric and Neonatal Nurses (AWHONN) practice monograph and ensures gestational age confirmation. but there are no data on the possibility of damage to the cervix by laminaria insertion or Foley catheter balloons. Nurses should ask patients who are being admitted to L&D units if they have used herbal methods to start their labors. midwifery. Of the women who experienced medical or self-attempts at induction. More study is needed to determine their long-term safety.. All discussions should be documented in the medical record. benefits.

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