Neonatal Outcomes

Elective Induction vs. Spontaneous Onset of Labor

Amanda Dycus Ashley Harrell Alyson Odermann Janet Stewart College of Nursing University of Oklahoma - 2010

PICO Question
How does elective induction vs. spontaneous onset of labor impact neonatal outcomes for full-term infants, 38 to < 41 weeks gestation?

Identification of the Problem

The rate for induction of labor has increased 125% from 1989 to 2002 with two-thirds of all U.S. labor inductions initiated for nonmedical reasons. Significant controversy surrounds the practice of elective induction and its increased use (Wilson, 2007).

Identification of the Problem

Elective induction can increase the risk of iatrogenic prematurity, arrested labor, dysfunctional labor, uterine rupture, cesarean rates, and adverse maternal and neonatal outcomes (Beebe, et al, 2007).

Identification of the Problem

Cost:
Increased rates of cesarean delivery, and adverse maternal and neonatal outcomes associated with elective induction also impact the total cost of obstetric services. Vaginal - $7,090 Cesarean - $11,450 Newborn Nursery Stay - $1,500 - $4,000 NICU (per day) - $1,000 - $2,500

Definitions
Apgar Score a scale used to assess the health of a newborn at one and five minutes after birth. Elective Induction initiation of labor performed in the absence of any medical indication. Expectant Management expectant management allows for the progression of the pregnancy to a future gestational age without medical intervention. Iatrogenic Prematurity the birth of a pre-term and/or low-weight infant as the result of medical intervention. Spontaneous Labor the natural onset and progression of labor without any medical or pharmacological intervention. Unfavorable Cervix a Bishops Score of less than 5 indicates an unfavorable cervix, which may complicate induction of labor, require the use of cervical ripening agents or may increase the risk for cesarean delivery.

What has been done to study the problem? While studies have been done regarding adverse neonatal outcomes with pre-term and post-term infants, little study has been done regarding the impact of elective induction on full-term infants (Clark, et al, 2009).

Review of the Literature

Systematic review: Elective induction of labor vs. expectant management of pregnancy (Caughey, et al, 2009). Maternal & neonatal outcomes by labor onset type and gestational age (Bailit, et al, 2010). Immediate neonatal outcomes after elective induction of labor (Beebe, et al, 2007). Neonatal & maternal outcomes associated with elective term delivery (Clark, et al, 2009). Elective induction vs. spontaneous labor: Associations and outcomes (Glantz, 2005). Assessing the effects of age, gestation, socioeconomic status, & ethnicity on labor inductions (Wilson, 2007).

Literature Review
Caughey, Sundaram, Kaimal, et al (2009) Systematic review consisting of a review of 36 research articles, 11 randomized control trials (RCTs) & 25 observational studies. Findings: Expectant management was associated with a higher increased risk for cesarean delivery than elective induction. Women expectantly managed had an increased incidence of meconium-stained amniotic fluid compared to those undergoing elective induction. No difference was found among women undergoing elective induction vs. expectant management for increased neonatal risk for transient tachypnea, sepsis, seizures, hypoglycemia, jaundice, polycythemia or low birth weight. Evidence for other neonatal outcomes regarding neonatal death, neonatal acidemia, fetal distress, fetal respiratory distress syndrome, and initiation of successful breastfeeding were insufficient and did not allow for development of conclusions.

Literature Review
Caughey, Sundaram, Kaimal, et al (2009) (Cont)
Limitations: No recent RCTs of elective induction of labor at < 41 weeks of gestation & two studies that were conducted were of poor quality and not generalizable to current practice. Conclusion: RCTs indicate that elective induction at or beyond 41 weeks of gestation is associated with a decreased risk of cesarean delivery and meconium-stained amniotic fluid. There are concerns regarding the translation of findings and further research is suggested regarding elective induction in settings where obstetric care is provided.

Literature Review
Bailit, Reddy, et al (2010)
Electronic medical records data search of 10 U.S. facilities reviewing statistics on 115,528 deliveries from 2002-2008. NICU admissions and sepsis rates decreased with each week of gestational age until 39 weeks. Neonatal outcomes are gestational age dependent regardless of labor onset type. Elective induction of labor was associated with a lower risk of ventilator use, sepsis & NICU admissions compared to spontaneous labor. Risk of hysterectomy at term was 3.21% with elective induction vs. 1.16% for medically indicated induction vs. 6.57% with csection without labor compared to spontaneous onset of labor. Unlabored cesarean deliveries had higher rates of maternal ICU admission rates, higher rates of endometritis & the highest risk for hysterectomy, in addition to poor neonatal outcomes. Conclusion: Babies delivered by elective induction have better neonatal outcomes, but elective induction should not be offered prior to 39 weeks of gestation due to fetal concerns.

Literature Review
Beebe, Beaty & Rayburn (2007)
Retrospective cohort study performed at two hospitals reviewing women undergoing elective induction at term (39 weeks, 0 days to 41 weeks, 0 days of gestation) with a viable, single fetus in cephalic presentation during a six month time period. Study population included 364 women undergoing induction of labor, 200 of which were electively induced. The odds of 1-minute APGAR scores being 3 were increased for elective inductions (4.5% for elective induction vs. 1.2% for medically indicated induction vs. 0.8% for spontaneous onset of labor. Elective induction was not associated with fetal intolerance of labor, a low 5-minute APGAR score or the need for admission to NICU units. Elective induction resulted in a cesarean delivery rate of 10.2%.

Literature Review
Clark, Miller, & Belfort, et al (2009)
Prospective observational study conducted in 27 hospitals for a 3-month time period during 2007. Of 17,794 deliveries, 71% were planned elective inductions 17.8% of those planned deliveries were electively induced without medical indication at 37-38 weeks gestation. 8% of the infants delivered electively at 38-39 weeks required NICU admission for an average of 4.5 days compared with 4.6% of infants delivered at 39 weeks or beyond. Cesarean delivery rate of women undergoing elective induction was not influenced by gestational age, but was influenced by initial cervical dilatation and parity, ranging from 0% for parous women induced at 5 cm or greater to 50% for nulliparous women at 0 cm. Elective delivery prior to 39 weeks of gestation is associated with significant neonatal morbidity. Initial cervical dilatation is associated with increased risk for cesarean delivery among women undergoing induction of labor.

Literature Review
Glantz (2005)
Observational study of low-risk laboring women in Lake Fingers, NY. Spontaneously laboring women (n=10,608) compared to women undergoing elective induction (n=1,241). Elective induction is associated with increased chance of intrapartum interventions and adverse maternal outcomes. Maternal length of stay was 0.34 days longer with induction than with spontaneous onset of labor. Infant outcomes were unaffected.

Literature Review
Wilson (2007)
Retrospective descriptive correlational design study of 1,325 women scheduled for induction at a large hospital in a southwestern U.S. state from January 1 - December 31, 2005. Elective induction for primiparous women increased the risk for cesarean delivery by 50%. Mothers educational level was a significant predictor for cesarean delivery with multiparous women being induced. Ethnicity & socioeconomic status had no effect on the cesarean rate for multiparous or primiparous women, regardless of reason for induction. Primiparous women should be advised that elective induction may increase their risk for cesarean delivery especially for women of advanced maternal age.

Summary of Literature
Neonatal outcomes are gestational age dependent regardless of labor onset type (Bailit, et al, 2010). Elective induction of labor was associated with a lower risk of ventilator use, sepsis, and NICU admissions compared to spontaneous labor (Bailit, et al, 2010). Elective induction was associated with an increased rate of hysterectomy and cesarean delivery (Bailit, et al, 2010). Elective induction prior to 39 weeks is inappropriate (Clark, et al, 2009).

Summary of Literature
Elective induction is associated with a greater likelihood of intrapartum interventions and adverse maternal outcomes (Glantz, 2005). NICU admissions and sepsis improved with each week of gestational age until 39 weeks (Bailit, et al, 2010). RCTs indicate that elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid (Caughey, et al, 2009). Unlabored cesarean deliveries had higher rates of maternal ICU admissions, higher rates of endometritis and the highest risk for hysterectomy in addition to poor neonatal outcomes (Bailit, et al, 2010).

Summary of Literature
Pros:
Elective induction is convenient for the patient and physician. Elective induction is considered to be relatively safe. Elective induction reduces morbidity associated with prolonged gestation.

Cons:
Elective induction is associated with a higher risk of cesarean delivery and hysterectomy. Elective induction may increase the risk of delivering an infant prematurely. Elective induction may increase length of hospital stay and its associated cost to the patient.

Recommended Protocol
We recommend following the guidelines developed by the American College of Obstetricians & Gynecologists (ACOG) and suggest that elective induction should not be performed prior to 39 weeks of gestation. In addition, women should be adequately counseled regarding the risks of adverse maternal outcomes such as the increased risk for cesarean delivery or hysterectomy.

Rationale for Protocol

Since the advantages of elective induction are primarily due to social or logistical reasons instead of medical, it can be argued that elective inductions should not be offered due to maternal risk of complications (Bailit, et al, 2010). Current research data validates the importance of adhering to ACOG guidelines that restrict the use of elective induction to women at or beyond 39 weeks of gestation (Clark, et al, 2009).

Evaluating Change
Evaluate facilitys guidelines regarding elective
induction. Chart reviews to determine rate of elective induction for individual facility. Chart reviews to assess maternal and neonatal outcomes for elective inductions. Assess expectant mothers knowledge regarding risks associated with elective induction. Assess physicians knowledge of maternal and neonatal outcomes associated with elective induction and their willingness to follow ACOG guidelines regarding the appropriate use of elective induction.

Suggestions for Further Study

Literature reviewed suggests that elective induction should not be compared with spontaneous onset of labor. Instead, future studies should compare the outcomes of elective induction with the outcomes of expectant management of pregnancy. In addition, further study should be conducted to accurately determine the impact of elective induction on full-term infants as most of the current data focuses on pre-term or post-term deliveries.

New Research Questions

How does elective induction vs. expectant management impact neonatal outcomes for full-term infants, 38 to < 41 weeks gestation? Do different cervical ripening agents change the outcome of elective induction for the mother or the infant? What role can nurses play in decreasing the rate of elective induction?

References
Bailit, J. L., Gregory, K. D., Reddy, U. M., Gonzales-Quintero, V. H., Hibbard, J. U., Ramirez, M.M., et al. (2010). Maternal and neonatal outcomes by labor onset type and gestational age. American Journal of Obstetrics & Gynecology, 202(3), 245.e1-245.e12. Beebe, L., Beaty, C., & Rayburn, W. (2007). Immediate neonatal outcomes after elective induction of labor. The Journal of Reproductive Medicine, 52(3), 173-175. Caughey, A. B., Sundaram, V., Kaimal, A. J., Gienger, A., Cheng, Y. W., McDonald, K.M., et al. (2009). Systematic review: Elective induction of labor versus expectant management of pregnancy. Annals of Internal Medicine, 151(4), 252-263.

References
Clark, S. L., Miller, D. D., Belfort, M. A., Dildy, G. A., Frye, D. K., & Meyers, J. A. (2009). Neonatal and maternal outcomes associated with elective term delivery. American Journal of Obstetrics & Gynecology, 200(2), 156.e1-156.e4. Glantz, J.C. (2005). Elective induction vs. spontaneous labor: Associations and outcomes. Journal of Reproductive Medicine, 50(4), 235-240. Wilson, B.L. (2007). Assessing the effects of age, gestation, socioeconomic status, and ethnicity on labor inductions. Journal of Nursing Scholarship, 39(3), 208-213.