Complications of labor induction among multiparous women in a community-based hospital system

Prevalence and factors associated with failed induction of labor in Worabe Comprehensive Specialized Hospital, Southern Ethiopia

Background

Induction of labor is one of the most used obstetric procedures in the world. It is performed in around 20% of all pregnancies. Failed induction of labor, on the other hand, has been associated with poorer mother and newborn health outcomes. Besides, there is a scarcity of data on the current burden and drivers. Therefore, this study aimed to assess the prevalence and factors associated with failed induction in Worabe Comprehensive Specialized Hospital, Southern Ethiopia.

Methods

A retrospective cross-sectional study was conducted on medical records of mothers who delivered through induction of labor during September 1^st, 2018 to August 30^th, 2020. The samples were collected using a systematic sampling technique. The data was extracted using a checklist. Data were entered into EpiData (version 3.1) and analyzed using SPSS (version 24). Multivariable logistic regression analyses were used to decide the association of explanatory variables with the outcome variable. Odds ratio with their 95% CI were calculated to identify the presence and strength of an association. A p-value of < 0.05 was used to declare statistical significance.

Results

In this study, the prevalence of failed induction was observed to be 22.2%. The associated factors included rural residence (AOR = 5.7, 95% CI: 3.12–11.02), primiparity (AOR = 8.4, 95% CI: 2.72–22.36) and unfavourable bishop score (AOR = 5.9, 95% CI: 4.52–16.12).

Conclusions

In comparison to the rate reported in developed countries, the study area had a high rate of failed induction. Being rural residence, primiparity and unfavourable bishop score were the associated factors of failed induction. Therefore, to reduce of the rate of failed induction, health care practitioners should analyze cervical status (using Bishop Score) to decide the possibility of successful induction, with a focus on associated factors like parity.

Induction of labor or expectant management? Birth outcomes for nulliparous individuals choosing midwifery care

BACKGROUND

Induction of labor (IOL) has been studied as a strategy to reduce rates of cesarean birth (CB). Midwifery care models are also associated with lower CB rates, even considering that midwives perform fewer IOLs. In this study, we examined childbirth outcomes among individuals undergoing IOL in certified nurse-midwifery (CNM) care as compared to two categories of expectant management (EM).

METHODS

Data were from two CNM practices in the United States (2007-2018). The sample was limited to term nulliparous, nondiabetic, singleton, vertex pregnancies. Individuals having an IOL in each week of gestation (37th, 38th, etc) were compared with those having EM. Two methods for defining EM were considered as each method when used alone limits interpretation. Inclusive EM included all births starting in the same week as IOL. The exclusive EM group was comprised of all births occurring in the next gestational age week relative to the IOL cases (ie, 39th week IOL versus all births occurring at 40 weeks or later). Adjusted regression models were used to examine differences in CB by IOL versus EM (inclusive or exclusive) at each week of gestation.

RESULTS

Among 4057 CNM-attended pregnancies, the overall rate of IOL was 28.9% (95% CI 27.5%-30.3%) and CB was 19.4% (95% CI 18.1%-20.6%). Most IOLs involved obstetric indications. CB rates did not differ by IOL versus inclusive EM when performed between 37 and 40 weeks, though post hoc power calculations indicate these comparisons were low-powered. In multivarable models, IOL in the 40th week was associated with lower odds for CB versus exclusive EM definition (ie, births occurring at 41 0/7 weeks or later, OR (95% CI) = 0.57 (0.36-0.90)). This finding is explained by the large increase in CB rates after IOL during the 41st week (34.3%, up from 21.9% in the 40th week). Furthermore, the adjusted odds for CB in the 41st week were 55% higher relative to inclusive EM (all labors 41st week and later), OR (95% CI) = 1.55(1.11-2.15). Neonatal outcomes (aside from macrosomia) did not differ by IOL/EM at any gestational age.

DISCUSSION

Outcomes for nulliparous individuals having IOL or EM in the context of a midwifery model of care include low overall use of CB and low frequency of IOL before 41 weeks. In this model, IOL in the 40th week may lower CB odds, especially in comparison to those who do not have spontaneous labor and later undergo an IOL in the 41st week.

Factors and outcomes associated with the induction of labor in referral hospitals of Amhara regional state, Ethiopia: a multicenter study

BACKGROUND

Induction of labor is an artificial initiation of uterine contractions after fetal viability with the aim of vaginal delivery prior to the onset of spontaneous labor. Prevalence of induction of labor is increasing worldwide with subsequent increase in failure rate. However, there is limited evidence on labor induction in Ethiopia. Therefore, this study was aimed at assessing the prevalence and associated factors of failed induction of labor among women undergoing induction of labor at referral hospitals of Amhara national regional state, Ethiopia, 2016.

METHOD

A multicenter cross-sectional study was conducted at referral hospitals found in Amhara national regional state from February 01 to September 30, 2016. Multistage sampling technique was employed to select a total of 484 women who underwent labor induction. Pre-tested structured questionnaires and checklists were used to collect the data. Data were entered into EPI info version 7 and analyzed using SPSS version 20 software. Stepwise Binary Logistic regression model was fitted to identify factors associated with failed induction of labor. The level of significance was determined based on the adjusted odds ratio with 95% confidence interval at the p-value of ≤0.05.

RESULT

The prevalence of failed induction of labor among women undergoing induction of labor was 31.4% (95% CI: 27.0, 36.0). Failed induction of labor was independently predicted by a Bishop score of ≤5 (AOR = 2.1; 95% CI: 1.3, 3.6), prolonged latent first stage of labor (AOR = 2.0; 95% CI: 1.2, 3.5), induction with oxytocin alone (AOR = 4.2; 95% CI: 2.2, 8.1), nulliparity (ARO = 1.9; 95% CI: 1.2, 2.9), post term pregnancy (AOR = 4.1; 95% CI: 1.8, 9.3) and hypertensive disorder of pregnancy (AOR = 2.4; 95% CI: 1.5, 5.1).

CONCLUSION

Failed induction of labor was high in the study area compared to the reports of previous studies done in Ethiopia. The majority of the determinants of failed induction of labor were connected with unjustifiable and inconsistent indication of induction of labor. Thus, preparing standardized practical guidelines and preventing unjustifiable case selection may help reduce the current high failure rates.

Prevalence, outcomes and associated factors of labor induction among women delivered at public hospitals of MEKELLE town-(a hospital based cross sectional study)

BACKGROUND

Induction of labor refers to iatrogenic stimulation of uterine contractions before the onset of spontaneous labor as a therapeutic option when benefits of expeditious delivery outweigh the risks of continuing the pregnancy. This research was to study the prevalence, outcomes and associated factors of labor induction among women delivered at Ayder comprehensive specialized hospital and Mekelle general hospital in Mekelle town, Tigray, North Ethiopia.

METHODS

A hospital based cross sectional study was conducted on 346 laboring mothers who delivered after induction of labor, from January 1st, to July 31st, 2017. Using structured questionnaire and quota sampling techniques, all eligible participants were immediately enrolled upon admission until the desired sample size was achieved. SPSS windows version 23.0 was used for analysis and both descriptive and inferential statistics were conducted; statistical significance to declare relationship between the dependent and independent variables was set at p < 0.05.

RESULTS

Total of 3834 women delivered at the study area out of which 346 were induced making (9%) prevalence of induction. Out of this, 244 (70.5%) delivered vaginally, 19 (5.5%) were instrumental deliveries and 83 (24%) by Cesarean section, induction was successful in 263 (76%) while the failure rate was 25 (7.2%). All who failed induction (25) were delivered by cesarean section making a 3.3% contribution of failed induction into the overall rate of the institutions cesarean deliveries during the study period. Prolonged rupture of membranes was the commonest indication and Bishop's score after cervical ripening significantly predicted the success of induction [AOR = 8.150, 95% CI = (1.265, 52.526)].

CONCLUSION

Our prevalence of labor induction is very low compared to the rate of other institutions in developed countries, rate of successful inductions (76%) is slightly higher than the rate of similar institutions in Ethiopia but comparable to the regional rates while failed induction is very low in comparison to both local and regional institutions. Bishop's score significantly predicted the success of induction.

Induction of labor using one dose vs multiple doses of misoprostol: a randomized controlled trial

BACKGROUND

Misoprostol is a common agent that is used to ripen the cervix and induce labor, yet there is no clear evidence of the optimal number of doses needed to achieve a higher rate of vaginal delivery.

OBJECTIVE

Our primary objective was to compare the rate of vaginal delivery within 24 hours between a 1-dose and a multiple-dose regimen of misoprostol for the induction of labor.

STUDY DESIGN

A randomized controlled trial was conducted from March 2016 to March 2017 that compared a single dose to up to 4 doses of misoprostol. Randomization was stratified by parity. Women with a singleton pregnancy ≥37 weeks gestation with intact membranes who had been admitted for labor induction with a Bishop score ≤6 were included. Our primary outcome was the rate of vaginal delivery within 24 hours. Secondary outcomes included time to vaginal delivery, cesarean delivery rate, and maternal and neonatal morbidity. Based on a power of 80%, an alpha of .05, and the assumption that 50% of women in the multiple-misoprostol group would deliver vaginally in 24 hours, a sample size of 220 patients was needed to detect a 20% increase in vaginal delivery rate within 24 hours in the 1-misoprostol group. Continuous variables were compared with the use of the Mann-Whitney test. Categoric variables were compared with the use of the Fisher's exact test. Probability values <.05 were considered statistically significant.

RESULTS

Two hundred fifty women were assigned randomly. Demographics and clinical characteristics were similar between groups. In the univariate analysis, there was no difference in the rate of vaginal delivery within 24 hours between the 1-misoprostol group and the multiple-dose group (41.7% vs 44.7%, respectively; P=.698) or time to vaginal delivery (1187 min vs 1321 min, respectively; P=.202). The 1-misoprostol group had a greater cesarean delivery rate (35.8% vs 22.8%; P=.034). In a Poisson regression that controlled for Bishop score before the initiation of oxytocin, parity, gestational age, body mass index, estimated fetal weight, artificial rupture of membrane at <6 cm, and Foley balloon placement, the treatment group was no longer associated with cesarean delivery rate. Instead, a Bishop score of <4 before the initiation of oxytocin and nulliparity were associated significantly with cesarean delivery rate.

CONCLUSION

In this first randomized controlled trial in the literature to compare a single with a multiple dosing of misoprostol, we found that the 1-dose regimen is an acceptable alternative for the induction for labor, especially for multiparous women and for patients with a Bishop score >4 after the first dose.

The effect of induction method in twin pregnancies: a secondary analysis for the twin birth study

Background

This secondary analysis for the Twin Birth Study, an international, multicenter trial, aimed to compare the cesarean section rates and safety between methods of induction of labor in twin pregnancies.

Methods

Women with twin pregnancies where the first twin was in a cephalic presentation and who presented for labor induction, were non-randomly assigned to receive prostaglandin or amniotomy and/or oxytocin. Main outcome measures were the rates of unplanned cesarean section and neonatal and maternal mortality or serious morbidity.

Results

153 (41.5%) were induced by prostaglandin (prostaglandin group) and 215 (58.5%) were induced by amniotomy and/or oxytocin alone (no prostaglandin group). Induction using prostaglandin was more common in countries with a low perinatal mortality rate <10/1000 (45.7 versus 32.5%, p = 0.02). Cesarean section rates were similar in the two groups: 62/153 (40.5%) in the prostaglandin group and 87/215 (40.5%) in the no prostaglandin group (odds ratio 1, 95% CI 0.65-1.5). Nulliparity, late maternal age, non-cephalic presentation of twin B and high country’s perinatal mortality rate were found to be independently associated with the induction to end with an unplanned cesarean section. There were no significant differences between groups with respect to maternal or neonatal adverse outcomes.

Conclusions

The need for cervical ripening by prostaglandin had no effect on the incidence of cesarean delivery or an abnormal outcome. There is a significant risk of unplanned cesarean section independent of chosen induction method.

Trial registration

This trial was registered at the International Standard Randomized Controlled Trial Register (identifier ISRCTN74420086; December 9, 2003) and retrospectively registered at the www.clinicaltrials.gov (identifier NCT 00187369; September 12, 2005).

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1201-8) contains supplementary material, which is available to authorized users.

Bishop scoring: Perceived benefits of using in labour induction by Turkish midwives

It is not always possible to achieve a successful induction. Bishop scoring system is an efficient method used in determining whether the induction will be effective or not. The aim of this study was to train midwives on the benefits and use of the Bishop scoring system and to minimize the unnecessary use of induction. This study was conducted as pretest-posttest quasi-experimental design. This study was conducted in a maternity hospital in Erzurum between 01 February and 31 July 2012. In the study, the midwives received training on the use of the Bishop scoring system, and changes in their knowledge levels and application during practice of induction were then evaluated. While only 20% of midwives were using the Bishop score before the training, 56.7% started to use this tool after the training. Comparing the examinations performed on pregnant women by the midwives in the pre-induction period before and after the training, the mean of the Bishop score changed from 7.26 to 9.68 after the training. It was determined that the training could increase the knowledge levels of midwives regarding the Bishop scoring system and their attention paid to the Bishop scoring system in the practice of induction.

Definition of Failed Induction of Labor and Its Predictive Factors: Two Unsolved Issues of an Everyday Clinical Situation

OBJECTIVE

The objectives of this review were to identify the predictive factors of induction of labor (IOL) failure or success as well as to highlight the current heterogeneity regarding the definition and diagnosis of failed IOL.

MATERIALS AND METHODS

Only studies in which the main or secondary outcome was failed IOL, defined as not entering the active phase of labor after 24 h of prostaglandin administration ± 12 h of oxytocin infusion, were included in the review. The data collected were: study design, definition of failed IOL, induction method, IOL indications, failed IOL rate, cesarean section because of failed IOL and predictors of failed IOL.

RESULTS

The database search detected 507 publications. The main reason for exclusion was that the primary or secondary outcomes were not the predetermined definition of failed IOL (not achieving active phase of labor). Finally, 7 studies were eligible. The main predictive factors identified in the review were cervical status, evaluated by the Bishop score or cervical length.

DISCUSSION

Failed IOL should be defined as the inability to achieve the active phase of labor, considering that the definition of IOL is to enter the active phase of labor. A universal definition of failed IOL is an essential requisite to analyze and obtain solid results and conclusions on this issue. An important finding of this review is that only 7 of all the studies reviewed assessed achieving the active phase of labor as a primary or secondary IOL outcome. Another conclusion is that cervical status remains the most important predictor of IOL outcome, although the value of the parameters explored up to now is limited. To find or develop predictive tools to identify those women exposed to IOL who may not reach the active phase of labor is crucial to minimize the risks and costs associated with IOL failure while opening a great opportunity for investigation. Therefore, other predictive tools should be studied in order to improve IOL outcome in terms of health and economic burden.

Investigating racial differences in risk factors for primary cesarean delivery

OBJECTIVE

The objective of the study was to investigate differences in sociodemographic, medical, and obstetric risk factors for primary cesarean delivery between black and white women.

STUDY DESIGN

We conducted a retrospective cohort study among 25,251 black and white women delivering a live, singleton infant with vertex presentation at a large, regional hospital between 2004 and 2010. Demographic and clinical data were derived from electronic hospital records. Differences in risk factors for primary cesarean delivery were analyzed using a modified Poisson regression approach stratified by race and parity.

RESULTS

Black and white women had a primary cesarean delivery rate of 24.7% and 22.2%, respectively (P < .001). Black women had an increased risk of cesarean delivery after adjusting for sociodemographic and clinical risk factors (adjusted relative risk [RR], 1.23; 95% confidence interval [CI], 1.17-1.29). Among nulliparas, labor induction had a greater effect on cesarean delivery for black women (adjusted RR, 1.32; 95% CI, 1.20-1.44) than for white women (adjusted RR, 1.13; 95% CI, 1.07-1.20). Among multiparas, labor induction reduced the risk of cesarean delivery for white women (adjusted RR, 0.63; 95% CI, 0.55-0.72), whereas no association was observed for black women (adjusted RR, 1.08; 95% CI, 0.92-1.28). Advanced maternal age was a stronger risk factor for black women (adjusted RR, 1.72; 95% CI, 1.43-2.08) than for white women (adjusted RR, 1.30; 95% CI, 1.11-1.52) among multiparas only. Among nulliparas, delivery at 37-38 weeks' gestation reduced the risk of cesarean delivery for black women (adjusted RR, 0.82; 95% CI, 0.73-0.92), whereas no association was observed for white women (adjusted RR, 0.96; 95% CI, 0.90-1.04).

CONCLUSION

Labor induction, among nulliparous women, and advanced maternal age, among multiparous women, are stronger risk factors for primary cesarean delivery for black women than for white women.

Is induction of labor risky for twins compare to singleton pregnancies?

OBJECTIVE

The aim of this study was to investigate whether induction of labor in twin pregnancies is associated with higher rates of maternal complications as compared to singletons.

METHOD

A retrospective population-based study was conducted to compare maternal complications following induction of labor in twin pregnancies and singletons at Soroka University Medical Center, Be'er-Sheva, Israel, between 1988 and 2010. Stratified analysis using a multiple logistic regression model was performed to control for confounders.

RESULTS

The study population included 25 913 patients following induction of labor, of these 191 (0.73%) were in twin pregnancies. Induction of labor in twin pregnancies was not associated with adverse maternal outcomes such as cervical tears, third degree perineal tears, uterine rupture, peripartum hysterectomy, post-partum hemorrhage or retained placenta. However, labor induction in twins was significantly associated with cesarean deliveries (31.2% versus 17.1%; p < 0.001). Using a multivariable analysis controlling for confounders, induction at twins was an independent risk factor for cesarean delivery (CD; adjusted OR = 2.2, 95% CI 1.7-2.7, p < 0.001).

CONCLUSION

Induction of labor in twin pregnancies does not increase the risk for maternal complications. However, it is an independent risk factor for CD.

Risk of caesarean section after induced labour: do hospitals make a difference?

Background

There is a well-known relationship between induced labour and caesarean rates. However, it remains unknown whether this relationship reflects the impact of more complex obstetric conditions or the variability in obstetric practices. We sought to quantify the independent role of the hospital as a variable that can influence the occurrence of caesarean section after induced labour.

Methods

As part of the Portuguese Generation XXI birth cohort, we evaluated 2041 consecutive women who underwent singleton pregnancies with labour induction, at five public level III obstetric units (April 2005-August 2006). The indications for induction were classified according to the guidelines of the American and the Royal Colleges of Obstetricians and Gynaecologists. Poisson regression models were adjusted to estimate the association between the hospital and surgical delivery after induction. Crude and adjusted prevalence ratios (PR) and a 95% confidence interval (95% CI) were computed.

Results

The proportion of women who were induced without formal clinical indications varied among hospitals from 20.3% to 45.5% (p < 0.001). After adjusting for confounders, the risk of undergoing a caesarean section after induced labour remained significantly different between the hospitals, for the cases in which there was no evident indication for induction [the highest PR reaching 1.86 (95% CI, 1.23–2.82)] and also when at least one such indication was present [1.53 (95% CI, 1.12–2.10)]. This pattern was also observed among the primiparous cephalic term induced women [the highest PR reaching 2.06 (95% CI, 1.23–2.82) when there was no evident indication for induction and 1.61 (95% CI, 1.11–2.34) when at least one such indication was present].

Conclusions

Caesarean section after induced labour varied significantly across hospitals where similar outcomes were expected. The effect was more evident when the induction was not based on the unequivocal presence of commonly accepted indications.

Induction of labour with a Foley catheter or oral misoprostol at term: the PROBAAT-II study, a multicentre randomised controlled trial

Background

Induction of labour is a common obstetric procedure. At present, different methods are used for induction of labour in women with an unfavourable cervix. Recently, we showed that in term women with an unfavorable cervix the use of a Foley catheter in comparison with vaginal Prostaglandin E2 gel, results in a comparable vaginal delivery rate. A meta-analysis on the subject indicated lower rates of hyperstimulation, and probably as a sequel fewer cases of postpartum haemorrhage. Misoprostol (PgE1) is another type of prostaglandin frequently used for labour induction, recommended by the international federation of gynaecology and obstetrics (FIGO). Misoprostol can be administered by vaginal, rectal and oral route. There is evidence that oral administration results in less asphyxia and hyperstimulation than vaginal administration. At present, valid comparisons between oral misoprostol and Foley catheter are lacking. Therefore, we propose a randomised controlled trial comparing Foley catheter to oral misoprostol in order to assess safety and cost-effectiveness.

Methods/Design

We plan a multicentre, randomised, controlled, open-label clinical trial among term pregnant women with a vital singleton in cephalic presentation, unfavorable cervix, intact membranes and an indication for induction of labour. After informed consent, women will be randomly allocated by a webbased randomisation system to transcervical Foley catheter or oral misoprostol (50 mcg every 4 hours). The primary outcome will be a composite of complications of uterine hyperstimulation, i.e. post partum haemorrhage and asphyxia. Secondary outcomes are mode of delivery, maternal and neonatal morbidity, costs and women’s preference. Serious adverse events such as severe maternal or neonatal morbitity or mortality will be monitored and reported to an independent data safety monitory board. With a sample size of 1860 women we will be able to demonstrate a 5% non-inferiority of the Foley catheter as compared to misoprostol for the composite outcome.

Discussion

Worldwide, various methods are being used for labour induction. Results of the proposed trial will contribute to the answer which method of induction of labour is most safe, cost-effective, and patient friendly and will help to construct evidence based guidelines.

Trial registration

The Netherlands Trial Register NTR3466

Risk factors associated with epidural use

Background

Identify variables associated with intrapartum epidural use.

Methods

Odds ratios were calculated to quantify associations between selected variables and epidural use using a population-based case-control study of Washington State birth certificate data from 2009.

Results

Non-Whites had 10 - 45% lower odds of epidural use relative to Whites. Foreign-born women had 25 - 45% lower odds of epidural use compared to their US-born counterparts, except for Asians. Women who smoked or induced labor had higher roughly 2-fold higher odds of epidural use compared with non-smokers or women giving birth spontaneously, respectively. Women without a high school diploma or equivalent had lower odds of epidural use relative to those who graduated. Delivering at perinatal units, rural hospitals, or non-profit hospitals had ~50% lower odds of epidural use compared with secondary/teritiary perinatal units, urban hospitals or for-profit hospitals, respectively. 

Conclusion

Several individual and health service-related variables were associated with epidural use. These findings elucidate the clinical relevance of epidural use, and dispariaties in its utilization and in quality of care during delivery.

Keywords

Epidural use; Foreign birth; Labor; Racial disparities

Elective induction versus spontaneous labour in Latin America

OBJECTIVE

To assess the frequency of elective induction of labour and its determinants in selected Latin America countries; quantify success in attaining vaginal delivery, and compare rates of caesarean and adverse maternal and perinatal outcomes after elective induction versus spontaneous labour in low-risk pregnancies.

METHODS

Of 37,444 deliveries in women with low-risk pregnancies, 1847 (4.9%) were electively induced. The factors associated with adverse maternal and perinatal outcomes among cases of spontaneous and induced onset of labour were compared. Odds ratios for factors potentially associated with adverse outcomes were calculated, as were the relative risks of having an adverse maternal or perinatal outcome (both with their 95% confidence intervals). Adjustment using multiple logistic regression models followed these analyses.

FINDINGS

Of 11,077 cases of induced labour, 1847 (16.7%) were elective. Elective inductions occurred in 4.9% of women with low-risk pregnancies (37,444). Oxytocin was the most common method used (83% of cases), either alone or combined with another. Of induced deliveries, 88.2% were vaginal. The most common maternal adverse events were: (i) a higher postpartum need for uterotonic drugs, (ii) a nearly threefold risk of admission to the intensive care unit; (iii) a fivefold risk of postpartum hysterectomy, and (iv) an increased need for anaesthesia/analgesia. Perinatal outcomes were satisfactory except for a 22% higher risk of delayed breastfeeding (i.e. initiation between 1 hour and 7 days postpartum).

CONCLUSION

Caution is mandatory when indicating elective labour induction because the increased risk of maternal and perinatal adverse outcomes is not outweighed by clear benefits.

Labor induction process improvement: a patient quality-of-care initiative

OBJECTIVE

To examine the effects that medical staff education and a new process for scheduling inductions had on decreasing inappropriate inductions.

METHODS

At our institution in 2004, guidelines were developed and shared with the medical staff and reinforced in 2005. The guidelines for elective induction required patients to have completed 39 weeks of gestation and to have a Bishop score of at least 8 for nulliparas and 6 for multiparas. In 2006, the induction scheduling process was changed and the guidelines were strictly enforced. All scheduled inductions during the same 3-month time period (June through August) in 2004 (n=533) and 2005 (n=454) and during a 13-month period from November 2006 to December 2007 (n=1,806) were compared. Outcomes included elective inductions less than 39 weeks, cesarean birth rate for elective inductions among nulliparas, and the overall induction rate.

RESULTS

From 2004-2007, the overall induction rate dropped from 24.9% to 16.6%, a 33% reduction(P<.001); the elective induction rate dropped from 9.1% to 6.4%, a 30% reduction (P<.001); the percentage of elective inductions before 39 weeks of gestation dropped from 11.8% to 4.3%, a decrease of 64% (P<.001); and the frequency of cesarean delivery among nulliparas undergoing elective induction dropped from 34.5% to 13.8%, a decrease of 60%. (P=.01).

CONCLUSION

Medical staff education and the development and enforcement of induction guidelines contributed to a decrease in inappropriate inductions, a lower cesarean birth rate for electively induced nulliparas, and a lower elective and overall induction rate.

LEVEL OF EVIDENCE

III.

Provider documentation and elective induction of labor: a 6-month experience at a university medical center

OBJECTIVE

This retrospective study investigated the documentation of clinical history that assured fetal lung maturity, presentation part, and gestational age by 3 provider groups (university obstetricians, family practice, and private obstetricians) before the elective induction of labor.

STUDY DESIGN

This study was conducted at a large university-based medical center. All labor/delivery admissions (n = 1297) and all elective inductions of labor (n = 268) were reviewed. The variables that were compared included provider group vs delivery percentages, induction rates, and cesarean deliveries.

RESULTS

Nine percent of elective inductions occurred before 39 weeks of gestation; 12.7% of the inductions lacked documentation of the presenting part; 17.6% of the inductions failed to meet any commonly accepted screening criteria that assured fetal lung maturity. Rates of elective inductions varied between 16% and 31% when the 3 groups of providers were compared (P < .0001).

CONCLUSION

Adequate documentation is lacking in electively induced patients. A statistically significant relation exists between provider group and clinical behavior as they relate to the elective induction of labor.

The active management of risk in multiparous pregnancy at term: association between a higher preventive labor induction rate and improved birth outcomes

OBJECTIVE

To determine whether exposure of multiparous women to a high rate of preventive labor induction was associated with a significantly lower cesarean delivery rate.

STUDY DESIGN

Retrospective cohort study involving 123 multiparous women, who were exposed to the frequent use of preventive labor induction, and 304 multiparous women, who received standard management. Rates of cesarean delivery and other adverse birth outcomes were compared in the 2 groups. Logistic regression controlled for confounding covariates.

RESULTS

The exposed group had a lower cesarean delivery rate (adjusted odds ratio, 0.09; 0.8% vs 9.9%; P = .02) and a higher uncomplicated vaginal delivery rate (odds ratio, 0.53; 78.9% vs 66.4%; P = .01). Exposure was not associated with higher rates of other adverse birth outcomes.

CONCLUSION

Exposure of multiparous women to a high rate of preventive labor induction was significantly associated with improved birth outcomes, including a very low cesarean delivery rate. A prospective randomized trial is needed to determine causality.