Induction of labor: an integrated review

In labor or in limbo? The experiences of women undergoing induction of labor in hospital: Findings of a qualitative study

BACKGROUND

Induction of labor currently accounts for around 25% of all births in high-resource countries, yet despite much research into medical aspects, little is known about how women experience this process. This study aimed to explore in depth the induction experience of primiparous women.

METHODS

A qualitative study was undertaken, using a sample of 21 first-time mothers from a maternity unit in the south of England. Semi-structured interviews were conducted in women's homes between 3 and 6 weeks postnatally. Data were recorded, transcribed, and analyzed thematically.

RESULTS

Women awaiting induction on the prenatal ward appeared to occupy a liminal state between pregnancy and labor. Differences were noted between women's and midwives' notions of what constituted "being in labor" and the ward lacked the flexibility to provide individualized care for women in early labor. Unexpected delays in the induction process were common and were a source of anxiety, as was separation from partners at night. Women were not always clear about their plan of care, which added to their anxiety.

CONCLUSIONS

Conceptualizing induction as a liminal state may enhance understanding of women's feelings and promote a more woman-centered approach to care. Thorough preparation for induction, including an explanation of possible delays is fundamental to enabling women to form realistic expectations. Care providers need to consider whether women undergoing induction are receiving adequate support, analgesia, and comfort aids conducive to the promotion of physiological labor and the reduction of anxiety.

Women's perceptions, expectations and satisfaction with induced labour—A questionnaire-based study

OBJECTIVES

To evaluate the understanding and expectations of women undergoing labour induction, to assess their actual experience of the process and to compare their satisfaction with labour to those labouring spontaneously.

STUDY DESIGN

Four hundred and fifty women at term undergoing induction of labour and cervical ripening with prostaglandinE2 vaginal tablets and 450 women labouring spontaneously were recruited into the study. The induction group were requested to complete a questionnaire prior to the start of their induction process and another questionnaire post-delivery. The post-delivery questionnaire contained two sections, one pertaining to issues to do with the induction and the second with the actual labour process. The spontaneously labouring group was requested to complete a questionnaire post-delivery, which only contained the section pertaining to the actual labour process. The main outcome measures were satisfaction with labour, perception of pain and length of labour between the induced and spontaneous labour groups, and issues that the women might wish changed about their induction.

RESULTS

In the induction group, 34.7% were not satisfied with the information they received about the induction prior to the procedure and 27.2% expected to deliver within 12h of the administration of the inducing agent. Post-induction, 40% of the women felt the most important aspect they would like to change about their induction were they to have another one, would be the speed of the induction, 13.6% felt they might wish to take the inducing agent orally, 7% to have fewer vaginal examinations and 9% to have fewer complications. Among the women who returned questionnaires, 26.3% had a caesarean delivery in the induction group and 21.4% in the spontaneous labour group. Significantly more women were satisfied with their labour in the spontaneous labour group 79.5% versus 70.4%, RR 0.89, 95% CI 0.8-0.96, P=0.006).

CONCLUSIONS

Labour that is artificially induced does result in lower satisfaction rates as compared to that following spontaneous onset. The longer time delay between the start of the induction and the delivery plays a significant part in this, with the mode of administration of the inducing agent, more vaginal examinations and the increase in caesarean deliveries being perceived as secondary issues. There is a need to improve the information provided to women undergoing labour induction, to counter unrealistic expectations and thereby improve satisfaction.

Emergency cesarean delivery in induction of labor: an evaluation of risk factors

BACKGROUND

Induction of labor has been associated with an increased risk of emergency cesarean delivery. Knowledge of factors that influence the risk of cesarean delivery in women with induced labor is limited.

METHODS

We performed a case-control study, nested within a population-based cohort of women with induced labor at term during 1991-1996 in Uppsala County, Sweden. Cases were women delivered with emergency cesarean delivery, and controls were women vaginally delivered (n = 193, respectively). Using logistic regression, analyses were performed. Odds ratio (OR) with 95% confidence intervals (CI) was used as a measure of relative risk.

RESULTS

Women with a previous cesarean delivery had high risks of cesarean delivery (adjusted OR = 10.10, 95% CI = 3.30-30.92). The risk of cesarean delivery was also increased among nulliparous (adjusted OR = 4.92, 95% CI = 2.81-8.61), short (adjusted OR = 2.20, 95% CI = 1.06-4.59), and obese women (adjusted OR = 2.03, 95% CI = 1.07-3.84). A cervix dilatation less than 1.5 cm doubled the risk of cesarean delivery (adjusted OR = 2.26, 95% CI = 1.09-4.66). Mother's age, epidural analgesia, oxytocin augmentation, gestational age, and birthweight were not significantly associated with risks of cesarean delivery.

CONCLUSIONS

Women with a previous cesarean delivery, nulliparous, short, and obese women with induced labor are at high risk of a cesarean delivery. When there is a need to deliver a woman with a previous cesarean section or a nulliparous woman with other risk factors for cesarean delivery, it may be prudent to consider an elective cesarean section.

Risks of induction of labour in uncomplicated term pregnancies

Our objective was to evaluate the risks of maternal and perinatal morbidity associated with induction of labour in uncomplicated term pregnancies. We conducted a retrospective cohort study including 7,430 women, not referred from another institution, with a single baby in vertex presentation, and delivering between 38 and 40 weeks of pregnancy. Among these women, 3,546 were excluded for prelabour pregnancy complications. Relative risks (RR), adjusted for parity, were computed to compare 3,353 women who went into labour spontaneously with 531 women whose labour was induced. Induction of labour was found to be associated with a higher risk of caesarean section [RR = 2.4, 95% CI 1.8, 3.4]. Use of non-epidural [RR = 1.5, 95% CI 1.2, 1.8] and of epidural analgesia [RR = 1.4, 95% CI 1.1, 1.7] was more frequent after labour induction. Resuscitation [RR = 1.2, 95% CI 1.0, 1.5], admission to the intensive care unit [RR = 1.6, 95% CI 1.0, 2.4] and phototherapy [RR = 1.3, 95% CI 1.0, 1.6] were more frequent after induction of labour. Results were similar when controlling simultaneously for parity, maternal age, gestational age, year of delivery, birthweight and the physician in charge of delivery in a logistic regression analysis. The results of this study suggests that induction of labour is associated with a higher risk of caesarean section and of some perinatal adverse outcomes. Induction of labour should be reserved for cases where maternal and perinatal benefits outweigh the risk of these complications.

Temporal changes in rates and reasons for medical induction of term labor, 1980-1996

OBJECTIVE

This study was undertaken to assess temporal changes in rates and reasons for medical induction of term labor.

STUDY DESIGN

A retrospective medical record review was conducted on a population-based cohort of 1293 women with term deliveries.

RESULTS

The rate of medical labor induction increased from 12.9% in 1980 to 25.8% in 1995. Stated indications also changed, with a 2-fold increase in induction for postdate gestation, a 23-fold increase in induction for macrosomia, a 15-fold increase in elective induction, and a 22-fold decline in induction for premature rupture of membranes. The average gestational age at delivery of postdate pregnancies declined from 41.9 weeks in 1980 to 41.0 weeks in 1995. By 1995, the average maternal length of stay and the percentage of cesarean deliveries were higher among women with induced labor at term than among those with spontaneous labor at term.

CONCLUSION

Induction of term labor has almost doubled in prevalence during the past 15 years. The most common indications are elective induction and postdate pregnancy, often applied to gestations of 40 to 41 weeks' duration.

Women's evaluations of induction of labor versus expectant management for prelabor rupture of the membranes at term. TermPROM Study Group

BACKGROUND

Induction of labor has become common practice in many Western countries, but few studies have assessed women's views.

METHODS

A randomized, controlled trial was conducted at 72 hospitals in six countries. Five thousand forty-one women meeting eligibility criteria, with no contraindications for induction of labor or expectant management, were randomly assigned to four groups: induction with intravenous oxytocin, induction with vaginal prostaglandin E2 gel, or expectant management followed by induction with either oxytocin or with prostaglandin E2 gel if complications developed. The three main outcome measures were evaluations of the treatment received, perceived control during childbirth, and evaluations of the experience of trial participation.

RESULTS

Questionnaires were completed by 81.9 percent of the sample. No significant differences occurred between the two induction groups. Compared with the expectant management groups, induced women were less likely to report there was nothing they liked about their treatment and less likely to report that the treatment caused additional worry. No between-group differences occurred in experienced control during childbirth. Women in the induction groups were more likely to be willing to participate in the study again and to feel reassured.

CONCLUSIONS

Women's preferences should be considered when making decisions about their method of management when membranes rupture before labor. Obtaining participants' views is both feasible and worthwhile when evaluating forms of medical care.