Elective induction of labor: a prospective clinical study, II: Psychological effects

Elective induction of labor

Induction of labor rates have more than doubled nationwide in the past 15 years. The increase in medically induced inductions was slower than the overall increase, suggesting that inductions for marginal or elective reasons rose more rapidly. Elective inductions seem to account for at least half of all inductions and 10% of all deliveries. Whether the experience of an elective induction is satisfactory to the patient, obstetrician, and intrapartum crew warrants more widespread attention. Cesarean rates are high for nulliparas undergoing an induction with an unfavorable cervix. Prospective studies are limited or nonexistent to recommend induction of labor for elective or marginal indications. Until more prospective work is performed, it will be difficult to evaluate the true impact of the elective induction of labor on population-wide cesarean delivery rates. Strategies for increased obstetrician awareness are proposed through practice guidelines and through clinical research trials.

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.

Induction of labor: an integrated review

Women's response to induction and augmentation of labor has received little attention in North America. A review of the literature revealed that these procedures epitomize the use of technology in childbirth. From a psycho-emotional perspective, women respond less positively to induction and augmentation than to spontaneous labor and report less satisfaction with the birth experience. In this review of the research and anecdotal literature, reasons for inattention to induction and augmentation are explored, and the nature of the procedures and women's response to them are examined.

Ultrasound assessment of cervical dynamics during the first stage of labor

OBJECTIVE

Assessment of cervical dynamics during the first stage of labor by a combination of ultrasound cervimetry and intrauterine tocography.

METHODS

Sixty-two parturients were divided into four groups: nulliparous women in spontaneous (n = 9) or oxytocin-induced labor (n = 26), parous women in spontaneous (n = 11) or oxytocin-induced labor (n = 16). Intrauterine pressure and cervical dilatation were continuously recorded and assessed by off-line computer analysis.

RESULTS

All women with spontaneous labor showed cervical responses to uterine contractions at the beginning of the recording. The first cervical response to a uterine contraction occurred at a significantly smaller dilatation in parous than in nulliparous women with induced labor (2.9 and 3.6 cm, respectively). Also, acceleration of cervical dilatation occurred at less dilatation in parous than in nulliparous women (3.4 cm and 4.8 cm, respectively), and myometrial work per cm of cervical dilatation was less in parous than in nulliparous parturients.

CONCLUSIONS

The results indicate significant differences between cervical dilatation patterns in nulliparous and parous women, which may be due to structural cervical changes caused by labor and parturition. The labor patterns found were different from those originally described by Friedman (Friedman EA. Graphic analysis of labor. Am J Obstet Gynecol 1954; 68: 1568-1575), as no deceleration phases were detected. Ultrasound cervimetry is a valuable technique for the study of cervical dynamics during labor.

Breast-feeding following spontaneous and induced labour

Carrying out the intention to breast-feed was assessed in 185 mothers divided into four groups according to whether labour was spontaneous, with or without oxytocin augmentation, or induced, either by their own choice or on the advice of their obstetrician. Intention to breast-feed was abandoned most frequently by women in whom labour had been electively induced. As the difference with the other groups could not be explained by obstetric factors, it is concluded that motivational factors may have played a part.

Characteristics and motives of women choosing elective induction of labour

Personal characteristics of healthy term pregnant women who chose elective induction or spontaneous onset of labour and the motives for their choice were assessed. Almost 50% of 237 women with uncomplicated pregnancies opted for elective induction when offered the opportunity. These women appeared to have had more complaints during their pregnancy and menstrual periods, more complications in their obstetrical history and to be more anxious about their labour than women who chose a spontaneous onset of labour. Predominant motives were a feeling of safety and the desire to shorten the duration of pregnancy. These characteristics and motives seem to reflect a lack of trust in physical reproductive functions. It is concluded that in evaluating effects of elective induction of labour, pre-existing differences between women who choose elective induction and women who opt for a spontaneous onset must be taken into account.