Elective Induction of Labor

       Labor induction has become increasingly more popular in recent years. In 1990, 9.6% of mothers chose to induce their labor, and the number of induced labors peaked in 2010 when 23.8% of mother’s chose to induce their labor (Kriebs, 2015). Families and healthcare professionals can choose to induce labor for a variety of reasons. A woman may choose to induce labor to better accommodate the family’s needs, for example, or a doctor may induce labor to manage a mother or a baby’s severe health conditions. This paper will evaluate the position statement from The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) regarding the induction of labor.

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      The induction of labor is the use of pharmacologic and/or mechanical methods to initiate labor (as cited in AWHONN, 2019), but one cannot look at labor induction without also considering the complexities associated with labor and fetal development. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) advocates against elective labor prior to 39 weeks gestation (as cited in AWHONN, 2019).  After 39 weeks gestation, however, the AWHONN notes that women are able and encouraged to make well informed decisions about the induction of labor, but only after they understand the process of induction, the risks and benefits associated with the methods used to induce labor, the available alternatives to induction, and the risks and benefits of allowing labor to progress spontaneously (AWHONN, 2019). Labor, after all, is a complex event with many possible complications, and the possibility of complications is only exacerbated when the mother is not adequately informed or when the individual labor is not adequately evaluated. It is important to inform the mother, for example, that the elective induction of labor can have harmful effects on both the mother and the newborn. A child requires 40 weeks gestation to be fully developed and equipped to survive, and when the family elects to induce labor before 40 weeks gestation, the child may not be fully developed and ready to be born. Since a nurse is a patient’s advocate, it is important to consider a nurse’s role in supporting and informing a mother as she decides whether she ought to electively induce labor. The nurse certainly supports the mother in her decision, but it is essential that the nurse also inform the mother of the potential complications she and her child may experience.

      This topic is relatable to pregnant mothers due to its rapidly increasing popularity. The rate of inductions has more than doubled in frequency since 1990 (as cited in AWOHNN, 2019). The frequency of inductions has increased due to medical advancements that have increased medically necessary inductions, but inductions have also become more popular for elective reasons. Medical indications for an induction of labor include various medical conditions the mother or fetus may possess. Conditions such as preeclampsia, gestational hypertension, comorbidities, and cardiac conditions are among the conditions that may require doctors to induce labor (Kriebs, 2015).  Elective induction of labor occurs after 39 weeks of labor and includes reasons such as a doctor being out of town on the due date, a family’s ability to be in town at a certain date, or even the planning of maternity leave around one’s work schedule (Kriebs, 2015). Medically indicated inductions are done for the safety of the mother and the baby; elective inductions are completed mainly out of convenience for the mother, child, and family.  AWHONN supports medically induced labors at any point when a healthcare professional feels an induction is the best solution to a health problem (2019). The AWHONN position statement specifically relates to the elective decision a family makes to induce the mother before her term date. Overall, there is a vast increase in the popularity of inductions, and it is a point of discussion in a significant number of pregnancies.

      While it is important to consider the recent increase in induced labor and the variety of factors that have caused its increase, one cannot adequately consider the trends and the accuracy of the position statement from The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) regarding the induction of labor without also considering patient safety. Jan Kriebs notes that, “labor induction should only be undertaken when there are specific indications for interrupting the moral processes of pregnancy” (Kriebs, 2015, p 130). Indications for the induction of labor can relate to maternal, fetal, and placental complications (Kriebs, 2015). The discovery that inducing labor prematurely was correlated with adverse pregnancy outcomes lead  to a slight decrease in inductions among women, particularly in non-Hispanic white women between the ages of 20 and 39 (Kriebs, 2015). The Joint Commission subsequently introduced a Core Performance Measure that addressed the induction of labor prior to 39 weeks, which played a significant role in this decline (Kriebs, 2015).

Clearly, then, informing mothers of the potential consequences of prematurely inducing labor is essential in decreasing the number of negative outcomes for the baby and the mother. Kriebs notes that it is very important for women and their families to know clear and precise information about early delivery and to be engaged and informed on the need for prenatal education (Kriebs, 2015). Kriebs notes, for example, that “A survey found that 24% of women considered 34 to 36 weeks to be full term, and more than 50% believed it was safe to deliver a baby at that gestation” (Kriebs, 2015, p. 132). That is not accurate, and the adverse consequences of that misinformation can easily be avoided by simply providing mothers with accurate and comprehensive information.  A fetus that has only had 34 to 36 weeks to develop simply is not as developmentally ready to survive outside of the womb as a fetus who has had 40 weeks to develop. Childbirth education classes also reduced the incidence of early induction as well, for they inform parents about fetal development and the potential complications a mother and newborn might endure by having a premature child (Kriebs, 2015).

Education is certainly helpful and educational initiatives have been effective in decreasing premature inductions, but many institutional safety initiatives have also been shown to decrease the incidence of labor inductions. Institutions are responsible for having clear protocols for the indications of induction of labor, the dose, the route of administration, and the timing of doses for any medication they use to induce a mother (Kriebs, 2015). Just as a parent’s prenatal education is important, the education the healthcare staff receives is very important as well. A healthcare provider is often not present with his or her patient, but the nurse or nursing staff is present when he or she is not. As a nurse, the use of inducting agents such as oxytocin should be understood (Kriebs, 2015). The nurse often is one-on-one with the patient and is responsible for monitoring the patient and for administering the inducing agents and the cervical ripening agents, so nurses should have appropriate knowledge of the drugs they use. The most important aspect of labor induction according to Jan Kriebs is the cohesive effort between the family, the physician or midwife, and the nurses to ensure the safety of the patient is their priority (2015).

      Kriebs’ artical relates to the AWHONN position statement discussed earlier because both articles stress the risks of inductions when the induction of the mother is not medically necessary. The AWHONN statement states that the mother is not able to have an elective induction prior to 39 weeks’ gestation (AWHONN, 2019).  The article written by Jan Kriebs stresses the importance of educating patients and medical staff about the risks of inducing labor (2015). Both of these articles indicate that the education provided by the healthcare team are the most crucial aspects of minimizing the unintended consequences of premature labor inductions. Labor is a process that is meant to be natural to the body. A woman should go into labor when both her body and the baby are ready, and the best indicator of that readiness is to naturally allow the body to enter into labor on its own unless there is a medical reason to induce earlier.

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      The Joint Commission establishes many rules and regulations a hospital must follow to ensure patient safety. One goal that is applicable to the induction of labor is the importance of accurate patient identification. The Joint Commission states at least two patient identifiers should be used to insure the correct patient prior to providing cares, treatments, and services to that patient (2018). Wrong patient errors happen too often in healthcare settings. This goal is crucial since the nurse is ultimately the individual responsible for administering agents that induce labor such as oxytocin, and administering those agents to the wrong patient could severely jeopardize the health and well-being of a mother and her child. Oxytocin is used to stimulate contractions and therefore initiate labor. If a nurse does not ensure that she is administering the correct medication to the correct patient, a number of unfortunate outcomes could occur. For example, the nurse could induce labor in the wrong patient.  The Joint Commission states acceptable patient identifiers include the individual’s name, assigned identification number, telephone number, or other person-specific identification methods (2018). If a nurse does not ensure she follows this rule, a number of unforeseeable outcomes could occur, and patient safety would be compromised.

      Overall, AWHONN established this position statement to ensure the safety of women and their children. The AWHONN position statement centers around the idea that a woman cannot electively decide to induce her labor until she is 39 weeks gestation (AWHONN, 2019). Once a woman reaches 39-week gestation, she must fully understand all aspects of elective labor inductions, including the potential complications she may face due to the induction (AWHONN, 2019).  Jan Kriebs’ article supports the AWHONN position statement and further underscores the importance of patient safety, especially by educating patients and medical staff.  Kreibs stresses the importance of educating the patient and the family about the importance of waiting until 40 weeks gestation or when the child is fully mature and ready to be born. The Joint Commission goal of accurate patient identification further underscores the importance of patient safety, for it calls attention to the importance of accurate patient identification when administering medications that induce labor (2018). This topic is crucial because the administration of these medications to the wrong patient could have devastating effects. Overall, the correlation between the AWHONN position statement, the research article written by Jan Kreibs, and the goal stated by the Joint Commission demonstrate the importance of limiting the induction of labor to ensure patient safety and the importance of following clear information and safety protocols to avoid unnecessary and premature induction of labor.

References

• Kriebs, J. M. (2015). Patient Safety During Induction of Labor. Journal of Perinatal & Neonatal Nursing, 29(2), 130–137. https://doi-org.methodistlibrary.idm.oclc.org /10.1097/JPN.000000000000009

• https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2018.pdf
• https://cdn.ymaws.com/www.awhonn.org/resource/resmgr/pdfs/positionstatements/JOGN_416_Elective_Induction_.pdf