A Menu of Change
Spontaneous Onset of Labor
Spontaneous labor is the safest course for women and newborns, but national survey data indicated that fewer than half of births were preceded by the spontaneous onset of labor.1 Rates of induction of labor and planned cesarean have increased dramatically in recent years, and much of this increase is driven by elective or non-medically supported indications. According to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, a critical element for improving the quality of maternity care services is the prevention of primary cesarean birth, which requires reassessment of the current maternity care practices related to interventions, such as induction of labor.2 The overuse of non-medically indicated induction may be a significant driver of the increasing cesarean rate.3-5 Elective deliveries that occur before 39 weeks gestation are associated with high rates of neonatal intensive care utilization and significant risk to infants.6
Because labor induction involves use of a high-alert medication and carries heightened risk of iatrogenic harm, close monitoring of the woman and fetus is warranted.7 As a result, induction of labor typically involves many co-interventions, including continuous internal or external fetal monitoring and intravenous lines. These in turn impair mobility and may lead to confinement in bed and increased discomfort. The results of an observational study demonstrated that induced labor was associated with increased use of epidural or opioid analgesia.8 Thus, induction of labor is frequently the start of a “cascade of interventions” that transforms a physiologic event into a high-tech, medicalized, care experience.9
Indications for Induction Without Evidence Base
According to the Northern New England Perinatal Quality Improvement Network, many commonly used indications for induction or cesarean are in fact elective.10 These include the following:
Post maturity prior to 41 weeks gestation
Suspected macrosomia or impending macrosomia
Low amniotic fluid index > 5
History of fast labors
Advanced cervical dilation
Prodromal or impending labor
Previous maternal pelvic floor injury (eg, 4th degree laceration)
—partner soon leaving town
—family in town
—maternal exhaustion or discomfort
—psychiatric issues (eg, anxiety or depression)
Promoting Best Practices
Best practices to safely increase the number of women who begin labor spontaneously include the following:
Implement hard stop policies to prevent elective induction of labor prior to 39 weeks gestation.11 Hard stop policies require compliance with the guidelines by all providers.
Only Induce labor before 41 0/7 weeks for evidence-based maternal of fetal indications and ideally with nulliparous women with Bishop score > 8 or multiparous women with Bishop score > 6.2,12
Use cervical ripening methods of labor induction for a woman with an unfavorable cervix.2
Provide prenatal education to women to increase awareness of the possible benefits and harms and evidence-based indications for induced labor.13
Offer external cephalic version to women with a breech or transverse fetus at term.14
When induction of labor is required for a medical indication, to reduce the risk of performing an unnecessary cesarean secondary to a failed induction, allow longer durations of the latent phase (up to 24 hours or longer) and require that oxytocin be administered for at least 12–18 hours after membrane rupture before deeming the induction a failure and performing a cesarean.2
"Go the Full 40" Campaign (AWHONN)
Developed by the AWHONN, with resources in both English and Spanish, this consumer campaign offers information to women about the importance of the last days and weeks of pregnancy to prepare their bodies and fetuses for labor. The campaign emphasizes the value of going into labor spontaneously when mother and fetus are healthy. Site contains patient education materials in English and Spanish.
Click to view additional resources available in the Promoting Spontaneous Onset of Labor Resource Toolbox, or search our resource library by clicking here.
Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to mothers II: report of the Second National U.S. Survey of Women’s Childbearing Experiences. http://www.childbirthconnection.org/pdfs/LTMII_report.pdf. Published October, 2006. Accessed March 2, 2014.
American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric care consensus: safe prevention of the primary cesarean delivery. http://www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery. Published March, 2014. Retrieved March 2, 2014.
Bailit JL, Gregory KD, Reddy UM, et al. Maternal and neonatal outcomes by labor onset type and gestational age.Am J Obstet Gynecol.2010;202(3):245.e1-245.e12. doi: 10.1016/j.ajog.2010.01.051.
Ehrenthal DB, Jiang X, Strobino DM. Labor induction and the risk of a cesarean delivery among nulliparous women at term. Obstet Gynecol. 2010;116(1):35-42. doi:10.1097/AOG.0b013e3181e10c5c.
Laughon SK, Zhang J, Grewal J, Sundaram R, Beaver J, Reddy UM. (2012). Induction of labor in a contemporary obstetric cohort. Am J Obstet Gynecol. 2012;206(6):486.e1-486.e9. doi:10.1016/j.ajog.2012.03.014.
Clark SL, Miller DD, Belfort MA, Dildy GA, Frye DK, Meyers JA. Neonatal and maternal outcomes associated with elective term delivery. Am J Obstet Gynecol. 2009;200(2):156.e1-156.e4. doi:10.1016/j.ajog.2008.08.068.
Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: New perspectives on an old drug.Am J Obstet Gynecol.2009;200(1):35.e1-35.e6. doi: 10.1016/j.ajog.2008.06.010.
King V, Pilliod R, Little A. Rapid review: elective induction of labor. Portland, OR: Center for Evidence-based Policy. https://www.ohsu.edu/xd/research/centers-institutes/evidence-based-policy-center/evidence/med/upload/Elective-Induction-of-Labor_PUBLIC_RR_Final_12_10.pdf. Published October, 2010. Accessed March 2, 2014.
Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to mothers III: report of the Second National Survey of Women’s Childbearing Experiences. http://transform.childbirthconnection.org/wp-content/uploads/2013/06/LTM-III_Pregnancy-and-Birth.pdf. Published May, 2013. Accessed March 2, 2014.
Northern New England Perinatal Quality Improvement Network. Guidelines.http://nnepqin.org/documentUpload/Guideline_for_Elective_Labor_Induction.pdf. Accessed March 2, 2014.
Clark SL, Frye DR, Meyers JA, et al. Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth. Am J Obstet Gynecol. 2010;203(5):449.e1- 449.e6. doi:10.1016/j.ajog.2010.05.036.
Fisch JM, English D, Pedaline S, Brooks K, Simhan HN. Labor induction process improvement: a patient quality-of-care initiative. Obstet Gynecol. 2009;113:797– 803.
Simpson KR, Newman G, Chirino OR. Patient education to reduce elective labor inductions. MCN Am J Matern Child Nurs. 2010;35(4):188-194. doi: 10.1097/NMC.0b013e3181d9c6d6.
Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2012;10:CD000083. doi: 10.1002/14651858.CD000083.pub2; 10.1002/14651858.CD000083.pub2.