Elective Induction of Labor and Early Term Delivery

Submitted by Elizabeth Johnson

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Elective Induction of Labor and Early Term Delivery

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Abstract

The rate of elective induction of labor without medical indication is on the rise.  Elective inductions carry long-term consequences for the maternal and infant dyad.  Maternal risk of induction includes hemorrhage, uterine dystocia, uterine rupture, and cesarean section related to failed induction of labor. Neonatal risks include respiratory distress, feeding difficulty, and long-term psychological and behavioral tendencies such as attention deficit and hyperactivity disorder (ADHD).  In reviewing a variety of studies, researchers have seen a decrease in morbidities and health care costs for both mother and infant when spontaneous labor occurs.  However, the risks of liability and malpractice suits tempt physicians to schedule elective inductions.  By creating and implementing policies on elective induction of labor, nurses have the ability to educate patients on the importance of letting labor occur naturally.

Elective Induction of Labor and Early Term Delivery

In the busy life that women lead today, the option of scheduling the birth of their baby is enticing.  Elective induction of labor has become a familiar term to most childbearing women.  However, the risks of long-term consequences are not often discussed in the health care setting.  According to the Association of Women's Health, Obstetric and Neonatal Nursing (AWHONN), spontaneous labor is the healthiest and safest ways to welcome a baby into the world (2012).  By educating patients on the importance of waiting until spontaneous labor begins, nurses can influence maternal decision-making and potential complications in the delivery room. 

Description of Terms

For those unfamiliar with the field of Obstetrics, the terminology used when discussing pregnancy and delivery of the fetus is cumbersome. Traditionally speaking, pregnancy length is described in months.  In the field of obstetrics, pregnancy is described as weeks and days of gestation.  A full term pregnancy starts at 37 weeks and lasts until 42 weeks gestation.  A pregnancy is considered prolonged or post term after 42 weeks (Doyle, Kenny, Von Gruenigen, Butz, & Burkett, 2012).  An early term infant is defined as an infant born between 37 and 39 weeks gestation (Ghartey, et al., 2012). 

An induction of labor is defined as elective when "there is no medical or obstetrical indication for delivery" (Laughon, et al., 2012, p. 486).  Medical indications to induce pregnancy include diabetes, elevated blood pressure, fetal growth restriction, premature rupture of membranes, fetal death, and post-term pregnancies (Akinsipe, Villalobos, & Ridley, 2012).  Defining complicated obstetric terminology to the patient and family throughout the pregnancy is essential quality patient education.

Method

To research literature on the subject, the Towson University Online Library collections were searched.  By utilizing the Nursing subject gateway, many articles were found in the CINAHL, Medline, Health Source, and OVID databases.  The search was conducted using a variety of key words and phrases.  Key words and phrases included:  induction of labor, early-term infants, neonatal respiratory morbidity, feeding in early-term infants, infant blood sugar, and Attention Deficit Hyperactivity Disorder (ADHD) in early term infants.  A similar search was done at the Mercy Medical Center library when articles were not available to view electronically through the Towson Library.  An Internet search using the Google search engine also proved beneficial in locating valuable information.  Searching the phrase "induction of labor by gestational age" provided statistical rates on induction of labor from the US Census Bureau (2012).  Searching for the AWHONN website led to the "Go the Full 40" campaign which helps educate women on the importance of carrying a baby to term gestation (2012).  All literature used in the review was conducted between the years of 2005 and 2012.  By searching electronically for journal articles using Towson University and Mercy Medical Center Library, and a simple Google search, reliable sources of literature were easily accessible to conduct a literature review.

Review of Literature

Between 1990 and 2008, term induction rates have almost doubled from 9.9% to 24.3%, while cesarean delivery rates have also increased from 22.7% to 30.3% between 1990 and 2005 (US Census Bureau, 2012).  This movement can be associated with many factors, "the most common being the ability to plan the date of birth by the patient, the family, and the physician" (as cited in Akinsipe et al., 2012, p. 5).  Patients often seek an elective induction of labor due to uncertainty of a non-controlled delivery environment.  For instance, a patient may choose and elective induction of labor if they're 5 centimeters dilated but not in active labor for fear that they may deliver in route to the hospital or at another facility in an emergency situation.  Other maternal reasons for elective inductions include discomforts of pregnancy, maternal fatigue, or if the physician suspects a large baby (Akinsipe et al., 2012).  Elective deliveries do not come without risk.  Unfortunately, many patients are not fully informed of the risks involved when delivering a baby.

In present practice, the American Congress of Obstetricians and Gynecologists (ACOG) argues elective inductions less than 39 weeks gestation (as cited in Doyle et al., 2012).  However in current practice, scheduled inductions are often made at 39 weeks without a medical indication.  An amniocentesis is often performed to test for fetal lung maturity if an induction is posted at or before 39 weeks gestation.  Current research suggests that even with a mature amniocentesis, "infants who are born at <39 weeks' gestation continue to have significant neonatal morbidity, which adds support to other studies that show that documented fetal lung maturity itself is insufficient to determine an infant's readiness for postnatal life" (Kamath, Marcotte, & DeFranco, 2011, p. 6).  It has become evident that elective induction of labor has led to an increase in morbidity and cost of health care while decreasing the quality of care for patients (Doyle et al., 2012). 

The risk for maternal and neonatal morbidity related to elective induction of labor is concerning.  A woman undergoing an elective induction has a considerably higher chance of undergoing a primary cesarean section (Clark et al., 2009).  Many patients are unaware that a cesarean section is major abdominal surgery and is often associated with its own complications.  Maternal risk from elective induction also includes "hemorrhage due to oxytocic agents, chorioamnionitis, sepsis, uterine dystocia, failed induction, and uterine hyperstimulation with potential rupture accompanied by a non-reassuring fetal heart rate" (Akinsipe et al., 2012, p. 6).  The length of labor also increases when a patient is induced.  For first time moms, the length of labor can range 13.6 to 21.5 hours with elective induction of labor.  For patients who have already had children, the length of time in labor ranges from 8.2 to 13.2 hours in elective cases (Clark et al., 2009).  This compares to 10-11 and 6-7 hours respectively for patients experiencing spontaneous labor (Clark et al., 2009). 

Morbidities following elective induction of labor found in the newborn often lead to admissions to the Neonatal Intensive Care Unit (NICU).  The admission of term NICU admissions is made up of "46.9% of infants born at 37-38 weeks and 44.2% of infants born at 39-41 weeks.  The average length of stay among infants delivered at 37-38 weeks was 5.9 days vs 4.9 days for those delivered at 39-41 weeks" (Ghartey et al., 2012, p. 4).  With this admission, the length of stay is increased for the dyad, health care costs skyrocket, and maternal-infant bonding is severed.  "Risk to the fetus/newborn include iatrogenic neonatal morbidity, pulmonary insufficiency from premature delivery, sepsis, cord prolapse, and possible asphyxial injury" (Akinsipe et al., 2012, p. 6).  Research has found that "significant morbidity persists at term, more specifically the 'early term' period defined as 37-38 weeks' gestation" (Ghartey et al., 2012, p. 1). 

Infants born in the early term period had a "2-fold increase" in the risk of respiratory morbidities than those delivered after 39 weeks (Ghartey et al., 2012, p. 2).  The transition from prenatal to postnatal life in the fetus is extraordinary.   At the time of birth, infant lungs must quickly clear the fluid and the lungs "convert quickly and efficiently from a fluid secreting to a fluid-absorbing organ" (Katz, Bentur, & Elias, 2011, p. 231).  Prior to spontaneous labor, the amount of intrauterine fluid secretion declines due to catecholamine secretion thus making the amount of fluid to be excreted after delivery smaller (Katz et al., 2011).  "There is considerable evidence to show that high levels of endogenous catecholamines at birth may be important for accelerating alveolar fluid clearance" (Jain & Eaton, 2006, p. 37).  In elective inductions, the infant does not experience the catecholamine release that often "leads to filling of the lung airspaces with fluid and causes a ventilation/perfusion mismatch, which eventually can culminate in respiratory distress of the newborn" (Katz et al., 2011, p. 232).  With a 40% reduction in fetal lung fluid prior to spontaneous labor, it is evident that infant respiratory distress can be avoided by preventing elective induction of labor (Jain & Eaton, 2006). 

The initiation of feeding is also an issue in early term infants.  "This may be due to the fact the synchronization of sucking-swallowing is potentially incomplete before 38 weeks, and sucking and rooting reflexes are not fully developed until 36 to 38 weeks" (Craighead, 2012, p. 141).  In addition, early term infants are found to be "less capable of sustaining breastfeeding in a manner that meets their physiologic needs" (Craighead, 2012, p. 141).  Without meeting the physiologic needs, early term infants are often hospitalized related to dehydration with exclusive breastfeeding (Craighead, 2012). 

The length of stay for the maternal and infant dyad increases during an induction.  "This observation has important implications with respect to resource utilization, an important issue, because labor and delivery ranks behind only cardiovascular care in terms of total cost in the United States"  (Clark et al., 2009, p. 3).  The cost of a NICU admission for infants in the 37 to 38 week group is $37,137 where as the cost of infants in the 39 to 41 week group is $29,771 (Ghartey et al., 2012).  In a study published by the British Medical Journal, researchers extrapolated that "for every 1,040 inductions one perinatal death would be avoided at the cost of seven additional neonatal unit admissions" (Chyne, Abhyankar, & Williams, 2012, p. 414).  These inductions would create additional NICU unit costs and potential long-term health issues for infants (Chyne et al., 2012).

The incidence of long-term adverse outcomes in infants born in the early term period is also if concern.  Studies have linked early term deliveries to attention deficit and hyperactivity disorder (ADHD) (Lindstrom, Linblad, & Hjern, 2011).  It was determined that "maturational lag in brain development was considered to be the most likely link between immature gestational age and ADHD" (Craighead, 2012, p. 141).  In addition, early term infants often require special education in the classroom and have a potential for psychiatric hospital care (Craighead, 2012).  Many early term infants not only require immediate specialized care at delivery but also may require additional resources later in life compared to infants born spontaneously at term gestation. 

The US Department of Health and Human Services has adopted elective deliveries into their core set of quality measures.  By doing so, they are hoping to provide a "crucial opportunity to ensure that evidence-based practice extends to a population already at high risk of prematurity, low birth weight, and other adverse birth outcomes" (AWHONN, 2012, p. 169).  Not only will the adoption of the elective delivery measure improve care for families but it will also have "the potential to reduce unnecessary Medicaid costs as the final weeks of pregnancy are very important period of fetal lung development and brain growth" (AWHONN, 2012, p. 169).

Physicians are placed in a peculiar situation when choosing the appropriate time to induce labor.  Seeing that the majority of elective inductions are without medical indications, they are primarily scheduled because the pregnancy is considered prolonged.  A prolonged pregnancy "is consistently associated with an increase in risk of perinatal death although the absolute risk remains low" (Cheyne et al., 2012, p. 412).  Prolonged pregnancies are associated with risks such as meconium aspiration and birth injury (Cheyne et al., 2012).  Physicians are forced to determine the risks and benefits of continuing the pregnancy as they are faced with liability issues (Engle & Kominiarek, 2008).  Doctors often fear a malpractice suits and opt for an early delivery for their patients (Broody, 2011).  Dr. Reddy from the National Institute of Child Health and Human Development analyzed live births from 1995 to 2006 (as cited in Brody, 2011).  While reviewing 46 million births, Dr. Reddy and colleagues "found that newborn death rates at 37 weeks of gestation were two and a half to nearly three times the number at 40 weeks" (Brody, 2011, para. 12).  Although the risk is minimal, "it seems both unlikely and undesirable that our aversion for perinatal death as an outcome will change" (Cheyne et al., 2012, p. 414).

Discussion

AWHONN's Healthy Mom and Baby magazine created the "Go the Full 40" campaign that encourages new mothers to wait for spontaneous labor to occur (2012).  This campaign gives new mothers 40 reasons to wait until 40 weeks gestation to deliver her baby.  Their 40 reasons highlight both serious and entertaining reasons to wait such as "Boost Breastfeeding" and "Postpone changing the eventual 5,000+ diapers" (AWHONN, 2012, p. 167).  The campaign "is busting the myth that it's OK for babies to be born just a little early"  (AWHONN, 2012, p. 166).  To reach a broad audience, the campaign is publicized on social media outlets, hospitals, doctor offices, the internet, and even radio programming (Craighead, 2012).  With literature supporting their 40 reasons, AWHONN is slowly changing the culture of childbirth.

An elective induction of labor consent form and scheduling guidelines developed by nursing can improve the quality of care patients receive.  In a multidisciplinary approach, a consent form should include "reason for induction, gestational age, method of gestational age determination, estimated fetal weight, Bishop score, and induction method"  (Doyle et al., 2012, p. 465).  The form would be completed in the physician's office and would contain both physician and patient signatures.  A new scheduling guideline created by nursing will verify that the consent form, orders for induction, and prenatal records are all available prior to scheduling.  If a patient would arrive for their scheduled induction without completed records, it should be expected that the induction would be held until the appropriate paperwork is complete.  By abiding by these standards, hospitals can assure quality evidence based care is provided to their patients. 

Prenatal education is key in preventing elective inductions.  Not only should education be initiated early in prenatal care, but it should also be reiterated at every appointment.  Nurses are vital in the quality of care a patient receives.  Nurses have the ability to "write or revise policies, procedures, and scheduling protocols that fundamentally change the induction process" (Doyle et al., 2012, p. 472).  As educators, nurses are able to teach patients about the best induction practices and evidence at the bedside and in prenatal classes.  Nurses should consider speaking with childbirth educators and encourage teaching fetal development and early term births to families. 

Early delivery has gained much attention over the last year due to the alarming evidence of morbidity and cost of health care.  In the ever-changing economy, hospitals are concerned with keeping the cost of health care down while still providing quality patient care and education.  The literature suggests that induction of labor should only take place when there is a medical indication.  Information regarding the risks of induction provided to the family prior to scheduling the procedure would ensure that the patient is making an informed decision for both herself and her unborn child.  By developing an induction of labor consent form, nurses can change the practice and improve quality of care provided by the health care team.  Nurses have the ability to improve outcomes for the mother-infant dyad by empowering their patients with the knowledge of consequences of elective induction of labor.

References

  1. Akinsipe, D.C., Villalobos, L.E., Ridley, R.T. (2012). A systematic review of         Implementing an elective labor induction policy. Journal of Obstetric,           Gynecologic, & Neonatal Nursing, 41, 5-16. doi:10.1111/j.1552-            6909.2011.01320.x
  2. Association of Women's Health, Obstetrics, and Neonatal Nursing. (2012). Babies need 40 weeks. Nursing for Women’s Health, 16(2), 166-169.     doi:10.1111/j.1751-486X.2012.01724.x
  3. Brody, J.E. (2011, August 8).  A campaign to carry pregnancies to term.  The New York Times.  Retrieved from    http://www.nytimes.com/2011/08/09/health/09brody.html?_r=0
  4. Cheyne, H., Abhyankar, P., Williams, B. (2012).  Elective induction of labour: The problem of interpretation and communication of risks.  Midwifery, 28, 412-      415.  doi:10.1016/j.midw.2012.06.009
  5. Clark, S.L., Miller, D.D., Belfort, M.A., Dildy, G.A., Frye, D.K., Meyers, J.A. (2009). Neonatal and maternal outcomes associated with elective term delivery.       American Journal of Obstetrics & Gynecology, 200(2), 1-4.  doi:10.1016/j.ajog.2008.08.068
  6. Craighead, D.V. (2012).  Early term birth: Understanding the health risk to infants. Nursing for Women's Health, 16(2), 138-145.  doi:10.1111/j.1751- 486X.2012.01719.x
  7. Doyle, J.L., Kenny, T.H., Von Gruenigen, V.E., Butz, A.M., Burkett, A.M. (2012). Implementing an induction scheduling procedure and consent form to improve quality of care.  Journal of Obstetric, Gynecologic, & Neonatal Nursing,     41(4), 462-473. doi:10.1111/j.1552-6909.2012.01380.x
  8. Engle, W.A. & Kominiarek, M.A. (2008).  Late preterm infants, early term infants, and     timing of elective deliveries.  Clinics in Perinatology, 35, 325-341. doi:10.1016/j.clp.2008.03.003
  9. Ghartey, K., Coletta, J., Lizarraga, L., Murphy, E., Ananth, C.V., Gyamfi-Bannerman, C. (2012).  Neonatal respiratory morbidity in the early term delivery.  American   Journal of Obstetrics & Gynecology, 207(4), 1-4.
  10. doi:10.1016/j.ajog.2012.07.022
  11. Jain, L., & Eaton, D.C. (2006).  Physiology of fetal lung fluid clearance and the effect of labor. Seminars in Perinatology, 30. 34-43.  doi:10.1053/j.semperi.2006.01.006
  12. Kamath, B.D., Marcotte, M.P., DeFranco, E.A. (2011).  Neonatal morbidity after documented fetal lung maturity in late preterm and early term infants.    American Journal of Obstetrics & Gynecology, 204(6). 1-8.              doi:10.1016/j.ajog.2011.03.038
  13. Katz, C., Bentur, L., Elias, N. (2011).  Clinical implication of lung fluid balance in the perinatal period.  Journal of Perinatology, 31, 230-235. doi:10.1038/jp.2010.134
  14. Laughon, S.K., Zhang, J., Grewal, J., Sundaram, R., Beaver, J., Reddy, U.M. (2012).  Induction of labor in a contemporary obstetric cohort. American Journal of             Obstetrics & Gynecology, 206(6), 1-9. doi:10.1016/l.ajog.2012.03.014
  15. Lindstrom, K., Linblad, F., Hjern, A. (2011).  Preterm birth and attention-  deficit/hyperactivity disorder in schoolchildren.  Pediatrics, 127(5). 858-865.             doi: 10.1542/peds.2010-1279
  16. U.S. Census Bureau. 2012. Induction of labor by gestational age: 1990 to 2008. Retrieved November 2, 2012, from http://www.census.gov/compendia/statab/cats/births_deaths_marriages_divorces.html 

Source

Description of Study

Description of Sample

Instruments

Results

Implication

Akinsipe, D.C., Villalobos, L.E., Ridley, R.T. (2012). A systematic review of Implementing an elective labor induction policy. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41, 5-16.

Observational studies between 2000 and 2010 focused on elective induction of labor policies within hospitals.

Six retrospective and three prospective observational studies regarding induction of labor policies reviewed.  In total, 9 studies were reviewed and 47,840 laboring women had policies in place.

Researchers utilized the Pub Med database to review articles.

There was a decrease in elective inductions scheduled without a medical indication when a policy was put in place. 

Hospitals should develop policies on elective labor induction on labor and delivery units.

Association of Women's Health, Obstetrics, and Neonatal Nursing. (2012). Babies need 40 weeks. Nursing for Women’s Health, 16(2), 166-169.

The article highlights the campaign that promotes waiting until spontaneous labor starts before inducing. 

        

Brody, J.E. (2011, August 8).  A campaign to carry pregnancies to term.  The New York Times. 

Newspaper article that promotes carrying pregnancies to term. 

Nine urban hospitals in the Intermoutain Health Care System in Utah.

Chart Review

Not until strict monitoring of births was instituted did the rate of early deliveries decrease from 28% to 3%.

Hospitals should start reviewing charts to determine implications to maternal-infant dyad.

Cheyne, H., Abhyankar, P., Williams, B. (2012).  Elective induction of labour: The problem of interpretation and communication of risks.  Midwifery, 28, 412-415. 

A study determining the appropriate timing of elective IOL. 

Population based, retrospective chohort of all singleton births at 37 weeks gestation or greater in Scotland between 1981 and 2007.  A total of 1,271,549 births were studied.

Used validated routinely collected data and record linkage.

Study determined that elective induction of labor was associated with decreased odds of perinatal mortality however they were associated with increased admission rates to the NICU. 

Study suggests that at 40 weeks gestation, 1,040 women would need an elective IOL to prevent one case of mortality but would result in 7 NICU admissions. Important to improve knowledge base about the likelihood of mortality.

Clark, S.L., Miller, D.D., Belfort, M.A., Dildy, G.A., Frye, D.K., Meyers, J.A. (2009). Neonatal and maternal outcomes associated with elective term delivery. American Journal of Obstetrics & Gynecology, 200(2), 1-4. 

The study attempted to quantify neonatal and maternal poor outcomes associated with elective IOL at <39 weeks gestational age.

Prospective observational study in 27 hospitals over 3 months in 2007. Examined a total of 17,793 deliveries.

Electronic data collection sheets analyzed centrally.  Statistical analysis performed.

17.8% of infants delivered electively without a medical indication between 37-38 weeks, and 8% delivered electively between 38-39 weeks were admitted to the NICU.  4.6% of infants born > 39 weeks admitted to NICU.

Women desiring an elective induction of labor prior to 39 weeks gestation should receive counseling regarding adverse outcomes.

Craighead, D.V. (2012).  Early term birth: Understanding the health risk to infants.  Nursing for Women's Health, 16(2), 138-145. 

A review of literature examining the short term and long term outcomes for infants.

Review of multiple studies.

Chart Review.

Respiratory distress, poor feeding habits and glucose control, and long-term behavioral problems seen in children born prior to 40 weeks.

Pregnant women need to be aware of infant's vulnerability and potential health requirements.  Nurses should educate patients on the risk of an early term delivery.

Doyle, J.L., Kenny, T.H., Von Gruenigen, V.E., Butz, A.M., Burkett, A.M. (2012).  Implementing an induction scheduling procedure and consent form to improve quality of care.  Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41(4), 462-473.

Purpose is to implement a induction scheduling procedure and consent form as a quality improvement project.  Aim was to eliminate elective IOL at less than 39 weeks gestation.

Study performed in a Midwest level III perinatal center with 3,000 births/year.  Of the patient population, 1/3 are high risk, 1/2 are publicly insured, and 2/3 are white.  The unit has 63 RN's and 6 LPN's and staffing is adjusted to volume. Cases reviewed from 2008 to 2011.

2 nurses audited records for the usage of an IOL consent form.  Monthly checks in live chart reviews and retrospective chart reviews electronically. 

Elective deliveries less than 39 weeks gestation decreased from 5.6/month to .7/month.  Induction consent form was completed 93% of the time where as the general hospital consent was used 7% of the time.

Strong action is needed to decrease the amount of elective induction of labor.  Physician support is necessary in addition to close monitoring of charts. 

Engle, W.A. & Kominiarek, M.A. (2008).  Late preterm infants, early term infants, and timing of elective deliveries.  Clinics in Perinatology, 35, 325-341. 

Examines reasons behind scheduling induction of labor from the patient and physician standpoint.

        

Ghartey, K., Coletta, J., Lizarraga, L., Murphy, E., Ananth, C.V., Gyamfi-Bannerman, C. (2012).  Neonatal respiratory morbidity in the early term delivery.  American Journal of Obstetrics & Gynecology, 207(4), 1-4.

Evaluating the risk of respiratory distress in infants born between 37-38 weeks and 39 weeks.

Retrospective cohort study of singleton deliveries between 37 and 39 weeks gestation.  Reviewed 2273 deliveries.  Studied between January and December 2010 at the New York Presbyterian Children's Hospital.

Review of electronic medical records for baseline maternal demographics, diagnoses, and indication for delivery.  Neonatal charts reviewed by neonatologists.

Infants delivered between 37 and 38 weeks had a 2-fold increased risk of respiratory distress than those born after 39 weeks. 

The results urge to limit elective induction of labor to greater than 39 weeks gestation.

Jain, L., & Eaton, D.C. (2006).  Physiology of fetal lung fluid clearance and the effect of labor. Seminars in Perinatology, 30. 34-43. 

Discusses respiratory morbidity and ion transport in the transitioning infant.

        

Kamath, B.D., Marcotte, M.P., DeFranco, E.A. (2011).  Neonatal morbidity after documented fetal lung maturity in late preterm and early term infants.  American Journal of Obstetrics & Gynecology, 204(6). 1-8. 

Study to determine if an amniocentesis to detect fetal lung maturity predicted the absence of morbidity in infants.

Retrospective cohort study examining 152 infants born between 37 and 39 weeks after a mature amniocentesis.  Study was between January 2005 and February 2010 at the Good Samaritan Hospital in Cincinnati Ohio.

Chart review of both mother and infant.  Data was analyzed electronically.

Despite a mature amniocentesis, infants born prior to 39 weeks had more morbidities than those born after 39 weeks.

Amniocentesis is insufficient in determining fetal lung maturity in the post natal life.

Katz, C., Bentur, L., Elias, N. (2011).  Clinical implication of lung fluid balance in the perinatal period.  Journal of Perinatology, 31, 230-235. 

Examines postnatal lung fluid reabsorption.

        

Laughon, S.K., Zhang, J., Grewal, J., Sundaram, R., Beaver, J., Reddy, U.M. (2012). Induction of labor in a contemporary obstetric cohort. American Journal of Obstetrics & Gynecology, 206(6),

Studied details of induction of labor including precursors, methods, and vaginal delivery rates.

Retrospective cohort study of 208,695 deliveries in 19 hospitals in the United States from 2002 to 2008.

Review of electronic medical records.

Elective induction of labor at term with patients who have had children has a high vaginal birth rate - 97%.  Those who have not had children had a 76.2% rate of vaginally delivery.  Vaginal rates were higher better bishops score. 

Selection of candidates for induction of labor is important.  Waiting for labor to occur spontaneously will dramatically decrease cesarean section rate across the country.

Lindstrom, K., Linblad, F., Hjern, A. (2011).  Preterm birth and attention-deficit/hyperactivity disorder in schoolchildren.  Pediatrics, 127(5). 858-865.

Analyzed effect of delivery prior to 39 weeks on the risk for ADHD.

Swedish cohort of 1,180,616 school age children born between 1987 and 2000 taking ADHD medication.

Logistic regression to create an odds ratio.

Increase in odds for ADHD medication with increasing degree of immaturity at birth.

Early term birth increases the risk of ADHD.  Avoidance of preterm or early term deliveries is necessary.

U.S. Census Bureau. 2012. Induction of labor by gestational age: 1990 to 2008. Retrieved November 2, 2012

Census statistics on induction of labor between 1990 to 2008.