American Academy of Nursing

View all recommendations from this society

June 12, 2016

Don’t promote induction or augmentation of labor and don’t induce or augment labor without a medical indication; spontaneous labor is safest for woman and infant, with benefits that improve safety and promote short- and long-term maternal and infant health.

The rate of induction in the United States (23.4% of all births) has more than doubled since 1990. The increase is not thought to be attributable to a similar rise in medical conditions in pregnancy that warrant induction of labor.

Researchers have demonstrated that induction of labor for any reason increases the risk for a number of complications for women and infants. Induced labor results in more postpartum hemorrhage than spontaneous labor, which increases the risk for blood transfusion, hysterectomy, placenta implantation abnormalities in future pregnancies, a longer hospital stay, and more hospital re-admissions. Induction of labor is also associated with a significantly higher risk of cesarean birth. For infants, a number of negative health effects are associated with induction, including increased fetal stress and respiratory illness.

Research on the risk-to-benefit ratio of elective augmentation of labor is limited. However, many of the risks associated with elective induction may extend to augmentation. In a recent systematic review, the authors found that women with slow progress in the first stage of spontaneous labor who underwent augmentation with exogenous oxytocin, compared with women who did not receive oxytocin, had similar rates of cesarean. Such results call into question a primary rationale for labor augmentation, which is the reduction of cesarean surgery.

In addition to the serious health problems associated with non-medically indicated induction of labor, hospitals, insurers, providers and women must consider a number of financial implications associated with the practice. In the United States, the average cost of an uncomplicated cesarean birth is 68% higher than the cost of an uncomplicated vaginal birth. Further, women who deliver vaginally have shorter hospital stays, fewer hospital readmissions, faster recoveries and fewer infections than those who have cesareans.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a health professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician or nurse.

How The List Was Created

The American Academy of Nursing has convened a workgroup of member fellows who are leaders of professional nursing organizations representing a broad range of clinical expertise, practice settings and patient populations. The workgroup collaboratively identifies nursing/interdisciplinary interventions commonly used in clinical practice that do not contribute to improved patient outcomes or provide high value. An extensive literature search and review of practice guidelines is conducted for each new proposed recommendation for the list. The supporting evidence is then reviewed by the respective nursing organization(s) with the most relevant expertise to each recommendation. The Academy workgroup fellows narrow the recommendations through consensus, based on established criteria. The final recommendations are presented to the American Academy of Nursing’s Board of Directors for approval to be added to the Choosing Wisely list created by the Academy.

The American Academy of Nursing’s conflict of interests and disclosures policy can be found at www.AANnet.org.

Sources

Non-medically indicated induction and augmentation of labor. J Obstet Gynecol Neonatal Nurs. 2014 Sep-Oct;43(5):678-81.

Bugg GJ, Siddiqui F, Thornton JG. Oxytocin versus no treatment or delayed treatment for slow progress in the fi stage of spontaneous labour. Cochrane Database Syst Rev. 2013 Jun 23;6:CD007123.

Goer H, Roman A, Sakala A. Childbirth Connection. Vaginal or cesarean birth: What is at stake for women and babies? New York (NY): Childbirth Connection; 2012. 52 p. Available from: http://transform.childbirthconnection.org/reports/cesarean/.

Institute for Safe Medication Practices. ISMP’s list of high-alert medications. ISMP Medication Safety Alert. 2007;5(8)1-4. Available from: http://www.ismp.org/Newsletters/nursing/Issues/NurseAdviseERR200708.pdf.

Martin JA, Hamilton BE, Ventura SJ, Osterman MJ, Wilson EC, Mathews TJ. Births: final data for 2010. Natl Vital Stat Rep. 2012 Aug 28;61(1):1-72.

Moore J, Low LK. Factors that influence the practice of elective induction of labor: what does the evidence tell us? J Perinat Neonatal Nurs. 2012 Jul-Sep;26(3):242-50.

Moore JE, Low LK, Titler MG, Dalton VK, Sampselle CM. Moving toward patient-centered: women’s decisions, perceptions, and experiences of the induction of labor process. Birth. 2014 Jun;41(2):138-46.

Zhang J, Troendle J, Reddy UM, Laughon SK, Branch DW, Burkman R, Landy HJ, Hibbard JU, Haberman S, Ramirez MM, Bailit JL, Hoff MK, Gregory KD, Gonzalez-Quintero VH, Kominiarek M, Learman LA, Hatjis CG, van Veldhuisen P; Consortium on Safe Labor. Contemporary cesarean delivery practice in the United States. Am J Obstet Gynecol. 2010 Oct; 203(4), 326.e1–326.e10.