Pros and Cons of Induction in L&D

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    This question is for seasoned L&D nurses, CNMs, and OBs: Are you supportive of inducing labor in your patients? Why/why not?

    After a year of working L&D, I'm stunned by how many of my patients are induced for one slightly elevated blood pressure, or for another reason that seems less than reasonable/urgent. I've seen many of these patients -- and their babies -- have poor outcomes and complications, including fetal distress, hemorrhage, unwanted c-section, and vacuum assisted delivery, among others. I have to wonder if it's (at least partly) a result of the induction, especially when they're a mere 36 or 37 weeks, or if the induction before baby and mom are ready to deliver contributes to these outcomes. While I *strongly* believe that medicine has a place in labor and birth when warranted, I question whether it's an interference in many of my patients whose bodies and babies are simply not yet ready for delivery.

    Experienced practitioners, what do you think?
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  3. 10 Comments so far...

  4. 12
    I think that without a legitimate medical indication, labor should not be induced prior to 41 weeks. Luckily the midwife practice and hospital I work with agrees. Not coincidentally, our hospital has a 16% C/S rate.
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    It's doubtful any practitioner will induce (especially at 36 weeks) for one elevated BP. Drawing PET labs or collecting a 24 hour urine can determine if the pt is preeclamptic, which is definitely an indication for induction. Look deeper. Ask questions of the practitioner such as, "What was/is the medical indication for this induction?" Apologize for probing deeper and tell her doc that you're new to L&D and want to learn and would he/she mind if you ask a few questions? Maybe she had an unfavorable BPP, perhaps an non-reactive NST. Maybe in addition to that elevated BP, her liver enzymes were climbing and her platelets dropping? There's usually a good reason you might be missing but every situation is unique so you, as her nurse, need to be proactive about asking questions so you understand how best to educate and co-manage this patient's care.

    The biggest downside to me for induction is the emotional factor. It's the long process of making the body do what it isn't ready to do, especially for primips. They come to the hospital with all their luggage, family and friends in tow, nerves on edge, and look like you just punched them in the stomach when you tell them no, the baby isn't coming tonight. Then they start the great debate of should I send my friends home when the answer is yes, you're going to need your sleep.

    Anyhow, I digress. I, personally, haven't seen a higher incidence of vacuum assisted deliveries with inductions but I have with GDM+ mothers with macrosomic babies or for fetal malpresentation. As for an increase in C/S rate, that answer can probably be found in her H&P (looking deeper) rather than just assuming it was because she was induced. Again, WHY is she being induced? Critical thinking really comes into play here.
  6. 3
    I have seen an improvement in things over the years. At least we no longer do elective inductions around here earlier than 39 weeks. As for inducing for high blood pressure, preeclampsia scares the dickens out of me, and I have seen some bad crap go down with preeclamptic moms, even when their BPs weren't terribly high. I agree with the poster who said to ask. You might be surprised at their reasoning. And just like good nurses, good docs have an instinct about things. I will never forget a patient we had years ago who had delivered her previous kids in another state with a midwife in a birthing center. We don't have these options, so she was forced to deal with a doctor and hospital. The doctor begged her to be induced at 40 weeks, patient refused adamantly, and the baby had a cord accident at 40 1/7 and was a stillbirth. The doctor told the nurses that she just had a bad feeling. The next 2 babies this patient had were induced at 39 weeks, following weeks of NSTs. Of course, not all inductions are reasonable. Yes, there are doctors out there who will find a reason to induce for some patients, just because they want to. I've seen some questionable medical indications for inductions when it's really because the doc is going out of town or something, but not often. Most of the OBs I've worked with really want the best for their patients and the babies.

    I can't see how induction and use of vacuums are tied together. There is a definite link between induction and cesarean, and for epidural and cesarean. But cesarean is a risk every laboring woman faces. I was neither induced nor had an epidural, and I ended up having a cesarean after 12 hours following SROM for CPD. My wee little man had a beautiful round head. He'd never engaged, at all. We had very few vacuum or forceps deliveries, but we also had a fair number of primary cesareans for suspected macrosomia. We also had very few shoulder dystocias.
    toomuchbaloney, Tonyac303, and Elvish like this.
  7. 3
    Not an L&D nurse, but I have to tell this story. When my dear D-i-L had her baby, every mother in that unit had their induction meds begun on Monday so they would deliver on Wednesday and be out of there by Saturday. No joke. It was well-known that the docs who did 90% of the deliveries at that shop liked it better that way. The nurses hated it when they got patients who didn't use that service, because that meant there were fewer opportunities to call off over the weekend.

    And my D-i-L who really wanted to breastfeed couldn't despite trying so hard and doing all the right things...come to be told that the meds they used for her induction tended to suppress lactation. I don't know if that's true but she was just crushed. Needless to say, baby #2 is being delivered elsewhere, and in its own sweet time.
    toomuchbaloney, bebbercorn, and klone like this.
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    Lately, it seems like the inductions we do are medically indicated, pre-e or severe range pressures being a biggie. Unless medically indicated, I believe all first timers should go naturally into labor on their own. Their risk of a C-section is decreased if that is allowed to occur. For our high bps, we do NST, serial bp, and pre-e labs to r/o complications.
  9. 1
    One of my hospitals implemented a hard stop policy for inductions prior to 40 weeks. All inductions prior to 40 weeks have to be cleared by the midwifery chief. I love it. My other hospital still induces prior to 40 weeks, ostensibly for medical reasons only, but. . . we had one mom last week who was induced for maternal tachycardia, and her pulse never broke 90 during her whole stay, and I didn't see a single elevated reading in her prenatal record. :/

    My favorite is the 38 week inductions for "LGA" babies. Sigh.
    toomuchbaloney likes this.
  10. 0
    We've been part of the MOD initiative and our inductions prior to 39 weeks has really declined. Our docs have been pretty good about having true medical complications for needing delivery prior to 39 weeks. We do still see a lot of patients being induced at exactly 39.0 but we are seeing more and more wait until 40 weeks
  11. 1
    Quote from GrnTea
    Not an L&D nurse, but I have to tell this story. When my dear D-i-L had her baby, every mother in that unit had their induction meds begun on Monday so they would deliver on Wednesday and be out of there by Saturday. No joke. It was well-known that the docs who did 90% of the deliveries at that shop liked it better that way. The nurses hated it when they got patients who didn't use that service, because that meant there were fewer opportunities to call off over the weekend.

    And my D-i-L who really wanted to breastfeed couldn't despite trying so hard and doing all the right things...come to be told that the meds they used for her induction tended to suppress lactation. I don't know if that's true but she was just crushed. Needless to say, baby #2 is being delivered elsewhere, and in its own sweet time.
    Typically they use Pitocin for inductions. It doesn't suppress lactation, but it does affect the physicality of breastfeeding. Pit causes retention of fluids (and we tend to give lots of fluid in L&D) which flattens out the nipples. I had extreme difficulty with breastfeeding. The lactation nurse looked at me and said, "Ah, pit nipples." Excuse me?? All my years in L&D, and I never thought of this being an issue. But if the breasts are fluid overloaded along with the rest of the body, the nipples tend to disappear making it hard for the baby to latch. Sorry she had such a rough time.
    toomuchbaloney likes this.
  12. 0
    Quote from monkeybug
    Typically they use Pitocin for inductions. It doesn't suppress lactation, but it does affect the physicality of breastfeeding. Pit causes retention of fluids (and we tend to give lots of fluid in L&D) which flattens out the nipples. I had extreme difficulty with breastfeeding. The lactation nurse looked at me and said, "Ah, pit nipples." Excuse me?? All my years in L&D, and I never thought of this being an issue. But if the breasts are fluid overloaded along with the rest of the body, the nipples tend to disappear making it hard for the baby to latch. Sorry she had such a rough time.
    Yeah, one of the things lactation showed us a few years back is to assess how much fluid mom had gotten in labor. If it was more than a couple bags we were taught areolar compression, which temporarily redistributes the fluid and helps baby latch.
    Reverse Pressure Softening - Breastfeeding Online


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