Evidence-Based Practice by Nurses for Nurses: Encouraging Waiting Spontaneous Labor

This article describes an evidence-based patient-centered campaign and clinical resources that were developed by nurses, for nurses. Evidence includes an older AHRQ systematic review combined with current and emerging evidence. The topic (early induction of labor) is a high priority across many disciplines and is a strong example of how evidence can stimulate and inform changes in practice that are entrenched routines (you know the refrain -- "because we've always done it that way."). We hope you enjoy this new posting and explore the embedded links to the evidence-based materials.

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Evidence-Based Practice by Nurses for Nurses: Encouraging Waiting Spontaneous Labor

Keeping women healthy during pregnancy and childbirth is critical not only to the health of the baby but also for the woman's lifelong health. Complications sustained during childbirth, including complications of cesarean birth, can negatively impact a woman's mental and physical health in the immediate postpartum period and in the long-term. Her newborn can be affected as complications can negatively affect breastfeeding, a woman's energy and her adjustment to parenting. A focus area of heightened attention in maternity care has been elective, or non-medically indicated, induction of labor because evidence shows this practice results in higher rates of cesarean for women who have induction of labor with their first pregnancy and/or with an unripe cervix.

NOTE: Since this article references materials not developed by AHRQ, we must note that the findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

Evaluating evidence for obstetric practices is complicated because practices, such as induction of labor without medical indications, began when there was less of an emphasis on an evidence basis for practice therefore the risks were not fully known or understood. The practice of elective inductions became culturally-accepted and widely used in obstetrical care. The practice paradigm is shifting away from elective inductions however many women are still expecting to have a non-medically indicated induction for convenience of family and work life. Women need to know the risks of elective inductions for themselves and their baby so they can make an informed decision about their birth choices.

Explaining the evidence behind culturally-accepted practices can be hard. Nurses are ideally suited to discuss the safety and harms of non-medically indicated induction of labor with their patients and also friends, family and their communities. No other group of professionals has such an intimate knowledge of the effects of induction on mothers and babies because nurses are responsible for the bedside monitoring of the high-alert medication oxytocin, which is used for most inductions. That's why the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) developed their public health campaign, Don't Rush Me--Go the Full 40, which gives women and nurses 40 reasons to wait for labor to start on its own when pregnancy is healthy. The reasons address what emerging evidence demonstrates regarding healthy labor and birth practices, such as:

  • Reason #3: Let nature take over--there are fewer complications and risks for both you and baby through natural birth
  • Reason #15: Give baby's development the benefit of time since you may not know exactly when you got pregnant
  • Reason #21: Ignore people who say an induction is more convenient. Nothing is convenient about a longer labor and increasing your risk of cesarean

The benefits of waiting for spontaneous labor and normal birth are well documented and result in giving mom and her baby the best possible start toward bonding, breastfeeding and recovery from labor and birth. Nurses can use the 40 Reasons article of the campaign (English & Spanish) to lead evidence-based, patient-centric discussions with women about the risks of elective induction of labor. Nurses can download a Go The Full 40 toolkit to share with their colleagues and patients, and engage with the Go The Full 40 Champions group, which advocates waiting for spontaneous labor when all is well in pregnancy.

Evidence has identified the risks and complications of administering exogenous hormones such as synthetic oxytocin to a woman and her baby to induce labor. An equally importance evidence question yet to be answered is what short and long term benefits do women and babies receive from the powerful natural hormones of spontaneous labor and birth?

Lynn Erdman, MN, RN, FAAN

AWHONN, Chief Executive Officer

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Thanks you for this great information! I Love the AHRQ!

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Great information. I'd love to read some EBP articles about positioning during labor as well. Why are women laying on their backs with legs splayed open for all to see? Give gravity a chance!

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Wow! This really helps. Thanks a lot.

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Specializes in RN, BSN, CHDN.

Many years ago I was a midwife in the UK-we encouraged all women to have natural child birth and it was successful majority of the time. Women developed such a wonderful relationship with their own midwife from conception through to birth, rarely did we induce

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Specializes in NICU, Trauma, Oncology.

While I agree with the evidence, as with the breastfeeding campaigns we need to remember that these are women trying to do what's best for their situation and sometimes these campaigns can become negative. In my personal experience, my water broke (SROM) at 39w1d at 3a.m. after being in pre-labor for about 36 hours. We went to the hospital, they checked the baby's position and he was transverse breech and I needed a section. I was devastated as I had a completely natural birth plan - no epidural, no pitocin, no interventions planned at all. So, I guess what I am trying to say is although the evidence is there, being bombarded with "if you didn't have natural birth (or breastfeed) your child won't be as healthy" talk. Just my two cents ...

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Great information. I'd love to read some EBP articles about positioning during labor as well. Why are women laying on their backs with legs splayed open for all to see? Give gravity a chance!

I've always wanted to see info on that, too, so I looked it up!

Maternal position, labor, and comfort

Effects of Sitting Position on Uterine Activity During Labor : Obstetrics & Gynecology

Labor pain: Effect of maternal position on front and back pain

Importance of the Lateral Position During Labor : Obstetrics & Gynecology

Alternative positions in the second stage of labour: a randomized controlled trial - GARDOSI - 2005 - BJOG: An International Journal of Obstetrics & Gynaecology - Wiley Online Library

Bottom line, there's not a huge difference for the baby, but there's typically as significant reduction in tearing, pain and other unpleasant side effects (such as reduction of the femoral pulse) when mom is NOT supine.

I've always wondered at why women were put up on display in the most physiological unreasonable position for labor, too. I've been told it was for the ease of the physician, who'd rather not have to squat to deliver a baby. I figure if I'm pushing for 12 hours, the least s/he can do is accomodate my preferred delivery position.

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While I agree with the evidence, as with the breastfeeding campaigns we need to remember that these are women trying to do what's best for their situation and sometimes these campaigns can become negative. In my personal experience, my water broke (SROM) at 39w1d at 3a.m. after being in pre-labor for about 36 hours. We went to the hospital, they checked the baby's position and he was transverse breech and I needed a section. I was devastated as I had a completely natural birth plan - no epidural, no pitocin, no interventions planned at all. So, I guess what I am trying to say is although the evidence is there, being bombarded with "if you didn't have natural birth (or breastfeed) your child won't be as healthy" talk. Just my two cents ...

Agreed. The studies I cited all deal with low-risk populations who were not determined to need any additional monitoring during labor.

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Specializes in Community, OB, Nursery.
While I agree with the evidence, as with the breastfeeding campaigns we need to remember that these are women trying to do what's best for their situation and sometimes these campaigns can become negative. In my personal experience, my water broke (SROM) at 39w1d at 3a.m. after being in pre-labor for about 36 hours. We went to the hospital, they checked the baby's position and he was transverse breech and I needed a section. I was devastated as I had a completely natural birth plan - no epidural, no pitocin, no interventions planned at all. So, I guess what I am trying to say is although the evidence is there, being bombarded with "if you didn't have natural birth (or breastfeed) your child won't be as healthy" talk. Just my two cents ...

There is always the situation where medical/surgical intervention is necessary/good/life-saving. Yours sounds exactly like that. You don't need to feel bad or beaten up because you had a necessary c/section.

Still, campaigns like this exist because we as a society seem to have swung the opposite way. C/section is viewed as no big deal because it's so routine, when the reality is it's major surgery. People go to their doctors asking to be induced at 35-36-37 weeks because they're tired of being pregnant. The general public doesn't get that Pitocin isn't a benign drug, or that epidurals do come with risks (and I had two so am on no sort of pedestal here), or that c/section babies do have a higher incidence of things like TTNB or breastfeeding issues, or that 35-weeker babies are not and should not be treated like full-term babies. That's what we're trying to combat here.

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Specializes in Nurse Educator; Family Nursing.

Finally. . .no more support for admissions and induction for "Tired of Being Pregnant" with a dubious due date because there was no menstrual history upon which to base the EDD and the ultrasound was performed after 24 weeks.

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Specializes in Nurse Educator; Family Nursing.

Keylimesqeez. . .the circumstances for your birth were totally different. Malposition. . .you couldn't have foreseen or controlled. I am so sorry that you didn't have the birth you anticipated.

This information is directed at caregivers who electively induce for social reasons (mother-in-law in town, so the baby can share his dad's birthday, tired of being pregnant, and on and on). The cost is too high for a baby who ends up with respiratory difficulty because his lungs aren't ready for breathing. The March of Dimes "Healthy Babies are Worth the Wait" program is like AWHONN's program.

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