Monday, September 14, 2009

Let's get started! Calling all labor nurses!

Every morning in report, we hear the scoop.  Who's being induced?  Why?  Who's the provider?  Is the patient due?  By what method? 
We've all been there, frustration sets in.  Your patient isn't due for a week or two.  She's only 1cm dilated.  She's only being induced because her provider is "on call".  Did she ask for this, or was she coerced? 

There are good reasons for inducing labor, and they are usually medically necessary for mother or child, or both.  But there are indicators and rules that providers should follow when they schedule an elective induction, meaning an induction for convenience. 

Please share your stories, ideas, and thoughts on this highly debated and controversial issue!

13 comments:

  1. I really truely believe that there are certain times when scheduled inductions of labor are appropriate. However, it's been the normally routine at my hospital for the physicians to induce just because they are either on call or it's convent. I do see the other side that patients are also putting more pressure on their providers to induce labor for their convenice or so it fits into their schedules as well. ACOG has standard guidelines for physicians in which they are allowed to schedule inductions, but at out current hospital we have several who do not follow these and may schedule 5-6 inductions on their call day. As a labor nurse, this makes it hard to also provide for those patients who really come into the hospital in labor on their own. Staffing becomes an issue as well as frustation. Not frustation from nursing staff, but the physician becomes harsh and edgy with the staff from numerous calls on several patient. Tension becomes a huge issue, and working together to provide the best care is no longer the focus....quick turn overs and fastest services is the current focus. We need to hold the physicians to their standard of practice and follow guideliunes set. Now, I do believe inductions serve a good purpose as well. Post date deliveries after 40 weeks are at higher risk for meconium aspirations, nuchal cords etc..When the mother is at risk for example: PIH and delivery is indicated for maternal health complication <39 weeks or any gestation that threatens her life. These are acceptable reasons. I know I've rambled on and hope that my point was made clearly. We need to start informing patients the risk of inductions: failed vagianl del and c/s, babies going to NICU for respiratory distress with a ballard score <37 weeks. Our focus should be the patient and the baby and not how having that baby fits into a schedule. <3

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  2. We live in a society of "me, me, me. it's all about me." and we treat our pregnant patients no different. Mothers should put the lives of their children above and beyond everything else in their lives. I can't stand an induction for "maternal discomfort" (thank goodness we are seeing less of this now!) and no one should be induced prior to 39 weeks gestation unless the health of the mother or fetus is as risk!! Health care providers need to stop "stripping membranes" at 35-36 weeks and patient education needs to start before the patient comes to the hospital. I was completely against my own induction and was willing to go all the way to 42 weeks - went to 39+5 weeks and had a major repair! - but I birthed a very healthy boy that had no risk of respiratory distress or low birth weight. I'm all for "natural labor" but I do understand the risk of post date deliveries. If only all our physicians would follow ACOG guidelines!!

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  3. I feel we should be educating mothers and families about what an elective induction truly means. Far too many women are so trusting of their providers that they don't even question when an induction is offered as a choice. In my many years of experience there have been numerous women who have come in for induction who have had no idea why or how they were being induced, let alone that there were added risks by coming in for an induction. Informed consent does not seem to apply to inductions. If mothers and their partners were given the information about increased risk of NIC admits, increased number or maternal and infant injuries, higher rate of interventions, and c/sections that come along with elective induction prior to 39 wks I think we would see far less of them. I also feel there should be an induction policy giving strict guidelines as to when an induction can be done put in place by the hospitals. This would help those providers that have a hard time telling patients no who are asking to be induced.
    It seems it has become the norm in our society to be induced. It is much easier to schedule an induction into a planner like we schedule a dental appointment or vacation; we like to be in control. It is time we let Mother Nature take control back, she has a better plan then we do and typically better outcomes. Education is the key.

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  4. So as not to consume too much time or space, I would like to summarize my concerns about induction of patients.

    1. Baby is not as developed as we think and ends up with lung issues and has to go to the NICU

    2. Failure to successfully induce labor which leads to a c section and subsequent surgical deliveries in the patient's future

    3. Reinforcing that instant gratification in our society is acceptable

    In this day and age, we have become a society that believes we should get what we want, despite the cost. That cost may not be monetary and could affect the quality of an event or a life. When did patients stop being patients and start being looked at as consumers by the medical profession? It seems physicians are more concerned with popularity and their patients liking them than what's really best for the patient and the baby.

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  5. I was induced both times and had successful deliveries. The first induction was me asking because I had limited time to spend with my newborn, not a good reason, I know. The second time, my doctor was on call. I feel like both of my inductions went smoothly and would do it again if I had to. I was also 4-5cm dilated when my inductions began, not 1-2cm, which makes a difference, in my opinion. I disagree with inductions for "maternal discomfort". I also agree that if inductions are started when a pt is not dilated much or not effaced enough, their chances of having a c-section increase significantly. Would I have liked to have gone into labor naturally? Hard to say really, I don't know any differently than being induced. I am one of the lucky ones whose inductions went well and took less than 6 hours from admittance to delivery! In the short time I did labor, I dreaded having the cyotec inductions that lasted forever, but didn't mind doing the pit, arom, pit/arom inductions, especially if the pt's were dilated more than 3cm. I think inductions should definitely be discussed with the patients along with the risks of being induced, so that they can make an informed decision. I also think inductions shouldn't happen unless the pt's are past 38 weeks or if there is a complication with mom or baby.

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  6. Alycia Patten MurdockSeptember 15, 2009 at 12:11 AM

    I had a baby 5 months ago and I was induced. It was my choice and I was only a week early. I had thought long and hard about it. I am 37 years old with degenerative disk disease and carrying that little guy was putting me in a lot of pain. I also had a sense that he needed to come in to the world... quickly. As it turns out, there was muconeum in his amniotic fluid when they "broke my water." And not just a little. He delivered very quickly (10 minutes) and as soon as he came out they were deep suctioning him. He was a sick little guy for a bit. The doctor said that it was fortunate that we decided to induce when we did. Not to mention, it relieved the pressure on my back. Now...as far as the whole argument for convenience...yes it was for both me and my doctor. Could I have waited one more week? Yeah, I could have...but could my perfect little son? Only God knows. I'm thankful that I had the option.

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  7. I was induced when I had my daughter 3 yrs ago. I went into the pregnancy thinking I did not want to be induced, but my dr started started talking about it at 13 wks. I agreed to the induction only because I wanted to avoid one of the other drs in the group. I, like Misty, was one of the "lucky" ones. I delivered an 8lb baby in 8 hrs from admission to delivery. Now that I'm thinking about having a second child, once again I am debating whether or not to be induced. I think this time I will talk to my dr right from the beginning about what I want for my labor/delivery - I'm leaning more towards an unmedicated, natural birth. If he is not willing to do that, I'll respect that but find another provider. Most pts aren't educated enough about the labor process or risks of induction to say that to their dr.
    It's amazing how much smoother (and quicker) labors seem to go when a mother comes in in labor. One problem I have with inducing a pt is they usually end up getting an epidural because they don't "ease" into labor. Yes, epidurals are less work as far as comforting pts goes, but they are so much more work as far as charting. We spend so much time charting, we can't labor the pt. They are also more intrusive on the pt with extra VS, catheters, etc.
    I'm with everyone else in that inductions should not be done unless there is a medical reason in the mother or baby.

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  8. Inductions have put many nurses in the middle of the debate between physicians. ACOG has a standard, AAP has a standard, and neonatology certainly has an opinion, unfortunately not all opinions are taken in account when an induction is scheduled.
    As a labor nurse, Nursery nurse, mother, and a not really wanting to be induced mother induced for gestational insulin dependent diabetic at 38 5/7 weeks, who was closed, thick and -4 station (if anyone can reach that) which ended in fetal distress and a c/s at 0323 in the morning, I am not in favor for inductions for patients who do not have a complication or true medical reason.
    We have seen so many infants induced at supposedly 39 weeks, who had "early sono's" and the babies come out with respiratory, blood sugar, temp control issues. Even a mature amnio does not mean an infant can maintain it's temp, keep it's blood sugar up, or breath adequately while eating. As a nurse the Pediatrician/neonatologist ask us why an induction was done, it's almost embarrasing to say "mothers convenience". A Baby is not a convenience so why does the world veiw going into labor as a convenient process. It is a privelege to be able to have a baby (all of us who were infertility patients know that), Priveleges should not be taken for granted. There are studies on late preterm infants out there that show, IQ goes up with each week of gestation completed. (We are cutting that brain development short with inductions) Children who went to term have fewer readmission rates and as a child have fewer hospital admissions and sickness.
    What mother would want an induction if she was educated that her baby could be smarter and healthier. I believe inductions are unnecessary without medical reason. I don't think the OB is using good judgement on the infants part when scheduling these. The OB has 2 patients to consider in this decision, not just a mother who is becoming overbearing and whining in their office every week.

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  9. I am not a nurse, just a mom whose labor didn’t go as planned. My pregnancy was quite healthy and uneventful, but at 38 weeks my water broke while out of town. When I got to the hospital, I wasn’t dilated at all, and was having no contractions, but my daughter WAS coming. I tried all kinds of things to get my labor moving along, none of which did any good. Six hours after my water broke, I hadn’t dilated past 1 cm, so they began pitocin, which I wouldn’t wish on anyone. After 18 hours and epidural issues, I progressed from 4 cm (where I’d been for hours) to 10 cm and got to start to push. She was born after just 15 minutes of pushing, perfect and healthy. I had heard all sorts of stories about inductions, and really didn’t want to be induced (although I don't count mine as a true induction because my water broke on its own).

    I am convinced, too, that had I had her with my own doctor’s group, I would have had a caesarian because of the amount of time I spent in labor, and the slowness at which it progressed. We ended up delivering at a large teaching hospital, so I’m not sure if they were more progressive because of that. We were also in a high risk unit due to our walk-in status, so my full term, adult mother, educated-about-pregnancy experience wasn’t their norm. When I first arrived, the doctor seemed a little taken back by my insistence that we try natural ways to start my labor. The nurse even complimented me on standing up for myself, and said she wished many more of her patients would do the same.

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  10. As a mom, a nurse, & a midwife I fully agree that the use of inductions are misused to the point one could use the term "abused". However, in a effort to shine a brighter light on this grim subject I hope everyone hears that it is not being misused all of the time everywhere. I have had the opportunity to work with some wonderful midwifes & OB/Gyns who have truly strived for a compromise and balance between persistant mothers and societal trends, to best/safest practices for moms and babies. I have seen a grand shift in the last couple of years from what seemed like "everyone" being induced between 38-39 weeks, to now much fewer inductions and if so very rarely before 40 weeks and most often into the 41 week. I realize in compared to the nation as a whole the area, community, & providers I am refering to make up a nearly unremarkable portion of the group. But I think it is important for us to stay positive about the possibility of change. And that with everyone's effort and support it is possible to impact lives and make a difference in practice.

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  11. I just assigned this very topic to my undergrad students yesterday! I've practiced as a labor and delivery nurse for many years, some in a hospital setting, some doing homebirths. I think medically necessary inductions save lives, but elective inductions, inductions for convenience sake, take too many risks, just for convenience. They increase the operative delivery rate, the NICU admission rate, and the rate of postpartum complications.

    I can think of a few social reasons, such as the father being in the country for a short time, where the benefits might outweigh the risks. I can also understand people wanting to lead "normal" lives and have babies arrive mostly during the day, mostly during the week. (Perhaps even on the doctor's lunch break!) I just wish we could change the thinking about convenience!! Babies are not convenient and should arrive, whenever possible, in their own good time.

    I cherish the memory of waiting for labor to begin, and how exciting it was when it did. I had my first at home and it is my best memory. With my second, I was coerced into an induction, and she was an emergency Cesarean delivery. I've always wondered if it that could have gone differently. I wonder if physicians were not so cavalier and/or pushy about inductions, if I wouldn't have felt the need to push back so hard. My placenta was old, so I probably did need to be induced, but nobody bothered to sit down and explain things, just told me what to do. And since I thought I was well-educated I didn't realize there were some things I didn't know. I learned them after the fact. From one of my doctors.

    It really frustrates me as nurse, too, that women come in for an induction and have no idea why. "My doctor scheduled it because I'm due."

    Something else that concerns me as a lactation consultant is that babies have more trouble learning to breastfeed. Even when they arrive just a little bit early.

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  12. As a long time OB nurse and lactation consultant I am saddened to see that we have taken a naturally occuring life event that has been in history handled by midwives has been turned into a medically generated procedure. That said, I agreed that there is a time and place for medical inductions. We are lucky to live in a time where those options are available as well as resources for neonates.

    A good reason against elective inductions is a recent study showed that 50% of women can't remember their exact LMP and of those, 50% were wrong on dating so that leaves only 25% with correct dating by LMP. Becuase of this most EDC's today are generated by sonograms. Since sonogram measurments are subjective and the most accurate scan is the approximately 6 week or earlier scan plus prenatal visits don't start typically until week 13 or greater this leaves a opening for dating error. I have also seen where due dates keep getting changed with every sonogram that is done.

    I agree with Kara, breastfeed babies born even a week early by induction can have difficulty with feedings. Medications and stress of long inductions also impact the natural immediate bonding and breastfeeding opportunities. Just because we have the knowledge and know how doesn't mean it has to be done. Where is medical judgement in the face of guidelines and standards of care. Hippocratic Oath - do no harm...

    What a great topic to debate. Thanks.

    A side thought, if these couples are asking for induction for "personal reasons" how will they handle to often messy uncomfortable role of parenthood.

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  13. Having been a labor nurse for over 23 years, I have seen many changes in the attitude toward inductions. It used to be that the majority of the inductions were done for postdates. And not that they were due yesterday, but we used to see people that were 42 wks. Not that I am advocating that. Now it seems that the majority are done for convenience of the mother or physician.
    I was not induced with either of my labors. My water broke at home. I really did not want to be induced unless I was postdates. Luckily I delivered 3 days before that with my first.
    I agree with what several people have said, in that mothers are not educated as to the process, risks and outcomes of elective inductions. I also think we do need to separate elective from medically indicated. Many women who don't want to be induced, end up being induced for reasons beyond their control. But I feel that many of the women today need to stand up and ask, "why do I need to be induced?", "how long can I go before needing to be induced?", or "what if the baby is not ready yet?" Times have changed and people do want what they want, when they want it, but need to realize that sometimes this results in difficulties for their baby that did not need to happen.

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