Why do some obstetricians, midwives and family physicians electively induce labor? The answer is long and politically infused. Nevertheless, it includes patient desires, physician convenience and the acceptance of induction as a form of labor.
The induction of labor is the use of medicine or other methods to initiate uterine contractions. If performed for nonmedical indications, the gestational age should be at least 39 weeks or more and the cervix ought to be favorable, especially in the nulliparous patient. Elective inductions do not include medically indicted inductions, for example, preeclampsia. The American College of Obstetrics and Gynecology Voluntary Review of Quality Care program lists induction of labor without clinical indication as a recurring issue that presents obstacles to patient safety.
As with any elective medical procedure there are potential risks, though in pregnancy this includes the mother-infant dyad. Risks include the increased exposure to oxytocin, uterine tachysystole, abnormal fetal heart rate patterns, and failure to perform a C-section in a timely fashion. An additional hospital concern is the financial strain due to fixed reimbursement and higher costs of care due to longer lengths of stay and more medical interventions for the mother and infant. This cost is significant as childbirth is the largest category of hospital admissions for commercial payers and Medicaid programs.
Some pregnant patients request the elective induction of labor. Reasons may include maternal discomfort, concern about being able to get to the hospital in time, having the spouse or partner at the delivery, and scheduling issues with work or childcare. For an elective induction of labor to proceed, the patient is required to sign a consent form. Induction consents vary between hospitals. However, they should contain educational information on favorable cervices with a Bishop score of ≥ 8 (soft and open), the potential for cesarean delivery and the possible risks of poor maternal and neonatal outcomes.
Health care providers may request a patient to have an elective induction of labor and the “fee for service” model is a factor. This routine is common for physicians in solo practice with needed time off call or impending vacation. In addition, many physicians in group practice schedule elective inductions when they are on call for the purpose of financial gain.
As a patient, I requested an elective induction of labor in 1998. I was training as a fellow and just over 40 weeks gestation. I recall being physically miserable. The gynecology residents would help me strap on a belly bra so I could endure the hours of standing in the operating room. Was my induction medically indicated? No, however, at that time there was a paucity of research in the area of elective inductions. Would I do it differently now because of evidenced based medicine? Yes.
In today’s health care environment, the elective induction of labor is no longer sustainable. Recent medical research questions the safety of inductions and labor and delivery units are closing secondary to negative financial margins. Patient and physician convenience can no longer be the driving force of elective inductions of labor. As physicians, we have a duty to educate our patients to the risks, benefits and alternatives to an elective procedure and take charge of our own quality, patient outcomes and cost.
Vivian E. von Gruenigen is chair, obstetrics and gynecology, Akron City and St. Thomas Hospitals. She blogs at flourish.
