23
Baby by Appointment? NURS 350~ Ferris State University Amanda Badgley Christine Demler Mariah Lab Tracie Strand Denise VanderWeele

Baby by Ap p ointment?

  • Upload
    marvel

  • View
    63

  • Download
    0

Embed Size (px)

DESCRIPTION

Baby by Ap p ointment?. NURS 350~ Ferris State University Amanda Badgley Christine Demler Mariah Lab Tracie Strand Denise VanderWeele F erris State University, NURS 350. Spontaneous Onset of Labor VS. Elective Induction of Labor. Spontaneous Onset of Labor starts naturally - PowerPoint PPT Presentation

Citation preview

Baby by Appointment?

Baby by Appointment?NURS 350~ Ferris State University Amanda BadgleyChristine DemlerMariah LabTracie StrandDenise VanderWeele

Ferris State University, NURS 350

As our lives become more complicated and schedule-driven, working parents are looking for ways to schedule their babys birth around their already busy lives. Labor and Delivery nurses have noticed an increased trend in what they call social inductions, which are inductions of labor for social not medical reasons. These are also called elective inductions of laborInducing labor in a woman whose health or babys well-being is compromised by the pregnancy is not considered an elective IOL in this paper. We are addressing the elective IOL at term gestation for which there is no medical reason to induce labor. The decision to have an elective IOL is between the patient and her doctor.

Spontaneous Onset of Labor VS.Elective Induction of Labor

Spontaneous Onset of Laborstarts naturallyusually occurs between 38-42 weeks gestation

Elective IOLno medical reason 1/3 of all deliverieshttp://www.123rf.com/photo

Spontaneous onset of labor refers to a labor starting on its own.Elective Inductions of Labor are started through medical intervention such as cervical ripening with prostaglandins, amniotomy, or the use of oxytocin to induce labor.From 1990-2004, overall induction of labor rates in the U.S. increased from 9.5% to 22.1%.(Caughey et al). By 2010, 1/3 of all deliveries were started by artificial means. This amounts to over 600,000 induced labors annually (Menacker & Hamillton, 2010).Of those induced, what percentage fail to deliver vaginally? Graphics from: http://www.123rf.com/photo_5383762_pink-baby-booties-on-a-calendar-background-baby-due-date.html

Expectant Management of Labor

C/section Trends53%Incr. between 1996-2007

32.8% Of all deliveries in 2010

OB nurse observations (Menacker, & Hamilton, 2010).

Expectant management of labor is a term used to describe watchful waiting close observation of the pregnancy without interference. Expectantly managed labors may require intervention if stalled or extending beyond 42 weeks gestation.

According to the Centers for Disease Control (Menacher & Hamilton, 2010) the c/s rate in the US has increased by 53% from 1996-2007.In 2010, 32.8% of all deliveries in the USA were surgical (Menacker, & Hamilton, 2010).Obstetric nurses are one the frontlines of these trends, since they care for women during labor. They have observed the increase in elective or social IOLs and the rising cesarean section rate. Which leads to this question:Graphics from: http://www.shutterstock.com/pic-4044196/stock-photo-smiling-young-doctor-holding-a-beautiful-newborn-baby.html

PICO Statement

P (Population) normal pregnant women at > 38 weeks gestationI (Intervention)having an elective IOLC (Comparison) waiting for the spontaneous onset of laborO (Outcome) have a higher c/s rate as a result of a failed induction

Our PICO statement:Do pregnant women with normal intrauterine pregnancies who elect to have an Induction of labor between 38 and 42 weeks gestation when compared with women who go into spontaneous labor, have a higher incidence of cesarean births as a result of a failed induction?The term failed" is used to indicate that for whatever reason a labor has not progressed to a vaginal delivery.Lets see what the evidence says.

Literature Search

High level of evidence

Peer reviewed

Recent research

Reliable publications

The Cochrane Library, PubMed, Medline and CINAHL databases were searched for relevant research on our topic. Ten stduies were originally selected by our group which were weighed based on how current, applicable, level of evidence and availability of the whole text. Some reearch was too old and the texts were unavailble without a fee. We discarded these studies.

The four studies selected were recent, relevant, and from reliable sources. They were published within the past three years. All were at an evidence level of 2 or 3, peer reviewed and associated with major medical centers.

Article #1 OverviewElective IOLsfull term pregnancies (37-41 weeks)frequency of emergency c/section using different induction methods.Conclusion:Elective IOLs = 2x chance of emergency c/section Cervical ripening = 3x chance of emergency c/section (Jonsson, Cnattingius, & Wikstrm, 2012)

This study was focused on the elective induction of full term pregnancies (37-41 weeks) and the frequency of emergency cesarean section using different induction methods (Jonsson, Cnattingius, & Wikstrm, 2012). The study concluded that electively inducing labor doubled ther chance of emergency cesarean section and using a cervical ripening agent tripled the incidence of having an emergency cesarean section (Jonsson, Cnattingius, & Wikstrm, 2012). Article #1 Evidence 13,980 births 7973 met criteria 7630 women had spontaneous labor343 had elective IOLProlonged labor: stress on babynon-reassuring fetal emergency c/section (Jonsson et al., 2012).

13,980 births were considered from a birth record database. It was then narrowed down to 7973 that met he exact criteria for the research.7630 women went into spontaneous labor while 343 chose an elective inductions of labor.

It ws found that prolonged labor can cause stress n the baby and lead to a no reassuring fetal status. This may precipitate an emergency cesarean section (Jonsson et al., 2012). Article #1 ConclusionsThe information in this article can help doctors and patients make a more informed choice on whether or not to induce labor especially if there is no medical need to induce.

The conclusions reach in this study were mentioned earlier: that elective induction of labor doubles the chance of cesarean birth and that use of cervical ripening agents triple the risk of c/section.

WE feel that the information in this article can help doctors and patients make a more informed choice on whether or not to induce labor when there is no medical need for the induction. Article #2 Overview13 hospitals in Finger Lakes, NY. 14,500 deliveries per year.New York State birth-certificate database from 2004-2008.38,000 women low-risk singleton vertex presentationlabored and delivered between 37 0/7 and 42 6/7 weeks (Glantz, 2010).

Our second article was an observational study conducted in Finger Lakes, NY. This included 13 hospitals which have a combined a 14,500 deliveries per year.The data was retrieved using a New York State birth-certificate database from 2004-2008. In this study, 38,000 women were chosen who had a low-risk, singleton, vertex presentation, who labored and delivered between 37 0/7 and 42 6/7 weeks (Glantz, 2010).

Article #2 EvidenceSpontaneously laboring women (n=10, 608)

Elective induction (n=1,241) were determined to have an increase chance of intrapartum interventions and adverse maternal outcomes.higher rates of NICU admissionsmaternal length of stay increased by 0.34 days (Glantz, 2010).

Spontaneously laboring women (n=10, 608) compared to women who chose and elective induction (n=1,241) were determined to have an increase chance of intrepartum interventions and adverse maternal outcomes.Induction was associated with higher rates of NICU admissions as compared with spontaneous labor. It was concluded that maternal length of stay was 0.34 days longer with elective induction compared to spontaneous labor (Glantz, 2010).

Article #2 Conclusions risk for cesarean deliveries by 1-2 deliveries per 25 elective IOLs v. spontaneous labor or expectant management. One million inductions in U.S.per yearcould mean as many as 40,000 cesarean deliveries could be potentially avoided (Glantz, 2010).

A conclusion was made that there is an increased risk for cesarean deliveries with elective induction compared to spontaneous labor or expectant management by a rate of one to two additional cesarean deliveries per 25 inductions. With an estimated one million inductions in the United States, this could mean as many as 40,000 cesarean deliveries could be potentially avoided (Glantz, 2010).

Article #3 OverviewBirth between 2006-2008

Chosen by a data base after the computer filtered through the women who met the inclusion criteria.

Divided into either the control group or the test group (Osmundson, Ou-Yang, and Grobman, 2010).

This article (Osmundson, Ou-Yang, and Grobman, 2010) used a Retrospective cohort study that included women who had given birth between 2006-2008.The women were chosen by a data base after the computer filtered through the women who met the inclusion criteria.

Then the women were divided into either the control group or the test group.Article #3 EvidenceTest Group & Control Group 294 women in each groupNulliparity (first pregnancy), Gestational age >39 0/7 weeksA singleton vertex presentationKnown cervical status at 38 0/738 6/7 weeks of gestation,A modified Bishop Score of at least 5(Osmundson et al., 2010).

The test groups and control group each had 294 women who were nulliparous, at 39 0/7 or greater gestational age with a singleton, vertex presentation. Their cervical status was known at 38 0/7-38 6/7 weeks gestation. Each had a modified Bishop Score of at least 5 (Osmundson et al., 2010)..

Article #3 Evidence (cont)

All data are mean +/- standard deviation or %. (Osmundson et al., 2010, p. 603)

There was no overwhelming evidence to prove that cesarean rates are related to the increase in elective inductions (Osmundson et al., 2010). This study did prove that women who chose to have an elective induction had longer labor times and need more medicalinterventions durin labor, which can lead to longer hospital stays and cost more money (Osmundson et al., 2010). Article #3 ConclusionPeer reviewed and has been approved by Northwestern University (Osmundson et al., 2010).

Without bias

Research information 1975 to present

Different results with larger sample size?

This study was Peer reviewed and approved by Northwestern University (Osmundson et al., 2010). The authors delivered the data without bias. The research information covered the years from 1975 to the study date.The authors acknowledged that there is always room for improvement in a research study. The allowed that this study might have seen different results if it had a bigger sample size. *It would be interesting to see how many inductions that are done nationally actually meet the induction criteria set forth in this study. Article #4Stanford -SCSF Evidence-Based Practice CenterMaternal risk in elective IOL vs. Expectant management & Spontaneous onset of Labor3,722 published articles reviewed76 met criteria (Caughey et al., 2009). further classified by gestational age

A study from The Stanford-SCSF Evidence-Based Practice Center explored maternal risk of elective IOLs versus expectant management of labor and spontaneous onset of labor with a focus on maternal and neonatal outcomes (Caughey et al, 2009). The method used was a systematic review of literature that produced 3,722 published articles, with 76 meeting their criteria. This seemed to be the most extensive analysis completed of all the studies reviewed. Caughey et al looked at expectant management v. elective IOL v. spontaneous labor and further divided their data sets by gestational age.

Article #4 EvidenceThe overall cesarean delivery rate among the women who were induced and those who were expectantly managed was 11 percent and 14 percent, respectively, (Caughey et al., 2009)

20% reduction in c/sect rate for women induced at > 41 0/7 wks. gestation.

< 41 weeks - no difference in C/sect rate(Caughey et al., 2009)

This study had some confounding data. The authors stated that The overall cesarean delivery rate among the women who were induced and those who were expectantly managed was 11 percent and 14 percent, respectively, (Caughey, et al, 2009)And then concluded Thus, if elective induction of labor leads to higher rates of cesarean delivery, it may lead to increases in perinatal complications and costs in both current and future pregnancies, (Caughey, et al, 2009)

Article #4 EvidenceThese findings are consistent with other meta-analysis of induction of labor in post term and term pregnancies but are contrary to many observational studies. (Caughey et al., 2009).

Another interesting conclusion is that the authors stated that "When measured against cost-effectiveness of inductions of labors, they found that IOLs at 41 weeks gestation required less hospitalization and less intervention than expectant management, and postulated that this may also be true for earlier gestations (Caughey et al, 2009).

Article #4 Conclusions9 RCTs =20 % c/s rate for elective IOLs at > 41 wks. gest. v. expectant management of labor

Observational studies = C/s rate for patients who choose elective IOL

No difference in c/s rate for those elective IOLs < 41 wks. gest

Some other data stated that in 9 random controlled studies there was a 20 % decrease c/s rate for elective IOLs at >41 wks. gest. v. expectant management of labor. This is contrary to most observational studies that claim an increased C/S rate for all patients who choose elective IOL (Caughey et al., 2009). There was also no difference in c/s rate for those elective IOLs < 41 wks. gest (Caughey et al., 2009).

So, who or what do you believe? Analysis & ApplicationElective induction?C/section? Gestational age?Expectant Management?Bishop score?Favorable Cervix?

Spontaneous Labor?

Our studies seem to contradict each other, and there was in fact two studies that named each other specifically when discussing their conclusions. These were articles # 3 & # 4 in this presentation. Because of the great variation in definitions of control groups, expectant management of labor and differences in comparing inductions of labor to those who went into spontaneous labor versus those who were expectantly managed, the conclusions are not clear. What did stand out in our research was the need for the Obstetric nurse to not assume that elective inductions of labor necessarily lead to a higher rate of emergency cesarean sections in spite of what we observe. The evidence has many variables to it and we would be wise to take that into account when holding such a belief. Article #4 brought up confounding data, which caused us to dig deeper into the evidence. Further research clearly needs to be done in order to standardize exactly what variables are being scrutinized in relation to the labor that is being electively induced. Nurses should keep an open mind and actively participate in the gathering of data to answer these questions.ReferenceCaughey , A., Sundaram , V., Kaimal , A., Cheng , Y., Gienger , A., Little , S., Lee , J., & Wong , L. (2009). Maternal and neonatal outcomes of elective induction of labor. 176(1), 1-257. Retrieved from http://0-www.ncbi.nlm.nih.gov.libcat.ferris.edu/books/NBK38679/

Glantz, J. (2010). Term labor induction compared with expectant management. Obstetrics & Gynecology,115(1), 70-76. doi:10.1097/AOG.0b013e3181c4ef96

Reference

Jonsson, M., Cnattingius , S., & Wikstrm , A. (2012). Elective induction of labor and the risk of cesarean section in low-risk parous women: a cohort study. Acta Obstet Gynecol Scand, 92(2), 198-203. doi: 10.1111/aogs.12043

Menacker, F. & Hamilton, B. (2010). Recent trends in cesarean delivery in the United States. NCHS Data Brief 35. Retrieved from: http://www.cdc.gov/nchs/fastats/delivery.htm

ReferenceOsmundson, S., Ou-Yang, R., & Grobman, W. (2010). Elective induction compared with expectant management in nulliparous women with a favorable cervix. Obstetrics & Gynecology, 116(3), 601-605. doi:10.1097/AOG.0b013e3181eb6e9b