Running head: INTEGRATIVE REVIEW 1

Integrative Review

Michelle Arslan

Bon Secours Memorial College of Nursing

Nursing Research

NUR 4222

Christine Turner, PhD, RN

April 23, 2017

On my honor, I have neither given nor received aid on this assignment or test, and I

pledge that I am in compliance with the BSMCON Honor System.

INTEGRATIVE REVIEW 2

Integrative Review

Abstract

The purpose of this integrative review is to appraise literature pertaining and supporting

the possible necessary complications of elective inductions of labor based on the sole case of

convenience due to patients request; placing the patient and fetus a great risk for possible life

threating events. Elective inductions are used and scheduled on a regular bases for sake of

convince at thirty nine weeks of gestational age for first time mothers on my unit at Mary

Immaculate Birth Center. Data bases such as EBSCO Discovery services and Pub Med were

utilized and located over 350 related articles from the years spanning from 1998-2017. The

results from these five articles support and prove that inductions of labor should only be

scheduled and instilled on patients due to medical necessity. The complications associated with

the risks of such medical practice are supported by the literature within this integrative review.
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An Integrative Review

A medical induction of labor is an induction based on medical necessity, and benefits

both mother and baby. Some medical reasons for an induction of labor may be maternal

hypertension, fetal intrauterine growth restriction, poor placenta profusion, and even fetal

macrosomia. The American Congress or Obstetrics and Gynecologists also known as ACOG is

the national body to which all evidence based practiced stems from, all hospitals and obstetric

physicians must adhere to the recommendations of ACOG. With the ACOG guidelines that are

reviewed on an annual basis ACOG states that elective inductions for multigravida patients or

for second time mothers who have had a successful vaginal delivery previously, and have

presented with a favorable cervix and who are least thirty-nine weeks gestation are now allowed

to be scheduled for an elective induction but no sooner for the sake of convince (American

Congress of Obstetricians and Gynecologists,2013). ACOG goes further on to state that within

these guidelines of inducing only multigravida mothers or second time mothers for elective

inductions has decreased the national cesarean rates by half and has also decreased the neonatal

intensive care NICU admission rate; there by also saving money to medical institutions

(American Congress of Obstetricians and Gynecologists, 2013). The aim of this integrative

review is to is to compile pertinent literature pertaining to my PICOT question , Is an elective

induction of labor at 39 weeks gestation necessary, or does this put patients at the greater risk of

caesarian section delivery? I located a great deal of literature on this topic both quantitative and

qualitative information . The information gathered was in a span of five years to stay current

with accurate information, and support evidence based practice as well as best practice. My

personal experience sparked my interest within my nursing practice I have noticed first time

mothers also known as primigravidas who elect to be induced for labor at 39 weeks based on
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convenience alone many times end up with a primary Cesarean (C-section) for various reasons.

Often through my own work experiences I have found that the elective induction process can

take up to 72 hours just to make any labor progress, and often times puts a patient at a greater

risk for a cesarean delivery because we are ensuing artificial hormones and not allowing this

mother to go into labor on her own.

Design and Search Methods

This integrative review focuses on five research articles, all web based, an additional

form supportive literature material is American Congress of Obstetricians and Gynecologists

website that updated regularly and government regulated; a total of six sources used for research.

The databases used are as follows EBSCO Discovery Services, and ACOG website. Some of the

key terms that I used to conduct my search for reliable information included induction of labor,

caesarean section rate in the United States, Health care costs, caesarean section and vaginal

birth: health care costs, NICU rates, administering Oxytocin, and maternal complications.

EBSCO discovery services yielded 257 articles spanning from the years 1998-2017. To narrow

my search I conducted a refined search I changed the setting to that only articles within the last

five years would generate. After significantly limiting the search criteria, I located and examined

five articles that all meet my required specifications. Included are five quantitative studies that

directly relate to my PICOT question.

Findings and Results

The results and findings of the research clearly identify and directly relate to between the

direct results of elective inductions the use and administration of oxytocin, and the rising rate of

cesarean sections with the United States. A summary of the research articles located in tables 1-

5. The review of table 1 includes the use and purpose of the administration of oxytocin; which in
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turn is used to start an induction of labor. Within table 1 its states the usage of oxytocin and that

it is noted to be a high risk medication (Gilreath-Osoff & Uribe, 2015). The article goes on to

state that the usage of oxytocin must only to be given in an inpatient setting by only licensed

practitioner. In addition the article goes on to state with proper safe use of oxytocin the

medication will mirror that of natural occurring contractions when a favorable cervix is present.

The study goes on to report that acceptable reasons for oxytocin administration include

gestational age greater than 42 weeks, intrauterine growth restriction, dystocia or prolonged

labor, as well as maternal health conditions that require interventions such as pre-eclampsia, Rh

incompatibility, and premature rupture of membranes (Gilreath-Osoff & Uribe, 2015). Within

the study there are also red flag warnings to include possible maternal adverse effects from the

use of oxytocin to include postpartum hemorrhage, fetal adverse reactions to include

bradycardia, fetal arrhythmias, and even fetal brain or CNS damage, due to over stimulation of

uterine contractions that decrease the ability for the fetus to properly profuse during the labor

process.

Cesarean section and maternal complications

A quantitative study was used to gain insight of what possible acute and chronic medical

conditions a mother may face after a C-section takes place. In the United States, the rate of

cesarean section deliveries increased from 20.7% in 1996 to 32.9%, and continues to rise (Hurst,

Strayer, & Schub, 2016). Many reasons indicated for this large jump is the health state of most

Americans but also additionally the increased number of first time mothers who elect to have an

elective induction based on convince sake alone. The article states that the effects of cesarean

section can be life threatening and should only be used in an emergency or when medically

necessary (Hurst, Strayer, & Schub, 2016). Not based on patient request for convenience. The
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report also informs this researcher that women undergoing C-section have a five to twenty fold

increased risk for infectious complications compared with those undergoing vaginal birth as well

as reported chronic and acute pain. The main complications that this study emphasized was post-

partum hemorrhage, surgical injuries, cardiac arrest, acute kidney injury, stroke, and even

maternal death due C-section. This researcher wanted to emphasize the importance of patient

knowledge and the complications associated with a C-section, in addition healthcare practitioners

must educate patients post op of all safety procedures following a C-section as well as pain

management, body image issues mothers may face and possible post-partum blues or depression

a mother may have following an unplanned C-section.

Cesarean cost verses vaginal delivery

In addition to the medical complications and administration of a high risk medication this

researcher also inquired about the costs associated with a cesarean verses a vaginal birth. To gain

knowledge of this aspect coupled with patient education and having transparency of care to

include the overall capital that is spent can definitely be a game changer for some woman who

may be seeking an elective indication based on convenience sake. With the study that was

researched some statistics indicated that sense 1996 within the United States the cost of labor and

delivery has tripled; and that delivery cost is directly related to the length of stay and the services

that a patient is provided during their stay (March & Walsh, 2016). In addition medication

administration will also drive up the cost of any medical bill. The research that was obtained

recommended that all healthcare providers to include doctors, midwifes, and registered nurses

should educate our patients to maintain a healthy lifestyle before, during and after pregnancy. In

addition woman should receive early and regular prenatal care (March & Walsh, 2016). This

article took the stance of empowerment and embraces the fact that some woman may need to
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have a scheduled C-section; but also informs the reader that first time mothers should be

educated and know the risk and costs associated with a C-section allowing the reader and patient

to make an educated decision.

Strategies for lowering C-section rates

Additional research was conducted to gain a full perspective on this topic and also to gain

knowledge on ways to find solutions to the problem. In 2013 an article was titled Strategies for

lowering C-section rates. Some areas of focus within this text indicate that the national average

of c-section performed annually have remained the same at about 37% (Packer-Tursman, 2015).

These statistics were obtained by the National Vital Statistics System. In addition C-section rates

are directly related to worse neonatal outcomes and Neonatal Intensive Care Unit admission

rates. Some strategies that are discussed are stating that healthcare providers be more patient and

less apt to use medical intervention by the usage of unnecessary Pitocin (Oxytocin) if a mother is

making cervical change on her own as well as stating that nationally it is important to react

correctly, and not overreact. (Packer-Tursman, 2015, p. 42) The study is stating that all

healthcare providers should wait to official call as C-section unless medically necessary.

Additionally ACOG states that the increased C-section rate is correlated without any clear

evidence of corresponding fetal monitoring and that there is no evidence that states that surgical

intervention improved fetal or maternal morbidity or mortality (Packer-Tursman, 2015).

Prevention of primary C-sections

An additional study was obtained to gain additional knowledge as well as skill set and

perspective on ways to prevent C-sections on first time mothers. This article is written by a nurse

midwife and uses a hand off approach. A less invasive approach must be taken with woman and

health care providers need to understand that childbirth is a natural process of life. Within the
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study the author states that doctors as well as labor and delivery nurses must be patient and

realize that for first time mothers may take longer during the patient and active phase of labor

(Krishnan, 2014). In addition the article states that additional time may be required for pushing

efforts and as long as the baby and mother are in no acute distress no medical or surgical

intervention needs to be made. Patient education is vital and this researcher supports this article.

Limitation and Conclusion

In closing what is the solution, what is the safest practice to induction of labor and proper

care for all mothers and their infants? ACOG recommends reducing preventable harm to moms

and babies by eliminating the overuse of labor induction medications and goes on to further state

that We strongly recommend that women with healthy pregnancies wait for spontaneous labor

to begin and to progress on its own. ACOG bases this recommendation on research that shows

that babies benefit from the full forty weeks of gestation, and waiting reduces the risk associated

with induction of labor poor outcomes (American Congress of Obstetricians and Gynecologists,

2013). Another approach that we as nurses must take is educating our patients and making them

aware of all their options and providing them with tangible reasons for the care they are

receiving. Evidence based practice states that we must provide the safest and up to date care. I

would also make a stand that every life is a sacred gift. I work with a very vulnerable population

to include pregnant mothers and their unborn children, we must keep them safe by upholding

best practice within our scope of practice coupled with national guidelines set and mandated

towards this patient population.

INTEGRATIVE REVIEW 9

First Author Alysia Gilreath-Osoff, RN, BSN, CEN, SANE

(Year)/Qualifications
Cinahl Information Systems, Glendale, CA

Lydia M. Uribe, PharmD, MLIS

Cinahl Information Systems, Glendale, CA (2015)

Background/Problem What is Administration of Oxytocin?

Statement

Conceptual/theoretical Injectable oxytocin is a synthetic hormone that is administered to

Framework induce labor, augment prolonged or ineffective labor, and control
postpartum uterine bleeding

Design/ Quantitative Experimental

Method/Philosophical Systematic review and meta-analysis compared low-dose with high-

dose oxytocin regimens for labor induction
Underpinnings
Oxytocin is classified as a high-risk medication because of its potential
for patient harm if used incorrectly.

Oxytocin is prescribed and administered in the inpatient healthcare

setting only

Sample/ National collection of mother reported to ACOG

Setting/Ethical
Considerations Inpatient setting

Major Variables Oxytocin should be administered only when medically necessary

Studied (and their because of potential maternal and fetal risks
definition), if
appropriate Oxytocin can induce uterine tachysystole or hyperstimulation, uterine
tachysystole reduces placental blood flow,which causes fetal hypoxia
and reduces fetal heart rate and can increase risk for uterine rupture,
placental abruption, amniotic fluid embolism, and fetal trauma.

Measurement Quantitative Experimental

Tool/Data Collection
Method Systematic review and meta-analysis compared low-dose with high-
dose oxytocin regimens for labor induction
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Data Analysis Oxytocin is U.S. FDA-approved for medical not elective labor induction
only

Maternal adverse reactions to oxytocin include nausea, vomiting,

postpartum hemorrhage, anaphylaxis, potentially lethal
afibrinogenemia, cardiac arrhythmias, premature ventricular
contractions (PVCs), and pelvic hematoma

Findings/Discussion Researchers found that oxytocin doses that were 4 milliunits

(mU)/minute reduced the length of labor and the number of cesarean
sections and increased the number of spontaneous vaginal births.
However, they concluded that there is still insufficient evidence to
support routinely administering high-dose oxytocin for women in the
first stage of labor.

Appraisal/Worth to Oxytocin is used in a safe manner within the hospital setting, however
practice it is not indicated for elective inductions of labor, and contraindicated
prior to 42 weeks for a first time mother with a uncomplicated
pregnancy with a reactive and reassuring fetal non-stress tracing.

Educate the patient/family about what to expect during and after

administration of oxytocin, and what outcome to expect. Encourage
and answer questions

Continually assess, educate, and reassure the patient (and her

spouse/partner, if present) about fetal health, nursing interventions,
and the expected time of delivery

References

First Author Amy Hurst, RN, MSN (2016)

(Year)/Qualifications Cinahl Information Systems, Glendale, CA
Background/Problem Cesarean Section and Maternal Complications
Statement
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Conceptual/theoretical Causes of major surgery performed and the after effects both chronic
Framework and acute.

Design/ The effects of cesarean section can be life threatening and should only
Method/Philosophical be used in an emergency or when medically necessary. Not based on
Underpinnings patient request for convenience.

Sample/ National Obstetric care consensus (2014)

Setting/Ethical Birth by cesarean section (C-section) is the surgical delivery of a fetus,
Considerations placenta, and membranes through an incision in the abdominal wall
and uterus. It is most often performed when a vaginal delivery would
put the babys or mothers life or health at risk but is being increasingly
used at the request of the patient, without compelling maternal or fetal
indications.
Major Variables Why are primary C-sections being performed and what complications if
Studied (and their any do patients endure.
definition), if
appropriate

Measurement American College of Obstetricians and Gynecologists (ACOG)and

Tool/Data Collection Society for Maternal-Fetal Medicine. (2014). National Obstetric care
Method consensus (2014)

Data Analysis Theme was extracted by the date reported from American College of
Obstetricians and Gynecologists and Society for Maternal-Fetal
Medicine during the national obstetric care consensus.
Findings/Discussion Women undergoing C-section have a 5- to 20-fold increased risk for
infectious complications compared with those undergoing vaginal birth
as well as reported chronic and acute pain.

Appraisal/Worth to National standards are set and kept by the American College of
practice Obstetricians and Gynecologists (ACOG).
ACOG conducted this study. Evidence based practice is ensured and
allows for best practice to be read during the entire text of article.

First Author Penny March, PsyD (2016)

(Year)/Qualifications
Cinahl Information Systems, Glendale, CA

Kathleen Walsh, RN, MSN, CCRN (2016)

Cinahl Information Systems, Glendale, CA

Background/Problem In the United States, the rate of cesarean section deliveries increased
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Statement from 20.7% in 1996 to 32.9%, and continues to rise.

A review of MarketScan Commercial and Medicaid databases reported

that despite a wide variation in costs between vaginal births and
cesarean births that vary according to geographic
location/facility/provider, both commercial insurers and Medicaid
payers paid approximately 50% more for cesarean than vaginal births.

Conceptual/theoretical Birth rates and method of delivery in 2013

Framework

Design/ Quantitative National Study of statistics collected and reported to the

department of health in each state.
Method/Philosophical

Underpinnings

Sample/ Quantitative National Study of statistics collected and reported to the

Setting/Ethical department of health in each state.
Considerations
Delivery cost is directly correlated with the duration of labor

Duration of labor is less for a spontaneous vaginal birth than for an

instrumental vaginal birth.

Duration of labor is less for an instrumental vaginal birth than for an

emergency cesarean section.

Major Variables A review of MarketScan Commercial and Medicaid databases reported

Studied (and their that despite a wide variation in costs between vaginal births and
definition), if cesarean births that vary according to geographic
appropriate location/facility/provider, both commercial insurers and Medicaid
payers paid approximately 50% more for cesarean than vaginal births.

Cesarean births also has longer recovery and possible complications

suffered by mothers.

Measurement
Tool/Data Collection
Method Quantitative National Study of statistics
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Data Analysis Descriptive statistics used by explaining the method of birth and the
cost associated with delivery method.

Findings/Discussion Vaginal birth medical costs are fifty percent less than C-sections

Appraisal/Worth to National standards of best practice and evidence based practice are
practice assocated with the national standards and statistics that are reported,
allowed me to learn about the health care costs of cesarean section
and vaginal delivery. Shared this knowledge with my patients and
colleagues.

First Author Krishnan, Vijaya

(Year)/Qualifications
2016

Background/Problem Prevention of the Primary Cesarean Section.

Statement

Conceptual/theoretical Researchers wanted to inform the public on was to prevent cesarean

Framework sections often times caused by elective inductions.

Design/ Mixed research methods used both quantitative and qualitative

Method/Philosophical

Underpinnings

Sample/ National ACOG national Consensus 2014

Setting/Ethical
Considerations

Major Variables How to prevent C-sections being performed and what complications if
INTEGRATIVE REVIEW 14

Studied (and their any do patients endure.

definition), if
appropriate

Measurement American College of Obstetricians and Gynecologists (ACOG)and

Tool/Data Collection Society for Maternal-Fetal Medicine. (2014). National Obstetric care
Method consensus (2014)

Data Analysis Theme was extracted by the date reported from American College of
Obstetricians and Gynecologists and Society for Maternal-Fetal
Medicine during the national obstetric care consensus.

Findings/Discussion Women undergoing C-section have a 5- to 20-fold increased risk for

infectious complications compared with those undergoing vaginal birth
as well as reported chronic and acute pain.

Appraisal/Worth to National standards are set and kept by the American College of
practice Obstetricians and Gynecologists (ACOG).

ACOG conducted this study. Evidence based practice is ensured and

allows for best practice to be read during the entire text of article.

First Author Judy Packer-Tursman,

(Year)/Qualifications Managed Healthcare Executive. Jan 2015
Background/Problem Efforts to reduce cesarean sections in the US need to be made, nearly
Statement 1/3 of all births in the US are vis C-section, author states that with OB-
GYN care that we must act react correctly amd not over react, and not
over react by using back for a section.
Conceptual/theoretical Proven Strategies for lowering C-section rates
Framework

Design/ Elective inductions cause C-section rates to skyrocket

Method/Philosophical Elective inductions also cause more NICU admissions and well as
INTEGRATIVE REVIEW 15

Underpinnings increased poor outcomes for mother and baby.

Increase in healthcare spending nation wide
Sample/ National birth statistics taken from the National Vital Statistics System
Setting/Ethical
Considerations

Major Variables Why are primary C-sections being performed and what complications if
Studied (and their any do patients endure.
definition), if
appropriate

Measurement National Vital Statistics System 2013

Tool/Data Collection
Method

Data Analysis C-section rate remained at 34 % nationwide due to overuse of elective

inductions as well as unnecessary surgical interventions.
Findings/Discussion Women undergoing C-section have a 5- to 20-fold increased risk for
infectious complications compared with those undergoing vaginal birth
as well as reported chronic and acute pain. Increased surgical
interventions increase national health spending as well as national
debt.
Appraisal/Worth to Forward thinking article that should be used as an example on every
practice unit and be on the forefront of all healthcare providers mind.
INTEGRATIVE REVIEW 16

References

Gilreath-Osoff, A., & Uribe, L. M. (2015, October 16,2015). Administration of Medication:

Administering Oxytocin. CINAHL Nursing Guide, EBSCO Publishing. Retrieved from

http://search.ebscohost.com/login.aspx?direct=true&db=nup&AN=T707180&site=nup-

live&scope=site

Hurst, A., Strayer, D., & Schub, T. (2016, May 27,2016). Cesarean Section: Maternal

Complications. CINAHL Nursing Guide, EBSCO Publishing. Retrieved from

http://search.ebscohost.com/login.aspx?direct=true&db=nup&AN=T704526&site=nup-

live&scope=site

Krishnan, V. (2014). Prevention of the Primary Cesarean Section. Retrieved from

http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=ccm&AN

=116407150&site=eds-live&authtype=ip,cookie,uid

March, P., & Walsh, K. (2016, September 16,2016). Cesarean Section and Vaginal Birth: Health

Care Costs. CINAHL Nursing Guide, EBSCO Publishing. Retrieved from

http://search.ebscohost.com/login.aspx?direct=true&db=nup&AN=T704987&site=nup-

live&scope=site

Packer-Tursman, J. (2015). STRATEGIES FOR LOWERING C-SEGTION RATES. Managed

Healthcare Executive, 25, 42-44. Retrieved from

http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=heh&AN=

100714927&site=eds-live&authtype=ip,cookie,uid

Restricting Elective Inductions Reduces Cesareans. (2013). Retrieved from

http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/Restricting-

Elective-Inductions-Reduces-Cesareans