Clinical Inquiry Series

Question: I’ve heard that inductions increase the cesarean section (C/S) rate. An article from AWHONN email this week reports research showing that inductions decrease the C/S rate. Which is true? And how can we decrease our C/S rate?

Answer: A review of the literature proves to be quite controversial. There were no randomized control trials found in the literature most likely due to the fact that pregnant women are a vulnerable population because of the risks to mother/infant. The majority of studies are retrospective and findings conflict. Two studies, one a systematic review and a large retrospective study found a decrease in C-section(C/S) rate when induction was used compared to usual care (spontaneous labor, induced at a later time, etc.)(Caughey et al., 2009; Wilson et al.,2010).
Other studies (Ehrenthal, Jiang & Strobino 2010; Glantz, 2010) discussed that problems exist in how researchers define the study population. These authors highlight that multiple factors, including increasing gestational age, alter the results mentioned above. Therefore after including these additional variables, they report that induction increases the C/S rate.
Two other articles (Klein 2010; Nicholson et al. 2009) mention the AMOR-IPAT scoring system. AMOR–IPAT stands for Active Management of Risk in Pregnancy at Term- Upper limit of Optimal Delivery. In their studies utilizing this scoring system (algorithm) assists with finding the ideal gestation for each woman and determines her best delivery date. This scoring system in two studies states that when this scoring system is utilized for induction it reduces the C-Section rate.
Final answer is the evidence is conflicting and there are many factors that influence the C-section rate. Maternal obesity for instance was not taken into consideration. Awareness and informed consent is imperative when deciding whether or not to induce. Ultimately this is something that should not be taken lightly and should be discussed thoroughly by the patient and her provider.

References: Akinsipe, C. D., Villalobos, L. E., & Ridley, R. T. (2012). A systematic review of implementing an elective labor induction policy. Journal of Obstetrics and Gynecology and Neonatal Nursing, 41(1) 5-16. doi:10.1111/j.1552-6909.2011.01320.x
Caughey, A. B., Sundaram, V., Kaimal, A. J. Gienger, A., Cheng, Y. W., McDonald, K. M., . . .Bravata, D. M. (2009) Systematic review: Elective induction of labor versus expectant management of pregnancy. Annals of Internal Medicine, 151(4) 252-263.
Ehrenthal, D. B., Jiang, X., & Strobino, D. M., (2010) Labor induction and the risk of cesarean delivery among nulliparous women at term. Obstetrics & Gynecology, 116(1) 35-42.
Glantz, J. G. (2010) Term labor induction compared with expectant management. Obstetrics & Gynecology, 115(1).
Nicholson, J. M., Cronholm, P., Kellar, L. C., Stenson, M. H., & Macones, G. A. (2009). The association between increased use of labor induction and reduced rate of cesarean delivery. Journal of Women’s Health, 18(11) 1747-1758.
Wilson, B. L., Effken, J., & Butler, R. J. (2010) The relationship between cesarean section and labor induction. Journal of Nursing Scholarship, 42(2) 130-138. doi:10.1111/j.1547-5069.2010.01346.x