Elective Induction of Labor

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Induction of labor is the process by which medical or surgical means are used to initiate uterine contractions in the nonlaboring pregnant woman to bring about cervical dilatation and, one hopes, vaginal delivery. Indicated inductions of labor are common and essential elements of contemporary obstetric practice. If medical or obstetric complications develop, the often difficult decision is made that the fetus will be better served by delivery from the uterine environment and that both mother and fetus can withstand labor. This chapter’s focus is on the elective induction of labor, ie, the induction of labor in the absence of medical or obstetric indication. Is there a place in obstetric practice for the elective induction of labor? If so, who should be induced, when should she be induced, and how should the induction be accomplished? The elective induction of labor is an appropriate practice in selected women. The benefit of elective induction of labor is mutual convenience. Labor can be planned for when the physician’s presence is guaranteed. The patient knows that her doctor will be available, allowing her to be able to make arrangements concerning her timed delivery. A second potential benefit is the avoidance of the rare, unexplained fetal death that can occur late in a normal pregnancy.
A potential risk of elective induction is that it may be undertaken before the uterus and cervix are ready for labor. Although the trigger that causes the onset of human labor is unknown, much is known about uterine and cervical physiology in late pregnancy. Gap junction formation increases, and so does the number of oxytocin receptors in the myometrium. The cervical ground substance changes and collagen fibers are dispersed. Attempted induction before these uterine and cervical changes have occurred may lead to ineffective and long labor and may necessitate operative vaginal delivery or cesarean delivery. Depending on the maturity of the fetus, the neonate may suffer consequences related to its delivery from the uterus earlier than nature would have accomplished.
I will first review two articles by Edward Bishop. 1,2 Although these publications are several decades old, Bishop made important observations and suggestions that are pertinent to elective induction today. Subsequent information that may cause us to modify Bishop’s suggestions will be reviewed and published trials of induction of labor will be evaluated to help us decide for whom elective induction of labor is a reasonable option. Finally, the more difficult issue of the “softly indicated” induction of labor will be addressed.

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