Running head: HEALTH POLICY PAPER

Health Policy Paper

Kateri Pletcher
University of North Georgia

October 24, 2014

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2
Health Policy Paper

Everyone knows of a woman who is 36+ weeks pregnant who is just tired of being
pregnant and wants the baby to be born. She is tired of carrying all the baby weight, she isnt
sleeping well or comfortably, she is miserable and is probably spending the majority of her time
in the bathroom, as the babys head is resting on her bladder. This leads many women to asking
for their labor to be induced, despite having no indication or medical necessity to do so. After
all, 36 weeks is considered to be full-term, isnt it? All a baby does the last four weeks is grow,
so why not induce labor, get the baby born and everyone will be happy.
Unfortunately, a large majority of people believe that a baby is considered to be full-term
at 36 weeks of pregnancy. A parenting website that was used in research had this quote as one of
the first sentences of a description of what is happening from 37-40 weeks of pregnancy, At the
end of this week, your baby is considered full term. That means that no special precautions will
be taken to prevent labor if it begins ("Fetal development," n.d., p. 2). This article is very
misleading, as the majority of Obstetricians will stop labor in patients who are less than 39
weeks unless there is a reason to let the patient deliver earlier. It is due to misleading statements
such as this, that pregnant women think that delivering their baby right at or after 36 weeks is a
good idea. Unfortunately, many Obstetricians are willing to let their patients electively induce
their labors prior to 40 weeks for non-medical reasons.
According to AWHONN (The Association of Womens Health, Obstetric and Neonatal
Nurses), women should wait for labor to start on its own and if labor has not started by the 40th
week of pregnancy, then induction of labor might be indicated. During the last month of
pregnancy, the baby is not only growing, but is maturing his lungs, adding additional fat to his
body to help maintain his own body temperature once born and is working on the suck, swallow,

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breathing coordination that is necessary for a baby to properly feed after birth. Women who
chose to electively induce their labor early without medical necessity run the risk of a cesarean
section delivery and put themselves at greater risk for infection and hemorrhage. Due to this
information, AWHONN stated a campaign called Go The Full 40 in order to help women
understand why it is better to wait until labor starts on its own or wait until 40 weeks to induce.
(Gillman, 2012)
The articles researched for this paper all agreed that waiting at least until 39 weeks of
gestation for induction of labor was best for the mother and infant. The exception to this 39
week rule is if the induction is medically necessary and if the patient is experiencing certain
pregnancy-related complications that could necessitate earlier induction. According to Akinsipe,
et al, elective or non-necessary inductions prior to 39 weeks gestation resulted in higher
incidences of cesarean sections due to complications of labor. Patients who waited to be
scheduled for induction after 39 weeks went into labor on their own more often, there was a
decrease in maternal and infant complications, and the amount of time spent in labor was
reduced, which reduced potential complications of labor, such as sepsis and hemorrhage.
(Akinsipe, Villalobos, & Ridley, 2012)
Two of the eight articles researched disagreed that induction of labor increased the
patients risk of cesarean section. Wilson, et al, said that there were factors that contributed to
the higher incidence of cesarean section other than induction of labor. Women of advanced
maternal age and the number of prenatal care visits the patient attended were factors that might
cause the patient to be considered at higher risk for cesarean section. (Wilson, Effken, & Butler,
2010). Mishanina, et als study said that the induction of labor did not necessarily increase the
risk of cesarean section but did mention that the data did not state why the patient was induced,

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which could change the results of the study, if this information was known. This study said that
the chance of patients who were induced needing a cesarean section was less than those of
patients who were expectantly managed, which is a different result that other studies found.
(Mishanina et al., 2014). Gerli, et als study found that patients who were in prolonged labor had
an increase in their rate of cesarean sections. They also found that no single indication for
induction of labor had a higher incidence of cesarean section delivery. The incidence of higher
rates of cesarean section deliveries can also be related to advanced maternal age, low parity and
low Bishop scores (which rates how successful induction might be based on several factors).
(Gerli, Favilli, Giordano, Bini, & Renzo, 2013)
A study done by Simpson et al, showed that women who had attended childbirth classes
tended to not decide to have an elective induction due to being more well-informed about the
definition of full-term and about the potential problems related to electively inducing labor
prior to full-term. These patients were given educational sheets with information that they could
discuss with their care providers about their plan of care concerning their pregnancy. This
empowered the patients to feel more educated and to be more able to be a part of the team caring
for her instead of just going along with her providers plan of care. (Gerli et al., 2013). One
study, done by Verhoeven, et al made an interesting correlation between women who had
previous preterm deliveries also having a higher incidence of cesarean section for their next
delivery. They also said that there was a correlation between women who were shorter in height
and had little to no dilation at the start of their labor and eventually needing a cesarean section.
(Verhoeven, Van Uytrecht, Porath, & Mol, 2013)
The last article reviewed did find that elective inductions prior to 39 weeks subjected the
mother and baby to risks that could have been avoided by waiting to go into labor naturally or by

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waiting until 42 weeks gestation. Interestingly enough, this study went farther than the other
studies and attempted to find out why patients were having elective inductions and ways to
prevent these decisions from being made. (Moore & Low, 2012)
Waiting for labor to start on its own and Obstetricians to not letting their patients have
elective inductions until at least 40 weeks, except when there is a medical necessity will have a
huge impact on the American people, the nursing profession, as well as a financial impact. An
elective induction can take up to three days, so waiting for a patient to go into labor on her own
or by not inducting until the patient is at least 40 weeks will decrease the amount of days that the
patient is in the hospital and will most likely decrease the amount of medical interventions
necessary during labor. By not having elective inductions, the patient can decrease the risk of
maternal complications, such as sepsis and hemorrhage, which can be exacerbated by the length
of time a patient is in labor and can decrease the risk of fetal complications, which can occur
when they mother is induced and in labor for a long period of time, both which can stress the
fetus and cause complications.
The impact on the nursing profession will be significant, as there will be fewer women
coming in to electively induce their labor. This will mean that there should be a decrease in the
amount of interventions done to the patient in order to induce her, decrease the rate of
complications and decrease the days spent in the hospital, all which will positively impact nurses
and their workload.
The majority of the studies researched found that women who electively induced their
pregnancy were at a greater risk for a cesarean section delivery. A cesarean section is major
abdominal surgery, which makes it riskier for the patient than a vaginal delivery. The patient
runs the risk of large blood loss, blood clots, damage to other organs due to the cesarean section,

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and death. The risk for the baby due to cesarean section can be injury during the surgery and
delivery, immature lungs or breathing difficulties due to the surgery and potentially needing to be
in the NICU after birth due to either of these factors. The long-term risks that a woman has
because of a previous cesarean section are abruption of the uterus due to weakness of the uterus
from the prior incision, placenta previa (the placenta is attached to the uterus near the cervix,
blocking the cervix) and from least to worst problematic, placenta accrete, increta and percreta,
which is when the placenta grows through the uterine wall instead of just attaching to it. In the
most serious (percreta), the placenta grows through the uterus and latches onto other internal
organs. Any of these three conditions can cause severe bleeding, make it impossible to deliver
the placenta and can lead to hysterectomy or maternal death. ("C-section," n.d.). The one study
that did state that there was no correlation between elective inductions and an increased rate of
cesarean sections suggested that the cesarean sections could instead be related to advanced
maternal age and lower prenatal visits.
The financial consideration of elective inductions and cesarean sections are many. If the
patient is in the hospital being induced for up to three days, with many medical interventions to
induce her, the bill is going to be quite a bit higher than if a patient comes into the hospital in
labor. If she ends up needing a cesarean section, the cost will include the increased cost of
surgery, extra personnel to perform and support the surgery, anesthesia costs and she will spend
extra days recovering in the hospital. A woman who delivers vaginally will stay 24-36 hours
after delivery. A woman who delivers by cesarean section with no complications will stay 3-4
days after delivery. A recovery from an uncomplicated cesarean section is 6 weeks. The
recovery from a vaginal delivery is around 1-2 weeks. The financial implications of these costs
can be devastating to a patient who does not have insurance, does not have maternity coverage

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through her insurance or is a self-pay patient. Even if the patient has health insurance, the out of
pocket costs to the patient will be quite a bit higher if she has an elective induction and/or a
cesarean section.
Go the Full 40 is a very important campaign to help improve the outcomes of
pregnancies, to avoid both maternal and fetal complications and to keep the costs down for the
patients and for the insurance companies. It is important to educate pregnant patients on the
reasons why it is important to Go the Full 40 so she will not be quite so eager to induce labor
electively. This will have a positive impact on the patient and her baby, as they will probably
avoid possible complications brought on by inducing her labor. This will also have a positive
financial impact, as it will help lessen the costs incurred by electively inducing patients, which
will benefit the patient, the insurance company and the general public, who are usually impacted
by rising insurance costs. The impact on the nursing staff will be significant, as the nursing staff
is already stretched very thin on a day-to-day basis. By not electively inducing except in cases of
medical necessity, it will make use of the nursing staff more wisely, instead of increasing the
incidence of high acuity patients who require more interventions and more one-on-one care, as
often is the case during elective inductions. This benefits both the patient and her baby, as more
positive outcomes should be the outcome.
Changing the current mindset of letting patients electively induce their pregnancies
earlier than 40 weeks for non-medical reasons would make a positive difference for patients,
their babies, for the financial well-being of the patient and for the nursing staff. It is a sound
decision to make, based on evidence-based practice and can only improve patient outcomes
going forward.

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References
Akinsipe, D., Villalobos, L., & Ridley, R. (2012). A systemic review of implementing an elective
labor induction policy. JOGNN: Journal of Obstetric, Gynecological & Neonatal
Nursing, 41(1), 5-16. http://dx.doi.org/10.1111/j.1552-6909.2011.01320.x
Fetal development from weeks 36-40. (n.d.). Retrieved from
http://www.parents.com/pregnancy/stages/fetal-development/weeks-36-40/?page=2
Gerli, S., Favilli, A., Giordano, C., Bini, V., & Renzo, G. (2013). Single indications of induction
of labor with prostaglandins and risk of cesearean delivery: A retrospective cohort study.
The Journal of Obstetric and Gynaecology Research, 39(5), 926-931.
http://dx.doi.org/10.1111/jog.12000
Gillman, J. (2012). Nurse experts emphasize the importance of full-term pregnancies with the
launch of Wait for Labor to Start on its Own pledge. Retrieved from
https://www.awhonn.org/awhonn/content.do?name=07_PressRoom
%2F07_Nov12LaborPledge.htm
Health and Pregnancy - Cesarean section - risks and complications. (n.d.). Retrieved from
http://www.webmd.com/baby/tc/cesarean-section-risks-and-complications
Hernandez, G., Korst, L., Goodwin, T., Miller, D., Caughey, A., & Ouzounian, J. (2011). Late
pregnancy complications can affect risk estimates of elective induction of labor. The
Journal of Maternal-Fetal & Neonatal Medicine: The Official Journal of the European
Association of Perinatal Medicine, The Federation of Asia and Oceania Perinatal
Societies, The International Society of Perinatal Obstetricians, 24(6), 787-794.
http://dx.doi.org/10.3109/14767057.2010.53078

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Mishanina, E., Rogozinska, E., Thatthi, T., Uddin-Khan, R., Khan, K., & Meads, C. (2014). Use
of labour induction and risk of cesarean delivery: a systematic review and meta-analysis.
CMAJ: Canadian Medical Association Journal=Journal De Lassociation Medicale
Canadienne, 186(9), 665-673. http://dx.doi.org/10.1503/cmaj.130925
Moore, J., & Low, L. (2012). . Factors that influence the practice of elective inductions of labor:
What does the evidence tell us?, 26(3), 242-250.
http://dx.doi.org/doi:10.1097/JPN.0b013e31826288a9
Verhoeven, C., Van Uytrecht, C., Porath, M., & Mol, B. (2013). Risk factors for cesarean
delivery following labor induction in multiparous women. Journal of Pregnancy.
http://dx.doi.org/10.1155/2013/820892
Wilson, B., Effken, J., & Butler, R. (2010, ). The relationship between cesarean section and labor
induction. Journal of Nursing Scholarship, 19(3), 130-138.
http://dx.doi.org/10.1111/j.1547-5069.2010.01346.x

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10

Academic Integrity Policy:

Honor Code: "On my honor, I will not lie, cheat, steal, plagiarize,
evade the truth or tolerate
those who do."
One of the following Academic Integrity Statements is required on
the last page of ALL
submitted papers:
I, Kateri Pletcher, attest that none of the information used in
composing this assignment
has been used in any assignment in this course, any other course
within the University of
North Georgia system, or at any other college or university.
"On my honor, I pledge that I have neither given nor received
unauthorized help on this work."